Levothyroxine Treatment and the Risk of Cardiac Arrhythmias - Focus on the Patient Submitted to Thyroid Surgery

Levothyroxine (LT4) is used to treat frequently encountered endocrinopathies such as thyroid diseases. It is regularly used in clinical (overt) hypothyroidism cases and subclinical (latent) hypothyroidism cases in the last decade. Suppressive LT4 therapy is also part of the medical regimen used to manage thyroid malignancies after a thyroidectomy. LT4 treatment possesses dual effects: substituting new-onset thyroid hormone deficiency and suppressing the local and distant malignancy spreading in cancer. It is the practice to administer LT4 in less-than-high suppressive doses for growth control of thyroid nodules and goiter, even in patients with preserved thyroid function. Despite its approved safety for clinical use, LT4 can sometimes induce side-effects, more often recorded with patients under treatment with LT4 suppressive doses than in unintentionally LT4-overdosed patients. Cardiac arrhythmias and the deterioration of osteoporosis are the most frequently documented side-effects of LT4 therapy. It also lowers the threshold for the onset or aggravation of cardiac arrhythmias for patients with pre-existing heart diseases. To improve the quality of life in LT4-substituted patients, clinicians often prescribe higher doses of LT4 to reach low normal TSH levels to achieve cellular euthyroidism. In such circumstances, the risk of cardiac arrhythmias, particularly atrial fibrillation, increases, and the combined use of LT4 and triiodothyronine further complicates such risk. This review summarizes the relevant available data related to LT4 suppressive treatment and the associated risk of cardiac arrhythmia.

Hyperbaric Oxygen Therapy and Vascular Complications in Diabetes Mellitus

Vascular complications in patients with diabetes mellitus (DM) are common. Since impaired oxygen balance in plasma plays an important role in the pathogenesis of chronic DM-associated complications, the administration of hyperbaric oxygen therapy (HBOT) has been recommended to influence development of vascular complications. Hyperbaric oxygen therapy involves inhalation of 100% oxygen under elevated pressure from 1.6 to 2.8 absolute atmospheres in hyperbaric chambers. Hyperbaric oxygen therapy increases plasma oxygen solubility, contributing to better oxygen diffusion to distant tissues and preservation of the viability of tissues reversibly damaged by atherosclerosis-induced ischemia, along with microcirculation restoration. Hyperbaric oxygen therapy exerts antiatherogenic, antioxidant, and cardioprotective effects by altering the level and composition of plasma fatty acids and also by promoting signal transduction through membranes, which are impaired by hyperglycemia and hypoxia. In addition, HBOT affects molecules involved in the regulation of nitric oxide synthesis and in that way exerts anti-inflammatory and angiogenic effects in patients with DM. In this review, we explore the recent literature related to the effects of HBOT on DM-related vascular complications.

Predictive Value of Carcinoembryonic and Carbohydrate Antigen 19-9 Related to Some Clinical, Endoscopic and Histological Colorectal Cancer Characteristics

BACKGROUND

Colorectal cancer (CRC) is an important oncological and public health problem worldwide, including Serbia. Unfortunately, half of the patients are recognized in an advanced stage of the disease, therefore, early detection through specific tumor biomarkers, such as carcinoembryonic (CEA) and carbohydrate antigen 19-9 (CA 19-9), is the only way to cope with CRC expansion.

METHODS

Our cross-sectional study evaluated the influence of some clinical, endoscopic and histological characteristics of CRC on CEA and CA 19-9 serum levels, to determine whether these biomarkers could be related to CRC detection. The study included 372 participants: 181 suffered from CRC and 191 participants were controls. Endoscopic and histological examinations were used for CRC diagnosis, while additional ultrasound and abdominal computerised tomography imaging were used for staging the disease. Measurement of CEA and CA 19-9 was performed after CRC confirmation.

RESULTS

Age, gender, tumor localization, macro-morphological and histological characteristics did not influence biomarkers serum levels. Both were significantly higher (p<0.01) in patients with Dukes D stage of CRC compared with controls. Sensitivity (76.8%) and specificity (76.6%) of CEA alone were higher than for CA 19-9, but with no statistical significance. Furthermore, sensitivity of CEA alone in the Dukes A/B group was similar to the entire CRC patient group.

