FIZIOLOGIA
physiology
FOUNDING EDITORCHIEF EDITOR
CO-CHIEF EDITORSASSOCIATE EDITORSEXECUTIVE EDITORSFRANCISC SCHNEIDERCARMEN PANAITESCUCARMEN TATUFLORINA BOJINMIHAI NECHIFORSORIN RIGAGABRIELA TANASIEDACIANA NISTORCALIN MUNTEANEDITORIAL BOARD
ARDELEAN AURELBĂDĂRĂU ANCA
BENEDEK GYORGYBENGA GHEORGHECOJOCARU MANOLEGĂLUȘCAN ATENAIANCAU MARIAMIHALAŞ GEORGETA
MUNTEAN DANINAMUREŞAN ADRIANANESTIANU VALERIUOPREA TUDORPANAITESCU CARMEN(Arad)(Bucureşti)(Szeged)(Cluj)(Bucureşti)(Timișoara)(Craiova)(Timişoara)(Timişoara)(Cluj)(Craiova)(New Mexico)(Timişoara)PĂUNESCU VIRGILPETROIU ANAPODARIU ANGELA CODRUTA
RÂCZ OLIVERRIGA DANSABĂU MARIUS
SAULEA I. AURELSIMIONESCU MAIASWYNGHEDAUW BERNARDTANGUAY M. ROBERTTATU ROMULUS FABIANVLAD AURELIANVOICU VICTORZĂGREAN LEON

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Fiziologia - Physiology • 2017.27.2(94)CONTENTS
1. Changes in Serum Leptin and Adiponectin Levels in Beninese Pregnant Women ......................................4
Awede B, Adehan G, Lawani S, Dossou E, Denakpo J, Djrolo F, Amoussou-Guenou M
2. Complications of Extreme Prematurity ..............................................................................................................8
Iacob D, Dima M, Nyiredi A, Iacob RE
3. Relapsed Pseudomyxoma Peritonei. A Case Report .....................................................................................13
Cioboata R, Georgescu M, Gaman AE
4. Diagnostic Performance of Strain Elastography for Thyroid Nodules .........................................................17
Oprea MC, Lazar F
5. The Global Social Functioning of Patients with Bipolar Affective Disorder with First-Rank
Symptoms ........................................................................................................................................................22Riviș IA, Barboianu R, Homorogan C, Romoșan AM, Papavă I, Hogea LM, Bredicean AC
6. Systolic Left Ventricular Function Evaluated with Two Dimensional and Three Dimensional Speckle
Tracking Echocardiography in Elite Rugby Players ....................................................................................26
Popescu I, Mancas S, Serbescu I, Mornos C, Ionac A

CUPRINS
1. Modificările nivelurilor leptinei și adiponectinei serice la femeile benineze însărcinate .............................4
Awede B, Adehan G, Lawani S, Dossou E, Denakpo J, Djrolo F, Amoussou-Guenou M
2. Complicațiile prematurității extreme .................................................................................................................8
Iacob D, Dima M, Nyiredi A, Iacob RE
3. Pseudomixom peritoneal recidivat. Prezentare de caz .................................................................................13
Cioboata R, Georgescu M, Gaman AE
4. Performanța diagnostică a elastografiei strain pentru nodulii tiroidieni .....................................................17
Oprea MC, Lazar F
5. Funcționarea socială globală a pacienților cu tulburare afectivă bipolară cu simptome de prim rang ....22Riviș IA, Barboianu R, Homorogan C, Romoșan AM, Papavă I, Hogea LM, Bredicean AC
6. Evaluarea functiei sistolice a ventriculului stang cu ajutorul metodelor ecocardiografice speckle
tracking bidimensional si tridimensional la un lot de sportivi de performanta (jucatori de rugby) ........26
Popescu I, Mancas S, Serbescu I, Mornos C, Ionac A

Fiziologia - Physiology • 2017.27.2(94)3CHANGES IN SERUM LEPTIN AND ADIPONECTINLEVELS IN BENINESE PREGNANT WOMENBONAVENTURE AWEDE1, GRACE ADEHAN2, SOULIATH LAWANI1, EMMANUELDOSSOU1, JUSTIN DENAKPO3, FRANÇOIS DJROLO4, MARCELLIN AMOUSSOUGUENOU2
1Unité de Physiologie, Faculté des Sciences de la Santé, Université d’Abomey-Calavi
2Unité de Biophysique et de Médecine Nucléaire, Faculté des Sciences de la Santé, Université d’Abomey-Calavi
3Unité de Gynécologie et d’Obstétrique, Faculté des Sciences de la Santé, Université d’Abomey-Calavi
4Unité d’Endocrinologie, Métabolisme et Nutrition, Faculté des Sciences de la Santé, Université d’Abomey-Calavi

ABSTRACT
Background: Adiponectin and leptin plasma levels during normal pregnancy and gestational diabetes mellitus have beenstudied but there are some variations in the reported results although some trends are observed. In the present study,
serum levels of these adipokines have been determined in normal and pregnant women with gestational diabetes mellitus.
Methods: OGTT test has been made in pregnant women for gestational diabetes mellitus screening and in non-pregnant
women to assess their glucose tolerance status. Three groups of 12 women were included in the study: non-pregnant
women with normal glucose tolerance, pregnant women without and pregnant women with gestational diabetes. Leptin andadiponectin serum levels were then determined by radioimmunoassay at 10-15 weeks and 24-28 weeks of gestational age
in normal pregnant women and at 24-28 weeks of gestation in pregnant women with gestational diabetes.
Results: serum leptin level in normal pregnant women at 24-28 weeks of gestation (13.24 ± 3.69 ng/mL) was significantly(p<0.05) higher than that in non-pregnant women.
In normal pregnant women, adiponectin levels were 82.83 ± 21.95 µg/mL and 76.31 ± 42.99 µg/mL respectively at 10-15
weeks and 24-28 weeks of gestation and were significantly higher (p<0.001) than adiponectin level in non-pregnant women(7.52 ± 4.66 µg/L). Leptin and adiponectin levels in women with gestational diabetes were not significantly different fromlevels in normal pregnant women.
Conclusion: These data suggest that leptin and adiponectin levels could not systematically be considered as marker ofgestational diabetes in all pregnant women population.
Keywords: Leptin, adiponectin, pregnancy, gestational diabetes mellitus

INTRODUCTION
Leptin and adiponectin are two hormones produced byadipose tissue and which are involved in many functions
such as reproduction, energy homeostasis and immune
system function [1]. In reproductive system, these
hormones, especially leptin, modulate sex hormones
secretion by acting at different levels of hypothalamicpituitary-gonadal system [9]. Leptin and adiponectin also
modulate tissue insulin sensitivity and high levels of leptin
and hypoadiponectinemia have been found associated withinsulin resistance [1; 2].
Pregnancy is a physiological condition where insulin
resistance occurs, especially, in the second half ofpregnancy due to the action of many hormones. Because ofthis insulin resistance, gestational diabetes mellitus (GDM)

is frequently observed during pregnancy [4]. Given theiraction on energy homeostasis and insulin resistance, therole of leptin and adiponectin during pregnancy has been
investigated by many authors. Changes in leptin andadiponectin levels during pregnancy have been described
but a great variability was observed in the published dataand ethnic differences were also reported [11, 12, 18, 20,
21, 26]. In pregnant women with GDM, compared to normal
pregnancy, decreased adiponectin levels have beenreported by several authors [3, 5, 28]. Thus, low adiponectinlevel has been suggested as a marker of GDM. In view ofthe variability observed from one study to another, it is ofgreat importance to characterize changes in levels of theseadipokines during pregnancy in each population. In thepresent work, we have investigated changes in leptin andReceived 10th of September 2017. Accepted 15th of October 2017. Address for correspondence: Dr Bonaventure AWEDE, Unité dePhysiologie, Faculté des Sciences de la Santé, Université d’Abomey-Calavi, 01 BP 188 Cotonou, BENIN; phone: 00229 95 10 43 53; e-mail:
Bonawed@yahoo.com

4

Fiziologia - Physiology • 2017.27.2(94)

*

15

10

5

Statistical analysis
Data are expressed as means ± standard deviation(SD). Means are compared using t-student test. Differenceswere considered significant for p<0.05.

RESULTS
Subjects characteristics
Mean age of all subjects was 27.64 ± 5.92 years. Meanages of control non-pregnant, normal pregnant andFiziologia - Physiology • 2017.27.2(94)

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Leptin and adiponectin levels measurement
Blood samples were taken from each subject formeasurement of adipokine levels.
Leptin and adiponectin levels were determined at 10-15
weeks and at 24-28 weeks of gestational age in all non-GDM
pregnant women. In women with GDM, leptin and adiponectinlevels were measured at 24-28 weeks of gestational age
because most of them have been recruited after a firsttrimester of gestation (only three were recruited in the firsttrimester). Leptin and adiponectin measurement was
performed by radioimmunoassay using specific kits
purchased from Demeditec Diagnostic (Germany) according
to manufacturer instructions.

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0
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Oral glucose tolerance test (OGTT)An OGTT was performed in all pregnant women at 24-28
weeks of gestational age by oral administration of 75g of glucose
for the diagnosis of gestational diabetes mellitus. Criteria of theInternational Association of Diabetes and Pregnancy Study
Groups (IADPSG) were used to define GDM [16].

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Data collection
Anthropometric and clinical data were collected at anantenatal clinic and using a questionnaire. For pregnant
women, weight at the first trimester of pregnancy was used
to determine the body index mass (BMI).

Leptin and adiponectin serum levels in control nonpregnant and in pregnant women without GDMee

Subjects
Pregnant women (135) have been recruited in the
Gynecology and Obstetrics Clinic of the University Hospital
Mother and Child (CHU-MEL) from July 2013 to June 2014.
After screening for gestational diabetes mellitus based onan oral glucose tolerance test (OGTT), 12 pregnant womenwith GDM, 12 pregnant women without GDM were includedin the study. Twelve non-pregnant women with normal
glucose tolerance served as control. Only subjects who
gave a written consent form were included in the study.

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MATERIAL AND METHODS

pregnant women with GDM were respectively 24.83 ± 4.22
years, 28.17 ± 4.20 years and 29.92 ± 7.86 years.
Mean BMI of all subjects was 25.85 ± 5.87 kg/m 2 andmean BMI of control non-pregnant, normal pregnant andpregnant women with GDM were respectively 24.09 ±6.05 kg/m 2 and 26.21 6.09 kg/m2 and 27.24 ± 5.24 kg/m 2.
Mean blood fasting glucose levels were identical inpregnant and non-pregnant women (0.83 ± 0.12 vs 0.83 ±0.08) but were significantly higher in women with GDM thanin normal pregnant women (0.93 ± 0.12 vs 0.74 ± 0.08;
p<0.001).

s e r u m le p tin le v e ls (n g /m L )adiponectin levels in normal and pregnant women with GDMfrom Benin population.

Fig. 1. Serum leptin levels in non-pregnant and pregnant women
without gestational diabetes
Values are means ± SD, n = 12 in each group.
*: significant different from control non-pregnant, p<0.05.

