Cardiac troponin elevation and mortality in takotsubo syndrome: new insights from the International Takotsubo (InterTAK) registry

Background/Introduction

Cardiac biomarker elevations are frequently observed in Takotsubo syndrome (TTS). The clinical relevance of cardiac troponin (cTn) elevations in TTS patients remains uncertain and threshold values indicating clinically relevant myocardial injury are unknown.

Purpose

This study sought to investigate the role of cTn elevations in mortality prediction of patients with TTS.

Methods

A total of 2,938 patients enrolled in the prospective International Takotsubo (InterTAK) Registry from January 2011 to February 2020 and with available data on baseline and peak cTn levels were included in the analysis. The threshold at which myocardial injury drives mortality was identified using restricted cubic spline analysis.

Results

Out of 2,938 patients, 222 (7.6%) patients died during 1-year follow-up. A more than 28.8-fold increase of cTn above the upper reference limit was identified as threshold for clinically relevant myocardial injury. Mortality at 1 year was significantly higher in patients with clinically relevant myocardial injury than in those without (Log Rank p<0.001, Figure 1). The presence of clinically relevant myocardial injury was significantly associated with an increased risk of mortality at 5 years (adjusted HR 1.58, 95% CI 1.18–2.12, p=0.002). Clinically relevant myocardial injury was related to 5-year mortality in patients with apical TTS (adjusted HR 1.57, 95% CI 1.21–2.03, p=0.001), with presence of physical stressors (adjusted HR 1.60, 95% CI 1.22–2.11, p=0.001), and with absence of emotional stressors (adjusted HR 1.49, 95% CI, 1.17–1.89, p=0.001).

Conclusions

This study for the first time determined a troponin threshold for the identification of TTS patients at excess risk of mortality. These findings advance risk stratification in TTS and assist in identifying patients in need for close monitoring and follow-up.

Funding Acknowledgement

Type of funding sources: Foundation.

Body weight and mortality in takotsubo syndrome: insights from the International Takotsubo (InterTAK) registry

Background/Introduction

The obesity paradox has been described in different cardiovascular conditions. Data on the association between obesity and outcomes in patients with Takotsubo syndrome (TTS) are lacking.

Purpose

The aim of this study was to determine the relation of body weight to mortality in TTS patients.

Methods

Patients enrolled in the International Takotsubo (InterTAK) Registry from January 2011 to July 2021 and with available data on BMI were included in the analysis. Patients were stratified according to BMI (underweight, <18.5 kg/m2; normal weight, 18.5–24.9 kg/m2; overweight, 25.0–29.9 kg/m2; obese, 30.0–34.9 kg/m2; and very obese, ≥35.0 kg/m2). The primary endpoint was mortality at 1 year.

Results

Of the 2'707 patients, 222 (8.2%) were underweight, 1340 (49.5%) of normal weight, 759 (28.0%) overweight, 268 (9.9%) obese, and 118 (4.4%) very obese. Mortality at 1 year as a function of BMI with 95% confidence interval is given in Figure 1. Mortality at 1 year was 11.3%, 6.9%, 5.5%, 4.9%, and 9.3% in underweight, normal weight, overweight, obese, and very obese patients (p=0.02, Figure 2). Being overweight or obese was significantly associated with a lower mortality at 1 year (HR 0.70, 95% CI 0.51–0.96, p=0.03), and associations remained significant after multivariable adjustments (adjusted HR 0.67, 95% CI 0.46–0.97, p=0.03). Associations were observed when including patients without emotional stressors (adjusted HR 0.64, 95% CI 0.43–0.94, p=0.02), but not when including those with emotional stressors (adjusted HR 1.14, 95% CI 0.30–4.27, p=0.85).

Conclusion

A U-shaped mortality curve across BMI categories was observed in TTS patients, with lowest mortality rates in obese patients. These observations provide first evidence for the existence of the obesity paradox in TTS.

Funding Acknowledgement

Type of funding sources: Foundation.

Assessment of Artificial Intelligence in Echocardiography Diagnostics in Differentiating Takotsubo Syndrome From Myocardial Infarction

Importance

Machine learning algorithms enable the automatic classification of cardiovascular diseases based on raw cardiac ultrasound imaging data. However, the utility of machine learning in distinguishing between takotsubo syndrome (TTS) and acute myocardial infarction (AMI) has not been studied.

