Impact of Right Heart Failure on Clinical Outcome of Left Ventricular Assist Devices (LVAD) Implantation: Single Center Experience.

The aim of this study was to examine the incidence and significance of right heart failure (RHF) in the early and late phase of left ventricular assist device (LVAD) implantation with the identification of predictive factors for the development of RHF. This was a prospective observational analytical cohort study. The study included 92 patients who underwent LVAD implantation and for whom all necessary clinical data from the follow-up period were available, as well as unambiguous conclusions by the heart team regarding pathologies, adverse events, and complications. Of the total number of patients, 43.5% died. The median overall survival of patients after LVAD implantation was 22 months. In the entire study population, survival rates were 88.04% at one month, 80.43% at six months, 70.65% at one year, and 61.96% at two years. Preoperative RHF was present in 24 patients, 12 of whom died and 12 survived LVAD implantation. Only two survivors developed early RHF (ERHF) and two late RHF (LRHF). The most significant predictors of ERHF development are brain natriuretic peptide (BNP), pre-surgery RHF, FAC < 20%, prior renal insufficiency, and total duration of ICU stay (HR: 1.002, 0.901, 0.858, 23.554, and 1.005, respectively). RHF following LVAD implantation is an unwanted complication with a negative impact on treatment outcome. The increased risk of fatal outcome in patients with ERHF and LRHF after LVAD implantation results in a need to identify patients at risk of RHF, in order to administer the available preventive and therapeutic methods.

Oxidative Stress in Patients before and after On-Pump and Off-Pump Coronary Artery Bypass Grafting: Relationship with Syntax Score.

OBJECTIVE: Coronary artery bypass grafting (CABG) represents the significant source of increased oxidative stress (OS). We aimed to follow the OS status parameters (i.e., ischemia-modified albumin (IMA), malondialdehyde (MDA), superoxide anion, prooxidant-antioxidant balance (PAB), total oxidant status (TOS), total antioxidant status (TAS), and superoxide-dismutase (SOD)) change through the predefined study times in two different surgical procedures, i.e., cardiopulmonary bypass (CPB) and off-pump coronary artery bypass grafting (OPCAB). Additionally, we aimed to investigate those OS status parameters in specific study times according to SYNTAX score (SS), an established angiographic score for evaluating the extensity and severity of coronary artery disease. Patients and Methods. A total of 107 patients that were planned to undergo CABG were included (i.e., 47 patients in OPCAB and 60 patients in CPB group). Blood samples were taken at 6 time intervals: before surgery (t1), immediately after intervention (t2), 6 h (t3), 24 h (t4), 48 h (t5), and 96 h after termination of the operation (t6). RESULTS: IMA levels were higher in CPB than that in OPCAB baseline and rose in CPB group in t2 point. TOS decreased in both study groups, compared to baseline values, but without statistical significance. Superoxide anion and PAB significantly increased in t3-t6 study times, in both groups. MDA significantly increased only in CPB group in t5 and t6 interval. MDA was significantly higher in CPB group compared to OPCAB in t6 study point. CPB patients had significantly lower TAS compared to OPCAB patients at the beginning and in t2 and t3 study points. They also had significantly lower SOD activities compared to OPCAB, baseline, and in several study points. Moreover, TAS, SOD, and TAS/TOS ratio were significantly lower, whereas PAB and TOS/TAS were significantly higher in patients with high SS compared to corresponding groups. SOD activity, IMA, and TAS level were the best predictors of high SS. CONCLUSION: CPB patients were in more severe ischemia baseline than OPCAB group and IMA rose in CPB patients immediately after the surgery end, but not later. Also, the antioxidant status was significantly lower, whereas the prooxidant status was significantly higher in patients with high SS compared to corresponding groups. SOD activity, IMA, and TAS level were the best predictors of CAD (as determined with SS), showing that SOD and IMA had very good discriminatory capability towards higher SS status.

New Markers of Platelet Activation and Reactivity and Oxidative Stress Parameters in Patients Undergoing Coronary Artery Bypass Grafting.

