Introduction: Since December 2019, the humanity is constantly under affection of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite global dissemination, neither the treatment or the specific predictive factors have been found or strictly defined yet. Aim: Aim of this study was to assess the long-term (1 year) predictive value of high-sensitive Troponin T (hsTnT) in COVID-19 affected, hospitalised patients. Methods: Between 5 March 2020 and 31 March 2020, 87 consecutive patients hospitalised at University Clinical Centre of the Republic of Srpska due to SARS-CoV2caused pneumonia, in whom hsTnT was measured, were included. The Kaplan-Meier analysis was used to assess differences in all-cause mortality between the groups. Independent predictors of all-cause mortality were identified through univariateand multivariate Cox regression analysis. Results: Compared with patients who had normal hsTnT levels, patients with raised hsTnT were significantly older (70.7 ± 13.23 vs 49 ± 15.29; p < 0.001). Glucose values were significantly increased in patients with raised hsTnT (9.29 ± 5.14 vs 6.76 ± 2.46 [4.1-5.9] mmol/L; p = 0.005), as well as serum creatinine (179.07 ± 225.58 vs 87.53 ± 18.16 μmol/L; p = 0.01), hsTnT (187.43 ± 387.29 vs 7.58 ± 3.40 pg/mL; p = 0.003), D-dimer (5.94 ± 13.78 vs 1.04 ± 1.26 [0-0.50] mg/L; p = 0.024), C-reactive protein (125.92 ± 116.82 vs 69.97 ± 73.09) [< 5.0] mg/L; p = 0.009) and calcium (1.32 ± 0.46 vs 1.03 ± 0.173 [2.20-2.65] mmol/L; p = 0.001). Kaplan-Meier analysis revealed that the number of all-cause deaths at 1 year was 19 of whom 18 were presented with elevated hsTnT (log-rank p < 0.001). When univariate Cox regression was applied, multiple predictors of all-cause mortality have been identified ie age, haemoglobin, haematocrit, urea, CK-MB as well as hsTnT. In a multiple regression model, hsTnT remained an independent predictor of poor outcome. Conclusion: Results from this study showed that the value of hsTnT during hospitalisation is possibly associated with long-term poor outcome of COVID-19 patients. Therefore, hsTnT may appear as a surrogate factor to differentiate between patients at high risk who need more intensive follow-ups.

1Medicinski fakultet, Katedra porodične medicine, Univerzitet u Banjaluci, 2Medicinski fakultet, Katedra porodične medicine, Univerzitet u Sarajevu, 3Medicinski fakultet, Foča, Katedra porodične medicine, Univerzitet u Istočnom Sarajevu, 4Dom zdravlja, Banjaluka, Bosna i Hercegovina Obrazac propisivanja benzodiazepina ambulantnim pacijentima koji nemaju dijagnozu mentalnih bolesti Retrospektivna studija

Freedom formula (FF) was derived very recently to assist in decision making by Heart Team in patients (Pts) with diabetes (DM) who are in need for myocardial revascularization (Percutaneous Coronary Intervention or Coronary artery bypass grafting (CABG)) due to complex ischemic Heart disease (but without left main steam disease (LM)). In external validation moderate C statistics values were obtained. To validate FF predictive value in Pts with DM and more complex patients (three vessel (3VD) and/or LM as well lower left ventricular ejection fraction (LVEF)) than in FREEDOM population. From our prospective data base of 2455 consecutive pts who had the first isolated CABG in the period 01/2012–12/2014 with 3VD and/or LM with 100% follow up of 4 years All-cause Mortality (Mt) we retrieved 925 pts with DM. DM was present in 925 Pts (Mt: 12.6%). On insulin were 318 (34.3%; Mt 14.5%). We analysed the predicative value of FF in the whole group (925) of pts with DM as well as in subgroups with LM (294) and without LM (631; most similar to original Freedom population), separately. Characteristics of pts, Freedom formula, predicating power by C Statistics, Calibration plots and Brier scores are presented in Picture 1. Our external validation of FF was almost identical as previous published one. Furthermore, the FF may be of value even in pts with LM disease and other vessels involved. Of note our pts as seen by combined LVEF, ClCr and LM were sicker than pts in FREEDOM. Picture 1 Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of education, science and technological development, Republic of Serbia