Objectives

To assess the utility of machine learning systems for automatic discrimination of TTS and AMI.

Design, Settings, and Participants

This cohort study included clinical data and transthoracic echocardiogram results of patients with AMI from the Zurich Acute Coronary Syndrome Registry and patients with TTS obtained from 7 cardiovascular centers in the International Takotsubo Registry. Data from the validation cohort were obtained from April 2011 to February 2017. Data from the training cohort were obtained from March 2017 to May 2019. Data were analyzed from September 2019 to June 2021.

Exposure

Transthoracic echocardiograms of 224 patients with TTS and 224 patients with AMI were analyzed.

Main Outcomes and Measures

Area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity of the machine learning system evaluated on an independent data set and 4 practicing cardiologists for comparison. Echocardiography videos of 228 patients were used in the development and training of a deep learning model. The performance of the automated echocardiogram video analysis method was evaluated on an independent data set consisting of 220 patients. Data were matched according to age, sex, and ST-segment elevation/non-ST-segment elevation (1 patient with AMI for each patient with TTS). Predictions were compared with echocardiographic-based interpretations from 4 practicing cardiologists in terms of sensitivity, specificity, and AUC calculated from confidence scores concerning their binary diagnosis.

Results

In this cohort study, apical 2-chamber and 4-chamber echocardiographic views of 110 patients with TTS (mean [SD] age, 68.4 [12.1] years; 103 [90.4%] were female) and 110 patients with AMI (mean [SD] age, 69.1 [12.2] years; 103 [90.4%] were female) from an independent data set were evaluated. This approach achieved a mean (SD) AUC of 0.79 (0.01) with an overall accuracy of 74.8 (0.7%). In comparison, cardiologists achieved a mean (SD) AUC of 0.71 (0.03) and accuracy of 64.4 (3.5%) on the same data set. In a subanalysis based on 61 patients with apical TTS and 56 patients with AMI due to occlusion of the left anterior descending coronary artery, the model achieved a mean (SD) AUC score of 0.84 (0.01) and an accuracy of 78.6 (1.6%), outperforming the 4 practicing cardiologists (mean [SD] AUC, 0.72 [0.02]) and accuracy of 66.9 (2.8%).

Conclusions and Relevance

In this cohort study, a real-time system for fully automated interpretation of echocardiogram videos was established and trained to differentiate TTS from AMI. While this system was more accurate than cardiologists in echocardiography-based disease classification, further studies are warranted for clinical application.

Establishment of the first stool bank in an Eastern European country and the first series of successful fecal microbiota transplantations in Bulgaria

OBJECTIVE

For safe implementation and broader application of fecal microbiota transplantation (FMT), quality controlled stool banking is a must. Establishing a stool bank is a complex, time-consuming, and expensive process, making it a real challenge in an Eastern European country. We aimed to establish the first stool bank in Eastern Europe - in Bulgaria.

SUBJECTS AND METHODS

A multidisciplinary team of gastroenterologists, microbiologists, infectionists, and geneticists was set up. We used a questionnaire based on the First European FMT Consensus in order to recruit possible stool donors. Laboratory blood and stool tests were performed on all potential donors.

RESULTS

Between October 2018 and April 2019, 112 donor volunteers completed a questionnaire; 70 (62.5%) were excluded, mainly because of age above 50, an unhealthy BMI, and risk behavior. Fourty-two (37.5%) donor candidates were invited for laboratory testing of blood and feces, of which 12 (28.6%) passed this screening. Of 12 donors, 4 (33%) failed at the following screening test, which is performed every 3-6 months. Finally, 8 (7.14%) active donors were enrolled. Ten successful FMTs were performed on patients with recurrent Clostridium difficile infection.

CONCLUSIONS

Even though we found many healthy volunteers, only a low percentage (7.14%) of them were suitable to become feces donors. Establishing a stool bank in an Eastern European country is essential for making FMT safe and more popular as a treatment method, finding further implementation and regulation of FMT and supporting physicians offering this treatment to their patients.

Prognostic impact of acute pulmonary triggers in patients with takotsubo syndrome: new insights from the International Takotsubo Registry

AIMS

Acute pulmonary disorders are known physical triggers of takotsubo syndrome (TTS). This study aimed to investigate prevalence of acute pulmonary triggers in patients with TTS and their impact on outcomes.