Figure 1 shows mean serum leptin levels control nonpregnant and in pregnant women without GDM.
In normal pregnant women mean leptin levels were
10.58 ± 5.57ng/mL and 13.24 ± 3.69 ng/mL at respectively
10-15 weeks and 24-28 weeks of gestation. Mean leptin
level at 24-28 weeks was significantly higher (p<0.05) thanleptin level in non-pregnant women (7.60 ± 6.2 ng/mL) but
was not different from leptin level at 10-15 weeks ofgestation.
Levels of adiponectin is represented in figure 2.
Adiponectin levels were 82.83 ± 21.95 µg/mL and 76.31 ±42.99 µg/mL in normal pregnant women respectively at 1015 weeks and 24-28 weeks of gestational age. These
adiponectin levels were significantly higher (p<0.001) thanthat in non-pregnant women (7.52 ± 4.66 µg/L). There was5

no significant difference between adiponectin levels at 1015 weeks and at 24-28 weeks.
Leptin and adiponectin levels in pregnant womenwith GDM
Serum leptin level at gestational age of 24-28 weeks
was 14.84 ± 8.45 ng/L in pregnant women with GDM. This
leptin level was significantly higher (p<0.05) than leptin levelin control non-pregnant women but was not different fromleptin level in normal pregnant women.
Adiponectin mean level at 24-28 weeks of gestation was
110.86 ± 50.99 µg/L. This adiponectin level was
significantly higher (p<0.001) than adiponectin level incontrol non-pregnant women but was not different from
adiponectin level in normal pregnant women.

S e r u m a d ip o n e c tin le v e ls (µ g /m L )

150

***
***
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Fig. 2. Serum adiponectin levels in non-pregnant and pregnant
women without gestational diabetes
Values are means ± SD, n = 12 in each group.
***: significant different from control non-pregnant, p<0.001.

DISCUSSION
The main findings of the present study were that inpregnant women, compared to non-pregnant women, there
were increased levels of both serum leptin and adiponectinlevels and that serum leptin and adiponectin levels inwomen with GDM and in women without GDM were notsignificantly different at 24-28 weeks of gestation.
As found in our study, increased leptin levels during
pregnancy have been reported by several studies [2, 14, 21,27]. Although many authors found an early significant
increase in leptin levels, in our study, leptin levels in the firsttrimester of pregnancy were not significantly different from
non-pregnant control levels. Many mechanisms including
increase maternal production and placental production of
leptin are thought to be involved in this rise of leptin levels
during pregnancy [6].

6

Leptin level in women with GDM was not significantly
different from that in normal pregnant women. Our results
are in agreement with many published data [2, 15, 20, 25].
However, increased leptin levels in women with GDM,
compared to normal pregnant women, has also beenreported [5, 11, 13]. Early significant increased leptin levels
in pregnant women who developed latter GDM have beenreported and thus increased leptin level has been suggested
as early marker of GDM [11, 24]. Further studies which will
investigate early changes in leptin levels should be
performed on large size of our population before making
such a conclusion.
Increased adiponectin levels during normal pregnancy
was observed in our study. In published data, variable
profiles of adiponectin level have been described. In moststudies, compared to non-pregnant women, adiponectinlevels in pregnant women were not significantly different,
during the first trimester [7, 10, 12]. After the first trimester,
either no change, a trend to a decrease or significant
decrease in adiponectin levels have been reported [7, 10,18, 23]. However, increased adiponectin level during
pregnancy, as we found in our study, has also been
described. Fuglsang and co-workers found an increased
level of adiponectin at 17 weeks of pregnancy before its
decline later during pregnancy [12]. In addition, althoughadiponectin level in all pregnant women of their study was
not significantly different from that of non-pregnant women,
Nien and co-worker found that adiponectin levels in
pregnant women with a BMI less than 25 were higher thanthat of non-pregnant women [22]. In our study, compared to
non-pregnant women, a more than ten-times increased inadiponectin level (which persisted until 24-28 weeks) was
already observed at 10-15 weeks in normal pregnant
women. This is the first time a dramatic increase inadiponectin levels is described in normal pregnant women.
As pregnancy is a physiological condition where tissue
insulin resistance occurs and as adiponectin is a hormone
which increases insulin sensitivity, this increase inadiponectin levels in women with normal glucose tolerance
could be a mechanism which prevents or limits insulin
resistance during pregnancy.
In our study, adiponectin levels, measured at 24-28
weeks in women with GDM, were not significantly different
from those in women without GDM. Our data are inagreement with a previous work which reported, in thesecond trimester, no significant difference in adiponectinlevels between GDM and normal pregnant women althougha significant decrease in adiponectin levels was observed in
GDM women in the third trimester [23]. In contrast to our
results, in almost all other studies, adiponectin levels havebeen shown to be lower in women with GDM than in women
without GDM [5, 13, 19, 25, 28]. Low levels of adiponectin
were also already observed early in pregnancy before thedevelopment of GDM and adiponectin has been suggested
as a marker of GDM [17, 28]. Our results suggest howeverthat decreased adiponectin levels could not be systematically
Fiziologia - Physiology • 2017.27.2(94)observed in all women with GDM. Ethnic specificity could be
involved in the regulation mechanisms of adiponectin in
pregnant women as ethnic differences in adiponectin levels
during pregnancy have been described [8, 26].
In the present study, changes in leptin and adiponectinlevels in women with GDM in were investigated only at 24-28
weeks of gestation. Longitudinal study should be performed
throughout the pregnancy and in the post-partum to allow a
best assessment of leptin and adiponectin changes during
pregnancy. Another limit of our study is the small size of ourstudy population. Further studies should be conducted onlarge population to confirm the findings of the present work.

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7

COMPLICATIONS OF EXTREME PREMATURITY
IACOB DANIELA1, DIMA MIRABELA1, NYIREDI ALEXANDRA2, IACOB RADU EMIL2
1Victor Babes University of Medicine and Pharmacy Timisoara, Neonatology Department
2Victor Babes University of Medicine and Pharmacy Timisoara, Pediatric Surgery Department

ABSTRACT
Extremely low birth weight newborns are exposed to developing a large spectrum of complications, which are responsiblefor increased mortality rates in this group of preterm infants. We aimed to analyse the perinatal complications of extreme
prematurity that cause high rates of infant morbidity and mortality. We have included 46 extreme low birth weight infants
admitted to the Neonatal Intensive Care Unit of Bega Maternity Hospital Timisoara, Romania in the period of 01.01.2012 31.12.2013, mean birth weight was 859.35+/-153g. The major causes of mortality were sepsis (46%), perinatal asphyxia(20%) and pulmonary hemorrhage (19%). Respiratory distress syndrome, perinatal hypoxic-ischemic encephalopathy,
cerebral hemorrhage, cardiopulmonary arrest, anemia of prematurity and of other causes, acute renal failure and infections
were among the most common complications in our group. We have found that complications of prematurity are inversely
proportional to birth weight and gestational age and are correlated with morbidity and mortality rates among ELBW preterm
infants.

INTRODUCTION
Fifteen million preterm infants (gestational age [GA]<259 days or <37 weeks) are born each year around theworld, and the incidence of prematurity is 5 – 18% [1-2].
The extremely low birth weight (ELBW) infant is weighing
under 1,000g at birth. Complications of extreme prematurity,
associated with neonatal adjustment disorders andresponsible for increased mortality rates, are: respiratory,
neurologic, cardiovascular, hematologic, metabolic, renal,
gastrointestinal, thermoregulation, immunologic, ophthalmologic and hearing disorders etc. [3-7]. This study aimed
to analyze the perinatal complications of extreme
prematurity, leading to increased infant morbidity andmortality risks for extremely low birth weight babies.

MATERIAL AND METHOD
The study group comprises 46 ELBW newborns, birthweight (BW) <1,000g, admitted to the Neonatal Intensive
Care Unit of Bega Maternity Hospital Timisoara, Romania in
the period of 01.01.2012 - 31.12.2013. This is a transversal(retrospective observational) study. Inclusion criteria:
preterm infants born alive during 2012 and 2013 years in the
Bega Maternity Hospital, birth weight under 1,000 g, GA
under 30 weeks. Exclusion criterion: ELBW infants born
dead.

Statistical analysis
Data extracted from clinical observation sheets ofpreterm babies were processed and analyzed using the
SPSS statistical programme version 20.0. We have used
95% confidence interval and 5% significance level.

RESULTS
The study group comprises 46 ELBW infants, treated in
the Neonatal Intensive Care Unit of Bega Maternity Hospital
Timisoara within two years. The gender distribution of ELBW
preterm infants was as follows: 52.1% girls and 47.9% boys;
the female gender prevails both in number and survival rate:
60.7% girls, compared with 39.3% boys. The mode ofdelivery was vaginal in 39.1% and caesarean section in
60.9% of the cases. The mean birth weight was 859.35+/153g (<1,000g; lowest BW=400g), with the mean
gestational age of 26.65+/-1 week (23 - 29 weeks). Survival
rate of ELBW preterm babies in the study group was 60.9%(Figure 1).

Received 10th of October 2017. Accepted 2nd of November 2017. Address for correspondence: Daniela Iacob, Department of Neonatology,”Victor Babeș” University of Medicine and Pharmacy Timișoara, Eftimie Murgu Square No. 2A, RO-300041, Timișoara, Romania; e-mail:danielariacob@yahoo.com

8

Fiziologia - Physiology • 2017.27.2(94)Neurologic complications:
Perinatal hypoxic-ischemic encephalopathy (HIE),
diagnosed by the means of transfontanellar ultrasound,occurred in a large number of ELBW preterms, as follows:
mild, 50% (57.6% survivors), moderate, 6.5% (100%survivors) and severe, 41.3% (63.6% survivors). Cerebral
hemorrhage (moderate and severe intraventricularhemorrhage), diagnosed by ultrasound, was seen in 52.1%of the cases. Periventricular leukomalacia was diagnosed in
4.3%, and porencephaly in 2.1% of the cases.

Fig. 1. Survival rate of ELBW preterm babies in the 2012-2013 period

Mortality rate of ELBW preterm babies varied by gender:
38.9% girls and 61.1% boys (Figure 2).

Cardiovascular complications:
21.7% of the patients enrolled in the study have hadpatent ductus arteriosus (PDA) and 52.2% developed
cardiopulmonary arrest. No significant differences havebeen found between percentages of deceased preterm
infants with and without PDA (p=0.9). A 0.58 correlation was
found between respiratory and cardiovascular complications(p=0.01).
Hematologic complications were mainly represented byanemia of prematurity and of other causes, which was seen
in 50% of the ELBW preterm infants: 78.2% survived and27.8% died.
Metabolic complications were seen in 76% of thepreterm infants included in the study, which had neonatal
hypo-/hyperglycemia, hypocalcemia, hyperkalemia anddisorders in protein metabolism.
Gastrointestinal complications were diagnosed in 47.8%of the ELBW preterm babies.
Renal complications were represented by acute renal
failure in 39.5% of cases, out of which 23.5% survived and72.5% died.

Fig. 2. Mortality rate of ELBW preterm babies in the 2012-2013 period

Respiratory complications:
Respiratory distress syndrome (RDS) was seen in
91.3% of the patients in this study and apnea in 17.4%. BothRDS and apnea of prematurity were seen in 19% of thepreterm babies. Pneumothorax was a complication seen in
13%, while pulmonary hemorrhage was present in 17.4% of
the ELBW preterm infants. Bronchopneumonia occurred in
15.2%, and chronic lung disease in 4.3% of the cases. We
found statistically significant differences between
percentages in the group of infants with RDS and respiratory
failure, and those without RDS who developed respiratory
failure (p<0.005). No significant differences were foundbetween percentages in the group of preterm babies withapnea and respiratory failure, and the group of preterm
infants without apnea who developed respiratory failure(p>0.05).

Fiziologia - Physiology • 2017.27.2(94)Immunologic complications: There was a 0.3 correlation
between premature rupture of membranes and fetalmaternal infection (p= 0.04, OR=3.5).
Ophthalmologic complications: A 0.5 correlation between
HIE and retinopathy of prematurity (ROP) (p<0.001) was
found. All preterm babies with retinopathy also had HIE,
accounting for 17.39% of the newborns included in thisstudy.

The death variable is explained by the aid of thefollowing variables: APGAR score and respiratory
failure, with 40% proportion invasion.
When generating the ROC curve for respiratory failureand deaths among ELBW preterms, we have obtained a
0.79 area (p=0.001); this proved to be a good model, with
72% sensitivity.