CONCLUSIONS

Although not recommended as a screening method for the general population, elevated values of each biomarker indicate further diagnostic procedures and their simultaneous testing can improve the diagnostic sensitivity in early detection of CRC, as shown by the united analysis (AUC 0.842).

Inflammation, nutritional status, PUFA profile and outcome in hemodialysis patients

Patients with end-stage renal disease (ESRD) include a significant percentage of malnourished patients with other risk factors: dyslipoproteinemia, insulin resistance, increased oxidative stress and inflammation that together impair endothelial function. Abnormal polyunsaturated fatty acids (PUFA) patterns are reported in patients with ESRD. The basic mechanisms of these disorders are connected with changes in cell functions at the membrane level. Vascular smooth muscle cell proliferation plays an important role in the pathogenesis of atherosclerosis. We have examined the association between atherosclerotic risk factors and nutritional status in hemodialysis (HD) patients. Mortality was followed for up to 18 month. Forty-three HD patients were examined (20 males, 23 females, ages 55?12 years). Nutritional and inflammatory markers, including serum concentrations of C-reactive protein (CRP), tumor necrosis factor alpha (TNF-alpha), and interleukin 6 (IL-6), were measured. There was significant positive correlation between the plasma albumin level and CRP. Significant correlation was found between plasma the cholesterol level and some PUFA. Increasing inflammation and endothelial dysfunction predict the development of vascular disease. We report on the relationship between inflammatory markers and nutritional parameter, indices of atherosclerosis and other cardiovascular risk factors in patients on hemodialysis.

A quality of life assessment and the correlation between generic and disease-specific questionnaires scores in outpatients with chronic liver disease-pilot study

INTRODUCTION

Chronic liver diseases (CLD) are an important cause of morbidity and mortality in general population. The aim of this study was to analyze potential differences between patients with CLD and healthy control group, and to estimate the severity of CLD by using simple questionnaires: general health questionnaire (GHQ-12) and chronic liver disease questionnaire (CLDQ).

METHODS

A cross-sectional pilot study was performed in Zemun Clinical Hospital during years 2014 and 2015. Sixty participants were divided into 4 groups (15 per group): chronic alcoholic hepatitis, other chronic hepatitis, liver cirrhosis, and healthy control group. Entire study population chose one of four offered answers of structured questionnaires GHQ-12 and CLDQ, based on which mean model of end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores were calculated.

RESULTS

Mean GHQ12 and CLDQ scores were 10.5 and 5.21 ± 1.11 respectively. Regarding certain CLDQ domain scores, a significant difference between alcoholic and non-alcoholic hepatitis groups in the worry domain was observed. Mean MELD score was 7.42 ± 2.89 and did not differ between chronic hepatitis groups, while mean CTP score was 5.73 ± 0.88. A statistically significant correlation was observed between GHQ12 and CLDQ scores (ρ = -0.404, p < 0.01), but not between subjective and objective scores.

CONCLUSIONS

Mean GHQ12 and CLDQ scores pointed out to general psychological no-distress condition of the studied participants, as well as scarcely expressed CLD-specific complaints. Mean MELD and CTP scores indicated stable chronic liver diseases, with low three-month mortality rates in the cases of chronic hepatitis, as well as determination to Child A group in the case of liver cirrhosis.

Serum nitric oxide levels correlate with quality of life questionnaires scores of hypothyroid females

Primary hypothyroidism can affect lipid metabolism, cardiovascular (CV) function, and overall patients' quality of life (QoL). Decrease in serum nitric oxide (NO) levels could promote the atherosclerosis acceleration in hypothyroid patients. Our hypothesis is that serum NO level is altered in hypothyroidism; more specifically, we hypothesize that the early vascular changes that can be observed in hypothyroidism could be due to these alterations and that serum NO levels are associated with lipid levels in female patients diagnosed with subclinical hypothyroidism (SCH) or clinical hypothyroidism (CH). Furthermore, since serum NO level is an early marker of atherosclerosis and related CV disorders, which are commonly present and follow hypothyreosis and greatly contribute to overall QoL, we further hypothesized that NO level would correlate with Thyroid Symptom Questionnaire (TSQ) and General Health Questionnaire 12 (GHQ12) scores in hypothyroid patients. A collaterally of our hypothesis was that levothyroxine (LT4) treatment would affect serum NO levels as well as TSQ and GHQ12 scores. Therefore, we have analyzed lipid profile, the level of NO and QoL scores in female patients diagnosed with SCH and CH in order to determine the correlation between NO and generic and thyroid disease symptoms in treatment naïve SCH and CH patients and after LT4 treatment and laboratory euthyroidism achievement. As a consequence of our hypothesis is that measurement of serum NO level in SCH and CH patients may be an innovative way to improve LT4 treatment efficacy. This assumption could have a practical significance for future investigations regarding the management of hypothyroidism treatment protocols in current guidelines.

