Rhythm Disturbance After Myocardial Revascularization.

INTRODUCTION: Heart rhythm disorders are common in the post-operative period following surgical myocardial revascularization (CABG). The incidence of any type of arrhythmia in the postoperative period can go up to 85%. While most are transient and short-term, it does not lead to deterioration of the postoperative course, in a smaller number of patients they can be predictors of various events that result in fatal outcome. Arrhythmias occur suddenly and need to be recognized and reacted in time. Standard monitoring consists of 12-channel electrocardiogram (ECG), laboratory findings and, if necessary, 24-hour HOLTER monitoring. Persistent arrhythmias increase overall morbidity and mortality, and costs treatments are increasing enormously. PATIENTS AND METHODS: The prospective study analyzed patients of all age groups and sexes in whom angiographically coronary arterial disease was confirmed and who underwent surgery CABG. A total of 60 patients were screened during 2016. All age groups of both sexes in whom no rhythm disorders were previously recorded were included in the study. RESULTS: A total of 60 patients undergoing CABG were analyzed. The average age of patients was 63.56 8.55 years. The most preoperative factor was hypertension, which was recorded in 53 (88.33%) patients. The higher number of patients was operated using CPB 75.86%. The most commonly performed 3 aorto-coronary by-pass 45 (75%). The most common form of rhythm disorder was POAF, which occurred in 18 (30%) patients. In 24 patients, a change in heart rhythm was observed in the postoperative period in the group of operated ON pump techniques, while in the case of the application of Off pump technique only 5 patients were present, which was statistically significant (p <0.05). CONCLUSION: Preoperative patient preparation and prophylaxis with good anesthesia monitoring and minimal trauma during surgery are the main preconditions for reducing the incidence of postoperative heart rhythm disorders.

Time of Occurrence and Duration of Atrial Fibrillation Following Coronary Artery Bypass Grafting.

INTRODUCTION: Dilatation of the left atrium and left ventricular diastolic dysfunction (DDLV) according to recent studies has significance in the occurrence of postoperative atrial fibrillation (AF), stroke and death. Authors of some studies found no relationship between these parameters and atrial fibrillation. OBJECTIVE: this study is to determine the time of occurrence and duration of atrial fibrillation in patients after surgical revascularization (CABG) due to the presence of left ventricular diastolic dysfunction and left atrium dilatation and identify the most significant predictors of incident AF. METHODS: Prospective study included 116 patients undergoing surgical myocardial revascularization followed from admission to discharge. The study was conducted at the Special Hospital "Heart Center BH" Tuzla for a period of one year (March 2011/2012 g.). For all patients was performed preoperative ultrasound examination, especially parameters of diastolic function of the left ventricle and left atrium volume index (LAVi), as the best parameter sized left atrium, and the postoperative occurrence of certain AF and day occurrence, duration in hours, the number of attacks. To assess whether an event occurred or not was used logistic regression, and the effect of time on the event of interest is analyzed by Cox 's regression hazard parallel. RESULTS: 75.9 % of patients had DDLV, and 91.4 % were hypertensives, 12.9 % from the previous stroke (ICV) and 42.2 % diabetics (DM), 14 % with COPD. The average age of patients was 61.41 ± 4.69 years. In both groups was 32.8 % women and 67.2 % men. LAVi preoperative values were significantly higher as DDLV greater degree. In patients with DDLV and higher values LAVi risk of AF is higher, the greater the length of AF and significantly higher number of attacks FA. Early occurrence of atrial fibrillation and its longer duration in function with increasing LAVi a marked increase in the value LAVi have the greatest hazard for the early appearance of atrial fibrillation. As a result of analysis of the most significant predictors of AF are DDLV and LAVi. CONCLUSION: Postoperative atrial fibrillation occurs earlier and lasts longer in patients with DDLV and elevated left atrial volume index especially LAV > 36ml/m(2). LAVi has the best explanation of the function of hazard occurrence of atrial fibrillation after CABG.

Cigarette smoking among students at the university of tuzla.

