Aleksandar Jovanovic

Quality of life in patients related to gender differences before and after coronary artery bypass surgery

OBJECTIVES The different aspects of quality of life (QOL) in patients of different sex structure have been examined as well as the presumption that sex structure could be a predictor of QOL changes after coronary artery bypass grafting (CABG). METHODS The study included 243 consecutive patients who underwent an elective CABG. The QOL analysis was performed by using structured interviews with the Nottingham Health Profile (NHP) questionnaire part 1. RESULTS Compared to men, women had worse preoperative QOL (in all sections except the section of sleep) and worse postoperative QOL (in all sections). Six months after CABG the QOL statistically improved in men and in women. Multivariate analysis showed that being female was an independent predictor of QOL worsening in section of pain [P=0.001, odds ratio (OR)=3.93, 95% confidence interval (CI) 1.74-8.88]. CONCLUSIONS Compared to men, women have worse preoperative and postoperative QOL. Female sex was an independent predictor of QOL worsening six months after CABG.

The reliability of body mass index in the diagnosis of obesity and metabolic risk in children

Abstract Background: Body mass index (BMI) is the most widespread and the simplest method for the evaluation of body mass; it is often used as a sole technique in the diagnosis of obesity in children. The objective of the study was to evaluate the relationship between anthropometric and biochemical parameters and the incidence of the metabolic syndrome in obese children. Methodology: A total of 110 children, aged 2–17 years, participated in the study. No overweight children (BMI 85–95 percentiles) were included. BMI was interpreted using the 2000 Centers for Disease Control and Prevention Growth Charts. The skinfold measurements were performed using an John Bull British Indicators Ltd. calipers, and interpreted using an the reference table values. Results: In addition to lower sensitivity (mentioned in several earlier studies), BMI also shows a lower specificity in the diagnosis of obesity in children: BMI showed at least 10% of non-concomitance with skinfold thickness and waist circumferences and 8% with waist-to-height ratio. In addition, subscapular skinfold thickness, waist circumference, and waist/height ratio showed stronger correlations with serum insulin levels, low-density lipoprotein cholesterol, and family history than BMI itself. Conclusion: The unreliability of BMI as the sole parameter for diagnosing obesity in children was found in our study. Even when overweight children were excluded from the study, the lack of specificity of BMI was demonstrated. We propose utilization of waist circumference and waist/height ratio along with the BMI for definitive diagnosis instead of relying on BMI only. In addition, waist circumference and subscapular fold thickness may be even better in estimation of metabolic risk than BMI.

Association of metabolic changes with mortality of patients treated by peritoneal dialysis or hemodialysis

Aim: The aim of this study was to determine the survival of patients treated by peritoneal dialysis (PD) and hemodialysis (HD) and to detect any association with the type of metabolic changes. Methods: The outcome of clinical treatment of 407 dialysis patients was analyzed over a 4-year period. This included the demographic characteristics, the duration of dialysis, smoking, residual renal function, existence of metabolic syndrome and malnutrition, waist girth, body mass index (BMI), comorbidity, and routine biochemical parameters. Results: The overall mortality of the treated patients during the 4-year period was 53%, 37% for HD patients and 65% for PD patients. Metabolic syndrome was the dominant metabolic disorder affecting more than half of the HD patients, as well as being a predictive mortality parameter (β = 0.560; p = 0.045). The PD-treated patients had an equal prevalence of metabolic syndrome and malnutrition, whereas statistically significant predictors of mortality outcome were BMI (β = 0.088; p = 0.002) and waist girth (β = 0.023; p = 0.031). The median survival value was significantly higher for HD patients [108 months; 95% confidence interval (CI) 65–151]. Residual renal function in PD patients was significantly related to mortality (p = 0.045). Conclusion: Metabolic syndrome is a predictive parameter of mortality for HD patients, whereas for PD patients it is the waist girth and BMI. Preserved residual renal function in patients on PD is an important factor in reducing mortality.

Frequency and characteristics of metabolic disorders in patients on haemodialysis

