Echocardiographic parameters as adjuncts to the Pulmonary Embolism Severity Index in predicting 30-day mortality in acute pulmonary embolism patients.

BACKGROUND: The Pulmonary Embolism Severity Index (PESI) is a validated tool to predict 30-day all-cause mortality in patients with acute pulmonary embolism (PE) but includes only clinical variables. AIMS: We aimed to determine the effectiveness of PESI extended with an echocardiographic parameter. METHODS: This cross-sectional observational study included consecutive patients with acute PE diagnosed with computed tomography pulmonary angiography. RESULTS: Of 117 subjects (57 men, 48.7%), at a median age of 69 (59-80) years, 16 patients died during the 30-day follow-up. Six modified models of PESI with an additional single echocardiographic parameter were created, which increased the predictive value of PESI (area under the curve [AUC] 0.8608): tricuspid annular plane systolic excursion (TAPSE) <18 mm, right ventricular (RV) free wall longitudinal strain (RVFWLS) >-23%, 60/60 sign, RV global longitudinal strain (RVGLS) >-16%, pulmonary ejection acceleration time (AcT) <67 ms, and thrombus in right heart cavities (AUC 0.8657 to 0.8976, respectively, all markers P <0.001). TAPSE, AcT, RVFWLS, and RVGLS showed significant correlations with the PESI score, but not a thrombus in the right heart cavity or the 60/60 sign. As PESI adjuncts, they independently predicted fatal outcomes: thrombus with hazard ratio (HR) 10.04 (95% confidence interval [CI], 2.81-37.12; P <0.001) and the 60/60 sign with HR 4.07 (95% CI, 1.27-12.81; P <0.001). CONCLUSIONS: The quantitative echocardiographic parameters of RV systolic function and pulmonary artery blood flow are associated with the PESI score and thus increase its predictive value to a limited extent. PE- specific findings: a thrombus in the right heart cavity and the 60/60 sign are effective adjuncts to the PESI score.

Indexing of Speckle Tracking Longitudinal Strain of Right Ventricle to Body Surface Area Does Not Improve Its Efficiency in Diagnosis and Mortality Risk Stratification in Patients with Acute Pulmonary Embolism.

BACKGROUND: Acute pulmonary embolism (PE) is associated with a serious mortality rate. Thus, the rapid diagnosis and identification of patients at high risk of death is pivotal. The search for echocardiographic parameters for this purpose continues. Recent publications reveal correlations between myocardial longitudinal strain (LS) and body surface area (BSA). The aim of the study was to evaluate the usefulness of indexing the right ventricular (RV) speckle tracking LS to BSA in detecting PE and stratifying the risk of 30-day all-cause mortality. METHODS: the prospective cross-sectional observational study group consisted of 167 consecutive patients (76 men, 45.5%) aged 69.5 ± 15.3 years, and they were referred for computed tomography pulmonary angiography. Patients underwent a transthoracic echocardiographic examination within 24 h of admission to the hospital ward. RVLS and their derivatives indexed to BSA were included in the analysis. RESULTS: PE was confirmed in 88 patients, while 79 patients had no radiological features of PE. The only echocardiographic parameters that differed between subgroups were pulmonary flow acceleration (Act), McConnell's sign, LS of the middle segment of the RV free wall, and its derivative indexed to BSA. During the 30-day follow-up of a subgroup of subjects with PE, 12 patients died. The mortality predictors with increasing prediction value included a RV free wall mid-segment LS (cut-off value: -21%, Area Under the Curve-AUC 0.6, p = 0.02) and its derivative indexed to BSA (-14 %/m2, AUC 0.62, p = 0.003), body mass index (24.7 kg/m2, AUC 0.63, p = 0.002), D-dimer serum concentration (3559 pg/mL, AUC 0.66, p < 0.001), Act (67 ms, AUC 0.67, p < 0.001), septal basal LS (-15%, AUC 0.68, p = 0.02), RV free wall basal segment LS (-14%, AUC 0.7, p = 0.015), age (66 years, AUC 0.74, p = 0.004), NT-proBNP (1120 pg/mL, AUC 0.75, p = 0.01), troponin T (66 ng/mL, AUC 0.78, p = 0.005), and the complex score of the Pulmonary Embolism Severity Index (AUC 0.88, p < 0.001). CONCLUSIONS: indexing of RVLS to BSA does not improve its prognostic value in patients with acute PE.