OBJECTIVE: Recent studies have shown that the red cell distribution width- (RDW-) to-platelet (PLT) count ratio (i.e., RPR) and the mean platelet volume (MPV)/PLT ratio (i.e. MPR) are more sensitive markers of atherosclerosis-connected risk than RDW and PLT alone. The present study is aimed at investigating the oxidative stress status and these two new markers of platelet activation in two different heart surgery modalities: cardiopulmonary bypass (CPB) and off-pump coronary artery bypass (OPCAB). We also aimed to test the possible relationship between RPR and MPR, respectively, and the severity and complexity of atherosclerotic plaque, measured as Syntax Score. Patients and Methods. A total of 107 patients encompassed this prospective study (i.e., 60 patients in CPB group and 47 patients in OPCAB). Blood samples were drawn at several time intervals: before skin incision (t1), immediately after intervention (t2), 6 h (t3), 24 h (t4), 48 h (t5), and 96 h after cessation of the operation (t6). RESULTS: The values of RPR and MPR were similar in CPB and OPCAB before surgery and started to rise in t2 (i.e., immediately after the intervention). This increase lasted to t5 (i.e., 48 hours after the intervention), when it became the highest. After that, both markers started to regress about the 96th hour after the beginning of surgery. Nominal values of both indices were higher in CPB than in OPCAB in all study points after the surgery. Furthermore, a significantly higher level of antioxidative parameters (i.e., total sulfhydryl groups and paraoxonase 1) in the OPCAB group compared to the CPB group was noted at t5 study point (i.e., 48 hours after the surgery), whereas no significant difference was noted in prooxidant levels (i.e., lipid hydroperoxides and advanced oxidation protein products) between these groups at this study point. MPR and RPR correlated positively with Syntax Score at several study points after the surgery completion. Syntax Score, MPR, and RPR showed good clinical accuracy in surgery-related complication prediction ((AUC = 0.736), 95th CI (0.616-0.856), P = 0.003)). CONCLUSION: When combined, MPV, RDW, and platelet count, such as MPR and RPR, could be good predictors of coronary artery disease status, regarding the aspect of joint inflammation, oxidative stress, and thrombosis.

The routine use of platelet function tests in elective coronary artery bypass grafting: A prospective observational trial.

BACKGROUND: Preoperative use of platelet function tests contributes to the decrease of re-intervention rate due to bleeding and the necessity of transfusion in coronary artery bypass grafting (CABG) patients. The aim was to investigate the predictive value and to justify routine preoperative use of multiple electrode aggregometry in these patients. METHODS: A prospective observational trial which included 416 consecutive patients subjected to elective isolated CABG was conducted. The Multiplate® test was used to assess platelet function. Platelet function test results, postoperative blood loss, and transfusion requirements were compared between high and low bleeding risk patients. Receiver operating characteristic analysis was performed to assess the sensitivity and specificity of the arachidonic acid (ASPI) and adenosine di-phosphate high sensitive (ADPHS) tests. RESULTS: ADPHS and ASPI test results significantly predicted total bleeding > 1000 ml (AUC, 0.685, p < .001; 0.695, p = .039). Sensitivity and specificity were 62.9% and 40.0%, for ADPHS ≤602, and 70.8% and 41.8%, for ASPI ≤ 453. The sensitivity and specificity of cut-off values recommended by the manufacturer were 84.2% and 40.0% for ADPHS ≤ 500, while for ASPI < 600 the values were 54.7% and 62.2%. More platelets and cryoprecipitate were transfused in patients with ADPHS ≤ 602.5 (p < .001; p = .035). Patients with ADPHS ≤ 500 had a higher rate of red blood count, platelet and cryoprecipitate transfusion (p<.001p<.001; p = .013). The manufacturer's ASPI test cut-off values showed no statistically significant prediction for a higher transfusion rate. CONCLUSION: Preoperative platelet function tests should be conducted systematically for all elective CABG patients who were on dual antiplatelet therapy after adjusting test cut-off values for each population.

Successfully Resected Cardiac Metastatic Melanoma in a Lifesaving Cardiac Surgery: A Case Report.