METHODS AND RESULTS

Patients with TTS were enrolled from the International Takotsubo Registry and screened for triggering factors and comorbidities. Patients were categorized into three groups (acute pulmonary trigger, chronic lung disease, and no lung disease) to compare clinical characteristics and outcomes. Of the 1670 included patients with TTS, 123 (7%) were identified with an acute pulmonary trigger, and 194 (12%) had a known history of chronic lung disease. The incidence of cardiogenic shock was highest in patients with an acute pulmonary trigger compared with those with chronic lung disease or without lung disease (17% vs. 10% vs. 9%, P = 0.017). In-hospital mortality was also higher in patients with an acute pulmonary trigger than in the other two groups, although not significantly (5.7% vs. 1.5% vs. 4.2%, P = 0.13). Survival analysis demonstrated that patients with an acute pulmonary trigger had the worst long-term outcome (P = 0.002). The presence of an acute pulmonary trigger was independently associated with worse long-term mortality (hazard ratio 2.12, 95% confidence interval 1.33-3.38; P = 0.002).

CONCLUSIONS

The present study demonstrates that TTS is related to acute pulmonary triggers in 7% of all TTS patients, which accounts for 21% of patients with physical triggers. The presence of acute pulmonary trigger is associated with a severe in-hospital course and a worse long-term outcome.

Proangiogenic signature in advanced laryngeal carcinoma after microRNA expression profiling

The aim of this study is to evaluate which dysregulated angiomiRs compose the specific proangiogenic microRNA signature of advanced laryngeal cancer and review the literature. Thirty-six samples from twelve patients with advanced laryngeal carcinoma were collected. Total RNA was extracted and microRNA global profiling was performed using Agilent Technologies Microarray Kit. Fifty-nine microRNAs were found to have significantly different expression levels. Eleven microRNAs from the whole group were sorted as regulators of tumor angiogenesis (angiomiRs): seven were up-regulated-miR-1246, miR-181b 5p, miR-18a 5p, miR-21 3p, miR-210 3p, miR-503 5p, miR-93 5p and four were down-regulated-miR148a 5p, miR-145 5p, miR-204 5p, miR-125b 5p. For none of those microRNAs we found heterogeneity in tumor tissue. We are the first to report the specific proangiogenic microRNA signature in advanced laryngeal carcinoma and we confirm and amplify findings from previous studies that expand our perception of a specific "molecular state" of angiogenesis that is distinctive only for laryngeal cancer.

Analytical studies of the Alexandrovo Thracian tomb wall paintings

A profound study of samples obtained from Thracian tomb wall paintings at Alexandrovo, Bulgaria (dating back to the fourth century BC) were carried out by differential scanning calorimetry (DSC), Fourier transform infrared spectroscopy (FTIR) and Attenuated Total Reflectance Fourier transform infrared spectroscopy (ATR FTIR), high-resolution transmission electron microscopy (HRTEM) and energy dispersive X-ray spectroscopy (EDS). The current work provides a glimpse of the ingenious construction and painting techniques used in Thracian tomb at Alexandrovo. The results suggest that beeswax was used as a paint binder and also revealed presence of various nano-materials.

Prostaglandin E2 promotes survival of naive UCB T cells via the Wnt/β-catenin pathway and alters immune reconstitution after UCBT

The outcome of umbilical cord blood transplantation (UCBT) is compromised by low hematopoietic stem cell (HSC) doses leading to prolonged time to engraftment, delayed immunological reconstitution and late memory T-cell skewing. Exposure of UCB to dimethyl-prostaglandin E2 (dmPGE2) increases HSC in vivo. We determined that exposure of UCB T lymphocytes to dmPGE2 modified Wnt signaling resulting in T cell factor (TCF)-mediated transcription. Wnt signaling upregulated interleukin (IL)-7R and IL-2Rβ, resulting in enhanced survival mediated by the homeostatic cytokines IL-7 and IL-15. dmPGE2 also induced components of the Wnt pathway and Wnt receptors, thereby priming UCB T cells to receive signals via Wnt ligands in vivo. We observed that the Wnt transcription factor TCF7 and its target EOMES were elevated in the T cells of patients who received PGE2-treated UCBs. Consistent with the role of Wnt/β-catenin signaling to induce and maintain naive, memory precursors and long-lived central memory CD8(+) cells, these patients also had increased fractions of CD8(+)CD45RO(-)CD62L(+) plus CD8(+)CD45RO(+)CD62L(+) subsets encompassing these T-cell populations. These effects of the PGE2/Wnt/β-catenin axis may have significant implications for harnessing immunity in the context of UCBT, where impaired immune reconstitution is associated with late memory T-cell skewing.

