Heart Transplantation and Risk of Cardiac Vasculopathy Development: What Factors Are Important?

BACKGROUND The aim of this study was to find the main risk factors for development of cardiac allograft vasculopathy (CAV), especially factors identified before the surgical procedure and factors related to the recipient profile and the medical history of the donor. MATERIAL AND METHODS There were 147 patients who had heart transplantation (HT) included in this study: mean age was 45.8±15.3 years. All study patients had coronary angiography after HT. Analyzed risk factors were: non-immunologic recipient risk factors (age of transplantation, smoking, hypertension, lipids, diabetes, obesity and weight gain after HT), immunologic recipient risk factors (acute cellular rejection (ACR), acute humoral rejection (AMR), cytomegalovirus (CMV) episodes), and donor-related risk factors (age, sex, catecholamine usage, ischemic time, compatibility of sex and blood groups, cause of death, cardiac arrest). RESULTS CAV was recognized in 48 patients (CAV group); mean age 53.6±13.6 years. There were 99 patients without CAV (nonCAV group); mean age 48.3±15.5 years. A univariate Cox analysis of the development of coronary disease showed statistical significance (p<0.05) for baseline high-density lipid (HDL), ACR, AMR, CMV, and donor age. Multivariate Cox regression model confirmed that only baseline HDL, episodes of ACR, donor age, and CMV infection are significant for the frequency of CAV after HT. CONCLUSIONS Older donor age is highly associated with CAV development. Older donor age and low level of HDL in heart recipients with the strongest influence of immunologic risk factors (ACR, CMV infection) were linked with development of CAV.

SIMULTANEOUS ASSAY OF ARIPIPRAZOLE AND ITS ACTIVE METABOLITE IN SERUM BY HPLC.

A rapid, convenient, precise HPLC method was developed for the simultaneous determination of aripiprazole and its active metabolite dehydroaripiprazole in blood serum. The separation was carried out by RP HPLC on Symmetry C18 column (150 x 4.6 mm; 5 µm). The mobile phase was composed of acetonitrile: water (30 : 70, v/v), pH 3.0 adjusted with o-phosphoric acid. The detection was monitored at 220 nm.

Sarcoidosis as a risk factor for venous thromboembolism.

Sarcoidosis as a chronic condition of immune dysregulation might be associated with increased risk of venous thromboembolism (VTE). In this study we report three cases of sarcoidosis and pulmonary embolism (PE) occurring together, that share common clinical, serological and pathological findings, confirming the diagnosis of active pulmonary sarcoidosis and no others co-existing prothrombotic factors. We hypothesized that the hypercoagulability and increased risk for VTE in sarcoidosis may be attributable to active local and generalized inflammatory process. The possible relation of clinical picture of sarcoidosis that favors thrombus formation and the bidirectional inflammation and coagulation process are discussed. Further investigation of PE in patients with sarcoidosis are required as the co-incidence of both diseases seems to be more frequent than expected. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 170-178).

Non-high risk PE in the patients with acute or exacerbated respiratory disease: the value of the algorithm based on D-dimer evaluation and Revised Geneva Score.

INTRODUCTION: The diagnostic algorithm of non-high risk pulmonary embolism (PE) is based on probability scoring systems and plasma D-dimer (DD) assessment. The aim of the present study was to investigate the efficacy of Revised Geneva Scoring (RGS) and DD testing for the excluding of non-high risk PE, in the patients admitted to the hospital due to acute respiratory diseases. MATERIAL AND METHODS: The consecutive patients, above 18 years of age, referred to the department of lung diseases, entered the study. The exclusion criteria were: the pregnancy and the suspicion of high risk PE. Plasma DD was measured with quick ELISA test, VIDAS D-dimer New, bioMerieux, France. Multislice computed tomography angiography was performed in all of the patients. RESULTS: 153 patients, median age 65 (19-88) years entered the study. The probability of PE was: low - in 58 patients (38%), intermediate - in 90 (59%), high - in 5 (3%). DD < 500 ng/ml was found in 12% of patients with low and intermediate probability of PE. PE was recognized in 10 out of 153 patients (7%). None of the patients with DD < 500 ng/ml was diagnosed with PE (NPV 100%). Median DD value was significantly higher in PE patients comparing to non-PE (4500 ng/ml and 1356 ng/ml respectively, p = 0.006). CONCLUSION: In the group of the patients with acute respiratory symptoms, low or intermediate clinical probability scoring combined with normal DD had a high NPV in excluding PE. Nevertheless, such approach was not very effective, as the increased DD was noted in 88% of the examined population.

