Biomarkers and their combination in a prediction of decompensation after an index hospitalization for acute heart failure

Introduction

Heart failure (HF) still remains as one of the most common causes of hospital admission with a high mortality rate.

Aim

To investigate the possible prognostic role of brain natriuretic peptide (BNP), high-sensitivity (hs) cardiac troponin (cTn) I, cystatin C, and cancer antigen 125 (CA125) in the prediction of decompensation after an index hospitalization and to investigate their possible additive prognostic value.

Patients and Methods

Two hundred twenty-two patients hospitalized with acute HF were monitored and followed for 18 months.

Results

BNP at discharge has the highest sensitivity and specificity in the prediction of decompensation. For a cutoff value of 423.3 pg/ml, sensitivity was 64.3% and specificity was 64.5%, with a positive predictive value of 71.6% and an area under the curve (AUC) of 0.69 (P < 0.001). The hazard risk (HR) for decompensation when the discharge BNP was above the cutoff value was 2.18. Cystatin C, at a cutoff value of 1.46 mg/L, had a sensitivity of 57% and specificity of 57.8%, with a positive predictive value of 65.8% and an AUC of 0.59 (P = 0.028). CA125, in the prediction of decompensation in patients with acute heart failure (AHF) and at a cutoff value of 80.5 IU/L, had a sensitivity of 60.5% and specificity of 53.3%, with a positive predictive value of 64.5% and an AUC of 0.59 (P = 0.022). The time till onset of decompensation was significantly shorter in patients with four versus three elevated biomarkers (P = 0.047), with five versus three elevated biomarkers (P = 0.026), and in patients with four versus two elevated biomarkers (P = 0.026). The HR for decompensation in patients with five positive biomarkers was 3.7 (P = 0.001) and in patients with four positive biomarkers was 2.5 (P = 0.014), compared to patients who had fewer positive biomarkers.

Conclusion

BNP, cystatin C, and CA125 are predictors of decompensation, and their combined usage leads to better prediction of new decompensation.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Efficacy and Safety of Perindopril in Patients with Essential Hypertension

Introduction

Perindopril is a tissue-specific ACE inhibitor with 24 hours long blood pressure-lowering effect, which protects blood vessels and decreases the variability of blood pressure.

Aim

The aim of our study was to investigate the effectiveness and safety of perindopril in newly diagnosed or previously treated but uncontrolled adult hypertensive patients.

Methods

This prospective cohort study included primary care patients with essential hypertension. Primary study outcomes were decreasing arterial blood pressure to normal levels (<140/90 mmHg), reducing systolic arterial blood pressure for 10 mmHg or more and reducing diastolic arterial blood pressure for 5 mmHg or more. Safety was evaluated by type and frequency of adverse events.

Results

In the great majority of the study patients (more than 96%) perindopril was effective as monotherapy, achieving a significant reduction in both systolic and diastolic blood pressure, and in three-quarters of the study patients it normalized both systolic and diastolic blood pressure. The effectiveness of perindopril was shown in both patients with previously and newly diagnosed hypertension, adverse events were mild and rare, even hyperkalemia was encountered less often than before the onset of the therapy with perindopril.

Conclusions

Our study confirmed excellent effectiveness of perindopril in the treatment of essential hypertension and its remarkable safety. When used as monotherapy of hypertension, perindopril's doses should be carefully titrated until the achievement of full effect, which in some patients should be awaited for at least 6 months from onset of the therapy.

Beta-blocker Use in Moderate and Severe Chronic Obstructive Pulmonary Disease

Introduction:

The most appropriate choice of pharmacological treatment of heart rhythm disorders occurring in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular comorbidity is often a topic of debate between pulmonologists and cardiologists in clinical practice, although numerous studies and clinical trials have demonstrated evidence to support the use of selective beta-blockers (BBs) in these patients.

Aim:

To examine the difference in the number of exacerbations in patients treated with a combination of verapamil and digoxin or BB alone in patients with different COPD stages.

Patients and methods:

The study included 68 patients (n = 68) diagnosed with COPD who were followed-up during a 12-month period, and the number of exacerbations were analyzed. The patients were divided into two groups according to the stage of COPD: GOLD II (moderate), and GOLD III (severe), and in each group a subdivision was established in relation to the use of either a combination of verapamil and digoxin or the use of BBs alone in pharmacological treatment. The inclusion criteria for patients were defined as following: a) established diagnosis of COPD according to present or deteriorated relevant clinical symptoms and signs, b) the ejection fraction (EF) of a left ventricle (LV) >35%, and c) spirometric cut-points classified as GOLD II (FEV1 / FVC <0.7, FEV1 predicted 50-80%), or GOLD III (FEV1/FVC <0.7, FEV1 predicted 30-50%) stage of the COPD. The exclusion criteria were EF of LV <35% and a lethal outcome during a follow-up period (2 patients were encountered). Exacerbation was defined as functional deterioration of the COPD symptoms verified by spirometric functional testing, frequency of hospitalizations according to GOLD stage assignment or verified clinical symptoms deterioration.