INTRODUCTION: Cigarette smoking among students is greatly widespread. Smoking prevalence ranges from 28% to 67% for students, respectively, from 19% to 34% for female students. AIM: The aim of this survey was to investigate the smoking habits of students, who are studying at three faculties at the University of Tuzla in academic Year 2012/2013 and to investigate whether there is a difference in smoking habits of students from different faculties and observed by gender. PATIENTS AND METHODS: The study included a total of 254 students, 170 females (66.93%) and 84 male patients (33.07%). A representative sample consisted of students of three faculties of the University of Tuzla. RESULTS: The conducted analyzes have shown that in this sample 22.8% of current smokers, and 7.8% are former smokers who now no longer smoke. Due to the adopted smoking habits, which some students began to adopt in the age of 13, in 47.5% part of students occasionally was observed some symptoms (cough, etc.) which are attributed to smoking. The analysis showed no statistically significant gender difference in smoking habits. Although the trend of smoking in the population students progression, one and the same quantity was well as male colleagues. We did not find any statistically significant difference in onset of adopting smoking habits. CONCLUSION: The analyzes have shown that in this sample 22.8% of current smokers, and 7.8% were former smokers who now no longer smoke. The analysis showed no statistically significant gender difference in smoking habits of all students. There were no statistically significant differences in the daily consumption of cigarettes between faculty.

Operative treatment of combined aortic stenosis and coronary artery disease.

INTRODUCTION: The aortic valve replacement is a standard operating procedure in patients with severe aortic stenosis. Structure of patients undergoing surgery ranges from young population with isolated mitral valvular disease to the elderly population, which is in addition to the underlying disease additionally burdened with comorbidity. One of the most commonly present factors that further complicate the surgery is coronary heart disease that occurs in, almost, one third of patients with aortic stenosis. The aim is to compare the results of surgery for aortic valve replacement with or without coronary artery bypass graft (CABG). PATIENTS AND METHODS: From August 2008 to January 2013 in our center operated on 120 patients for aortic stenosis. Of this number, 75 were men and 45 women. The average age was 63.37 years (16-78). Isolated aortic valve replacement was performed in 89 patients and in 31 patients underwent aortic valve replacement and coronary bypass surgery. Implanted 89 biological and 31 mechanical valves. RESULTS: Patients with associated aortic stenosis and coronary artery disease were more expressed symptomatic symptoms preoperatively to patients with isolated aortic stenosis who were on average younger age. Intra-hospital morbidity and mortality was more pronounced in the group of patients with concomitant aortic valve replacement and coronary bypass surgery. Morbidity was recorded in 17 patients (14.3%) in both groups, while the mortality rate in both groups was 12 patients (10.1%). CONCLUSION: Evaluation of preoperative risk factors and comorbidity in patients with aortic stenosis and coronary artery disease contributes to a significant reduction in intraoperative and postoperative complications. Also, early diagnosis of associated coronary artery disease and aortic stenosis contributes to timely decision for surgery thus avoiding subsequent ischaemic changes and myocardial damage.

Metabolic syndrome in schizophrenia - who is more to blame: FGA polypharmacy or clozapine monotherapy?

BACKGROUND: To establish the prevalence of metabolic syndrome and its parameters in group of patients with schizophrenia in polypharmacy - receiving first generation antipsychotics versus clozapine alone treated group. SUBJECTS AND METHODS: 48 outpatients with schizophrenia divided into two groups: the first group of 21 patients in polypharmacy with first generation antipsychotics, and the second group of 27 patients treated with clozapine alone were assessed for the presence of metabolic syndrome. We used logistic regression models to assess the relationship between metabolic syndrome and antipsychotic therapy, gender and age. RESULTS: Metabolic syndrome was found in 52.1% of all subjects. Compared to first generation antipsychotics polypharmacy, the monopharmacy with clozapine was associated with elevated rates of metabolic syndrome (28.6% vs. 70.4%, p=0.004). With regard to particular parameters of metabolic syndrome, the elevated plasma triglycerides were significantly more present in subjects within Clozapine group (p=0.03). Logistic regression analysis showed that female gender (p=0.004), and clozapine treatment (p=0.005) were significantly associated with metabolic syndrome. CONCLUSION: Compared to polypharmacy with first generation antipsychotics, the higher prevalence of metabolic syndrome is found in patients treated with Clozapine alone. The most prevalent metabolic disorder is dyslipidemia.

Does the Duration of the Illness Affect the Severity of Negative Symptoms of Schizophrenia?