9Fig 3. ROC curve for respiratory failure and deaths

DISCUSSIONS
Our study intended to show the complications ofprematurity among extremely low birth weight newborns(BW<1000g) treated in the Neonatal Intensive Care Unit ofBega Maternity Hospital Timisoara, Romania; complicationsof prematurity are inversely proportional to birth weight andgestational age and determine morbidity and mortality rates
among ELBW preterm newborns.
Results of researches on the survival rate among ELBW
newborns vary according to the countries where studies[6,8,10,12,23] were performed (from 52% to 56%). In ourgroup, we have calculated a 60.9% survival rate, with better
outcomes for female newborns. The major causes of mortality
were sepsis (46%), perinatal asphyxia (20%) and pulmonary
hemorrhage (19%). The most frequent respiratorycomplications were: RDS, apnea of prematurity, pulmonary
hemorrhage, pneumothorax, and chronic lung disease.
Antenatal corticosteroids given to mothers at risk of prematuredelivery (<34 weeks pregnancy), decreases RDS incidence to50%, with significant impact on mortality reduction [8,14,18].
Antenatal corticosteroids, surfactant therapy, non-invasive
respiratory support, prevention of infections and optimal
nutritional support for ELBW infants increase their survival
rate both on the short and long run [13,14,18]. In our study,
antenatal corticosteroids were used in 23.9% of the ELBW
preterms with respiratory distress syndrome. RDS was foundin 91.3% of the ELBW newborns in our study group.
Neurologic complications are a hallmark of extreme
prematurity. Intracranial hemorrhage (intraventricularhemorrhage-IVH, subdural hemorrhage, subarachnoid
hemorrhage and intraparenchymal hemorrhage) are often
seen in ELBW preterm infants [25-27]. IVH incidence is 16 65%; in 22.5% of the cases, IVH was the cause of death10[8,26]. Moderate and severe HIE (47.8%), as well as
moderate and severe intraventricular hemorrhage (52.2%)
were the main neurologic complications in the ELBW
newborns in this study.
As cardiovascular complications concerns, PDA wasseen in 21.7% of the cases in our clinic.
The hematologic complications in this study were anemia
and hyperbilirubinemia. Hyperbilirubinemia was encounteredin 59.8% of the cases. Anemia of prematurity and of othercauses was seen in 50% of the newborns in the study.
Metaboliccomplications(hypo-/hyperglycemia,
disorders in calcium metabolism): approximately 53% of the
ELBW preterm babies with metabolic disorders die
perinatally or have neurologic sequelae [29-31]. In ourstudy, this type of complications represent 76% of the cases.
Renal complications, such as acute renal failure (ARF)
and fluid and electrolyte imbalances, increase mortality
rates among ELBW preterm infants. ARF was seen in 39.5%of the preterm newborns in the study group.
The gastrointestinal complications of prematurity arenecrotizing enterocolitis (NEC), diarrheal disease andfeeding disorders. In our study, 47.8% of the newborns had
gastrointestinal disorders.
The main ophthalmologic complications of extreme
prematurity are retinopathy of prematurity and retinal
detachment, complicated with vision loss or blinding.
Incidence of blindness caused by ROP is 2 - 9% in ELBW
newborns with high risk of ROP [37]. ROP was diagnosed in
17.3% of the cases (n=8). In this study, all the preterm
infants who had ROP also had HIE, as shown by ultrasound.

CONCLUSIONS
Extremely premature newborns are at increased risk ofcomplications and death. Respiratory, neurologic,
cardiovascular, hematologic, metabolic, gastrointestinal,
renal complications, immunologic and ophthalmologic
complications were seen in the study group. Complicationsof prematurity are inversely proportional to birth weight andgestational age and are correlated with morbidity andmortality rates among ELBW preterm infants. Extremely low
birth weight, mechanical ventilation and hypotensive shock
are predictors of morbidity. Antenatal corticosteroids,
surfactant therapy, non-invasive respiratory support,
prevention of infections and optimal nutritional support for
ELBW infants increase their survival rate.

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COMPLICAȚIILE PREMATURITĂȚII EXTREMEREZUMAT
Nou-născuții cu greutate extrem de mică la naștere sunt expuși unui spectru larg de complicații, care determină o ratăcrescută a mortalității în acest grup de prematuri. Scopul nostru a fost să analizăm complicațiile prematurității extreme,care duc la rate mari de morbiditate și mortalitate infantilă. Am inclus în studiu 46 de prematuri cu greutate extrem de micăla naștere internați în Secția Neonatologie și Terapie Intensivă a Maternității Bega Timișoara, România în perioada
01.01.2012 - 31.12.2013, cu o greutate medie la naștere de 859,35+/-153g. Cauzele majore de deces au fost sepsisul(46%), asfixia perinatală (20%) și hemoragia pulmonară (19%). Sindromul de detresă respiratorie, encefalopatia hipoxic
ischemică perinatală, hemoragia cerebrală, stopul cardio-respirator, anemia prematuriății și de alte cauze, insuficiența
renală acută și infecțiile au fost unele dintre cele mai frecvente complicații în grupul de studiu. În urma acestui studiu am
constatat o relație invers proporțională între complicațiile prematurității, pe de o parte, și greutatea la naștere și vârsta
gestațională, pe de altă parte, acestea corelându-se cu ratele morbidității și mortalității în rândul prematurilor cu greutate
extrem de mică la naștere.

12

Fiziologia - Physiology • 2017.27.2(94)RELAPSED PSEUDOMYXOMA PERITONEI.
A CASE REPORTRAMONA CIOBOATA1, MARIUS GEORGESCU2, ALICE ELENE GAMAN3
1 Internal Medicine-Pulmonology Department, University of Medicine and Pharmacy Craiova, Romania
2 Physiology Department, University of Medicine and Pharmacy “Victor Babes”, Timisoara, Romania
3 Microbiology Department, University of Medicine and Pharmacy of Craiova, Romania

ABSTRACT
Pseudomyxoma peritonei (PMP) constitutes a rare, chronic, relapsing pathological entity with an estimated incidence of 1-2
cases per 10000 laparoscopies (1 case / million / year) characterized by the accumulation of relatively mucous semi-solid
masses in the peritoneal cavity.
Pseudomyxoma peritonei presents a wide spectrum of manifestations, ranging from benign to borderline to malignant.
We present the case of a 49-year-old patient diagnosed four years previous with pseudomyxoma peritonei, admitted to the
Department of Internal Medicine -Pneumology, with dyspnea, fever, physical asthenia, cramp-like abdominal pain, weight loss.
The diagnosis of recurrent pseudomyxoma peritonei has been established following imaging investigations correlated withelevated tumour markers.
Key words: pseudomyxoma peritonei, computed tomography, relapse, ascites

INTRODUCTION
The term of pseudomyxoma peritonei (PMP) was
introduced in 1884, used in relation to a mucinous ovariancarcinoma [1]. In 1901, Frankel [2] described another case,
one associated with a cyst of the appendix. Overall, the term
pseudomyxoma peritonei has been broadly applied toinclude a heterogeneous assembly of pathological lesions,
ranging from benign through borderline to frankly malignant
lesions [3].
Pseudomyxoma Peritonei (PMP) represents a recurrent
chronic clinical entity, with a low frequency, characterized byaccumulation of diffuse intra-abdominal collections of gel(jelly belly) within the peritoneal cavity. This mucin ascites
forms from the secretion of the epithelial implants of the
epiploon and peritoneum, which in most cases originate
from the adenocarcinomas or adenomas of the appendix orthe ovary [4].
Pseudomyxoma peritonei constitutes a tumour, of an
estimated incidence rate of 1-2 million per year [5].
While the cause of the pathology is the production of
mucinous implants and mucin in the abdominal cavity,
involving peritoneal surfaces diffusely, PMP as a whole is apoorly understood disease.
In spite of the abdominal viscera being thickly coatedwith mucus-secreting tumour cells, invasion into extra
peritoneal sites or the substance itself does not occur.

Instead, the abdominopelvic cavities are slowly filled withsemisolid, tenacious, glycoproteins rich neoplastic mucus.
This is often organized into large loculated cystic masses [6].
The exact incidence of pseudomyxoma peritonei remains
speculative. The clinical caseload experience of the UK
national centres (Basingstoke and Manchester), as well as arecent publication from the Netherlands reporting from anationwide pathological/epidemiological database, suggest a
PMP incidence of approximately two per million, per year [7].

CASE REPORT
49-year-old female patient diagnosed three years
previously with pseudomyxoma peritonei, admitted to the
Department of Internal Medicine-Pulmonology with dyspnea,
fever, physical asthenia, cramp-like abdominal pain, weightloss. Symptomatology debuted approximately 10 days
previous, heightened in the 24 hours previous to admission.
From the pathological personal history, we note that in
July 2013 the patient was diagnosed with appendiceal
mucocele and pseudomyxoma peritonei, which prompted
surgical intervention, with appendectomy, bilateralovariectomy and partial omectomy. In 2014, surgicalreintervention was performed with total hysterectomy,
splenectomy and ablation of hepatogastric ligament with

Received 14th of September 2017. Accepted 10th of October 2017. Address for correspondence: Marius Georgescu, MD, PhD, Assistant
Teaching Professor, Department of Functional Sciences, Physiology, Eftimie Murgu Square No. 2A, RO-300041 Timișoara; phone:
0040765527318; e-mail: mgeorgiu83@yahoo.com

Fiziologia - Physiology • 2017.27.2(94)13total omentectomy, followed by intraoperative intraperitoneal
chemotherapy.
On admission, patient appeared to be extremely unwell,presenting the following vital parameters measurements: abody temperature of 38.5 Celsius degrees; a heart rate of
94 beats/minute; oxygen saturation was 93%; respiratory
rate was 17 /minute and blood pressure was 110/70 mmHg.
Physical examination revealed abdominal distension
accompanied by abdominal tenderness, with no palpableorganomegaly or lymphadenopathy. The cardiovascular andrespiratory system investigation did not reveal any
remarkable changes.The remainder of the physicalexamination was normal.
Laboratory investigations performed, including full bloodcount, amylase, liver function tests, urea and electrolytes,
were all within normal limits excepting the elevated whiteblood cells (12 5000/mm3) ,low hemoglobin level (11.4 g/dl)
and high sedimentation rate (79mm). Tumor marker CA19-9
was evaluated and its value was elevated (1240 U/ml).
Thoracic radiography was normal. An abdominal
ultrasonography was performed and revealed perigastric fluid
collection and echogenic foci in ascites in the pelvic cavity.
Based on clinical examination, laboratory analysis, andabdominal ultrasound, at the time of the investigation thefollowing diagnostic suspicions were raised: peritoneal
secondary determinations (peritoneal carcinomatosis) orrecurrent pseudomyxoma peritonei.
Computed tomographic scan of abdomen and pelvis
demonstrated a large epigastric hypoechoic mass withirregular thickening of the gastric wall and other peritoneal
masses with “scalloping effect as well as an iodophil softtissue mass 11mm diameter located in the anterior gastricwall (Figures 1, 2 and 3).
Based on the clinical, biological, imagistic chart, thediagnosis of recurrent pseudomyxoma peritonei has been
established.

Fig. 2. CT scan of abdomen and pelvis showing pseudomyxoma
peritonei with peritoneal masses (arrow) with “scalloping effect.