Chronic hepatitis C, insulin resistance and vascular disease

The role of hepatitis C virus (HCV) infection in the development of vascular disease is controversial. Insulin resistance (IR) is a recognized risk factor for cardiovascular disease (CVD) and is associated with chronic hepatitis C (CHC) infection. Thus, IR may promote atherosclerosis and vascular disease in CHC patients. HCV-associated IR may also cause hepatic steatosis and resistance to antiviral treatment. In addition, HCV may impose direct, proatherogenetic action in the vascular wall. This review will elaborate the impact of IR on interferon-α based therapy of HCV infection and the role of insulin-sensitizing agents on the response to antiviral treatment and prevention of IR complications, including vascular disease.

Non-alcoholic fatty liver disease: a multidisciplinary clinical practice approach—the institutional adaptation to existing Clinical Practice Guidelines

Abstract

Non-alcoholic fatty liver disease (NAFLD) is among the most frequently encountered chronic liver diseases in everyday clinical practice. It is considered the hepatic manifestation of metabolic syndrome. Today, liver biopsy is still the gold standard for NAFLD confirmation and assessing NAFLD's possible progression to non-alcoholic steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Because of the high prevalence of NAFLD and potential associated risks of invasive diagnostic procedures, it is of great interest to recruit the patients for liver biopsy. However, as the presence of liver fibrosis determines the further clinical course, liver biopsy is expectedly reserved for those with increased fibrosis risk. The quality of liver biopsy recruitment and patient monitoring could be significantly improved by using non-invasive tools to assess liver fibrosis presence and interactive collaboration between general practitioners, gastroenterologists, and endocrinologists. As a result, the quality of liver biopsy recruitment and patients monitoring could be significantly improved. Here, we proposed clinical practice guidelines that could be implemented for everyday clinical practice in NAFLD patients.

Novel insights regarding the role of noncoding RNAs in diabetes

Diabetes mellitus (DM) is a group of metabolic disorders defined by hyperglycemia induced by insulin resistance, inadequate insulin secretion, or excessive glucagon secretion. In 2021, the global prevalence of diabetes is anticipated to be 10.7% (537 million people). Noncoding RNAs (ncRNAs) appear to have an important role in the initiation and progression of DM, according to a growing body of research. The two major groups of ncRNAs implicated in diabetic disorders are miRNAs and long noncoding RNAs. miRNAs are single-stranded, short (17-25 nucleotides), ncRNAs that influence gene expression at the post-transcriptional level. Because DM has reached epidemic proportions worldwide, it appears that novel diagnostic and therapeutic strategies are required to identify and treat complications associated with these diseases efficiently. miRNAs are gaining attention as biomarkers for DM diagnosis and potential treatment due to their function in maintaining physiological homeostasis via gene expression regulation. In this review, we address the issue of the gradually expanding global prevalence of DM by presenting a complete and up-to-date synopsis of various regulatory miRNAs involved in these disorders. We hope this review will spark discussion about ncRNAs as prognostic biomarkers and therapeutic tools for DM. We examine and synthesize recent research that used novel, high-throughput technologies to uncover ncRNAs involved in DM, necessitating a systematic approach to examining and summarizing their roles and possible diagnostic and therapeutic uses.

The involvement of Akt, mTOR, and S6K in the in vivo effect of IGF-1 on the regulation of rat cardiac Na+/K+-ATPase

BACKGROUND

We previously demonstrated that insulin-like growth factor-1 (IGF-1) regulates sodium/potassium adenosine triphosphatase (Na+/K+-ATPase) in vascular smooth muscle cells (VSMC) via phosphatidylinositol-3 kinase (PI3K). Taking into account that others' work show that IGF-1 activates the PI3K/protein kinase B (Akt) signaling pathway in many different cells, we here further questioned if the Akt/mammalian target of rapamycin (mTOR)/ribosomal protein p70 S6 kinase (S6K) pathway stimulates Na+/K+-ATPase, an essential protein for maintaining normal heart function.

