Monocyte to HDL ratio may predict thrombosis in patients with mechanical mitral and aortic valve prosthesis

Increased inflammatory biomarkers have been reported in prosthetic heart valve thrombosis (PHVT). Monocyte to HDL ratio (MHR) and albumin to CRP levels (CAR) are two biomarkers used widely for systemic inflammation but there is a lack of data on prosthetic heart valves. This study aimed to find out the potential predictive value of MHR and CAR for PHVT. Patients who had the diagnosis of mechanical mitral/aortic PHVT and normally functioning prosthesis were retrospectively analyzed. Laboratory data including complete blood count and biochemistry were recorded. Transesophageal echocardiography was performed to diagnose PHVT. The study included 118 patients with mechanical PHVT and 120 patients with normally functioning prosthesis. White blood count, monocyte levels, C-reactive protein, MHR and CAR were significantly higher whereas the lymphocyte, HDL and INR levels on admission were lower in patients with PHVT. Multivariate analysis showed that as well as inadequate anticoagulation, MHR, but not CAR, was found to be an independent predictor of thrombosis in patients with PHVT. Receiver operating characteristic curve analysis was performed to detect the best cut-off value of MHR in the prediction of thrombosis in patients with prosthetic valves. MHR level of > 12.8 measured on admission, yielded an AUC value of 0.791 [(CI 95% 0.733-0.848 p < 0.001) sensitivity 71%, specificity 70%]. Inadequate anticoagulation is the primary cause that leads to thrombosis in mechanical prosthetic valves. Increased MHR, but not CAR, was also shown to be an independent predictor of thrombosis in patients with mechanical mitral and aortic prosthetic valves.

Thrombolysis or Surgery in Patients With Obstructive Mechanical Valve Thrombosis: The Multicenter HATTUSHA Study

BACKGROUND

Prosthetic valve thrombosis (PVT) is one of the life-threatening complications of prosthetic heart valve replacement. Due to the lack of randomized controlled trials, the optimal treatment of PVT remains controversial between thrombolytic therapy (TT) and surgery.

OBJECTIVES

This study aimed to prospectively evaluate the outcomes of TT and surgery as the first-line treatment strategy in patients with obstructive PVT.

METHODS

A total of 158 obstructive PVT patients (women: 103 [65.2%]; median age 49 years [IQR: 39-60 years]) were enrolled in this multicenter observational prospective study. TT was performed using slow (6 hours) and/or ultraslow (25 hours) infusion of low-dose tissue plasminogen activator (t-PA) (25 mg) mostly in repeated sessions. The primary endpoint of the study was 3-month mortality following TT or surgery.

RESULTS

The initial management strategy was TT in 83 (52.5%) patients and surgery in 75 (47.5%) cases. The success rate of TT was 90.4% with a median t-PA dose of 59 mg (IQR: 37.5-100 mg). The incidences of outcomes in surgery and TT groups were as follows: minor complications (29 [38.7%] and 7 [8.4%], respectively), major complications (31 [41.3%] and 5 [6%], respectively), and the 3-month mortality rate (14 [18.7%] and 2 [2.4%], respectively).

CONCLUSIONS

Low-dose and slow/ultraslow infusion of t-PA were associated with low complications and mortality and high success rates and should be considered as a viable treatment in patients with obstructive PVT.

The effects of urgent percutaneous coronary intervention on right ventricular systolic functions in non-ST-elevation acute coronary syndromes

BACKGROUND

Although the importance of the right ventricle (RV) involvement has been known for many years in patients with ST-elevation myocardial infarction (STEMI), it is scarce in non-ST-elevation acute coronary syndrome (NSTE-ACS).

OBJECTIVES

We aimed to investigate the effects of urgent percutaneous coronary intervention (PCI) on the RV systolic functions in patients with NSTE-ACS.

MATERIALS AND METHODS

Ninety-five patients diagnosed with NSTE-ACS and who underwent urgent PCI were prospectively investigated. RV systolic functions were analyzed and compared before and after PCI in all patients by using RV index of myocardial performance (RIMP), tricuspid annular plane systolic excursion (TAPSE), two-dimensional (2D) RV fractional area change (FAC), and isovolumic acceleration (IVA) parameters with transthoracic echocardiography.