Background: The negative symptoms of schizophrenia are less known aspects of the illness although they often mark its course and outcome. Negative symptoms refer to loss of function, and they are associated with poor outcomes. It is considered that they are more prominent with the longer duration of illness. Objective: To determine the negative symptoms in the patients with schizophrenia with regard to the duration of illness. Methods: A cross-sectional study was conducted in 60 consecutive outpatients with schizophrenia. Two groups were formed regarding the duration of illness (⩽2 years, and >3 years). The negative symptoms were established with the Brief Negative Symptom Assessment - BNSA. Results: Average score of negative symptoms in the group with the shorter duration of illness was 8.37±2.94, and in the group with longer duration was 10.73±2.86. Independent Samples Test was significant p=0.003, t-2.367, and therefore the difference between scores on BNSA within groups was significant. Moderate size effect was found (p = 0.69). Conclusion: Negative symptoms of schizophrenia are more prominent with the longer duration of illness.

Myocardial Surgical Revascularization in Patients with Reduced Left Ventricular Ejection Fraction.

Background: Myocardial surgical revascularization in patients with low left ventricular ejection fraction (LVEF) is accompanied by a high rate of morbidity and mortality. Objective: The aim of this study was to investigate and eliminate the reasons for the most common perioperative and postoperative complications. Methods: A total of 64 were analyzed. of patients during 2019 who underwent coronary artery bypass grafting (CABG), average age 61.29±9.12 years. Results: Out of the total number of operated patients, there were 16 women and 48 men. Patients were divided into two groups. The first group consisted of patients who underwent surgery with the use of cardiopulmonary bypass (cCABG-CPB) and the second group those who underwent surgery without the use of cardiopulmonary bypass (OPCAB). In 41 patients, myocardial infarction was previously recorded. Critical stenosis of the main trunk of the left coronary artery was present in 14 patients. The incidence of postoperative complications was higher in the cCABG-CPB 16/10 group (p0.030). Conclusion: In our study, we confirmed that myocardial revascularization is justified, especially in the case of multivessel coronary disease. In the long term, it significantly improves the systolic function of the left ventricle, and thus and quality and length of life.

The possible role of early post-transplant inflammation in later anemia in kidney transplant recipients.

UNLABELLED: Delayed kidney graft function and acute rejection in the early post-transplant period affect both short and long-term allograft survival. Allograft rejection, as an inflammatory state, results in increased erythropoietin resistance, which leads to decreased haemoglobin (Hb) level. We conducted this study to evaluate whether inflammation in the early post-transplant period could predict later anemia.This is a retrospective cohort study based on the analysis of 64 existing clinical records. PREDICTOR: White blood cells (WBC) count obtained by the end of the first week post-transplant (W1). Covariates: Donor's age, recipient's age and sex. OUTCOME: Anemia identified at 12 months (M12) post engraftment. Median WBC count at W1 was 9,5 x103/microL (5th - 95th percentile 5,2 x103/microL -17,8 x103/microL). Mean Hb values at M12 were 129,9 +/- 20,3 g/L, in males 136,2 +/- 20,1 g/L and in females 119,4 +/- 16,2 g/L. The significant correlation was found between WBC at W1 and Hb at M12. Pearson coefficient of correlation r was -0,26, and 95% confidence interval (CI) for r was -0,47 to -0,015 (p=0,03). Univariate logistic regression showed significant association between WBC at W1 and Hb at M12 (OR 1,20; 95% CI 1,04 to 1,39, p=0,01). After the adjustment for donor's and recipient's age by transplantation and recipient's sex, multiple regression showed that WBC count remained predictive of anemia at M12 (OR 1,17; 95% CI 1,01 to 1,36, p=0,03). Early post-transplant inflammatory response predicts later anemia in kidney transplant recipients. An increase in WBC count in the first week post-transplant by 109/L increases the risk for anemia after twelve months by 17%.

Pharmacological Prophylaxis of Atrial Fibrillation After Surgical Myocardial Revascularization.