Context-dependent differences in miR-10b breast oncogenesis can be targeted for the prevention and arrest of lymph node metastasis

Metastases, and not the primary tumor from which they originate, are the main reason for mortality from carcinoma. Although the molecular mechanisms behind metastasis are poorly understood, it is clear that epigenetic dysregulation at the level of microRNA expression is a key characteristic of the metastatic process that can be exploited for therapy. Here, we describe an miRNA-targeted therapeutic approach for the prevention and arrest of lymph node metastasis. Therapy relies on the inhibition of the pro-metastatic microRNA-10b. It is delivered to primary and lymph node metastatic tumor cells using an imaging-capable nanodrug that is designed to specifically home to these tissues. Treatment of invasive human breast tumor cells (MDA-MB-231) with the nanodrug in vitro downregulates miR-10b and abolishes the invasion and migration of the tumor cells. After intravenous delivery to mice bearing orthotopic MDA-MB-231-luc-D3H2LN tumors, the nanodrug accumulates in the primary tumor and lymph nodes. When treatment is initiated before metastasis to lymph nodes, metastasis is prevented. Treatment after the formation of lymph node metastases arrests the metastatic process without a concomitant effect on primary tumor growth raising the possibility of a context-dependent variation in miR-10b breast oncogenesis.

Assessment of pharmacy patients' compliance in Bulgaria (2001--2002)

The goal of this issue is to assess the level of compliance, respectively of non-compliance among pharmacY patients between the years 2001 and 2002 in Sofia, Bulgaria. The authors study and emphasize on the factors that influence the non-compliance of the patients and also try to find different ways to increase the rate of compliance in Bulgaria. Two types of standard individual questionnaires are applied for assessment of the state of compliance and non-compliance among the pharmacy patients. The obtained results show that the main reasons, influencing the non-adherence of the patients are: the high average price of the drugs, the overload daily regimen, inattention, distrust to the treatment and others. The drug form appears to be one of the main factors that cause non-compliance, especially when the patients receive more than one drug in different drug forms few times a day and especially if elderly patients are addressed. Despite the presented comparatively high level of compliance among the patients (from 53% for 2001, to 82% for 2002), there are strategies to enhance compliance that have to be initiated. They incorporate communication tactics, patient's education, and proper dosage of the drugs and scheduling of the drug application. The results of the analysis of the received data show an increase in the level of compliance for the pharmacy patients in Bulgaria. For 2001 it was 53%, while for 2002 it has increased to 82%. This fact shows the influence of strategies for improvement of compliance.

The role of information for improvement of patients' treatment in Bulgaria

PURPOSE

This issue is an attempt to assess patients' role as regards their compliance, respectively their non-compliance. The authors try to elucidate the factors concerning the patient-physician interrelation and patient-pharmacist interrelation that influence the non-compliance in order to increase the compliance rate.

METHODS

Standard individual questionnaires and interviews were developed and applied to study an attitude to compliance and non-compliance among different categories of patients, suffering from chronic diseases.

RESULTS

The obtained results show that the main reasons, influencing the patients' non-adherence to physicians' advise are: the high price of the drugs, the overburdened daily regimen, negligence, distrust towards the treatment and others. The insufficient information in the patient's leaflet together with the inappropriate drug form appears to be the main factors that cause non-compliance. This happens especially in the cases, when the patients are treated with more than one drug in different drug forms and particularly it concerns elderly people. Even though the compliance among the patients investigated was comparatively high (50% to 92%), possibility for improvement still exists if the treatment that have to be initiated could be individualised. Thus the level of compliance will be improved and increased.

DISCUSSION

The results from the data analysis show a great variation in the level of compliance among the chronic patients in Bulgaria. It ranges from 50 to 92%, depending on the type of the chronic disease and on the age of the patients. This fact shows the necessity for improvement of the different factors that has to begin as soon as possible.