Results:

Regardless the pharmacological treatment, there is a statistically significant increase in the number of COPD exacerbations, in a 12-month period follow-up, in the GOLD III group (severe) compared to the GOLD II group (moderate). In the group of patients taking verapamil and digoxin, a two-tailed t-test was used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.01, and 2. In the group of patients taking BBs, a two-tailed t-test was also used to analyze the results between the GOLD II and GOLD III stage groups, p = 0.003). Within the COPD GOLD II stage group, there appears to be no statistically significant difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 24) and the patients taking BBs alone (n = 15), although, in patients taking BBs alone, there appears to be a trend towards a decrease in the exacerbations compared to the number of exacerbations in patients taking verapamil and digoxin (p = 0.007). Within the COPD GOLD III stage group, there is no difference in the number of exacerbations between the patients taking verapamil and digoxin (n = 20), and the patients taking BBs alone (n = 9), as analyzed by a two-tailed t-test, p = 0.577.

Conclusion:

Use of selective BBs in the treatment of cardiovascular comorbidity in patients with COPD represents a far better choice of pharmacological approach in the treatment of patients diagnosed with COPD GOLD II (moderate) stage.

Optimal choice of pharmacological therapy – Prevention of stroke and assessment of bleeding risk in patients with atrial fibrillation

Background:

The aim of the study was to highlight the importance of adequate anticoagulant therapy and the correlation of higher risk of stroke.

Methods:

This study analyzed data obtained from 103 patients with diagnosis of atrial fibrillation (AF) (39 of them had a stroke). Patients were divided into groups according to the CHADS₂, CHA₂DS₂-VASc, and HASBLED scores.

Results:

An analysis showed that anticoagulant drugs were more often prescribed to subjects <75 years of age (P = 0.001). Patients with a higher CHADS₂ score had a higher CHA₂DS₂-VASc score and vice versa (rho = 0.513; P = 0.0001). According to the CHA₂DS₂-VASc, 91.3% of the patients examined were prescribed an anticoagulant medication as a therapy at discharge from the hospital. The result was statistically significant compared to the practice where an anticoagulant was prescribed to 55.9% of high-risk subjects as estimated by the CHA₂DS₂-VASc score (P < 0.05). Our results also show that rivaroxaban is more commonly prescribed as a discharge therapy than warfarin (χ² = 12.401; P = 0.0001). Furthermore, a significantly higher number of patients who were being prescribed aspirin (38.5%) had a stroke compared to 12.8% of patients who were being prescribed warfarin (χ² = 12.259; P = 0.0001).

Conclusions:

Novel oral anticoagulants (NOACs) seem to be a better choice as a pharmacological therapy in the treatment of AF, due to a lack of adequate monitoring of patients’ international normalized ratio (INR) values. CHA₂DS₂-VASc and HASBLED scores must be used as a part of routine clinical diagnostics when dealing with patients with AF.

Predictors of Hospitalization for Heart Failure Decompensation in 18-months Follow-up After Index Hospitalization for Acute Heart Failure

Introduction

Heart failure (HF) has very high rate of repeat hospitalizations due to HF decompensation (HHFD), sometimes very shortly after discharge for acute HF.

Aim

The aim of this paper is to investigate rate of HHFD and to identify their possible predictors.

Patients and Methods

Total amount of 222 patients hospitalized at Clinic for heart and vessel disease and rheumatism in acute HF were followed for next 18 months for occurrence of HHFD. During hospitalization were collected demographic data, risk factors, routine laboratory tests and admission BNP (brain natriuretic peptide), discharge BNP, percentage change of BNP during hospitalization, high sensitive troponin I, CA125 (cancer antigen125) and cystatin C.

Results

In next 18 months 129 patients (58.11%) reached end-point HHFD- mean time of its occurrence was 2.2 (95% CI=1.67-2.7) months. Patients with HHFD had more often arterial hypertension (HTA) (p=0.006), had higher BMI (p=0.035) and had higher values of bilirubin, admission BNP (p=0.031), discharge BNP (p <0.001), CA125 (p=0.023) and cystatin C (p=0.028). There was no difference in troponin values (p=0.095), while % reduction of BNP during hospitalization was lower (p<0.001) in group with HHFD. In univariate Cox hazard analysis HTA was positively and BMI negatively correlated with HHFD, while in multivariate Cox hazard analysis independent predictors were HTA (HR 1.6; 95% CI=1.1-2.2; p=0.018) and BMI<25 (HR 1.6; 95% CI=1.1-2.3; p=0.007). In univariate Cox hazard analysis admission BNP, discharge BNP, rise of BNP during hospitalization, CA125 and bilirubin were positively correlated, while sodium was negatively correlated with HHFD. In multivariate Cox hazard analysis there was only one independent predictor of HHFD - discharge BNP (HR 6.05; 95% CI=1.89-19.4; p=0.002). Conclusion: Arterial hypertension, BMI>25 and discharge BNP are independent predictors of HHFD. This could help us to identify high-risk patients for readmission who should be monitored more frequently and treated with sophisticated drug and device therapy.

Potential Anti-Inflammatory Treatment of Ischemic Heart Disease

Introduction

Ischemic heart disease (IHD) is clinical manifestation of chronic inflammatory progressive pathological process of atherosclerosis in coronary arteries. IHD is the leading cause of morbidity and mortality in the world. The question is whether it is possible to improve and direct the therapeutic treatment of IHD patients in the treatment of the inflammatory process in the atherosclerotic leasions.

