Obstruction of left ventricular outflow tract by a calcified mass at mitral valve

A case of an unusual left ventricular outflow tract obstruction by mitral valve pathology in a 35-year old female with diabetes and end-stage renal disease is presented in the study. The patient suffered from fever of an unknown origin after lower-leg amputation. Although the wound healed well, fever persisted for three weeks despite a triple antibiotic treatment until the infection was resolved with vancomycin. Three months later echocardiography displayed a floating mass attached to mitral valve, producing a newly developed systolic murmur and a mild haemodynamic obstruction of the left ventricular outflow tract. The calcified vegetation was probably formed during an unrecognized subacute infective endocarditis.

[Natriuretic peptides in clinical practice]

The natriuretic peptide (NP) system is primarily an endocrine system that maintains fluid and pressure homeostasis in healthy humans. The cardiac NP, ANP (atrial natriuretic peptide) and BNP (brain natriuretic peptide) are secreted by the heart in proportion to cardiac transmural pressures. The relationship between plasma levels of these peptides and "cardiac load" has led to their use as biomarkers of cardiac health with diagnostic and prognostic applications in a variety of disorders affecting the cardiovascular system. Elevated NP levels may serve as an early warning sign to help identify patients at a high risk of cardiac events. BNP and its N-terminal fragment (NT-BNP) are especially sensitive indicators for cardiac dysfunction and remodeling (correlate with severity) and play a role in the detection of coronary artery disease. The favorable biological properties of NP have also led to their use as therapeutic agents. Recombinant human ANP (carperitide) and BNP (nesiritide) are useful in the management od acutely decompensated heart failure.

[Obesity--a global public health problem]

Obesity and overweight, as a part of the metabolic syndrome, are well known risk factors for the development of diabetes, hypertension, coronary heart disease, hyperlipidemia, stroke, sleep apnea syndrome, osteoarthritis and certain forms of cancer. Cardiovascular disease remains the leading killer in industrialized countries, where it accounts for 40% of deaths. Obesity is defined either by increased waist circumference, waist to hip ratio, or body mass index. Obesity results from an interaction of genes and lifestyle. As people in both developed and developing countries eat more and more energy dense food, and have ever less physical activity, the number of overweight and obese people increases to epidemic proportions. Abdominal obesity plays a key role in the pathophysiology of metabolic disorders, is associated with insulin resistance, and predicts the development of type 2 diabetes and subsequent coronary artery disease. In the general population, obesity is associated with an increased mortality, but paradoxically, a positive correlation between body mass index and survival in congestive heart failure has been reported. In secondary prevention, obesity is underrecognized, underdiagnosed and undertreated in persons with cardiovascular diseases. Weight loss and prevention of weight gain have to be considered one of the most important strategies to reduce the incidence of cardiovascular disease. Increased physical activity and appropriate diet are the cornestones of treatment. Considering the high prevalence of overweight and obesity in Croatia, there is urgent necessity to improve the level of knowledge and skills in understanding obesity by health care services, and to implement appropriate professional strategy to achieve the desired lifestyle modifications.

[Specific characteristics of hypertension in postmenopausal women]

Sex-specific differences in the incidence of cardiovascular diseases have long been known, and estrogens have been considered responsible for this dissimilarity. After the menopause, the consequences of hypertension in women change. Their risks of myocardial infarction and stroke rise, which has in part been ascribed to the loss of estrogen and onset of menopausal metabolic syndrome. Sex differences in the components of the renin-angiotensin system have been shown to exist, and may play a central role in the blood pressure control. Hypertensive menopausal women do not receive optimal treatment. They have poorer prognosis than men of the same age. Therefore, their antihypertensive management calls for special attention.

