Focus on Pneumonia After Organ Transplantation: Is There a Need for Specific Medical Care in the Emergency Department?

BACKGROUND

Pneumonia is a major cause of hospitalization and has a substantial impact on health care costs. Diagnosis and treatment of pneumonia in solid organ transplant (SOT) patients remain a challenge for clinicians in the emergency department. This study aimed to evaluate demographic features, clinical patterns, history of hospitalization, and diagnosis of adult patients after organ(s) transplantation (liver, kidney, pancreas) with severe pneumonia requiring hospitalization. The aim is to determine whether patients undergoing SOT receive or require specific care and whether they need to be prioritized.

METHOD

This was a single-center observational study of adult patients after SOT with severe pneumonia requiring hospitalization. The data set for the analysis included only patients with pneumonia as the main reason for hospitalization. The diagnosis of pneumonia was suspected based on the American Thoracic Society criteria.

RESULTS

The study revealed that the standard of care for patients with a history of SOT did not significantly differ from care provided to the non-SOT patients with pneumonia admitted to the same hospital during a 94-week period.

CONCLUSION

There were notable differences, such as post-transplant patients being transferred more quickly to the hospital ward, having longer hospital stays, and receiving antibiotics earlier than the non-SOT group.

Recommendations for modern perioperative care for elective surgery: consensus of panel of exerts

INTRODUCTION

Correct surgical technique and perioperative care are two factors that can reduce the number of complications, improve treatment outcomes and shorten the length of hospital stay. The introduction of enhanced recovery protocols has changed the approach to patient care in some centers. However, there are significant differences among centers, and in some the standard of care has remained unchanged.

AIM

the goal of the panel was to develop recommendations for modern perioperative care in accordance with current medical knowledge in order to reduce the number of complications associated with surgical treatment. An additional goal was to optimize and standardize perioperative care among Polish centers.

MATERIALS AND METHODS

the development of these recommendations was based on a review of the available literature from the PubMed, Medline and Cochrane Library databases from January 1, 1985 to March 31, 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations were formulated in a directive form and were assessed using the Delphi method.

RESULTS AND CONCLUSIONS

34 recommendations for perioperative care were presented. They cover aspects of pre-, intra- and post-operative care. Implementation of the presented rules allows to improve the results of surgical treatment.

Valsartan reduces arterial stiffness along with level of soluble ST2 independently of blood pressure changes

Introduction

Arterial stiffness is one of end-organ damage signs in patients with arterial hypertension. Carotid femoral pulse wave velocity (cfPWV) is a clinical measure of arterial stiffness and its values above 10 m/sec are associated with increased cardiovascular risk. Soluble ST2 is a cytokine involved in fibrotic processes. There is paucity of data on the association between sST2, arterial stiffness, and effect of valsartan on these parameters.

Objectives

The aim of the study was to assess the effect of valsartan on arterial stiffness and level of soluble ST2 over a 12-month long treatment.

Methods

This was a randomized, blinded, placebo controlled single center study. There was a 24-hour-long wash-out period from angiotensin converting enzyme inhibitors (ACEI) and other than valsartan, angiotensin receptor blockers ARB (previous use of valsartan was an exclusion criterion). Drugs other than ACEI and ARB were allowed in follow-up to control blood pressure. CfPWV was assessed at baseline and at 12 months using applanation tonometry. Soluble ST2 was measured with lateral flow cassette-based immunofluorescent assay. We present the data for 28 placebo patients (Plac) and 60 valsartan patients (Vals).

Results

Patients from both groups have had comparable peripheral and central blood pressures. CfPWV has risen in Plac by 6.2% and has fallen by 6.2% in Vals (P=0.01) over 12 months. Soluble ST2 has risen in Plac by 9.4% and has fallen by 43.3% in Vals (P=0.001) over 12 months.

Conclusion

Valsartan has positive effect on improvement of arterial stiffness. Decrease in soluble ST2 concentration may help explain the alternative mechanism for protective role of valsartan.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Silesia

Clinical risk scores versus simple integrated clinical judgment in patients with suspected acute coronary syndromes

Background

The clinical utility of clinical risk scores in patients presenting with suspected acute coronary syndromes to the emergency department (ED) is uncertain.

Purpose

We aimed to directly compare the performance of three established clinical risk scores to simple integrated clinical judgment (ICJ) of the treating ED physician.

Methods

Thirty day major adverse cardiac events (MACE) including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (AMI, including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the emergency department (ED) with acute chest discomfort in an international multicenter study (12 centres in 5 European countries). ICJ for the likelihood that an ACS is the cause of acute chest discomfort was quantified by the treating ED physician using a visual analogue scale at 90 minutes after patient's presentation to the ED. At this time, the ED physician had obtained the patient history, physical examination including vital signs, the 12-lead electrocardiogram at presentation, and the first local (hs)-cTn measurement. We directly compared the prognostic performance of the HEART-score, the GRACE-score, and the T-MACS decision aid to simple integrated clinical judgment (ICJ) of the treating ED physician. We also assessed the safety for rule-out of MACE at 30-days.

Results

Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy as quantified by the area under the receiver-operating characteristics curve was 0.85 (95% CI, 0.84–0.87) for the HEART-score, 0.85 (95% CI, 0.84–0.87) for the GRACE-score, 0.79 (95% CI, 0.77–0.80) for the TIMI decision aid, and 0.87 (95% CI, 0.85–0.88) for ICJ (Figure). The HEART-score identified 1893/4551 (41.6%) patients as low-risk with an NPV of 96.0% (95% CI, 95.0–96.8), the GRACE score identified 1542/4551 (33.9%) patients as low-risk with an NPV of 97.0% (95% CI, 96.0–97.7), the TIMI score identified 2157/4551 (47.4%) patients as low-risk with an NPV of 93.1% (95% CI, 91.9–94.1), and simple ICJ identified 1743/4551 (38.3%) patients as low-risk with an NPV of 95.6% (95% CI, 94.5–96.5).

Conclusion

The simple ICJ of the treating physician performed well for the prediction of 30-day MACE and might be an alternative to the well-validated HEART-score, GRACE-score, and T-MACS decision aid.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The study was supported by research grants from the the Swiss Heart Foundation and the University of Basel.