Controversies exist how to predict medium term mortality (Mt) in diabetics (DM) with 3 vessel (3VD) and/or left main (LM) disease undergoing myocardial revascularization ranging from Syntax Score II (SSII) where DM was not predicative variable up to FREEDOM formula which was derived, just from population with DM (without LM), having DM patients (Pts) requirement of insulin as one of predicative variable. To compare predicative power of SSII, FREEDOM and formula developed in our institution in Pts post first isolated CABG with 3VD and/or LM with DM. From our prospective data base of 2455 consecutive pts who had the first isolated CABG in the period 01/2012–12/2014 with complex Ischemic Heart Disease with 100% follow up of 4 years all-cause Mt we created by random sampling Training (1321; Mt:10.4%; DM 511; Mt:13.3%) and Validation (1134; Mt:10.0%; DM 414; Mt: 11.8%) sets. After deriving predicative formula (Cox regression) from training population we validated FREEDOM, SSII and Our Formula in 414 pts with DM from the Validation set. Characteristics of pts, our formula, predicating power by C Statistics, Calibration plots and Brier scores are presented in Picture 1. FREEDOM formula designed just for DM pts with complex Ischemic Heart Disease without LM had the smallest standard error in the estimate, but moderate C statistics as Syntax Score II and our formula which may be used for pts with and without DM and 3VD and/or LM. Picture 1 Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of education, science and technology development, Republic of Serbia

Introduction Results of currently available trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Current guidelines do not recommend PCI in patients with diabetes and a SYNTAX score ≥ 23. Aim To compare all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics. Material and methods The study group comprised consecutive patients with three-vessel CAD and/or unprotected left main CAD (≥ 50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG. Results Out of 342 diabetics, 177 patients underwent PCI and 165 patients were referred for CABG. The incidence of all-cause death was different between diabetics treated with PCI or CABG at 4 years (16/177, 9.0% vs. 26/165, 15.8%, respectively, p = 0.03). The difference was not evident in non-diabetics (PCI: 41/450, 9.1% vs. CABG: 19/249, 7.6%, p = 0.173). In diabetics, there was a higher incidence of all-cause mortality in PCI patients with intermediate-high (≥ 23) SYNTAX scores compared with those with low (0–22) SYNTAX scores (10/56, 17.9% vs. 6/121, 5.0%, respectively, p < 0.01). On the other hand, diabetics who underwent CABG showed similar mortality rates irrespective of the SYNTAX scores (SYNTAX 0–22: 3/29, 10.3%; SYNTAX ≥ 23: 23/136, 11.9%, p = 0.46). In the subgroup analysis, there was no interaction according to presence or absence of left main CAD (p for interaction = 0.12) as well as according to diabetes status (p for interaction = 0.38), whereas gender and SYNTAX scores were differentiators between PCI and CABG with a p for interaction < 0.1. Conclusions Our analysis supports recent evidence that diabetes is not a differentiator between PCI and CABG.

Aim To examine the prevalence of undiagnosed depression among primary care elderly patients in the entity of the Republic of Srpska (Bosnia and Herzegovina) as well as the sociodemographic and clinical risk factors associated with depression. Methods A cross-sectional study was conducted between April and June 2019 in nine towns of the Republic of Srpska. The study sample included 1,198 primary care patients older than 65 years of age. Research instruments included a sociodemographic questionnaire and Geriatric Depression Scale - Short Form (GDS-SF). Results Positive screening test (GDS-SF score > 5), which indicates depression was found in 484 (40.4%) participants. Multivariate regression analysis showed that lower education levels [OR = 1.565, 95% CI (1.13-2.17)], divorced and widowed [OR = 1.366, 95% CI (1.16-1.62)], poor financial situation [OR = 1.690 , 95% CI (1.25-2.29)], non-home residents [OR = 2.200, 95% CI (1.41- 3.44)], non-hobby patients [OR = 2.115, 95% CI (1.54-2.91) ], non-friends [OR = 3.881, 95% CI (2.70-5.57)], patients suffering from chronic pain [OR = 2.414, 95% CI (1.72-3.39)], patients with daily life limitation activities [OR = 1.415, 95% CI (1.03-1.95)], patients with three or more chronic diseases [OR = 1.593, 95% CI (1.12-2.27)], patients using five or more drugs [OR = 1.425. 95% CI (1.00-2.03)], and patients with history of previous depression [OR = 2.858, 95% CI (1.94-4.21)] were at higher risk for depression. Conclusion The prevalence of undiagnosed depression in the elderly in Republic of Srpska is high. Future strategies are needed to strengthen screening of geriatric depression in primary health care.

