Modern critical approach to the diagnosis of acute viral myocarditis and inflammatory cardiomyopathies in clinical practice: Focus on the roles of echocardiography and antivirus antibodies

SIGNIFICANCE OF THE PROBLEM: The diagnosis of acute viral myocarditis is one of the diagnoses most difficult to make in cardiology and medicine in general. Echocardiography and cardiomagnetic resonance play a crucial role in the clinical diagnosis and the serum titer of antiviral antibodies to cardiotropic viruses is still unjustifiably used for the diagnosis of myocarditis in everyday practice. RESEARCH OBJECTIVES: To analyze the frequency and significance of echocardiographic parameters in the diagnosis of clinically suspected acute viral myocarditis, to determine the role of antiviral antibody titer (AVA) dynamics for the diagnosis of myocarditis and to compare viral serology and echocardiographic function versus echocardiographic function. METHODOLOGY: A retrograde transverse study was performed in the ten-year period from 2006. to 2015, where 126 consecutive patients from the database of the Office of Internal medicine ''Dr. Bastać'' were analyzed, with a working diagnosis of clinically suspected viral myocarditis. They were clinically, ECG, echocardiographically and serologically monitored for 4 to 8 weeks due to the dynamics of AVA titer. The examined group (A) was divided into subgroups: A1 with elevated AVA class IgM titer in 43 (32%) subjects and subgroup A2 without elevated IgM titer in 83 (68%) patients. The control group of healthy (B) of 103 subjects was comparable.Statistical processing was done in the EXCELL database via descriptive statistics, Student's-T test and Chi2 test. RESULTS: 126 patients had clinically suspected myocarditis (≥2 ESC criteria). Diastolic left ventricular dysfunction in 39/126 (31%) patients was the dominant echocardiographic criterion for clinically suspected myocarditis. Reduced ejection fraction (EF <50%) was measured at 19/126 (15%), followed by left ventricular dilatation. Regional systolic dysfunction was found in 21/126 (17%) and changes in myocardial texture in 17 (13%) subjects. The clinical probability of viral etiology was diagnostically supported by elevated titer of IgM antibodies in 43 (32%) subjects (subgroup A1) where IgM antibodies to Parvo B 19 virus predominate in 36/43 patients (84%). Most were without elevated titer of IgM antibodysubgroup A2 83 (68%). Clear dynamics of IgM antibody titer was observed in 23 persons, a decrease in IgM titer with an increase in IgG titer (seroconversion) in 13 patients. Determination of anti-heart autoantibodies (AHA) was done in 17 severe cases, of which 9 had positive AHA. A comparison of subgroups A1 and A2 did not reveal a statistically significant difference in echocardiographic parameters. The whole group A of clinically suspected myocarditis compared to control group B has statistically highly significantly lower parameters of global systolic (EF=8,7±4,6 vs. 63±7,9; p<0,001), longitudinal systolic (S'=6,9±1,3 vs. 9,9±2,1) and diastolic function (E/e'11,9±4,8 vs. 8,7±4,6; p<0,001), and a highly statistically significant increase in left ventricular telediastolic dimension, myocardial mass index, and left atrial size. CONCLUSION: The diagnosis of acute viral myocarditis in clinical practice is made on the basis of the clinical picture, ECG and echocardiography that indicate myocarditis with the exclusion of cardiac comorbidities, based on the ESC criteria for suspected clinical myocarditis. The whole group A had highly statistically significantly lower parameters of systolic and diastolic function compared to control group B. Normal ECG and echocardiography cannot serve to exclude the diagnosis of myocarditis. Comparison of subgroups A1 and A2 did not reveal a statistically significant difference in echocardiographic parameters.

Invention of ovarian cancer in Nišav district

Introduction : Ovarian cancer is the eighth most common malignant disease in women in the world, accounting for 3.4% of all malignant tumors in women. It has the highest lethality among gynecological malignancies. The aim of this paper was to analyze the incidence of this malignancy in the Nisava district in the period 1999-2018. years. Material and method: Descriptive method applied. The population registry for cancer of the Institute of Public Health in Nis was the source of the data. Raw and standardized incidence rates per 100,000 women were calculated. Standardization was performed by the direct method. The linear trend of the incidence rate was calculated. Results: In the structure of malignant diseases in women, ovarian cancer accounts for 5%. The average annual standardized incidence rate is 13.5. In the observed twenty-year period, an increase in the linear trend of incidence rates is registered. The highest standardized rate was recorded in 2016 (20.4), and the lowest in 2002 (10.1). The disease is not registered under the age of fifteen, and is most common in the age group of 70-74. There is a statistically significant increase in the trend of standardized incidence rates with age. The highest standardized incidence rate is recorded in the municipality of Svrljig (18.5) and the lowest in the municipality of Merošina (7.2). Conclusion: The registration of an unfavorable trend in the incidence of ovarian cancer indicates a lack of adequate primary and secondary prevention. It is necessary to effectively implement preventive measures and education of women in order to reduce risk factors and early detection of the disease.

