Month: October 2020

• I am Cholkov Vancho from Skopje and I came to the Zan Mitrev Clinic about a month ago. Before coming here, I had chest pain, a cold, and I was hospitalized in one of the state hospitals. After a few days in the state hospital, I realized that my condition was not improving and I was feeling even worse. It was clear to me that I had to find another solution and go to a private hospital. I told my wife that I wanted to be transferred to the Zan Mitrev Clinic and I was immediately brought there – this is how Mr. Cholkov began his story.

He was brought to our clinic in a serious condition and Covid 19-positive. Dr. Dragica Vezenkova Vuchkova, anesthesiologist and specialist in intensive care, talks about how his treatment started and what was its course.

• The patient Vancho Cholkov came to our clinic at night in a severe, critical condition with peripheral saturation 40 and a diagnosis of Covid 19 pneumonia. We immediately took him to the intensive care unit at the Covid 19 Center and started the process of hemofiltration by CytoSorb and Oxyris filter. All laboratory parameters indicated this viral condition. The patient was also immediately placed on non-invasive mechanical ventilation with a Cipap mask, which he tolerated well. However, due to his difficult general condition proved by the serious chest X-ray finding, even with the Cipap mask he achieved a saturation of 70 to 75 – explains Dr. Vuchkova.

She adds that it is truly a wonder how the patient tolerated that saturation and how he performed all physical and recovery activities.

After the fourth day, a slight improvement in the patient’s clinical picture was observed. Uncle Vancho, as we called him during his stay in our hospital, continued the treatment in a good mood. He received 3 consecutive cycles of hemofiltration, and after 22 days of intensive care and treatment he went home Covid 19-negative in stable and good condition.

However, Uncle Vancho returned to our clinic after only two weeks, but this time to solve the problem with the blood flow in his legs. He immediately underwent a leg peripheral bypass, and after a short recovery, he went home.

We wish Uncle Vancho good health and a successful complete recovery.

Infection with Covid-19 is a major health problem because it affects not only the lungs but also other organs such as the heart muscle. The virus has been shown to cause inflammation of the heart muscle, or myocarditis.

It is not yet clear whether Covid-19 causes myocarditis more frequently and whether this myocarditis has a more severe clinical presentation than the myocarditis caused by other viruses. The virus triggers an immune response in the body in an unconventional way. Survivors may be at increased risk of heart muscle inflammation. The heart is prone to inflammation from Covid-19 because of the angiotensin-converting enzyme 2 (ACE2) receptor found on the surface of heart muscle cells to which the virus binds. For this reason, several studies have been conducted with patients who had recovered from Covid-19 several months earlier and had a mild to moderate clinical presentation.

Magnetic resonance imaging (MRI) scan of the heart was performed, as the most accurate non-invasive technique for diagnosing inflammation of the heart muscle. The MRI scans showed heart involvement in 78 out of 100 patients. It is interesting to note that 60 out of 78 patients showed signs of acute inflammation 71 days after their infection with Covid-19. The study concludes that even a mild course of Covid-19 in relatively healthy people can leave a mark on the heart.

Another study examines competitive athletes. 4 out of 26 athletes from Ohio State University, USA, who recovered from Covid-19 had myocarditis.

Myocarditis can lead to cardiac arrhythmia, sudden death (during intense training), and heart failure. Therefore, cardiac examination, echocardiography, and cardiac magnetic resonance imaging are recommended 3 months after infection with Covid-19.

The recommendations of the European Society of Cardiology for patients recovered from myocarditis are to avoid strenuous physical activity for 3-6 months.

In the future, a frequent question of cardiologists will be whether you have been infected with the Covid-19 virus.

The last 8 months of life in a pandemic caused by the Coronavirus, has greatly changed our normal life and introduced new rules.

For better control of the pandemic and for your own health, taking into account all possible consequences of the Coronavirus, we recommend that you wear protective masks everywhere, and wash your hands frequently.

In addition, if you have recovered from Covid-19 infection, we recommend at least one cardiac examination, regardless of your age or the severity of your clinical presentation.

Early diagnosis of myocarditis can prevent the development of serious complications.

* Myocarditis finding using cardiac magnetic resonance (CMR) imaging

Dr. Milka Klincheva

Cardiologist

Pregnancy, breast self-exam, menopause and related osteoporosis, prevention of cervical cancer, infertility, are just some of the topics covered by the phrase “female health”. However, talking about women’s health is much more than determining a high-risk or non-risk pregnancy, infertility, breast cancer, an urgent need for a mastectomy, a hysterectomy, etc.

