Volume 17 (2020): Issue 2 (May 2020)

It is well known that the severity of coronary heart disease is associated with a poor prognosis. 70% of patients with NSTEMI have multivascular disease, the percentage being 40% for STEMI patients. Knowing the grade severity of the coronary artery disease has importance for the therapeutic management of the case and to establish the prognosis. However, until now, we have no possibilities to identify these patients before performing the coronarography.

The objective of this study was to establish a correlation between cardiovascular risk factors, ECG changes, echocardiographic changes, GRACE score and the severity of coronary artery disease invasively detected by coronarography, in patients with myocardial infarction without ST-segment elevation.

Material and methods. We performed a study on 125 patients diagnosed with NSTEMI, who performed coronarography. For each patient we noted age, sex, history of high blood pressure, dyslipidemia, chronic kidney disease, smoking habit, HS troponin T levels, LDL cholesterol, triglycerides, C-reactive protein, creatinine clearance, ejection fraction of left ventricle, number of lesions discovered on angiography, GRACE and SYNTAX score.

Results. Of the 125 patients included, 86 (68.8%) were men, with a mean age of 63.66 ± 11.54. The average of the laboratory tests and the parameters studied: creatinine Cl 83.80 ± 33.862 ml / min, FEVS 46.37 ± 7.394%, troponin HS 3533.625 ± 7460.873 pg / ml, CRP 2.811 ± 5.262 mg / dl, LDL 113.618 ± 50.13 mg / dl, triglyceride ± 100.58mg / dl. The mean Syntax score in the studied group was 17, 58 ± 13.65, Grace score 118.80 ± 26.980, and the number of coronary lesions 2.19 ± 1.162 The number of coronary lesions and the SYNTAX score were significantly correlated statistics with age, Grace score, presence of diabetes and chronic kidney disease. With regard to laboratory tests, creatinine clearance proved to be the most important predictor for both the number of vessels affected (r =-0.322, p=0.000) and for the Syntax score (r = -0.323,p=0.000), the latter being influenced also by the level of triglycerides (r = -0.177, p = 0.048) and that of the high sensitive troponin (r = 0.322, p = 0.015).

Conclusions. Independent predictors of multivascular disease in patients with NSTEMI are : age, diabetes, chronic kidney disease, creatinine clearance and Grace score. The severity of the coronary heart disease assessed by the Syntax score, is also correlated with age, history of diabetes and chronic kidney disease, creatinine clearance, Grace score, but also with the value of tiglycerides and high-sensitive T troponin.

Determination of serum glycosylated hemoglobin, blood glucose and insulinemia (Homa IR) can be used in the assessment and prognosis of patients with diabetic versus non-diabetic acute ischemic stroke.

The European Guidelines for Diagnosis and Treatment of Chronic Coronary Syndromes (CCS) were published in 2019 with a different title than the previous 2013 Guidelines that referred to “chronic stable coronary heart disease”, underlining the dynamic nature of the atherosclerotic process. The main changes in these guidelines refer to the most frequent clinical presentations of CCS, to the assessment of the pretest probability of atherosclerotic coronary heart disease with the recommendation to include cardiovascular risk factors and other factors, as well as the choice of invasive anatomical and/or functional diagnostic tests, invasive and/or non-invasive, depending on the probability of the existence of the disease.

Regarding the treatment, these guidelines underline the importance of a healthy lifestyle and the modalities for the implementation and the strategy of anti-ischemic drug treatment, antithrombotic therapy being more widely addressed. Recommendations for myocardial revascularization on top of drug treatment for symptoms control and for improving prognosis are less restrictive in these guidelines. The recommendations of the CCS guidelines are harmonized with the recommendations of the other European guidelines, especially with those on diabetes, prediabetes and cardiovascular diseases which were also published in 2019.

Granulomatosis with polyangiitis (GPA, Wegener’s granulomatosis) is one of the antineutrophil cytoplasmic antibody (ANCA) - associated small vessel vasculitis, involving various organs such as nasal septum, sinuses, upper respiratory tract, lungs, and kidneys. GPA is pathologically characterized by necrotizing granulomatous inflammation. ANCA-associated small vessel vasculitis represent a major challenge in hospital admissions; therefore, early and accurate diagnosis with aggressive treatment is essential to improve the disease outcome.

Renal involvement of granulomatosis with polyangiitis is characterized morphologically by extensive crescent formation (extracapillary proliferation in Bowman’s space), and clinically by crescentic or rapidly progressive glomerulonephritis that causes hematuria, erythrocyte casts, and proteinuria with progressive loss of renal function. The diagnosis of granulomatosis with polyangiitis is established most securely by biopsy specimens showing the triad of vasculitis, granulomata, and large areas of necrosis (known as geographic necrosis) admitted with acute and chronic inflammatory cells. Usually, renal involvement is severe and is the leading cause of mortality. The combination of high-dose corticosteroids and cyclophosphamide is the mainstay of treatment for vasculitis and disease resistance to this combination is rare.

