Patients with rheumatoid arthritis facing sick leave or work disability meet varying regulations: a study among rheumatologists and patients from 44 European countries.

OBJECTIVES: To describe and explore differences in formal regulations around sick leave and work disability (WD) for patients with rheumatoid arthritis (RA), as well as perceptions by rheumatologists and patients on the system's performance, across European countries. METHODS: We conducted three cross-sectional surveys in 50 European countries: one on work (re-)integration and social security (SS) system arrangements in case of sick leave and long-term WD due to RA (one rheumatologist per country), and two among approximately 15 rheumatologists and 15 patients per country on perceptions regarding SS arrangements on work participation. Differences in regulations and perceptions were compared across categories defined by gross domestic product (GDP), type of social welfare regime, European Union (EU) membership and country RA WD rates. RESULTS: Forty-four (88%) countries provided data on regulations, 33 (75%) on perceptions of rheumatologists (n=539) and 34 (77%) on perceptions of patients (n=719). While large variation was observed across all regulations across countries, no relationship was found between most of regulations or income compensation and GDP, type of SS system or rates of WD. Regarding perceptions, rheumatologists in high GDP and EU-member countries felt less confident in their role in the decision process towards WD (ß=-0.5 (95% CI -0.9 to -0.2) and ß=-0.5 (95% CI -1.0 to -0.1), respectively). The Scandinavian and Bismarckian system scored best on patients' and rheumatologists' perceptions of regulations and system performance. CONCLUSIONS: There is large heterogeneity in rules and regulations of SS systems across Europe in relation to WD of patients with RA, and it cannot be explained by existing welfare regimes, EU membership or country's wealth.

Vagus nerve stimulation inhibits cytokine production and attenuates disease severity in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a heterogeneous, prevalent, chronic autoimmune disease characterized by painful swollen joints and significant disabilities. Symptomatic relief can be achieved in up to 50% of patients using biological agents that inhibit tumor necrosis factor (TNF) or other mechanisms of action, but there are no universally effective therapies. Recent advances in basic and preclinical science reveal that reflex neural circuits inhibit the production of cytokines and inflammation in animal models. One well-characterized cytokine-inhibiting mechanism, termed the "inflammatory reflex," is dependent upon vagus nerve signals that inhibit cytokine production and attenuate experimental arthritis severity in mice and rats. It previously was unknown whether directly stimulating the inflammatory reflex in humans inhibits TNF production. Here we show that an implantable vagus nerve-stimulating device in epilepsy patients inhibits peripheral blood production of TNF, IL-1ß, and IL-6. Vagus nerve stimulation (up to four times daily) in RA patients significantly inhibited TNF production for up to 84 d. Moreover, RA disease severity, as measured by standardized clinical composite scores, improved significantly. Together, these results establish that vagus nerve stimulation targeting the inflammatory reflex modulates TNF production and reduces inflammation in humans. These findings suggest that it is possible to use mechanism-based neuromodulating devices in the experimental therapy of RA and possibly other autoimmune and autoinflammatory diseases.

Takotsubo Syndrome: An International Expert Consensus Report on Practical Challenges and Specific Conditions (Part-1: Diagnostic and Therapeutic Challenges)

In the recent years, there has been a burgeoning interest in Takotsubo syndrome (TTS), which is renowned as a specific form of reversible myocardial dysfunction. Despite the extensive literature available on TTS, clinicians still face several practical challenges associated with the diagnosis and management of this phenomenon. This potentially results in the underdiagnosis and improper management of TTS in clinical practice. The present paper, the first part (part-1) of the consensus report, aims to cover diagnostic and therapeutic challenges associated with TTS along with certain recommendations to combat these challenges.

Takotsubo Syndrome: An International Expert Consensus Report on Practical Challenges and Specific Conditions (Part-2: Specific Entities, Risk Stratification and Challenges After Recovery)

Takotsubo syndrome (TTS) still remains as an enigmatic phenomenon. In particular, long-term challenges (including clinical recurrence and persistent symptoms) and specific entities in the setting of TTS have been the evolving areas of interest. On the other hand, a significant gap still exists regarding the proper risk-stratification of this phenomenon in the short and long terms. The present paper, the second part (part-2) of the consensus report, aims to discuss less well-known aspects of TTS including specific entities, challenges after recovery and risk-stratification.

EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis.

OBJECTIVE: To develop evidence-based recommendations on the use of imaging of the joints in the clinical management of rheumatoid arthritis (RA). METHODS: The task force comprised an expert group of rheumatologists, radiologists, methodologists and experienced rheumatology practitioners from 13 countries. Thirteen key questions on the role of imaging in RA were generated using a process of discussion and consensus. Imaging modalities included were conventional radiography, ultrasound, MRI, CT, dual-emission x-ray absorptiometry, digital x-ray radiogrammetry, scintigraphy and positron emission tomography. Research evidence was searched systematically for each question using MEDLINE, EMBASE and Cochrane CENTRAL. The experts used the evidence obtained from the relevant studies to develop a set of 10 recommendations. The strength of recommendation was assessed using a visual analogue scale. RESULTS: A total of 6888 references was identified from the search process, from which 199 studies were included in the systematic review. Ten recommendations were produced encompassing the role of imaging in making a diagnosis of RA, detecting inflammation and damage, predicting outcome and response to treatment, monitoring disease activity, progression and remission. The strength of recommendation for each proposition varied according to both the research evidence and expert opinion. CONCLUSIONS: Ten key recommendations for the role of imaging in the management of RA were developed using research-based evidence and expert opinion.

Serum level of tumor marker carbohydrate antigen-CA125 in heart failure.

OBJECTIVE: To assess serum levels of tumor marker carbohydrate antigen 125 (CA125) in patients with heart failure (HF) and to investigate possible correlation with echocardiographic parameters and level of brain natriuretic peptide (BNP). PATIENTS AND METHODS: We included 76 patients with different cardiac symptoms hospitalized at Clinic for heart disease and rheumatism. Control group (n = 26) was consisted of patients without signs and symptoms of HF, normal left ventricle ejection fraction (LVEF) and normal BNP level. Patients with diagnosis of HF (n = 50) were subdivided into 2 group depending on signs and symptoms of fluid overload: compensated (compHF, n = 10) and decompensated group (decompHF, n = 40). Serum CA125 and BNP were measured on admission and all patient underwent ECG recording and trans thoracic echocardiographic examination. RESULTS: The median CA125 level in HF group was significantly higher compared to control group (71.05 [30.70-141.47]U/ml vs 10.75 [8.05- 14.32] U/ml, p < 0.0005). Higher CA125 levels were found in decompHF group compared to compHF group (94.90 [49.75-196.75]U/ml vs 11.90 [10.25-15.80]U/ml, p < 0.0005). In decompHF group 13 of patients had pleural and/or pericardial effusion- their CA125 levels were significantly higher compared to patients without serosal effusion (n = 27) (205.10 [106.50-383.90]U/ml vs. 71.50 [47.30-109.55] U/ml, p < 0.002). We found significant difference in CA125 levels between patients with atrial fibrillation and sinus rhythm (98.40 [48.20-242.70] U/ml vs. 47.30 [12.95-99.05] U/ml, p = 0.015). There was no significant difference in CA125 levels in group with enlarged left atrium compared to normal sized atrium (p = 0.282), as well as in group with moderate/severe mitral regurgitation compared to group with no/mild mitral regurgitation (p = 0.99). Finally, levels of serum CA125 positively correlated with serum level of BNP (r = 0.293, p = 0.039), but not with LVEF (p = 0.369) and left atrium diameter (p = 0.636). CONCLUSION: Serum CA125 is elevated in decompensated HF patients: more pronounced elevation was found in patients with pleural and/or pericard effusion compared to patients with no serosal effusion. CA125 level correlated with BNP, but not with left atrium diameter nor with LVEF. Tumor marker CA125 could be used as a marker of systemic congestion and volume overload in decompensated HF. We hypothesized that high CA125 level indicates that measured high BNP is actually wet BNP.

Biphasic and monophasic pattern of brain natriuretic peptide release in acute myocardial infarction.