RESULTS

Among 95 NSTE-ACS patients, 31 had impaired RIMP, 13 had impaired TAPSE, 8 had decreased 2D FAC, and 32 had impaired IVA values at baseline. There was a significant increase in 2D FAC and IVA values after PCI.

CONCLUSIONS

The right ventricular functions may also be affected in patients with NSTE-ACS, and urgent PCI has a significant effect on the recovery of right ventricular systolic functions in patients with NSTE-ACS.

The effects of tirofiban infusion on clinical and angiographic outcomes of patients with STEMI undergoing primary PCI

Objective:

The present study was designed to determine the effects of tirofiban (Tiro) infusion on angiographic measures, ST-segment resolution, and clinical outcomes in patients with STEMI undergoing PCI. Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI), while the most effective timing of administration is still under investigation.

Methods:

A total of 1242 patients (83.0% males, mean (standard deviation; SD) age: 54.7 (10.9) years) with STEMI who underwent primary PCI were included in this retrospective non-randomized study in four groups, composed of no tirofiban infusion [Tiro (-); n=248], tirofiban infusion before PCI (pre-Tiro; n=720), tirofiban infusion during PCI (peri-Tiro; n=50), and tirofiban infusion after PCI (post-Tiro; n=224). In all Tiro (+) patients, bolus administration of Tiro (10 pg/kg) was followed by infusion (0.15 pg/kg/min) for a mean (SD) duration of 22.4±6.8 hours.

Results:

The pre-PCI Tiro group was associated with the highest percentage of patients with TIMI 3 flow (99.4%; p<0.001), the lowest corrected TIMI frame count [21(18-23.4); p<0.001], the highest percentage of patients with >75% ST-segment resolution (78.1%; p<0.001), and the lowest rate of in-hospital sudden cardiac death and in-hospital all-cause mortality (3.2%, p<0.05, 3.3%, p=0.01). Major bleeding was reported in 18 (1.8%) patients who received tirofiban.

Conclusion:

Use of standard-dose bolus tirofiban in addition to aspirin, high-dose clopidogrel, and unfractionated heparin prior to primary PCI significantly improves myocardial reperfusion, ST-segment resolution, in-hospital mortality rate, and in-hospital sudden cardiac death in patients with STEMI with no increased risk of major bleeding.

Neutrophil gelatinase-associated lipocalin levels in right and left heart failure: an observational study

OBJECTIVE

Neutrophil gelatinase-associated lipocalin (NGAL) is a novel marker for early detection of renotubular deterioration. Despite the limited data concerning the NGAL in heart failure (HF), significance of NGAL in right-sided HF remains unknown. We assessed serum and urinary NGAL in left and right-sided HF due to non-ischemic cardiomyopathy (NICMP) and severe pulmonary arterial hypertension (PAH).

METHODS

In this cross-sectional observational study, we compared three groups; 35 patients with NICMP, 28 patients with PAH and 27 healthy controls. None had a serum creatinine ≥1.5 mg/dL. Plasma brain natriuretic peptide (BNP) levels, estimated glomerular filtration rate (eGFR) by Cockroft-Gault (CG) and Modification of Diet in Renal Disease Study formulas, echocardiographic measures of left and right ventricles (LV, RV) and non-invasive measurement of cardiac index (CI) by echocardiography and impedance cardiography were assessed. Differences among the groups for continuous variables were evaluated by the ANOVA and the Kruskal-Wallis test as appropriate. The Chi-square test was used for comparison of categorical variables.

RESULTS

Despite eGFR with CG formula was lower in NICMP and PAH subsets as compared to those in controls (102±27 and 99.4±29.4 vs 122.4±25.9 mL/min, p<0.05 and p<0.005 in order), serum NGAL [141 (113-151), 174 (130-192) and 132 (95-181) ng/mL] and urinary NGAL [15 (12-18), 15 (12-22) and 13 (8-18) ng/mL] levels were not different among groups (p=0.15 and p=0.35, respectively).

