Ahmet Cemal Pazarli

The value of computed tomographic obstruction index in the identification of massive pulmonary thromboembolism

PURPOSE In this study, the pulmonary arterial computed tomography obstruction index ratio, which indicates the degree and extent of thrombotic arterial occlusion, was calculated in cases with pulmonary thromboembolism. Our objectives were to investigate the value of this index for the identification of cases with massive pulmonary thromboembolism and to search for correlations between this index and clinical parameters. MATERIALS AND METHODS Data from 68 patients were evaluated retrospectively. For the clinical evaluation, the Wells scoring system was used. Pulmonary computed tomographic angiography examinations were acquired using an eight-channel multidetector computed tomography. The presence of arterial filling defects was recorded, and the clot burden was quantified based on the degree and extent of thrombotic arterial occlusion. RESULTS According to the Wells scoring system, the patients were assigned to low (n = 14), moderate (n = 34), and high clinical (n = 20) possibility groups, and the difference among the mean pulmonary arterial computed tomography obstruction index ratios of the three groups was significant (P = 0.001). A positive correlation was observed between the pulmonary arterial computed tomography obstruction index ratio and the Wells score (r = 0.470, P < 0.001). The pulmonary arterial computed tomography obstruction index ratio cut-off point was determined to be 40% for the discrimination of massive and nonmassive cases (sensitivity, 72.7%; specificity, 91.4%). CONCLUSION We found that in cases where the pulmonary arterial computed tomography obstruction index ratio was above 40%, a diagnosis of massive pulmonary thromboembolism was demonstrated. Furthermore, a positive correlation between the obstruction index and the Wells score suggested the use of a clinical evaluation as a means of developing a recommendation regarding the thrombotic load.

Monocyte Count/HDL Cholesterol Ratio and Cardiovascular Disease in Patients With Obstructive Sleep Apnea Syndrome A Multicenter Study

Background: Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for cardiovascular disease (CVD). Although monocyte to high-density lipoprotein cholesterol ratio (MHR) is increasingly being implicated in cardiovascular morbidity and mortality, no study has attempted to determine the role of MHR in cardiovascular morbidity of patients with OSAS. We aimed to investigate the association between MHR and CVD in patients with OSAS and the relationship between severity of OSAS, polysomnographic parameters, and MHR. Methods: In this cohort study, patients who had undergone a full-night polysomnography for the diagnosis of OSAS were recruited. Included patients were grouped according to the apnea–hypopnea index (AHI) as mild (5-15), moderate (15-30), and severe (>30) OSAS. Patients with AHI < 5 served as the control group. The presence of heart failure, coronary artery disease, or arrhythmia was defined as CVD. Results: A total of 1050 patients were included (131 controls, 222 mild, 228 moderate, and 469 severe OSAS). The severe group had higher MHR compared with the control and other OSAS groups (9.99, 12.11, 13.65, and 20.67 in control, mild, moderate, and severe OSAS groups, respectively, P < .001). The MHRs were significantly correlated with AHI, oxygen desaturation index, and minimum O2 saturation values (P < .001). Values of MHR were significantly higher in patients with CVD compared with those without (P < .001). Multiple regression analysis demonstrated that MHR is an independent predictor of CVD. Conclusion: The MHR is strongly associated with CVD and the severity of OSAS and might be used as a biomarker to predict CVD in patients with OSAS.

Intervention for CPAP adherence in OSAS: a choice to patient or technique?

To the editor, We have a great interest in the recently published article entitled BFactors predicting CPAP adherence in obstructive sleep apnea syndrome^ byM. Riachy et al. [1]. The authors studied the determinants of short-term and long-term CPAP adherence in a group of Lebanese patients. However, we have some drawbacks for the aforementioned article for proper clinical explanations. First, patient enrollment did not follow a strict physiologic and demographic criterion. In this regard, the text lacks demographical features of the patients. Authors did not compare body mass index (BMI) for continuous positive airway pressure (CPAP) adherence. Especially for morbid obese patients with obstructive sleep apnea (OSA), level of oxygen desaturation due to hypoventilation continues despite efficacy of CPAP therapy. In this group of patients, significant hypoxemia observed during the day and CPAP therapy failure is greater that non obese OSA [2]. Second, authors did not clarify patient’s daytime sleepiness and hypoxemia and implications of their results described. It is a well-known fact that CPAP adherence rate is highest in patients with excessive daytime sleepiness and severe hypoxemia. Patients with excessive daytime sleepiness, but not have severe hypoxemia, had less CPAP adherence than patients with hypoxemia without excessive daytime sleepiness (55 and 70%). The best indicator of CPAP adherence is hypoxia [3]. This association needs to take into account by authors. Third, we could not see the data about tolerance and complications due to mask. Nasal complications as skin irritation and dermatitis, conjunctivitis developed due to air leak from mask, and the other factors affects mask usage and CPAP adherence. These data needs to be addressed properly in the study. We consider that prior to the start of CPAP therapy, identification of the risk group for less CPAP compliance could provide early integration of basic education and behavior support as well as factors of facilitation such as automatic CPAP [4]. We conclude that simple and inexpensive efforts to improve compliance of CPAP therapy could be effective, especially when applied at the start of CPAP therapy. Optimal interventions may vary with certain patient characteristics.