This study evaluated brain natriuretic peptide (BNP) release in acute myocardial infarction (AMI), absolute values as well as pattern of its release. There are two different patterns of BNP release in AMI; monophasic pattern--concentration in the first measurement is higher than in the second one, and biphasic pattern--concentration in the first measurement is lower than in the second one. We observed significance of biphasic and monophasic pattern of BNP release related to diagnostic and prognostic value. We included in this prospective observational study total of 75 AMI patients, 52 males and 23 females, average age of 62.3 +/- 10.9 years with range of 42 to 79 years. BNP was measured and pattern of its release was evaluated. In AMI group BNP levels were significantly higher than in controls (462.88 pg/mL vs. 35.36 pg/mL, p < 0.001). We found statistically significant real negative correlation (p < 0.05) between BNP concentration and left ventricle ejection fraction (LVEF) with high correlation coefficient (r = -0.684). BNP concentrations were significantly higher among patients in Killip class II and III compared to Killip class I; Killip class I BNP = 226.18 pg/mL vs. Killip class II 622.51 pg/mL vs. Killip class III 1530.28 pg/mL, p < 0.001. BNP concentrations were significantly higher in patients with; (i) myocardial infarction vs. controls; (BNP 835.80 pg/mL vs. 243.03 pg/mL); (ii) in pts with positive major adverse cardiac events (MACE) vs. negative MACE (BNP 779.08 pg/mL vs. 242.28 pg/mL, p < 0.001); (iii) in pts with positive compared to negative left ventricle (LV) remodelling (BNP 840.77 pg/mL vs. 341.41 pg/mL, p < 0.001). Group with biphasic pattern of BNP release had significantly higher BNP concentration compared to monophasic pattern group. In biphasic pattern group we found significant presence of lower LVEF, Killip class II and III, LV remodelling and MACE. We found that BNP is strong marker of adverse cardiac events in patients presenting with a myocardial infarction. In our AMI group we found significant elevation of BNP and it is suspected that second peak secretion is not only due to systolic dysfunction and subsequent remodeling of LV but also due to impact of ischaemia. Patients with biphasic pattern probably have worse prognosis due to severe coronary heart disease. Besides its diagnostic role as a simple blood marker of systolic function, BNP is also important prognostic marker who helps making clinical decision about early invasive vs. conservative management.

Effect of atorvastatin on systolic and diastolic function in patients with heart failure with reduced ejection fraction (HFrEF).

Aim To investigate the benefit of high-dose lipophilic statin therapy on cardiac remodelling, function and progression of heart failure (HF) in patients with ischemic heart disease. Methods A total of 80 patients with ischemic HF diagnosis were followed during 6 months, and they were divided in two groups. First group (n=40) was treated by high-dose lipophilic statin therapy (atorvastatin 40 mg) and conventional therapy for HF, while the second group (n=40) had no atorvastatin in the therapy. Results In the beginning of study, from all of the observed parameters, only the ratio of flow rates in early and late diastole (E/A ratio) differed between the test groups (p=0.007). After six months, a statistically significant increase in left ventricular end-diastolic diameter (LVIDD) in patients who had not been treated with atorvastatin was found. In the patients treated with atorvastatin, there was a significant reduction in basal right ventricle diameter in diastole and systole (p<0.001 and p<0.001, respectively), and in tricuspid annular plane systolic excursion (TAPSE) (p<0.001); there was a reduction in LVIDD (p<0.001), and an increase of ejection fraction of the left ventricle according to Teicholtz and Simpson (p<0.001 and p<0.001, respectively). Also, there was an increase of deceleration time of early diastolic velocity (DTE) (p<0.05) and a decrease of isovolumic relaxation time (IVRT) (p<0.001). Conclusion The reduction in the right and left ventricle diameters was noted after the six-month atorvastatin therapy. Atorvastatin in the therapy resulted in increased EFLV and better systolic function and should be a part of a therapeutic modality of HF.

Impact of Different Types of Statins on Clinical Outcomes in Patients Hospitalized for Ischemic Heart Failure.