CONCLUSION

Despite the mildly impaired eGFR in left-sided HF due to NICMP and right-sided HF due to PAH, neither serum, nor urinary NGAL levels are elevated in these patients.

The prognostic relevance of angiogenesis and mast cells in squamous cell carcinoma of the oesophagus

AIMS

Angiogenesis, an important prognostic factor in several tumours, is a complex event mediated by angiogenic factors released from cancer cells and host immune cells. Among the host immune cells, a role has been implicated for mast cells in tumour progression via promoting angiogenesis. Data have been recorded that indicate a correlation between intratumoral neovascularisation, as assessed by microvessel density (MVD), and prognosis in squamous cell carcinoma (SCC) of the oesophagus. However, a correlation between mast cell density (MCD) and either prognosis or angiogenesis has not been delineated yet in this disease. The aim of this study was to investigate the prognostic value of MVD and MCD in SCC of the oesophagus. The correlation between MVD and MCD was also evaluated.

METHODS

MVD and MCD were investigated in tumour specimens from 53 patients diagnosed with SCC of the oesophagus. Intratumoral microvessels were stained with anti-CD34 antibody and mast cells with toluidine blue before being measured by light microscopy.

RESULTS

Both MVD and MCD were associated with the depth of wall invasion, lymph node metastasis, and tumour progression (stage). A significant correlation was noted between MVD and MCD values (r = 0.72). The prognosis was significantly worse in patients with high MVD (> or = 92) and high MCD (> or = 18) values. Multivariate analysis indicated that MVD and stage were independent predictors of survival.

CONCLUSIONS

These findings support the suggestion that MVD is a reliable prognostic marker in SCC of the oesophagus. Moreover, MCD may have a role in the angiogenesis of these tumours and might be responsible for their aggressive behaviour.

Endonasal endoscopic surgical treatment of paranasal sinus inverted papilloma--first experiences

PURPOSE

Surgical excision is generally regarded as the treatment of choice for inverted papilloma. However, the approach and extent of surgery has been subject of much debate. The purpose of this study is to evaluate the results of endoscopic sinus surgery in the treatment of paranasal sinus inverted papilloma.

PATIENTS AND METHODS

Thirteen cases of inverted papilloma of the paranasal sinuses treated via endoscopic sinus surgery were evaluated. The follow-up averaged from 9 months to 48 months with a mean of 27 months.

RESULTS

A close follow-up of all patients was maintained. Seventy-seven per cent (10/13) of the patients had no recurrence after the initial endoscopic procedure. Three patients had recurrences of their tumor within 11 months after surgery, which means a rate of 23% (3/13). In 2 patients, the recurrences were treated endoscopically. In one patient, recurrence and malignant transformation (squamous cell carcinoma) developed after 36 months, which means that the associated carcinoma rate was 7% (1/13). This patient underwent radical maxillectomy and postoperative radiotherapy. None of the patients died of inverted papilloma.

CONCLUSION

Endoscopic sinus surgery is a viable treatment alternative for paranasal sinus inverted papilloma in selected cases. This approach should be performed by experienced surgeons and a close follow-up is mandatory. When the disease is more extensive, it should be approached by radical surgery, e.g. en-bloc excision by medial maxillectomy via lateral rhinotomy or mid-facial degloving.

Evaluation of the effect of passive smoking on otitis media in children by an objective method: urinary cotinine analysis

OBJECTIVES

We aimed to determine objectively the effect of the passive smoking on otitis media with effusion (OME) and recurrent otitis media (ROM) by using the method of cotinine urinalysis.

STUDY DESIGN

We designed a prospective case-control study with follow-up of the case group for 1 year after insertion of tympanostomy tubes to evaluate postoperative complications such as otorrhea and early extrusion (<6 months), in case a significant risk factor was found.

