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Journal: Polskie Archiwum Medycyny Wewnetrznej

160

INTRODUCTION There is no research that evaluated the tendency to reduce the traditional cardiovascular risk in patients with different values of coronary artery calcium score (CACS). The aim of the study was to evaluate the influence of the CACS examination for the reduction of the global cardiovascular risk. PATIENTS AND METHODS Research was conducted as prospective single center study. 180 subjects (aged 58.8) were included in the trial. Calcifications in computed tomography were calculated using the Agatston scale and “2DVScore with Color” semiautomatic presets by 2 experts. The selected cardiovascular risk factors were analyzed along with clinical procedures. RESULTS Invasive coronary angiography was performed on 60 patients (33.2%). Among these, the invasive examination did not show significant changes in the coronaries of 26 patients (43.3%), while in the other 26 patients (43.3%), coronary angioplasty (stents) were performed. Qualification for cardiac surgery without stents implantation was taken for eight subjects (13.3%). CABG procedures were performed exclusively in group III who had a CACS≥400AU; while angioplasty was performed 10 times more frequently in group III as compared to group II. A significant correlation between the CACS and cardiovascular risks was observed related to age, weight, systolic and diastolic blood pressure.  CONCLUSIONS The CACS results let to invasive coronary angioplasty to be performed in selected patients, or in some cases to qualify patients for coronary artery bypass grafts. This can strengthen the role of CACS as support for classic CVR risk evaluation. Additional continuing education about the role of the CACS should be implemented.

Concepts: Myocardial infarction, Atherosclerosis, Angina pectoris, Cardiology, Heart, Atheroma, Blood pressure, Coronary artery bypass surgery

154

INTRODUCTION Dyscalcemia is associated with adverse cardiovascular effects. Therapy of heart failure (HF) may change serum calcium by reduction of urinary wasting or increased calcium apposition to bones.  OBJECTIVES Our objectives were to assess the prevalence of dyscalcemia in patients with newly up-titrated HF therapy, to explore clinical and laboratory determinants of abnormal serum calcium levels and to analyze the relation of dyscalcemia to prognosis. PATIENTS AND METHODS In 722 HF patients (age 53 ± 10 years, 13% female, NYHA class III-IV) naïve to HF drugs, we have assessed crude prevalence of serum dyscalcemia and adjusted risk of calcium abnormalities on top of recommended therapy and analysed the association of calcium abnormalities with mortality at 2 years of follow-up. RESULTS During therapy up-titration NYHA class improved in 66.7% patients, in 31.0% did not change and worsened in 2.4%. Hypocalcemia occurred in 166 (23.0%) patients and was more prevalent in patients who became less symptomatic on target HF therapy. ypercalcemia was diagnosed in 63 (8.7%) patients and predominated in those who did not respond to treatment. These findings were independent of kidney function, BMI, HF ethiology, thiazides use, age and sex. Hypercalcemia was associated with more catabolic profile, hemodynamic compromise, inflammation and lower bone mineral density. Lower albumin, higher serum phosphorus, were independently of kidney function significant predictors of hypercalcemia.  Hypocalcemia was associated with less catabolism, higher albumin, lower phosphorus, treatment of thiazides, smoking history. Neither hypocalcemia nor hypercalcemia affected prognosis.  CONCLUSIONS We concluded that serum dyscalcemia is related to response to HF therapy and HF severity on top of treatment. Mild hypocalcemia is associated with clinical improvement and does not worsen HF outcome. Hypercalcemia occurs more frequently in non-responders to therapy, its clinical significance requires further studies.  

Concepts: Kidney, Bone, Vitamin D, Medical statistics, Calcium, Urinary system, Prevalence, Calcium metabolism