INTRODUCTION: The effect of statins on risk of heart failure (HF) hospitalization and lethal outcome remains dubious. AIM: To investigate whether statin therapy improves clinical outcomes in patients hospitalized for ischemic heart failure (HF), to compare the efficacy of lipophilic and hydrophilic statins and to investigate which statin subtype provides better survival and other outcome benefits. MATERIAL AND METHODS: Total amount of 155 patients in the study were admitted to the Clinic for Cardiology, Rheumatology and Vascular diseases in Clinical Center University of Sarajevo in the period from January 2014- December 2017. Inclusion criteria was HF caused by ischemic coronary artery disease upon admission. For each patient the following data were obtained: gender, age, comorbidities and medications on discharge. New York Heart Association (NYHA) class for heart failure was determined by physician evaluation and left ventricle ejection fraction (LVEF) was determined by echocardiography. The patients were followed for a period of two years. Outcome points were: rehospitalization, in-hospital death, mortality after 6 months, 1 year and 2 years. All-cause mortality included cardiovascular events or worsening heart failure. RESULTS: Overall, 58.9% of HF patients received statin therapy, with 33.9% patients receiving atorvastatin and 25.0% rosuvastatin therapy. The most frequent rehospitalization was in patients without statin therapy (66.7%), followed by patients on rosuvastatin (64.1%), and atorvastatin (13.2%), with statistically significant difference p = 0.001 between the groups. Mortality after 6 months, 1 year and 2 years was the most frequent in patients without statin therapy with a statistically significant difference (p = 0.001). Progression of HF accounted for 31.7% of mortality in patients without statin therapy, 12.8% in patients on rosuvastatin therapy and 3.8% in patients on atorvastatin therapy (p = 0.004). CONCLUSION: Lipophilic statin therapy is associated with substantially better long-term outcomes in patients with HF.

Leptin is associated with disease activity but not with anthropometric indices in rheumatoid arthritis patients.

INTRODUCTION: Leptin is a cytokine-like hormone which has a complex role in inflammation. However, the importance of leptin in the pathogenesis of rheumatoid arthritis (RA) is far from being fully elucidated. The aim of the study was to determine serum leptin levels in RA patients and to evaluate whether there is an association between disease activity, anthropometric indices and leptin levels. MATERIAL AND METHODS: This hypothesis-generating study included 55 RA patients and 25 matched healthy subjects. The serum leptin concentration was determined by enzyme-linked immunosorbent assay (ELISA). RESULTS: Median serum leptin level in RA patients of 27.4 ng/ml (14.5-54.9 ng/ml) was statistically significantly higher (p = 0.03) compared with the median leptin value of 16.3 ng/ml (9.6-38.8 ng/ml) determined in healthy controls. The serum leptin level in the high disease activity group was significantly higher (p < 0.0005) than that in the low disease activity group and in healthy controls. A significant difference (p = 0.001) in serum leptin level was also found when the high disease activity group was compared with the moderate disease activity group. In the RA group a statistically significant positive correlation (rho = 0.390; p = 0.003) was observed between serum leptin level and disease activity score (DAS28). CONCLUSIONS: The present results show that serum leptin levels are increased and significantly associated with disease activity in patients with RA and may have a valuable role in the inflammatory reactions and pathogenesis of RA.

Echocardiographic Assessment of Ischaemic Mitral Regurgitation, Mechanism, Severity, Impact on Treatment Strategy and Long Term Outcome.