Paroxysmal Sustained Ventricular Tachycardia with Cardiac Arrest and Myocardial Infarction in 29-Year-Old Man Addicted to Medical Marijuana-It Never Rains but It Pours.

This article presents the case of a 29-year-old male patient, addicted to prescribed medical marijuana administered for mixed anxiety and depressive disorder and without classic cardiovascular risk factors and history of myocarditis, suffering from episodes of paroxysmal hemodynamically unstable ventricular tachycardia. Cardiovascular magnetic resonance imaging of the heart revealed disseminated non-ischemic myocardial injury lesions of subepicardial and intramuscular location. Additionally, the individual experienced myocardial infarction without ST segment elevation following marijuana intake. Treatment required implantation of a cardioverter-defibrillator and ablation of the myocardial areas responsible for the origin of the arrhythmia, as well as appropriate pharmacotherapy and marijuana addiction treatment.

Subcostal echocardiographic assessment of tricuspid annular kick (SEATAK): A novel independent predictor of 30-day mortality in patients with acute pulmonary embolism.

BACKGROUND: The most commonly used parameter of right ventricular (RV) systolic function - tricuspid annular plane systolic excursion (TAPSE) - is unavailable for some patients. Subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) has been proposed as its alternative. AIM: The study aimed to assess the feasibility of SEATAK use in patients with acute pulmonary embolism (PE) and its value in prognosis after PE. METHODS: The observational study included 164 consecutive patients (45.7% men; average age, 70 years) with a high clinical probability of PE referred for computed tomography pulmonary angiography. RESULTS: SEATAK was unavailable due to inadequate quality of echocardiogram in 2.8% of patients, whereas TAPSE could not be calculated in 4.9%, both parameters were not estimated only in 0.6%. SEATAK and TAPSE values did not differ between groups of patients with PE (n = 82) and without (n = 82). In the whole study, SEATAK correlated positively with TAPSE (r = 0.71; 95% confidence interval [CI], 0.62-0.78; P < 0.001), fractional area change of the RV, left ventricular ejection fraction, and peak systolic tricuspid annular velocity assessed with tissue Doppler imaging. There were only 3 echocardiographic predictors of 30-day all-cause mortality in patients with with PE (n = 10): SEATAK, pulmonary acceleration time, and the 60/60 sign. SEATAK predicted 30-day all-cause mortality with AUC (area under the curve) 0.726 (95% CI, 0.594-0.858; P = 0.01) and 30-day PE-related mortality (n = 4) with AUC, 0.772 (95% CI, 0.506-0.998; P = 0.03). CONCLUSIONS: SEATAK is a promising practicable echocardiographic parameter reflecting RV systolic function and might be an accurate alternative to TAPSE. Moreover, SEATAK could be an independent predictor of all-cause and PE-related 30-day mortality in patients with acute PE.

Insights into the microbial community of treated wastewater, its year-round variability and impact on the receiver, using cultivation, microscopy and amplicon-based methods.