Fig. 3. Iodophil soft-tissue mass located in the anterior gastric wall(arrow)DISCUSSION

Fig. 1. Abdominal CT scan shows perigastric fluid collection

14

Pseudomyxoma peritonei or jelly belly, is a rare
pathological entity with a reserved prognosis, characterized
by a complete redistribution of mucin in the peritoneal cavity.
Due to the rarity of this disease, the full biological, clinicaland pathogenic behaviour is not fully known [8].
Peritoneal jelly disease occurs with a frequency of 2
cases per 10000 laparoscopies (1 case / million / year) andgenerally affects women with an average age of 53 years,
the ratio of women:men being 2-3: 1 [7].
The origin of PMP is considered to be adenomas or
mucoscrystalline cystic carcinomas of the appendix andovary. [9] Other uncommon starting points can be: uterine
Fiziologia - Physiology • 2017.27.2(94)carcinomas, colon, collage, pancreas, breast, lung, andtesticle. However, the techniques of immunohistochemistry
and molecular genetics tests support the hypothesis that formost women the ovarian tumour is secondary to a
perforated appendicular mucinous tumour [10, 11].
Symptomology is nonspecific; frequently, the disease is
not diagnosed or is confused with other pathologies [12].
The most common symptoms are the progressive increasein abdominal volume, with diffuse abdominal pain. Other
possible symptoms are asthenia, weight gain, nausea,
vomiting, diarrhoea or urinary symptoms. The patient may
present fever, signs of peritoneal irritation with leucocytosis
and / or anemia [13].
Our patient was admitted with fever, physical asthenia,
cramp-like abdominal pain. She also complained ofdyspnoea and weight loss, which are less common
symptoms for this pathological entity.
Physical examination in pseudomyxoma peritonei may
present a bulky abdomen, organomegaly, bilateral or
unilateral ovarian tumours and appendicitis like syndrome[14]. Abdominal distension increases over time, whiledigestive and cardiorespiratory functional disorders develop.
Early stages of the disease are difficult to diagnose, due tothe uncharacteristic symptom for PMP.
The pathology is often accidentally discovered during
CT investigations and ultrasound for non-specific abdominal
symptoms [9, 15].
In our case the patient was already diagnosed withappendicular mucocele and pseudomyxoma peritonei four
years previous, followed by surgical intervention, withappendectomy, bilateral ovariectomy and partial
omentectomy. A year later a second intervention wasnecessary with total hysterectomy, splenectomy andablation of hepatogastric ligament with total omentectomy,
followed by intraoperative intraperitoneal chemotherapy.
Patient presented abdominal distension accompanied
by abdominal tenderness but no palpable organomegaly or
lymphadenopathy was present.
The most frequent investigation for diagnosis is
abdominal ultrasonography, in which case commuted
tomography – the gold standard – can be used to establish
the extent of disease. Moreover, the levels of tumourmarkers such as CA 19-9 and CEA can be used to establish
prognosis [14]. The patient may also present leucocytosis
and / or anaemia [13].
Laboratory investigations were assessed and revealed
leucocytosis, anemia, high sedimentation rate and elevatedtumor marker CA19-9.
CT and ultrasonography have been reported to be
helpful in detecting pseudomyxoma peritonei [9, 15]. While
computed tomography remains the gold standard for
diagnostic imaging, abdominal ultrasonography is lowpriced, available in most cases, well tolerated, and canidentify most common PMP findings such as ascites andomental caking. Computed tomography shows the following
patterns: posterior displacement of the intestines; diffuse
Fiziologia - Physiology • 2017.27.2(94)peritoneal infiltration appearing similar to ascites;
intrahepatic low density attenuated lesions; and (4)scalloping of intra-abdominal organs, especially the liver andthe spleen [16].
Both investigations were performed on our patient.
Abdominal ultrasonography revealed perigastric fluid
collection, echogenic foci in ascites in the pelvic cavity. CT
scan of the abdomen and pelvis indicated a large epigastrichypoechoic mass with irregular thickening of the gastric walland other peritoneal masses with “scalloping effect’’ of theliver as well as an iodophil soft-tissue mass 11mm diameter
located in the anterior gastric wall.
A treatment strategy for PMP should pursue complete
cytoreduction and prevention of recurrence or progression.
Mayo Clinic, Gough DB reported that chemotherapy can
improve survival only if administered intraperitoneally [17].
Systemic chemotherapy does not appear to affect prognosis[18].
In the presented case, the patient had been previously
diagnosed with appendicular mucocele and pseudomyxoma
peritonei. A complete cytoreduction was performed followed
by intraoperative intraperitoneal chemotherapy, howeverafter four years pseudomyxoma peritonei relapsed.
In general, surgical reintervention is difficult to perform
due to adhesions and fibrosis greatly increasing the risk ofunintentional enterotomies, with subsequent formation offistulae and leaks [19]. Our patient refused a third looksurgery.

CONCLUSION
We have described a female patient who developed
PMP, a heterogeneous and rare condition as a result ofappendiceal tumours and who underwent complete
cytoreduction
andintraoperative
intraperitoneal
chemotherapy. After four years relapse of thepseudomyxoma peritonei occurred. Surgery is the election
treatment for pseudomyxoma peritonei, although total
resection is rarely possible. Because of the low morbidity
and slow growth of the tumour, reintervention is indicated for
symptoms of recurrence.

REFERENCES
1. Werth R. Pseudomyxoma peritonei. Arch Gynaecol. 1884, 24:
100-118.
2. Frankel E. Uher das sogenaute pseudomyxoma peritonei.
Med Wochenschr. 1901;48:965-970.
3. Bryant J, Clegg AJ, Sidhu MK, Brodin H, Royle P, Davidson P.
Systematic review of the Sugarbaker procedure forpseudomyxoma peritonei. Br J Surg. 2005;92(2):153-158.
4. Ronnett BM, Zahn CM, Kurman RJ, Kass ME, Sugarbaker PH,
Shmookler BM. Disseminated peritoneal adenomucinosis andperitoneal mucinous carcinomatosis. A clinicopathologic
analysis of 109 cases with emphasis on distinguishing15

pathologic features, site of origin, prognosis, and relationshipto “pseudomyxoma peritonei.” Am J Surg Pathol.
1995;19(12):1390-1408.
5. Bevan KE, Mohamed F, Moran BJ. Pseudomyxoma peritonei.
World J Gastrointest Oncol. 2010;2(1):44-50.
6. Gupta S, Singh G, Gupta A, et al. Pseudomyxoma peritonei:
An uncommon tumor. Indian J Med Paediatr Oncol.
2010;31(2):58-61.
7. Loungnarath R, Causeret S, Bossard N, Faheez M, SayagBeaujard AC, Brigand C, Gilly F, Glehen O. Cytoreductive
surgery with intraperitoneal chemohyperthermia for thetreatment of pseudomyxoma peritonei: a prospective study.
Dis Colon Rectum. 2005;48:1372-1379.
8. Qu Z, Liu L (2006) Management of pseudomyxoma peritonei.
World J Gastroenterol 12 (38): 6124-6127.
9. Sugarbaker PH, Ronnett BM, Archer A, Averbach AM, Bland
R, Chang D, et al. Pseudomyxoma peritonei syndrome. Adv
Surg. 1996;30:233–280.
10. Ronnett BM, Zahn CM, Kurman RJ, Kass ME, Sugarbaker PH,
Shmookler BM. Disseminated peritoneal adenomucinosis andperitoneal mucinous carcinomatosis. A clinicopathologic
analysis of 109 cases with emphasis on distinguishingpathologic features, site of origin, prognosis, and relationshipto “pseudomyxoma peritonei”. Am J Surg Pathol.
1995;19:1390-1408.
11. Smeenk RM, van Velthuysen ML, Verwaal VJ, Zoetmulder FA.
Appendiceal neoplasms and pseudomyxoma peritonei: apopulation based study. Eur J Surg Oncol. 2008;34:196-201.

12. Järvinen P, Lepistö A. Clinical presentation of pseudomyxoma
peritonei. Scand J Surg. 2019;9(4):213-216.
13. Meshikhes AW, Al-Abkari HA, Al-Momen SA, Saad FE.
Pseudomyxoma peritonei. Saudi Med J. 2006;27(3):389-391.
14. Touloumis Z, Galyfos G, Kavouras N, Menis M, Lavant L.
Aggressive Pseudomyxoma Peritonei: A Case Report with an
Unusual Clinical Presentation. Case Reports in Oncological
Medicine. 2013;10:69-73.
15. Bechtold RE, Chen MY, Loggie BW, Jackson SL, Geisinger K.
CT appearance of disseminated peritoneal adenomucinosis.
Abdom Imaging. 2001;26:406-410.
16. Lawate PS, Singh SP, Jasper MP, et al. Computed tomography
and sonographic features of pseudomyxoma peritonei. AJR
Am J Roentgenol 1989;152:429.
17. Gough DB, Donohue JH, Schutt AJ, et al. Pseudomyxoma
peritonei. Long-term patient survival with an aggressive
regional approach. Ann Surg. 1994;219(2):112-119.
18. Kojimahara T, Nakahara K, Shoji T, et al. Identifying prognostic
factors in Japanese women with pseudomyxoma peritonei: aretrospective clinico-pathological study of the Tohoku
Gynecologic Cancer Unit. Tohoku J Exp Med. 2011;223(2):9196.
19. Al-Buainain H, Al-Jehani Y, Moghazy K, Al-Quorain A.
Psuedomyxoma peritonei secondary to adenocarcinoma of
the cecum. J Family Community Med. 2010;17(2):103-106.

PSEUDOMIXOM PERITONEAL RECIDIVAT.
PREZENTARE DE CAZ
REZUMAT
Pseudomixomul peritoneal (PMP) este o entitate patologica rara, cronica, recidivanta cu o incidenţă estimată de 1-2
cazuri la 10000 laparoscopii (1 caz/million/an) caracterizată prin acumularea unor mase semisolide mucinoase relativ
transparente în cavitatea peritoneală.
Pseudomixomul peritoneal îmbracă un spectru larg de manifestari, de la benigne la cele ‘’la limită’’ (borderline) şi până lacele maligne.
Prezentam cazul unei paciente in varsta de 49 de ani , diagnosticata in urma cu patru ani cu pseudomixom peritoneal, carese prezinta in Departamentul de Medicina Interna -Pneumologie, acuzand, dispnee, febra astenie fizica, dureri abdominale
difuze, scadere ponderala.
In urma investigatiilor imagistice corelate cu valori crescute ale markerilor tumorali s-a stabilit diagnosticul de pseudomixom
peritoneal recidivat.
Cuvinte cheie: pseudomixom peritoneal, computer tomograf, recidiva, ascita

16

Fiziologia - Physiology • 2017.27.2(94)DIAGNOSTIC PERFORMANCE OF STRAIN
ELASTOGRAPHY FOR THYROID NODULESMARIA-CRISTINA OPREA1,2, LAZAR FULGER3
1 Victor Babes University of Medicine and Pharmacy Timisoara, Endocrinology Department
2 Korall Clinic Satu-Mare
3 Pius Brinzeu County Clinical Emergency Hospital Timisoara, 2nd Surgery Clinic

ABSTRACT
Thyroid disorders are common and are associated with levels of thyroid-stimulating hormone and iodine availability. Thyroid
nodules are among the most prevalent thyroid conditions detected in 50% to 60% of healthy people. Most thyroid nodules
are benign, with less than 5% cancerous lesions, and the challenge for clinicians is to accurately discriminate between
benign disease and malignancies. US elastography is a recent technique currently used in combination with B-mode
ultrasound and is able to provide useful information for the differentiation of benign and malignant nodules based on tissue
stiffness/elasticity.
We have analysed 44 thyroid nodules (31 benign, 13 malignant) assessed by means of conventional and Doppler
ultrasound, as well as by strain elastography. The ultrasound and strain elastography studies were performed during asingle procedure on the same equipment. At conventional ultrasound, except for the presence of halo sign, all the otherfeatures (margins, echogenicity, homogeneity, microcalcifications and transonic areas) considered to be predictive ofmalignancy reached statistical significance. The blood flow assessed by the means of colour-flow Doppler also reachedstatistical significance.
Strain ratios were recorded for each nodule, with a mean strain ratio value of 1.55 in the benign nodule group and 3.42 in
the malignant nodule group and the results obtained at strain elastography were compared with the blinded histologicaldiagnosis. The diagnostic performance of strain elastography proved to be high, with 92.3% sensitivity, 67.7% specificity,
100% positive predictive value and 88.57% negative predictive value, thus being a reliable tool in the differentiation of
benign and malignant thyroid nodules.
Keywords: strain elastography, thyroid nodule, thyroid cancer