INTRODUCTION: The commonest mitral regurgitation etiologies are degenerative (60%), rheumatic post-inflammatory, 12%) and functional (25%). Due to the large number of patients with acute MI, the incidence of ischaemic MR is also high. Ischaemic mitral regurgitation is a complex multifactorial disease that involves left ventricular geometry, the mitral annulus, and the valvular/subvalvular apparatus. Ischaemic mitral regurgitation is an important consequence of LV remodeling after myocardial infarction. RESEARCH OBJECTIVES: The objective of this study is to determine the role of echocardiography in detecting and assessment of mitral regurgitation mechanism, severity, impact on treatment strategy and long term outcome in patients with myocardial infarction during the follow up period of 5 years. Also one of objectives to determine if the absence or presence of ischaemic MR is associated with increased morbidity and mortality in patients with myocardial infarction. PATIENTS AND METHODS: The study covered 138 adult patients. All patients were subjected to echocardiography evaluation after acute myocardial infarction during the period of follow up for 5 years. The patients were examined on an ultrasound machine Philips iE 33 xMatrix, Philips HD 11 XE, and GE Vivid 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated mechanisms and severity of mitral regurgitation which includes the regurgitant volume (RV), effective regurgitant orifice area (EROA), the regurgitant fraction (RF), Jet/LA area, also we measured the of vena contracta width (VC width cm) for assessment of IMR severity, papillary muscles anatomy and displacement, LV systolic function ± dilation, LV regional wall motion abnormality WMA, LV WMI, Left ventricle LV remodeling, impact on treatment strategy and long term mortality. RESULTS: We analyzed and follow up 138 patients with previous (>16 days) Q-wave myocardial infarction by ECG who underwent TTE and TEE echocardiography for detection and assessment of ischaemic mitral regurgitation (IMR) with baseline age (62 ± 9), ejection fraction (EF 41±12%), the regurgitant volume (RV) were 42±21 mL/beat, and effective regurgitant orifice area (EROA) 20±16 mm(2), the regurgitant fraction (RF) were 48±10%, Jet/LA area 47±12%. Also we measured the of vena contracta width (VC width cm) 0,4±0,6 for assessment of IMR severity. During 5 years follow up, total mortality for patients with moderate/severe IMR-grade II-IV (54.2±1.8%) were higher than for those with mild IMR-grade I (30.4±2.9%) (P<0.05), the total mortality for patients with EROA ≥20 mm(2)(54±1.9%) were higher than for those with EROA <20 mm(2)(27.2±2.7%) (P<0.05), and the total mortality for patients with RVol ≥30 mL (56.8±1.7%) were higher than for those with RVol<30ml (29.4±2.9%) (P<0.05). After assessment of IMR and during follow up period 64 patients (46%) underwent CABG alone or combined CABG with mitral valve repair or replacement. In this study, the procedure of concomitant down-sized ring annuloplasty at the time if CABG surgery has a failure rate around 24% in terms of high late recurrence rate of IMR during the follow period especially after 18-42 months. CONCLUSION: The presence of ischaemic MR is associated with increased morbidity and mortality. Chronic IMR, an independent predictor of mortality with a reported survival of 40-60% at 5 years. Ischaemic mitral regurgitation has important prognosis implications in patients with coronary heart disease. Recognizing the mechanism of valve incompetence is an essential point for the surgical planning and for a good result of the mitral repair. It is important that echocardiographers understand the complex nature of the condition. Despite remarkable progress in reparative surgery, further investigation is still necessary to find the best approach to treat ischaemic mitral regurgitation.

The First Mediterranean Seminar on Science Writing, Editing and Publishing, Sarajevo, December 2-3, 2016.

