The role of exercise test in stratifying the risk of asymptomatic patients with moderate/severe aortic stenosis.

OBJECTIVES: The role of exercise test in risk stratifying of asymptomatic patients with moderate and severe aortic stenosis (AS) in recent literature is still controversial. The aim of this study was to evaluate the role of exercise test in stratifying the risk of patients with moderate to severe aortic stenosis. METHODS: At the Internal Medicine Clinic, Department of Cardiology in Tuzla, in the period from January 2008 until January 2010 was followed 33 patients with clinical and echocardiographic parameters of moderate to severe asymptomatic aortic stenosis (mean effective orifice area EOA 0.9 +/- 0.34 cm2). In statistical analysis we used descriptive statistics, t-test, chi-square test and Kaplan-Meier life table for predictive values, sensitivity and specificity. A significance level of 0.05 was used. RESULTS: Two patients were excluded due to exclusion criteria, so 31 patient was followed up during 12 months period. Eighteen patients (58%) with EOA pounds sterling 0.8 cm2 had limiting symptoms during the test. During follow-up period, 11 patients developed serious spontaneous symptoms, and out of them 8 patients underwent surgical valve replacement, one patient died (sudden cardiac death), and 2 patients had serious complications (ischemic cerebral stroke). Twenty patients remained asymptomatic. The highest positive predictive accuracy had EOA pounds sterling 0.8 cm2 with limiting symptoms and it was 85%. The highest negative predictive accuracy had ST depression. CONCLUSION: only limiting symptoms along with EOA pounds sterling 0.8 cm2 had positive predictive accuracy.

Mortality at the Clinic of Internal Medicine of University Clinical Center in Tuzla during 2008.

INTRODUCTION: Accurate information about the cause of death is given by expert teams based on pathological or forensic expertise. Reliable information can be obtained from doctors from clinical-hospital institutions if the deceased person was treated in such an institution and with previously diagnosed disease (hospital mortality). Analysis of hospital mortality provides a lot of data that can be used in planning the hospital beds capacities, the amount of drug procurement, purchasing equipment, organization and creation of highly specialized medical teams (medical team for resuscitation), the number of reanimation techniques, the number of pathologists who are required for autopsy procedures, etc. GOAL was to determine the total number of deaths, the most common causes of death and the 10 leading diagnoses of deceased patients at the Clinic for Internal Medicine of Clinical Center in Tuzla during 2008. MATERIAL AND METHODS: We used the material from the archive (medical records and reports on deceased patients, delivered by physicians working at the Clinic for Internal Medicine of Clinical Center in Tuzla). RESULTS: During 2008 at the Clinic for Internal Medicine 368 patients died. According to the analyzed data leading cause of death and leading diagnosis as cause of death at the Clinic for Internal Medicine in 2008 were as follows: cardiogenic shock in 73 (19.84%), cerebrovascular stroke in 46 (12.50%), coma due to stroke in 32 (8.70%), coma not classified as cerebral in 25 (6.79%) (metabolic 13 (3.53%) and hepatic 12 (3.26%), cardiomyopathy in 22 (5.98%), malignant neoplasm of the abdomen in 17 (4.62%), respiratory insufficiency in 17 (4.62%), acute myocardial infarction and myocardial infarction with rupture in 17 (4.62%), pulmonary edema in 16 (4.35%), and cardiorespiratory arrest in 13 (3.53%) deaths. CONCLUSION: During 2008 at the Clinic for Internal Medicine of Clinical Center in Tuzla died a total of 368 patients. The most common cause of death of patients at the Clinic for Internal Medicine of Clinical Center in Tuzla are cardiovascular disease (n = 175; 47.55% of deaths), in second place was cerebrovascular disease (n = 76; 20.65% of deaths) for a total of 251 (68.20%) of deaths from cardiovascular and cerebrovascular disease.

Atherosclerotic changes on head and neck blood vessels in patients with systemic lupus erythematosus.