INTRODUCTION
Thyroid gland is central to metabolic processes, but its
structure and function can be affected by various conditions,such as hypo- or hyperthyroidism, goiter, nodules, thyroiditis
or cancer. In fact, thyroid disorders are common and areassociated with levels of thyroid-stimulating hormone (TSH),
being linked with iodine availability, so that goiter isprevalent where iodine is scarce, while autoimmune thyroid
conditions are frequent in iodine-replete areas [1]. A recent
meta-analysis [2] of studies conducted in Europe between
1975 and 2012 has calculated a mean prevalence of total
thyroid dysfunction of 3.82% and an incidence of
259.12/100,000/year, whereas the mean prevalence of
undiagnosed thyroid dysfunction was estimated to be as
high as 6.71%.
While low TSH levels are seen in people withhyperthyroidism and elevated levels in those withhypothyroidism, goiter and thyroid nodules are present inboth settings. Thyroid nodules are among the mostprevalent thyroid conditions detected in 50% to 60% of
healthy people [3] and their formation is caused by either
their fail or their ability to synthesize thyroid hormones
regardless of the TSH level. Most thyroid nodules are
benign, with less than 5% cancerous lesions, and thechallenge for clinicians is to accurately discriminate between
benign disease and malignancies. This is important not only
for the timely diagnosis of cancer, but also to prevent
overtreatment of benign thyroid nodules. During the last two
decades, an increased incidence of thyroid cancer has beenrecorded, so that the estimated worldwide incidence forthyroid cancer in 2012 was 300,000 new cases, out of whichmore than 1/3 were found in women [4]. This increased
incidence is mainly due to the improved detection by new
thyroid and neck ultrasound techniques, which madepossible the detection of nodules as small as 0.2 cm [5,6].

Received 15th of August 2017. Accepted 10th of October 2017. Address for correspondence: Oprea Maria Cristina, Endocrinology
Department, „Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square No. 2A, RO-300041, Timisoara,
Romania; e-mail: mary_mignona@yahoo.com

Fiziologia - Physiology • 2017.27.2(94)17Diagnosis of thyroid masses includes clinicalexamination, laboratory tests, fine needle aspiration biopsy(FNAB) and various imaging techniques. Ultrasound (US),measurement of TSH levels and FNAB are the mainelements in the management of thyroid nodules [3].
Ultrasound has very good performance in the detection of
thyroid nodules, but its ability to discriminate between
benign and malignant masses is limited [7,8]. FNAB istherefore recommended for nodules larger than 10 mm andfor those with suspicious US features, although its
diagnostic value is also limited as up to 30% of results areeither non-diagnostic or indeterminate [9,10].
US elastography is a recent technique currently used in
combination with B-mode ultrasound and is able to provide
useful information for the differentiation of benign andmalignant nodules based on tissue stiffness/elasticity[11,12]. Thus, by using a compression force, elastographic
techniques enable the assessment of tissue elasticity bymeasuring the degree of tissue displacement [13], so that
hard or firm nodules are associated with a higher risk ofmalignancy [3].
After reporting on our results using shear-wave
elastography [14], we here describe the results obtained ona series of 44 patients with suspicious thyroid nodules who
underwent strain elastography.

flow Doppler and classified into intranodular, perinodular,
intra- and perinodular or absent blood flow. Lastly, we have
performed strain elastography, by applying a slight pressure
with the hand-held transducer, while the system produced acolor-coded image superimposed on the B-mode image,with the images separately displayed on two screens. The
region of interest was selected so that to comprise thenodule and a large part of the surrounding thyroid tissue.
The qualitative assessment of nodule elasticity provides
information on tissue strain and is displayed as a continuumof colors (red-green-blue), with blue for stiff tissue and redfor soft tissue. The semiquantitative assessment consists inthe characterization by strain ratio, which is calculated as
the ratio of strains in the lesion to that of the surrounding
parenchyma.

MATERIALS AND METHODSRESULTS

NodulesThis retrospective study included 44 nodules found in 31
patients (28 women and 3 men), mean age 52.3 years (min.
17 years, max. 70 years) seen from August 2016 to
September 2017 in the Korall Clinic in Satu Mare. All thepatients underwent surgery and the final blindedhistopathologic diagnosis performed on the excised thyroid
tissue served as reference standard. We have included
solitary thyroid nodules or multinodular goiter examined bymeans of elastography, as well as conventional and Doppler
ultrasound. The inclusion criterion was the availability ofhistopathological diagnosis after surgery.
We have recorded the following patient data: gender,
age, weight, thyroid volume, nodule localization and sizes,
US features, elastographic score and histological diagnosisof the excised nodules.

Histology
All patients underwent surgical treatment consisting ineither lobectomy or total thyroidectomy. After surgery,histopathologic diagnosis was performed by a pathologist
who was blinded regarding the elastography findings. A
histological diagnosis of malignancy was made in 13
nodules (29.5%), out of which 4 were classical papillarycarcinomas, 2 papillary-follicular, 6 microcarcinomas and 1
medullary carcinoma. These malignant nodules were foundin 10 patients (7 women and 3 men), six being located in theleft lobe and seven in the right lobe. The majority (n=27,87%) of the 31 benign masses (70.5%) presented as simple
or multinodular goiter, 2 were colloid goiters, 1 Hürthle celladenoma and 1 chronic autoimmune thyroiditis, out of which
18 were found in the right lobe, 12 in the left lobe and one in
the isthmus.

Equipment and method
Strain elastography was performed by means of an SIUI
ultrasound system (Shantou Institute of Ultrasonic
Instruments Co., Ltd., China), Apogee 1200 model, using an
8 MHz 50 mm linear transducer. We have first assessed thesonographic features of the nodules by conventional
ultrasound, namely nodule number and sizes, aspect ofmargins, echogenicity, homogeneity, and presence of halo
sign, microcalcifications and transonic areas inside nodules.
Afterwards, the blood flow was evaluated by means of color-

UltrasoundDuring the conventional US examination, we haverecorded nodule length, width and thickness for all masses,
the mean values of each revealing no statistically significant
differences between malignant and benign nodules. On thecontrary, except for the presence of halo sign, all the otherfeatures considered to be predictive of malignancy reachedstatistical significance: margins (p = 0.000), echogenicity (p= 0.002), homogeneity (p = 0.057), microcalcifications (p =0.009) and transonic areas (p = 0.031). Then, we have

18

Statistical Analysis
The statistical analysis was performed using Statistical
Package for the Social Sciences (SPSS) programme(version 17.0 for Windows, SPSS Inc., Chicago, Illinois,
USA). We split the 44 nodules in two groups, malignant (13nodules, 29.5%) and benign (31 nodules, 70.5%). All data
were compared using a chi square test, with a p-value <0.05
considered to be statistically significant. Histologicaldiagnosis served as reference standard.

Fiziologia - Physiology • 2017.27.2(94)assessed the blood flow by the means of colour-flow
Doppler US and found statistically significant differences
between the two groups at a p-value of 0.049.
Strain elastography
The concept of elastography was first demonstrated by
Ophir et al. [15] in 1991 and became an important diagnostic
tool used to assess the elasticity of various tissues in the body,relying on the principle that an externally applied compression
leads to tissue deformation, which is smaller in hard tissues.
The first type of elastographic technique introduced in clinicalpractice was strain elastography. Based on the assessmentof tissue displacement, strain elastography is able todifferentiate benign from malignant masses, providing an
objective evaluation of tissue stiffness/elasticity. We haveassessed the elasticity of nodules qualitatively, on the colorcoded image, and quantitatively, by recording the strain ratios.
First method relies on the visual evaluation of the colors
displayed on the screen.
We here report on the results of the second method. We
have drawn two regions of interest, one comprising theentire nodule and the second including a significant portionof the adjacent thyroid tissue, which was the reference
region. Then, the system automatically calculated anddisplayed the parenchyma-to-nodule strain ratios, i.e. themean strain in the normal thyroid parenchyma divided by themean strain in the thyroid nodule. With the patient in supine
position with the neck extended, the transducer wastransversally placed on the thyroid and we assessed eachlesion three to five times. The procedure took up to 8
minutes per patient.
The strain ratios ranged from 0.8 to 4 in the entire groupof patients. The mean strain ratio value was 1.55 (lowest
value 0.8; largest value 2.7) in the benign nodule group and3.42 in the malignant nodule group (lowest value 1.8; largest
value 4). Table I shows the distribution of nodules by thestrain ratios, where values greater than 2 were considered
to be suggestive of malignancy.
Table I. Strain ratios in the two groups
Strainratio

Benign nodules
Patients,n (%)<1
6 (19.5%)>1
23 (74.1%)>2
2 (6.4%)

Strainratio

Malignant nodules
Patients,n (%)>2
2 (15.4%)>3
8 (61.5%)
4
3 (23.1%)

After the histological diagnosis was available, we
compared our results with those obtained on histology andconcluded that two lesions (one multinodular goiter in thesetting of chronic autoimmune thyroiditis and Hürthle celladenoma) were misclassified, having strain ratios of 2.7 and3, respectively. The higher strain ratios may be explained in
the first case by the presence of autoimmune thyroiditis,known to cause greater tissue stiffness, and by the
Fiziologia - Physiology • 2017.27.2(94)microcalcifications present in the nodule diagnosed as
Hürthle cell adenoma.
However, this did not elicit a significant impact on the study,
and the diagnostic performance of strain elastography proved
to be high, with 92.3% sensitivity, 67.7% specificity, 100%
positive predictive value and 88.57% negative predictive
value. We found a strain ratio 2 to be the best cut-off value(area under the curve of 0.968), as obtained with receiver
operating characteristic (ROC) curve analysis (Fig. 1).

Fig. 1. ROC curve for strain elastography

DISCUSSIONS AND CONCLUSION
Strain elastography relies on the measurement of tissue
elasticity and provides valuable information, in addition to
those obtained by conventional ultrasound. Current
guidelines [3,8,16] state US features considered suggestiveof malignancy are not enough sensitive, nor specific to allow
detection of all malignant nodules. Instead, elastography
has been proved to be a promising diagnostic tool, althoughfurther studies are needed to validate it.
Various studies on the use of strain elastography indifferentiating benign from malignant thyroid nodules
reported this method may predict malignancy with very good
specificity and sensitivity. Among the pioneering studies,
Lyshchik et al.[17] showed that off-line processed
elastograms with a strain index above 4 was the strongest
predictor of malignancy, exhibiting 96% specificity and 82%
sensitivity. At the time, however, the criteria (margin
regularity and tumor area ratio) used for real-timeelastographic images, although showing high specificities,
had low sensitivities. Only two years after, Rago et al.[12]used the elasticity score for thyroid nodule elastography andconcluded that scores 4 to 5 were highly predictive ofmalignancy, with 97% sensitivity, 100% specificity andpositive predictive value, an 98% negative predictive value.
19

The semiquantitative approach was also proved to beaccurate in diagnosing malignant thyroid nodules, as shownby the study of Cantisani et al.[18] who reported 93%
sensitivity, 89% specificity, 82% PPV and 94% NPV. The
authors concluded that a strain ratio greater than 2 should
prompt further investigation. Another study [19] that
intended to assess the clinical value of strain ratio, as
compared with the elasticity score, found 81% sensitivity
and 83% specificity for the former. Similar to these studies,
our retrospective analysis shows that a strain ratio scoreabove 2 is highly predictive of malignancy, with 92.3%
sensitivity, 67.7% specificity, 100% positive predictive value
and 88.57% negative predictive value. In our study, theresults obtained at elastography also correlated withfindings on conventional and color-flow Doppler ultrasound.
In spite of the two false positive results we found, which
may be explained by the presence of thyroid pathologies
that cause greater tissue stiffness, in this study all
malignancies were correctly diagnosed. In conclusion, strain
elastography is a reliable tool for diagnosing malignant
thyroid nodules, given that an accurate diagnosis is critical
for timely, effective therapy.