The First Mediterranean Seminar on Science Writing, Editing & Publishing (SWEP 2016) was held in Sarajevo, Bosnia & Herzegovina from 2nd to 3rd December 2016. It was organized by Academy of Medical Sciences of Bosnia and Herzegovina, running concurrent sessions as part of its Annual Meeting titled " "Days of AMNuBiH - Theory and Practice in Science Communication and Scientometrics". Hotel Bosnia in the city centre was the chosen venue. On the first day, nineteen presentations on various issues of science writing and publication ethics were delivered by speakers from Croatia, Serbia, Macedonia, Albania, Bosnia & Herzegovina and the UK (Asim Kurjak, Milivoj Boranic, Doncho Donev, Osman Sinanovic, Miro Jakovljevic, Enver Zerem, Dejan Milosevic, Silva Dobric, Srecko Gajovic, Izet Masic, Armen Yuri Gasparyan, Sekib Sokolovic, Nermin Salkic, Selma Uzunovic, Admir Kurtcehajic, Edin Begic and Floreta Kurti). Each presentation had a take-home message for novice and seasoned authors, encountering numerous problems in non-Anglophone research environment. Lecturers, who were internationally recognized editors of regional journals, generously shared their experience of adhering to the best ethical guidance. Elegant presentations by Srecko Gajovic (Editor-in-Chief of the Croatian Medical Journal) and Armen Yuri Gasparyan (past Chief Editor of the European Science Editing) showcased their accomplishments that strengthened ties between authors from all over the world. Gasparyan reflected on educational resources of editorial associations, such as the International Committee of Medical Journal Editors (ICMJE) and the Committee on Publication Ethics (COPE), and called not just to declare the adherence to, but also to enforce their ethical guidance in daily practice. Editors of Medical Archives, Croatian Medica Journal, Vojnosanitetski Pregled, Psychiatria Danubina, Acta Informatica Medica, Materia Socio-Medica, The Donald School Journal of Ultrasound in Obstretics and Gynecology, Acta Medica Saliniana and Medicinski Glasnik presented their editorial strategies aimed at attracting best authors and resolving problems with authorship, conflicts of interest, and plagiarism. Topical education on science writing and editing was considered as an inseparable part of continuing professional development in biomedicine. Armen Yuri Gasparyan (UK) was offered an opportunity to interact with more than 70 participants, attending the SWEP 2016 on the second day. The lecturer talked about author contributions, disclosures of conflicts of interests, plagiarism of ideas and words, research performance and impact indicators, and targeting ethical journals. Topics were presented in a way to help non-Anglophone authors, reviewers and editors avoid common ethical problems. Dr Gasparyan stressed the importance of regularly arranging such meetings across Balkan and Mediterranean countries to eradicate plagiarism and other forms research misconduct. The organizers of the SWEP 2016 awarded selected keynote speakers with certificates of lifetime achievement in journal editing, and decided to run the Seminar annually with support of Balkan and Mediterranean editors and publishers. The SWEP 2016 marked a turning point in the process of regional developments since all attending editors opted for nurturing enthusiasm of the organizers and launching the Mediterranean Association of Science Editors and Publishers (MASEP). The Seminar was a great success with its impressive scientific and social activities. It attracted more than 100 students, researchers, editors, and publishers from Bosnia & Herzegovina and neighbouring countries. Proceedings, in the form of short reports, were published in Acta Informatica Medica and archived in PubMed Central. New friendships were forged between regional experts in editing and young specialists during those unforgettable two days of intensive discussions and informal interactions (a-y).

Mental health status can reflect disease activity in rheumatoid arthritis.

OBJECTIVE: A significant number of patients with rheumatoid arthritis (RA) link the start of illness with psychological trauma or severe stress. Impaired mental health (IMH), defined as depression and anxiety with psychoneuroimmunological factors, can play a significant role in RA. The main objective of this research was to investigate the mutual correlation of IMH and RA activity, estimated by the laboratory and clinical parameters in RA patients. MATERIAL AND METHODS: An open clinical prospective study that lasted for 6 months was designed. There were 72 patients included, 58 women and 14 men, aged 34 to 80 years and screened for mental health status. The study population was randomized following the Brief Symptoms Inventory (BSI) scale, comprised of 53 questions with a range from 0 (no symptoms) to 4 (severe). This mental test was done only once during the study. Following the results from the BSI scale, RA patients were divided into mentally stable and mentally unstable patients to investigate the influence of RA activity on mental health. The following laboratory and clinical parameters were analyzed: sex, age, erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), C-reactive protein (CRP), anti-cyclic citrullinated peptide (anti-CCP) antibody, and disease activity score (DAS28). All RA patients did not express extra-articular manifestations or Sjögren's syndrome. The chi-square test, ANOVA, Pearson's coefficient, and IBM Statistics - SPSS v19 were used. RESULTS: From a total of 72 RA patients, there were 44 mentally stable and 28 mentally unstable patients. All patients had either moderate or severe active disease. The only significant correlation of IMH and activity of RA was found in CRP and DAS28, but no significance was observed in ESR, RF, and anti-CCP. The DAS28 showed high disease activity with an average of 5.3 and CRP of 20.9 mg/L in patients with unstable mental health compared to stable mental health patients, where RA was associated with a moderate DAS average value of 4.35 and CRP of 14.1 mg/L. Depression and anxiety were found in all 28 (39%) RA patients. CONCLUSION: Mentally unstable RA patients correlate more with severe disease activity, while mentally stable patients express moderate disease activity.