INTRODUCTION: Metastatic tumors are the most frequent tumors of the heart with the melanoma metastasis being the most frequent. In cases of a cardiac tamponade or a low cardiac output syndrome due to the position of the tumor it could lead to an acute life-threatening condition for the patient. CASE REPORT: We present a case of a successfully treated metastatic cardiac melanoma in a lifesaving cardiac surgery. A 42-year-old woman was admitted to the emergency department of the Clinical Center of Serbia in a critical state with signs of tricuspid orifice obstruction with a tumor mass. Her previous medical history showed that she had an adequate surgical excision of the melanoma in the right lumbar region at the age of 39. An emergency cardiac surgery was performed with the resection of the tumor and the atrial wall. The postoperative course was uneventful and a HP exam once again confirmed the same type of melanoma as previously diagnosed. The patient was alive and well on follow-up exams for 4 months when she was diagnosed with metastatic tumor masses in the pelvis with ascites and melanosis of the entire skin followed by lethal outcome 5 months after the cardiac surgery. CONCLUSION: Surgical resection of metastatic cardiac melanoma can be safe and effective in an emergency scenario, especially in the case of solitary metastasis. It can be performed with excellent results and very few postoperative complications. However, due to the nature of the principal disease, the long-term survival rate remains low, giving the surgery a place in palliative treatment.

The Challenges to Abdominal and Cardiac Surgeons: Emergency Splenectomy after LVAD Implantation-A Case Report.

The paper presents collaboration of an abdominal surgeon and heart team in deciding upon surgical management of a patient with the implanted left ventricular assist device, who has undergone emergency abdominal operation for spleen rupture. The paper focuses on the significance of prompt diagnostics, clinical challenges of hemodynamic and anticoagulant treatment, abdominal organ exposure along the placed left ventricular assist device driveline, identification of vascular structures in conditions of continuous blood flow, and reconstruction of the surgical wound in the driveline projection.

Successful establishment of a left ventricular assist device program in an emerging country: one year experience.

BACKGROUND: The primary goal of this study was to evaluate the outcomes of patients with end-stage heart failure (HF) who underwent continuous flow left ventricular assist device (CF-LVAD) in a developing country and to compare to those reported by more developed countries. The secondary goal was on determining factors that may be connected to improved survival. METHODS: We prospectively analyzed 47 consecutive patients who underwent CF-LVAD at our institution. After one year the survival and adverse event profiles of patients were evaluated. At 3, 6 and 12 months, the cardiac, renal and liver function outcomes were assessed. RESULTS: The 30-day, 6-month and 1-year survival rates were 89%, 85% and 80%, respectively. A significant improvement in dimensions and ejection fraction of left ventricle, BNP, functional capacity, blood urea nitrogen (BUN) and total bilirubin (P<0.05 for all) were noticed 3 months post-CF-LVAD implantation, and patients were stable throughout the entire first year follow up. In the group of patients with baseline renal dysfunction (RD) there were significant improvements of renal function (P=0.004), with no changes on follow up. 57% of patients exhibited some kind of adverse event, commonly in the form of bleeding. In multivariate Cox regression analysis renal failure was found to be as an independent risk factor for the overall survival (HR =13.1, P<0.001). CONCLUSIONS: In conclusion, our data extends previous findings from centers of developed countries, that CF-LVAD is an adequate treatment option for patients suffering from end-stage HF, and encourages expansion of CF-LVAD implantation in developing countries with nascent HT program.

Postoperative Bleeding Following Preoperative Clopidogrel Administration in Patients with Haemoglobin Level Above 110 g/L Undergoing Urgent CABG.

INTRODUCTION: Patients with acute coronary syndrome usually receive dual antiplatelet therapy (DAPT) (usually clopidogrel + aspirin) prior to coronary catheterization, and approximately 10% of these patients require coronary artery bypass grafting (CABG). DAPT has favorable effects on prevention of thrombus formation, but it can have deleterious effects on surgical hemostasis. Anaemia, if present, gives additional risk to such patients. The aim of this study was to examine if DAPT affects postoperative bleeding in patients with haemoglobin levels above 110 g/L, who underwent urgent or emergent CABG, less than five days after stopping DAPT therapy. METHODS: Data were collected prospectively on 122 CABG patients, operated by a surgical team from March 2008 to August 2013. Patients were stratified into two groups: group 1 received DAPT within 5 days of CABG (n=65), and group 2 where DAPT was discontinued for more than 5 days prior to CABG (n=57). All patients were diagnosed with acute coronary syndrome preoperatively, and all of them had haemoglobin levels above 110 g/L. Patients who needed reoperation, combined procedures, or off-pump revascularization were excluded. RESULTS: There was no hospital mortality. Mean chest tube losses after the surgical revascularization did not differ significantly, but group 1 received a higher quantity of transfused red blood cells and platelets. CONCLUSION: Urgent and emergent surgical revascularization using extracorporeal circulation in patients with acute coronary syndrome whose preoperative haemoglobin levels are above 110 g/L is a safe and effective procedure. We suggest that, where indicative, one may perform CABG in less than 5 days after the clopidogrel discontinuation.