METHODS AND RESULTS

There were 14 adult male Wistar rats, half of whom received bolus injections of IGF-1 (50 μg/kg) for 24 h. We evaluated cardiac Na+/K+-ATPase expression, activity, and serum IGF-1 levels. Additionally, we examined the phosphorylated forms of the following proteins: insulin receptor substrate (IRS), phosphoinositide-dependent kinase-1 (PDK-1), Akt, mTOR, S6K, and α subunit of Na+/K+-ATPase. Additionally, the mRNA expression of the Na+/K+-ATPase α1 subunit was evaluated. Treatment with IGF-1 increases levels of serum IGF-1 and stimulates Na+/K+-ATPase activity, phosphorylation of α subunit of Na+/K+-ATPase on Ser23, and protein expression of α2 subunit. Furthermore, IGF-1 treatment increased phosphorylation of IRS-1 on Tyr1222, Akt on Ser473, PDK-1 on Ser241, mTOR on Ser2481 and Ser2448, and S6K on Thr421/Ser424. The concentration of IGF-1 in serum positively correlates with Na+/K+-ATPase activity and the phosphorylated form of mTOR (Ser2448), while Na+/K+-ATPase activity positively correlates with the phosphorylated form of IRS-1 (Tyr1222) and mTOR (Ser2448).

CONCLUSION

These results indicate that the Akt/mTOR/S6K signalling pathway may be involved in the IGF-1 regulating cardiac Na+/K+-ATPase expression and activity.

Anemia as a Problem: GEH Approach

BACKGROUND

Anemia is present in almost 5% of adults worldwide and accompanies clinical findings in many diseases. Diseases of the gastrointestinal (GI) tract and liver are a common cause of anemia, so patients with anemia are often referred to a gastroenterologist.

SUMMARY

Anemia could be caused by various factors such as chronic bleeding, malabsorption, or chronic inflammation. In clinical practice, iron deficiency anemia and the combined forms of anemia due to different pathophysiological mechanisms are most common. Esophagogastroduodenoscopy, colonoscopy, and the small intestine examinations in specific situations play a crucial role in diagnosing anemia. In anemic, GI asymptomatic patients, there are recommendations for bidirectional endoscopy. Although GI malignancies are the most common cause of chronic bleeding, all conditions leading to blood loss, malabsorption, and chronic inflammation should be considered. From a gastroenterologist's perspective, the clinical spectrum of anemia is vast because many different digestive tract diseases lead to bleeding. Key Messages: The gastroenterological approach in solving anemia's problem requires an optimal strategy, consideration of the accompanying clinical signs, and the fastest possible diagnosis. Although patients with symptoms of anemia are often referred to gastroenterologists, the diagnostic approach requires further improvement in everyday clinical practice.

Is the routine abdominal ultrasound a sufficiently sensitive method for the detection of colonic malignancy?

OBJECTIVE

This study examined the sensitivity of routine abdominal ultrasound scanning in the detection of colonic malignancy.

PATIENTS AND METHODS

A case control prospective study included 101 patients hospitalized at the Department of Gastroenterology and Liver Diseases of Zemun Clinical Hospital over a four-year period. Since the complaints pointed to colonic malignancy, the patients underwent routine golden standard diagnostic procedures. These patients were referred to an experienced abdominal ultrasound operator who searched for some characteristic signs of colonic malignancy. All of the participants were surgically treated after the completion of relevant procedures for diagnosing colonic malignancy. SPSS for Windows 10.0 was used for data analysis.

RESULTS

The sensitivity of an abdominal ultrasound scan in the detection and location of pathological changes pointed to colonic malignancy was different- 76% and 84% respectively. This method was very reliable in detecting right-sided colonic carcinoma (100%). Some specific ultrasonographic signs of colonic carcinoma were observed at the advanced stages of disease.

CONCLUSIONS

The routine abdominal ultrasonography can be used for the screening of colonic malignancy owing to its high sensitivity, particularly in advanced disease, but solely in conjunction with other methods. Finally, abdominal ultrasonography cannot be a definitive diagnostic tool for colonic carcinoma.