Change for the Better: Severe Pneumonia at the Emergency Department

This is a single-centre observational study of adult patients with severe pneumonia requiring hospitalization conducted at the emergency department. During the observation period (94 weeks), 398 patients were diagnosed with severe pneumonia and required further treatment at the hospital. The median age of patients was 73 years. About 65% of patients had at least one chronic comorbidity. Almost 30% of patients had cardiovascular disorders, and 13% had diabetes mellitus. The average Emergency Department length of stay was 3.56 days. The average length of hospitalization was 15.8 days. Overall, 94% of patients treated for pneumonia received a beta-lactam antibiotic. The median time from ED admission to the administration of the first dose of antimicrobial agent was less than 6 h. Microbiology test samples were obtained from 48.7% patients. Gram-positive cocci were isolated most commonly (52.9%) from blood samples. Biological material from the lower respiratory tract was collected from 8.3% of patients, and from 47.2% of positive samples, fungi were cultured. The urine samples were obtained from 35.9% patients, and Gram-negative rods (76%) were isolated most commonly. Overall, 16.1% of patients died during the hospitalization. The mean age of patients who died was 79 years. This observational study is the first single-centre study conducted as part of the Polish Emergency Department Research Organization (PEDRO) project. It aims to provide up-to-date information about patients with pneumonia in order to improve medical care and develop local diagnostic and therapeutic recommendations.

What we actually know about the pathogenicity of Bacteroides pyogenes

The aim of the study was to evaluate the pathogenic potential of Bacteroides pyogenes, rarely identified in clinical laboratories anaerobic bacteria. To increase the knowledge about this poorly understood anaerobic microorganism, the study also includes cases of infections described so far in the literature. Only the use of 16S rRNA sequencing and mass spectrometry technique allowed the identification of B. pyogenes from clinical specimens. We reported 13 severe human infections caused by B. pyogenes. Bacteria were cultured from the wound after biting by animals, chronic infections within the oral cavity, from patients with histologically or radiological proven osteomyelitis, surgical site infection, and from urine sample collected after a urological procedure. Most (9/13) of the patients required hospitalization. Almost 70% of them needed urgent admission via the emergency room. Two inpatients due to a life-threatening condition were admitted to the intensive care unit. Almost 50% of isolates were resistant to penicillin. All resistant to penicillin strains were isolated from skin and mucous membrane infections.

Early diagnosis of acute myocardial infarction in patients with a history of percutaneous coronary intervention

Background

Recurrence of acute chest pain after percutaneous coronary intervention (PCI) is common. The early detection of acute myocardial infarction (AMI) as a possible cause of acute chest pain can be challenging in patients with a history of PCI due to e.g. pre-existing electrocardiographic abnormalities. It is unknown, whether high-sensitivity cardiac troponin T (hs-cTnT) concentrations and hs-cTnT-based rapid algorithms perform equally well in patients with a history of PCI.

Purpose

To investigate the impact of prior PCI on the diagnostic performance of hs-cTnT concentrations for early rule-out and rule-in of AMI.

Methods

In an ongoing multicentre international study, we prospectively enrolled unselected patients presenting to the emergency department (ED) with symptoms suggestive of AMI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records obtained during clinical care including 90 day follow-up information and cardiac imaging. High-sensitivity cTnT concentrations at presentation and after 1h were compared against the adjudicated final diagnosis. Patients were stratified according to the presence or absence of previous PCI.

Results

Among 5536 patients (1313 with and 4223 without previous PCI), incidence of AMI was significantly higher in patients with previous PCI (26.3% versus 21.4%; p<0.001). Patients with prior PCI and a final diagnoses other than AMI had significantly higher concentrations of hs-cTnT at presentation to the ED (median 9ng/l [IQR 6 to 15.8] vs 5.5ng/l [IQR 3 to 10]; p<0.001). However, in patients with final adjudicated diagnosis of AMI, hs-TnT concentrations at presentation were lower in patients with previous PCI (median 46ng/l [IQR 23 to 94] vs 55ng/l [IQR 25 to 175]; p=0.003). The diagnostic accuracy of hs-cTnT was high in patients with history of PCI, but significantly lower compared to patients without PCI (AUC 0.91 [95% CI 0.89–0.92] versus AUC 0.94 [95% CI 0.94–0.95]; p<0.001, respectively). When applying the ESC 0/1-algorithm among patients with previous history of PCI, the rule out pathway showed also very high safety in patients with a history of PCI (sensitivity 99.2 [95% CI 97.2–99.8] and negative predictive value 99.6 [95% CI 98.5–99.9]). However, the efficacy of the ESC 0/1h-algorithm for early rule out of NSTEMI was lower in the PCI group compared to no PCI (45.2% vs 65.1%; P<0.001, respectively), triaging more patients to the observe zone (36.8% versus 18.8%; p<0.001). Time to discharge from the ED was significantly longer in patients with prior PCI (334 min vs 290 min; p<0.001). When stratified for index AMI, patients with history of PCI waited longer for a final diagnoses of AMI (285 vs 217 min; p<0.001).

Conclusions

History of PCI impacts on the diagnostic performance of hs-cTnT. Although the ESC 0/1h-algorithm still performs very safe when applied to patients with a history of PCI, its efficacy is significantly reduced.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the Stiftung für kardiovaskuläre Forschung Basel the University of Basel and the University Hospital Basel

Valsartan improves left ventricle contractility and prevents its remodeling in patients with dual chamber pacemaker

Introduction

Permanent right ventricle pacing leads to left ventricle dyssynchrony, systolic dysfunction, remodeling, and symptomatic heart failure in the long run. Valsartan is well known for its preventive anti-remodeling function in the post infarction heart remodeling.

Objectives

To assess the effect of valsartan on left ventricle contractility, measured as global longitudinal stain, and its remodeling in patients with second and third degree atrioventricular block with first-time implantation of dual chamber pacemaker.

Methods

This was a randomized, double-blind, placebo controlled single center study. One hundred eligible patients were assigned in a 1:1:1 fashion to receive placebo, valsartan 80mg or 160mg once daily, respectively. Echocardiographic assessment of left ventricle geometry, its systolic and diastolic function was performed at baseline and at twelve months. Global longitudinal strain (GLS) was measured off-line with EchoPac software. One patient from placebo group suffered stroke. We present the baseline date for 100 enrolled patients and follow-up data for 88 patients who have completed the study. Data in valsartan arms are pooled in one group.

Results

Results are presented in table. Data are presented as mean and standard deviation.

Valsartan alleviates diastolic dysfunction, left ventricle dilation and protects from loss of systolic function.

