rss_2.0Romanian Journal of Internal Medicine FeedSciendo RSS Feed for Romanian Journal of Internal Medicine Journal of Internal Medicine 's Cover in patients with atrial fibrillation – the challenge of thromboembolic prophylaxis<abstract> <title style='display:none'>Abstract</title> <p>Ibrutinib is a novel drug used in haematological malignancies. Its use is associated with an increased risk of atrial fibrillation (AF), which, in turn, exposes patients to embolic risk, including stroke. Reducing this risk requires anticoagulant therapy which is a matter of concern in the context of the increased bleeding risk of patients with haematological malignancies. In this context the presence of thrombocytopenia related to haematological disorder, ibrutinib-anticoagulants and ibrutinib-platelets interactions contribute to the amplification of the problem. The correct assessment of the thrombosis vs. haemorrhage balance represents a significant challenge for the clinician.</p> <p>In this paper we discuss practical issues related to anticoagulation in patients treated with ibrutinib and incident AF.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00Unmet needs in the diagnosis and treatment of Romanian patients with bilio-pancreatic tumors: results of a prospective observational multicentric study<abstract> <title style='display:none'>Abstract</title> <p><bold>Background.</bold> Biliopancreatic tumors (BPT) are among the most aggressive solid malignancies, and their incidence is rising. Good patient outcome relies heavily on a multidisciplinary approach to therapy, including timely access to endoscopy, surgery and chemo/radiotherapy. We aimed to evaluate current practices as reflected in the management and outcome of patients diagnosed with BPT in the setting of a low-resource medical system in order to identify areas suitable for improvement.</p> <p><bold>Material and methods.</bold> We conducted a prospective observational study of patients with pancreatic cancers and extrahepatic cholangiocarcinomas evaluated in 4 referral centers in Romania. We collected data on the pathology of the tumors, staging at diagnosis, ECOG status, surgical interventions, chemo/radiotherapy and endoscopic drainage where applicable. A telephonic follow-up visit at 3 months after the enrollment visit collected additional data regarding evolution, subsequent treatment, performance status and disease-related events and outcomes.</p> <p><bold>Results and conclusions.</bold> One hundred seventy-two patients were included in the study during a one-year period at the four participating centers. 72.1% were diagnosed with pancreatic cancer while 27.9% had extrahepatic cholangiocarcinoma. We identified several unmet needs in the current practices of treatment for these malignancies: a lack of pathological confirmation in 25.6% of the cases, a very low percentage of resectable lesions (only 18% of the patients operated with curative intent), and suboptimal choice of drainage in patients who required palliative drainage at their first endoscopic intervention. Significant effort is required to ensure standard-of-care treatment for patient with BPT in low-resource medical systems, including comprehensive auditing and protocol surveillance.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00A plea for a unified approach to sedation in gastrointestinal endoscopy in Romania: results from a prospective multicentric trial<abstract> <title style='display:none'>Abstract</title> <p><bold>Background.</bold> Adequate sedation is a prerequisite for quality endoscopic examination of the digestive tract. We aimed to evaluate the current practices and safety profile of sedation for gastrointestinal endoscopy in Romania and its impact on the technical success of the procedure and procedure-related adverse events.</p> <p><bold>Methods.</bold> We conducted a prospective, multicentric, observational study including all patients undergoing digestive endoscopic procedures under various degrees of sedation. We collected data regarding the endoscopic procedure, type and degree of sedation, drug regimens, personnel in charge of sedation, and relevant patient related information. The main study outcome was the rate of sedation-related adverse events; secondary study outcomes included procedure-related adverse events and the impact of sedation on procedure success.</p> <p><bold>Results.