Successful Immunomodulatory Treatment of COVID-19 in a Patient With Severe ACTH-Dependent Cushing's Syndrome: A Case Report and Review of Literature

INTRODUCTION

Patients with Cushing's syndrome (CS) represent a highly sensitive group during corona virus disease 2019 (COVID-19) pandemic. The effect of multiple comorbidities and immune system supression make the clinical picture complicated and treatment challenging.

CASE REPORT

A 70-year-old female was admitted to a covid hospital with a severe form of COVID-19 pneumonia that required oxygen supplementation. Prior to her admission to the hospital she was diagnosed with adrenocorticotropic hormone (ACTH)-dependent CS, and the treatment of hypercortisolism had not been started yet. Since the patient's condition was quickly deteriorating, and with presumend immmune system supression due to CS, we decided on treatement with intraveonus immunoglobulins (IVIg) that enabled quick onset of immunomodulatory effect. All comorbidities were treated with standard of care. The patient's condition quickly stabilized with no direct side effects of a given treatment.

CONCLUSION

Treatment of COVID-19 in patients with CS faces many challenges due to the complexity of comorbidity effects, immunosupression and potential interactions of available medications both for treatment of COVID-19 and CS. So far, there are no guidelines for treatment of COVID-19 in patients with active CS. It is our opinion that immunomodulating therapies like IVIg might be an effective and safe treatment modality in this particularly fragile group of patients.

Proton Pump Inhibitors and Radiofrequency Ablation for Treatment of Barrett's Esophagus

Gastroesophageal Reflux Disease (GERD) is characterized by acid and bile reflux in the distal oesophagus, and this may cause the development of reflux esophagitis and Barrett's oesophagus (BE). The natural histological course of untreated BE is non-dysplastic or benign BE (ND), then lowgrade (LGD) and High-Grade Dysplastic (HGD) BE, with the expected increase in malignancy transfer to oesophagal adenocarcinoma (EAC). The gold standard for BE diagnostics involves high-resolution white-light endoscopy, followed by uniform endoscopy findings description (Prague classification) with biopsy performance according to Seattle protocol. The medical treatment of GERD and BE includes the use of proton pump inhibitors (PPIs) regarding symptoms control. It is noteworthy that long-term use of PPIs increases gastrin level, which can contribute to transfer from BE to EAC, as a result of its effects on the proliferation of BE epithelium. Endoscopy treatment includes a wide range of resection and ablative techniques, such as radio-frequency ablation (RFA), often concomitantly used in everyday endoscopy practice (multimodal therapy). RFA promotes mucosal necrosis of treated oesophagal region via high-frequency energy. Laparoscopic surgery, partial or total fundoplication, is reserved for PPIs and endoscopy indolent patients or in those with progressive disease. This review aims to explain distinct effects of PPIs and RFA modalities, illuminate certain aspects of molecular mechanisms involved, as well as the effects of their concomitant use regarding the treatment of BE and prevention of its transfer to EAC.

Morphofunctional characteristics of endothelial cells in coronary atherosclerosis

Atherosclerosis represents a complex disease which encompasses all the components of the vascular wall. Nevertheless, according to all known theories of the pathogenesis of atherosclerosis, the key role in this process belongs to the endothelial cells, i.e. the changes that they are subjected to especially during the initial stage of the lesion. In this review we have attempted, according to the results of our continuous research and numerous data from available modern literature, to show the cytohistological characteristics of endothelial cells, as well as the changes they are subjected to in all stages of atherosclerosis. In the first part we have reviewed the ultrastructure, function and pathology of the endothelium, subcellular organization of the endothelial cells, their specific characteristics, micro compartments and intercellular junctions. In the second part we have described the morphological and functional changes of endothelial cells during atherosclerosis. Special attention is given to the role of endothelial cells in the development of the initial stage of lesion: endothelial dysfunction, factors that cause the increased expression of adhesion molecules in endothelial cells and mechanisms that cause leukocytes to migrate through the endothelial layer to subendothelial connective tissue in the early stage of atherosclerosis.

Could the level of nitrite/nitrate contribute to malignant thyroid nodule diagnostics?