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Paschke R, Valcavi R, Vitti P. American Association of Clinical
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M, Parkin DM, Forman D, Bray F. Cancer incidence and mortality
worldwide: sources, methods and major patterns in GLOBOCAN
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5. Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging
has increased detection and treatment of low risk tumours. BMJ
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6. Vecchia C, Malvezzi M, Bosetti C, Garavello W, Bertuccio P, Levi
F, Negri E. Thyroid cancer mortality and incidence: a global
overview. International Journal of Cancer. 2015;136(9):2187-95.

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7. Moon HG, Jung EJ, Park ST, Ha WS, Choi SK, Hong SC, Lee YJ,
Joo YT, Jeong CY, Choi DS, Ryoo JW. Role of ultrasonography inpredicting malignancy in patients with thyroid nodules. World
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SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman
SI. Revised American Thyroid Association management
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Thyroid. 2009;19(11):1167-214.
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12. Rago T, Santini F, Scutari M, Pinchera A, Vitti P. Elastography:
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Fiziologia - Physiology • 2017.27.2(94)PERFORMANȚA DIAGNOSTICĂ A ELASTOGRAFIEISTRAIN PENTRU NODULII TIROIDIENIREZUMAT
Tulburările glandei tiroide sunt frecvente și se asociază cu nivelurile hormonului de stimulare tiroidiană și cu disponibilitatea
iodului. Nodulii tiroidieni se numără printre bolile tiroidiene cu cea mai mare prevalență, fiind detectați la 50% - 60% dintre
persoanele sănătoase. Majoritatea nodulilor tiroidieni sunt benigni, mai puțin de 5% fiind maligni, iar disciminarea cu
precizie între boala benignă și cancer reprezintă o provocare pentru clinicieni. Elastografia este o tehnică recentă, utilizată
în prezent împreună cu ecografia în mod B, oferind informații utile pentru diferențierea între nodulii benigni și cei maligni
pe baza durității / elasticității țesutului.
Am analizat 44 de noduli tiroidieni (31 benigni, 13 maligni) prin ecografie convențională și Doppler, precum și prinelastografie. Studiile ecografice și elastografice de tip strain au fost realizate în cursul unei singure proceduri, utilizândacelași echipament. La ecografia convențională, cu excepția prezenței haloului, toate celelalte caracteristici (contur,
ecogenitate, omogenitate, microcalcificări și zone transonice) considerate sugestive pentru malignitate au avut semnificație
statistică. Fluxul sangvin, evaluat prin examen Doppler vascular, s-a dovedit, de asemenea, semnificativ din punct devedere statistic.
Scorurile cantitative (strain ratios) au fost înregistrate pentru fiecare nodul, cu o valoare medie de 1.55 în grupul nodulilor
benigni și 3.42 în cel al nodulilor maligni, iar rezultatele obținute la elastografia strain au fost comparate cu diagnosticul
histopatologic realizat de un anatomo-patolog care nu cunoștea rezultatele investigațiilor imagistice. Performanța
diagnostică a elastografiei strain s-a dovedit a fi foarte bună, cu sensibilitatea de 92.3%, specificitatea 67.7%, valoarea
predicitvă pozitivă 100% și valoarea predictivă negativă 88.57%, fiind, așadar, un instrument valoros în diferențierea
nodulilor tiroidieni benigni de cei maligni.
Cuvinte cheie: elastografie strain, nodul tiroidian, cancer tiroidian

Fiziologia - Physiology • 2017.27.2(94)21THE GLOBAL SOCIAL FUNCTIONING OF PATIENTSWITH BIPOLAR AFFECTIVE DISORDER WITH
FIRST-RANK SYMPTOMSRIVIȘ IOANA-ALEXANDRA1, BARBOIANU RUXANDRA1, HOMOROGAN CLAUDIA1,
ROMOȘAN ANA-MARIA1, PAPAVĂ ION2, HOGEA LAVINIA MARIA3, BREDICEAN ANACRISTINA2
1Timișoara County Emergency Clinical Hospital “Pius Brînzeu”, Psychiatry Clinic “Eduard Pamfil”
2Victor Babeș University of Medicine and Pharmacy Timișoara, Timișoara County Emergency Clinical Hospital “Pius Brînzeu”, Psychiatry

Clinic “Eduard Pamfil”
3Victor Babeș University of Medicine and Pharmacy Timișoara, Discipline of Psychology, Department of Neurosciences

ABSTRACTIntroduction. One important factor that must be taken into consideration when talking about a patient’s quality of life, isthe degree of social functioning. Our patients` social functioning represents a topic of maximum interest for the psychiatry
specialists, the patients and for their family.
Objectives. This study serves the purpose of evaluating the global social functioning, the marital status, as well as theprofessional life of patients diagnosed with Bipolar Affective Disorder (BAD).
Material and methods.We have analyzed a group of 34 patients diagnosed with BAD, who had a continuity in diagnosisof over 9 years.
We have applied the Global Assessment of Functioning Scale (GAFS) to patients in remission during their last visit in theoutpatient ambulatory system.
Results. We have obtained significant differences between the marital status at the debut of the disorder and the one
reported during the last hospital admission (p=0.19).
Also, there were significant differences between the professional status reported during the first episodes of BAD and theone reported during the last hospital admission (p=0.000).
The GAFS reported statistical significant differences between the two sexes (p=0.033).
There were no evidences to support the fact that the presence of FRS (first-rank symptoms) might directly influence apatients social functioning, marital status or professional status.

INTRODUCTION
Differentiation between the psychosis from bipolar
affective disorder, schizophrenia and schizoaffective disorder
has always been somewhat of a challenge for any psychiatry
clinician. Kurt Schneider was concerned with elaborating aseries of criteria in order to improve the methods of diagnosis
in psychiatry. He discovered that a number of symptoms aremost often found in schizophrenia; we know them today as
Schneiderian first-rank symptoms (FRS).
Even though experience has taught us that FRS are notpathognomonic for schizophrenia and can appear in any
psychotic episode, this topic represents a permanent issueof maximum interest amongst psychiatry specialists.

The purpose of this study is to determine if the presence of
FRS at a patient with Bipolar Affective Disorder affects thelong-term prognosis and the quality of life from a
professional, social and personal point of view. We have
tried to limit ourselves to a specific First-Rank Symptom(transparence-influence) and see how the presence of thissymptom has affected the life and evolution of a patient.

MATERIAL AND METHOD
A number of 34 patients with bipolar affective disorderwere admitted in this study. The cases presented in thisstudy have had a continuity in diagnosis of over 9 years anda long-term evolution, also over 9 years.

Received 12th of August 2017. Accepted 15th of September 2017. Address for correspondence: Claudia Homorogan, MD, Emergency Clinical
Hospital “Pius Brînzeu” Timisoara, Liviu Rebreanu Bd. 156, Timisoara, RO-300723, Psychiatry Clinic “Eduard Pamfil” Timișoara; phone: 0746160322; e-mail: claudiah_15@yahoo.com

22

Fiziologia - Physiology • 2017.27.2(94)All the patients in this study have had psychotic
episodes at least once throughout the evolution of thedisorder. 20 patients have had FRS at least once during
the evolution of the disorder, without having the diagnosischanged and the other 20, have never had FRS. The data
was collected from the cases Registry in The Psychiatric
Clinic of Timisoara, from the patients’ medical records,
from interviews that took place between years 1978 and2016.
Criteria for inclusion:
1. Patients diagnosed with Bipolar Affective Disorder,
according to the ICD-10 criteria, with an evolutionof at least 9 years with this diagnosis.
2. Patients that have been and still are under
medical supervision through the psychiatricambulatory system in Timisoara from onset until
present time.
3. Patients that have had at least one psychotic
episode since first diagnosed until present.
Criteria for exclusion:
1. History of substance abuse.
2. The presence of another psychiatric pathology.
We collected socio-demographical data, age of onset,
family history of psychiatric disorders, number ofadmittances in the hospital, level of education, marital status
and applied the GAFS during the last visit in the ambulatory
system.
The cases have been divided into two groups:a) Group A included 17 patients who presented FRS
during at least one psychotic episode.
b) Group B involved a number of 17 patients who
have never presented FRS.
The data has been processed in SPSS, using nonparametric tests, seeing as the data does not respect thenormal distribution condition required for parametric tests.

Fig. 1. Age of onset of the disorder (entire group)

The average age of onset of the disease, amongst out
patients is 28.56, as shown below (Table I).
Table I. Age of onset
Age of onset
Mean
28.56

N
34

Std. Deviation
9.365

The further analysis of the age of onset in group A(patients who have presented TI throughout the evolution of
the disorder) has revealed that a percentage of 11.76% have
had the debut of the disorder between 30-35 years old andover 35 years.
Equal percentages (29.41%) have had the debut of thedisorder between 15 and 20 years old and 25-30 years ofage. 17,65% have had the first episode during 20 and 25
years old (Figure 2).

RESULTSThe group included into the study is composed of 9 men
and 25 female patients that have had a period of evolutionof the Bipolar Affective Disorder of 9 or more years.
Out of the total of 34 patients, an equal percentage ofpatients (23.53%) have had the age of onset between 1520 years and over 35 years. A percentage of 17.65 have had
a debut of the disorder between 20-25 years, 26.47% ofthem, between 25 and 30 years. A small percentage (8.82%)
have had the debut of the disorder between 30 and 35 years
old (Figure 1).
Fig. 2. Age of onset of the disorder in group A (patients who
presented TI).

Fiziologia - Physiology • 2017.27.2(94)23

As for group B (patients who have never presented TI),
an equal percentage of 17.65 have had their first symptoms
appear between the ages of 15-20 years and between 2025 years of age. 23.53% have had their debut of the disorder
between the ages of 25-30 years old, 5.88% between 30-35
years old and 35.29% over the age of 35 (Figure 3).

Also at the debut, a percentage of 8.82 were divorced,
whereas now, 32.35% of the patients are divorced or
separated.
While discussing the professional status, the one declaredby the patient at his first episode of BAD, compared to theprofessional status established during the last admission, there
were highly significant differences (p=0.000).

DISCUSSION

Fig. 3. Age of onset of the disorder in group B (patients who havenever presented TI)

We have also established the types of episodes
presented most often by the 34 patients included in our study.
Equal percentages, of 17.65% have has most often
depressive episodes and manic episodes with psychotic
symptoms. A majority of 38.24% have had mostly manic
episodes without psychotic symptoms and 26.47%, mixed
episodes.
In group A, a majority of 35.29% have had mostly manic
episodes with psychotic symptoms, equal percentages of
23.53 have presented most often depressive episodes andmanic episodes and 17.65% mixed episodes.
As for the patients included in group B, a majority of
52.94% have had most often manic episodes without
psychotic symptoms, 35.29% have had mostly mixed
episodes and a percentage of 17.76 have had mostly
depressive episodes without psychotic symptoms.
There have been no significant differences between thetwo groups regarding the number of episodes which neededhospital admission.
We compared the GAFS scores between the two sexes,
obtaining significant differences (p=0.033, 2-tailed). The
same GAFS scores showed no significant differences whencomparing the two groups, A and B.
As for the marital status reported at the debut of thedisorder, compared to the one declared during the lasthospital admission, we have detected a statisticalsignificance (p=0.011). If at the debut of the disorder55.88% of the patients were married, when last evaluated,
after 9 or more years of BAD, only 44.12% remain married.
24

The presence or absence of FRS in patients with BAD,
evidently has a serious impact on both the patient and on
the immediate family members, even though it may notdirectly influence the patients` personal, professional lifeand his overall ability to function well in a society.
What we have established with certainty is that patientswith BAD suffer from a severe alteration of their social,professional and personal life because of this specificdisorder. Taking into consideration that this is a chronic
disorder, focusing on these particular aspects starting fromthe first episode, might have a significant long-term impact.
This study is not without limitations, taking into
consideration that we have been able to select only a small
number of patients, for which we have had accurate andprecise information.