Postoperative bleeding following preoperative clopidogrel administration in patients with haemoglobin level above 110 g/l undergoing urgent cabg

Abstract Introduction: Patients with acute coronary syndrome usually receive dual antiplatelet therapy (DAPT) (usually clopidogrel + aspirin) prior to coronary catheterization, and approximately 10% of these patients require coronary artery bypass grafting (CABG). DAPT has favorable effects on prevention of thrombus formation, but it can have deleterious effects on surgical hemostasis. Anaemia, if present, gives additional risk to such patients. The aim of this study was to examine if DAPT affects postoperative bleeding in patients with haemoglobin levels above 110 g/L, who underwent urgent or emergent CABG, less than five days after stopping DAPT therapy. Methods: Data were collected prospectively on 122 CABG patients, operated by a surgical team from March 2008 to August 2013. Patients were stratified into two groups: group 1 received DAPT within 5 days of CABG (n=65), and group 2 where DAPT was discontinued for more than 5 days prior to CABG (n=57). All patients were diagnosed with acute coronary syndrome preoperatively, and all of them had haemoglobin levels above 110 g/L. Patients who needed reoperation, combined procedures, or off-pump revascularization were excluded. Results: There was no hospital mortality. Mean chest tube losses after the surgical revascularization did not differ significantly, but group 1 received a higher quantity of transfused red blood cells and platelets. Conclusion: Urgent and emergent surgical revascularization using extracorporeal circulation in patients with acute coronary syndrome whose preoperative haemoglobin levels are above 110 g/L is a safe and effective procedure. We suggest that, where indicative, one may perform CABG in less than 5 days after the clopidogrel discontinuation.

Potential of Legume-Brassica Intercrops for Forage Production and Green Manure: Encouragements from a Temperate Southeast European Environment.

Legumes and brassicas have much in common: importance in agricultural history, rich biodiversity, numerous forms of use, high adaptability to diverse farming designs, and various non-food applications. Rare available resources demonstrate intercropping legumes and brassicas as beneficial to both, especially for the latter, profiting from better nitrogen nutrition. Our team aimed at designing a scheme of the intercrops of autumn- and spring-sown annual legumes with brassicas for ruminant feeding and green manure, and has carried out a set of field trials in a temperate Southeast European environment and during the past decade, aimed at assessing their potential for yields of forage dry matter and aboveground biomass nitrogen and their economic reliability via land equivalent ratio. This review provides a cross-view of the most important deliverables of our applied research, including eight annual legume crops and six brassica species, demonstrating that nearly all the intercrops were economically reliable, as well as that those involving hairy vetch, Hungarian vetch, Narbonne vetch and pea on one side, and fodder kale and rapeseed on the other, were most productive in both manners. Feeling encouraged that this pioneering study may stimulate similar analyses in other environments and that intercropping annual legume and brassicas may play a large-scale role in diverse cropping systems, our team is heading a detailed examination of various extended research.

The First Attested Extraction of Ancient DNA in Legumes (Fabaceae).

Ancient DNA (aDNA) is any DNA extracted from ancient specimens, important for diverse evolutionary researches. The major obstacles in aDNA studies are mutations, contamination and fragmentation. Its studies may be crucial for crop history if integrated with human aDNA research and historical linguistics, both general and relating to agriculture. Legumes (Fabaceae) are one of the richest end economically most important plant families, not only from Neolithic onwards, since they were used as food by Neanderthals and Paleolithic modern man. The idea of extracting and analyzing legume aDNA was considered beneficial for both basic science and applied research, with an emphasis on genetic resources and plant breeding. The first reported successful and attested extraction of the legume aDNA was done from the sample of charred seeds of pea (Pisum sativum) and bitter vetch (Vicia ervilia) from Hissar, southeast Serbia, dated to 1,350-1,000 Before Christ. A modified version of cetyltrimethylammonium bromide (CTAB) method and the commercial kit for DNA extraction QIAGEN DNAesy yielded several ng µl(-1) of aDNA of both species and, after the whole genome amplification and with a fragment of nuclear ribosomal DNA gene 26S rDNA, resulted in the detection of the aDNA among the PCR products. A comparative analysis of four informative chloroplast DNA regions (trnSG, trnK, matK, and rbcL) among the modern wild and cultivated pea taxa demonstrated not only that the extracted aDNA was genuine, on the basis of mutation rate, but also that the ancient Hissar pea was most likely an early domesticated crop, related to the modern wild pea of a neighboring region. It is anticipated that this premier extraction of legume aDNA may provide taxonomists with the answers to diverse questions, such as leaf development in legumes, as well as with novel data on the single steps in domesticating legume crops worldwide.