</bold> 1,043 consecutive endoscopic procedures from eight Romanian endoscopy units were included in our study. Sedation regimens were highly variable between participating centers, with 566 (54%) of procedures being performed under sedation provided by an anaesthesiologist. Sedation-related adverse events occurred in 40 cases (3.8%), most of them were mild respiratory and cardiovascular events and all reversed spontaneously.</p> <p>On multivariate analysis, male gender, procedure type (endoscopic ultrasound and endoscopic retrograde cholangiopancreatography) and deep sedation were risk factors for complications. The endoscopy unit, ASA status, age and type of sedative did not influence the complication rate.</p> <p><bold>Conclusion.</bold> In conclusion, sedation for endoscopic procedures is generally safe, despite a high variability in sedation practices between centers in Romania. Establishing a national guideline on sedation for gastrointestinal endoscopy will ensure consistent and safe practice for these procedures.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00A single center experience: physician related diagnostic delay and demographic and clinical differences between patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis<abstract> <title style='display:none'>Abstract</title> <p><bold>Background.</bold> A large number of comparative studies have been conducted for ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis (nr-axSpA), including disease burden, treatment modalities and patient characteristics. The aim of this study was to compare physician related diagnostic delay time between patients with AS and nr-axSpA.</p> <p><bold>Methods.</bold> In our retrospective study we included 266 patients with axSpA. Patients were classified into two subgroups, AS and nr-axSpA. The time from back pain onset until diagnosis of axSpA was defined as the diagnostic delay. The first specialist referred to and the first diagnosis for each patient was noted in detail. Patient characteristics, clinical manifestations and laboratory and imaging results at diagnosis were also compared between subgroups.</p> <p><bold>Results.</bold> The diagnostic delay time was significantly longer for AS patients [6 ± 8.14 years vs 1.62 ± 2.54 years]. 40.9% of all patients were initially consulted by specialists in physical therapy and rehabilitation, followed by 29.7% consulted by a neurosurgeon and 19.9% by a rheumatologist. The most common initial diagnosis was fibromyalgia, 52.6% (140), followed by ankylosing spondylitis, 28.9% (77), and lumbar disc hernia, 12.7% (34).</p> <p><bold>Conclusion.</bold> The vast majority of patients were initially evaluated by healthcare providers other than rheumatologists and mostly diagnosed with fibromyalgia. Efforts to increase awareness and to educate first healthcare providers may shorten the diagnostic delay time.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00Pure extra-thoracic sarcoidosis: about 24 cases<abstract> <title style='display:none'>Abstract</title> <p><bold>Introduction.</bold> Pure extra-thoracic sarcoidosis is rare and poorly characterized in the literature. Herein we present features of pure extra-thoracic sarcoidosis, in comparison with sarcoidosis with intra-thoracic involvement, in a population from the south of Tunisia.</p> <p><bold>Methods.</bold> Retrospective, descriptive and comparative study of the patients presenting systemic sarcoidosis and attending the Department of Internal Medicine at the Hedi Chaker University Hospital, Sfax, Tunisia, for 21 years, from January 1996 to December 2016.</p> <p><bold>Results.</bold> Twenty-four patients presented pure extra-thoracic sarcoidosis (30% of the cases of systemic sarcoidosis). There was a female predominance (79%). The mean age was 50 years. The main features were polyadenopathies (10 patients: 41.7%), cutaneous involvement (10 patients: 41.6%), inflammatory polyarthralgia (8 cases: 33.3%), general symptoms (6 patients: 25%), uveitis (6 cases: 25%), cholestasis (3 cases) and kidney involvement (2 cases). Lymphopenia, hypercalcemia, and hypercalciuria were observed each one in 12.5% of the cases, and high angiotensin converting enzyme (ACE) level in 38.5% of the cases. The histological proof was required in all the patients. Statistically significant associations identified were mainly hepatic involvement with general symptoms (p=0.035), peripheral lymphadenopathies (p=0.035) and kidney damage (p=0.022), and cutaneous involvement with articular manifestations (p=0.032). Systemic corticosteroids were used in half of the cases, with a good outcome in 21 cases, and recurrence in two cases. One patient was lost to follow up. The comparison to the form with mediastino-pulmonary involvement showed less lymphadenopathies (p=0.001), less lymphopenia (p=0.006), and less frequent use of corticosteroids (p=0.044).