RNA leaching of transcription factors disrupts transcription in myotonic dystrophy

Myotonic dystrophy type 1 (DM1) is caused by a CUGn expansion (n approximately 50 to 5000) in the 3' untranslated region of the mRNA of the DM protein kinase gene. We show that mutant RNA binds and sequesters transcription factors (TFs), with up to 90% depletion of selected TFs from active chromatin. Diverse genes are consequently reduced in expression, including the ion transporter CIC-1, which has been implicated in myotonia. When TF specificity protein 1 (Sp1) was overexpressed in DM1-affected cells, low levels of messenger RNA for CIC-1 were restored to normal. Transcription factor leaching from chromatin by mutant RNA provides a potentially unifying pathomechanistic explanation for this disease.

Phospholipid black foam films: dynamic contact angles and gas permeability of DMPC+DMPG black films

The behavior of black foam films from aqueous dispersions of dimyristoylphosphatidyl-choline (DMPC) with addition of the soluble phospholipid dimyristoylphosphatidylglycerol (DMPG) has been studied in dynamic conditions. The dynamic contact angles theta and the gas permeability coefficient K have been measured using the diminishing bubble method. The DMPC vesicle suspension in water is obtained through sonication and DMPG is dissolved in it. Two solutions with different NaCl concentrations (0.1 M and 0.5 M) have been studied. The behavior of the dynamic contact angles is very different for DMPC black films with, and without DMPG, respectively. They follow very different time dependence during spontaneous or forced variations of the bubble size. The gas permeability coefficient is significantly reduced by the DMPG addition. The NaCl concentration also influences this specific behavior. It seems that the electrically charged DMPG anions, which determine a significant electrostatic disjoining pressure, play an important role for this specific behavior. The results are discussed in connection with data regarding the thickness and structure of these black foam films. Films from DMPC+DMPG solutions in ethanol plus water mixed solvent have been studied as well, but no quantitative results could be obtained.

Comparison of the compliance of pharmacy patients

This issue is an attempt to be compared the compliance, respectively non-compliance among pharmacy patients between the years 1998 and 2001. The authors make an attempt to elucidate the factors that influence the non-compliance of the patients in order to improve it and to increase the rate of compliance among them. A questionnaire is applied for assessment the state of compliance and non-compliance among the pharmacy patients. The results of the analysis of the received data show that the level of compliance was 69% in 1998 and has decreased to 53% in 2001. The main reasons that influence the non-adherence of the patients are shown.

Phospholipid black foam films: dynamic contact angles and gas permeability of DMPC bilayer films

The behavior of bilayer Newton Black Films (NBF) from aqueous dispersions of dimyristoylphosphatidylcholine (DMPC) have been studied in dynamic conditions. The dynamic contact angles theta and the gas permeability coefficient K have been measured using the diminishing bubble method. Two different solutions have been used: (i) DMPC vesicle suspension in water obtained through sonication and (ii) DMPC dissolved in ethanol plus water mixed solvent. Both solutions contain 0.1 M NaCl. The behavior of the dynamic contact angles is very different for NBF from the two types of solutions. In the case (i) the initially constant theta(t) sharply increase after approximately 2 h of the spontaneous diminishing of the bubble, they follow the gas pressure variation in the cell and depend on the film area. On the contrary in case (ii) the theta(t) values are almost constant during the spontaneous diminishing of the bubble as well as during the gas pressure variation in the cell and they do not depend on the film area. The gas permeability coefficient is larger in case (ii). The results are discussed in connection with the thickness and structure of the NBF from the two types of solutions, taking into account the solubility (or insolubility) and the hydration of the adsorption layers of the DMPC molecules.

Information needs of young scientific workers and pre-graduated students in the sphere of pharmacy

The development of the Pharmaceutical science and its information insurance in the conditions of a transition period attain greater importance. The increase of the stream of information is more and more difficult for processing and from there-for usage.

Asthma, drug medication and noncompliance

According to the new concepts, asthma is a chronic disease of the upper respiratory tracts, caused by different cells, including the mastocits and eozinofils. The patients that are suffering from episodic, frequent, or chronic asthma are participating very energetic in the treatment--they have to know and control the symptoms of their disease and also to possess technical skills to perform the treatment.

METHODOLOGY

Between March 1 and July 31, 1999, 30 patients [19 women and 11 men, mean age 35 years (range 2.50 to 65)], followed at the Clinic for Allergic Diseases of the University hospital "Aleksandrovska", Medical University of Sofia, Bulgaria, were interviewed blindly in order to assess their compliance with pharmacologic therapy. All patients were suffering from different types of asthma.