INTRODUCTION: Postoperative Atrial Fibrillation (POAF) is associated with a higher rate of postoperative complications and mortality, as well as with longer hospitalization and increased treatment costs. We have designed and performed a randomized, trial of pharmacological prophylaxis in which the event of interest is POAF. AIM: The aim of this study is to reduce the risk of postoperative, complications associated with this arrhythmia. METHODS: We included 240 stable patients with a coronary heart disease, who were referred to elective surgical revascularization of the myocardium. The patients were assigned into three groups of 80 patients each: group A (BB, beta blocker, comparator), group B (BB+ Amiodarone) and group C (BB + Rosuvastatin). The goal was to establish whether intervention by combination therapy was more useful than a comparator. RESULTS: An event of interest (POAF) has occurred in 66 of the total 240 patients. Number of new POAF cases is the lowest in Group B, 14 (17.5%) compared to 25 (31.25%) new cases in the comparator group, and 27 new cases (33.75%) in group C. Absolute risk reduction was 13.75%, ≈14% less POAF in group B compared to comparator. Relative risk reduction was 56% (RR 0.56, p = 0.04). Number Needed to Treat was 7.27. In group C, 33.75% of patients developed POAF. Absolute risk was insignificantly higher in group C (2.5%, NS) compared to the comparator .The number needed to harm was high, 40. CONCLUSION: The results of our research show that prophylaxis of POAF with combined therapy BB + Amiodarone was the most efficient one.

Microalbuminuria as a possible marker of risk of Balkan endemic nephropathy.

AIM: To evaluate whether microalbuminuria could be a marker of early tubular damage in individuals at risk of developing Balkan endemic nephropathy (BEN). METHODS: A cross-sectional study was used to determine urinary albumin-to-creatinine ratio (UACR) in a test group of 61 participants from a BEN endemic region and control group of 64 participants from a nearby non-endemic region, both recruited from the general population of Bosnia and Herzegovina. The correlation between UACR and urinary b2 microglobulin-to-creatinine ratio (UBCR) and the receiver operating characteristic curve for UACR were analyzed in the test groups of 58 participants. The correlation analysis was also performed in a subset of nine subjects with elevated UBCR. RESULTS: Medians, interquartile ranges and confidence intervals (CI) for medians of UACR in the test and control groups were 2 mg/mmol, 0.975-8.247 mg/mmol, 1.3472-3.2691 mg/mmol and 1 mg/mmol, 0.695-1.41 mg/mmol, 0.8466-1.2053 mg/mmol, respectively (P = 0.0001). Microalbuminuria was found in 30 of the 61 examinees in the test group, in contrast to six of the 64 examinees in the controls (P < 0.0001). Participants from the endemic region had 9.3 times the odds of having microalbuminuria in contrast to participants from the non-endemic region. Pearson's correlation coefficients r of the log-transformed ratios and Kendall-tau coefficients of rank correlation in the group of 58 and in a subset of nine subjects with elevated UBCR were: 0.55 (P < 0.0001); 0.317 (P = 0.0005) and 0.59 (P = 0.045); 0.48 (P = 0.037), respectively. The area under the curve for UACR was 0.882 (P = 0.0001), sensitivity 100% and specificity 67.3%. CONCLUSION: Microalbuminuria may be a useful marker of early tubular injury in individuals at risk of developing BEN.

Nonthyroidal illness syndrome in off-pump coronary artery bypass surger.

OBJECTIVE: It is well known that coronary artery bypass grafting (CABG) is often the cause of non-thyroidal illness syndrome (NTIS). Non-thyroidal illness syndrome (NTIS) is a state characterized by low levels of tri-iodo-thyronine (T3) and high levels of reverse T3 (rT3), with normal or low levels of thyroxin (T4) and normal, low-normal, or low levels of thyroid-stimulating hormone (TSH). Today, there are two main techniques of CABG: CABG with the use of cardiopulmonary bypass (on-pump coronary artery bypass - ONCAB) and CABG without the use of cardiopulmonary bypass (off-pump coronary artery bypass OPCAB), or 'beating-heart surgery.' The OPCAB technique is considered to be less invasive. We prospectively investigated the influence of these surgical techniques on the occurrence of NTIS. METHODS: Serum levels of free fractions of thyroid hormones (FT3 and FT4) and TSH were analyzed in 70 consecutive patients subjected to CABG surgery, using the ONCAB technique in 36 patients and OPCAB technique in 34 patients. The measurements of hormone levels were performed prior to surgery and 12 hours and 14 days after surgery. RESULTS: The basic, the early, and the late postoperative serum levels of FT3 (p=0.458, p=0.632, p=0.869, respectively), FT4 (p=0.664, p=0.301, p=0.417, respectively), and TSH (p=0.249, p=0.058, p=0.324, respectively) were similar in both groups. The levels of FT3 and TSH were significantly lower 12 hours after surgery (p<0.0001, p<0.0001, respectively), and the FT4 levels rose at the same time (p<0.0001). The third measurement showed the return of all investigated parameters back to physiological levels, although they were still not precisely within the initial values. CONCLUSION: NTIS occurs significantly in patients subjected to CABG. Although the OPCAB technique is considered to be less invasive, its impact on the occurrence of NTIS does not differ significantly from the ONCAB technique.