</p> <p><bold>Conclusion.</bold> Our series was characterized by the frequency of the pure extra-thoracic form and the diversity of the systemic manifestations.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00 infection: a comprehensive review for primary providers<abstract> <title style='display:none'>Abstract</title> <p><italic>Clostridioides difficile</italic> infection (CDI) is an issue of great concern due to its rising incidence, recurrence, morbidity and impact on healthcare spending. Treatment guidelines have changed in the last few years, and new therapies are being considered. This is a practical review for the primary care practitioner of the latest guidelines for CDI diagnosis, treatment, and emerging therapies.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00Sepsis and the muscle tissue. A narrative review<abstract> <title style='display:none'>Abstract</title> <p>Sepsis and septic shock are considered major factors in the development of myopathy in critically ill patients, which is correlated with increased morbidity rates and ICU length of stay. The underlying pathophysiology is complex, involving mitochondrial dysfunction, increased protein breakdown and muscle inexcitability. Sepsis induced myopathy is characterized by several electrophysiological and histopathological abnormalities of the muscle, also has clinical consequences such as flaccid weakness and failure to wean from ventilator. In order to reach definite diagnosis, clinical assessment, electrophysiological studies and muscle biopsy must be performed, which can be challenging in daily practice. Ultrasonography as a screening tool can be a promising alternative, especially in the ICU setting. Sepsis and mechanical ventilation have additive effects leading to diaphragm dysfunction thus complicating the patient’s clinical course and recovery. Here, we summarize the effects of the septic syndrome on the muscle tissue based on the existing literature.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00Hepatorenal syndrome: pathophysiology and evidence-based management update<abstract> <title style='display:none'>Abstract</title> <p>Hepatorenal syndrome (HRS) is a functional renal failure that develops in patients with advanced hepatic cirrhosis with ascites and in those with fulminant hepatic failure. The prevalence of HRS varies among studies but in general it is the third most common cause of acute kidney injury (AKI) in cirrhotic patients after pre-renal azotemia and acute tubular necrosis. HRS carries a grim prognosis with a mortality rate approaching 90% three months after disease diagnosis. Fortunately, different strategies have been proven to be successful in preventing HRS. Although treatment options are available, they are not universally effective in restoring renal function but they might prolong survival long enough for liver transplantation, which is the ultimate treatment. Much has been learned in the last two decades regarding the pathophysiology and management of this disease which lead to notable evolution in the HRS definition and better understanding on how best to manage HRS patients. In the current review, we will summarize the recent advancement in epidemiology, pathophysiology, and management of HRS.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00Nailfold capillaroscopy in systemic diseases: short overview for internal medicine<abstract> <title style='display:none'>Abstract</title> <p>Nailfold capillaroscopy (NFC) is now one of the main imaging tools in systemic sclerosis and imposed over time as an easy, non-invasive method for the nailfold microvascular bed assessment.</p> <p>In qualitative NFC normal pattern is characterized by homogeneous, parallel fashion arrangement of the last capillaries row as well as by capillaries with hairpin or non-specific variations like tortuous and/ or crossing shape.</p> <p>Nailfold capillaroscopy is strongly recommended for evaluation of all patients with Raynaud phenomenon. Appearance of giant capillaries is chronologically the first relevant finding for scleroderma spectrum disorders development (systemic sclerosis, dermatomyositis, undifferentiated and mixed connective tissue disease). Collapses of the giant loops generate microhemorrhages and further capillary loss with subsequent hypoxia, and neoangiogenesis seen as ramified/ bushy capillaries. Nailfold capillaroscopy is indicated especially in systemic sclerosis, being also included in the classification criteria.