The role of dobutamine stress echocardiography in detecting coronary artery disease compared with coronary angiography.

BACKGROUND: Ischemic heart disease (IHD) causes more deaths, disability and economic loss in developed and developing countries than any other disease. Our country belongs to the group of countries in transition, and it has seen a continuous growth in mortality and morbidity rates caused by cardiovascular diseases. An early, accurate and fast diagnosis of the myocardial ischemia is the main step toward reducing patient morbidity and mortality, and hospital costs. It also reduces prolonged diagnostic observation, defines the strategy of approach and etiological treatment in order to prevent serious complications. OBJECTIVES: The aim of this study is to examine the occurrence of segmental wall motion abnormalities during pharmacological stress and measurement of coronary flow reserve in order to establish the diagnostic value of Dobutamine stress echocardiography in detecting and assessing the degree of myocardial ischemia and coronary stenosis in patients with suspected coronary artery disease, and to justify its wider application as a non-invasive diagnostic method. METHODS: The research study covered 86 adult subjects of both genders, referred to dobutamine stress echocardiography test and assessment of coronary flow reserve as part of their cardiological evaluation. RESULTS: The study results obtained indicate a high degree of sensitivity (97%), specificity (83%) and accuracy (95%) of the dobutamine stress echocardiography as a non-invasive diagnostic method compared to invasive diagnostics i.e. coronary angiography. Measurement of coronary flow reserve represents a strong diagnostic and prognostic tool in evaluation patients with suspected CAD. CONCLUSIONS: The Dobutamine stress echocardiography (DES) has come a long way as a diagnostic tool, from detecting myocardial ischemia, viability, and prognostics to problems underlying the coronary artery diseases. The safety and cost-effectiveness of the Dobutamine stress echocardiography as a diagnostic procedure has been proved. In modern cardiology, the DSE occupies a significant place in the evaluation of patients with known or suspected coronary artery disease, which has contributed to its accessibility and availability in a great number of centers.

The role of echocardiography in diagnosis and follow up of patients with takotsubo cardiomyopathy or acute ballooning syndrome.

BACKGROUND: The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy was first described in Japan approximately 20 years ago (Satoh and coworkers, 1991). It was later described elsewhere as well and is being increasingly recognized. Takotsubo Cardiomyopathy characterized by transient apical and midventricular LV dysfunction in the absence of significant coronary artery disease that is triggered by emotional or physical stress. Its name refers to a contraption used for catching octopuses and suggests the aspect assumed by the ventricle during the systole due to the typical regional wall motion abnormalities that occur after onset. Takotsubo cardiomiopathy occurring mainly in post-menopausal women, echocardiography in the Takotsubo cardiomyopathy reveals during its acute phase a ballooning resembling the octopus trap configuration--the apex and lateral ventricular segments are hypokinetic while the base is hyperkinetic--along with reduced ejection fraction. Ventricular function will usually recover within a few days/weeks. OBJECTIVE AND PURPOSE: The objective of this study is to determine the role of echocardiography in detecting and establishing the diagnosis of Takotsubo cardiomiopathy in patients with suspect acute coronary syndrome and during the follow up period. PATIENTS AND METHODS: The study covered 12 adult patients the majority are women (92%) who were subjected to echocardiography evaluation as part of the clinical cardiological examination due to suspect acute coronary syndrome or Takotsubo Stress Cardiomyopathy. The patients were examined on an ultrasound machine Philips iE 33 x Matrix, ATL HDI and GE Vived 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated clinical characteristics, LV systolic function, biomarkers, and prognosis in all patients. RESULTS: Among all the patients referred for Echocardiographic evaluation for left ventricle motion abnormalities with suspect acute coronary syndrome, the echo exam revealed 12 patients with acute apical ballooning which involving the left ventricular apex and med-ventricle. The triggering factors were physical stress in 4 patients (33%) and emotional stress in 8 patients (67%). The initial symptom was chest pain (n = 8, 67%) rather than dyspnea (n = 4, 33%). An initial electrocardiogram (EKG) presented ST-elevation (n = 10, 83%) and T-wave inversion (n = 2, 17%), other data are shown on Table 2. Among the all patients 8 of them (66%) had normal EF by the 1st follow up (47 +/- 51 days), and the rest 4 patients (34%) had normal EF by 68 +/- 96 days. CONCLUSION: Widespread uses of echocardiography has contributed to more frequent recognition of Takotsubo stress cardiomyopathy and highlight the central role of this noninvasive method from an echocardiographers' perspective.