Methotrexate as a single agent for treating pulmonary sarcoidosis: a single centre real-life prospective study.

INTRODUCTION: The first-line therapy in chronic sarcoidosis, according to WASOG/ATS/ERS recommendations, is GCS. This therapy is associated with significant adverse effects and finally does not alter the natural history of the disease. The objective of our study was to evaluate the efficacy and safety of monotherapy with MTX, as an alternative to GCS, in progressive pulmonary sarcoidosis. MATERIAL AND METHODS: An open prospective real-life, single-centre trial was performed on 50 patients with biopsy proven sarcoidosis, 28M and 22F, mean age 45.55 ± 8.9 years. The average duration of disease before MTX therapy was 12.34 ± 20.49 years, GCS therapy in the past was applied in 41 patients. All patients received MTX (10 mg or 15 mg weekly) between 2004 and 2013 because of chronic progressive pulmonary sarcoidosis. Therapy was planned for 24 months. Patients underwent regular clinical evaluation, pulmonary function assessment, exercise ability testing (6MWT), and chest radiography for therapy effectiveness every six months and side effects monitoring every 4-6 weeks. Forty-nine patients were included for statistical analysis of treatment efficacy. They were retrospectively allocated to "MTX responder" group if an improvement of 10% of FEV1, FVC, TLC, or 15% of DLCO from the initial value was documented for at least one parameter or "non-responders" if the patient did not meet the above-mentioned criteria. RESULTS: Duration of treatment ranged from 6 to 24 months, mean time 60.75 ± 34.1 weeks. For the whole cohort significant improvement after MTX therapy was observed for minimal SaO2 (%) (p = 0.043) and for decrease of DSaO2 (%) (p = 0.048) in six-minute walk test. The results were significantly better for patients treated with 15 mg than for those treated with 10 mg weekly and for those who obtained a greater total amount of MTX during therapy. Significant difference of DLCO%pred was observed after six months of MTX therapy between groups treated 15 mg vs 10 mg weekly (73.27 ± 12.7% vs. 63.15 ± 16.4%, p = 0.03). Twenty-five patients (55%) met the criteria of "MTX responders" group. Patients who responded well to treatment had significantly lower TLC and FVC initial values comparing to "MTX non-responders". After treatment the only significant difference in PFT between groups was noted for DLCO%pred. Eleven patients (22%) stopped the treatment due to adverse events of MTX, mild hepatic abnormalities were observed in ten patients (20%), and concomitant infection was found in four patients. There were no patients with a fatal outcome. CONCLUSIONS: MTX as a single agent in the treatment of sarcoidosis has proved to be a safe and effective steroid alternative. Selected patients with chronic pulmonary sarcoidosis experience definite PFT improvements after MTX treatment. There is need to search for predictors of MTX treatment effectiveness.

Standards of the Polish Ultrasound Society - update. Examination of extracranial carotid and vertebral arteries.