Gastroenterocardiology: Or what do the gut and the heart have in common?

The gut microbiota of our organism is a community of bacteria, archaea, fungi, viruses and parasites that make up a unique ecosystem in the digestive tract, which consists of about 1014 microorganisms. The diversity of this community between individuals occurs because of the differences in the host genome and the impact of environmental factors, including hygiene, diet, lifestyle and the use of different drugs. Significant evidence suggests that changes in the microbiota could play a role in cardiovascular diseases. The results of research papers for the last two decades have confirmed that altered gut microbiota composition (dysbiosis) contributes to the development of various diseases, including cardiovascular diseases, type 2 diabetes, chronic kidney disease, nonalcoholic fatty liver disease, chronic inflammatory bowel disease and even certain types of cancer. There is growing evidence that in the future, apart from current predisposing factors for cardiovascular and metabolic diseases, including genetic, environmental and lifestyle factors, one should count on new risk factors such as nutritional disproportion and gut dysbiosis. Thus, we look upon the relationship between the gastrointestinal tract and cardiovascular system, i.e. the "gut-heart axis" in a new way.

Why and when is it important to use the standardized questionnaire 'Ages & Stages Questionnaires' (ASQ-3)-'Age & development of the child', for assessment and monitoring of children's development in early childhood?

In pediatric primary health care, one of the basic activities is the prevention of diseases and conditions that endanger the quality of life of the child and his/her daily functioning in the environment. According to world data , about 17% of children have some developmental difficulties which are discovered in only 50% of them before they start school. The goal of development assessment is systematic and precise early detection of deviations from normative development, timely undertaking of appropriate interventions, as well as elimination or mitigation of disorders. Research has shown that the use of instruments has increased the early detection of developmental delays or developmental disorders (in this way, 70-80% of children with developmental problems are detected) and provided an opportunity for early application of intervention measures. The set of 21 Ages & Stages Questionnaires ASQ-3 has been used for more than 30 years worldwide to screen and evaluate children's development by observing how children progress in important areas such as speech, physical ability, social and problem-solving skills for children aged 2 months to 5.5 years. It is filled in by parents and returned to professionals, and they further make an assessment based on clear instructions on the procedure of writing results in the domains of development, scoring (graphical and tabular) interpretation and communication, as well as training parents to stimulate development through play, ie. what to do next with the child's parent to stimulate development through play, ie. how and what to do next with the child. In the past ten years, the Association of Pediatricians of Serbia, together with its partners, has advocated for a comprehensive assessment and monitoring of children's development using valid instruments in the framework of preventive pediatric examinations. Through a series of projects in this area, through education of pediatricians and associates, and by application in practice, the standardized questionnaire ASQ-3, entitled "Age and development of the child" was tested and adapted in 2019.

Pierre-Joseph Desault, 1744-1795

Pierre-Joseph Desault (1744-1795) was the first French professor of clinical surgery. The clinical school of surgery which he instituted at the hospital Hôtel-Dieu attracted great numbers of students from France and other countries. In 1791 he established a Journal de chirurgerie, a record of the most interesting clinical cases. He introduced many improvements to surgical practice and construction of surgical instruments. Desault published his work rarely, but his students later did, based upon his lectures. He was teaching surgery in an innovative way, in French, with a lot of demonstration and practice. Therefore, he is rightly considered a forerunner of modern medical teaching. Although primarily a surgeon, Desault practically signed the birth certificate of nephrology by clinical observation, and is considered, together with Chopart, a pioneer of urology. His influence on the development of medical science in France is great, but his ability to organize the hospital and his exceptional pedagogical activities are especially emphasized.

Excessive calcium consumption as a risk factor for cardiovascular diseases

Calcium is the most abundant mineral in the human body that participates in the construction of bones and teeth, nerve impulse transmission, intracellular signaling, hormone secretion, muscle contraction, coagulation, ensuring normal heart rhythm and physiological values of blood pressure. Excessive calcium concentration, predominantly caused by improper use of supplements, predisposes to the development of cardiovascular disease. High serum calcium induces reprogramming and differentiation of smooth muscle cells into an osteoblast-like phenotype, translocation of prohypertrophic cardiomyocyte transcription factors, compromise of diastolic relaxation of the myocardium and necrosis of its contractile girdle, stimulation of coagulation reactions, stimulation of platelet aggregation, hemodynamic changes and metabolic abnormalities. Acute intoxication with calcium supplements results in an increase in blood pressure. Chronic consumption of excessive calcium concentration predisposes to atherosclerosis and calcification of blood vessels, heart attack and stroke, hypertrophy and heart failure, and heart rhythm disorders. There is a need to strengthen the response and role of the health system in informing the public about the side effects of excessive calcium consumption, limiting the widespread prescribing of supplements, as well as a possible comprehensive reassessment of the same.