Material and Methods

A prospective, comparative, analytica,clinically applicable, open-type study was performed. The study was conducted on 80 subjects with controlled biohumoral markers: troponin, CK, CK MB, BNP; markers of atherogenesis: LDL and homocystein; inflammatory markers: CRP, amyloid, cytokines IL-2, IL-6,TNF-alpha. The experimental group of 38 respondents had in addition to the conventional IHD treatment with: ampicillin (which included organosulfur compounds), cyancobalamin, vitamin B complex (B1, B2 and B6) and folacin. A control group of 42 respondents did not have this additional treatment.

Results

Major adverse cardic events (MACE) such as postinfarctic angina pectoris and repeated infarction, need for surgical interventions of myocardial revascularization, signs of cardiac insufficiency and death were observed during the one-year period. There was no correlation between the IL-2, IL-6 and TNF-alpha, as well as CK, CKMB and troponin and MACE in one-year follow-up. There was a strong positive correlation between MACE and CRP (p = 0,0002) and amyloid (p = 0,0005) as inflamatory markers; a strong positive correlation between MACE and homocysteine as an atherogenic marker (p = 0,0002, and amoderate positive correlation between MACE and BNP (p = 0.0403) as ischemic marker and marker of cardiac insufficiency. The echocardiographically monitored systolic function showed a moderate difference in the groups with average higher values in the experimantal group (p = 0.0282).

Conclusion

The applied treatment exhibited a moderate positive effect on the systolic function of LV and significantly reduced the MACE in the work compared to the control group (p <0.0001), and demonstrated a potential anti-inflammatory effect.

Assesment of Rhythm Disorders in Classical and Nonclassical Mitral Valve Prolapse

Introduction

Mitral Valve Prolapse (MVP) is the most common cardiac valve pathology of to day. Aim of article was to identify the types and frequency of potentially malignant arrhythmia and atrial brillation in patients with MVP, to determine the differences in these arrhythmias between classical and non-classical MVP, to evaluate the correlation of potentially malignant arrhythmia and atrial fibrillation with MVP with possible clinical complications of arrhythmogenic sudden cardiac death and potential risk of thromboembolic vascular incident.

Patients and methods

Article has retrospective-prospective analytical character and present observational study on 239 patients (120 with MVP (66 with classical and 54 with non-classical MVP), who had a subjective feeling of palpitations and/or pain in the chest, and/or episode of syncope, and did not have ischemic heart disease or another valve pathology) and 119 healthy patients in the control group. All patients were analyzed by 24-hour ECG Holter.

Results

Signifficant difference in all analyzed arrhythmias between classical MVP and control group (p <0.001) between non-classical and control group in the presence of preexcitation signs (p = 0.047), and between classical and non-classical in presence of QT prolongation and AV block of II and III degree (p = 0.023), ventricular arrhythmias of the 3rd, 4th and 5th grade at scales according to Lown (p = 0.002) and atrial brillation in favor of classical MVP (p = 0.016).

Conclusion

The potential risk of cardiac death and vascular incidence is signi cantly higher in classical MVP than in non-classical MVP, implying the need for routine ECG-Holter monitoring in their diagnosis for timely prevention of clinical arrhythmogenic complications.

Gigantic Thrombus of the Left Atrium in Mitral Stenosis

Introduction

Excess dilatation of the left atrium >65 mm is known in the literature as gigantic atrium. This dilation is most commonly encountered in the mitral insufficiency of rheumatic etiology, but also in severe prolapses of the mitral valve, permanent atrial fibrillation, and at the left right shunt with cardiac insufficiency.

Case report

In this paper is presented a case study of echocardiographically verified giant thrombus in left atrium in a 50 years old female patient aged 50 hospitalized because of tiredness, choking, heartburn and urinary tract symptoms. The patient had rheumatic fever at age of 18 years. At age of 35, she was diagnosed with mitral stenosis. In permanent atrial fibrillation with anamnestic data on the previous cerebrovascular stroke (CVI) and the repeated transitional ischemic seizures. Echocardiographic examination confirmed severe mitral stenosis with moderate aortic insufficiency and gigantic left atrium (LA) with gigantic thrombus. Invasive diagnostics were indicated and performed, followed by an acute cardiac surgery including left atrial thrombectomy and implantation of the mechanical aortic and mitral valve. The surgical course was without complications.

Conclusion

On eleven postoperative day, after mobilization, the patient experiences stroke with motor aphasia. She was clinically recovering from stroke consequences, and remains cardiollogically stable.

Tetralogy of Fallot - Clinical Course and Treatment as a Mirror of Contemporary Cardiology/Cardiac Surgery Development in Correction of Congenital Heart Disease in the Adults

AIM

The aim of this paper was to present a 65 year old female patient with chronic heart disease, surgically treated for congenital heart defect type Tetralogy of Fallot.

CASE REPORT

In the sixth year of life the patient underwent palliative Potts anastomosis surgery which created an anastomosis between the left pulmonary artery and the descending aorta. Total correction was made in 34 years of life, six months after catheterization, which indicated malignant pulmonary hypertension. She is regularly followed up by the cardiologists and receives daily therapy. The present state of the patient is satisfactory with cardiomegaly, light left ventricular dysfunction, moderate mitral and tricuspid regurgitation, pulmonary arterial hypertension, and aneurysmatic dilatation of left pulmonary artery as well as atrial fibrillation.

CONCLUSION

The intense development of cardiology and cardiac surgery in the USA in children and adults over the last fifty years has led to the extension and improvement of the quality of life.