The role of a standard is to describe examination techniques, recommended norms as well as principles necessary to obtain results and draw appropriate conclusions, rather than a description of pathologies. The paper presents a technique for carotid artery examination as well as currently recommended standards. According to San Francisco Consensus from 2003, a significant stenosis of 70% may be detected when systolic velocity in the internal carotid artery stenosis is >230 cm/s, and the diastolic velocity is >100 cm/s. The common carotid artery velocity is also taken into account. Hemodynamic evaluation is therefore the primary method for the assessment of the degree of internal carotid artery stenosis. It is important that the examination is performed at an insonation angle of 60° as measurements at higher angles result in an exponential increase in measurement error. Also, an extended version of standards involving measurements performed behind stenosis, which are used in some clinics, is included in the paper. The paper further presents guidelines for the description of the identified pathologies, which ensure that the findings prove unambiguous for clinicians, especially when stenosis eligible for surgical intervention is detected. Morphological measurement of stenosis (according to NASCET criteria) is only of supplementary character (confirming morphological grounds for the increase of velocity) and has no critical importance, especially due to high measurement divergence. Description of atherosclerotic plaques, especially hypoechoic ones, which are considered potentially unstable and may lead to a raised risk of stroke, is a very important element of examination. The paper is based on Standards of the Polish Ultrasound Society and updated based on the latest literature reports.

Standards of the Polish Ultrasound Society - update. Ultrasound examination of the aorta and arteries of the lower extremities.

A Doppler ultrasound examination has an advantage over other vessel imaging methods as it can be carried out by the patient's bedside and allows to make a diagnosis without exposing the patient to the inconveniency of transportation or an X-ray scan. The purpose of testing the lower extremities and the aorta is to objectively confirm a preliminary clinical diagnosis, localize lesions responsible for the symptoms of the disease, determine their severity and nature (e.g., if they are calcifications or soft lesions), and finally evaluate the hemodynamic criteria. In assessment of the aorta attention is paid not only to aortic diameter measurements, but also to the vascular lumen (dissections with the formation of two flow channels, detachments, balloting of atherosclerotic plaques, etc.) and the presence of atherosclerotic plaques with influx into them (PAU - penetrating ulcer in the plaque or lesions surrounding the aorta, such as retroperitoneal fibrosis or mycotic aneurysm). A correct diagnosis of an abdominal aortic aneurysm requires repeated measurements of the abdominal aorta diameter, and in particular its transverse dimension. When assessing the degree of peripheral arterial stenosis on the basis of hemodynamic parameters, degree of morphological stenosis must be taken into consideration. Collateral circulation may reduce the flow through the main vessel, and thus, the achieved systolic velocities are lower and may understate the degree of the assessed stenosis. Calf vessels are difficult to detect, which results both from the thickness of the muscle and the presence of calcifications. This article has been prepared on the basis of Standards of the Polish Ultrasound Society (2011) and updated on the basis of the latest reports from relevant literature.

Standards of the Polish Ultrasound Society - update. Sonography of the lower extremity veins.

This article has been prepared on the basis of the Ultrasonography Standards of the Polish Ultrasound Society (2011) and updated based on the latest findings and reports. Ultrasound examination of the lower extremity veins is relatively easy and commonly used to confirm or rule out venous thrombosis. However, a relatively easy compression test frequently requires experience, particularly in situations when imaging is difficult (due to lymphedema, dressing or thick tissues). The technique is time-consuming and requires assessment of each deep vein every 1 cm. Lesions in the deep veins cannot be ruled out when the vessels are assessed in only 2-3 points - a full examination is needed. The value of the method is the highest when the proximal section is assessed and the lowest when crural veins are evaluated. Doppler sonography is the basic method used when patients are prepared for a surgery of varicose veins. The assessment of the superficial veins prior to this procedure is tedious and requires knowledge of anatomy together with numerous variants. A considerable challenge is posed by re-assessment of recurrent varicose veins following a previous surgery. The Standards include anatomic nomenclature proposed by the Polish Society for Vascular Surgery and Polish Society of Phlebology, which should facilitate communication with clinicians. The most beneficial patient positions have been thoroughly discussed in terms of safety and effectiveness of the examination. Sometimes during such an examination, no venous pathology is found, but other changes with symptoms that suggest deep thrombophlebitis are detected. In such a situation, it is necessary to conduct an initial (or complete, if possible) assessment of lesions as well as provide recommendations connected with further, more detailed diagnosis.

[Acute lupus pneumonitis--case report and literature review]. / Ostre toczniowe zapalenie pluc--opis przypadku i przeglad pismiennictwa.

Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disease that is characterized by its chronic course and the involvement of many organs and systems. The most common abnormality in the respiratory system of SLE patients is lupus pleuritis. Less common is parenchymal involvement, which may present as acute lupus pneumonitis (ALP) or chronic interstitial lung disease. Other possible pulmonary manifestations of SLE include pulmonary embolism, diffuse alveolar haemorrhage, acute reversible hypoxaemia, and shrinking lung syndrome. We present the case report of a young woman with previously diagnosed membranous glomerulonephritis with nephrotic syndrome and antiphospholipid syndrome, who was admitted with marked of shortness of breath. The diagnostic process, including imaging studies and laboratory tests, enabled us to confirm a diagnosis of ALP. After initiation of treatment with high doses of methyloprednisolone, nearly complete remission of pulmonary changes was observed. We also perform a literature review regarding acute lupus pneumonitis.

Incidence of malignancies in cardiac allograft recipients - a single-center experience.

BACKGROUND: Most of the available data suggest that the risk of malignancy in solid organ recipients is higher than in the general population. In Poland, the prevalence rate for malignancy in the general population is about 1.02%. MATERIAL AND METHODS: At out Outpatient Clinic for patients after heart transplantation we analyzed all 324 patients transplanted from 1987-2011 for the presence of malignancies. The end-point of the analysis was determined by malignancy diagnosis, patient death, or end of the observation period (December 12, 2011). RESULTS: We detected 31 malignancies in 29 of 324 patients (8.95%). In 2 patients we found 2 types of malignancies. The dominant type of malignancy was pulmonary carcinoma, diagnosed in 11/29 (37.93%) patients. Skin carcinoma was recognized in 7 patients (24.14%). Fourteen (48.3%) patients died (12 men and 2 women): 5 of them in the course of pulmonary carcinoma (35.7%), 3 of skin carcinoma (21.4), 3 in the course of lymphoma, 1 in the course of renal carcinoma, 1 in the course of stomach carcinoma, 1 of colorectal carcinoma, and 1 of prostatic carcinoma. CONCLUSIONS: The risk of malignancy development is many times higher for HT patients than in the general population. The high incidence rate for pulmonary carcinoma in the analyzed group of patients was most likely related to smoking before transplantation and continuation of smoking after the procedure in the case of patients who received immunosuppressive therapy.

Vena cava filter occlusion and venous thromboembolism risk in persistently anticoagulated patients: a prospective, observational cohort study.

BACKGROUND: Inferior vena cava (IVC) filter placement may be life-saving, but after contraindications to anticoagulation remit, patient management is uncertain. METHODS: We followed patients who had venous thromboembolism, followed by treatment with permanent IVC filter placement, and were anticoagulated long-term as soon as safety allowed. We conducted annual physical examinations and ultrasound surveillance of the lower extremity deep veins and of the IVC filter site. Clot detected at the filter site was treated with graded intensities of anticoagulation, depending on the clot burden. RESULTS: Symptomatic DVT occurred in 24 of 121 patients (20%; 95% CI, 14%-28%); symptomatic pulmonary embolism (one fatal) was diagnosed in six patients (5%; 95% CI, 2%-10%). There were 45 episodes of filter clot in 36 patients (30%; 95% CI, 22%-38%). The rate of major bleeding (6.6%) was similar to that of a concurrent persistently anticoagulated cohort without IVC filters (5.8%). CONCLUSIONS: If therapeutic anticoagulation can be safely begun in patients with IVC filters inserted after venous thromboembolism, further management with clinical surveillance, including ultrasound examination of the IVC filter and graded degrees of anticoagulation therapy if filter clot is detected, has a favorable prognosis. This approach appears valid for patients with current IVC filter and can serve as a comparison standard in subsequent clinical trials to optimize clinical management of these patients.

[Chest ultrasound in the diagnosis of pulmonary embolism in a pregnant patient - a case report]. / Ultrasonografia klatki piersiowej w diagnosytce zatorowosci plucnej u ciezarnej - opis pryzpadku.