Association Between 25-Hydroxyvitamin D and Bone Mineral Density in People with Obstructive Sleep Apnea Syndrome

The aim of this study was to evaluate the association between bone mineral density (BMD) and 25-hydroxyvitamin D [25(OH) D] levels in patients with obstructive sleep apnea syndrome (OSAS). This study was designed as a cross-sectional and observational study. Patients who underwent polysomnography evaluation were classified as normal, mild, moderate, severe, or position-dependent OSAS, and OSAS + obesity hypoventilation syndrome (OHS). BMD was measured with the dual-energy X-ray absorptiometry method at the femur and lumbar spine. The chemiluminescence microparticle immunoassay was used for the measurement of 25(OH) D levels. A total of 126 patients (73 males, 53 females) with a mean age of 48.55 ± 11.8 years were included. Body mass index was significantly higher in the OSAS + OHS group than in the other groups (p < 0.01). There was no statistically significant difference between the groups in terms of total BMD, T-scores and Z-scores of the lumbar spine, femural neck, and total femur (p > 0.05 for all). Post hoc analyses showed that OSAS + OHS subgroup had lower level of 25(OH) D compared to the normal subjects (p = 0.006). Yet no significant difference was observed between the other OSAS groups. No significant correlation was observed between the apnea hypopnea index, the Epworth Sleepiness Scale scores, desaturation index, and BMD parameters (all for p > 0.05). While 25(OH) D levels were lower in OSAS + OHS patients, there was no statistically significant relationship between OSAS and BMD values.

Pleural lipoma presenting with back pain.

To the editor, Lipoma is a benign, slow-growing and uncapsulated soft tissue tumor composed of adipose tissue. There are mainly two types of lipoma as the superficial (subcutaneous) and deep lipomas. Intrathoracic lipoma is one of the presentations of deep lipomas and it is reported several times in the literature as mediastinal, bronchial or at the pulmonary levels. However, pleural lipoma is a rare entity and reported in the data a few times. In a review of 3502 cases of thoracic tumors, Jensen and Peterson reported only three cases of pleural lipomas. Likewise, presented here is a patient with pleural lipoma presenting with persistent back pain. A 47-year-old man was admitted with the complaints of right-sided exceeding back pain (blunt) for 3 months. Physical examination was unremarkable. Posterior-anterior chest radiograph designated a pleural-based mass on the right side (Figure 1A). Computed tomography (CT) clearly demonstrated the mass with regular borders and isodense to fatty tissue (2126 HU) (Figure 1B). The patient underwent surgical excision of the mass (Figure 1C). On gross examination the mass was encapsulated, weighed a total of 145 g and measured the big part 9 3 4 3 4 cm. Histopathological examination was consistent with lipoma. Follow-up visits were recommended for the recurrence. Pleural lipomas are commonly asymptomatic and can be diagnosed incidentally. Yet, as lipomas can grow to a large size, they can cause non-productive cough, thoracic tightness sensation, dyspnea and they can provoke any sort of compression symptoms depending on sites and size of mass. Our patient presented with persistent pain. As regards the imaging thoracic lipomas, plane radiographs can be used as the first line imaging modality. Nonetheless, thorax CT is quite useful to demonstrate pleural origin, quantify and characterize these lesions. CT illustrates homogenous fat attenuation with values of 250 to 2150 HU. Magnetic resonance imaging is required when there is a doubt in CT scan diagnosis. Concerning the differential diagnosis; thoracic fatcontaining lesions include germ cell neoplasms, thymolipomas, lipomas and liposarcomas. Metastases and malignancies can cause rib/bone destruction and they are seen as heterogeneous masses. Endobronchial hamartoma has a smooth edge and focal fat collections with calcification. Teratoma is a heterogeneous mass with soft-tissue, fluid, fat and calcium attenuation. Symptomatic cases can be treated surgically, however, if the lesion is asymptomatic, the treatment strategy remains controversial. While some authors suggest radiological follow-up, others recommend

Association of Acromegaly and Central Sleep Apnea Syndrome

Acromegaly is usually characterized by the excessive secretion of growth hormone (GH) after the closure of epiphyseal plaques, resulting from functional pituitary adenomas. The most common manifestations of acromegaly are acral and soft tissue overgrowth, diabetes mellitus, hypertension, and heart and respiratory failure. In patients, obstruction of the upper airway may develop due to enlargement of the tongue and thickening of the tissues of the larynx; consequently, obstructive sleep apnea syndrome (OSAS) occurs commonly in acromegaly. Previous studies have shown an association between acromegaly and central sleep apnea syndrome (CSAS). Some of these described patients described showed that an elevation in the GH level may cause a defect in the respiratory drive. Most systemic diseases seen in acromegaly require effective treatment. We believe that it is necessary to perform effective treatments by examining respiratory disorders in sleep.