Beauty will save the world, but will the world save beauty? The case of the highly endangered Vavilovia formosa (Stev.) Fed.

MAIN CONCLUSION: Vavilovia formosa (Stev.) Fed. is a scientifically valuable common ancestor of the plant tribe Fabeae and also important in breeding and agronomy studies of the cultivated Fabeae, but it is close to extinction. A concerted academic and geovernmental effort is needed to save it. Since 2007, an informal international group of researchers on legumes has been working to increase awareness of Vavilovia formosa (Stev.) Fed., a relict and endangered wild-land relative to crop plant species. A majority of the modern botanical classifications place it within the tribe Fabeae, together with the genera vetchling (Lathyrus L.), lentil (Lens Mill.), pea (Pisum L.) and vetch (Vicia L.). V. formosa is encountered at altitudes from 1,500 m up to 3,500 m in Armenia, Azerbaijan, Georgia, Iran, Iraq, Lebanon, Russia, Syria and Turkey. This species may be of extraordinary importance for broadening current scientific knowledge on legume evolution and taxonomy because of its proximity to the hypothetical common ancestor of the tribe Fabeae, as well as for breeding and agronomy of the cultivated Fabeae species due to its perenniality and stress resistance. All this may be feasible only if a concerted and long-term conservation strategy is established and carried out by both academic and geovernmental authorities. The existing populations of V. formosa are in serious danger of extinction. The main threats are domestic and wild animal grazing, foraging, and early frosts in late summer. A long-term strategy to save V. formosa from extinction and to sustain its use in both basic and applied research comprises much improved in situ preservation, greater efforts for an ex situ conservation, and novel approaches of in vitro propagation.

Water deficit down-regulates miR398 and miR408 in pea (Pisum sativum L.).

MicroRNAs (miRNAs), recently recognized as important regulator of gene expression at posttranscriptional level, have been found to be involved in plant stress responses. The observation that some miRNAs are up- or down regulated by stress implies that they could play vital roles in plant resistance to abiotic and biotic stress. We investigated the effect of water stress treatment during 10 days on expression of conserved miRNAs-miR398a/b and miR408 in pea plants. This time frame reflects the changes as close as possible to the changes where water stress causes visible effects under field condition. It was observed that dehydration strongly down regulates the expression of both miR398a/b and miR408 in pea roots and shoots. The down-regulation of miR398a/b and the up-regulation of potential target genes - copper superoxide dismutase, CSD1, highlight the involvement of this miRNA in pea stress response. To the contrary, the mRNA level of cytochrome c oxidase subunit 5 (COX5b) did not change in roots and shoots of water-stressed plants, compared to control (well) hydrated plants. This suggests that COX5b is not the target of miR398, or that its expression is regulated by some other mechanism. P1B-ATPase expression increased during water deficit only in the shoots of pea; in the roots there were no changes in expression. Our results help to understand the possible role of investigated miRNAs and their contribution to pea capacity to cope with water deficit.

Why do treatment failure and recurrences of benign paroxysmal positional vertigo occur?

OBJECTIVE: To investigate the potential risk factors associated to the treatment failure and recurrence of benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. PATIENTS: Four hundred patients with benign paroxysmal positional vertigo, 119 men and 281 women, aged 27 to 88 years. INTERVENTION: Patients were treated once a week, with only one, appropriate, depending on the affected canal, repositioning maneuver (modified Epley, Semont, barbecue/inverted Gufoni, Kim). The control Dix-Hallpike test and the roll test were performed on 7 days. MAIN OUTCOME MEASURES: The treatment outcome and recurrence were evaluated with regard to sex, age, duration of symptoms, etiologic factors, migraines, osteoporosis, vascular risk factors, endocrine diseases, localization of otoconia, and simultaneous involvement of multiple canals. RESULTS: The results indicate that treatment was negatively affected by patients' age, osteoporosis, and head trauma, without them causing recurrent symptoms. The highest number of uncured patients was observed in the 73- to 88-year-old age group (14.8%). The application of more than one maneuver was necessary in 27.5% of cases with primary BPPV and 88.9% with secondary BPPV. The highest treatment success was achieved in the group with BPPV of the posterior semicircular canal (F = 3.668, p = 0.026). The recurrence rate was 15.5%. CONCLUSION: Potential risk factors associated to the treatment failure were as follows: the age older than 50, secondary BPPV, head trauma, the occurrence of osteoporosis, and localization of otoconia in the anterior semicircular canal. The analyzed factors did not have impact on the recurrence.