The aim of this study was to evaluate the presence of atherosclerotic plaque of head and neck blood vessels and to determine the dynamics of circulation through the brain blood vessels in patients with systemic lupus erythematosus (SLE). In 35 patients with SLE aged 37.67+/-9.96 and whose disease lasted 3.8+/-4.51 years, Doppler carotid ultrasonography was used to identify the presence of intima-media thickness or atherosclerotic plaque. Brain perfusion scintigraphy was done in 15 out of 35 patients in order to evaluate the dynamics in circulation through carotid and cerebral media arteries. Measured by Doppler ultrasound, 2/35 of examined lupus patients had a plaque and the 2/35 had an intimal-medial thickness. The results of perfusion scintigraphy in 15 examined patients out 35 with SLE showed that 5/15 had mild circulatory changes in carotidogram. 4/15 patients had mild changes in cerebra media arteries circulation, 1/15 had severe changes in carotid circulation and 5/15 patients had normal brain scintigraphy finding. Some of the patients with SLE have atherosclerotic changes and only the early detection of atherosclerosis may provide an opportunity for therapeutic intervention.

[Valorisation results of home exercises in patients with rheumatoid arthritis]. / Valorizacija rezultata kineziterapije u bolesnika sa reumatoidnim artritisom u kucnim uvjetima.

UNLABELLED: In order to preserve functional ability of patients with rheumatoid arthritis (RA) one needs to continuously apply exercises which will preserve range of joint motion. There is not enough data in the literature about their real value in the preservation of joint movement of RA patients. The aim of this work was to examine the effects of home exercising on the joint movement duration one year, as well as to determine optimal treatment periods of RA patients in hospital conditions. WORK METHODS: Examination was conducted on 31 RA patients treated at the Clinic for physical medicine and rehabilitation. During their treatment patients were educated about their illness and they were trained to exercise, independently, at their homes every day for 30 minutes in order to improve the range of motion. Their functional disability was assessed by Health Assessment Questionnaire (HAQ) that was conducted three times; at the end of first rehabilitation period, and then after a year at the beginning and the end of new rehabilitation period at the Clinic. RESULTS: Most examined patients (55%) did not have any education, and poor economic condition of life had 69% of the patients. All examined patients have been exercising at home, alone, although most of them, as a result of exposed deformities had a need for assisted exercising. Among them 56.1% of the patients exercised every day and 43.9% exercised occasionally (2-3 times a week). Mean HAQ value was 1.25 after the end of first rehabilitation period. Achieved results were preserved during the following 8 months, but after that period HAQ increased to 1.90 (by 96.7% of the patients). After new rehabilitation treatment, which lasted for four weeks, HAQ returned to its earlier level (1.26). During the examined period there was no significant difference between the HAQ among patients that exercised on a daily basis and the ones that exercised occasionally (p > 0.05). DISCUSSION: Low level of education and poor socio-economic conditions influenced the decreased effect of education. Only 7% of the patients visit the rheumatologist for control every 1-2 months. According to Ward study, less than 7 visits to rheumatologist per year is connected with the progression of functional disability. Patients with University degree had the least decrease in HAQ after a year. After new rehabilitation HAQ has been improved by all patients, and it has been returned to earlier value in 80.35% of the patients. CONCLUSION: Home exercises are not sufficient in order to preserve functional ability of RA patients. Examination determined that rehabilitation needs to be conducted in the specialized institutions at least once a year, optimally twice a year. It contributes to reduction of progression of functional disability.

[Effects of therapy on functional ability of patients with rheumatoid arthritis]. / Uticaj terapije na funkcionalnu sposobnost bolesnika sa reumatoidnim artritisom.

