Echocardiographic epicardial fat thickness and neutrophil to lymphocyte ratio are novel inflammatory predictors of cerebral ischemic stroke

Effect of the Xanthine Oxidase Inhibitor, Febuxostat, on WBC Count in Asymptomatic Hyperuricemia: Subanalysis of the Randomized PRIZE Study

AIMS

The anti-inflammatory effects of the xanthine oxidase inhibitor, febuxostat, a urate-lowering agent, have been reported in animal studies. However, the anti-inflammatory effects of urate-lowering therapy and its associated cardiovascular protective effects have not been fully determined in actual clinical practice. This study aimed to investigate the effect of febuxostat on white blood cell (WBC) count in patients with asymptomatic hyperuricemia and to assess for potential correlations between changes in WBC count and inflammatory biomarkers and atherosclerosis in this patient population.

METHODS

This was a post hoc subanalysis of the PRIZE study, a multicenter, prospective, randomized, open-label clinical trial. In the PRIZE study, asymptomatic hyperuricemia patients were randomized to febuxostat group or control group with non-pharmacological therapy and evaluated the effect on vascular. The primary endpoints of this study were the assessment of the time course of WBC count over 24 months and its changes from baseline. Correlations of WBC count with high-sensitivity C-reactive protein (hs-CRP) and mean common carotid artery (CCA)-IMT were also exploratorily examined in the febuxostat group.

RESULTS

A total of 444 patients (febuxostat group, n=223; control group, n=221) with WBC measurements available at baseline and at least one of the follow-up time points of 12 or 24 months, were enrolled. Febuxostat modestly, but significantly, reduced WBC counts at 12 and 24 months compared with the baseline levels (P=0.002 and P=0.026, respectively). Notably, the WBC count in the febuxostat group at 12 and 24 months was significantly lower than that in the control group (P=0.007 and P=0.023, respectively). The changes in WBC count were associated with those of hs-CRP (P=0.038), but not with CCA-IMT (P=0.727).

CONCLUSIONS

Febuxostat therapy for 24 months modestly, but significantly, decreased WBC count in patients with asymptomatic hyperuricemia. This might potentially reflect a modest anti-inflammatory action of febuxostat in clinical settings.

Arsenic trioxide alleviates atherosclerosis by inhibiting CD36-induced endocytosis and TLR4/NF-κB-induced inflammation in macrophage and ApoE-/- mice

BACKGROUND

Inflammation and lipid accumulation are key events in atherosclerosis progression. Despite arsenic trioxide's (ATO) toxicity, at appropriate doses, it is a useful treatment for various diseases treatment. ATO prevents vascular restenosis; however, its effects on atherosclerotic plaque development and instability remain unclear.

METHODS

ApoE-/- mice were fed high-fat diet for 4 months, and starting at the third month, ATO was intravenously administered every other day. Atherosclerotic lesion size, histological characteristics, and related protein and lipid profiles were assessed using samples from the aorta, carotid artery, and serum. The anti-inflammatory and anti-pyroptosis effects of ATO were investigated by stimulating RAW264.7 and THP-1 cell lines with oxidized low-density lipoprotein (ox-LDL) or lipopolysaccharide (LPS).

RESULTS

ATO reduced atherosclerotic lesion formation and plasma lipid levels in ApoE-/- mice. In the serum and aortic plaques, ATO reduced the levels of pro-inflammatory factors, including interleukin (IL) 6 and tumor necrosis factor α, but increased IL-10 levels. Mechanistically, ATO promoted the CD36-mediated internalization of ox-LDL in a peroxisome proliferator-activated receptor γ-dependent manner. Furthermore, ATO downregulated Toll-like receptor 4 (TLR4) expression in plaques and macrophages and inhibited p65 nuclear translocation and IκBα degradation. ATO reduced macrophage pyroptosis by downregulating NLR family pyrin domain-containing 3 (NLRP3) expression and caspase 1 activation.

CONCLUSION

ATO has potential atheroprotective effects, especially in macrophages. The mechanisms were inhibition of CD36-mediated foam cell formation and suppression of inflammatory responses and pyroptosis mediated by TLR4/nuclear factor κB and NLRP3 activation. Our findings provide evidence supporting the potential atheroprotective value of ATO.

Echocardiographic epicardial fat thickness and immature granulocyte are novel inflammatory predictors of acute ischemic stroke: a prospective study

BACKGROUND

Acute ischemic stroke (AIS) is the most common type of stroke. Inflammation is the primary factor in the pathogenesis of atherosclerosis. Use of immature granulocytes (IGs) has been recommended as a new indicator of systemic inflammation. However, data on the association between echocardiographic epicardial fat tissue thickness (EFT) and IGs in patients with AIS are limited.

OBJECTIVE

To evaluate the association between the presences of IGs, epicardial fat tissue and AIS.

DESIGN AND SETTING

Prospective study in a tertiary-care university hospital in Antalya, Turkey.

METHODS

Our study included 53 AIS patients and 41 healthy controls with age and gender compatibility. Blood samples and transthoracic echocardiography of all participants were compared.

RESULTS

IG levels were significantly higher in patients with AIS than in controls (0.62 ± 0.36 versus 0.28 ± 0.02, P < 0.001). The mean EFT was 3.74 ± 0.61 mm in the control group and 6.33 ± 1.47 mm in the AIS patient group. EFT was significantly greater in AIS patients than in controls (P < 0.001). For the optimum cut-off value for IG (0.95), the area under the curve (AUC) was determined to be 0.840; sensitivity was determined to be 81.1% and specificity, 92.5%. For the optimum cut-off value for EFT (4.95 mm), the AUC was determined to be 0.953; sensitivity was determined to be 90.6% and specificity, 90%.