Medical service in Serbia before the First world war

Modern medicine in Serbia began to develop only after the liberation from the Turks in the Second Serbian Uprising of 1815. The first European-educated doctors came to Serbia in 1819, by order of Prince Milos. The military medical service, in charge of systematic treatment and care of wounded and sick Serbian soldiers, was founded in 1835. The first military doctors and chiefs of Serbian medicine were foreigners, Dr. Emerich Lindenmeier (1806-1884) and Dr. Carlo Belloni (1812-1878), who founded military hospitals in Belgrade, Ćuprija and Paraćin. During the Serbian-Turkish wars (1876-1878), Serbia had only 19 military doctors for about 130,000 soldiers, the divisions had only dressing stations for first aid, and there was also a medical ship for the evacuation of the wounded. Foreign doctors were succeeded by Serbian doctors educated in Vienna, Dr. Vladan Djordjevic (Chief of Medical Services 1877-1884), Dr. Mihajlo Mika Markovic (Chief of Medical Services 1886-1903) and Dr. Lazar Gencic (Chief of Medical Services 1909-1915). By 1885 (Serbian-Bulgarian war), the number of military doctors was increased to one doctor per 1,000 soldiers, and each division (5,000 soldiers) received a field hospital with 200 beds and a medical company with 5 doctors and 100 paramedics. Before the Balkan War (1912), 5 permanent military hospitals with surgical wards were opened, and the medical companies of the divisions had 4 doctors and 450 paramedics, and 4 field hospitals for 400 wounded. For the first time, ambulance trains were used for evacuation and treatment of the wounded. The hygienic-epidemiological service was neglected, and dysentery, typhoid fever and malaria were frequent: in 1913, over 5,000 Serbian soldiers died of cholera alone.

History of implantology from the aspect of osseointegration and mucointegration

The tendency to replace lost teeth by implanting foreign material is as old as civilization itself. The accelerated development of implantology as a science started only in the middle of the last century. The essence of implantology is the process of osseointegration. The greatest merits for this phenomenon belong to prof. Per Ingvar Brenemark, who accidentally discovered the possibility of complete incorporation of a titanium implant into the surrounding bone. With the discovery of osseointegration and defining the conditions that enable it, the period of implantology development begins with the improvement of endosseous implantation into an efficient method of prosthetic rehabilitation, predictable outcome and extended lifespan of implants and dental restoration in function. Implantology initially aimed to improve the function and quality of life of partial and complete edentulism patients, and since the 1990s it has become prosthetically guided not only by functional but also by aesthetic principles. With the beginning of the 21st century, implantology is aimed at improving the appearance and stability of soft tissues, thus beginning the era of mucointegration.

The importance of operative hysteroscopy in treating pathologies of the uterine cavity in infertile patients

According to the definition of the World Health Organization (WHO), infertility is the inability of a sexually active, non-contracepting couple to achieve pregnancy in one year. One of the causes of sterility is inborn and acquired uterine anomalies. The best visualization of the inside of the uterus is achieved hysterscopically. Hysteroscopy is a minimally invasive surgical procedure and has the greatest significance in the diagnosis and treatment of congenital anomalies of the uterus. It is possible to eliminate and correct most of the congenital anomalies of the uterus, and it also enables the removal of other pathological changes in the cavity of the uterus. The incidence of congenital uterine anomalies in general population is 0.1-3.5%. Infertile patients have a higher incidence of these anomalies which range from 3-6%, and 5-10% in habitual abortions. The study included 200 infertile patients up to 40 years of age, with performed surgical hysteroscopy due to diagnosed changes in the uterine cavity. The patients were operated at the Department of infertility of the Obstetrics and Gynecology Clinic "Narodni Front" in Belgrade, in 2013. and 2014. The following pathological changes of the uterine cavity, were hysteroscopically removed: submucosal fibroids type 0 and type I. The aim of this paper was to evaluate the success of operative hysteroscopy in the treatment of pathological changes of the uterine cavity in infertile patients, based on the number of relapses in the first six months upon surgery. Relapses occurred in 0.5% of patients during a six-month postoperative course. Complications during hysteroscopic operations were intraoperative and postoperative. There were 1.5% of overall complications in the participants.

Leadership, appreciative management and empowerment in physiotherapy practice

Within national health systems, there is an inadequacy in terms of human resource management due to the specificity of operational activities of health workers, patient relations and the fulfillment of organizations' requirements.The paper views distributive or shared leadership and appreciation management as a new management concept that has a focus on employees, and which especially appreciates and emphasizes professionalism, cooperation, interaction skills and employee support and proposes the application of this concept in health systems, especially in physiotherapy practice.