</p> <p>Based on these major NFC pathologic findings (giant capillaries, microhemorrhages, avascularity and neoangiogenesis), three evolutive stages were described in systemic sclerosis, namely the early, active, and late scleroderma pattern.</p> <p>In other connective tissue diseases than those scleroderma-related, like systemic lupus erythematosus, psoriatic arthritis, or antiphospholipid syndrome, the interest for capillaroscopy is growing, but the attempts of defining specific characteristics failed until now.</p> <p>Besides qualitative NFC, semiquantitative and quantitative capillaroscopic assessments were proposed for more accurate evaluation. Lately, automated systems are under development. There is still need of more studies to sustain the nailfold capillaroscopy validity as diagnostic and prognostic test.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00Impact of laparoscopic sleeve gastrectomy on esophageal physiology<abstract> <title style='display:none'>Abstract</title> <p><bold>Introduction.</bold> Laparoscopic sleeve gastrectomy (LSG) is a popular weight loss surgery technique, but the impact on esophageal physiology and esophagogastric junction is still debatable. The aim of our study was to evaluate the manometric changes of the lower esophageal sphincter (LES) after LSG in order to indicate LES manometry pre- procedure.</p> <p><bold>Methods.</bold> In a prospective study we evaluated clinically, with upper gastrointestinal endoscopy, and high-resolution esophageal manometry 45 morbidly obese patients before, and 6–12 months after LSG.</p> <p><bold>Results.</bold> The BMI (body mass index) decreased from 46.28±5.79 kg/m<sup>2</sup> to 32.28±4.65 kg/m<sup>2</sup> postoperatively (p &lt;0.01), with a reduction of ~14 kg/m<sup>2</sup> of BMI, 39.9 (±11.9) kg body weight and 29.9 (± 6.2)% of the TWL (Total Weight Loss index), in a median interval of 7.9 months. Gastroesophageal reflux disease (GERD) prevalence increased from 17.8% to 31.1% postoperatively, with new GERD onset in 22.2%, but mild symptomatology (the median GERD-HRQL score increased from 1.56 to 2.84 points). Postoperatory reflux was associated with lower esophageal sphincter (LES) hypotonia, shortening of LES length and IIGP (increased intragastric pressure). Hiatal hernia repair rate was 17.8%, and proton pump inhibitor consumption 20%. After weight loss, the 10 cases of esophagitis discovered preoperatively cured, but 3 patients were diagnosed with de novo esophagitis. The prevalence of manometric dysmotility after LSG was 28.9%, lower than before surgery (44.4%).</p> <p><bold>Conclusion.</bold> Even if GERD remains the main limitation of LSG, the high-resolution esophageal manometry has proved useful and should be implemented in morbidly obese evaluation protocol, to better select the bariatric procedure.</p> </abstract>ARTICLE2021-08-26T00:00:00.000+00:00Cardiac biomarkers alterations in patients with SARS-CoV-2 infection<abstract><title style='display:none'>Abstract</title><p>Reliable biomarkers are necessary for the risk stratification of patients infected with SARS-CoV-2. This novel coronavirus is now established to affect several organs in addition to the lungs, most prominently the heart. This is achieved through direct damage to the myocardium and indirect immune-associated effects during the cytokine storm. We performed a literature review aiming to identify the prognostic value of alterations of cardiac biomarkers in SARS-CoV-2 infection. Cardiac biomarkers are significantly elevated in patients with severe COVID-19 and are independent predictors of mortality. High-sensitivity troponin I and T are correlated with multiple inflammatory indexes and poor outcomes. Although cut-off values have been established for most of cardiac biomarkers, lower limits for troponins may have better prognostic values and longitudinal monitoring of cardiac biomarkers can help the clinician assess the patient’s course. Additional measurements of NT-proBNP, can detect the subgroup of patients with poor prognosis.