CONCLUSIONS

IG and echocardiographic EFT are clinical markers that can be used to predict AIS risk.

The Relationship Between Hematologic Parameters and Erectile Dysfunction

INTRODUCTION

Certain hematologic parameters related to blood cells, known as the biomarkers that predict cardiovascular disease, might be potential predictors of erectile dysfunction (ED) due to the shared pathophysiology between ED and cardiovascular disease .

AIM

To investigate the relationship between ED and these hematologic parameters and the clinical significance of hematologic parameters for the diagnosis of ED.

METHODS

A total of 113 male patients diagnosed with ED were included in this study. Blood samples were collected before 10:00 AM for blood cells examination, biochemical tests, and sex hormone analysis. Another 212 healthy controls without ED from the health management center was included as the control group. The relationship between hematologic parameters and ED was assessed by comparing differences in body mass index (BMI), biochemical indexes and hematologic parameters between the 2 groups, and the diagnostic value of hematologic parameters for ED was also examined and compared.

MAIN OUTCOME MEASURES

International Index of Erectile Function, hematologic parameters RESULTS: The neutrophil count (NC), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) in ED patients were significantly higher than those in healthy controls, whereas the lymphocyte count (LC) was significantly lower than that in healthy controls. After adjusting for age, BMI, uric acid (UA), fasting blood glucose (FBG), total cholesterol (TC), triglycerides (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL), increases in the NC, NLR, and PLR and a decrease in the LC were shown to be independent risk factors for ED. Receiver operating characteristic (ROC) curve analysis showed that the NLR exhibited better diagnostic performance for ED than the other parameters.

CONCLUSION

Increases in the NC, NLR, and PLR and a decrease in the LC significantly increased the risk of ED. The NC, LC, NLR and PLR could contribute to the diagnosis and assessment of ED. Zhangcheng L, Yuxin T, Xiucheng L and Dongjie L, et al. The Relationship Between Hematologic Parameters and Erectile Dysfunction. Sex Med 2021;9:100401.

Prognostic role of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune inflammation index in acute ischemic stroke: A STROBE-compliant retrospective study

The acute ischemic stroke (AIS) is a devastating disease and remains the leading cause of death and disability. This study aims to evaluate the role of hematological inflammatory markers (neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], and systemic immune inflammation index [SII]) in predicting the neurological recovery in acute cerebrovascular events over 1-year follow-up.Adult patients diagnosed with AIS within 3 hours from January 2016 to December 2018 were recruited retrospectively. The modified Rankin Scale (mRS) was recorded upon admission to the emergency department (ED) and 1, 3, 6, and 12 months after a stroke. The primary outcome measure was the neurological recovery. The neurological recovery was defined as an improvement in mRS score ≥ 1 compared with that at the ED admission baseline.A total of 277 consecutive adult patients with AIS within 3 hours were enrolled. The initial average of the National Institute of Health Stroke Scale was 9.2 ± 7.8, and 90.3% of patients had an mRS ≥ 2 at ED admission baseline. The overall neurological recovery rates of 48.7%, 53.7%, 59.2%, and 55.9% were observed at 1, 3, 6, and 12 months follow-up, respectively. The multivariate analysis revealed that the baseline NLR value was a significant predictor of neurological recovery at 3 months after a stroke (adjusted odds ratio = 0.89, 95% confidence interval = 0.80-0.99, P = .035).A low NLR at ED admission could be useful marker for predicting neurological recovery at 3 months after stroke.

Association Between Epicardial Adipose Tissue and Stroke

Epicardial adipose tissue (EAT) is correlated with endothelial dysfunction, metabolic syndrome, increased mortality and recent studies showed a possible association with the increased risk of stroke. We performed a systematic review of studies evaluating the association between EAT and stroke. Eighty studies met the inclusion criteria and were consequently analyzed. The review had Five main findings. First, the increased epicardial fat thickness (EFT) may be associated with the stroke episode. Second, regardless of the imaging method (echocardiography, MRI, and CT) this association remains. Third, the association of metabolic syndrome and atrial fibrillation seems to increase the risk of stroke. Fourth, this systematic review was considered as low risk of bias. Despite being unable to establish a clear association between EAT and stroke, we have organized and assessed all the research papers on this topic, analyzing their limitations, suggesting improvements in future pieces of research and pointing out gaps in the literature. Furthermore, the mechanistic links between increased EAT and stroke incidence remains unclear, thus, further research is warranted.

Is the differential diagnosis of epilepsy and psychogenic nonepileptic seizures possible by assessing the neutrophil/lymphocyte ratio?

INTRODUCTION

The neutrophil-to-lymphocyte ratio (NLR), which can be calculated directly from the complete blood count, is a parameter that can be accepted as an indicator of systemic inflammation. In this study, we tried to distinguish seizures from pseudo-seizures by evaluating the NLR value in the pre- and post-seizure period in epilepsy and psychogenic nonepileptic seizures (PNES).

MATERIAL AND METHOD

Of the 50 patients included in our study, 36 had epilepsy and 14 had PNES. Comparison of pre- and post-seizure values of leukocyte, neutrophil, and NLR values and heart rate were made between focal, generalized onset seizures, and PNES. The pre- and post-seizure NLR was assessed for each group.