Conclusion

Valsartan has protective effect of left ventricle contractile function and remodeling. It may be useful in prevention of pacing induced heart failure. (ClinicalTrials Identifier NCT01805804)

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Medical University of Silesia

Early diagnosis of myocardial infarction in patients presenting late after chest pain onset

Background

The European Society of Cardiology (ESC) recommends the clinical use of the 0/1h-algorithms in patients with suspected acute coronary syndrome (ACS) to rule-out or rule-in non-ST elevation myocardial infarction (NSTEMI). However, the diagnostic performance of the ESC 0/1h-algorithms was only validated in patients presenting within 12 hours after chest pain onset (=early presenters) to the emergency department (ED). To this date, evidence regarding their performance in patients with chest pain onset >12h (=late presenters) is lacking.

Purpose

To evaluate the diagnostic performance of the ESC 0/1h-algorithms in late presenters.

Methods

We prospectively enrolled patients presenting to the ED with symptoms suggestive of ACS such as acute chest discomfort. Two independent cardiologists adjudicated the final diagnoses based on all available clinical information including serial hs-cTn concentrations, follow-up information and cardiac imaging. Hs-cTnT/I concentrations at 0h and 1h were measured in a blinded fashion. The primary diagnostic endpoint was the diagnostic performance of the hs-cTnT/I ESC 0/1h-algorithms in patients presenting late after chest pain onset compared to those presenting early. Diagnostic performance was quantified by safety of rule-out (sensitivity and negative predictive value), accuracy of rule-in (specificity and positive predictive value), and efficacy (proportion of patients) classified as rule-out or rule-in within 1 hour after presentation to the ED. The primary prognostic endpoint was all-cause mortality after 30-days and two-years in patients in whom NSTEMI was ruled-out by the ESC 0/1h-algorithms.

Results

Among 4733 patients, 308/4733 (7%) presented late to the ED. The ESC hs-cTnT 0/1h-algorithm ruled-out 185/308 (60%) of late presenters with a sensitivity of 100% (95% CI, 93.7–100) and a negative predictive value (NPV) of 100% (95% CI, 98.0–100). Sixty-one of 308 (20%) were ruled-in with a specificity of 95.2 (95% CI, 91.8–97.2) and a positive predictive value (PPV) of 80.3% (95% CI, 68.7–88.4). The remaining 62/308 (20%) were classified as observe with a NSTEMI prevalence of 13%. In comparison, 59% of early presenters were ruled-out (sensitivity 99.3% [95% CI, 98.4–99.7]; NPV 99.8 [99.5–99.9]), 17% were ruled-in (specificity 96.2 [95% CI, 95.5–96.8]; PPV 81.4 [95% CI, 78.4–84.0]), and 45% were classified as observe. Late presenters in whom NSTEMI was ruled-out had 30-day and two-year survival rates of 100% and 98.2%, respectively. Similar findings were made for the ESC hs-cTnI 0/1h-algorithm.

Conclusion

The ESC hs-cTnT/I algorithms also provide excellent diagnostic performance for early triage and specifically safe rule-out of NSTEMI in patients presenting late after chest pain onset to the ED.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss Heart Foundation, Swiss National Science Foundation

Reoperation in Early Kidney Post-transplant Period as a Strong Risk Factor of Surgical Site Infection Occurrence

BACKGROUND

One of the most common infective complications after kidney transplant (KTx) is surgical site infection (SSI). Providing indications of improvement of perioperative antibiotic prophylaxis (PAP) and allowing the characterization of risk factors are critical to reduce SSI. The purpose of this study was to evaluate the SSI risk factors and impact of reoperation in the early post-transplant period on SSI occurrence and assess if standard PAP in those cases is a best consideration.

METHODS

Between April 2014 and October 2015, a total of 236 KTxs were performed in our center. Deceased donor data, recipient data, and data related to surgical procedures were collected.

RESULTS

Surgical site infections were reported in 5.6% (12/214) of patients. Seven patients were diagnosed as having superficial SSI (7/12; 58.3%), 2 with deep SSI (2/12; 16.6%), and 4 with organ-specific SSI (4/12; 33.3%). Extended criteria donor-related transplant, cold ischemia time > 22 hours, dialysis period > 30 months, recipient age older than 45 years, recipient body mass index > 27, induction therapy prior to transplant, diabetes prior to transplant, and ≥ 1 reoperation during 30 days of observation were independent risk factors of SSI occurrence. A total of 19 reoperations were performed in 17 patients. In 8 of all 12 patients with SSI diagnosis, the reoperation was performed (66.7%). In 202 patients of non-SSI patients, only 9 reoperations were performed (4.5%).

CONCLUSIONS

Early reoperation after Ktx is a strong risk factor of SSI occurrence. There is a probability that > 4 SSI risk factors and reoperation in the early post-transplant period could require different and more aggressive proceeding, as standard PAP in those cases is insufficient.

Resistance to Aminoglycosides of Methicillin-Resistant Strains of Staphylococcus aureus, Originating in the Surgical and Transplantation Wards of the Warsaw Clinical Center-A Retrospective Analysis

INTRODUCTION

Aminoglycoside resistance (AR) is common in health care-associated methicillin-resistant Staphylococcus aureus (HA-MRSA). AR is most often associated with the production of antibiotic modifying enzymes: bidomain AAC(6')-Ie/APH(2″)-Ia acetyltransferase and phosphotransferase, ANT(4')-Ia nucleotidyltransferase, and APH(3″)-IIIa phosphotransferase.

AIM

Determination of aminoglycoside sensitivity, presence of genes encoding enzymes, and molecular typing of HA-MRSA strains derived from patients hospitalized in surgical and transplantation wards.

MATERIALS AND METHODS

Fifty-four HA-MRSA strains, isolated from various materials from patients in the surgical and transplantation wards of Warsaw's clinical hospital, hospitalized between 1991 and 2007. The MIC values of gentamicin-GEN/tobramycin-TOB/amikacin-AK/netilmicin-NET were determined by the E-test (CLSI/EUCAST). Genes mecA/aacA-aphD/aadD/aph(3″)-IIIa were detected using PCR. SCCmec types were determined according to the Oliveira method and the sequence type (ST)/clonal complex (CC) by the MLST method.