Apart from chemical constituents, wastewater treatment plant (WWTP) effluents also release microorganisms that can be important to the receiving water bodies either from a sanitary point of view, or taking to the account the biogeochemical potential of the recipients. However, little is known about the treated wastewater microbial community, its composition, seasonal changes, functions and fate in the waters of the receiver. Thus, this study presents a synergistic approach coupling new and traditional methods: analytical chemistry, classical microbiology (cultivation- and microscopy-based methods), as well as Next Generation Sequencing and a quantitative real-time polymerase chain reaction (qPCR). The results show that in terms of bacterial community composition, treated wastewater differed from the environmental samples, irrespectively if they were related or unrelated to the WWTP effluent discharge. The canonical correspondence analysis (CCA) taking into account chemical parameters and taxonomical biodiversity indirectly confirmed the seasonal deterioration of the treated wastewater quality as a result of temperature-driven change of activated sludge community structure and biomass washout (observed also by DAPI staining). Despite seasonal fluctuations of total suspended solids and inter-related parameters (such as COD, BOD, TN, TP), the treated wastewater quality remained within current discharge limits. It was due to treatment processes intensively adjusted by WWTP operators, particularly those necessary to maintain an appropriate rate of autotrophic processes of nitrification and to support biological phosphorus removal. This can explain the observed microbiome composition similarity among WWTP effluents at high taxonomic levels. Obtained data also suggest that besides wastewater treatment efficiency, WWTP effluents are still sources of both human-related microorganisms as well as bacteria equipped in genes involved in N-cycling. Their potential of participation in nutrients cycling in the receivers is widely unknown and require critical attention and better understanding.

The evaluation of COD fractionation and modeling as a key factor for appropriate optimization and monitoring of modern cost-effective activated sludge systems.

A study was conducted to characterize the raw wastewater entering a modern cost effective municipal WWTP in Poland using two approaches; 1) a combination of modeling and carbonaceous oxygen demand (COD) fractionation using respirometric test coupled with model estimation (RT-ME) and 2) flocculation/filtration COD fractionation method combined with BOD measurements (FF-BOD). It was observed that the particulate fractions of COD obtained using FF-BOD method was higher than those estimated by RT-ME approach. Contrary to the above, the values of inert soluble fraction evaluated by FF-BOD method was significantly lower than RT-ME approach (2.4% and 3.9% respectively). Furthermore, the values for low colloidal and particulate fractions as well as soluble inert fractions were different than expected from a typical municipal wastewater. These observations suggest that even at low load (10% of the total wastewater treatment inflow), the industrial wastewater composition can significantly affect the characteristics of municipal wastewater which could also affect the performance and accuracy of respirometric tests. Therefore, in such cases, comparison of the respirometric tests with flocculation/filtration COD/BOD measurements are recommended. Oxygen uptake rate profile with settled wastewater and/or after coagulation-flocculation, however, could still be recommended as a "rapid" control method for monitoring/optimising modern cost-effective wastewater treatment plants.

Ionic liquids strongly affect the interaction of bacteria with magnesium oxide and silica nanoparticles.

Quaternary ammonium theophylline-based ionic liquids and imidazolium-based ionic liquids, magnesium oxide and silica nanoparticles were used in order to investigate the interaction with Gram negative Escherichia coli and Gram positive Bacillus cereus. The changes of bacterial sensitivity to both nanoparticles (NPs) and ionic liquids (ILs) were examined. In order to assess the impact of ILs on the interaction of nanoparticles with bacteria, respirometric analysis, activity of dehydrogenases, peroxidase analyses as well as scanning and fluorescence microscopy examinations were conducted. The interactions of ILs with nanoparticles based on adsorption and sedimentation tests were also investigated in order to assess how the ILs affect the agglomeration of NPs. It was assumed, as the main hypothesis of the present studies, that the differences in sensitivity of bacteria to combined ILs and NPs can be observed, even if the concentration of both compounds are below the minimum inhibitory concentration (MIC). The results indicated that ILs strongly affected the sensitivity of bacteria to nanoparticles however, the changes of sensitivity depended on the surface characteristics of the nanoparticles. The presence of ILs at non-lethal concentrations caused an increase of bacterial sensitivity to MgO nanoparticles. Notably, the sensitivity of Gram positive bacteria increased significantly when ILs were present. This was an important observation because the toxicity of nanoparticles toward Gram positive bacteria is usually lower than their toxicity toward Gram negative bacteria. Using silica nanoparticles, the presence of ionic liquids caused the adsorption of bacteria onto the surface of nanoparticle agglomerates. In conclusion, two opposing effects have been observed. On the one hand, the toxicity of MgO NPs in the presence of ILs has increased. On the other hand, the presence of silica nanoparticles caused a decreased sensitivity of both types of bacteria toward ILs. Our studies indicate potentially useful processes in many environmantal protection technologies like water treatment where flocculation and disinfection are extremely needed.