RESULTS

The number of leukocytes and neutrophils determined after the seizure was significantly higher in the group with generalized onset seizures compared to the PNES group. When the pre- and post-seizure leukocyte counts were examined in the generalized onset seizure group, it was observed that the post-seizure leukocyte count was significantly higher (p: <0.001). In our study, there were no differences in the ictal and postictal heart rates between the PNES and epilepsy groups, unlike previous studies. We found that the ictal heart rate was statistically higher than the preictal heart rate in the epilepsy group, as expected, but the differences in heart rate between PNES and epilepsy did not separate the groups in a meaningful way.

CONCLUSION

As a result of these examinations, we observed that patients with epilepsy with generalized and focal onset seizures had a significantly higher number of leukocytes in their post-seizure blood. However, pre- and post-seizure NLR could not help us, within this group of patients, to separate PNES from epileptic seizures.

New stroke prognostic factors

Background

Understanding ischemic stroke pathogenesis helps in prevention, prognosis, and treatment. Stroke is greatly related to inflammation and thrombo-genesis as inflammatory cells (as neutrophils-lymphocytes) and thrombo-genic agents as von Willebrand factor antigen (VWF: Ag) and epicardial fat.

Objectives of the study

Evaluation of epicardial fat thickness (EFT), neutrophil/lymphocytic ratio (NLR), and (VWF: Ag) levels as predisposing and prognostic factors of ischemic stroke.

Patients and methods

Sixty acute ischemic stroke patients were subjected to clinical assessment (Oxford stroke sheet), National Institute Health Stroke Scale: NIHSS), Modified Rankin Scale (MRS), NLR and VWF: Ag levels, transthoracic echo, duplex on carotid and vertebro-basilar arteries, and brain computed tomography (CT). Thirty-five healthy controls matched for age and sex were subjected to the same steps except NIHSS and MRS.

Results

EFT, NLR, and VWF among patients were significantly higher than control group. NLR ≥ 2 and VWF: Ag were significant risk factors among stroke patients with VWF: Ag had the higher risk than NLR ≥ 2. NLR was a high valid prognostic marker in predicting stroke outcome (MRS) with (optimal cutoff value 2.05) for prediction of primary unfavorable outcome. There was no statistical significance between (MRS) and EFT or VWF: Ag level.

Conclusion

EFT represents inexpensive and readily available clinical marker that may be useful in estimating risk of ischemic stroke. NLR is non-expensive easy marker for predicting stroke severity and primary unfavorable outcome. High VWF level increases ischemic stroke risk.

Epicardial adipose tissue, inflammatory biomarkers and COVID-19: Is there a possible relationship?

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Adipose tissue is a biologically active organ with pro-immunogenic properties.

•

Inflammation plays a major role in the pathogenesis and progression of COVID-19.

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Data representing status of inflammation could convey useful prognostic information.

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EAT volume was significantly correlated with other systemic inflammatory biomarkers.

•

This correlation might explain the more severe disease in obese patients with COVID-19.

Background & Aims

Adipose tissue is a biologically active organ with pro-immunogenic properties. We aimed to evaluate the prognostic value of epicardial adipose tissue (EAT) in COVID-19 and its correlation with other inflammatory biomarkers.

Material and Methods

One-hundred patients with COVID-19 were enrolled. C-reactive protein (CRP), lactate dehydrogenase (LDH), neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-CRP ratio (LCR), and platelet-to-lymphocyte ratio (PLR) were evaluated on admission. EAT volume and density were measured by computed tomography. Patients were followed until death or discharge. Univariate and multivariate analysis was performed and ROC curve analysis was used to assess the ability of inflammatory markers in predicting survival. The relationship between EAT and other inflammatory markers was also investigated.

Results

The mean ± SD age of patients was 55.5 ± 15.2 years old; 68% were male. Univariate analysis revealed that increased lung involvement, blood urea nitrogen, LDH and NLR, and decreased platelet count were significantly associated with death. After adjustment, LDH was independently predictive of death (OR = 1.013, p-value = 0.03). Among inflammatory markers, LCR had the best ability for predicting survival with 79.7% sensitivity and 64.3% specificity at an optimal cut-off value of 20.8 (AUC = 0.744, 95% CI = 0.612–0.876, p-value = 0.004). EAT volume demonstrated positive correlation with NLR and PLR (p = 0.001 and 0.01), and a negative correlation with LCR (p = 0.02). EAT density was significantly different between decedents and survivors (p = 0.008).

Conclusion

Routine laboratory tests that represent status of inflammation can be used as cost-effective prognostic markers of COVID-19. Also, the significant association between EAT volume and other inflammatory biomarkers might explain the more severe disease in obese patients.

Epicardial Adipose Thickness and Neutrophil Lymphocyte Ratio in Acute Occlusive Cerebrovascular Diseases

OBJECTIVES

We investigate the relationship between the severity of vascular disease and epicardial adipose tissue thickness(EAT-t) and the neutrophil/lymphocyte (NEU/LY) ratio in acute stroke patients.

METHODS

Seventy-six patients and 38 healthy controls were included in the study. Strokes were divided into three groups: lacunar infarction, middle cerebral artery infarction (MCA), and other arterial infarcts. Patients were assessed using the GCS (Glasgow coma scale) and NIHSS (National Institutes of Health Stroke Scale) scales. In addition to laboratory measurements, EAT-t was evaluated in all patients by using echocardiography.