RESULTS

Of the isolates tested, 36 (66.7%) showed resistance to at least one aminoglycoside: TOB (57.4%), GEN (53.7%), AK (55.6%), NET (24.1%). The aacA-aphD gene was present in 29 MRSA-GEN-R (most often in combination with aadD, 15/29 or aph(3″)-IIIa, 10/29); the aacA-aphD gene was the only determinant of resistance in 1 isolate. The AR variants mainly belonged to the CC8 clonal complex (ST239/247/241/254/8) and most frequently contained SCCmec type III (3A) cassettes.

CONCLUSIONS

Resistance to at least one aminoglycoside was present in 66.7% of HA-MRSA and in more than 22% to all of them. The presence of the aacA-aphD gene was sufficient to express the resistance phenotype to GEN/TOB/AK/NET. Resistant isolates were closely related to each other.

Significance of Screening Tests and the Incidence of New Delhi Metallo-beta-lactamase-Producing Gram-negative Bacilli in the Surgery and Transplantation Wards of a Warsaw Medical Center During the Period From April 2014 to May 2017

BACKGROUND

The first New Delhi metallo-beta-lactamase (NDM)-producing bacteria were isolated in 2008 in the world, and in 2011 in Poland. Due to the high clonal diversity (17 types) of their blaNDM gene, encoded on (Tn125-like) mobile genetic elements, these strains usually exhibit resistance to nearly all available antibiotics, which is particularly dangerous for organ transplant recipients.

PURPOSE

To assess of the prevalence of Gram-negative NDM-positive bacilli in surgery/transplantation wards of a teaching hospital in Warsaw and to ascertain the significance of screening tests on the rates and nature of colonization.

MATERIALS AND METHODS

The evaluated strains were isolated from 30 patients (between April 2014 and May 2017). The species were identified with VITEK-MS, antibiotic susceptibility was determined with VITEK 2, disk-diffusion, and/or E-test methods, according to EUCAST guidelines. The presence of the blaNDM-1 gene was confirmed using the polymerase chain reaction technique.

RESULTS AND CONCLUSIONS

There were 77 blaNDM-1-positive Klebsiella pneumoniae strains isolated from 30 patients. Cultures from individual patients, mainly from rectal swabs (53.9%) and urine samples (39.8%), yielded 1-11 isolates. Fifteen patients were already colonized on admission, and the other 15 developed a symptomatic infection. In total, 24 (80%) patients were carriers, and their colonizations persisted for <1-20 months. Most isolates were susceptible only to colistin, gentamicin, amikacin, tigecycline, and/or sulfamethoxazole/trimethoprim. Gastrointestinal-tract-colonizing K pneumoniae are the main reservoir of the blaNDM-1 gene. Following the introduction of on-admission mandatory screening for carbapenem-resistant strains, the rates of NDM-producing K pneumoniae isolation increased (7.5-fold), while the rates of isolation from patients with symptomatic infections considerably decreased (2.8-fold).

Fournier's Gangrene: Clinical Presentation of 13 Cases

BACKGROUND Fournier's gangrene (FG) is a fulminant form of infective, polymicrobial, necrotizing fasciitis of the perineal, genital, and perianal regions. It commonly affects men, but women and children may also develop this type of tissue necrosis. MATERIAL AND METHODS This study is a retrospective analysis of the management of 13 cases of Fournier's gangrene, diagnosed from among about 45 000 patients (men, women, and children) treated in the Department of General, Oncological, and Functional Urology (Medical University of Warsaw) from 1995 to 2013. All patients with Fournier's gangrene underwent adequate surgical debridement of the necrotic tissues. Additional procedures (suprapubic cystostomy and orchiectomy) were necessary in 10 out of 13 (77.0%) patients. Seven out of 13 (53.8%) patients required subsequent reconstructive surgery of the scrotum. RESULTS All 13 patients were males, with a median age of 59.6 years (range: 42-68 years). The average hospital stay was 31.9 days (range: 16-46 days). None of our patients died due to Fournier's gangrene. Bacteriological cultures of samples from the wounds showed polymicrobial flora, including the following genera of aerobes and anaerobes: Escherichia, Proteus, Klebsiella, Moraxella, Gemella, Enterococcus, Streptococcus, Staphylococcus, Bacteroides, Pseudoflavonifractor, Parabacteroides, Porphyromonas, Prevotella, Peptoniphilus, Peptostreptococcus, Actinomyces, Collinsella, and Lactobacillus. CONCLUSIONS Favorable outcome of FG treatment with low morbidity and no mortality can be achieved with rapid diagnosis, urgent surgical debridement of all necrotic tissues, and broad-spectrum empirical antimicrobial therapy, usually with combined antibiotics, against aerobic and anaerobic bacteria. Prevention of uroseptic shock by treating localized infection is compulsory.

Bacterial and fungal infections in the early post-transplant period after kidney transplantation: etiological agents and their susceptibility

BACKGROUND

Infections remain serious complications in solid-organ transplant recipients, despite professional medical care, the introduction of new immunosuppressive drugs, and treatment that decreases the risk of infections.

METHODS

The study covered 295 adult patients undergoing kidney transplantation (KTx) between September 2001 and December 2007. All the patients were followed prospectively for infections from the KTx date and during the first 4 weeks after surgery. Samples of clinical materials were investigated for microbiological cultures. The microorganisms were cultured and identified in accordance with standard bacteriological procedures. Susceptibility testing was carried out through the use of Clinical and Laboratory Standards Institute procedures.

RESULTS

From 295 KTx recipients, 1073 clinical samples were taken for microbiological examination. Positive cultures were 26.9% (n = 289) of all samples tested; 525 strains were collected. Gram-positive bacteria were isolated in 52.2% (n = 274), Gram-negative bacteria were isolated in 40.8% (n = 214), and fungal strains were isolated in 7% (n = 37). Urine specimens (n = 582) were obtained from 84.5% of 245 recipients during the first month after transplantation. Among the isolated bacterial strains (n = 291), the most common were Gram-negative bacteria (56.4%). Gram-positive bacteria comprised 35.7%; fungal strains were found in 23 cases (7.9%). In surgical site specimens (n = 309), Gram-positive bacteria (72.1%) were the most common. Gram-negative bacteria comprised 24.4%. In blood specimens (n = 138), Gram-positive bacteria (81.6%) were the most common. Gram-negative bacteria comprised 15.8%; fungi were isolated in 2.6%. In respiratory tract specimens (n = 13), among the isolated bacterial strains (n = 8), the most common were Gram-positive bacteria (57.1%). Gram-negative bacteria comprised 14.3%; fungi were isolated in 28.6%.