METHODS

One hundred fourteen children between 3 and 8 years of age requiring tympanostomy tubes because of OME and ROM were chosen and compared with 40 age-matched children. Exposure to environmental tobacco smoke was assessed by cotinine urinalysis, which was performed by means of the radioimmunoassay method.

RESULTS

In this study, 73.7% (84 of 114) of the children in the case group and 55.0% (22 of 40) of the children in the control group were found to be "exposed" (P = .0461). This difference was statistically significant. Comparing the cotinine urinalysis results with parental smoking histories, 23.1% (9 of 39) of the children without parental smoking histories were "exposed" to tobacco smoke versus 84.3% (97 of 115) of the children with parental smoking histories (at least one person smoking).

CONCLUSIONS

Our results indicate that sidestream smoking increases the risk of OME and ROM. Legal regulations and guidelines must be established to protect children from passive smoking. Because cotinine urinalysis is a noninvasive and reliable method for the determination of passive smoking, it can be used for that purpose.

Relationship of passive cigarette smoking to otitis media

OBJECTIVE

To determine the effect of passive smoking on otitis media with effusion (OME) and recurrent otitis media (ROM).

DESIGN

A case-control study of children who received ventilation tubes and who were followed up for 1 year to determine the risk of developing postoperative otorrhea and early extrusion in relation to exposure to passive cigarette smoke.

SETTING

Otorhinolaryngology Clinic of Istanbul School of Medicine, Istanbul, Turkey.

PATIENTS

A total of 166 children 3 to 7 years old who required tympanostomy tubes because of OME and ROM (case group) compared with an age-matched control group of 166 children. The control group consisted of children who did not meet and never had met criteria for insertion of tympanostomy tubes.

MAIN OUTCOME MEASURES

Statistical analysis of factors associated with a higher prevalence of OME or ROM, postoperative otorrhea, and early tube extrusion.

RESULTS

Passive smoking was a significant risk factor for OME and ROM. The case group was exposed to a mean of 19.6 cigarettes per day vs 14.4 cigarettes per day for the control group (P<.004). Only maternal smoking was a significant factor (P<.001); no association was found with paternal smoking. Prospective follow-up of the case group showed no significant difference in the clinical course of OME and ROM between maternally exposed and non-maternally exposed children.

CONCLUSIONS

Passive smoking increases the risk of OME and ROM in children between 3 and 7 years old. The avoidance of daily exposure to domestic tobacco smoke could have a public health impact.

The effects of different levels of air pollution on atopy and symptoms of allergic rhinitis

We evaluated the prevalence of symptoms of allergic rhinitis and atopy among two groups living in areas with different pollution levels. The study was conducted among high school students living in Bayrampaşa (polluted by SO2 and TSP) and Beykoz (unpolluted, residential area) in Istanbul (n = 386). Each subject filled out a standardized self-administered questionnaire. Atopic status was evaluated by skin-prick testing using eight different allergens. Also, anterior active rhinomanometry was performed to evaluate the symptoms objectively. Significantly higher prevalence rates for symptoms of allergic rhinitis were found in Bayrampaşa (22.8%) compared to Beykoz (6%). However, no significant difference was found for atopic status among the two groups. When we evaluated the atopic status of subjects with symptoms of allergic rhinitis between the two areas, the prevalence of atopic students was found to be relatively higher in the unpolluted area (BZ). This difference was not statistically significant. Within the atopic population, subjects complaining of symptoms of allergic rhinitis were significantly more frequent in the polluted area (BP), suggesting that air pollution causes an increase in symptoms of allergic rhinitis in the atopic population, but this is not significantly higher than the increase in symptoms of allergic rhinitis of the total study group. Our results suggest that pollutants exert irritant effects on mucous membranes of the population in general rather than aggrevating symptoms in predisposed individuals. Smoking was more frequent in the unpolluted area. Exposure to parental smoking in childhood and heating systems in houses were evenly distributed. Household crowding was lower in Beykoz. Rhinomanometric measurements among the two groups did not show significant difference. Multiple logistic regression models estimating the role of each risk factor independently showed significant odds ratio associated with residence in Bayrampaşa for symptoms of allergic rhinitis (OR = 4.6, 95% CI = 9.0-2.3). In conclusion, this study suggests that outdoor pollution has adverse effects on the symptoms of allergic rhinitis, while it has no effect on the prevalence of atopy in Istanbul in the 1990s.