Troponin and CRP as Indicators of Possible Ventricular Arrhythmias in Myocardial Infarction of the Anterior and Inferior Walls of the Heart

Introduction

Heart rhythm disorders are quite common in the clinical course of acute myocardial infarction and have a significant influence on the prognosis of the disease.

Aim

To investigate the type and frequency of ventricular arrhythmias in patients with acute myocardial infarction (AMI) by sex and age, according to localization of myocardial infarction, and correlated with troponin and C reactive protein (CRP).

Material and Methods

A prospective, analytical, comparative clinical study was performed. A total of 100 patients was included who were hospitalized at the Clinic for Heart Disease and Rheumatism at the Clinical Center University of Sarajevo for a period of 6 months, of both sexes, aged from 20 to 90 years. The occurrence of ventricular arrhythmias, CRP and troponin, were observed in relation to the localization (anterior and inferior myocardial wall).

Results

It was found that men are more represented in comparison to women and that the largest number of males were in the age group of 51-60 years of life and women in the age group of 71-80 years. It has been established that there is no significant difference between ventricular arrhythmia according to localization of AMI. By determining the mean CRP and troponin levels, a positive correlation was found between CRP and troponin values and recorded ventricular arrhythmias.

Conclusion

There is a positive correlation between the troponin and CRP values and ventricular arrhythmias, not related to the localization of AMI, which is important in prevention and planning the treatment of complications of potentially malignant ventricular arrhythmias and fatal outcome at AMI.

Seasonal Incidence of Acute Coronary Syndrome and Its Features

Introduction

Acute coronary syndrome (ACS) is one of the most common health problems in the world and the leading cause of death.

Goal

The goals of this study are to determine: ACS type, risk factors, incidence and the seasonal distribution of occurrence Spring/Summer, Autumn/Winter, ACS incidence by age and gender, and complications (post-infarction angina and heart failure) and fatal outcomes of ACS per season.

Material and methodology

This study is designed as retrospective-prospective and analytical, which included 250 patients hospitalized in the Intensive Cardiac care unit of the Clinic for heart disease, blood vessels and rheumatism in the period from June 2013 to July 2014. It was assumed that there is the influence of the seasons on the incidence and characteristics of ACS. Material used were the medical records and data from the history of illness.

Results

The most common type of ACS was ST elevation myocardial infarction (STEMI), without statistical significant difference between seasons. Presence of risk factors is not significantly different between seasons, with the hypertension as the most common risk factor for ACS during both seasons. The highest incidence of ACS was recorded in December during the winter season, while the lowest incidence was recorded in March. The occurrence of ACS during the Spring/Summer, Autumn/Winter was different according to age, with more frequent occurrence of ACS in older patients during the winter months. ACS complications (postinfaction angina and cardiac insufficiency) were also statistically different between seasons (p=0.048). Fatal ACS is more often recorded during the season Autumn/Winter compared to Spring/Summer season (p=0.001).

Conclusion

The results suggest seasonal meteorological impact on the incidence, complications and outcomes of ACS, so there is a necessity that patients adapt their lifestyle and health professionals to improve the ACS treatment.

Co-infection of Ornithodoros coriaceus with the relapsing fever spirochete, Borrelia coriaceae, and the agent of epizootic bovine abortion

The soft tick, Ornithodoros coriaceus (Koch) (Acari: Argasidae), is a common mammalian parasite of livestock in many arid regions of the western U.S.A. The tick is a known vector of the undescribed bacterial pathogen that causes epizootic bovine abortion (EBA), which results in late-term abortions in beef cattle and subsequent economic loss, which can be considerable, to producers. A second reported bacterial pathogen, Borrelia coriaceae, a member of the relapsing fever complex, has also been identified in this tick and was at one time hypothesized to be the aetiological agent of EBA. In order to test whether bacterial infections in ticks overlapped geographically and to determine the prevalence of co-infection in O. coriaceus populations, we used molecular methods to detect bacterial DNA from ticks collected from a wide variety of habitats in California, Nevada and Oregon. Of the 15 sites at which ticks tested positive for the agent of EBA (aoEBA), eight also contained ticks positive for Borrelia spp. by polymerase chain reaction assay. Additionally, two ticks were co-infected; both of these were collected from the same location. Univariate risk analysis indicated the presence of juniper-dominated habitat at the collection site and geographic location to be significantly associated with infection of the tick vector by either pathogen.

Lyme Neuroborreliosis in 2 Horses

Lyme neuroborreliosis—characterized as chronic, necrosuppurative to nonsuppurative, perivascular to diffuse meningoradiculoneuritis—was diagnosed in 2 horses with progressive neurologic disease. In 1 horse, Borrelia burgdorferi sensu stricto was identified by polymerase chain reaction amplification of B burgdorferi sensu stricto–specific gene targets ( ospA, ospC, flaB, dbpA, arp). Highest spirochetal burdens were in tissues with inflammation, including spinal cord, muscle, and joint capsule. Sequence analysis of ospA, ospC, and flaB revealed 99.9% sequence identity to the respective genes in B burgdorferi strain 297, an isolate from a human case of neuroborreliosis. In both horses, spirochetes were visualized in affected tissues with Steiner silver impregnation and by immunohistochemistry, predominantly within the dense collagenous tissue of the dura mater and leptomeninges.