RESULTS

The level of compliance among the studied group of patients is 86%. In comparison with the literary data where the level of non-compliance is 20% the obtained level is lower--14%. The reasons for non-compliance according to the patients are: the appearance of ADRs, the high prize of the drugs, the hard application of the drug form.

Pharmaco-economical analysis of the treatment with antibiotics in a surgery department

The fulfillment of a pharmaco-economical analysis of the treatment with antibiotics is an important task in the conditions of a transition period, that is currently in Bulgaria. The great problem with the insufficient financial sources prevents the supply with drugs, medical supply and technology. This analysis is a kind of an auxiliary source in the process of managing in the sphere of the health policy and in particular--in the sphere of the pharmacy.

Psychotropic drugs in Bulgaria-frequency and risk of adverse drug reactions

The aim of the study is to determine the frequency and risk of appearance of adverse drug reactions/ADRs/during the treatment with psychotropic drugs. The first part of the study is an analysis of the use of the psychotropic drugs for one-year period of time in our country, performed by DDD methodology. An attempt is made to equalize the Bulgarian list of the psychotropic drugs with the ATC classification and to estimate the DDD/1000/day. The data for Bulgaria is compared with that of the other countries. The collected data for the psychotropic drug use is divided into 2 groups: Psycholeptics and Psychoanaleptics. It is made an attempt to explain the main differences between them. The number of the standard therapeutic courses/NT/is used for assessment of the frequency and risk of ADRs. The results from the study show that the determined frequency of appearance of ADR for the different drugs is within "rare" and "very rare' for 100,000 inhabitants, according to the WHO terminology. Only for the drug Tardyl (EGIS Pharmaceuticals, Hungary) with INN Aminobarbitalum + Glutethimidum + Promethazini hydrochloridum the frequency is above 1%. That fact makes us to recommend a limitation of the prescription and usage of this drug to the Bulgarian Ministry of Health and to the National Drug Agency.

[Diagnostic problems of post-intoxication states]

Complete clinical examination covered 37 patients in various stages after acute occupational poisonings with pesticides (8 examinees), with explosive gases (9 subjects), with carbon oxide (3 examinees), with cadmium oxides (1 examinee), with nitrogen compounds (4 ones), with sulfurous gases (2 examinees), with organic solvents (10 subjects) including chlorinated hydrocarbons (2 subjects). Post-intoxication period appeared to include syndromes characteristic for each poison and corresponding to severity of acute state (from cephalgia to parkinsonism and thyrotoxicosis after acute poisoning with carbon oxide, organic neurologic signs and toxic hepatitis after acute poisoning with phosphorus organic compounds, cerebral asthenia after acute exposure to organic solvents, severe encephalopathy and toxic auditory and optic neuropathy after hydrogen sulfide). Inadequate medical rehabilitation and continuous occupational exposure induced deterioration in clinical signs and advanced post-intoxication syndromes.

Interaction between YY1 and the retinoblastoma protein. Regulation of cell cycle progression in differentiated cells

Overexpression of the transcription factor YY1 activates DNA synthesis in differentiated primary human coronary artery smooth muscle cells. Overexpression of the retinoblastoma protein together with YY1 blocked this effect. In growth-arrested cells, YY1 resides in a complex with the retinoblastoma protein, but the complex is not detected in serum-stimulated S phase cultures, indicating that the interaction of the retinoblastoma protein and YY1 is cell cycle-regulated. Recombinant retinoblastoma protein directly interacts with YY1, destabilizing the interaction of YY1 with DNA and inhibiting its transcription initiator function in vitro. We conclude that in differentiated cells elevation of the nuclear level of YY1 protein favors progression into the S phase, and we propose that this activity is regulated by its interaction with the retinoblastoma protein.