</p></abstract>ARTICLE2021-10-05T00:00:00.000+00:00Non secretory myeloma in young man mimicking the Gorham disease: case report and the literature review<abstract><title style='display:none'>Abstract</title><p>Multiple myeloma is a neoplasm of plasma cells affecting mostly the elderly with incidence peaks between 60 and 70 years. This disease is exceedingly rare in younger people, especially in adults under 30-year-old. Non-secretory multiple myeloma accounts for 1–5% of all cases of multiple myeloma. It is also a rare condition in young adult patients, and only six cases have been reported [1]. We herein describe a rare case of non-secretory myeloma in a 22- year-old male, explaining from chest wall pain, without general manifestation. Plain radiography and CT scans revealed diffuse osteolytic lesion mimicking the Gorham disease. A bone marrow biopsy was conducted, revealing the diagnosis of myeloma.</p></abstract>ARTICLE2021-10-05T00:00:00.000+00:00Hyper-inflammation after COVID-19 mARN vaccination: at the crossroads of multisystem inflammatory disease and adult-onset Still’s disease. Does terminology matter? of Eculizumab treatment after hematological remission in patients with atypical and drug-induced hemolytic uremic syndrome<abstract><title style='display:none'>Abstract</title><p><bold>Introduction:</bold> To evaluate the effect of therapeutic plasma exchange(TPE) and eculizumab on hematological and renal survival in atypical hemolytic uremic syndrome(aHUS). Additionally, to examine the reliability of discontinuation of eculizumab treatment.</p><p><bold>Methods:</bold> This was an observational and retrospective study of 18 patients diagnosed with aHUS.</p><p><bold>Results:</bold> The median age of the study population was 30(22-66) years. Four of 18 patients achieved hematological remission with the TPE alone. However, one patient in the died after three sessions of TPE. Eculizumab was used in 13 patients and no death was observed. One year after treatment, improved kidney function was observed in 2 of 3(66%) patients for TPE and 5 of 9(56%) patients for Eculizumab. We discontinued eculizumab treatment in 9 patients. One of the patients who had a C3 gene mutation experienced disease relapse after Eculizumab discontinuation. None of the patients who had drug associated aHUS, developed disease relapse after Eculizumab discontinuation.</p><p><bold>Conclusion:</bold> Eculizumab treatment is a life-saving therapy in aHUS. Treatment discontinuation may be considered at least six months after hematologic remission in patients who had stable renal function or no expectancy for renal survival. Moreover, drug-associated cases seem to tend not to develop disease relapse in the long term.</p></abstract>ARTICLE2021-08-26T00:00:00.000+00:00Non-invasive laboratory, imaging and elastography markers in predicting varices with high risk of bleeding in cirrhotic patients<abstract><title style='display:none'>Abstract</title><p><bold>Introduction.</bold> Upper digestive tract endoscopy remains the gold-standard for detecting esophageal or gastric varices and assessment of bleeding risk, but this method is invasive. The aim of the study was to identify non-invasive factors that could be incorporated into an algorithm for estimating the risk of variceal bleeding.</p><p><bold>Methods.</bold> A prospective study was performed on 130 cirrhotic patients. Tests were performed on all patients which included liver enzymes, complete blood count and coagulation parameters, abdominal ultrasound, elastography of both the liver and the spleen. Upper gastrointestinal endoscopy was performed in all patients included in the study and the results were classified, in accordance with Baveno VI into 2 outcome groups: Group 1 – patients with low bleeding risk and Group 2 – patients with varices needing treatment.</p><p><bold>Results.</bold> The study lot (130 patients) was divided into: Group I (low bleeding risk – 102 patients), and Group II (high bleeding risk – 28 patients). Parameters found to have significant differences in univariate analysis were transaminases, platelet count, spleen size, INR, portal vein diameter and both liver and spleen elastography. Calculating AUROC for each parameter identifies spleen elastography as having the best result, followed by INR, AST and platelet count. Liver elastography had the worst AUROC. Independent variables identified by logistic regression included spleen elastography, INR, platelet count, spleen diameter, ALT, age, and gender.</p><p><bold>Conclusions.</bold> Spleen stiffness is the best single parameter predicting the presence of high-risk esophageal varices.