CONCLUSIONS

Urine samples were predominantly positive after KTx. Our study showed Gram-positive bacteria in 52.2% after kidney transplantation. The proportion of isolates of multi-drug-resistant bacterial strains (MRCNS, vancomycin-resistant strains, high-level aminoglycoside-resistant strains, extended-spectrum beta-lactamase producers, and high-level aminoglycoside-resistant strains) was increased. These data indicate the need for strict adherence to infection control procedures in these patients.

Bacterial and fungal infections in the early post-transplantation period after simultaneous pancreas-kidney transplantation: etiological agents and their susceptibility

OBJECTIVE

This study aims to evaluate the frequency of microbial isolates and their susceptibility profiles cultured from clinical samples obtained from 26 simultaneous pancreas-kidney transplant (SPK) recipients suspected of infections during the early post-transplantation period.

PATIENTS AND METHODS

Data on microbiologic culture of 26 adult patients undergoing SPK were collected prospectively from 2001 to the end of 2006. Isolation and identification of cultured micro-organisms were performed according to standard microbiological procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was made by the Clinical and Laboratory Standards Institute guidelines.

RESULTS

All the patients were followed prospectively for the first 4 weeks after surgery. In total, 263 samples from clinical materials obtained from 26 SPK recipients were cultured. Bacterial cultures were positive in 29.3% (n = 77) clinical samples. Of these, 219 microbial strains were cultured. Gram-positive bacteria were found in 64% (n = 140), Gram-negative bacteria in 22.8% (n = 50), and fungal strains were isolated in 13.2% (n = 29). Incidence rate values for subsequent isolation of micro-organisms in the sub-periods of time for decreasing the SPK were Gram-positive bacteria (102.3-18.7; I versus IV), growing the Gram-negative bacteria (14-46.1 I versus III) IV were 14, decreasing to fungi (22.1-1.6, I versus IV). Until now this early post-transplantation period was considered homogeneous time after transplantation. This study shows that this period is actually heterogenous, with statistically significant differences being observed between results obtained in consecutive 4 weeks after transplantation.

CONCLUSIONS

The results of this study show that the incidence rate was elevated with increasing age in the SPK group of patients. In the SPK group, our data showed the highest rate of isolation of micro-organisms compared with recipients of kidneys or liver.

Fournier's gangrene--current concepts

Fournier's gangrene (FG) is a rapidly progressive form of infective necrotising fasciitis of the perineal, genital, or perianal regions, leading to thrombosis of the small subcutaneous vessels and necrosis of the overlying skin. It is believed that the occurrence of the disease in women is underreported and may be unrecognised by some clinicians. Fournier's gangrene is a life-threatening condition, constituting an urological emergency. Many patients with Fournier's gangrene have medical or surgical conditions, which are predisposing factors to this disease or its more severe or fatal course. These comprise diabetes mellitus, hypertension, alcoholism and advanced age. Recent reports in the literature point to changes in the epidemiology of FG, comprising an increasing age of patients. Several authors reported that the mean age of FG patients is at present 53-55 years. Prognosis in FG patients is based on FGSI (Fournier's gangrene severity index) score. Despite the progress in medical care for FG patients, the mortality rate reported in the literature remains high--most often 20-40%, but ranges from 4% to 80%. The most common isolates cultured from FG lesions are both Gram-positive and Gram-negative, as well as strictly anaerobic bacteria. Recently community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as an etiological agent of FG with severe clinical course and even fulminant sepsis. Rarely FG may have a fungal etiology, being caused by yeast-like fungi Candida spp. or by moulds. Antibiotics should be administered parenterally and in doses high enough to reach an effective concentration in the infected tissues.

Circulating endothelial progenitor cells are inversely correlated with in-stent restenosis in patients with non-ST-segment elevation acute coronary syndromes treated with EPC-capture stents (JACK-EPC trial)

AIM

Aim of the study was to evaluate the association between circulating endothelial progenitor cells (EPCs) and angiographic outcomes after implantation of GenousTM stent in patients with non-ST-segment elevation acute coronary syndromes (ACS) (NSTE-ACS) undergoing urgent percutaneous coronary intervention (PCI).

METHODS

Sixty patients treated with EPC-capture stent (N.=30) or bare metal stents (BMS) (N.=30) receiving 80 mg atorvastatin and dual antiplatelet therapy (DAT) for 12 months. Restenosis was assessed after 6 months by quantitative coronary angiography (QCA) and major acute coronary events (MACE) evaluated after 6 and 12 months.

INCLUSION CRITERIA

de novo lesion >70% in native vessel, diameter 2.5-4 mm, lesion length <30 mm.

EXCLUSION CRITERIA

diabetes, previous revascularization, significant left main stenosis, chronic total occlusions (CTO) and multivessel disease.

RESULTS

Majority of patients in EPC-capture stent and BMS groups presented with NSTEMI (73.3% and 70%, respectively). Mean stent length was 20.1±8 and 19.9±10 mm, diameter 3±0.97 and 3.1±0.88 mm in respective groups. The binary restenosis was significantly lower in GenousTM (13 vs. 26.6%, P=0.04). Risk of MACE after 6 and 12 months were comparable in both groups. There was no stent thrombosis. Numbers of circulating EPCs were significantly approximately 2-fold higher during the ACS than after 6 months. Mobilization of EPCs during acute ischemia was significantly lower in patients who developed restenosis after 6 months (3 vs. 4.5 cells/μL, P=0.002) and it was negatively correlated with late-loss after 6 months (R=-0.42; P<0.03).

CONCLUSION

Use of GenousTM stents in NSTE-ACS is associated with lower restenosis rate than BMS at 6 months. There was no ST through 1 year. The number of circulating EPCs is inversely correlated with in-stent late loss (LL).

Urinary tract infections in the early posttransplant period after liver transplantation: etiologic agents and their susceptibility

BACKGROUND

We performed an analysis of etiologic agents for urinary tract infections in the early posttransplant period after orthotopic liver transplantation (OLT) in adult recipients.

PATIENTS AND METHODS

The study covered the first 4 weeks after OLT of 190 patients from September 2001 to the end of 2007. Immunosuppression consisted of steroids and tacrolimus. Antimicrobial prophylaxis was piperacillin/tazobactam, fluconazole, and SBD. Urine samples were cultured to identify microorganisms in accord with standard microbiological procedures and to test susceptibility using Clinical Laboratory and Standards Institute guidelines.