Clinical, echocardiographic and echophonocardiographic characteristics of the atrial myxomas in 22 years period

INTRODUCTION

Atrial myxomas are the most frequent benign tumors of the heart. Left atrial myxomas are about 3-4 times more frequent then right. Clinical findings reveal atrioventricular obstruction symptoms and signs, symptoms and signs of peripheral arteries or pulmonary artery embolisation and/or nonspecific symptoms.

AIM

Review of atrial myxomas diagnosed at the Clinic of Cardiology in 20 years period and analysis of clinical characteristics, transthoracic echocardiographic (TTE), transesophageal echocardiographic (TEE), and M-mod echophonographic findings.

METHODS

TTE is performed in all, but TEE in 16 patients. Simultaneous M-mod echophonocardiographic examination were performed in 11 patients, when optional equipment was applicable.

RESULTS

We found 24 atrial myxomas: 19 (79.2%) in left and 5 (20.810%) in right atrium. 21(87.5%) patients had some of the symptoms, but 3 (12.5%) were asymptomatic. TTE was performed in all patients, but we found 1 (2.4%) false negative result. TEE was performed in 14 (58.3%) patients. Echophonocardiographic recordings showed early diastolic tumor "plop" in 10 patients and unusual late diastolic tumor "plop" in one right atrial myxoma, which has not yet been described.

CONCLUSIONS

TTE is a reliable method in diagnosis of atrial myxomas, but not in all cases, while TEE has been found as always reliable. Echophonocardiographic recording is useful for confirmation and understanding of auscultatory finding when applicable.

Acquisition dynamics of Borrelia burgdorferi and the agent of human granulocytic ehrlichiosis at the host-vector interface

The population dynamics of two cotransmitted tick-borne pathogens, Borrelia burgdorferi and the agent of human granulocytic ehrlichiosis (aoHGE), were assessed at the skin-vector interface at intervals after tick attachment on infected mice. Quantitative real-time polymerase chain reaction targeting the B. burgdorferi flagellin gene revealed consistent decreases in spirochete numbers in skin at the sites of tick attachment compared with non-tick attachment sites. This phenomenon was found during early (2 weeks) and late (8 weeks) infection and at 24, 48, and 72 h after tick attachment. A nonspecific inflammatory stimulus, implantation of suture material, did not have this effect. In contrast to B. burgdorferi, copy numbers of an aoHGE p44 target gene target were significantly increased at the sites of tick attachment, compared with non-tick sites. The non-specific stimulus of suture material had the same effect on aoHGE recruitment as tick attachment in aoHGE infected mice. These results reinforce the concept that B. burgdorferi interfaces with its vector by virtue of its non-systemic dermatotropism, and not via systemic hematogenous acquisition. In contrast, results indicate that the aoHGE relies upon hematogenous acquisition. Thus, these two cotransmitted tick-borne pathogens utilize distinctly different means of vector acquisition.

Humoral immune response associated with lyme borreliosis in nonhuman primates: analysis by immunoblotting and enzyme-linked immunosorbent assay with sonicates or recombinant proteins

The immune response to Borrelia burgdorferi, the causative agent of Lyme disease, is complex. We studied the immunoglobulin M (IgM) and IgG antibody response to N40Br, a sensu stricto strain, in the rhesus macaque(nonhuman primate [NHP]) model of infection to identify the spirochetal protein targets of specific antibody. Antigens used in enzyme-linked immunosorbent assays were whole-cell sonicates of the spirochete and recombinant proteins of B. burgdorferi. Immunoblotting with a commercially available strip and subsequent quantitative densitometry of the bands were also used. Sera from four different groups of NHPs were used: immunocompetent, transiently immunosuppressed, extended immunosuppressed, and uninfected. In immunocompetent and transiently immunosuppressed NHPs, there was a strong IgM and IgG response. Major proteins for the early IgM response were P39 and P41 and recombinant BmpA and OspC. Major proteins for the later IgG response were P39, P41, P18, P60, P66, and recombinant BmpA and DbpA. There was no significant response in the NHPs to recombinant OspA or to Arp, a 37-kDa protein that elicits an antibody response during infection in mice. Most antibody responses, except for that to DbpA, were markedly diminished by prolonged dexamethasone treatment. This study supports the hypothesis that recombinant proteins may provide a useful adjunct to current diagnostic testing for Lyme borreliosis.

[Characteristics of the early posttransplantation period in kidney transplantation]

INTRODUCTION

Renal transplantation has become the procedure of choice and the most cost-effective strategy for the management of patients with end stage renal disease. Posttransplant period is very important because possible complications, which have to be detected and treated according to approve statements. The aim this paper with is to show all characteristics of early postransplant period in patients operated at the Clinical Center of Tuzla.

METHODS AND RESULTS

Eighteen patients with end stage renal diseases has been analyzed with average age 32 + 8.6 years. Glomerulonephritis as primary kidney diseases has been found in 16 patients, lupus nephritis and reflux nephropathy in one patient. We paid attention on: creatinine level, urine output and balance, level of cyclosporin, body weight, ultrasound fallow-up, number episodes of acute rejection and number of additional dialysis. Clinical and labs sign of acute rejection have been found in 6 patients. Two of them recidive pulse dose of corticosteroides and four ATG. Additional haemodialysis has been performed in 5 patients. One patient died because of the rupture aneurism of aorta. Other 17 patients have been discharged after average hospitalisation of 20.87 8.18 days.