Model based evaluation of plant improvement at a large wastewater treatment plant (WWTP).

In this work, the effect of the improvement carried out at a large-scale wastewater treatment plant (WWTP) was evaluated, by means of modelling works, with the aim to determine the influence of the modernization over the process performance. After modernization, the energy consumption due to the aeration decreased about a 20% maintaining the effluent quality. In order to double-check the good effluent quality, modelling works were carried out at the full-scale plant. After calibration, the model was applied to the upgraded full-scale plant obtaining deviations lower than 10%. Then, the performance of the main biochemical processes was evaluated in terms of oxygen uptake rate (OUR), ammonia uptake rate (AUR), and chemical oxygen demand (COD) consumption. The rate of the main processes depending on the aeration, that is OUR and AUR, were about 22 gO2/(kg VSS·h) and 2.9 gN/(kg VSS·h), respectively.

Right-sided aortic arch with aberrant left subclavian artery and hearing loss in patient with abnormal cardiomediastinal contours in routine chest X-ray.

Although the development of technologically advanced imaging techniques has progressively reduced the use of chest X-ray in clinical practice, it is still an invaluable tool to evaluate different diseases of the respiratory and cardiovascular systems. We are presenting a case of a 55-year-old male with arterial hypertension, severe mixed hearing loss who was referred to an internal medicine ward due to abnormal mediastinal and cardiac contours observed in a routine chest X-ray. The finding was linked to an anomalous aortic course what was confirmed within transthoracic echocardiography. The computed tomography angiography of the whole aorta revealed the right sided aortic arch (RSAA) with four large arteries arising from the aortic arch, including the aberrant left subclavian artery compressing the esophagus causing though no symptoms. Since RSAA might be associated with other cardiovascular diseases and genetic disorders including 22q11.2 deletion syndrome, we have conducted a complex diagnostics which showed additionally a decreased level of lymphocytes. The patient did not consent to genetic diagnostics and was qualified for conservative treatment of his disorders. In conclusion, a plain chest radiograph with the assessment of heart silhouette must not be neglected in cardiologic diagnostics. The identification of even asymptomatic aortic anatomic variant should be followed by the whole aorta angiography and a detailed assessment of the patient. RSAA bears potential risk of tracheostomy bleeding, unforeseen problems in transradial coronary procedures and potential problems during thyroid surgery, also because of abnormal recurrent laryngeal nerves' course.

1000 liver transplantations at the Department of General, Transplant and Liver Surgery, Medical University of Warsaw--analysis of indications and results.

THE AIM OF THE STUDY: was to analyze indications and results of the first one thousand liver transplantations at Chair and Clinic of General, Transplantation and Liver Surgery, Medical University of Warsaw. MATERIAL AND METHODS: Data from 1000 transplantations (944 patients) performed at Chair and Clinic of General, Transplantation and Liver Surgery between 1994 and 2011 were analyzed retrospectively. These included 943 first transplantations and 55 retransplantations and 2 re-retransplantations. Frequency of particular indications for first transplantation and retransplantations was established. Perioperative mortality was defined as death within 30 days after the transplantation. Kaplan-Meier survival analysis was used to estimate 5-year patient and graft survival. RESULTS: The most common indications for first transplantation included: liver failure caused by hepatitis C infection (27.8%) and hepatitis B infection (18%) and alcoholic liver disease (17.7%). Early (< 6 months) and late (> 6 months) retransplantations were dominated by hepatic artery thrombosis (54.3%) and recurrence of the underlying disease (45%). Perioperative mortality rate was 8.9% for first transplantations and 34.5% for retransplantations. Five-year patient and graft survival rate was 74.3% and 71%, respectively, after first transplantations and 54.7% and 52.9%, respectively, after retransplantations. CONCLUSIONS: Development of liver transplantation program provided more than 1000 transplantations and excellent long-term results. Liver failure caused by hepatitis C and B infections remains the most common cause of liver transplantation and structure of other indications is consistent with European data.