149

Introduction Atrial fibrillation (AF) increases risk of thromboembolic events by promoting clot formation in the left atrial appendage (LAA). Transesophageal echocardiography (TEE) is routinely used to exclude presence of LAA thrombus prior toAF ablation. The optimal combination of non-invasive parameters for thromboembolic risk stratification in this setting and the need for TEE in very low risk patients have not been established. Objectives To assess predisposing factors for LAA thrombus in patients scheduled for AF ablation and to identify those in whom pre-procedural TEE could be omitted. Patients and methods In consecutive 151 patients (107 males, mean age 57±10 years) the type of AF and renal function were used in addition to CHA2DS2VASc score to improve thromboembolic risk stratification. Results LAA thrombus or dense echo contrast with probable thrombus were detected in 15 (10%) patients. Diabetes, age≥65 years, persistent AF and eGFR<60 ml/min/1.73 m2 were predictors of LAA thrombus. Multivariate logistic regression showed that only persistent AF and eGFR<60 ml/min/1.73 m2 were independent predictors of LAA thrombus. The ROC curves showed that the greatest AUC (0.845) was achieved for CHA2DS2VASc+AF type+renal status (NS). A 100% sensitivity in identifying patients with LAA thrombus was achieved for CHA2DS2VASc-AFR≥2 or CHA2DS2VASc≥1 with a corresponding specificity of 54% and 36%, respectively. Conclusions LAA thrombus or dense contrast are often encountered in patients scheduled for AF ablation. Addition of AF type and renal function to the CHA2DS2VASc score slightly improves thromboembolic risk stratification and may help to identify patients who do not need pre-procedural TEE.

Concepts: Cardiology, Echocardiography, Stroke, Atrial fibrillation, Warfarin, Thrombus, Left atrial appendage occlusion, Left atrial appendage

142

INTRODUCTION    There are no widely accepted standards of diagnosis of sarcoidosis.  OBJECTIVES    The aim of the study was to assess the relative diagnostic yield of endobronchial ultrasound needle aspiration (EBUS-NA) and endoscopic ultrasound needle aspiration (EUS-NA), and to compare them with the standard diagnostic techniques, i.e. endobronchial biopsy (EBB), transbronchial lung biopsy (TBLB), transbronchial needle aspiration (TBNA) and mediastinoscopy.  PATIENTS AND METHODS    A prospective randomized study including consecutive patients with clinical diagnosis of stage I or II sarcoidosis. In all patients EBB, TBLB and TBNA were performed initially. Subsequently, patients were randomized to group A (EBUS-NA) or group B (EUS-NA). Next, a crossover control test was performed: all patients with negative results in group A underwent EUS- NA and all patients with negative results in the group B underwent EBUS-NA. In case of lack of confirmation of sarcoidosis, mediastinoscopy was performed. RESULTS    There were 106 patients enrolled, and 100 were available for the final analysis. Overall sensitivity and accuracy of standard endoscopic methods were both 64%. When analyzing each of the standard endoscopic methods separately, diagnosis was confirmed with EBB in 12 patients (12%), TBLB in 42 patients (42%) and TBNA in 44 patients (44%). The accuracy and sensitivity of each endosonography technique was statistically significantly higher than that of EBB+TBLB+TBNA (P = 0.0112 and 0.0134).  CONCLUSIONS    Sensitivity and accuracy of EBUS-NA and EUS-NA are significantly higher than the standard endoscopic methods (P <0.01). Sensitivity and accuracy of EUS-NA is higher than EBUS-NA, but the difference is not statistically significant.

Concepts: Statistics, Biopsy, Pathology, Type I and type II errors, Medical tests, Standardization, Biostatistics, Statistical theory

3

Physical activity and exercise are interrelated but separate concepts. Activity refers to bodily movement produced by skeletal muscles that results in energy expenditure. Exercise is a subset of physical activity, in which generally higher levels of muscular activity are performed for a purpose, such as achieving physical fitness or winning a sporting contest. Higher exercise capacity is considered to be permissive of greater physical activity in the home and community settings. Individuals with COPD are physically inactive when compared with healthy age-matched control subjects. Furthermore, physical inactivity is independently associated with adverse outcome in COPD, including more rapid disease progression, impaired health status, and increased health care utilization and mortality risk. While there are several methods to objectively measure physical activity; recent scientific studies have commonly utilized questionnaires and activity monitors. The latter include simple pedometers and complex accelerometers, which can measure and record movement in up to three planes. In COPD, multiple patient characteristics and disease severity markers are related to activity level, including pulmonary physiologic abnormalities such as airways obstruction and hyperinflation; exercise capacity such as the six minute walk distance; exacerbations of respiratory disease; and comorbid conditions. Clinical trials of bronchodilators, supplemental oxygen therapy, exercise training or pulmonary rehabilitation, or physical activity counseling have inconsistent results in demonstrating increased physical activity from the interaction. This is probably because the phenomenon of physical inactivity is complex, resulting not only from physiologic impairments, but symptoms, cultural, motivational, and environmental factors.