RESULTS

The EAT-t value and NEU/LY ratio were higher in the patient group than in the control group. The MCA group was found to have a significantly higher NEU/LY ratio than the lacuna group (p = 0.017) as well as the other patient (p = 0.025) group. There was a positive correlation of NIHSS score with EAT-t (r = 0.291; p = 0.013), and NEU/LY ratio (r = 0.289; p = 0.014).

CONCLUSION

The EAT-t and NEU/LY ratio were high in patients with acute ischemic stroke patients. The higher ratio of NEU/LY compared to other infarcts in the MCA group. These findings support the relationship between acute ischemic stroke severity and inflammation .

Is epicardial fat thickness associated with acute ischemic stroke in patients with atrial fibrillation?

BACKGROUND

Atrial fibrillation (AF) is the most common etiology of acute ischemic stroke (AIS). In recent years, epicardial fat tissue (EFT) has been found to be associated with the presence and chronicity of AF. However, the potential association between EFT and AIS in AF patients has not been fully elucidated. The aim of this study was to evaluate the effectiveness of EFT on prediction of AIS in patients with AF.

METHODS

This cross-sectional study has included 80 AF patients with AIS and 80 age-gender matched AF controls without AIS. Echocardiographic evaluations were performed in the first three days after hospitalization between July 2019 and December 2019 in Sakarya University Education and Research Hospital. Echocardiographic measurement of EFT was conducted according to previously published methods.

RESULTS

In comparison with the control group, AF patients with AIS had significantly higher epicardial fat thickness (8.55 ± 1.08 vs 5.90 ± 1.35 mm; P < 0.0001). The multivariate regression analysis indicated that EFT independently predicts AIS in patients with AF.

CONCLUSIONS

The present study showed that, EFT is an independent predictor for the development of acute ischemic stroke in patients with AF.

Clinical Significance of Baseline Neutrophil-to-Lymphocyte Ratio in Patients With Ischemic Stroke or Hemorrhagic Stroke: An Updated Meta-Analysis

Background and purpose: Stroke is a leading cause of death and acquired disability in adults today. Inflammation plays an important role in the pathophysiology of stroke. The peripheral neutrophil-to-lymphocyte ratio (NLR) is an important global inflammatory indicator becoming more mainstream in stroke care. This meta-analysis aims to evaluate the relationship between the baseline NLR and acute ischemic and hemorrhagic stroke, as well as define the clinical significance of NLR in subtypes of ischemic stroke. Methods: This meta-analysis was registered in PROSPERO with the number CRD42018105305. We went through relevant articles from PubMed Central (PMC) and EMBASE. Prospective and retrospective studies were included if related to baseline NLR levels prior to treatment in patients with ischemic or hemorrhagic stroke. Studies were identified up until April 2019. The cutoff value for NLR and the sources of odds ratios (ORs)/risk ratios (RRs) were measured. Modified Rankin Scale (mRS) was used to investigate the outcomes during clinical follow-up. Predefined criteria were used to evaluate the risk of bias in eligible studies. P-values < 0.05 were considered statistically significant. STATA version 14.0 (STATA, College Station, TX) was used in all statistical analyses. Results: Thirty-seven studies with 43,979 individuals were included in the final analysis. Higher NLR levels were correlated with increased risk of ischemic stroke (ORs/RRs = 1.609; 95% CI = 1.283-2.019), unfavorable functional outcome at 3 months (ORs/RRs = 1.851; 95% CI = 1.325-2.584), and increased mortality in patients with ischemic stroke (ORs/RRs = 1.068; 95% CI = 1.027-1.111). While in terms of hemorrhagic stroke (including SAH and ICH), elevated NLR levels only had deleterious effects on mortality (ORs/RRs = 1.080; 95% CI = 1.018-1.146). Conclusions: Baseline NLR level is a promising predictor of the clinical outcomes in both ischemic and hemorrhagic stroke. In addition, elevated NLR is also associated with a high risk of ischemic stroke occurrence. However, future studies are needed to demonstrate the underlying mechanisms and further explain this association.

Serum C-reactive protein/albumin ratio and restless legs syndrome

OBJECTIVES

Our study aimed to assess the variation in serum C-reactive protein/albumin ratio (CAR), a biomarker of peripheral inflammation and oxidative stress, in patients with restless legs syndrome (RLS).

METHODS

The study included a total of 380 individuals including 197 with RLS diagnosis. RLS diagnosis was determined according to the "International Restless Legs Syndrome Study Group" questionnaire. Disease severity was assessed according to the "International Restless Legs Syndrome Study Group Severity Scale''.

RESULTS

The mean age of patients with restless legs syndrome was 52.5 ± 12.7 years, while the mean age in the control group was 50.8 ± 11.2, with no statistically significant difference found (p = 0.156). The hemoglobin, iron and ferritin levels in the patient group were lower than in the control group (p < 0.001; p < 0.01; p < 0.001), with total iron binding capacity levels higher than the control group (p < 0.001). The mean ferritin in the RLS group (49.8 ± 51.2) was lower than the control group (76.9 ± 44.7). In patients, the c-reactive protein, albumin and c-reactive protein/albumin ratio were found to be 0.21 ± 0.18, 4.43 ± 0.31 and 0.07 ± 0.05, respectively. When compared with the control group, the patient group had high c-reactive protein (CRP), CAR and low albumin levels (p < 0.001). Among patients with "very severe" disease severity, ferritin levels were found to be lower than those with "moderate" disease severity. Additionally, patients with "very severe" disease had albumin levels which were significantly low compared to those with "mild" disease severity (p < 0.05).