REFRENCES
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Relationship between Cognitive Decline and Psychopathology

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VA: American Psychiatric Association.

FUNCȚIONAREA SOCIALĂ GLOBALĂ
A PACIENȚILOR CU TULBURARE AFECTIVĂBIPOLARĂ CU SIMPTOME DE PRIM RANGREZUMAT
Introducere. Un factor important care trebuie luat în considerare când vorbim despre calitatea vieții pacienților este gradulde funcționare socială. Funcționarea socială a pacientului reprezintă un subiect de interes maxim pentru medicii psihiatri,pentru pacienți și pentru familiile acestora.
Obiective. Acest studiu este destinat evaluării funcționării sociale globale, statusului marital, precum și al vieții profesionalea pacienților diagnosticați cu tulburare afectivă bipolară (Bipolar Affective Disorder - BAD).
Materiale și metode. Am analizat un grup de 34 de pacienți diagnosticați cu BAD, care au avut o continuitate în
diagnosticare de mai mult de 9 ani. Am aplicat testul de evaluare globală a scării funcționale (Global Assessment of
Functioning Scale - GAFS) la pacienții aflați în remisiune, în timpul ultimei vizite în ambulatorul de specialitate.
Rezultate. Am obținut diferențe semnificative în ceea ce privește statusul marital al pacienților la debutul afecțiunii și celraportat la ultima internare spitalicească (p=0.19). De asemenea, au existat diferențe semnificative între statusul profesionalla debutul primelor episoade de BAD și cel raportat la ultima internare în spital (p=0.000). Testul GAFS a relevat diferențe
semnificative între cele două sexe (p=0.033).
Nu au existat dovezi referitoare la faptul că simptomele de prim rang (first-rank symptoms - FRS) ar putea influența directfuncționarea socială a pacientului, statusul marital sau profesional.

Fiziologia - Physiology • 2017.27.2(94)25

SYSTOLIC LEFT VENTRICULAR FUNCTIONEVALUATED WITH TWO DIMENSIONAL AND THREEDIMENSIONAL SPECKLE TRACKINGECHOCARDIOGRAPHY IN ELITE RUGBY PLAYERS
IRINA POPESCU1,2, SILVIA MANCAS1,2, IOAN SERBESCU3, CRISTIAN MORNOS1,2,
ADINA IONAC1,2
1 Institute of Cardiovascular Diseases Timisoara, Romania
2 ʺVictor Babesʺ University of Medicine and Pharmacy Timisoara, Romania
3 County Hospital, Sportive Medicine Ambulatory, Timisoara, Romania

ABSTRACT
Background: The athlete’s heart is associated with physiological adaptation remodeling due to effort training protocols.
These effects on left ventricular (LV) strain were equivocal and the results in literature are controversial. The aim of ourstudy was to evaluate LV systolic deformation in elite rugby players using two new echocardiographic methods: twodimensional (2D) speckle tracking method and three-dimensional speckle tracking echocardiography ( 3D STE).
Methods: 26 male rugby players underwent standard 2D and 3D echocardiography at rest. LV global systolic longitudinalstrain (GLS) was assessed by speckle tracking methods using both 2D and 3D echocardiography.
Results: We found statistically significant positive correlations between 2D GLS and interventricular septum thickness(IVST), posterior wall thickness (PWT), 3D GLS (p<0.05, r<0.75) and negative correlation with mitral and tricuspid annularsystolic excursion (MAPSE) (p=0.034), respectively TAPSE (p=0.041). Also a negative correlation was detected with 3D
ejection fraction (EF) (p=0.016).
We also found a significant positive correlation between 3D GLS and body mass index (BMI) (p=0.032), A’lat velocity of
mitral annulus (p=0.049), 2D GLS (p=0.006) and a negative correlation with E velocity of mitral inflow (p=0.03), E’ lat andE ‘ med velocity of mitral annulus (p=0.002, respectively p<0.001), 3D EF (p=0.04), the strongest correlation being with
E’ med (p<0,001, r= -0.816). By linear regression analyses, 3D GLS was independently associated with E’ med, E’ lat
and 2D GLS, adjusted value of R square coefficient showing that 76% of the 3D GLS variability can be predicted by thevariation of the independent variables included in the model.
Conclusions: 2D and 3D STE are new and feasible technique for assessing LV myocardial deformation in athletes. We
concluded that athletes with the highest LV physiological hypertrophy had the most increased longitudinal systolic function,in opposite with hypertensive patients with pathological LV hypertrophy, where 2D GLS was found significantly decreased.
Keywords: athlete, speckle tracking, strain, systolic left ventricular function.

INTRODUCTION
New echocardiographic techniques such as Speckle
tracking and three-dimensional (3D) echocardiography havealready demonstrated an important role in evaluation of left
ventricular (LV) systolic and diastolic function in elite
athletes [1-4]. Physiological LV hypertrophy in athlete’s
heart is a complex adaptive mechanism, a response of theheart to intense effort training programs. It is well known that
endurance training protocols in athletes (aerobe sports)
increases LV volumes (eccentric hypertrophy) and strength
efforts (anaerobe sports) predominantly increases LV wall

thickness (concentric hypertrophy). In real life, there is nosport in which the type of effort is only aerobe or anaerobe
and that’s the reason why athletics’ heart has usually mix
hypertrophy (volume load plus pressure load adaptation)[5-6].
The aim of our study was to evaluate LV systolic
deformation in an elite rugby players’ team using two
dimensional (2D) speckle tracking method and 3D speckle
tracking echocardiography (STE). The reason for choosing
this hypothesis is the fact that this issue represent
controversial even in the last research. Two-dimensional
global longitudinal strain (2D GLS) of athletes appeared to

Received 10th of October 2017. Accepted 15th of November 2017. Address for correspondence: Irina Popescu, MD, PhD, Institute ofCardiovascular Diseases Timisoara, Gheorghe Adam 13 A, Timisoara, Romania; phone: 0040744687019; e-mail: irinap75@yahoo.com

26

Fiziologia - Physiology • 2017.27.2(94)be significantly increased at rest in comparison with healthy
subjects [4,7-8]. Other studies showed no change in 2D
GLS in athletes [9]. and in few other observations, 2D GLS
was lower than in controls [10-11].
By using 3D speckle tracking method, 3D GLS inathletes did no differ from sedentary controls in one study[12] and in other, 3D GLS was even lower than in sedentary
normals [13].
The difference between 3D and 2D STE strain analysis
consists mainly in the advantage to asses LV deformation
inside a volumetric single image rather than bidimensional
multiple images, to calculate all the strain data at the sameheart rate in a single heart beat acquisition.
So, given the latest data in this area, the aim of ourstudy was to analyze myocardial strain parameters (GLS)
using both STE methods (2D and 3D GLS evaluation) in ateam of elite rugby players.

Simpson’s monoplane method in the apical four-chamber
and two-chamber view according to the guidelines [18].
Pulsed tissue Doppler imaging data were obtained froma 2 mm sample volume placed at the lateral mitral annulus
and medial mitral annulus in the apical 4 chamber viewrecorded during an end-expiratory apnea period [19].
Mitral respective tricuspid annular plane systolicexcursion (MAPSE respective TAPSE) was calculated by
the difference between end-diastolic and end-systolicmeasurements (mm) [19-20].
For 2D Speckle tracking evaluation, global longitudinalstrain (2D GLS) was computed from high frame rate (>50
frame/sec) apical views (four chambers, two chambers andthree chambers) using speckle tracking analysis (Echo Pac,
Version 12BT, GE Healthcare). 2D GLS was obtained byaveraging the segmental strain curves of all 17 segments of
LV [21-23] and was represented in a color coded bull’s eye
plot (Figure 1).

MATERIAL AND METHODS
Twenty six male athletes fromthe regional rugby players’ team (partof Romanian national rugby team)
were evaluated in the Institute ofCardiovascular Diseases Timisoara,
Romania. All of the subjects were
engaged in a training programme ofat least 25 ours/week in the last year.
All participants gave written informed
consent to the procedures included
in our study. The athletes underwent
a complete 2D and 3D transthoracic
echocardiographic exam at rest.
Within the clinical examination were
measured: weight (W), height (H),body surface area (BSA) (after
diagram Du Bois) [14], body massindex (BMI).
Standard transthoracic bidimensional (2D) echocardiographic study was performed by an experienced
echocardiographer using a Vivid E9 ultrasound machine(GE Healthcare) with an M5S probe. All athletes were
examined in the left lateral position.
Standard 2D measurements - LV diastolic diameter(LVDD) and LV systolic diameter (LVSD), interventricular
septum thickness (IVST) and posterior wall thickness (PWT)- were obtained in the parasternal long axis view [15]. LVmass was automated calculated according to the ASE
recommendations [16]. LV end diastolic and endsystolicvolumes (LVEDV, LVESV) were obtained in the apical fourand two chamber view. LV ejection fraction (EF) was
calculated using the Simpson biplane method [16-17].
Resting LV diastolic function was assessed by E and A wave
velocities from the mitral inflow. Left atrium (LA) volume wasassessed in ventricular end-systole by the modified
Fiziologia - Physiology • 2017.27.2(94)Fig. 1. Speckle tracking imaging with normal representation of 2D
GLS (strain curves and bull’s eye plot)

Real time three dimensional (3D) echocardiography data
set acquisitions were acquired by the same examiner using a
3V matrix array transducer (GE Healthcare). A full volumedata set of the LV was acquired from apical view, consisted infour consecutive beats ECG-gated subvolumes at the end of
expiration and breathe holding. Two or three datasets forpatient were obtained, stored and exported to an off-line
workstation for further analysis (Echo Pac, Version 12BT, GE
Healthcare). With a specific software algorithm (4D
AutoLVQTM – GE Healthcare), LV volumes, LV EF, LV Massand 3D global longitudinal strain (3D GLS) were calculated
according to actual recommendations [21-23]. All steps were
followed as described in the previous studies [24-25]:

27

-

Automatic slicing of the entire full LV volume dataset
Automatic alignment of all the three planes from apicalview
Identification of LV endocardial border both indiastole and systole (automatic with manual correction
if necessary) with calculation of LVEDV and LVESV
Analysis and data display (EF % = LVEDVLVESV/LVEDV x100)
Further evaluation of LV mass and strain were
calculated using automatic border detection of
epicardium (with optional manual correction).

LV Mass = (LV epicardial volume –LV endocardial volume) x1.05.

3D LV mass was indexed for height powered to 2.7.
3D GLS was automated generated and presented inregional and average strain curves and also in color-coded
17 segments bull’s eye plot
Statistical analysis of the data was performed with SPSS
17 software. Clinical and echocardiographic characteristics arepresented as mean value ± standard deviation (SD) using
descriptive analysis. Pearson’s correlation was used toevaluate statistical significant correlations of a given Gaussianvariable, while linear regression analysis was used to assess
the variation of 3D GLS, a dependent variable by using different
predictor variables as independent variables. The null
hypothesis was rejected at p ≤ 0.05.