Physiologic and hypertonic saline solutions impair ciliary activity in vitro

OBJECTIVE/HYPOTHESIS

Physiologic saline (NaCl 0.9%) is commonly used in treating acute and chronic rhinosinusitis. Moreover, physiologic saline is used as a control medium, vehicle, or solvent in studies on ciliary beat frequency (CBF). Hypertonic saline (NaCl 7% and 14.4%) has been applied in attempts to enhance mucociliary transport in patients with cystic fibrosis or asthma and in healthy subjects. Therefore the objective of this study is to document in vitro effects of saline solutions in different concentrations on CBF.

STUDY DESIGN

Experimental, in vitro.

METHODS

The effects on CBF of cryopreserved mucosa of the sphenoidal sinus was measured by a photoelectrical method. Initial frequencies, measured in Locke-Ringer's solution (LR), were compared with CBF after exposure to NaCl in concentrations of 0.9%, 7.0%, and 14.4% (w/v).

RESULTS

NaCl 0.9% has a moderately negative effect on CBF. The 7% solution leads to a complete ciliostasis within 5 minutes, although this effect turns out to be reversible after rinsing with LR. A hypertonic solution of 14.4% has an irreversible ciliostatic effect.

CONCLUSION

LR is an isotonic solution that has no effect on CBF. Therefore it is probable that this solution is more appropriate than saline for nasal irrigation and nebulization or antral lavage. Moreover, the results of this study suggest that mucolytic effects induced by hyperosmolarity should be attained preferably with hypertonic saline 7% in patients with cystic fibrosis or asthma. At this concentration, the ciliostatic effect is reversible, whereas irreversible changes are to be expected at higher concentrations.

Objective and subjective assessment of nasal obstruction in patients undergoing endoscopic sinus surgery

Functional endoscopic sinus surgery (FESS) is the surgical treatment of choice for many physicians in chronic inflammatory diseases of the sinuses. Although subjective benefit has been claimed after surgery, there are not enough studies reporting objective improvement. We evaluated 40 patients undergoing FESS for chronic and recurrent sinusitis with visual analog scale (VAS) scoring of sensation of nasal obstruction and active anterior rhinomanometry of nasal resistance. The results of postoperative measurements demonstrated that baseline total nasal resistance measured with rhinomanometry and evaluated with VAS scoring (baseline and after decongestion) were significantly lower than preoperative measurements. However, improvement in nasal resistance was not statistically significant after decongestion, whereas VAS scoring was. These findings indicate that FESS improves nasal mucosal edema but does not change the structural anatomy of the nose.

The impact of outdoor pollution on upper respiratory diseases

We evaluated the prevalence of upper airway diseases among two groups living in areas with different pollution levels. The study was conducted among highschool students living in Bayrampasa (an area polluted by SO2 and total suspended particulates) and Beykoz (an unpolluted residential area) in Istanbul (n = 386). Each subject filled out a standardized zelf-administered questionnaire. Also, anterior active rhinomanometry was performed to objectively evaluate the symptoms in all students. A significantly higher prevalence rate for rhinitis was found in Bayrampaşa, as compared to Beykoz. However, the prevalence rate for pharyngitis was not significantly different between both groups. Smoking was more frequent in the unpolluted area. Exposure to parental smoking in childhood and heating systems in houses were evenly distributed. Household crowding was lower in Beykoz. Rhinomanometric measurements did not show any significant difference between both groups. Multiple logistic regression models estimating the role of each risk factor independently, showed a significant odds ratio associated with residence in Bayrampasa for rhinitis (OR: 2.0; 95% CI: 3.0-1.3). In conclusion, this study indicates that outdoor pollution has adverse effects on the degree of upper airway diseases in Istanbul in the 1990s.