RESULTS

Urine specimens (n=539) examined from 185 recipients (97.4%) showed 210 microbial strains. The most common were Gram-negative (n=131; 62.4%) with predominance of Escherichia coli (28.2%), Enterobacter cloacae (19.1%), and Acinetobacter baumannii (11.4%). Extended-spectrum β- lactamases (ESBL(+)) strains were isolated in 38.5% of cases. Gram-positive bacteria comprised 28.6% (n=60): The most common strains were enterococci (85% including HLAR 80.4% and VRE 17.6%] and staphylococci 11.8% [MRSA/MRCNS; 100%]. There were 19 (9%) fungal strains.

CONCLUSIONS

In general, the identification in urine samples of multi-drug-resistant bacterial and fungal strains in patients after OLT such as ESBL(+) 38.5%; HLAR 80.4%; VRE 17.6%; and MRSA/MRCNS 100% requires better infection control.

Bacterial infections in the early period after liver transplantation: etiological agents and their susceptibility

BACKGROUND

The study comprises an analysis of bacterial infections in the early period after liver transplantation (LT) in adults.

MATERIAL/METHODS

Eighty-three patients were followed for four weeks after LT. Samples comprised mainly blood, urine, surgical-site specimens, sputum, and stool. Culture and identification of the isolated microorganisms was done in accordance with standard microbiological procedures. Susceptibility testing was carried out using CLSI guidelines. Statistical analysis was done with Medi-Stat.

RESULTS

In total, 913 samples from LT recipients were cultured. Of the 469 isolated strains, 331 (70.6%) were Gram-positive bacteria, 133 (28.4%) were Gram-negative bacteria, and 5 (1.0%) were yeast-like fungal strains. Of the 284 surgical-site isolates, 222 (78%) were Gram-positive and 61 (21.5%) were Gram-negative bacteria. Of the 99 blood culture isolates, 75 (75.8%) were Gram-positive and 22 (22.2%) of Gram-negative bacterial strains. Of the 73 urine samples, 46 (63.0%) were strains of Gram-negative, 25 (34.0%) of Gram-positive bacteria, and 2 (3.0%) fungal strains. In the 13 respiratory tract samples were 9 (69.0%) Gram-positive and 4 (31.0%) Gram-negative strains. In the 54 stool samples, 63.0% and 16.7% were C. difficile toxin- and culture-positive, respectively. In total, 138 strains of MRCNS, 10 of MRSA, 80 of HLAR, and 19 ESBL(+) were detected.

CONCLUSIONS

The isolation of MDR bacterial strains such as MRSA (52.6%), MRCNS (81.7%), HLAR (86.0%), and ESBL(+) Gram-negative rods (12.5%) from patients after LT indicates the need for strict adherence to infection control procedures.

[Application of real-time PCR and LightCycler system for investigating the presence of human herpesvirus 7 DNA]

Human herpesvirus 7 (HHV-7) is a beta-herpesvirus widely spread within a population and has been recognized as a potential pathogen in immunocompromised hosts. The goal of the study was development of real-time PCR assay for detection of human herpesvirus 7 DNA in clinical samples, using primers targeting a conserved region of the viral DNA major capside proteine gene and a specific TaqMan hydrolyzing probe. Sixty four plasma samples taken from a group of adult recipients of allogeneic HSCT, during detectable CMV viremia or neutropenic fever, were tested for the presence of viral DNA in the LightCycler system with method described above. HHV-7 DNA was detected in 40 specimens (62.5%). The conclusion is that developed TaqMan-based probes real-time PCR test is very reliable and valuable tool for detection of HHV-7 viremia in plasma samples. The high level of sensitivity and accuracy provided by the LightCycler instrument is favorable for the use of this method in the detection of human herpesvirus 7 DNA in clinical specimens.

[Frequency of detection of human herpesvirus type 6 DNA in patients of Public Independent Central Hospital in Warsaw in years 2003-2007]

Human herpesvirus 6 (HHV-6) has been recognized as a potential significant pathogen in haemopoietic stem cell transplant recipients. Different clinical manifestations have been described including fever, skin rash, bone marrow suppression and encephalitis. The aim of the study was to show frequency of presence of human herpesvirus type 6 DNA in patients of Public Independent Central Clinical Hospital in Warsaw in years 2003-2007. 1357 clinical samples taken from 71 a group of adult recipients of allogeneic HSCT were tested for the presence of HHV-6 DNA using the quantitative in-house real-time PCR assay. Positive results were obtained in 12.5% of all examinations made during described period and also in 35.2% of investigated patients. All of them developed fever of unknown origin, and over 50% had GvHD features. Nine individuals from this group died during detectable HHV-6 viremia.

Detection of Clostridium difficile in stool samples from patients in the early period after liver transplantation

OBJECTIVE

We examined the frequency of detection of Clostridium difficile (CD) toxins compared with the recovery of C. difficile in stool specimen cultures among orthotopic liver transplant (OLT) patients with nosocomial diarrhea in the early period.

MATERIALS AND METHODS

The study included stool samples obtained during the first 30 days after OLT in adults who were suspected of CD-associated diseases. The identification of cultured CD strains was performed by standard microbiological methods. The presence of CD toxins was assayed using a commercial immunoassay.

RESULTS

All patients were followed prospectively for CD infections from the date of OLT for the first 4 weeks after surgery. Among 54 samples, 16.7% were culture-positive for CD. CD toxins were tested on 54 samples, yielding 63% toxin-positive samples and 30% toxin- and culture-negative results. In the first week after OLT, samples from 19 patients were subjected to CD investigation. Among 19 samples positive for toxin, 52.6% of all samples were culture-negative. We analyzed 35 samples from the second to the fourth week after OLT in 31 recipients. Among 35 samples, 68.6% and 25.7% were positive for CD toxin and for culture, while 20% of samples were negative for toxin and culture.

CONCLUSION

In our study, 63% of samples were toxin-positive with 16.7% yielding growth of CD and 30% being negative for toxins and cultures.