Stress echocardiography in differentiation of fixed vs. low flow-low gradient and pseudo severe aortic stenosis.

PURPOSE: To present the importance of stress echocardiography in diagnosis of low flow-low gradient aortic stenosis (AS). MATERIAL AND METHOD: Two patients were tested, one male patient, aged 62, weight 72 kg, height 172 cm, and BSA 1.86 cm2, and the other one was female, aged 59, weight 83 kg, height 168 cm and BSA, were found to have at least moderate ASs with low flow and low gradients at rest. Dobutamine stress test was performed using standard protocol starting at 2.5 mcg/kg/min at rest as continuous infusion and increasing every five minutes intervals with stepwise increase up to 20 mcg/kg/min. Monitoring with 12-lead ECG and blood pressure measurements at each step was performed. After completing the test, transthoracic echocardiography (TTE) showed in male patient increasing in transvalvular flow and gradients across aortic valve and ejection fraction (EF) measured by Simpson method increased from 33% at rest up to 40% following Dobutamine administration. EOA (effective aortic valve area) from 0.8 cm2 at rest increased insignificantly to 0.85 cm, (0.425 m2) afterwards. CONCLUSION: Final diagnosis therefore was severe aortic stenosis with preserved contractile reserve. The patient was scheduled for surgical valve replacement. In female patient after DST, the area of aortic valve increased significantly from 0.75 cm2 up to 1.05 cm2, while all transvalvular gradients remained almost unchanged. Pseudo-Aortic Stenosis and surgical valve replacement had not been indicated at this time.

The impact of Rituximab therapy on the chromosomes of patients with Rheumatoid arthritis.

The open prospective combined cytogenetic and clinical study investigated the impact of biological therapy Rituximab on number and structure of chromosomes in Rheumatoid arthritis patients. The purpose of this study was to investigate safety of Rituximab on chromosomes as well as cytotoxic therapy Methotrexate. A total of 8 seropositive Rheumatoid arthritis patients were analyzed for primary end point of eventual cytotoxic effect of Rituximab. Assessment was done before and 1 month later, actually 2 weeks after the administration of full course of Rituximab in infusion. Patients suffering from active Rheumatoid arthritis were randomly assigned according to established protocol to receive infusion of Rituximab in a full dose of 2.0 grams divided in a two doses of 1.0 gram on days 1 and 15. The lymphocytes from peripheral blood were cultured according to Moorhead method. The results obtained from this investigation showed that normal male and female karyogram was found after the full therapy of Rituximab. The results from this study, that was done on a rather small number of subjects, indicate that Rituximab does not express either clastogenic or aneugenic effects. But, co-finding of this study was that Methotrexate had a side effect on chromosomal aberration in one female RA patient, and after discontinuation of this treatment the normal karyogram was observed.

[Multicentric reticulohistiocytosis]. / Multicentrina retikulohistiocitoza.

A very rare inflammatory systemic rheumatic disorder--Multicentric reticulohistiocytosis--was described as a case report in this paper. A 22 year old female patient was presented with a destructive polyarthritis and prominent multiple skin nodules that pointed to possible presence of this rare disease. The final diagnosis was made based on the biopsy finding. Application of the cytotoxic drug Metotrexate in the therapy, besides non-steroidal anti-inflammatory drugs and corticosteroids, leaded to full remission with disappearance of skin changes.