[Serum arginase activity in patients with liver cirrhosis and hepatocellular carcinoma]. / Arginaza w surowicy krwi chorych z marskoscia i rakiem watrobowokomórkowym.

Preoperative and postoperative arginase activity was determined in blood serum of 25 patients with liver cirrhosis and 25 patients with hepatocellular carcinoma. The rise of serum arginase activity was observed in the majority of patients before the surgery and the decrease after tumor resection or liver transplantation. The preoperative values of serum arginase activity were similar in both groups of patients. A presence of additional, anionic arginase isoform (All) was demonstrated in serum of studied patients, which was absent in healthy subjects. Thus, our results indicate that the arginase activity cannot differentiate liver cirrhosis and hepatocellular carcinoma. However, arginase isoform All seems to be specific for studied liver diseases.

Results of liver transplantation for hepatocellular cancer.

BACKGROUND: Liver transplantation (LTx) for hepatocellular carcinoma (HCC) in cirrhotic liver is nowadays generally accepted treatment modality. AIM OF STUDY: Overview of the indications and results of the LTx in the patients with HCC, the first one performed in 2001. MATERIAL/METHODS: Among 357 adult liver transplant recipients in the period 1994-04.2005, in 26 (7%) the indication was HCC (16 men: 10 women, age 20-65, mean 46.5 years). HCC developed in cirrhotic liver in 25 pts. 12 (48%) were Child C, 10 (30%)--Child B and 3 (12%)--Child A patients. As underlying disease in 2 patients (8%) was alcoholic cirrhosis, in 7 (28%)--HBV cirrhosis, in 12 (48%)--HCV cirrhosis and in 4 (16%)--HBV/HCV cirrhosis. Milano criteria were met in 20 patients (77%). The mean waiting list time was 2.9 months (range 1-6 months). Seven patients underwent liver resection and 1 transarterial chemoembolization prior to LTx. 11 patients (42%) were operated on with use of veno-venous bypass, in 15 patients (58%) the piggy back technique was applied. Rapamycine based immunosuppression was preferred in post-LTx treatment. RESULTS: Operative mortality was 0.4 patients required relaparotomy for intraperitoneal bleeding. 21 patients (81%) are alive in good general condition, 19--free of the disease. 5 patients died 7-28 months after LTx (mean 16.7). The mean survival time is 20 months (range 1-38). CONCLUSIONS: Liver transplantation is safe and effective method of treatment of the selected patients with HCC in cirrhotic liver. Further investigations concerning the precise indications, timing of the transplantation and adjuvant treatment are necessary.

[Arginase as a marker of cancerogenesis. III. Comparison of arginase activity with CEA and Ca 19-9 in liver metastases of colorectal cancer]. / Arginaza jako marker procesu nowotworowego. III. Porównanie aktywnosci arginazy z CEA i Ca 19-9 w przerzutach raka jelita grubego do watroby.