COVID-19 epidemic caused by an influenza-like virus strain (SARS-CoV-2) invaded the world. The World Health Organization (WHO) announced this infection outbreak as a global pandemic on 11 March 2020. From one day to another the number of new cases is growing and also the number of deaths. This infection emerged earlier in Wuhan City and rapidly spread throughout China and around the world since December 2019. Another silent pandemic disease spreading mainly in industrialized countries is obesity. The best example is US were about 34% of the Americans are obese.

In actual context, it can be said there is a coalition of 2 pandemics. In Romania, obesity and overweight prevalence assessed by Predatorr study is at a high level: 34,7% overweight and 31,9% obesity. Systemic inflammation in obesity is the central mechanism leading to lung function decline. There are two main questions a) is obese more sensible to viral infection or b) potentially more contagious? The answer is positive to both. Recent WOF official position stated that obesity is a risk factor for developing severe forms of COVID-19. Donna Ryan’s message, as president of World Obesity Federation WOF, US emphasized at the beginning of April the risk for severe complications for persons with obesity who contracted the infection with SARS-CoV-2. Nutritional support in COVID-19 should prefer oral feeding, whenever is possible. A special attention should be dedicated to a healthy microbiome and intestinal immunity. Energy intake should be 25-30 kcal/body weight, with 1.2-2 g/kg proteins. Enteral nutrition will be recommended in severe cases. Evidence is supporting the recommendation that for people at risk of developing COVID-19 to consider for few weeks a dosage of 10000 UI/day of vitD3, than a maintainance dose of 5000 UI/day. The target must be to stabilize a level of 40-60 ng/ml for 25(OH) D concentration. Pulmonary rehabilitation, smoking cessation, included in a healthy lifestyle will be further steps after patients recovery from this infection.

Facing this pandemic coalition, our messages should be stronger in stimulating prevention of obesity. Since more than a half of Romanian population is already overweight or obese, healthy lifestyle should become a daily prescription, not just a luxury recommendation. Daily, right messages from doctors acting like role models, in a partnership between general practitioner and other specialties like diabetologists, pneumologists, cardiologists, nutritionists will be efficient weapons against this cruel coalition: Obesity and COVID 19.

The clinical manifestations in sleep disorders vary according to the type of hypnopathies, a heterogeneous group of conditions, characterized by the presence of any sleep-related symptoms capable of generating discomfort.

We aimed to present the diagnostic criteria and the classification of the subtypes of sleep disorders in the most recent classification published in the medical literature. I have searched in the PubMed, Medline, Google Scholar Search databases, using keywords to select the right items. We selected the articles published in English and French language, in the period of 2000-2018.

The sleep disturbances may be of quantitative order (hyper- or hyposomnia) or of qualitative order (parasomnia), respectively hypnopathies related to breathing or movement, due to the circadian rhythm and other categories, according to ICSD-3.

Conclusions. The correct classification in the subtypes of sleep disorders is the key to their optimal treatment, but this process is complex, staged and multidisciplinary.

Introduction. Sarcoidosis is a multisystemic disease, that can basically affect any organ of the body, the lungs and the intrathoracic lymph nodes being the most affected. Despite the attempts to understand the exact pathogenic mechanism of the disease, this continues to remain uncertain. Histopathologically, the trademark of sarcoidosis is the presence of nonnecrotizing granuloma.

Case presentation. We report the case of a 33-year-old man without significant past medical history, who is admitted to our clinic for bilateral supraclavicular and axillary adenopathies, progressive asthenia for the last three months and pain in the latero-thoracic region. The patient denies weight loss, odynophagia and fever.

Clinically, the patient is afebrile and has supraclavicular, bilateral laterocervical and axillary adenopathies which are painless, elastic and mobile with a maximum diameter of 1.5 cm. The prehepatic diameter is 16 cm, with rounded inferior edge and the spleen in not palpable.

The laboratory tests reveal moderate inflammatory syndrome, with C-reactive protein (CRP) of 1.4mg/dL (N<0.5mg/dL) and the erythrocyte sedimentation rate (ESR) 65mm/h (N<40mm/h). There is no lymphocytosis or neutrophilia. The ENT (Ear Nose Throat) consultation found no evidence of angina and, combined with the paraclinical investigations, excluded mononucleosis.

Thus, the presumptive diagnosis was difficult because of the non-specific symptomatology and included the following: lymphoma, mononucleosis, sarcoidosis, tuberculosis and systemic vasculitis.

The chest X-ray reveals enlarged pulmonary hilums, diffuse outlined-adenopathic/tumoral aspect, diffuse changes in the pulmonary interstitium and micronodular opacities of medium intensity, being diffusely outlined with the tendency of basal merging on the left side and slight asymmetrical enlargement of the superior mediastinum on the right side, para trachealadenopathic aspect.

The lymph node biopsy reveals the aspect of non-necrotizing granuloma, which suggests the diagnosis of sarcoidosis.

We used the dosage of angiotensin convertase, which reveals high values of 108.20U/L (N 13.3-63.9 U/L). Therefore, a pulmonary clinical evaluation was recommended.

Conclusion. Case of 33-year-old man with sarcoidosis. The diagnosis was difficult, considering the non-specific symptomatology and the numerous pathologies that can be included in the differential diagnosis.