CONCLUSION

Our study supports the hypothesis that serum albumin level, ferritin, CRP, and CAR may be associated with restless legs syndrome.

The Relation Between Echocardiographic Epicardial Fat Thickness and CHA2DS2-VASc Score in Patients with Sinus Rhythm

Objective

To evaluate the predictive value of epicardial fat thickness (EFT) in CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) score risk groups.

Methods

A total of 158 consecutive patients (75 females, 83 males, mean age 70.8±6.3 years) admitted routinely for cardiologic control were divided into two groups according to their CHA₂DS₂-VASc scores (scores 0 and 1 were regarded as low risk, and score ≥2 as high risk). One hundred twenty-five of 158 patients had a high-risk score.

Results

Mean EFT was significantly higher in the high-risk group than in the low-risk group (4.34±0.62 vs. 5.37±1.0; P<0.001). EFT was positively correlated with CHA₂DS₂-VASc score (r=0.577, P<0.001). According to receiver operating characteristics (ROC) analysis, EFT value of 4.4 mm was found to be predictive of high risk in CHA₂DS₂-VASc score with 80% of sensitivity and 79% of specificity (C-statistic = 0.875, P<0.001, 95% confidence interval [CI] = 0.76-0.90). And according to multivariate logistic regression analysis, EFT was an independent predictor of high thromboembolic risk in terms of CHA₂DS₂-VASc score.

Conclusion

Our findings suggest that echocardiographic EFT measurement could provide additional information on assessing cardiovascular risks, such as thromboembolic events, and individuals with increased EFT should receive more attention to reduce unfavorable cardiovascular risk factors and the development of future cardiovascular events.

Neutrophil Lymphocyte Ratio and Cardiovascular Disease Risk: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review aimed to measure the association between neutrophil lymphocyte ratio (NLR) and cardiovascular disease (CVD) risk.

METHODS

Relevant studies were identified from Medline and Scopus databases. Observational studies with NLR as a study factor were eligible for review. The outcomes of interest were any type of CVD including acute coronary syndrome, coronary artery disease, stroke, or a composite of these cardiovascular events. Mean differences in NLR between CVD and non-CVD patients were pooled using unstandardized mean difference (USMD). Odds ratios of CVD between high and low NLR groups were pooled using a random effects model.

RESULTS

Thirty-eight studies (n=76,002) were included. High NLR was significantly associated with the risks of CAD, ACS, stroke, and composite cardiovascular events with pooled ORs of 1.62 (95% CI: 1.38-1.91), 1.64 (95% CI: 1.30, 2.05), 2.36 (95% CI: 1.44, 2.89), and 3.86 (95% CI: 1.73, 8.64), respectively. In addition, mean NLRs in CAD, ACS, and stroke patients were significantly higher than in control groups.

CONCLUSION

High NLR was associated with CAD, ACS, stroke, and composite cardiovascular events. Therefore, NLR may be a useful CVD biomarker.

Early prediction of severity in acute ischemic stroke and transient ischemic attack using platelet parameters and neutrophil-to-lymphocyte ratio

BACKGROUND

It is still not easy to predict severity promptly in patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA). We investigated that platelet parameters or combinations of them could be a useful tool for early prediction of severity of AIS and TIA at admission and after 3 months.

METHODS

We prospectively recruited 104 patients newly diagnosed with AIS and TIA. We investigated their neutrophil-to-lymphocyte ratio (NLR) and platelet parameters. According to the Modified Rankin Scale scores, the patients were divided into two groups.

RESULTS

In receiver operating characteristic (ROC) curve analyses, mean platelet volume (MPV), NLR/platelet count (PLT), MPV/PLT, MPV*NLR, and MPV*NLR/PLT showed statistically significant results in both at admission and after 3 months. Values of area under ROC curves for those tests at admission were 0.646, 0.697, 0.664, 0.708, and 0.722, respectively. Also, values after 3 months were 0.591, 0.661, 0.638, 0.662, and 0.689, respectively.

CONCLUSION

MPV*NLR/PLT could be used as a relatively good tool for predicting severity at the time of admission and after 3 months than other parameters or combinations of them. Further studies have to be carried out to investigate the best parameter for predicting the severity of AIS and TIA.

Evaluation of Epicardial Fat Thickness in Young Patients With Embolic Stroke of Undetermined Source

OBJECTIVES

Epicardial adipose tissue is metabolically active and is an important predictor of metabolic and cardiovascular diseases. This study investigated the echocardiographic epicardial adipose tissue measurement in young patients with embolic stroke of undetermined source (ESUS).

MATERIALS AND METHODS

We studied 77 volunteers, including 40 patients with ESUS (mean age 43±8 y, 16 female patients) and 37 healthy subjects (mean age 38±7 y, 20 female subjects). All necessary biochemical parameters were analyzed, and epicardial fat thickness (EFT) was measured by echocardiography in all subjects. Additional related diagnostic work-up was conducted in each patient, according to the patients' clinical presentation.

RESULTS

The patients with ESUS had a significantly higher EFT than the control group (5.51±0.82 vs. 3.96±0.51; P<0.01). Furthermore, there was a positive correlation between EFT and serum C-reactive protein levels (r=0.284; P<0.05). As an optimal cut-off point, a high-risk EFT value of 4.6 mm was determined to predict ESUS, with an 87.5% sensitivity and an 81.1% specificity.