Thyroid nodules are among highly prevalent thyroid diseases. To make a distinction between benign and malignant thyroid nodules are of cumbersome significance for each endocrinologist. There is no unique and completely accurate diagnostic test, method, or even biomarker that points to a malignant thyroid nodule. Many studies in modern thyroidology are conducted to determine the usefulness of individual biomarkers, which could help clinicians detect thyroid nodules' potential malignant nature. One interesting biomarker with a promising diagnostic potential for the thyroid gland pathological conditions is nitric oxide (NO). Inducible nitric oxide synthase expression is increased in thyroiditis cases and even more in thyroid carcinoma cases, directly connected with increased NO levels in both pathological conditions. We hypothesize that the basal levels of nitrite/nitrate in serum and biopsy washout could indicate nodules' malignant nature.

The Link between miRNAs and PCKS9 in Atherosclerosis

Cardiovascular disease (CDV) represents the major cause of death globally. Atherosclerosis, as the primary cause of CVD, is a chronic immune-inflammatory disorder with complex multifactorial pathophysiology encompassing oxidative stress, enhanced immune-inflammatory cascade, endothelial dysfunction, and thrombosis. An initiating event in atherosclerosis is the subendothelial accumulation of low-density lipoprotein (LDL), followed by the localization of macrophages to fatty deposits on blood vessel walls, forming lipid-laden macrophages (foam cells) that secrete compounds involved in plaque formation. Given the fact that foam cells are one of the key culprits that underlie the pathophysiology of atherosclerosis, special attention has been paid to the investigation of the efficient therapeutic approach to overcome the dysregulation of metabolism of cholesterol in macrophages, decrease the foam cell formation and/or to force its degradation. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a secretory serine proteinase that has emerged as a significant regulator of the lipid metabolism pathway. PCSK9 activation leads to the degradation of LDL receptors (LDLRs), increasing LDL cholesterol (LDL-C) levels in the circulation. PCSK9 pathway dysregulation has been identified as one of the mechanisms involved in atherosclerosis. In addition, microRNAs (miRNAs) are investigated as important epigenetic factors in the pathophysiology of atherosclerosis and dysregulation of lipid metabolism. This review article summarizes the recent findings connecting the role of PCSK9 in atherosclerosis and the involvement of various miRNAs in regulating the expression of PCSK9-related genes. We also discuss PCSK9 pathway-targeting therapeutic interventions based on PCSK9 inhibition, and miRNA levels manipulation by therapeutic agents.

Impact of treatment modalities on quality of life and depression in type 2 diabetes

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is a chronic disease with numerous complications that increase mortality and reduce the quality of life (QoL). The current study compares QoL in T2DM patients treated with insulin to those treated with oral antihyperglycemics (OAHs), as well as the frequency and severity of depression in patients.

SUBJECTS AND METHODS

This prospective cross-sectional study included 200 patients with insulin or OAHs. Triglycerides, total cholesterol, low-density lipoprotein, and high-density lipoprotein cholesterol levels were measured. The Beck Depression Inventory and the SF-36 Quality of Life Questionnaire were used to assess depression symptoms and QoL in response to different treatment modalities.

RESULTS

Insulin-treated patients have a longer duration of illness, higher preprandial glycemic levels, lower scores in three of four dimensions of the SF-36 physical component, and a lower score in the SF-36 psychological component's emotional role dimension. Patients on insulin have milder depression symptoms than those with OAHs. Depression symptoms, according to the findings, worsen QoL and glycemic control in insulin-treated patients.

CONCLUSIONS

According to these findings, any treatment modality's success in T2DM patients primarily depends on psychological support and preventive measures that promote and maintain mental health.

Cardiac myxoma: The influence of surgical technique on long-term prognosis

The aim of our study was to analyze the influence of different surgical techniques (left atriotomy, right atriotomy, biatrial approach and tumor basis solving) on early and late outcomes of patients operated on for cardiac myxoma. We evaluated 74 patients operated on for cardiac myxoma from 1982 through 2011. Sixty-six patients (89.19%) had left atrial myxoma and 8 (10.81%) right atrial myxoma. Histopathologic examination confirmed the diagnosis of atrial myxoma in all patients. In analyzing different surgical techniques we found that they had no influence on the duration of extracorporeal circulation and aortic cross-clamp time. Mortality analysis revealed: no intraoperative mortality; early mortality in 2 patients; late mortality in 12 patients. Survival after 29 years was 81.08%. There were no myxoma recurrences. 83.78% of the patients had functional improvement. In our opinion the best approach for right atrial myxoma is through right atriotomy, for left atrial myxoma through left atriotomy, with a biatrial approach for large tumors of the left atrium or when exploration of all 4 chambers is necessary. Subendocardial excision or thermocauterization was used for small tumors with bases less than 5 mm. Myxoma with a wider basis, depending on the localization, were partially resected at the atrial septum in the whole thickness or subendocardial excision of the tumor basis.