UNLABELLED: Rheumatoid arthritis (RA) is a diseases which causes great suffering of patients, and it demands a complex medicamentosus therapy (including diseases modifying antirheumatic drugs DMARD) and physical therapy. Disease often progresses, in spite of therapy and leads to severe functional disability. That is why it is often discussed whether the usage of expensive therapy such as DMARD is justified. This question is often asked in countries with poor socio economic standard where health funds cannot cover all expenses of the treatment for RA, and patients themselves cannot afford expensive therapy. In order to assess the real potential of DMARD therapy it is necessary to compare results of treatment of patients which do not take those medications. This cannot be done in a country where DMARDs are available to all patients because it would be unethical to take them off drugs. In Bosnia and Herzegovina, a country with a recent war history, there are many RA patients who could not afford those expensive medications and could be examined as a control group in this research. Effects of treatment could be evaluated by analysis of functional ability of patients, because its loss is the first thing that is noticed by patients, right after pain. It is a key factor in the strategy development of examination, treatment and analysis of patients with RA. The aim of this research was to evaluate the efficacy of the DMARD and physical therapy on the functional ability of patient with rheumatoid arthritis (RA). METHODS: The research was conducted on 40 RA patients who were under the control of the rheumatologist, were taking DMARD and were hospitalized at the rehabilitation clinic for physical therapy once in a year, and later conducted exercises at home. Control group had 70 RA patients, who were not under the control of rheumatologists and did not take drugs from the DMARD group, nor did they use physical therapy. Groups were comparable according to age, duration of their disease, sex and presence of RF. Functional ability was assessed with Health Assessment Questionnaire (HAQ). Walking quality and need for prostheses were also evaluated. RESULTS: According to HAQ mild functional disability was found in 69% of the examined group and in 9% of the control group, moderate functional disability was found in 30% of the examined group and in 29% of the control group. Severe functional disability and dependency of other people's help was found in 2% of the examined group and in 26% of the control group. Complete disability was not found in the examined group and was found in 14% of the control group. 65% of patients in the examined group did have problems with walking while 25% did not. Remaining 10% had to use one stick while walking. In control group 3% did not have any problems with walking, 42% did, 31% used stick, 13 % used crunches, and wheel chairs were necessary for 7% of patients. DISCUSSION: This research showed that functional disability progresses in patients who are treated and the ones that are not. There is a significant difference in the severity of functional disability among examined groups (p < 0.00001). Among patients that are using DMARD and physical therapy there are no patients that are completely dependent, using crutches or wheel chair. That is justified reason for finding the means for quality treatment of patients with RA. CONCLUSION: Out of this research one can conclude that drugs can slow the progression of the disease, but with the usage of the contemporary therapy with DMARD and regular physical therapy one could modify the course of the disease and significantly reduce the functional disability of RA patients.

[Pericarditis and exudative pleuritis in patients with systemic lupus erythematosus before and after therapy]. / Perikarditis i eksudativni pleuritis u bolesnika sa sistemskim eritemskim lupusom prije i poslije terapije.

AIM OF THE STUDY: To establish the presence of pericarditis and exudative pleuritis in patients with systemic lupus erythematosus (SLE) prior to and after glicocorticoid and cytotoxic therapy. PATIENTS AND METHODS: In 43 patients, 39 women and 4 men, with SLE (disease was diagnosed according to revised American College of Rheumatology ACR criterias, 1997), aged between 20 and 61 and averaged disease duration of 5.54 +/- 5.74 years, heart/lung radiology and heart echosonography were performed in order to discover possible serositis (pericarditis and exudative pleuritis) prior to and after cytotoxic and glucocorticoid therapy. RESULTS: The presence of pericarditis and exudative pleuritis was established in 20 patients (47%) before the therapy. After the therapy pericarditis was present in 2 patients, average volume of 150 ml, and exudative pleuritis was also present in phrenicocostal sinus, but its volume was minimal. This table is showing the results of our study on patients with SLE and serositis. The results were compared with the results of European and Belgrade group in year 2000. [table: see text] CONCLUSION: Higher frequency of serositis (pericarditis and exudative pleuritis) in our study is probably a result of more active disease, and the effects of cytotoxic and glucocorticoid therapy were satisfing exept in two patients who were resistant on therapy. That is the reason why we had to consider plasmapheresis.

[Sensitivity, specificity and predictive value of the treadmill stress test in comparison with coronary angiography findings]. / Senzitivnost, specificnost i prediktivna vrijednost tredmil testa opterecenja srca u odnosu na koronarografski nalaz.