Occupational exposure to lead and induction of genetic damage

To investigate whether occupational exposure to lead is genotoxic, we evaluated data from 103 lead-exposed workers and 78 matched controls. These data correspond to three different sampling periods, and we measured genetic damage as increases in the frequency of binucleated cells with micronuclei (BNMN) in peripheral blood lymphocytes. The levels of exposure were determined according to the lead levels in blood. Clearly significant increases in BNMN were observed in the exposed groups when compared to the control group. In addition, for the overall population (n = 181), we observed a clear relationship between lead levels in blood and BNMN (r = 0.497; p < 0.001). When we examined four exposure levels--very low exposure (< 1.20 microM/L), low exposure (1.20-1.91 microM/L), high exposure (1.92-2.88 microM/L), and very high exposure (> 2.88 microM/L)--we found significant differences in the genetic damage induction. We conclude that exposure to levels of lead higher than 1.20 microM/L may pose an increase in genetic risk. In addition, our data show that blood lead level is a good indicator of genetic damage induction.

Occupational exposure to lead and induction of genetic damage

To investigate whether occupational exposure to lead is genotoxic, we evaluated data from 103 lead-exposed workers and 78 matched controls. These data correspond to three different sampling periods, and we measured genetic damage as increases in the frequency of binucleated cells with micronuclei (BNMN) in peripheral blood lymphocytes. The levels of exposure were determined according to the lead levels in blood. Clearly significant increases in BNMN were observed in the exposed groups when compared to the control group. In addition, for the overall population (n = 181), we observed a clear relationship between lead levels in blood and BNMN (r = 0.497; p < 0.001). When we examined four exposure levels--very low exposure (< 1.20 microM/L), low exposure (1.20-1.91 microM/L), high exposure (1.92-2.88 microM/L), and very high exposure (> 2.88 microM/L)--we found significant differences in the genetic damage induction. We conclude that exposure to levels of lead higher than 1.20 microM/L may pose an increase in genetic risk. In addition, our data show that blood lead level is a good indicator of genetic damage induction.

An attempt for complex assessment of the elderly patients' compliance

Compliance is taking the correct amount of the correct medicine at the correct time. Today, the problem of prescription medicine noncompliance is gaining considerably more attention within the pharmacy community as a part of the pharmaceutical care and by the other health professionals. Sometimes, compliance is defined "objectively" by how much medication a patient takes, such as taking a certain percentage of prescribed medication or taking a certain number of pills over a specific time period. Undoubtedly the care for the elderly patients and especially for the elderly patients that are bedridden can be an especially difficult challenge. The extent of non-compliance among them is estimated to be about 40% to 50%. The aim of this research is to assess the level of compliance and the factors, that influence this process among a group of elderly patients. We applied a complex methodology in order to avoid the mistakes that are connected with the use of a single method separately.

Low dose treatment with methotrexate-adverse drug reactions survey

Antineoplastic drugs caused various and frequent adverse drug reactions (ADR) in connection with their pharmacodynamics. Methotrexate (MTX) ADRs are preferably gastrointestinal disorders and hepatotoxicity (hepatic enzyme abnormalities). The aim of this study was to detect and analyse ADR induced by low-dose MTX treatment in rheumatology. We observed 94 patients, 63 with rheumatoid arthritis and 31 with psoriatic arthritis. All patients were co-medicated with nonsteroidal anti-inflammatory drugs (NSAID) as Diclofenacum, Indomethacinum, Piroxicamum and 51% with glycocorticosteroides. During the follow-up study we collected 18 case-reports with ADR for 17% of the patients. From the patients with registered ADR, 11 was treated with standard dose of 7.5 mg MTX for a week and 7 patients received from 10 to 15 mg for a week. The distribution of the cases according patients' gender was 9 females and 7 males. Prevail individuals in age groups' 41-50 and over 61 years. The most frequent adverse drug reactions were leucopenia, trombocytopenia, skin reactions and gastrointestinal disorders as vomiting, melaena, epigastrial pain, etc. The primary risk connected with long therapy of low doses MTX is hepatotoxicity that diagnose and treatment are painful and expensive. As a result of the appearance of ADR in 5 patients the therapy with MTX was not changed, in two cases MTX is stopped timely or the dosage is changed and in the rest 11 patients MTX was excluded from the therapeutic scheme.

[Lipid peroxidation in chronic lead exposure]

The state of lipid peroxidation, monitored by MDA concentration in the blood plasma of 46 battery workers with lead level in the blood in the 1.26-5.6 mol/l range is investigated. Higher MDA concentration (4.61 + 0.6) mol (ml in the blood plasma of exposed workers in comparison with the control sample of nonexposed workers is statistically established. The greater part of exposes workers (56.6%) have MDA concentration above the upper reference range. The significant correlation (r = +0.54) of the lipid peroxidation with the lead level in the blood is established. The investigation results show the rise of lipid peroxidation in workers chronically exposed to lead. This rise is more significant at lead levels above 1.92 mol/l.