</p></abstract>ARTICLE2021-05-08T00:00:00.000+00:00: a comprehensive review for primary care providers<abstract><title style='display:none'>Abstract</title><p><italic>Helicobacter pylori</italic> is the most prevalent bacteria infecting humans resulting in a variety of gastrointestinal and extra gastrointestinal complications. Although most of the infected adults are asymptomatic, the prevalence varies in different parts of the world it is higher in Eastern and Southern Europe. Eradication of <italic>Helicobacter pylori</italic> is necessary to prevent precancerous conditions like gastric atrophy, gastric intestinal metaplasia and gastric dysplasia. This comprehensive review addresses briefly on: whom and how to test and treat including recommended first line therapies, salvage therapies, testing for eradication and strategy to be used in primary care clinics.</p></abstract>ARTICLE2021-05-08T00:00:00.000+00:00Steroid resistant focal segmental glomerulosclerosis: effect of arterial hyalinosis on outcome: single center study<abstract><title style='display:none'>Abstract</title><p><bold>Background.</bold> Few data with adequate evidence exists as regards the effect of Cyclosporine (CsA) and mycophenolate mofetil (MMF) on pathological prognostic parameters in patients with steroid resistant focal segmental glomerulosclerosis (FSGS). The purpose of the present study is to compare the effect of cyclosporin and mycophenolate mofetil in addition to steroids on functional and histopathologic renal parameters in patients with steroid resistant FSGS one year after treatment.</p><p><bold>Material and methods.</bold> Thirty-seven adults with primary FSGS patients resistant to steroid therapy consecutively randomized to treatment with either MMF or cyclosporine. Low dose prednisolone added to both groups. Glomerular filtration rate (GFR) and blood pressure (BP) were determined at all examinations and a second renal biopsy was taken 12 months after treatment with either of cyclosporin and mycophenolate mofetil.</p><p><bold>Results.</bold> GFR significantly increased in MMF group p &lt; 0.01 after 6 months and unchanged after 12 months. On the other hand, GFR significantly decrease in CsA group p &lt; 0.001 after 6 months and reduced more after 12 months p &lt; 0.001 compared to base line levels. There was a significant difference of GFR between the 2 groups at 6 months p &lt; 0.001. The extent of proteinuria decreased significantly in CsA group after 12 months p &lt; 0.001. The extent of arteriolar hyalinosis increased significantly in CsA group (0.78 to 1.81 score, p &lt; 0.001) but was unchanged in MMF group (0.93 to 0.96 score), whereas interstitial fibrosis increased to same level in both groups (grade 3).</p><p><bold>Conclusion.</bold> Conversion to MMF in those patients may be superior to CsA as regards GFR after 12 months after treatment in spite of the presence of greater level of protein excretion. The increased arteriolar hyalinosis during CsA treatment most likely results in higher BP compared to MMF treatment in patients with FSGS resistant to steroids.</p></abstract>ARTICLE2021-05-08T00:00:00.000+00:00Relationship between serum leptin levels, non-cardiovascular risk factors and mortality in hemodialysis patients<abstract><title style='display:none'>Abstract</title><p><bold>Introduction.</bold> Hemodialysis (HD) patients have higher mortality rate than the general population. Recent studies indicate a significant role of non-cardiovascular risk factors in for mortality in HD patients. Leptin is protein hormone and may indicate malnutrition in HD patients. Its role in mortality in these patients is being examined. This study aimed to investigate the correlation between serum leptin levels and non-cardiovascular risk factors and relationship between leptin level and mortality in HD patients.</p><p><bold>Methods.</bold> The prospective study included 93 patients on maintenance HD and follow-up period was 12 months. We measured leptin level and evaluated non-cardiovascular risk factors: nutritional status, anemia, volemia, parameters of mineral and bone disorder.</p><p><bold>Results.</bold> Out of 93 patients 9 died during study and 1 underwent kidney transplantation. Malnutrition and hypervolemia were two main non-cardiovascular risk factors among deceased subjects. Leptin showed a significant direct correlation with nutritional BMI (r = 0.72, <italic>P</italic> &lt; 0.001), fat tissue index (r = 0.74, <italic>P</italic> &lt; 0.001) and statistically significant inverse correlation with leantissue index (r = -0.349, <italic>P</italic> &lt; 0.05) and inverse correlation with volemic parameters (overhydration / extracellular water ratio (r = -0.38, <italic>P</italic> &lt; 0.001), but no association with anemia and mineral bone parameters was observed. Elevated leptin levels were associated with better survival. However, no statistically significant difference in survival rates was observed between the study groups (Log-Rank <italic>P</italic> =0.214, Breslow <italic>P</italic> =0.211, Tarone-Ware <italic>P</italic>=0.212).