BACKGROUND/AIM . Metabolic syndrome and malnutrition represent metabolic abnormalities which significantly characterize patients on haemodialysis. The aim of the study was to determine the incidence and find characteristics of metabolic disbalance in patients on haemodialysis. METHODS The study involved 124 patients on chronic haemodialysis at the Clinical Centre Kragujevac. There were analyzed demographic and anthropometric characteristics of the examined patients. Of clinical characteristics, there were determined smoking habit, time on dialysis, arterial pressure; of comorbid states there were recorded heart diseases and diabetes mellitus. Routine biochemical analyses were carried out by a standard laboratory procedure. RESULTS Metabolic syndrome was found in 29.8% of the examined patients. The patients with metabolic syndrome were older as compared to the patients without metabolic syndrome (58.45 +/- 12.91 vs 52.25 +/- 11.63 years). The values of systolic pressure (143.88 +/- 19.75 vs 133.01 +/- 22.93 mmHg; p = 0.014), body mass index (21.2 +/- 3.71 vs 19.4 +/- 2.88 kg/m2;p = 0.001), fat body mass (19.57 +/- 8.47 vs 16.45 +/- 5.82%; p = 0.0002) and waist scope (89 +/- 12.54 vs 96 +/- 12.34 cm; p = 0.0001) were significantly higher in the patients with metabolic syndrome as compared to those without metabolic syndrome. The values of erythrocytes (3.4 +/- 0.45 vs 19 +/- 0.53 x 10(12); p = 0.04) and hemoglobin (107 +/- 15.76 vs 101 +/- 13.87 g/l; p = 0.009), glycaemia (9.5 +/- 8.15 vs 5.6 +/- 1.4 mmol/l; p = 0.04) triglycerides (2.44 +/- 1.8 vs 1.41 +/- 0.64 mmol/l; p = 0.007), HDL cholesterol (1.11 +/- 0.19 vs 0.82 +/- 0.25 mmol/l; p = 0.005) and albumins (32.5 +/- 5.6 vs 29.5 +/- 3.7 g/l; p = 0.007) were statistically higher in the patients with metabolic syndrome than in patients without disturbance. Diabetes mellitus was a significant etiological factor of renal insufficiency in the patients with metabolic syndrome (p = 0.008). CONCLUSION In our study approximately 30% of patients on haemodialysis had pronounced metabolic syndrome. The older, more obese men with increased levels of triglycerides and glucose in the serum dominated among them. Diabetes mellitus was a leading etiological factor of renal insufficiency in these patients.

Non-atherosclerotic arteriopathy as the cause of ishemic stroke among young adults

The study comprised 100 ischemic stroke patients of both sexes aged 15-45 years who were treated at the Clinic of Neurology of the Clinical Center of Vojvodina in the period January 2001-September 2004. All study subjects were divided into three age groups: 15-25, 26-35 and 36-45 years. Sex, age and risk factors for cerebrovascular disease were determined in all patients. Diagnostic procedures applied in all patients included brain computed tomography and/or magnetic resonance imaging, routine laboratory tests, Doppler imaging of extra and endocranial blood vessels and coagulation tests. Contrast and/or transesophageal echocardiography, immunological blood assays, magnetic resonance angiography and/or computed tomography angiography and/or conventional angiography, thrombophilia markers, antiphospholipid antibodies and toxicological examination, etc. were performed in selected patients. Non-atherosclerotic arteriopathies were found in 8% of all study subjects, and were the most frequent cause of stroke in the age group 15-25. Carotid artery dissection was the most frequent diagnosis overall, found in 6% of all patients. Fibromuscular dysplasia and systemic vasculitis were diagnosed in one patient each. Moyamoya disease, Takayasu disease, infectious and isolated vasculitis of the CNS were not found in our patients.

Impact of arteriosclerosis on the functioning of arteriovenous fistula for hemodialysis

BACKGROUND/AIM Numerous clinical studies have shown that the incidence of artheriosclerosis is higher in patients with progressive renal insufficiency. The aim of this study was to examine the incidence of artheriosclerosis in patients on chronic hemodialysis and its influence on survival and functioning of vascular access. METHODS The study was organized as one-year prospective study. All the patients had arteriovenous fistulas native as a vascular access. The study analyzed demographic, biochemical, clinical and Doppler echomorphological characteristics of the patients in order to make an evidence of artheriosclerotic incidences as compared to functioning arteriovenous fistulas for hemodialysis. RESULTS The examined patients were of the mean age 55.7+/-12.68 years. Of them, 53.8% were males and 46.2% females. Functioning arteriovenous fistulas for haemodialysis were found in 56.8% of the examined patients. Concentration of hemoglobin was a significant parameter of functioning fistula (group with complications--89<--14.034 vs. group with no complications-- 96.6+/-17.71;p = 0.0489. An amount of urea removed (URR) was a statistically more significant parameter among the patients without fistula complications: (group with complications--58.67+/-7.92% vs. group with no complications--62.80+/-7.53%; p = 0.037). A Cox regressive analysis of an index of Doppler parameters of the carotid arteries found no statistical significance between the examined groups. There was a positive correlation between artheriosclerosis and the age, as well as the time on dialysis. In multiple regression, where intima media is a dependent and the age and time on dialysis independent variables, the regressive model was statistically significant (F = 8.22, p = 0.001). Both independent variables had statistically significant inclinations, p < 0.01. CONCLUSION Anemia and the level of urea elimination, as a statistically significant indicator of hemodialysis adequacy, were in correlation with the risk for fistula complications. B-mode ultrasonography of the carotid arteries is a significant non-invasive method for detecting artheriosclerosis. Intima-media thickness of the carotid arteries was an important marker of artheriosclerosis correlating significantly with the age and time on dialysis, but not with the traditional risk factors.