Burnout syndrome--assessment of a stressful job among intensive care staff

The purpose of the study was to investigate the degree of burnout experienced by intensive care staff particularly, in Medical (MICU) and Surgical Intensive Care Units (SICU) General Hospital "Sveti Duh", Zagreb. A sample group of 41 emergency physicians and nurses from MICU and 30 from SICU was tested. The survey included demographic data and Maslach Burnout Inventory (MBI) scoring test identified by the three main components associated with burnout: emotional exhaustion (MBI-EE), depersonalization (MBI-DEP), and personal accomplishment (MBI-PA) were assessed using 22-item questionnaire. The degrees of burnout were stratified into low, moderate, and high range. Mean total MBI (X +/- SD) were high in both groups: higher for the MICU (65.5 +/- 6.7) than for SICU staff (55.7 +/- 3.8, p < 0.05). MICU staff showed moderate degree of MBI-EE (24.9 +/- 11.2), MBI-DEP (6.0 +/- 5.6), and as well as MBI-PA (34.4 +/- 8.8). The same parameters showed better results among SICU staff: low degree of MBI-EE (17.1 +/- 5.2), as well as low level of MBI-DEP (5.2 +/- 5.0), and moderate degree of MBI-PA (33.7 +/- 9.8). The differences between the groups was statistically significant only for the total MBI, and for MBI-EE (p < 0.05). There were no significant differences between MICU and SICU staff for MBI-DEP or MBI-PA parameters. Overall job burnout represented in a moderate degree. The presence of burnout is a serious phenomenon, because it can lead to psychosomatic complaints, work-associated withdrawal behaviour, and a lower quality of care at intensive care units. Early recognition of burnout phenomenon as a result of prolonged stress and frustration among intensive care staff, contributes to better professional behavior, organizational structure changes in the work environment and better health care quality for critically ill patients.

[Erectile dysfunction and cardiovascular disease]

Erectile dysfunction (ED) is a highly prevalent disorder worldwide. ED and cardiovascular disease (CVD) share many risk factors, the former often being the presenting symptom. The knowledge of the relationship between CVD and ED, the cardiovascular implications of phosphodiesterase type 5 inhibitors for the treatment of ED can help improve the quality of life of patients with both conditions. Cardiologists have a prominent role in treating ED.

Effect of educational programs on asthma control and quality of life in adult asthma patients

This study investigated the effectiveness of different educational programs in obtaining better asthma control and asthma-related quality of life (QoL). In 60 adult patients with moderate persistent asthma we tested the benefit of individual verbal instructions (IVI), written information ("asthma booklet", B), and integrated asthma classes ("asthma school", AS). At the enrollment and at the end of the study, all participants completed the questionnaires regarding their asthma-related knowledge (ArK) and QoL. During the 12-week period all patients recorded their asthma symptoms, morning and evening peek expiratory flow rates (PEFR), and the use of rescue medication. AS and IVI groups showed a significantly greater improvement in QoL than the B group. AS group obtained the highest ArK but no difference in the level of improvement among the groups has been documented. The improved average asthma symptom score and decreased utilization of the rescue medication were documented in all groups without significant differences among them. We also found significant improvements in both morning and evening PEFR in IVI group as well as in the morning PEFR in AS group. We conclude that among tested educational interventions the AS caused the best improvement in QoL while IVI produced the best overall response in both parameters of the asthma control and QoL.

[Primary pulmonary hypertension in pregnancy: case report]

Primary pulmonary hypertension (PPH) is a rare, progressive and currently incurable disease characterised by an increase in pulmonary artery pressure without a demonstrable cause. When associated with pregnancy, the maternal mortality ranges from 30 to 50%. In this report we present a 26-year old patient diagnosed with primary pulmonary hypertension during her twenty-first week of gestation. She was treated with a low-molecular-weight heparin and sedatives and underwent pregnancy termination without complications. Although cases have been reported with positive maternal and fetal outcome, the available evidence suggests that pregnancy with primary pulmonary hypertension should be avoided. Thus, in cases of pregnancy occurring, a therapeutic abortion is indicated.