Aortic valve disease as a first manifestation of Alcaptonuria in surgically treated patient. Case report.

BACKGROUND: Alcaptonuria, a rare metabolic disorder (1:250 000), is usually presented with symptoms such as arthropathies of weight bearing joints. CASE REPORT: In this case, a 65 year old woman was admitted to our hospital with severe aortic stenosis and no other symptoms that would suggest the existance of Alcaptonuria. Intraoperative findings of black discoloration of the affected valve and ascending aorta, pointed towards the diagnosis of cardiac ochronosis, what was then confirmed by a PH examination. CONCLUSION: This case suggests that although alcaptonuria is a slow progressive disease with cardiac ochronosis as a predictable late complication, it can nevertheless be a first sign. In that case the attention should be brought to the surely affected lumbar spine and weight bearing joints, and other connective tissue. KEY WORDS: Alcaptonuria, Aortic valve, Cardiac ochronosis, Surgery.

Right ventricular myxoma - a case report.

INTRODUCTION: Myxomas arising from the right ventricle are extremely rare. CASE REPORT: We presented a 71-year-old patient with worsening symptoms of the exertional dyspnea and atypical chest pains lasting 6 months. A transthoracic and transesophageal echocardiogram revealed a large, 2.6 x 2.2 cm, ovoid, well-circumscribed, echogenic mass in the right ventricle outflow tract attached by small pedicle, partly obstructing the right ventricular outflow tract and protruding through the pulmonic valve during systole. The tumor was completely removed with the stalk and 5 mm of the surrounding tissue. The histopathological findings confirmed the diagnosis of myxoma. CONCLUSION: This case illustrates the usefulness of echocardiography both in diagnosis of patients with atypical symptoms without family history and associated syndromes (like Carney's complex), and in surgical approach planning. It also stresses the importance of surgical excision of tumor as soon as possible following the diagnosis to prevent the complications such are: valvular obstruction, pulmonary embolization and syncopes.

A 30-year-single-center experience in atrial myxomas: from presentation to treatment and prognosis.

BACKGROUND: The symptoms of myxoma are atypical, vary greatly, and may mimic numerous conditions. Our aim was to investigate the correlation of localization, size, and consistency of myxoma with its treatment and prognosis. METHODS: Over a span of 30 years, 74 consecutive patients (24 men, mean age 46.7 years) were surgically treated for echocardiography-diagnosed myxomas at our center. RESULTS: Left atrial myxomas were more frequent (89.19%), with the racemous form being predominantly left-sided and having no difference in tumor size regardless of localization. Three patients were asymptomatic; and those who were symptomatic, symptoms appeared 2 to 36 months (mean 13.60 ± 7.52) before diagnosis. Nonspecific symptoms and signs were present in 91.98% of patients, whereas specific symptoms and signs were present in 74.32%. More often, patients with myxomas >5 cm in diameter were symptomatic. Embolic events occurred in 15 patients (9 cerebral, 4 pulmonary, 2 peripheral), more frequently in right atrial myxomas of >5 cm diameter. All patients were surgically treated on diagnoses, with no intraoperative mortality or recurrences. CONCLUSIONS: Symptoms in our cardiac myxoma patients were more pronounced when the myxomas were left-sided, racemous, and over 5 cm in diameter. Even in asymptomatic patients, a high index of suspicion assured timely diagnosis and management.

Penetrating wound of the heart manifested with peripheral embolism--case report.