[The effect of the zinc-containing preparation Oxyrich in the treatment of chronic saturnism (preliminary results)]

Under indoor conditions the effect of the Bulgarian zinc-containing preparation Oxyrich was studied in the treatment of 12 workers (males) with chronic saturnism. The preparation was orally administered in a dose of 150 mg (0.45 mmol Zn++) daily for 10 days in three equal receivings, after which three day antidotal therapy with CaNa2 EDTA was carried out according to the classic schedule. The complex investigation of the workers besides the clinical exmination included some key indices of the porphirine metabolism (5-ALK-D, 5-ALK, free protoporphirine in the red bolld cells), as well as the content of zinc and lead in the blood and their excretion with the urine prior and post the administration of Oxyrich and CaNa2 EDTA. The results of the carried out study revealed that the therapy with Oxyrich demonstrated a tendency to normalization of the activity of 5-ALK-D and decrease of the elimination of 5-ALK. This gave grounds for further study with higher doses of Oxyrich, as well as enlargement of the spectrum of the indices of the porphirine metabolism.

[Evaluation of initial results of treatment of lead poisoning with EDTA]

The results of EDTA therapy were studied in 37 workers of a battery factory consisting of males with varying degrees of occupational lead poisoning (low exposure: 10 subjects, blood lead levels (PbB) lower than 400 micrograms/l with slight alterations in heme biosynthesis; beyond limit of effect: 5 subjects, PbB > 400 micrograms/l; slight intoxication: 19 subjects, with marked alterations in heme synthesis and preclinical signs of intoxication; average degree of intoxication: 3 subjects with clinical signs of intoxication. Clinical symptoms and the following parameters were investigated: blood lead (PbB), delta-aminolevulinic acid dehydratase in erythrocytes (ALA-D), zinc protoporphyrin (PP) in erythrocytes and delta-aminolevulinic acid (ALA) in 24-hour urine before and after EDTA chelating therapy. Simultaneous measurement of ALA-D and PP showed high diagnostic sensitivity in detecting lead poisoning in occupationally exposed subjects. In view of the high interindividual variability of the results, these indices did not, however, permit a useful differentiation to be made of the different degrees of intoxication at individual level, even though a good correlation was observed between PbB and porphyrin metabolism indices. From the alterations observed in ALA-D and PP values it was not possible to establish an association between degree of alteration and types of clinical symptoms in the different intoxication studies. At the end of EDTA treatment, a clinical improvement was observed in all cases studied but only in 5 cases was a reduction in PbB observed, to levels below 1.20 mol/l, which is accepted as a permissible limit for the general population; in 17 cases PbB remained at levels above the critical value for occupational lead poisoning (400 micrograms/l), although there was a decrease after treatment. The improvement observed in the indices of porphyrin metabolism at the end of treatment was only slight: significant variations were measured only for PbB. After treatment no association was observed between ALA-D and PP variations in erythrocytes and improvement in clinical symptoms; measurement of these indices therefore seems to be of little use in assessing the efficacy of the treatment. In spite of its limited diagnostic sensitivity during intoxication, measurement of ALA in urine could be useful to assess the efficacy of chelating therapy in subjects in whom the values are initially altered.

[A clinical observation of vinyl chloride-induced disease]

Analysis is performed on the observed clinical picture of vinyl-chloride disease in 12 persons, developed at concentrations of toxic substance about MAC after exposure from 5 to 34 years. After enlarged clinical test on individual organs and systems the authors establish that the most frequent result of chronic poisoning with vinyl-chloride is the combination of peripheral neurovegetative symptoms with toxic hepatitis on the background of neurosis-similar (astheno-vegetative) manifestations. In the cases, observed by the authors, the poisoning takes a light course affecting the neurovegetative structures and prevailing of the vegetovasal forms of polyneuropathy ending with Raynaud-similar syndrome, or affecting the distal parts of the peripheral nerves with early electromyographic find. The Raynaud-similar syndrome and the bone changes ad specificity to the clinical picture, but are not constant manifestation of poisoning and can be developed at more continuous occupational exposure. The authors propose a discussion on the legality of the appelation vinyl-chloride disease in the cases, when not all classical clinic symptoms are present.