Pregnancy is a risk factor for both pulmonary embolism (PE), and an incorrect diagnostic assessment in cases of suspected PE with potentially dangerous consequences for the mother and foetus. The major concern is ionising radiation utilized by diagnostic tests and its potential negative effect on foetal safety. This paper presents diagnostic difficulties encountered in a 31-year-old patient at 20 weeks of gestation who was admitted to hospital with non-specific chest pain and suspected PE as a complication of right lower limb venous thrombosis. The case study reminds of chest ultrasound as a useful tool in the diagnosis of PE. The official clinical practice guidelines do not recommend the use of chest ultrasound for diagnosing of PE due to lack of a sufficient number of published studies. This case report may encourage further, prospective studies in the hope to define whether and when chest ultrasound might find its place in the diagnostic strategy of PE, especially in pregnant women.

Accuracy of compression ultrasound in screening for deep venous thrombosis in acutely ill medical patients.

The value of vein ultrasonography for diagnosis of symptomatic deep vein thrombosis (DVT) is widely accepted. We are unaware of published data comparing ultrasonography with the "gold standard" of venography for DVT diagnosis in asymptomatic persons in the patient group of acutely ill medical patients. It was the objective of this study to evaluate sensitivity and specificity of compression ultrasound (CUS) examinations in the diagnosis of proximal and distal DVT in acutely ill medical patients [with congestive heart failure (NYHA class III and IV), exacerbations of respiratory disease, infectious disease, and inflammatory diseases] considered to be at moderate risk of venous thromboembolism (VTE). CUS examination was performed prior to ascending venography on day 6-15 of the hospital stay. Both investigations were done on the same day, each interpreted without knowledge of the other's result. Proximal and calf veins were separately evaluated. Technically satisfactory venography was obtained in 160 patients. In 12 of 160 patients (7.5%, 95% CI=[4.0%-12.7%]), venography confirmed the presence of DVT, all of which was asymptomatic. Proximal DVT was detected in five patients (3.1%, 95% CI=[1.0%-7.1%]) and distal DVT in seven patients (4.4%, 95% CI=[1.8%-8.8%]). CUS of proximal veins was technically satisfactory in all 160 patients and CUS of distal veins in 150 patients. In three of five patients with venographically proven proximal DVT, the diagnosis was confirmed by CUS (sensitivity 60%, 95%CI=[23%-88%]). In one patient, the CUS was false positive (specificity 99.4%, 95%CI=[96%-99%]). Positive and negative predictive values (PPV and NPV) of CUS in the diagnosis of proximal DVT were 75% (95%CI=[30%-95%]) and 98% (95% CI=[95%-99%]), respectively. In two of seven patients with venographically proven calf DVT, the diagnosis was confirmed by CUS (sensitivity 28.6%, 95%CI=[8%-64%]) and in two patients, CUS was false positive (specificity 98.6, 95%CI=[95%-99%]). PPV and NPV of CUS in diagnosis of distal DVT were 50% (95%CI=[15-85%]) and 96% (95% CI=[92%-98%]), respectively. In conclusion, CUS underestimates the incidence of proximal and distal DVT compared to contrast venography in acutely ill medical patients without thrombosis symptoms.

[Recurrent pneumothorax as alone manifestation of mesothelioma pleurae]. / Nawracajace odmy oplucnowe jako jedyna manifestacja miedzybloniaka oplucnej.

Malignant mesothelioma of the pleura is a rare neoplasm with a poor prognosis. The most often symptoms of this disease are dyspnoe and chest wall pain, which is often associated with pleural effusion. We present 35-years old woman with 5 epizodes of pneumothorax during 3 years (4 of right side and 1-bilateral) in whom bilateral pleurodesis was performed. Specimens of lung and pleurae were examinated. Result of microscopic and immunohistochemical examination was: mesothelioma epithelioides pleurae (mesothelium +, calretyninaa +, EMA+ membrane reaction, desmine +/-).