INTRODUCTION: Heart injuries can be classified as penetrating and non-penetrating (blunt). Penetrating wounds are usually caused by stabbing with a piercing object, weapon or projectiles--missiles. The right atrium is damaged in most cases, because of its anatomical position--making the most of the anterior side of the heart. Morbidity caused by stabbing injuries to the heart is 20%-30%, while piercing wounds cause 30%-60% of deaths. CASE REPORT: . A 28-year-old patient was admitted to our clinic with acute ischemia of the extremities. Angiography revealed a bullet in the right common femoral artery, occluding it. The patient denied having any piercing or shooting wound to his leg, but he said that four years before he had been shot to his chest. Echocardiography revealed an atrial septal defect of secondary type. An event reconstruction revealed that, four years after shooting, the bullet was displaced from the heart to the right common femoral artery. CONCLUSION: This case report is unique because of the rare type of injury, time that passed from the injury, the way bullet entered the artery (via atrial septal defect) and especially the success of both surgical procedures (embolectomy and repair of atrial septal defect).

Origin of the words denoting some of the most ancient old world pulse crops and their diversity in modern European languages.

This preliminary research was aimed at finding the roots in various Eurasian proto-languages directly related to pulses and giving the words denoting the same in modern European languages. Six Proto-Indo-European roots were indentified, namely arnk(')- ('a leguminous plant'), *bhabh- ('field bean'), *[Formula: see text] ('a kernel of leguminous plant', 'pea'), ghArs- ('a leguminous plant'), *kek- ('pea') and *lent- ('lentil'). No Proto-Uralic root was attested save hypothetically *kaca ('pea'), while there were two Proto-Altaic roots, *bukrV ('pea') and *[Formula: see text] ('lentil'). The Proto-Caucasianx root *[Formula: see text] denoted pea, while another one, *howl(a) ('bean', 'lentil') and the Proto-Basque root *ilha-r ('pea', 'bean', 'vetch') could have a common Proto-Sino-Caucasian ancestor, *hVwlV ('bean') within the hypothetic Dené-Caucasian language superfamily. The Modern Maltese preserved the memory of two Proto-Semitic roots, *'adas- ('lentil') and *pul- ('field bean'). The presented results prove that the most ancient Eurasian pulse crops were well-known and extensively cultivated by the ancestors of all modern European nations. The attested lexicological continuum witnesses the existence of a millennia-long links between the peoples of Eurasia to their mutual benefit. This research is meant to encourage interdisciplinary concerted actions between plant scientists dealing with crop evolution and biodiversity, archaeobotanists and language historians.

Mitral valve endocarditis during brucellosis relapse.

INTRODUCTION: Endocarditis is the most common cardiovascular manifestation of brucellosis with high mortality rate. Brucella is less accesable to antibiotic (but not for all) and relapse can occur after a various period of clinical latency. CASE REPORT: A 55-year-old farmer was diagnozed with acute systemic Brucella infection in May 2008 and treated with antibiotic therapy in regional hospital for two months and for three months after discharge. He began to feel myalgia, arthralgia, malaise, shortness of breath, abdominal pain, vomiting, diarrhoea and lost weight eight months after initial symptoms occured. Because symptoms progressed he was admitted to our hospital in February 2009. Based on a combination of epidemiological, clinical data (on admission he was catchetic, adynamic, dyspneic, hypotensive 80/50 mmHg, fever up to 39.5 degrees C), positive serological Wright test for brucellosis (1 : 5,120), and echocardiographic examination findings, the diagnosis of very severe relapse of brucellosis with mitral valve endocarditis, complicated with perforation of anterior mitral leaflet, severe mitral regurgitation and pulmonary hypertension was established. He was treated with a combined triple antibiotic therapy (vancomycin, ciprofloxacin and gentamicin, and swiched to regimen with doxycycline, gentamicin and imipenem, replacing gentamicin by rifampicin) for 4 weeks and for the next 2 weeks was receiving trimetoprime/sulfamethoxazole and rifampicin. The patients' condition was improved and he was operated. The diagnosis of infective endocarditis was confirmed intraoperatively. Mitral valve replacement was performed, and combined triple antibiotic treatment (amikacin + ciprofloxacin + cefazolin, for 2 weeks and cephazolin + doxycycline + rifampicin, for 2 weeks) was continued, following with two antibiotics (doxycycline + rifampicin) for 5 months. The patient completely recovered without any signs of infection 30 months postoperatively. CONCLUSION: A combined antibiotic therapy and surgery reduce complications and mortality associated with Brucella endocarditis and improve quality of patients' life.