Women’s health is more than that, not because of some presumed (and by the way, often infertile) “political correctness” for the needs of the public, but because neither health nor women are homogeneous terms outside the biological discourse, and even in it, not entirely because of the functional nature of health. This is necessary to emphasize because October is dedicated to women’s health and requires a consideration that covers, but also transcends the range of examples related to the female reproductive system.

Namely, it is quite meaningful and necessary to talk about challenges that affect exclusively women in different periods of life, contexts (work, home, travel), degrees and cultures (policies that exist to protect vulnerable categories, tradition and stereotypes, family values etc.), but their health obviously goes beyond the above-mentioned spectrum by simply asking in what context, with what family and social dynamics, or with what social and personal capacity we see the woman.

Health, for us humans, is above all an experience, or more precisely, a meaningful experience. It is this experience that today is influentially standardized as a state where health is defined positively (not only as the absence of disease, but as a well-being),  holistically or multidimensionally (as a complete well-being that necessarily includes more parameters through physical, mental and social health). This change in the understanding of the term health has very specific, temporal-historical and political roots, which we have no room to address here (we will be silent about the concept of ‘woman’, because it remains a secret), but one benefit is the emphasized awareness of the importance of the personal and emotional-motivational processes in the health dynamics of each individual, and the irreplaceability of social support, cultural identity, context and social challenges that often place the clinical picture in the categories “healthy / sick”.

The opposite of this expanded concept of health is the possibility of pathologisation of all suboptimal conditions, and in part unreality, because “it finds most of us unhealthy most of the time” (Smith, 2008). It seems that we are called not only upon health, but upon multidimensional “perfection” too. But upon what kind, what for or more precisely for whom? The today’s almost ubiquitous narcissistic culture burdened by likability (or, if you will, “likeholism”) tends to normalize and standardize a kind of measurable and public perfection of unrelated or less and less unrelated individuals. Standards are in fact a group phenomenon, which has a powerful regulatory function not only in the individual’s  behavior, but also in the dynamics of occurrence, development and prognosis of health problems. Fortunately, man does not cease to be a community being simply because he lives in such a social climate, but it is necessary to distinguish the “cockle from the grain” – the cockle of sterile perfection, from the grain of creative love for the other as the greatest virtue. If we are a bit perfect, then it is because of the other, through the possibility for giving and, equally important, gratitude.

Giving and gratitude, when both are expressions of the most fundamental human indicator – free will – are in fact the fullness of a healthy woman or man (even when one or the other is sometimes feared). And how would you talk about one without the other? Therefore, no matter how much they are imposed on us in the spirit of the (neo)liberal ideology, days or months dedicated to cluster-covered topics, we are obliged to think about them from the perspective of what connects us and not only intra- and inter-gender, or intra- and inter-culturally, nationally, etc., but as individuals – health as self-giving is the real free space, where our action actually ennobles us. There are numerous examples that support this claim – of the more risky ones (saving the life of a stranger, a parent who donates a kidney for the life of their child) to the less risky ones, and no less important (non-judgment, meek word, singing a lullaby, or a handshake that speaks louder than any word). Living in a time when only brief information holds people’s attention, health today is each of our relationships, which through dedication will in time grow from a seed into a tree on whose branches the birds nest, a space where the other is valued for what he/she is.

May the month dedicated to women’s health be a reminder of what life actually shows us again – by seeking, we lose freedom, and with it love and joy. By giving, we find love and joy and through it we grow creatively even when we suffer because of the losses or unexpected diseases. We must not forget that despite the longer lifespan, cardiovascular diseases are the leading cause of death in women, unipolar depression affects women twice as often as men, female health workers make up 70% of the global workforce, and half their contribution to health is in the form of unpaid care, or that 1 in 3 women worldwide experiences physical or sexual violence, a fact that certainly has a profound effect on woman’s physical, sexual, reproductive and mental health. And facts, like deeds, always speak louder than words.

Docent  Kristina Egumenovska, MD
Psychologist-psychotherapist

On 22.09.2020, Zan Mitrev Clinic received a new publication on topic “Early Initiation of Extracorporeal Blood Purification Using the AN69ST (oXiris®) Hemofilter as a Treatment Modality for COVID-19 Patients: a Single-Centre Case Series.

This is our original work and the first publication in the Republic of North Macedonia when it comes to COVID – 19, and it was published in the prestigious Brazilian journal of cardiovascular surgery.