</p><p><bold>Conclusion.</bold> Deceased patients had significantly lower leptin values. Leptin was associated with two non-cardiovascular risk factors for mortality: malnutrition and hypervolemia.</p></abstract>ARTICLE2021-05-08T00:00:00.000+00:00Retinal changes in patients with angina pectoris and anginal equivalents: a study of patients with normal coronary angiography<abstract><title style='display:none'>Abstract</title><p><bold>Background and aims.</bold> Approximately 10–30% of the patients with typical symptoms of angina pectoris have normal angiography showing normal macrovasculature. In these patients, however, the microvascular problems should be monitored. Hence, the main aim of this study is to evaluate retinal changes in normal angiographic patients.</p><p><bold>Methods.</bold> In this descriptive cross-sectional study, 60 normal angiographic patients with typical chest pain or anginal equivalents visiting Modarres Hospital Cardiology Research Center between 2018 and 2019 were enrolled and retinal changes were determined in Labbafinejad Hospital by Optical Coherence Tomography Angiography using Foveal Avascular Zone (FAZ), Superficial Vascular Density (SVD), and Deep Vascular Density (DVD).</p><p><bold>Results.</bold> The results of this study demonstrated that FAZ was normal in all subjects, but SVD and DVD were abnormal in 45% and 8.3%, respectively. Totally, 18.5% and 66.7% showed abnormal SVD among stable angina (SA) and unstable angina (UA) cases, respectively (P &lt; 0.001). There was no statistically significant difference between abnormal DVD in SA and UA cases (P = 0.058). Abnormal SVD was significantly more common among diabetic patients (P &lt; 0.001), while DVD was not related to diabetes presence in the study population (P &gt; 0.05). Moreover, abnormal SVD was more common among patients with chest pain (P = 0.036), while there was no significant difference for DVD (P = 0.371). Interestingly, abnormal ECG was associated with both abnormal DVD and SVD.</p><p><bold>Conclusions.</bold> The results of this study showed that nearly half of the patients with angina pectoris or anginal equivalents who revealed normal angiographic findings may suffer from retinal changes. Thus, retinal assessment is needed in these patients to evaluate microvascular changes.</p></abstract>ARTICLE2021-05-08T00:00:00.000+00:00Effects of an actual insulin injection demonstration on insulin acceptance among patients with T2DM: a pragmatic randomized controlled trial<abstract><title style='display:none'>Abstract</title><p><bold>Introduction.</bold> Insulin injection refusal is a challenge when initiating insulin therapy. This study aimed to investigate the effects of an actual insulin injection demonstration on insulin acceptance in patients with type 2 diabetes mellitus (T2DM).</p><p><bold>Methods.</bold> A pragmatic randomised controlled trial (RCT) was conducted. The participants were patients with T2DM aged 18–65 years old. The control group (CG) received an educational programme regarding T2DM. The intervention group (IG) received the educational programme and actual insulin injection demonstration (a physician-led sample insulin injection using an insulin pen). The main outcome was immediate insulin acceptance. Insulin adherence, glycated haemoglobin (HbA1c), and adverse effects of insulin were evaluated at three months after the intervention.</p><p><bold>Results.</bold> Forty-nine participants with T2DM were allocated to the IG (n = 24) and the CG (n = 25). The immediate insulin acceptance was significantly higher in the IG (79.17%, n = 19) than the CG (24.00%, n = 6; p &lt; 0.05; RR 3.30, 95% CI 1.59 to 6.82). At the three-month follow-up, the insulin adherence was significantly different between the two groups (IG: 75.00%, n = 18 vs CG: 20.00%, n = 5; p &lt; 0.05; RR 3.75, 95% CI 1.66 to 8.49). Adverse effects of insulin, HbA1c levels, and changes in HbA1c levels between the IG and CG were not different.</p><p><bold>Conclusion.</bold> The physician-led actual insulin injection demonstration is effective for increasing insulin acceptance among participants with T2DM.</p></abstract>ARTICLE2021-05-08T00:00:00.000+00:00en-us-1