Preoperative activity of arginase was determined in blood serum of 86 patients with colorectal liver metastases and compared with the level of CEA and Ca 19-9. Arginase activity was elevated in 94% patients, whereas the levels of CEA and CA 19-9 were higher in 63% and 45% patients, respectively. The number of not detected by each marker cases (false negative) was much lower in arginase determination (only 6%) than in CEA (37s%), and Ca 19-9 (55%). Sensitivity and specificity of arginase test was much higher than these of CEA and Ca 19-9. The combination of CEA or Ca 19-9 with arginase determination improved the sensitivity of either test, but the combined parameters were still lower than these for arginase itself. Obtained results indicate that arginase test demonstrate higher clinical value in the early diagnosis of colorectal liver metastases than CEA and Ca 19-9.

Orthotopic liver transplantation for acute liver failure resulting from "acute fatty liver of pregnancy".

Steatosis of the liver, demonstrating itself as the acute liver failure during the third trimester of pregnancy (Acute Fatty Liver of Pregnancy--AFLP) is a rarely observed liver pathology. Herewith we describe the case of a 19-years old pregnant patient with this rare disease. The authors present the clinical course, dynamics, diagnostics, and outcome of treatment in this unique case. In this patient the ultimate treatment chosen was the liver transplantation. The opinions, concerning liver transplantation in AFLP (expressed in the world literature) are somewhat controversial. This paper presents the first case of AFLP treatment with orthotopic liver transplantation (OLTx) in Poland.

Serum arginase activity in postsurgical monitoring of patients with colorectal carcinoma.

BACKGROUND: Colorectal carcinoma (CRC) is one of the most common malignancies. In the current work, the role of arginase as a diagnostic marker in patients with recurrent CRC and colorectal liver metastases (CRCLM) was studied. METHODS: Arginase activity was monitored in serum from 40 patients with primary CRC and from 100 patients with CRCLM. Blood was taken before and after patients underwent tumor resection. Studies were conducted for 3 years. RESULTS: Preoperative arginase activity in serum from patients with CRC and CRCLM was much greater compared with the arginase activity in serum from healthy control blood donors. One and two cut-off levels of increased arginase activity were observed in patients with CRC and CRCLM, respectively. After patients underwent tumor resection, the arginase activity decreased to normal values in both patients with CRC and patients with CRCLM. Activity levels remained low in patients who did not develop recurrent CRC or CRCLM (first or second). In patients who developed subsequent recurrences or metastases that appeared after surgery, during 3 years of surveillance, a significant rise in serum arginase activity was observed. The clinical prognosis for patients was worst when the postoperative serum arginase activity was very high, because those patients more often developed second liver metastases or died. CONCLUSIONS: The authors conclude that the determination of serum arginase activity may be a complementary test to confirm the occurrence of CRC and may be useful for the early diagnosis of patients who develop recurrent CRC and/or CRCLM.

[Arginase a marker of cancerogenesis. II. Monitoring of patients after resection of colorectal liver metastases]. / Arginaza jako marker procesu nowotworowego. II. Monitorowanie chorych po resekcji przerzutów raka jelita grubego do watroby.

Preoperative activity of arginase in blood serum of patients with colorectal cancer metastases to the liver is much higher than in serum of healthy blood donors. Before tumour resection in serum of 100 patients two cut-off levels of arginase activity were observed--in 65 subjects the activity ranged from 10 to 70 U/(group I), and in 35 subjects (group II), from 100 to 200 U/l. The raised arginase activity was observed in 83% of patients from group I, and in all studied patients (100%) from subgroup II. After liver surgery, arginase activity decreased to the normal value in the majority of patients. During three years of surveillance, in 88% and 63% of patients from either subgroup, respectively, no significant increase in arginase activity was observed, and the patients remained cancer-free. However, the rise of arginase activity was demonstrated in 13% and 37% subjects from either subgroup, respectively--the patients developed second liver metastases or died. Metastases and deaths were observed more often in patients from group II than I. The rise in arginase activity in blood serum after resection of colorectal cancer metastases to the liver indicates the possibility of new cancerogenesis. The special group at risk are patients with high (100 or more U/l) preoperative serum arginase activity.