The team that worked on this publication is composed of experienced specialist doctors (cardiologists, anesthesiologists, microbiologists, transfusiologists) from the Zan Mitrev Clinic, led by Petar Ugurov, MD.

Petar Ugurov, MD answered several questions related to this research conducted in our clinic and the importance of its application, especially when it comes to patients’ safety, health and fast and safe recovery.

What was the main reason for starting research in this field and what makes this study so specific and significant?

Petar Ugurov, MD – The main reason for our research work is the SARS-CoV 2 virus itself, a virus that has become a challenge for the whole world.

We already know that COVID-19 is a disease caused by SARS-CoV-2, a virus of the Coronavirus family, which was first discovered in China in December 2019.

Before talking about this study, I would like to explain once again how the virus itself leads to deterioration of the general health condition in patients with SARS – CoV2 virus.

The respiratory dysfunction in COVID-19 patients is associated with changes in the respiration mechanics. Decreased mobility of the diaphragm and chest, decreased contraction of the respiratory muscles, and decreased motor activity of the patient may occur. This leads to impaired pulmonary ventilation and gas exchange.

When COVID-19 patients start coughing and have a fever, it is a sign that the infection has reached the respiratory system.

The protective layer of these respiratory organs is damaged, leading to inflammation, and even the slightest amount of dust can cause coughing.

– What makes this study unique and important is that we are the only clinic in the country and a rare one in the region that managed to show how to prevent the progressive deterioration of the general health condition with early initiation of extracorporeal blood purification in combination with systemic heparinization and respiratory support through a specially designed treatment protocol for SARS CoV2 patients.

How did you come up with the idea to start this study?

Petar Ugurov, MD – The study we started to work on and the very idea of this study is based on our previous experiences and work with patients with elevated inflammatory markers, as well as patients in septic shock.

The main challenge that we posed to ourselves is how to prevent the progressive deterioration of the general health condition of SARS – CoV-2 patients.

• We based the overall treatment of COVID-19 patients on the fact that if we have control over the inflammatory markers, then we could have control of the general patient condition, as well as the cytokine storm.

Can you tell us more about the study?

Petar Ugurov, MD – Our study included a group of 15 patients positive for SARS – CoV-2 virus. The continuous monitoring of the level of inflammatory markers, cytokines, and differential blood counts along with D-dimers, LDH, and ferritin, is a powerful predictor of when to initiate haemofiltration as part of the treatment in Covid-19 patients.

Treatment consisted of early initiation of extracorporeal blood purification using the AN69ST (oXiris®) Hemofilter, systemic heparinization, and respiratory therapy.

During this period, we became quite interesting to the general population with the haemofiltration we use and I would like to briefly explain how to use these filters and their function.

The filter we use is oXiris®, which uses a modified AN69ST membrane and which has an affinity for both endotoxins and cytokines. This filter has a three times bigger adsorption power for endotoxins and cytokines.

Additionally, the oXiris set is authorized by the US Food and Drug Administration to treat patients with Sars – CoV2 virus.

• If we go back to our beginnings and to what I mentioned earlier, i.e., how we came up with the idea to start treating patients this way, we will understand that this is actually the way we established control over the inflammatory markers of the cytokine storm.

There has been a lot of talk about the cytokine storm during this period. Can you explain to us what a cytokine storm is and what worries us most about this condition?

Petar Ugurov, MD – Cytokine storm syndrome refers to over-release of cytokines in response to external stimuli and is a major cause of acute respiratory distress syndrome as well as multiorgan failure.

When there is an increased cytokine level, such as of TNF-α, IL-6, IL-1 and IFN, it can cause pathological reactions such as diffuse damage to the alveoli, formation of the so-called transparent membrane and pulmonary fibrosis.

Circulating cytokines can cause widespread endothelial dysfunction with disseminated intravascular coagulation (DIC) and multiorgan failure.

What might be the conclusion of this study and why is it so specific and important?

Petar Ugurov, MD – From the study itself, it can be concluded that early initiation of blood purification using an oXiris® haemofilter may be an effective way to prevent abnormal levels of inflammatory markers in COVID-19 patients.

Also, the continuous monitoring of the vital parameters, biochemical, immune markers as well as coagulation factors and X-rays gives us the opportunity to monitor the severity of the disease and allows us to adjust therapy.

The combination of systemic heparin and extracorporeal blood purification using cytokine-absorbing haemofilters can reduce hyperinflammation, prevent coagulopathy, and support clinical recovery.