Serratia marcescens isolated in 2005 from clinical specimens from patients with diminished immunity

Serratia marcescens is an important agent in hospital infections. The aim of this paper was to compare the resistance patterns of S. marcescens strains isolated during 1 year from patients of various wards of the Institute of Transplantology. The mechanisms of beta-lactam antibiotic resistance were of especial interest. We investigated the 81 strains of S. marcescens, isolated during 2005 from patients on 3 wards and 1 clinic of the Transplantation Institute. An unusually high resistance to most antibiotics was observed among S. marcescens strains. Extended spectrum beta-lactamases (ESBLs) were probably produced by 63.2% to 84.6% of strains, depending on the ward. Additionally, about 30% of them were probably derepressed AmpC producers. The patterns of resistance indicated that at least 2 resistant clones of S. marcescens spread among the patients. One of the clones demonstrated both ESBL and derepressed AmpC production and was susceptible only to carbapenems. The second, producing ESBL, was susceptible to piperacillin/tazobactam and carbapenems. All investigated strains were resistant to nitrofurantoin. Strains of the second group were rarely susceptible to other antibiotics: aminoglycosides, ciprofloxacin, cotrimoxazole, or fosfomycin.

Surgical site infections in liver recipients in the early posttransplantation period: etiological agents and susceptibility profiles

OBJECTIVE

This study evaluated the frequency of microbial isolates and their susceptibility profiles from cultures at the surgical site of 83 liver recipients in the early posttransplantation period.

PATIENTS AND METHODS

We prospectively collected microbiologic culture data on 83 adult patients undergoing orthotopic liver transplantation (OLT) using standard procedures and commercially available tests. Susceptibility of the strains to antibacterial agents was performed by the Clinical and Laboratory Standards Institute (CLSI) guidelines.

RESULTS

All patients were followed prospectively for the first 4 weeks after surgery. Among 284 microbial isolates from clinical surgical site samples in 80 liver recipients, cultures were positive in 110 samples. The most commonly isolated species were: Gram-positive cocci (n = 222 isolates, 78%) with dominance of methicillin-resistant coagulase-negative staphylococci (MRCNS; 42%) and high-level aminoglycoside-resistant enterococci (HLAR strains; 24.3%). Gram-negative bacteria were identified in 21.5% of positive cultures, including 30 strains (24%) from the Enterobacteriaceae family, with 13.3% of extended spectrum beta-lactamase producers [ESBL(+)]. Significant differences (P = .0012) were observed during the analysis of changes in the occurrence of Gram-positive bacteria isolated from the surgical site in the first week versus the second to the end of the fourth week.

CONCLUSION

Gram-positive bacteria predominated as 78% of isolates.

Clinical Glycopeptide-Resistant Enterococci Isolated From Patients After Solid Organ Transplantation

The aim of this study was to confirm the identification and resistance to vancomycin and teicoplanin of nosocomial enterococcal strains using molecular biology methods. Glycopeptide-resistant enterococci (GRE) strains were isolated from clinical specimens of hospitalized patients. Bacterial identification was performed in an automatic ATB Expression system (bioMérieux SA). Susceptibility to glycopeptides was determined by the disc diffusion method and Etest (AB BIODISK, Sweden). We performed polymerase chain reactions (PCR) for Enterococcus faecium and E. faecalis identification and van genes detection. Fifteen GRE strains were cultured over 2 years (2003-2004). Fourteen isolates were highly resistant to vancomycin (MIC range, 128->256 mg/L) and teicoplanin (MIC range, 32->256 mg/L). Twelve strains harbored van A gene (Van A phenotype). Seven isolates were identified as E. faecium and seven as E. faecalis by the multiplex-PCR method. One strain-E. casseliflavus-showed low resistance to vancomycin (MIC 8 mg/L) with retained susceptibility to teicoplanin (MIC 4 mg/L). It harbored the van C2/C3 gene and was identified as the Van C2/C3 phenotype. GRE strains were more often isolated from hospitalized patients in Poland. Constant monitoring by reliable microbiological methods has become necessary to prevent the spread of these strains in the hospital environment.

Enzymatic Variability of Candida krusei Isolates in a Course of Fungal Infection in a Liver Transplant Recipient

Transplant recipients are at high risk of fungal infections. The main site of fungal infections in patients undergoing liver transplantation is the abdominal cavity. One factor determining the pathogenicity of fungi is their ability to secrete hydrolytic enzymes. The aim of this study was to assess the enzymatic activity of Candida krusei, which caused an infection in a liver transplant recipient. The clinical specimens included swabs of throat, nose, and two drains, as well as bile, stool, and abdominal cavity aspirate. The yeast-like fungi isolated were identified by an ID 32 C test (bioMérieux) and their enzymatic activity assayed with the use of an API-ZYM test. Two biotypes of C. krusei were identified, depending on the source of the clinical specimen. The C. krusei isolates cultured from a throat swab, a nasal swab, and one of the drains secreted esterase lipase C8 (enzyme IV) and valine arylamidase (enzyme VII), in contrast to those isolated from the bile, abdominal cavity fluid, another drain, and stool. Characterization of two biotypes of C. krusei isolates cultured from different clinical samples from several infection sites indicated an ability of C. krusei to adapt to variable environmental conditions.

Sleep study in patients with overweight and obesity

Obstructive sleep apnea syndrome (OSAS) is a disorder characterized by repetitive collapse of the pharyngeal airway during sleep, which leads to oxygen desaturation, sleep fragmentation and daytime somnolence. Obesity is one of the most important risk factor for the development of OSAS. The exact mechanisms responsible for the relationship between obesity and OSAS are still unclear. The fat deposits in the pharynx region as well as the reduction in the lung volume have been considered as factors that might be responsible for the increase of the upper airway collapsibility. The aim of our study was to evaluate the correlation between the Body Mass Index (BMI) and sleep study parameters in overweight and obese patients suffering from breathing disturbances during sleep. We studied a group of 106 consecutive obese or overweight patients with a primary complaint of snoring or other breathing disturbances during sleep. In all cases, BMI and sleep studies (PolyMESAM) were examined. We evaluated relationship between the BMI and sleep study parameters such as Respiratory Disturbance Index (RDI), Apnea Index (AI), Desaturation Index (DI) and Average of Lowest Saturation (LSAT). The results showed the lack of significant statistical correlations between BMI and all the sleep parameters studied in the overweight patients and the statistical positive correlation between the BMI and RDI in the obese cases. We conclude that BMI determination may be considered as a simple, yet important predictor, of the OSAS in the group of obese patients.