CONCLUSION

We found that echocardiographic EFT was significantly higher in young patients with ESUS than in healthy individuals. Increased EFT might be a novel risk factor in these patients.

Epicardial Adipose Tissue May Mediate Deleterious Effects of Obesity and Inflammation on the Myocardium

Epicardial adipose tissue has unique properties that distinguish it from other depots of visceral fat. Rather than having distinct boundaries, the epicardium shares an unobstructed microcirculation with the underlying myocardium, and in healthy conditions, produces cytokines that nourish the heart. However, in chronic inflammatory disorders (especially those leading to heart failure with preserved ejection fraction), the epicardium becomes a site of deranged adipogenesis, leading to the secretion of proinflammatory adipokines that can cause atrial and ventricular fibrosis. Accordingly, in patients at risk of heart failure with preserved ejection fraction, drugs that promote the accumulation or inflammation of epicardial adipocytes may lead to heart failure, whereas treatments that ameliorate the proinflammatory characteristics of epicardial fat may reduce the risk of heart failure. These observations suggest that epicardial adipose tissue is a transducer of the adverse effects of systemic inflammation and metabolic disorders on the heart, and thus, represents an important target for therapeutic interventions.

In Paroxysmal Atrial Fibrillation Patients, the Neutrophil-to-lymphocyte Ratio Is Related to Thrombogenesis and More Closely Associated with Left Atrial Appendage Contraction than with the Left Atrial Body Function

Objective The neutrophil-to-lymphocyte ratio (NLR) is an inflammation marker that can be used to detect atrial inflammatory changes, which may contribute to a reduced left atrial (LA) function and thrombosis. Our study aimed to determine whether or not the association of NLR with the LA appendage (LAA) function in relation to thrombogenesis differs from the association with the LA body function in paroxysmal atrial fibrillation (PAF) patients. Methods A total of 183 PAF patients were studied. The LA volume index, mitral flow velocity (A), and mitral annular motion velocity (A') were examined using transthoracic echocardiography. The LAA area, LAA wall motion velocity, and presence of spontaneous echo contrast (SEC) were examined using transesophageal echocardiography. Results The NLR of patients with cerebral embolism was significantly greater than in patients without the disorder. A cut-off point of 2.5 for the NLR had a sensitivity of 71% and a specificity of 74% in predicting cerebral embolism. The patients with an NLR ≥2.5 had a higher CHADS2 score and greater LA volume index or LAA area than those with an NLR <2.5. The NLR was an independent risk factor for SEC and was significantly correlated with the LAA wall motion velocity (r=-0.409) in 153 patients without SEC and with the LAA wall motion velocity and LAA area (r=-0.583, r=0.654, respectively) in 30 patients with SEC, but not with the LA volume index, A, or A' in either group. Conclusion In PAF patients, a high NLR indicates thrombogenesis with a high degree of certainty and is associated with reduced LAA contraction rather than with the LA body function.

Association of Neutrophil/Lymphocyte Ratio With Intravenous Immunoglobulin Treatment in Children With Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is an acute immune-mediated inflammatory polyneuropathy of the peripheral nervous system. The authors aimed to investigate whether the neutrophil/lymphocyte (N/L) and platelet/lymphocyte (P/L) ratios are the parameters that associated with the drug treatment or severity of GBS. Twenty-seven children with GBS were retrospectively analyzed from the medical records of patients who attended to the Pediatric Neurology Department of the Gaziantep University Hospital. Biochemical and hematologic parameters were measured. Leukocytes, neutrophils counts and N/L ratio were significantly higher before the intravenous immunoglobulin treatment ( P < .001). However, there were no marked differences in platelet count and P/L ratio. In addition, marked correlation was observed between the N/L ratio after treatment and duration of weakness. The results of the study showed that N/L ratio is significantly higher in GBS patients, and reduces following with intravenous immunoglobulin treatment.

Neutrophil to Lymphocyte Ratio as a Novel Predictor of Outcome in Patients With Severe Traumatic Brain Injury

OBJECTIVE

The neutrophil to lymphocyte ratio (NLR) has been reported to be a predictor of outcome in critical illness. Objective of this study was to investigate the changes of the NLR in patients with severe traumatic brain injury (TBI) and analyze the relationship between the NLR and TBI outcome.

SETTING

China.

PARTICIPANTS

A total of 855 patients with severe TBI from January 2007 to April 2012.

DESIGN

Retrospective.

MAIN MEASUREMENT

Data on the NLR and other indicators were collected. After follow-up until death or 1 year, the relationship between the NLR and TBI outcome was analyzed retrospectively.

RESULTS

The final analysis included 688 patients. There were 508 (73.8%) who had an unfavorable outcome by 1 year after head trauma. The value of the NLR on admission was significantly higher in the unfavorable outcome group than in the favorable outcome group (P < .001). Multivariate logistic analysis showed that higher NLR was associated with an unfavorable outcome (odds ratio, 1.100; P < .001). Receiver operating characteristic curve analysis showed that the NLR had a sensitivity of 60.2% and a specificity of 71.1% for predicting unfavorable outcome at 1 year on the basis of the best threshold.

CONCLUSION

The NLR might be useful as a novel predictor for 1-year outcome and mortality in severe TBI.