RESULTS
Physical and echocardiographic characteristics of theentire group of athletes were illustrated in Table I.
Table I. Physical and echocardiographic characteristics data ofentire group of athletes
Characteristics

Mean±standard
deviation

Characteristics

Mean±standard
deviation

Age (years)
Height (H) (cm)Weight (W) (kg)BMI (kg/m2)
BSA (m2)
LVEDD (cm)LVESD (cm)
IVST (cm)PWT (cm)
LVEDV (ml)
LVESV (ml)
LVEDVi (ml)
LVESVi (ml)
2D EF (%)
LVMi (mg)
LAA (cm2)
LAV (ml)25.77±3.32
182.88±7.02
101.77±15.15
30.37±3.75
2.23±0.18
5.28±0.43
3.47±0.36
1.19±0,11
1.17±0,12145.38±37.86
59.34±15.75
67.11±9.16
27.63±3,88.58±0.04
136.89±16,73
22.17±3.55
69.12±17.73

E (m/s)A (m/s)S' lat (m/s)
E' lat (m/s)
A' lat (m/s)
S' med (m/s)
E' med (m/s)
A' med (m/s)
MAPSE (mm)TAPSE (mm)2D GLS (%)
3D GLS (%)
3D LVEDV (ml)
3D LVESV (ml)
3D EF(%)
3D LVM(mg)0.85±0.15
0.42±0.09
0.10±0,01
0.17±0.04
0.07±0.02
0.14±0.20
0.12±0.02
0.07±0.01
20.04±1.90
29.88±4.81-18.01±2.12-15.99±2.70
166.12±25.37
71.27±13,95
0.56±0.03
139.92±12.81

Legend: BMI, body mass index; BSA body surface area; LVEDD, left
ventricular end-diastolic diameter; LVESD, left ventricular end-systolic

28

diameter; IVST, interventricular septum thickness; PWT, posterior wall
thickness; LVEDV, left ventricular end-diastolic volume; LVESV, left
ventricular end-systolic volume; LVEDVi, LVEDV index, LVESVi,
LVESV index; 2D EF, two-dimensional ejection fraction; LVMi, left
ventricular mass index; LAA, left atrial area; LAV, left atrial volume; E,
peak E velocity; A, peak A velocity; S’ lat, peak S’ velocity of lateral
mitral annulus; E’ lat, peak E’ velocity of lateral mitral annulus; A’ lat,peak A’ velocity of lateral mitral annulus; S’ med, peak S’ velocity of
medial mitral annulus; E’ med, peak E’ velocity of medial mitralannulus; A’ med, peak A’ velocity of medial mitral annulus; MAPSE,
mitral annulus plane systolic excursion; TAPSE, tricuspid annulus
plane systolic excursion; 2D GLS, two-dimensional global longitudinalstrain; 3D GLS, three-dimensional global longitudinal strain; 3D
LVEDV, three-dimensional LVEDV; 3D LVESV, three-dimensional
LVESV; 3D EF, three-dimensional ejection fraction; 3D LVM, threedimensional left ventricular mass.

We found statistically significant positive correlations
between 2D GLS and IVST, PWT, 3D GLS (p<0.05, r<0.75)
and negative correlation with MAPSE (p=0.034), TAPSE(p=0.041) and 3D EF (p=0.016) (Table II).
Table II. Significant correlation of 2D GLS
2D GLS

Correlated
variables
IVST
PWT
MAPSE
TAPSE
3D GLS
3D EF

Pearsoncorrelation
coefficient (r)
0.423
0.590
-0.425-0.4120.571-0.478

p
0.035
0.002
0.034
0.041
0.006
0.016

Legend: 2D GLS, two-dimensional global longitudinal strain; IVST,
interventricular septum thickness; PWT, posterior wall thickness;
MAPSE, mitral annulus plane systolic excursion; TAPSE, tricuspid
annulus plane systolic excursion, 3D GLS, three-dimensional global
longitudinal strain; 3D EF, three-dimensional ejection fraction.

We also found a significant positive correlation between
3D GLS and BMI (p=0.032), A’lat (p=0.049), 2D GLS(p=0.006) and a negative correlation with E (p=0.03), E’ lat(p=0.002), E’ med (p<0.001), 3D EF (p=0.04), the strongest
correlation being with E’ med (p<0,001, r= -0.816) (Table III).
Table III. Significant correlations of 3D GLS
3D GLS

Correlated
variables
BMI
E
E’ latA’ latE’ med2D GLS
3D EF

Pearsoncorrelation
coefficient (r)0.458-0.464-0.6590.445-0.8160.571-0.441

p
0.032
0.03
0.002
0.049
<0.001
0.006
0.04

Legend: 3D GLS, three-dimensional global longitudinal strain; BMI,
body mass index; E, peak E velocity; E’ lat, peak E’ velocity of lateral
mitral annulus; E’ med, peak E’ velocity of medial mitral annulus; 2D
GLS, two-dimensional global longitudinal strain; 3D EF, threedimensional ejection fraction.

Fiziologia - Physiology • 2017.27.2(94)A linear regression analyses was performed to identify
independent association of 3D GLS as dependent variable
using as covariates different echocardiographic and clinicalparameters. By these analyses 3D GLS was independently
associated with E’ med, E’ lat and 2D GLS, adjusted valueof R square coefficient showing that 76% of the 3D GLS
variability can be predicted by the variation of the
independent variables included in the model (Table IV).
Table IV. Linear regression analysis
Dependent
variable
3D GLS

CovariateßP

E’ lat-0,3210,040

E’ med-0,4750,001

2D GLS

0,322

0,032

Adjusted
R SquareStandard
Error

0,769

3,073%

Legend: 3D GLS, three-dimensional global longitudinal strain; E’ lat,peak E’ velocity of lateral mitral annulus; E’ med, peak E’ velocity of
medial mitral annulus; 2D GLS, two-dimensional global longitudinalstrain.

DISCUSSION
The results of the present study demonstrate that (i)there was a strong negative correlation between 3D GLS(systolic parameter of the LV function) and E’med (diastolic
parameter of the LV function, (ii) there was a significant
positive correlations between 2D GLS and IVST, PWT(concentric hypertrophy of the LV) and (iii) 3D GLS was
independently associated with E’ med, E’ lat and 2D GLS,
76% of the 3D GLS variability could be predicted by thevariation of these independent variables included in themodel.
In literature we found that Galderisi M at al. in a previous
study demonstrated a correlation of 2D GLS (measured by
Speckle tracking method) with LV diastolic function (E/E’)
regardless of degree of LV hypertrophy [26]. In our study
diastolic function was not complete evaluated, tissue
Doppler velocities of mitral annulus being a raw estimationof LV diastolic function. However, in accordance with
Galderisi studies [25-26] we found a negative correlation
between 3D GLS and E’med (our parameter of diastolic
function).
DÁndreea et al. studied the effects of different effort
training protocols on LV strain indices. They showed nodifferences of 2D GLS between endurance and strength
athletes. Also they demonstrated a positive association
between E’lat, E’med and LVEDV (p<0.001) and an
independent correlation between 2D GLS and sum of LV
wall thickness (p<0.005) [27]. In our study we also found asignificant correlation of 2D GLS with IVST (p=0.035) andPWT (p=0.002). This correlation is a practical demonstrationof the influence exerted from physiologic LV hypertrophy on
systolic function of the athlete’s heart. On the other hand, in
Fiziologia - Physiology • 2017.27.2(94)hypertensive patients with pathological LV hypertrophy,
GLS has been shown to correlate negatively with themagnitude of LV hypertrophy [26].
More recent studies, which analyzed contribution of LV
strain components in myocardial function at rest, inendurance athletes using 3D STE, showed that sinus
bradycardia and LV mass are independent determinants of
3D GLS at rest [28-29]. Our study revealed that diastolic
function (E’ med and E’ lat) and also 2D GLS was
independent predictors of 3D GLS at rest in our team ofrugby players.
Limitations
The entire group included in the analysis had only 26
athletes, so the results can be biased by the small numberof participants to the study. Furthermore, we can notextrapolate these results to the entire population of rugby
athletes, because we already know that the study group is
not representative.
The difference of 24% of the variability of the 3D GLS
variable could be explained by the existence of otherpredictor factors not investigated in our study.
Another limitation is the lack of quantification of otherstrain parameters like global circumferential or radial strain
or LV twisting and torsion. Some of this measurement was
obtained but could not be analyzed (inadequate quality
echocardiography images).

CONCLUSIONSThe strain evaluation of our athlete’s left ventricle using
2D STE revealed the fact that the higher the physiologicalhypertrophy of the left ventricle, the more increased
longitudinal systolic function, in opposite with hypertensive
patients with pathological LV hypertrophy, where 2D GLS
was found significantly decreased.
3D STE is a new and feasible technique for assessing
LV myocardial deformation in athletes. 3D GLS (a systolic
parameter of the LV function) correlated both with a LV
diastolic function parameter and another systolic parametermeasured by 2D method (2D GLS), emerging as
independent predictors of rugby players’ longitudinal myocardial
deformation at rest.

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Fiziologia - Physiology • 2017.27.2(94)EVALUAREA FUNCTIEI SISTOLICE
A VENTRICULULUI STANG
CU AJUTORUL METODELOR ECOCARDIOGRAFICESPECKLE TRACKING BIDIMENSIONALSI TRIDIMENSIONAL LA UN LOT DE SPORTIVI
DE PERFORMANTA (JUCATORI DE RUGBY)REZUMAT
Remodelarea adaptativa a cordului la sportivi apare ca urmare a modificarilor morfologice si functionale datorate
protocoalelor de antrenament fizic intens.Studiile asupra deformarii ventriculului stang la sportivi sunt echivoce iar
rezultatele sunt controversate. Scopul studiului nostru este evaluarea strainului sistolic al ventriculului stang la un lot derugbysti folosind tehnici ecocardiografice noi (metoda speckle tracking bidimensionala respectiv tridimensionala). In acest
scop am evaluat intreg lotul regional de rugby constand in 26 de sportivi si le-am efectuat masuratorile standard
ecocardiografice bidimensional respectiv tridimensional. Am gasit corelatii pozitive semnificative statistic intre strainul
longitudinal global bidimensional (2D GLS) si grosimea septului inerventricular si peretelui posterior al ventriculului stang(p<0,05, r<0,75) si corelatie negativa cu excursia inelului mitral respectiv tricuspidian (p<0,05) . Am gasit de asemenea ocorelatie pozitiva semnificativa negativa intre strainul longitudinal global tridimensional (3D GLS) si indicele de masa
corporala (p = 0,032), viteza A'lat a inelului mitral (p = 0,049), 2D GLS (p = 0,006) si o corelatie negativa cu viteza E afluxului mitral (p = 0,03), E“lat si E ' med a inelului mitral (p = 0,002, respectiv p <0,001), fractia de ejectie 3D (p = 0,04),
corelatia cea mai puternica fiind cu E' med (p < 0,001, r = -0.816). Prin analiza de regresie liniara, am aratat ca 76% dinvariabilitatea 3D GLS poate fi prezisă prin variația variabilelor independente incluse in model (E „med E“ lat și 2D GLS).
Concluzii: Ecocardiografia spekle tracking 2D și 3D sunt tehnici noi și fezabile pentru evaluarea deformarii miocardice a
ventriculului stang la sportivi. Am ajuns la concluzia că sportivii cu cea mai mare hipertrofie fiziologică a ventriculului stang
au avut cel mai crescut 2D GLS, spre deosebire de pacienții hipertensivi cu hipertrofie patologica de ventricul stang, unde
2D GLS a fost găsit mult scazut.
Cuvinte cheie: sportivi, ecografia speckle tracking, strain, functia sistolica a ventriculului stang

Fiziologia - Physiology • 2017.27.2(94)31