Results of currently available randomized trials have shown divergent outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The 2018 ESC/EACTS guidelines on myocardial revascularization do not recommend PCI in patients with diabetes and SYNTAX score ≥23. We aimed to compare the all-cause 4-year mortality after revascularization for complex coronary artery disease (CAD) in diabetics. The study group comprised consecutive diabetics with angiographically proven three-vessel CAD (≥50% diameter stenosis) and/or unprotected left main CAD (≥50% diameter stenosis) without major hemodynamic instability, who were treated in two institutions with PCI or referred for CABG between 2008 and 2010. All-cause mortality was ascertained by telephone contacts and/or from Mortality Registries. Using the hospital data system, 5145 patients were screened and 4803 elected not to follow the inclusion criteria. Out of 342 included patients, 177 patients underwent PCI and 165 patients were referred for CABG. Patients with whom CABG was performed were significantly older (64.69±8.8 vs. 62.6±9.4, p=0.03), more often on insulin treatment (91/165=55.2% vs. 26/177=14.7%, p<0.01), had more complex anatomical characteristics i.e. higher SYNTAX scores (32.5 IQR (15) vs. 18.0 IQR (15), p<0.01) and with left main stenosis (70/165=42.4% vs. 7/177=4.0%, p<0.01), compared to patients treated with PCI. The cumulative incidence rates of all-cause death were significantly different between PCI and CABG at 4 years (16/177=9.0% vs. 26/165=15.7%, respectively, log-rank p=0.03). There was a higher incidence of all-cause mortality in PCI patients with intermediate (23–32) and high (≥33) SYNTAX scores compared with those with low (0–22) SYNTAX scores (6/32=18.8% vs. 6/124=4.8%, log-rank p=0.01; 4/21=19.1% vs. 6/124=4.8%, log-rank p=0.02, respectively). On the contrary, patients who underwent CABG displayed similar morality rates irrespective of the SYNTAX scores (SYNTAX 0–22: 5/34=14.7%; SYNTAX 23–32: 9/54=16.7%; SYNTAX ≥33: 12/77=15.6%; log-rank p=0.9). Finally, when compared with CABG, more deaths were observed following PCI with intermediate and high SYNTAX scores (intermediate SYNTAX (23–32) PCI: 6/32=18.8% vs. CABG: 26/165=15.8%, log-rank p=0.94; high SYNTAX (≥33) PCI: 4/21=19.1% vs. CABG 26/165=15.8%, log-rank p=0.87). During a 4-year follow-up, CABG in comparison with PCI was associated with a higher rate of all-cause death, which can be accounted for by older age and comorbidities. In diabetics, our analysis is suggestive that PCI probably should be avoided in patients with SYNTAX ≥23, which is in concordance with the most recent guidelines. Individualized risk assessment as well as quantification of CAD by SYNTAX score remains essential in choosing appropriate revascularization method in patients with diabetes and complex CAD. None