Immunomodulatory activity and influence on mitotic divisions of N-benzoylphenylisoserinates of Lactarius sesquiterpenoid alcohols in vitro

Six N-benzoylphenylisoserinates of Lactarius sesquiterpenoid alcohols, which previously showed antiviral activities, were tested for their biological properties. Their influence on the mitotic division of the cells and on selected immunological parameters, e. g., T and B lymphocyte proliferation and synthesis of the cytokines: interleukin 2 (IL-2), tumour necrosis factor alpha (TNF-alpha) and interferon gamma (IFN-gamma) was assessed in vitro. All of the tested compounds significantly decreased the number of cell divisions. It appears that their influence on cellular divisions may be associated with anti-HSV activity. Moreover, one compound - isolactarorufin 8-epi-[N-benzoyl-(2' R,3' S)-3'-phenylisoserinate] significantly inhibited T lymphocyte proliferation and the synthesis of all tested cytokines.

Infection by a Dimorphic Fungus Sporothrix schenckii in an Immunocompromised Patient

Infections caused by dimorphic fungi, rarely observed in a temperate climate, may cause chronic infections in immunocompromised patients. We describe a case of sporotrichosis in a 50-year-old woman, who underwent mastectomy due to breast carcinoma, followed by radiation and chemotherapy. She developed skin lesions, localized along the lymphatics. Discharge samples repeatedly yielded a characteristic growth of the dimorphic fungus Sporothrix schenckii. The isolate was resistant to all commonly used antifungal agents, except for itraconazole. Therapy with this antifungal agent resulted in disappearance of the clinical symptoms.

Epidemiology and susceptibility to antifungal agents of fungi isolated from clinical specimens from patients hospitalized in the Department of General and Liver Surgery of the Medical University of Warsaw

The aim of this study was to analyze the type and antibiotic susceptibility of fungi isolated from clinical specimens obtained from patients hospitalized in the Department of General, Transplantation and Liver Surgery of the Medical University of Warsaw between 2000 to 2002. Among the 326 clinical samples found to be positive on mycological culture, 356 strains were cultured. The most common isolates were yeastlike fungi of the genus Candida 334 (93.8%), while others included 33 other types (6.2%). The most commonly isolated species were Candida albicans, 194 strains (54.5%); Candida glabrata, 68 (19.1%); Candida krusei, 20 (5.6%); Candida inconspicua, 20 (5.6%); Candida tropicalis, 17 (4.8%); and Candida parapsilosis, 6 (1.7%). Upon testing for susceptibility to antifungal agents, all strains were susceptible to amphotericin B, while 43.8% of strains showed intermediate susceptibility to fluconazole and 25.3%, to itraconazole. Control of fungal infections in transplant and in immunocompromised patients is hindered by the low percentage of strains susceptible to commonly used antifungal agents, particularly of the triazole group.

[Statistical analysis of decision making in the treatment in two-vessel coronary artery disease]

The objective of this paper was to analyze the choice of treatment in two-vessel coronary artery disease and to evaluate the effectiveness of the chosen treatment. The data of sixty-five patients with two-vessel coronary artery disease was analyzed. Two-vessel coronary artery disease was recognized when critical stenoses were present in two arteries with a diameter no less than 2 mm across. Patients who had a CABG were excluded. Patients were divided into three groups according to their treatment: those treated with CABG (29 patients), those treated with coronary angioplasty (20 patients), and those treated conservatively (16 patients). The mean follow-up was 29.3 months (12-48 mo). There were two groups of data collected. The first group consisted of data which might have influenced the decision-making and state of the patients after they had been introduced to the selected treatment. The second group consisted of data necessary to evaluate the state of the patients during the follow-up period. The statistical analysis was divided into three stages. In the first stage, clinical data connected to the selected treatments was studied. In the second, the effects of the chosen treatment were examined. During the third stage of analysis, variables which influenced the effectiveness of the specific treatment were evaluated. Decision-making in patients with two-vessel coronary artery disease depended on the co-existence of hypertension, diabetes, lower-limb ischemia and earlier-performed coronary angioplasty. The only statistically important angiographic feature was the condition of the proximal LAD. Objective improvements in the states of patients (evaluated by exercise tests) were frequently connected to CABG treatment. Subjective improvements in the states of patients were more often connected to conservative treatment. Elevated cholesterol levels were connected to the progression of the disease both in those treated conservatively and interventionally.

[Results of promoting fibrinolytic therapy for myocardial infarction in the Katowice Province from 1996-1998]

The action promoting fibrinolytic treatment of myocardial infarction and questionnaire-based follow up of the results was carried out over a four million people area. 5262 questionnaires, in which physicians answered a number of questions, were received. The poll revealed that 79% of patients received fibrinolytic treatment. The authors estimate the overall percent of patients, treated in hospital wards, at about 27.7%. The mortality rate in the group of patients, who received streptokinase, was 8.61% and in the group of patients, who did not receive the treatment, was 16.28%. The signs of reperfusion were present in 60.38% of patients. The authors conclude that the increase in the number of patients administered fibrinolytic treatment should be aimed, and the results obtained in this group of patients come close to published data. Exercise tests are performed in too small number of myocardial infarction patients and only little proportion of them undergoes further coronary angiography.

[Troponin T--is it a marker of restenosis after transluminal percutaneous angioplasty in unstable angina patients?]

Troponin T (TpT) is a protein implicated in skeletal muscle contractions, including myocardium. It was shown that the presence of troponin TpT in unstable angina patients' blood is associated with poor prognosis. In the present study amongst 25 patients with unstable angina 12 were found to have TpT present in their blood. TpT concentration was higher in patients with III and IVo CCS symptoms in comparison with class I and IIo CCS symptoms: 0.207 +/- 0.275 and 0.144 +/- 0.186 ng/mL respectively (p = 0.053; nonparametric Kolmogorow-Smirnov test). Patients were subjected to percutaneous transluminal coronary angioplasty (PTCA). After 3 months of follow up 17 patients (the rest of them dropped out) were assigned to two groups: A (n = 8)--without and B (n = 9)--with clinical and electrocardiographic signs of restenosis. Retrospective analysis revealed the presence of TpT before PTCA in 6 group B patients and 2 group A patients. Relative risk of stenocardia recurrence was calculated as 2.25. TpT was present in the blood of 20 patients in the first 24 hours after PTCA, and group B patients had higher mean TpT concentration; that could result from reperfusion of more ischaemic myocardium. It seems that the presence of TpT in unstable angina patients' blood may be an important factor characterizing patients with more serious prognosis.