CONCLUSION

We can say it's very important to recognise the sings of acute rejection and to start with therapy. In patients with cardiovascular risk, postoperative period has to be guided careful.

Evaluation of diagnostic methods for Helicobacter bilis infection in laboratory mice

Disease-susceptible (C3H) and -resistant (B6) immunocompetent and immunodeficient (C3H-scid and B6-rag1) mice were examined up to 10 weeks after inoculation with Helicobacter bilis (a prototype species of proven virulence). Infection was monitored weekly by use of fecal culture, polymerase chain reaction (PCR) nucleic acid amplification, membrane extract enzyme-linked immunosorbent assay (ELISA), and histologic examination. All mice became infected by three to five weeks after inoculation, on the basis of results of culture and PCR analysis of feces. The PCR analysis was more sensitive than culture at determining infection status, particularly during early infection. None of the mice had evidence of disease by week 10. Immunoglobulin G seroconversion was detectable in C3H mice by week eight and in B6 mice by week nine. Results indicated that culture and PCR analysis are more sensitive than is membrane extract ELISA serologic testing for detecting early infection in individual mice, regardless of genotype or immune status. Results underscore the need for improved seroassays for this important group of murine pathogens.

Central and peripheral nervous system infection, immunity, and inflammation in the NHP model of Lyme borreliosis

The relationship between chronic infection, antispirochetal immunity, and inflammation is unknown in Lyme neuroborreliosis. In the nonhuman primate model of Lyme neuroborreliosis, we measured spirochetal density in the nervous system and other tissues by polymerase chain reaction and correlated these values to anti-Borrelia burgdorferi antibody in the serum and cerebrospinal fluid, and to inflammation in tissues. Despite substantial presence of Borrelia burgdorferi, the causative agent of Lyme borreliosis, in the central nervous system, only minor inflammation was present there, though skeletal and cardiac muscle, which contained similar levels of spirochete, were highly inflamed. Anti-Borrelia burgdoferi antibody was present in the cerebrospinal fluid but was not selectively concentrated. All infected animals developed anti-Borrelia burgdorferi antibody in the serum, but increased amplitude of antibody was not predictive of higher levels of infection. These data demonstrate that Lyme neuroborreliosis is a persistent infection, that spirochetal presence is a necessary but not sufficient condition for inflammation, and that antibody measured in serum may not predict the severity of infection.

Infection of mice with the agent of human granulocytic ehrlichiosis after different routes of inoculation

Population kinetics of the agent of human granulocytic ehrlichiosis (aoHGE) were examined after needle and tickborne inoculation of C3H mice. Blood, skin, lung, spleen, liver, kidney, brain, lymph node, and bone marrow samples were analyzed by using real-time polymerase chain reaction (PCR) at various intervals after inoculation, using a p44 gene target. The highest number of copies of the p44 gene target occurred in blood and bone marrow samples, emphasizing aoHGE leukocytotropism. Numbers of copies of the p44 gene target in other tissues reflected vascular perfusion rather than replication. Needle-inoculated infected mice had earlier dissemination, but kinetics of infection in both groups were parallel, with declining rates of infection by day 20 and recovery in some mice on days 20-60 after inoculation. On the basis of an aoHGE lysate ELISA, mice seroconverted by day 10 after inoculation. Therefore, real-time PCR is useful for quantitative studies with the aoHGE in experimental infections, and results showed that needle inoculation can be used to study the aoHGE infection because of its similarity to tickborne inoculation.

Lyme arthritis resolution with antiserum to a 37-kilodalton Borrelia burgdorferi protein

A 37-kDa protein from Borrelia burgdorferi (the agent of Lyme disease) was identified as a target for immune-mediated resolution of Lyme arthritis. Studies in a mouse model have shown that arthritis resolution can be mediated by antibodies (against unknown target antigens) within immune sera from actively infected mice. Immune sera from infected mice were therefore used to screen a B. burgdorferi genomic expression library. A gene was identified whose native product is a putative lipoprotein of approximately 37 kDa, referred to here as arthritis-related protein (Arp). Active and passive immunization of mice with recombinant Arp or Arp antiserum, respectively, did not protect mice from challenge inoculation. However, when Arp antiserum was administered to severe combined immunodeficient (SCID) mice with established infections and with ongoing arthritis and carditis, treatment selectively induced arthritis resolution without affecting the status of carditis or influencing the status of infection, including spirochetemia. The selective arthritis-resolving effect of Arp antiserum mimics the activity of immune serum from immunocompetent mice when such serum is transferred into SCID mice with established infections. The arp gene could not be amplified from unrelated B. burgdorferi isolates but hybridized with those isolates only under very-low-stringency conditions. Arp antiserum reacted against proteins of similar size in a wide range of B. burgdorferi isolates.