OBJECTIVE To investigate the level and causes of stress and the risk of onset of burnout syndrome among physicians employed at the Primary Health Care Centre, Banja Luka. SUBJECTS AND METHODS Between March 1, 2018, and May 31, 2018 all physicians from the Primary Health Care Centre, Banja Luka were offered the following questionnaires to fill in: a socio-demographic questionnaire, a questionnaire for self-assessment of the level of stress and the Maslach Burnout Inventory for assessment of the risk of burnout syndrome. RESULTS Out of 211 physicians, 85.8% were female. A high level of stress was found in 77.7% of the subjects. Older doctors had higher levels of emotional exhaustion compared to younger doctors with a shorter length of service (r=0.236, P=0.01). Emotional exhaustion was significantly correlated with a high level of depersonalization, a low level of personal accomplishment and a high level of stress (r=0.380, r=-0.174 and r=0.574, P=0.01, P=0.04 and P<0.01, respectively). Depersonalization correlated with a low level of personal accomplishment and stress (r=-0.347 and r=0.283, P<0.01 and P=0.01, respectively), while the level of personal accomplishment was in a negative correlation with stress (r=-0.281, P=0.01). A high stress level was associated with a high degree of emotional exhaustion (OR 56.543; 95% CI 11.35-213.09; P<0.001) as well as lack of personal accomplishment (OR 0.155; 95% CI 0.04-0.50; P=0.003). CONCLUSION A high level of stress was associated with older age, female gender, as well as with a high degree of emotional exhaustion and a lack of personal accomplishment. Preventive measures are warranted.

Introduction. Burnout syndrome is a common problem among healthcare workers. The aim of the study was to investigate the level of stress, components of burnout syndrome and the most common causes of workplace stress among the physicians working in the Primary Health Care Center Banja Luka, after which the obtained results concerning family physicians and the physicians of other specialties were compared. Methods. The observational study was conducted by interviewing physicians during the period March to May 2018. All employed physicians were provided with the following questionnaires: The socio-demographic questionnaire, the questionnaire for self-assessment of the level of stress, the questionnaire about the most frequent causes of stress at work and the Maslach Burnout Inventory. Results. The study included 211 physicians, out of a total of 246 physicians (127 family physicians and 84 physicians of other specialties) working in the Primary Health Care Center Banja Luka. There was a significantly higher level of stress (p = 0.011), emotional exhaustion (p < 0.001) and depersonalization (p < 0.001) among family physicians compared to the physicians of other specialties. There was a significant difference in the presence of all causes of stress among family physicians, except the stress concerning the patients requiring emergency care. The multivariate logistic regression analysis found that stress was significantly associated with emotional exhaustion in both groups and with personal accomplishment in family physicians. In family physicians, there was a significant association between a high level of depersonalization and personal accomplishment. In physicians of other specialties significant association was found between education and emotional exhaustion as well as personal accomplishment, and between female gender and high level of depersonalization. Conclusion. The level of stress and the burnout syndrome were considerably more present in family physicians compared to physicians of other specialties.

Background: Right ventricular dysfunction (RVD) is a well-known predictor of early death in patients with acute pulmonary embolism and thus early identification of RVD is critical in the risk stratification or management of acute pulmonary embolism (PE). Aim of this study was to investigate a useful role of cardiac biomarker NTproBNP for predicting echocardiographic right ventricular dysfunction in patients with acute pulmonary embolism. Methods: A retrospective analysis was performed in 195 consecutive adult patients with pulmonary embolism from the Serbian University Pulmonary Embolism Registry (SUPER 2015-2019) created by six university clinics: Military Medical Academy (Belgrade), Institute of Pulmonary Diseases (Sremska Kamenica), Clinical Center (Nis), University Clinic Zvezdara, Clinical Center (Kragujevac) and University Clinical Centre of Republic of Srpska (Banja Luka). All patients were divided into RVD group and non-RVD group according to whether there was increase in systolic pressure in right ventricle (>40mmHg) on echocardiography. Odds ratios (OR) and 95% confidence intervals (CI) assessing the risk factors for RVD were assessed by multivariate logistic regression. The ability of the NT proBNP in predicting the RVD was described by the Receiving Operating Curves analysis. Results: The mean age is a strong predictor of echocardiographic RVD in patients with PE. The simple measurements of this cardiac biomarker could be helpful in clinical decision-making or risk stratification in patients with PE.

Tamara Kovačević-Preradović1,2, Bojan Stanetić1,2, Ljiljana Kos1,2, Vlastimir Vlatković2,3 1Department of Cardiology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina, 2Medical School, University of Banja Luka, Banja Luka, Bosnia and Herzegovina, 3Department of Nephrology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina; Case presentation