[Non-alcoholic fatty liver disease in obese persons with diabetes]

BACKGROUND

Obesity, diabetes and different lipid metabolic disorders are the most frequent risk factors for nonalcoholic fatty liver disease, presented with a high variability in clinical and histological findings.

CASE REPORT

We presented a case of 37-year-old male, suffering from type 2 diabetes mellitus, grade III obesity (BMI 45 kg/m2) and multiple metabolic disorders. Abdominal ultrasound revealed hepatomegaly during the last six months. Laboratory diagnostics showed increased serum transaminase levels. Serologic markers for viral hepatitis B and C were negative. The patient denied significant alcohol consumption. Liver biopsy and pathohistologic finding revealed macro- (III grade) and microvesicular (I grade) fatty degeneration, as well as mixed-cell portal infiltration with moderate liver fibrosis, corresponding to the typical presentation of NASH (Non Alcoholic Steatohepatitis).

CONCLUSION

NASH treatment options include the reduction of body mass and an adequate antidiabetic and dislipidemia treatment. The aim of all therapeutic measures was to stop the progression of the disease, to prevent the progression of fibrosis and the development of cirrhosis.

The effect of nutritional status, body composition, inflammation and serum iron on the developement of insulin resistance among patients on long-term hemodialysis

We investigated the effect of body composition, nutrition, inflammation and iron status on insulin resistance in patients with long-term hemodialysis. We selected 43 stable end-stage chronic renal failure patients, on maintenance hemodialysis. We evaluated the nutritional status, body composition by subjective global assessment (SGA), anthropometric measurements (BMI and waist circumference), bioelectrical impedance analysis and biochemical parameters measurements [serum albumin, cholesterol, HDL-cholesterol, triglyceride, hematocrit, hemoglobin, iron, ferritin, calcium, phosphorus, intact parathormone (i-PTH), TNF-alpha, IL-6 and high sensitivity C-reactive protein]. All parameters were evaluated by comparisons between HOMA-IR tertiles, and after simple regression analysis, by backward multivariate regression analysis we identified independent variables for IR. As the tertile of HOMA-IR increased, serum level of glucose, insulin, and waist increascd, whereas HDL-cholesterol level decreased, or the prevalence of the metabolic syndrome increased across the tertiles of HOMA-IR. After adjustment for gender, age, hemodialysis duration, ferritin, phosphorus, waist and total fat percentages, multivariate regression analysis was performed and the association with HOMA-IR was still strong only for serum levels of iron and TNF-alpha. That explains 16% of the total variation in HOMA-IR. Our results suggest that the increase of IR in end-stage chronic renal failure patients on hemodialysis could be related to anemia and particularly to iron overload. Moreover, chronic inflammatory status with over-production of adipokine TNF-alpha participate in the pathogenesis of IR too. The present study demonstrated that adipokine TNF-alpha and serum iron participated as independent predictors in the pathogenesis of insulin resistance on long-term hemodialysis patients.

A non-invasive method for estimating the severity of liver steatosis and the risk of fibrosis in non-obese type 2 diabetes patients with NAFLD

CONTEXT

Prognostic considerations include assessing the risk of liver fibrosis in people with non-alcoholic fatty liver disease (NAFLD).

OBJECTIVES

This study evaluates the use of hematologic and metabolic parameters regarding liver steatosis and fibrosis scores (FLI and Fib-4) in non-obese type 2 diabetes mellitus (t2DM) patients with NAFLD.

METHODS

Subjects underwent abdominal ultrasound examinations, and FLI and Fib-4 scores were calculated to evaluate liver steatosis and the risk of liver fibrosis non-invasively: 61 non-obese NAFLD subjects with t2DM were included in the cohort study and were divided into 2 groups depending on the t2DM treatment regimen.