Mean platelets volume and neutrophil to lymphocyte ratio as predictors of stroke

BACKGROUND

Mean platelets volume (MPV) is a marker, which indicates platelet function, and is a potential link between inflammation and thrombosis. Previous studies have found a relation between high MPV levels and high risk of stroke. Another factor that has been associated with the risk of stroke is neutrophil to lymphocyte ratio (NLR). Several studies have reported an association between increased NLR and increased risk of cerebrovascular disease. It was found that NLR levels have a relation to the prognosis as well. Since both NLR and MPV have been associated with increased risk of cardiovascular disease, together they may predict the risk of stroke and the prognosis with higher sensitivity and specificity.

METHODS

This is a descriptive retrospective study. Data were gathered from medical records of patients who applied the Ziv medical center and were diagnosed with stroke. Stroke severity was evaluated using the NIHSS (national institutes of health stroke scale). MPV and NLR levels of patients with stroke were compared to those of 30 healthy individuals.

RESULTS

Neutrophil to lymphocyte ratio levels were found significantly higher in patients with stroke compared with healthy individuals. NLR was also found higher in patients with moderate/severe stroke compared with those with minor stroke. No association was found between MPV level, the risk of stroke, and stroke prognosis. Moreover, an interaction effect between MPV and NLR level was not found.

CONCLUSION

Neutrophil to lymphocyte ratio is a good predictive factor of stroke and stroke prognosis. Further prospective studies are needed to establish the relationship between the MPV level and the risk of stroke. NLR and MPV interaction effect can be tested again in the future after establishing the association between MPV, the risk of stroke, and stroke prognosis.

Prognostic value of hematological parameters in patients with paraquat poisoning

Paraquat (PQ) is a non-selective contact herbicide, and acute PQ poisoning has a high mortality. The aim of the present study is to evaluate the prognostic value of hematological parameters in patients with acute PQ poisoning. We retrospectively reviewed the records of patients with acute PQ poisoning from January 2010 to December 2015 at the First Affiliated Hospital, Anhui Medical University (Hefei, China). A total of 202 patients were included in the study, and the 30-day mortality was 51.98%. Leukocyte, neutrophil counts and neutrophil-lymphocyte ratio (NLR) were significantly higher in non-survivors than in survivors. In the receiver operating characteristic (ROC) curve analysis, the NLR had an area of 0.916(95%CI, 0.877–0.954) and the optimal cut-off value was 10.57 (sensitivity, 86.70%; specificity, 83.51%; Youden’s index, 0.702). The leukocyte counts had an area of 0.849(95%CI, 0.796–0.902) and the optimal cut-off value was 13.15 × 10³/mm³ (sensitivity, 77.10%; specificity, 83.50%; Youden’s index, 0.606). The neutrophil counts had an area of 0.878(95%CI, 0.830–0.925) and the optimal cut-off value was 10.10 × 10³/mm³ (sensitivity, 83.80%; specificity, 79.38%; Youden’s index, 0.632). NLR, leukocyte and neutrophil counts are associated with the 30-day mortality, which may be useful and simple parameters in predicting the prognosis of PQ poisoning.

Neutrophil-to-lymphocyte ratio in occlusive vascular diseases: the literature review of the past 10 years

BACKGROUND

This study aims to evaluate the results of studies investigating neutrophil-to-lymphocyte ratio (NLR) and to identify the prognostic and diagnostic value of NLR in occlusive vascular diseases.

METHODS

With the aim of identifying the studies related to NLR, a search was performed on http://www.ncbi.nlm.nih.gov/pubmed by using the key words "neutrophil lymphocyte ratio" between January 2005 and December 2014. All of the original articles were evaluated according to date of publications, countries, clinics and topics. Studies about occlusive vascular diseases were evaluated according to their qualifications, review methods and results. SPSS for Windows 16.0 was used in data analysis and data were expressed as mean, standard deviation and percentage.

RESULTS

A total of 735 original research articles were investigated. The number of publications have shown a regular logarithmic increase over the years. Thirty-two percent of all publications were performed by clinics in Turkey and 56.4% were performed by general-oncological surgery and cardiology clinics. A total of 107 publications were identified to be about occlusive vascular diseases, 80.3% of these publications were found to be prognostic and 19.6% to be diagnostic, 82.2% of them were found to be planned as retrospective and 17.7% as prospective. In 95.3% of prognostic publications, there was a positive correlation between high NLR values at admission and poor prognosis. In 95.3% of diagnostic publications high NLR values at admission were identified to be significant diagnostically.

CONCLUSION

Elevated neutrophil-to-lymphocyte ratio at admission, could be used as a diagnostic and/or prognostic parameter in occlusive vascular diseases.

Increased Epicardial Fat Thickness Correlates with Aortic Stiffness and N-Terminal Pro-Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Patients

Epicardial fat, a metabolically active tissue, has emerged as a risk factor and active player in metabolic and cardiovascular diseases. We investigated epicardial fat thickness in patients who had sustained an acute ischemic stroke, and we evaluated the relationship of epicardial fat thickness with other prognostic factors. We enrolled 61 consecutive patients (age, ≥18 yr) who had sustained a first acute ischemic stroke and had been admitted to our hospital within 24 hours of the onset of stroke symptoms. The control group comprised 82 consecutive sex- and age-matched patients free of past or current stroke who had been admitted to our cardiology clinics. Blood samples were taken for measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at admission. Aortic stiffness indices and epicardial fat thickness were measured by means of transthoracic echocardiography within the first 48 hours. In comparison with the control group, the patients with acute ischemic stroke had significantly higher epicardial fat thickness (4.8 ± 0.9 vs 3.8 ± 0.7 mm; P <0.001), lower aortic distensibility (2.5 ± 0.8 vs 3.4 ± 0.9 cm(2) ·dyn(-1); P <0.001) and lower aortic strain (5.5% ± 1.9% vs 6.4% ± 1.8%; P=0.003). We found a significant association between epicardial fat thickness, NT-proBNP levels, and arterial dysfunction in patients who had sustained acute ischemic stroke. Increased epicardial fat thickness might be a novel risk factor and might enable evaluation of subclinical target-organ damage in these patients.