UNLABELLED: Precondition to prevention and control of morbidity and mortality of myocardial ischemia--coronary disease, is its good diagnostic. Goal of this study is to asses diagnostic significance of positive trademill stress test in diagnosis of coronary disease. MATERIAL AND METHODS: we analyzed 120 patients with markedly positive classic trademill stress test using Bruce protocol in the year 2003. In all cases, positive stress test was followed by selective angiography, using standard technique with multiple sections. Blood vessel narrowing of more than 50% was chosen as the criteria for positive angiographie finding. With the help of coronary angiography, it was found that 62 (51.7%) of patients has stenosis of less than 50% or normal angiographic finding. 58 (48.3%) of patients had stenosis of more than 50%. Of that number, 24 (41.4%) had one-vessel coronary disease, 12 (20.7%) two-vessel coronary disease, and 10 (34.5%) three-vessel coronary disease. 2 patients (3.4%) had stenosis of the trunk of left coronary artery. Results of this study show that the sensitivity of trademill stress-test is less than optimal, and should be supplemented by other non-invasive techniques (such as myocardial perfusion scintigraphy, radionuclide ventriculography and stress echocardiography) in diagnostics of coronary disease.

[Criteria for work capacity evaluation in rheumatoid arthritis]. / Prijedlog kriterija za ocjenu radne sposobnosti u reumatoidnom artritisu.

The Rheumatoid arthritis (RA) causes early retirement and great number of working day losses. According to our investigation, retirement of patient in our country comes even earlier then in other countries. Possible causes for that are limited possibilities of application of contemporary therapy, which result in severer clinical course of the diseases as well as of the different criteria of the physicians for evaluation of the working ability. The aim of this work was to propose the criteria, which would help physicians to evaluate temporary or permanent working ability. For the purpose of forming the proposal of criteria, functional tests, parameters from our own research as well as the suggestions of the top world's institutions OMERACT, EULAR) are used. In order to assess working ability one should need: pain assessment, Ritchie articular index, the number of painful and swollen joints, morning stiffness duration, index of joint motion, functional ability measured by HAQ, ESR, CRP, Disease Activity Score (DAS), and rtg of both hands. Decision of working ability should not be made based on the current status of some parameters; it should be made by the analysis of the disease's progression. If the index of joint motion, functional status and rtg changes are severer every year, the retirement should be considered. The appropriate evaluation of current activity and follow up of its progression with the usage of the proposed criteria should help primary care physicians to evaluate temporary and permanent working disability.

[Functional ability and parameters of disease activity in rheumatoid arthritis]. / Funkcionalna sposobnost i parametri aktivnosti bolesti u reumatoidnom artritisu.

After the pain, the loss of functional ability is the most important sign of severity of the disease for patient who suffer from rheumatoid arthritis (RA). Our research is based on the correlation between functional disability with other parameters which determine the course of a disease, its activity and the level of its progression. The sample consists of 40 patients with RA, with mean age 56.67 + 10.1 and mean disease duration 11.1 + 7.69. We examined functional ability of the patient with Health Assessment Questionnaire-HAQ (0-3), pain with Visual Analogue Scale-VAS (0-100), duration of disease, acute phase reactant, morning stiffness, joint counts (28), Ritchie articulare index, radiographic changes and range of motion. Radiographic changes are measured with Short Erosion Scale--SES (Score 0-60), and range of motion with Numerical model of range of motion (1-5). A stronger correlation of HAQ was found with most of the disease activity parameters, but not with acute phaze reactant and the duration of disease. Strong correlation of HAQ exists with the number of tender joints (p < 0.001), number of swelling joints (p < 0.05), with VAS (p < 0.001), Ritchic articulare index (p < 0.001), morning stiffness (p < 0.01), range of motion (p < 0.001) and radiographic progression (p < 0.01). The received correlations say that duration of disease and lab, results do not have an influence on functional ability, but the increase of pain, radiographic progression of the disease and the reduction of range of motion influence aggravation of functional status. Drugs which lead to decrease of pain and radiographic progression, as well as physical therapy which increases range of motion will stop functional disability.