RESULTS

Fib-4 and WBC count demonstrated a significant inverse correlation (OR = 0.509, p = 0.007). WBC count had an R2 of 0.237, indicating that this marker could account for up to 23.7% of a variation in Fib-4. Fib-4 and FFA had positive correlation which did not achieve statistically significant prediction (OR=7.122, p=0.062). Additionally, a significant prediction of HbA1c (OR=1.536, p=0.016) and haemoglobin (OR=1.071, p=0.020) for FLI was revealed.

CONCLUSION

HbA1c and other haematological and metabolic parameters, such as haemoglobin and WBC, may be another non-invasive tool for determining whether non-obese NAFLD patients with t2DM are at risk of developing liver steatosis and fibrosis.

Is cardiac venous anatomy a crucial factor in maximizing the response to cardiac resynchronisation therapy?

Cardiac resynchronization therapy (CRT) restores the synchrony of the heart?s contractions. The most critical issue in CRT implantation is the positioning of the coronary sinus (CS) lead because not every region can be accessed due to variations in coronary venous anatomy. The aim was to determine the correlation between different CS lead positions and hemodynamic changes and clinical outcome over time. Our study prospectively enrolled 51 patients with conventional indications for CRT which was divided into three groups according to the vein in which the left ventricle lead was placed during the procedure (posterior, lateral, and anterior). The groups were compared by baseline demographic characteristics, comorbidity, complications, new hospitalizations as well as by hemodynamic parameters before and six months after the procedure. After six months, all patients responded to CRT in the lateral group, 66.7% patients in the posterior group and 50% in the anterior group (p<0.01). Patients in the anterior group had a smaller decrease in NYHA functional class compared to the posterior and the lateral groups (p<0.01). The largest increase of preoperative ejection fraction value was in the posterior group (68.7%) compared to the lateral (42.2%) and anterior groups (19.8%) (p<0.01, A vs. P&L; P vs. A&L). In the anterior group there was a smaller decrease of QRS complex compared to the posterior and lateral groups (p< 0.05, A vs. P&L). Also there was a smaller decrease in the degree of mitral regurgitation in the anterior group compared to the lateral and posterior groups (p<0.05, A vs. P&L). One of the main determinants of CRT response is the anatomy of CS tributaries, and therefore the position of the LV lead is crucial in maximizing the effect of CRT.

Impact of different hormones on the regulation of nitric oxide in diabetes

Polymetabolic syndrome achieved pandemic proportions and dramatically influenced public health systems functioning worldwide. Chronic vascular complications are the major contributors to increased morbidity, disability, and mortality rates in diabetes patients. Nitric oxide (NO) is among the most important vascular bed function regulators. However, NO homeostasis is significantly deranged in pathological conditions. Additionally, different hormones directly or indirectly affect NO production and activity and subsequently act on vascular physiology. In this paper, we summarize the recent literature data related to the effects of insulin, estradiol, insulin-like growth factor-1, ghrelin, angiotensin II and irisin on the NO regulation in physiological and diabetes circumstances.

A CASE REPORT OF HAND AND FOOT SKIN CHANGES RESEMBLING PTU-INDUCED VASCULITIS IN A YOUNG MALE WITH DIFFUSE TOXIC GOITRE

CONTEXT

Propylthiouracil (PTU) could cause lupus or vasculitis-like hypersensitivities thus interfering with some other concomitant diseases.

OBJECTIVE

Clinicians must be aware of the side effects of medications, particularly after their introduction and long-term use. Some clinical manifestations may be similar to well-known drug side effects or hypersensitivity. Every unusual clinical scenario related to drug use must be evaluated individually and thoroughly.

SUBJECTS AND METHODS

Hands and feet skin changes were observed several days after PTU administration in a male patient with severe diffuse toxic goitre. A complete blood count, biochemistry analyses, thyroid function tests and antibodies, and immunology analyses were performed.

RESULTS

As the skin changes were distributed regionally, liver function tests were normal, and there were no signs of clinical deterioration, it was decided to continue PTU treatment and monitor the patient. The initial maculopapular rash quickly turned vesicular, then scaly. After two weeks, the skin changes were wholly restored, with no scarring. Hand, Foot, and Mouth disease (HFMD) was diagnosed after a thorough epidemiological survey and clinical workout.

CONCLUSIONS

Our case study demonstrates that skin changes associated with HFMD may resemble those associated with PTU-induced vasculitis.