Stability of Borrelia burgdorferi outer surface protein C under immune selection pressure

Outer surface protein (Osp) C immune pressure during persistent infection with Borrelia burgdorferi was examined in relation to genetic variation of ospC. Mice were infected with clonal B. burgdorferi sensu stricto (s.s.) N40 or B. afzelii PKo and then were hyperimmunized with homologous recombinant OspC or with decorin-binding protein A (DbpA) (controls). After 6 months, B. burgdorferi isolates were subjected to restriction enzyme analysis of the amplified ospC genes and were found to have no differences among 9 B. burgdorferi s.s. N40 and 9 B. afzelii PKo isolates from OspC hyperimmune mice or among 10 B. burgdorferi s.s. N40 and 10 B. afzelii PKo isolates from DbpA hyperimmune mice, compared with input inocula. Comparison of gene sequences among 4 B. burgdorferi s.s. N40 and 9 B. afzelii PKo isolates from OspC-immunized mice revealed no ospC variation from input inocula. Variation in ospC among B. burgdorferi isolates and species during chronic infection is not likely to be an important mechanism for immune evasion.

Acquisition and transmission of the agent of human granulocytic ehrlichiosis by Ixodes scapularis ticks

The purpose of the present study was to investigate the transmission of a human isolate of the agent of human granulocytic ehrlichiosis (HGE agent) from infected mice to larval ticks and to examine the population kinetics of the HGE agent in different stages of the tick life cycle. The HGE agent was quantitated by competitive PCR with blood from infected mice and with Ixodes scapularis ticks. The median infectious dose for C3H mice was 10(4) to 10(5) organisms when blood from an infected severe combined immunodeficient mouse was used as an inoculum. Uninfected larval ticks began to acquire infection from infected mice within 24 h of attachment, and the number of HGE agent organisms increased in larval ticks during feeding and after detachment of replete ticks. Molted nymphal ticks, infected as larvae, transmitted infection to mice between 40 and 48 h of attachment. Onset of feeding stimulated replication of the HGE agent within nymphal ticks. These studies suggest that replication of the HGE agent during and after feeding in larvae and during feeding in nymphs is a means by which the HGE agent overcomes inefficiencies in acquisition of infection by ticks and in tick-borne transmission to mammalian hosts.

Humoral immunity to Borrelia burgdorferi N40 decorin binding proteins during infection of laboratory mice

A Borrelia burgdorferi N40 genomic expression library was screened with serum from actively infected mice to identify gene products that elicit protective immunity. A clone that contained a putative bicistronic operon containing two genes that encoded 20- and 22-kDa lipoproteins was identified and sequenced. These genes showed homology with the genes encoding decorin binding proteins DbpB and DbpA, respectively, of B. burgdorferi 297 and B31. N40-dbpA DNA hybridized with B. burgdorferi N40 DNA on a single 48-kb linear plasmid. Homologous genes could be amplified under various degrees of stringency by PCR or hybridized by Southern blotting from B. burgdorferi sensu stricto N40 and B31, and from B. burgdorferi sensu lato PBi and 25015, but not PKo. Recombinant N40-DbpB and N40-DbpA were reactive with antibody in serum from infected mice, and serum was more reactive against N40-DbpA than against B. burgdorferi N40 recombinant P39, OspC, or OspA. Sera from mice infected with B. burgdorferi sensu lato strains PKo and PBi were weakly reactive against N40-DbpB and N40-DbpA, and sera from mice infected with 25015 were moderately reactive, compared to sera from mice infected with B. burgdorferi N40. Hyperimmunization of mice with N40-DbpA, but not N40-DbpB, induced protective immunity against syringe challenge with cultured B. burgdorferi N40. DbpA may therefore be one of the antigens responsible for eliciting protective antibody known to exist in serum from infected mice. DNA amplification and serology suggest that DbpB and DbpA are likely to have homologs throughout the B. burgdorferi sensu lato family, but they are likely to be heterogeneous.

PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States

OBJECTIVE

The authors' goal was to describe the characteristics of posttraumatic stress disorder (PTSD) symptoms on resettlement in the United States and at 1-year follow-up among Bosnian refugees as well as possible factors affecting the PTSD symptom profile among these refugees.

METHOD

They used standardized instruments to assess 34 Bosnian refugees for PTSD at resettlement in the United States and 1 year later.

RESULTS

Fifteen of the refugees were diagnosed with PTSD at 1-year follow-up, compared with 25 at initial assessment. The average PTSD severity score at follow-up was 12.5, compared with 20.6 at initial assessment. At 1-year follow-up, 25 of the refugees experienced a decrease in severity of PTSD symptoms, one remained the same, and eight experienced an increase in severity. Older refugees were significantly more likely to have PTSD than younger refugees, and older refugees had more severe symptoms.

CONCLUSIONS

The level of PTSD diagnosis and symptoms in Bosnian refugees remained substantial 1 year after their resettlement in the United States, although there were notable overall decreases. Older refugees appeared to be at greater risk.

Granulocytic ehrlichiosis in tick-immune guinea pigs

We investigated whether Ixodes scapularis-mediated host immunity interrupts transmission of the agent of human granulocytic ehrlichiosis (aoHGE) to guinea pigs. Ticks infected with aoHGE readily transmitted aoHGE to tick-immune guinea pigs, despite incomplete tick engorgement and host attachment. Although tick immunity can prevent Lyme borreliosis, protection is not afforded against granulocytic ehrlichiosis.