Changes in serum albumin levels and neutrophil-lymphocyte ratio in patients with convulsive status epilepticus

AIM

Inflammation may be involved in the ictogenesis and development of some partial epilepsies. Serum albumin levels and the neutrophil-lymphocyte ratio (NLR) are markers of inflammation. The aim of this study was to investigate the ability of serum albumin levels and NLR to predict inflammation in patients with convulsive status epilepticus (CSE).

METHODS

This retrospective study was conducted on 58 patients who were diagnosed with CSE and control group comprised of 58 healthy individuals. Albumin levels and NLR were evaluated during both the acute and subacute periods of CSE.

RESULTS

The average serum albumin levels were 3.27 ± 0.62 g/dL during the acute period and 3.4 ± 0.67 g/dL in the subacute period in the patient group and 3.92 ± 0.52 g/dL in the control group. Neutrophil counts were higher in patients in the acute phase of CSE, but lymphocyte counts were lower compared to the control group and the subacute phase. The average NLR values were 4.83 ± 5.1 in the acute period, 3.07 ± 3.02 during the subacute period and 1.98 ± 0.42 in the control group. Serum albumin and NLR levels were significantly different between the patients in the subacute and acute periods of CSE and the control group (p < 0.05). There were significant negative correlational relationships between serum albumin and NLR levels (p < 0.05).

CONCLUSION

We found serum albumin levels were significantly lower and the NLR was significantly higher in the acute period of CSE. Neutrophil-mediated inflammation may be important in the aetiopathogenesis of CSE.

The Abundance of Epicardial Adipose Tissue Surrounding Left Atrium Is Associated With the Occurrence of Stroke in Patients With Atrial Fibrillation

Epicardial adipose tissue (EAT) is positively associated with risk factors for cardiovascular disease, but the role of EAT in the development of atrial fibrillation (AF)-related stroke and its association with the anatomical and functional remodeling of the left atrium (LA) have not been elucidated.This was a comparative cross-sectional study. Twenty-seven patients with paroxysmal or persistent AF and cardioembolic stroke were selected and compared with 68 age- and sex-matched AF patients without stroke. In addition, 20 controls without a history of AF or stroke were included. The periatrial EAT and the structural and functional properties of the LA and left ventricle were evaluated using contrast-enhanced 64-slice multidetector computed tomography during sinus rhythm. Total EAT around the LA was significantly increased across the groups (control vs AF vs AF-related stroke, P < 0.001). The volumes of the LA and the LA appendage (LAA) were also significantly increased across the 3 groups (P < 0.001 for each). The emptying fraction of the LA and LAA and the booster-pump function of the LA and LAA were all reduced across the 3 groups (P < 0.001 for all). In addition, the Hounsfield unit (HU) ratio of the LAA to the ascending aorta (LAA/AA) was also decreased in patients with stroke (P < 0.001). Furthermore, EAT had a negative correlation with the dynamic function of the LA, LAA, and the HU ratio. After a multivariate analysis, increased EAT (P < 0.001) was shown to be independently associated with the occurrence of AF-related stroke.Periatrial EAT was increased and was correlated with atrial dysfunction in patients with AF-related stroke. Hence, EAT assessment may potentially offer an incremental value for grading the risk of cardioembolic stroke in patients with AF.

Association of Increased Epicardial Adipose Tissue Thickness With Adverse Cardiovascular Outcomes in Patients With Atrial Fibrillation

The thickness of epicardial adipose tissue (EAT) was reported to be highly associated with the incidence and severity of atrial fibrillation (AF). This study was conducted to analyze the ability of EAT thickness in predicting adverse cardiovascular (CV) events in AF. In 190 persistent AF patients, we performed a comprehensive transthoracic echocardiographic examination with assessment of EAT thickness. The definition of CV events included CV mortality, hospitalization for heart failure, myocardial infarction, and stroke. There were 69 CV events including 19 CV deaths, 32 hospitalizations for heart failure, 3 myocardial infarctions, and 15 strokes during a mean follow-up of 29 (25th-75th percentile: 17-36) months. The multivariable analysis demonstrates that chronic heart failure, increased left ventricular (LV) mass index and the ratio of transmitral E-wave velocity to early diastolic mitral annulus velocity, decreased body mass index, and increased EAT thickness (per 1-mm increase, odds ratio 1.224, 95% confidence interval [CI] 1.096-1.368, P < 0.001) were associated with adverse CV events. Additionally, the addition of EAT thickness to a model containing CHA2DS2-VASc score, left atrial volume index, and LV systolic and diastolic function significantly improved the values in predicting CV events (global χ increase 14.65, P < 0.001 and integrated discrimination improvement 0.10, 95% CI 0.04-0.16, P < 0.001). In AF, EAT thickness was useful in predicting adverse CV events. Additionally, EAT thickness could provide incremental value for CV outcome prediction over traditional clinical and echocardiographic parameters in AF.