Distinctive Characteristics and Specific Management of Diabetic Ketoacidosis in Patients with Acute Myocardial Infarction, Stroke and Renal Failure

Diabetic ketoacidosis (DKA) is considered a predominantly acute type 1 diabetic complica‐ tion, although it may occur in type 2 diabetes as well, particularly in patients who already have a decreased insulin secretion capacity. Stress –induced burst in catecholamine and ACTH secretion in acute myocardial infarction (AMI) promotes release of free fatty acids and their hepatic and muscular tissue utilization. The impairment in insulin-mediated intra‐ cellular glucose influx owing to the absent or insufficient pancreatic insulin secretion is the prerequisite for the occurrence of diabetic ketoacidosis.

Stroke and diabetic ketoacidosis--some diagnostic and therapeutic considerations.

Cerebrovascular insult (CVI) is a known and important risk factor for the development of diabetic ketoacidosis (DKA); still, it seems that the prevalence of DKA among the patients suffering CVI and its influence on stroke outcome might be underestimated. Diabetic ketoacidosis itself has been reported to be a risk factor for the occurrence of stroke in children and youth. A cerebral hypoperfusion in untreated DKA may lead to cerebral injury, arterial ischemic stroke, cerebral venous thrombosis, and hemorrhagic stroke. All these were noted following DKA episodes in children. At least some of these mechanisms may be operative in adults and complicate the course and outcome of CVI. There is a considerable overlap of symptoms, signs, and laboratory findings in the two conditions, making their interpretation difficult, particularly in the elderly and less communicative patients. Serum pH and bicarbonate, blood gases, and anion gap levels should be routinely measured in all type 1 and type 2 diabetics, regardless of symptomatology, for the early detection of existing or pending ketoacidosis. The capacity for rehydration in patients with stroke is limited, and the treatment of the cerebrovascular disease requires intensive use of osmotic and loop diuretics. Fluid repletion may be difficult, and the precise management algorithms are required. Intravenous insulin is the backbone of treatment, although its effect may be diminished due to delayed fluid replenishment. Therefore, the clinical course of diabetic ketoacidosis in patients with CVI may be prolonged and complicated.

Predictors of Quality of Life Improvement after 2 Years of Coronary Artery Bypass Surgery

PURPOSE The aim was to examine the predictors of improvement of quality of life after 2 years of coronary artery bypass grafting (CABG). METHODS In all, 208 patients who underwent the elective CABG at the Institute for Cardiovascular Diseases Dedinje in Belgrade were contacted and examined 2 years after the surgery. All patients completed Nottingham Health Profile Questionnaire part one. RESULTS Two years after CABG, quality of life (QOL) in patients was significantly improved in all sections compared to preoperative period. Independent predictors of QOL improvement after 2 years of CABG were found to be serious angina under sections of physical mobility [p = 0.003, odds ratio (OR) = 1.76, 95% confidence interval (CI) 1.21-2.55], energy (p = 0.01, OR = 1.63, 95% CI: 1.11-2.38), sleep (p = 0.005, OR = 1.65, 95% CI: 1.16-2.35), pain (p <0.001, OR = 2.43, 95% CI: 1.57-3.77), absence of hereditary load in energy section (p = 0.002, OR = 0.35, 95% CI: 0.18-0.68), male sex in the sleep section (p = 0.03, OR = 0.43, 95% CI: 0.20-0.93), and absence of diabetes in pain section (p = 0.006, OR = 0.27, 95% CI: 0.10-0.68). CONCLUSION Predictors of improvement of QOL after 2 years of CABG are serious angina, absence of hereditary load, male sex, and absence of diabetes.

Predictive parameters of survival in hemodialysis patients with restless leg syndrome

Restless leg syndrome (RLS) affects the quality of life and survival in patients on hemodialysis (HD). The aim of this study was to determine the characteristics and survival parameters in patients on HD with RLS. This study was a non-randomized clinical study involving 204 patients on HD, of whom 71 were female and 133 were male. Symptoms of RLS were defined as positive responses to four questions comprising the criteria of RLS. We recorded the outcome of treatment, biochemical analyses, demographic, sexual, anthropometric and clinical characteristics in all study patients. Patients with RLS who completed the study had a significantly higher body mass index and lower intima-media thickness and flow through the arteriovenous fistula. Among patients with RLS who died, there were more smokers as well as higher incidences of cardiovascular disease and diabetes mellitus. Among patients with RLS who survived, there were a greater number of patients with preserved diuresis and receiving erythropoietin therapy. Patients who completed the study had significantly higher levels of hemoglobin, creatinine, serum iron and transferrin saturation. Diabetes mellitus (B = 1.802; P = 0.002) and low Kt/V (B = -5.218; P = 0.001) were major predictive parameters for survival.