Granulocytic ehrlichiosis in the laboratory mouse

C3H mice that were inoculated with ehrlichiae isolated from a patient with human granulocytic ehrlichiosis (HGE) developed anemia and leukopenia, but by day 24, they returned to normal values. Granulocytic morulae were present in peripheral blood and spleen smears on days 5 and 10, and there was a reduction in morulae on day 17. Ehrlichiae were present in HL-60 cell cultures of blood and spleen from all mice at all intervals. Pathogenicity, but not infectivity, waned with mouse passage but could be resurrected by SCID mouse passage. Various methods were tested for their relative sensitivity in detecting infection: blood smears, HL-60 cell cultures, polymerase chain reaction (PCR) amplification of a 16S recombinant DNA target, and a mouse infectivity assay. All assays detected the HGE agent in blood during early infection, but PCR and the mouse infectivity assay were most sensitive during late infection. Xenodiagnosis demonstrated that mice remain persistently infected through 55 days.

Immune evasion by tickborne and host-adapted Borrelia burgdorferi

Immune sera from mice infected with the Lyme disease spirochete, Borrelia burgdorferi, have strong biologic activity against spirochetes cultured in vitro. Recent studies with rodents and ticks infected with B. burgdorferi indicate that spirochetes undergo major changes in protein expression as they adapt to the diverse environments encountered by a vectorborne pathogen. The purpose of this study was to explore the susceptibility of three different adaptive forms of B. burgdorferi (in vitro cultured, host-derived, and tickborne) to immune sera. Passive transfer of immune sera protected mice when they were challenged with spirochetes cultured in vitro. Immune sera did not protect mice from tickborne spirochetes or spirochetes derived from infected mice. These results indicate that spirochetes that have adapted within either the feeding tick or host are relatively invulnerable to the protective effects of immune sera, unlike spirochetes grown in vitro, which are highly susceptible.

Individual change after genocide in Bosnian survivors of "ethnic cleansing": assessing personality dysfunction

The authors used the SCID-DES (disorders of extreme stress) instrument to assess for personality change in Bosnian survivors of "ethnic cleansing." Twenty four refugees underwent systematic, trauma-focused, research assessments, including the SCID-DES interview. Overall, this group of Bosnian survivors had been severely traumatized as a result of the Serbian nationalists' genocide. However, no subject met diagnostic criteria for DES. The SCID-DES yields far lower rates of trauma-related personality change in Bosnian survivors of genocide than in adult survivors of prolonged early life traumas. Therefore, the DES construct may have better application to prolonged, interpersonal, early life traumas than to the prolonged, communal traumas of genocide.

Immunization against the agent of human granulocytic ehrlichiosis in a murine model

The agent of human granulocytic ehrlichiosis (HGE) is a newly recognized tick-borne pathogen that resides within polymorphonuclear leukocytes. C3H/HeN mice can become infected with the agent of HGE (designated aoHGE) by syringe inoculation or tick-borne infection and develop transient neutropenia. They thereby partially mimic human disease and provide a model in which to study immunity to this microorganism. Mice vaccinated with lysates of purified aoHGE, or administered aoHGE antisera, were partially protected from both syringe- and tick-transmitted challenge with aoHGE. These data suggest that antibodies are sufficient to provide substantial, but not complete, immunity against aoHGE.

Borrelia burgdorferi strain-specific Osp C-mediated immunity in mice

Antibodies to the outer surface proteins (Osps) A, B, and C of the spirochete Borrelia burgdorferi can prevent infection in animal models of Lyme borreliosis. We have previously demonstrated that immune serum from mice infected with B. burgdorferi N40 can also prevent challenge infection and induce disease regression in infected mice. The antigens targeted by protective and disease-modulating antibodies are presently unknown, but they do not include Osp A or Osp B. Because Osp C antibodies are present in immune mouse serum, we investigated the ability of hyperimmune serum to recombinant Osp C (N40) to protect mice against challenge infection with N40 spirochetes. In both active and passive immunization studies, Osp C (N40) antiserum failed to protect mice from challenge infection with cultured organisms. Mice actively immunized with recombinant Osp C (N40) were susceptible to tick-borne challenge infection, and nymphal ticks remained infected after feeding on Osp C-hyperimmunized mice. In contrast, similar immunization studies performed with Osp C (PKo) antiserum prevented challenge infection of mice with a clone of PKo spirochetes pathogenic for mice. Both Osp C (N40) and Osp C (PKo) antisera showed minimal in vitro borreliacidal activity, and immunofluorescence studies localized Osp C beneath the outer membrane of both N40 and PKo spirochetes. We conclude that Osp C antibody-mediated immunity is strain specific and propose that differences in Osp C surface expression by spirochetes in vivo may account for strain-specific immunity.

The early humoral response in human granulocytic ehrlichiosis

The early antibody response in patients with human granulocytic ehrlichiosis (HGE) and in mice infected with the HGE agent was characterized by using sera to probe lysates of HL-60 cells infected with HGE organisms. Sera were obtained from 18 patients with HGE, mostly within the first 6 weeks of clinical infection, and from mice infected with the HGE agent for up to 3 weeks. A 44-kDa antigen was reactive with IgG in all 18 patients, and IgG to 40-, 65-, and 80-kDa antigens was present in 6, 8, and 7 patients, respectively. In addition, IgM to 40-, 44-, 65-, and 80-kDa antigens was found in 9, 5, 4, and 4 subjects. Immunoglobulins to antigens ranging between 95 and 125 kDa were detected less frequently. HGE agent-infected C3H/HeJ mice had an antibody response similar to that in humans. Thus, the 40- and 44-kDa proteins of the HGE agent elicit early strong antibody responses during infection. Characterization of the antigens recognized by antibodies during HGE should aid in diagnosis and understanding of the disease.