Concepts: Oxygen, Obesity, Muscle, Physical exercise, Exercise, Chronic obstructive pulmonary disease, Oxygen therapy, Physical fitness

2

Clostridium difficile infection (CDI) is one of the most commonly reported nosocomial pathogens in the United States (US) and Europe with recent US CDI-associated mortality approaching 30,000 deaths annually. Antibiotics remain the preferred CDI treatment, however a minority of patients experience numerous relapses and are treated with restoration of the bowel microbiota, termed fecal microbiota transplantation (FMT). FMT involves the introduction of a fecal suspension from a healthy donor into the gut of the infected patient to cure the CDI and replace depleted components of the gut microbiota. FMT is particularly effective and safe in curing CDI using a colonoscope or enema to deliver 1-2 infusions. Given that 6425 CDI were reported in Poland in 2014 practicing physicians should understand the benefits and limitations of FMT in CDI as this novel therapy has rapidly advanced to the level of ‘standard-of-care’ status in Australia, the US and many parts of Europe. FMT has been administered either as a suspension in saline, a highly refined liquid product which can be frozen, as lyophilised powder in capsules, and as an encapsulated spore preparation. The ultimate products to reach the market will be shaped by the indications approved by regulatory bodies. At present the faecal suspension in saline remains the treatment of choice to terminate relapsing and severe CDI, which we will review here. The use of FMT for non-CDI indications such as inflammatory bowel disease and irritable bowel syndrome, is likely to increase. Presently, these indications remain in the domain of research institutions.

Concepts: Inflammation, Bacteria, Gut flora, Constipation, Gastroenterology, Irritable bowel syndrome, Flatulence, Clostridium difficile

2

During their lifetimes, 94.5% of all people are stung by wasps, honey-bees, hornets or bumble-bees (order Hymenoptera). After a sting, most of them have typical local symptoms, 5-15% of the stung individuals develop local allergic reactions and 3-8.9% manifest systemic allergic reactions (SR) which may be potentially life-threatening in 10% of them. In the mild forms of Hymenoptera venom allergy (HVA), grades I and II according to Mueller, the leading symptoms are urticaria and edema, respectively. Severe SR are classified as grades III (respiratory symptoms) and IV (cardiovascular symptoms). Rare manifestations of HVA are Kounis syndrome and Tako-tsubo cardiomyopathy. All HVA patients with SR require standard (skin test, sIgE, tryptase) or extended (component diagnosis, basophil activation test) HVA diagnosis. All the patients with SR manifesting hypertension and disturbances in consciousness should be diagnosed for mastocytosis. Additionally, a relationship was found between the severity of HVA symptoms and intake of ACEI. A similar, though less documented, reservation concerns the use of beta blockers. HVA patients who have experienced SR are potential candidates for venom immunotherapy (VIT) which is effective in 80-100% of the individuals treated for 3-5 years. A heightened risk of a VIT failure is reported in patients with mastocytosis and these treated with ACEI. In certain groups (bee-keepers, these who react with SR to stings during VIT, as well as those with SR to maintenance doses of VIT) higher maintenance dose is recommended. Indications, contradictions, treatment protocols and dosage are regulated by the international guidelines of allergy societies.

Concepts: Immune system, Allergy, Mast cell, Dose, Angioedema, Wasp, Basophil granulocyte, Basophil activation

0

INTRODUCTION    Antibodies against donor`s human leukocyte antigens (HLA) play a significant role in the pathogenesis of antibody mediated rejection, although their role during the late post-transplant period is unknown. A non-HLA polymorphic antigenic system like major histocompatibility class I chain-related antigen A (MICA) might be another target for antibody responses involved in rejection. OBJECTIVES    We conducted a 7-year prospective study to determine the effect of positivity for anti-HLA and anti-MICA antibodies on kidney graft survival. PATIENTS AND METHODS    One random blood sample was collected from 457 kidney recipients during regular outpatient visit. Patients who were < 6 months post-transplant were excluded. Anti-HLA (classes I and II) and MICA antibodies evaluation was performed with the use of Luminex assays. Outpatients registry was used to monitor kidney function during 7 year follow-up  RESULTS    A total of 147 (32%) patients had anti-HLA and 88 (19%) anti-MICA antibodies. Graft failure occurred: in 67 (46%) anti-HLA positive vs. 81 (26%) negative individuals (P < 0.05) and in 30 (34%) anti-MICA positive vs. 118 (32%) negative subjects (P = 0.52). Anti-HLA antibodies were associated with increased graft failure incidence: 200 patients with eGFR of > 30 ml/min/BSA at > 5 years post-transplant (P < 0.005). CONCLUSIONS    Anti-HLA but not anti-MICA antibodies in randomly obtained blood samples were the significant predictor of late kidney graft failure and could be a low-cost method enabling identification of patients requiring special post-transplant approach. The results of our study provide the additional justification to investigate the immune biomarkers in certain diseases.