Inbreeding and learning disability in Croatian island isolates

The aim of this study was to investigate the prevalence of learning disability (LD) in isolate populations with different inbreeding coefficients (F). Prevalence of LD and F were determined in 10 villages from five Croatian islands: Brac, Hvar, Korcula, Lastovo and Susak. For the purpose of this study, LD was defined as the inability to attend the public school system. As the elementary schools (grade 1-8) in the place of the study are both public and compulsory, the assessment of child's inability to attend the school is performed at the age of six. This is required by all children in the country based on standard set of tests of cognitive performance defined by the Ministry of Education and Culture of the Republic of Croatia. The average inbreeding coefficients in each village population (F) were estimated in a random sample of 20-30% adults in each of the 10 villages based on 4 ancestral generations and using Wright's path method. Prevalence of LD ranged from 0.43% to 2.47%, and the inbreeding coefficients ranged from 0.8% to 4.9%. The Pearson's correlation coefficient between F and LD prevalence was 0.80 (p < 0.01). Although the relative risk per 5% inbreeding appeared very high (about 10), the absolute risk only increased from 0.18% to 1.77%. The genetic effect of inbreeding (GEI) was approximately 0.69% and the population-attributable fraction 76.6%. A review of the literature and the results of this study lead to a conclusion that a very large number of predominantly recessive genetic factors might mediate the genetic susceptibility to various forms of LD in these populations.

The relationship between left ventricular filling shortly after an uncomplicated myocardial infarction and subsequent exercise capacity

Resting measurement of only left ventricular systolic function, is not enough sufficient parameter that predicts exercise capacity in patients with cardiac disease. Therefore, left ventricular filling shortly after an acute myocardial infarction (AMI) was prospectively studied to determine whether it could predict subsequent exercise time. Consecutive AMI patients underwent Doppler and two-dimensional echocardiography within 48 hours of infarction. The study group consisted of 63 participants: 33 patients with an uncomplicated AMI who had undergone symptom-limited stress testing during recovery and 30 healthy subjects. Systolic function was evaluated by wall motion score index (WMSI), and diastolic one was assessed by the peak transmitral Doppler velocity in early diastole (E) and atrial systole (A), then by their ratio (E/A), normalized E/A ratio, and by diastolic filling period (DFP). Myocardial infarction (MI) size was measured electrocardiographically, using Selvester's QRS scoring system (QRSSI) and then expressed in percentages. Healthy participants and patients were compared, through common parameters. The patients receiving BB treatment at the time of exercise testing, had a lower resting pulse, and achieved a lower maximal pulse, yet their exercise time was similar incomparison to that of the group not receiving BB therapy. Our results have shown a strong positive correlation between exercise time and WMSI (r = 0.77, p < 0.001) DFP (r = 0.56, p < 0.001), respectively weak negative correlation with QRSSI (r = -0.17, p < 0.001) and better negative correlation with normalized E/A ratio (r = -0.56, p < 0.001). This correlation was not influenced by beta-blokers (BB) at the time of stress testing. Normalized E/A ratio and DFP are the only diastolic function parameters, which predict exercise capacity during recovery, measured soon after an uncomplicated AMI.

[Intravenous magnesium in acute myocardial infarct]

The effects of magnesium (Mg) on the incidence of arrhythmias and on mortality were evaluated in 61 patients with documented acute myocardial infarction (AMI), in a randomized, double blind placebo controlled study. During the first 24 hours 31 patients received infusion of 1000 ml isotonic saline with 17 g MgSO4 and 30 ones received only equal volumes of saline as placebo. The baseline characteristics of the population including serum Mg and potassium were similar in the two groups. Severe arrhythmias were not as frequent in the Mg group (22%) as in the placebo one (36%), but the difference was not statistically significant (p = 0.05). There is no significant difference between the groups neither in mortality (3.2%; 0%) nor in conduction disturbances (3.2%; 3%). The adverse effects of Mg therapy were transient and therapy interruption was not required.

CONCLUSION

Although the trial is not an extensive one, and the results are nonsignificant, we consider intravenous Mg therapy to be simple and cheap with its place in the treatment of AMI in properly selected patients. According to available data it should be administered as soon as possible after the onset of AMI symptoms, before thrombolytic therapy, in 24-hrs. dose not exceeding 50-65 mmol probably through several days, but the optimal duration of therapy should be further investigated.