Survival of living-related kidney graft recipients in the era of modern immunosuppressive treatment.

BACKGROUND AND OBJECTIVES: Currently, there is no consensus about immunosuppressive therapy following kidney transplantation. Acute rejection rates and allograft survival rates are the clinical outcomes traditionally used to compare the efficacy of various immunosuppressive regimens. Therefore, we conducted this study to evaluate whether patient survival rates improved in the era of modern immunosuppressive treatment during living-related kidney transplantation. DESIGN AND SETTING: Retrospective cohort study in a university-based tertiary internal medicine teaching hospital performed between 1999 and 2009 and patients followed up to 7 years. PATIENTS AND METHODS: Survival rates were assessed in 38 patients receiving basiliximab and mycophenolate mofetil (regimen A) and 32 patients receiving antithymocyte globulin and azathioprine (regimen B). The rest of the regimen (cyclosporine A and steroids) remained the same. A secondary end point was acute rejection episode. RESULTS: Seven-year survival rates were 100% and 72% (P=.001) and 7-year acute rejection-free survival rates were 82% and 53% (P=.03), in groups A and B, respectively. CONCLUSION: Long-term survival after living-related kidney transplantation has improved in the era of modern immunosuppressive treatment.

Kidney graft outcomes in living-related transplantation have improved with substitution of basiliximab and mycophenolate mofetil for antithymocyte globulin and azathioprine: a single center retrospective cohort study.

BACKGROUND: Despite significant reduction in acute rejection rates and improvements in one year kidney allograft outcomes over the past decade, there is an overall lack of improvement in long-term allograft outcomes. We conducted this study to evaluate whether immunosuppressive regimens involving basiliximab and mycophenolate mofetil improved allograft outcomes in living-related kidney transplantation beyond the first year. METHODS: In a retrospective cohort study we analyzed kidney graft survival, acute rejection-free survival, kidney function, delayed graft function, and primary non-function in patients receiving an immunosuppressive regimen that included basiliximab and mycophenolate mofetil (group A), and compared to patients receiving antithymocyte globulin and azathioprine (group B). The rest of the treatment protocols remained the same, including cyclosporine A and steroids in both groups. RESULTS: Seven-year graft survival rates in groups A and B were 83% and 44%, respectively (p=0.005), 7-year acute rejection-free survival rates were 82% and 53%, respectively (p=0.03), kidney function was better (p=0.004) and its deterioration rate was lower (p=0.006) in patients receiving regimen A. In group A 1 primary non-function event was observed in contrast to 4 composite events of delayed graft function and primary non-function in group B (p>0.05). CONCLUSION: Long-term graft outcomes in living-related kidney transplantation have improved with substitution of basiliximab and mycophenolate mofetil for antithymocyte globulin and azathioprine in immunosuppressive protocols.

Direct coronary stenting in reducing radiation and radiocontrast consumption.

INTRODUCTION: Coronary stenting is the primary means of coronary revascularization. There are two basic techniques of stent implantation: stenting with balloon predilatation of stenosis and stenting without predilatation (direct stenting). Limiting the time that a fluoroscope is activated and by appropriately managing the intensity of the applied radiation, the operator limits radiation in the environment, and this saves the exposure to the patient and all personnel in the room. Nephrotoxicity is one of the most important properties of radiocontrast. The smaller amount of radiocontrast used also provides multiple positive effects, primarily regarding the periprocedural risk for the patients with the reduced renal function. The goal of the study was to compare fluoroscopy time, the amount of radiocontrast, and expenses of material used in direct stenting and in stenting with predilatation. PATIENTS AND METHODS: In a prospective study, 70 patients with coronary disease were randomized to direct stenting, or stenting with predilatation. RESULTS: Fluoroscopy time and radiocontrast use were significantly reduced in the directly stented patients in comparison to the patients stented with balloon-predilatation. The study showed a significant reduction of expenses when using a direct stenting method in comparison to stenting with predilatation. CONCLUSIONS: If the operator predicts that the procedure can be performed using direct stenting, he is encouraged to do so. Direct stenting is recommended for all percutaneous coronary interventions when appropriate conditions have been met. If direct stenting has been unsuccessful, the procedure can be converted to predilatation.