Concepts: Immune system, Antibody, Blood, Immunology, Immunity, Antigen, Major histocompatibility complex, Human leukocyte antigen

0

INTRODUCTION    It is controversial whether the modification of arterial stiffness and intima-media thickness (IMT) is plausible in patients with clinically significant atherosclerosis.  OBJECTIVES    We evaluated the effects of the one-year pharmacological therapy on the arterial stiffness and IMT in survivors of non-ST elevation myocardial infarction (NSTEMI) who were treated according to the clinical guidelines.  PATIENTS AND METHODS    For this study 298 NSTEMI patients (median age 64 years; 85 females) were enrolled. Local (carotid) arterial stiffness and IMT were measured noninvasively before the discharge and after 12 months of the applied contemporary pharmacological treatment. The study group was subdivided into those with normal systolic blood pressure (BP), (<140 mmHg) and increased systolic BP (≥140 mmHg) at follow-up. The results are presented as median and 25th-75th percentile. RESULTS    In both groups with normal and increased systolic BP there were no significant changes in the local arterial stiffness (8.9 (7.9-10.9) vs 8.7 (7.8-10.1) m/s; 9.6 (8.3-11.0) vs 10.4 (9.1-12.4) m/s, P = 0.67 and P = 0.05), however a significant reduction in the IMT was found (777 (664-896) vs 715 (619-841) µm; 818 (720-962) vs 760 (674-897) µm; P = 0.0003 and P = 0.001). Arterial stiffness and IMT are influenced by age and mean BP, however adjustment for these variables did not affect the obtained results in the multivariate models. CONCLUSIONS    The pharmacological treatment of the post-NSTEMI patients for one year was accompanied by a significant reduction in the IMT but had no effects on the properties of the vessel structure.

Concepts: Myocardial infarction, Atherosclerosis, Hypertension, Atheroma, Blood pressure, Median, Artery, Acute coronary syndrome

0

Over the last few decades, in reproductive medicine have allowed an improvement in the management and outcome of pregnancy in connective tissue diseases (CTD), such as Systemic progress Lupus Erythematosus and Antiphospholipid Syndrome; however, pregnancy and other related issues represent a crucial moment for patients and their family and some unmet needs are still present. In routine clinical practise, health professionals involved in the care of SLE and/or APS patients need to consider many aspects of the reproductive life of patients, involving not only pregnancy and family planning but also fertility, contraception, cancer surveillance and menopause. The development of new EULAR recommendations for women’s health issue and family planning reflects the need for a novel approach in the patient-physician relationship, in which a more comprehensive communication begins from the firsts encounter.  Pre-conceptional counselling is essential for ensuring optimal pregnancy outcomes, through a careful risk stratification involving disease activity, organ involvement, autoantibody profile, use of drugs, previous pregnancy outcomes, and to engage the more appropriate preventive and therapeutic strategies to limit complications. In patients with stable/inactive disease and low risk of thrombosis, an adequate hormonal contraception and a menopause replacement therapy should be discussed and proposed; assisted reproduction techniques can be safely use in the same category of patients but, in those with aPL positivity, anticoagulation and/or low dose aspirin should be added. All menstruating women should be counselled on fertility and on the possibility to preserve it with gonadotropin-releasing hormone analogues if receiving alkylating agents. A strict clinical, serological, laboratory and multidisciplinary monitoring approach during pregnancy is mandatory to early recognize and effectively treat a disease flares or obstetric complications; therefore, Doppler ultrasonography and foetal biometry should be regularly performed, especially in the second and third trimester. Eventually, physicians should recommend screening for cervical dysplasia related to human papillomavirus (HPV) infection, especially during immunosuppressive therapy, and HPV immunisation can be used in women with stable/inactive disease.

Concepts: Immune system, Medicine, Pregnancy, Rheumatology, Systemic lupus erythematosus, Lupus erythematosus, Immunosuppressive drug, Antiphospholipid syndrome