Ahmet Ozturk

Effect of Corticosteroids on Hemostasis and Pulmonary Arterial Pressure during Chronic Obstructive Pulmonary Disease Exacerbation

Background: Hemodynamic and hemostatic abnormalities are reportedly frequent in chronic obstructive pulmonary disease (COPD). Objectives: We investigated the changes in systolic pulmonary artery pressure (PAPs) and hemostatic status and the effects of systemic steroid treatment (SST) during COPD exacerbation. Methods: Consecutive 26 male and 4 female patients as well as 10 controls were enrolled. The nonsteroid treatment (NST) group received standard treatment without steroids, and the other group received additional SST. Initial values of blood gases, spirometry and PAPs, P-selectin, D-dimer and fibrinogen levels, activities of thrombocyte aggregation, antithrombin III (AT III), protein C (PC), protein S, activated PC resistance (APCR), prothrombin time and partial thromboplastin time were obtained and compared with values at day 10. Results: Improvement in spirometry and blood gases was more prominent with SST. At presentation, patients had higher PAPs, P-selectin, D-dimer and fibrinogen but lower AT III levels than controls. PAPs and fibrinogen levels significantly decreased in the SST group while P-selectin levels further increased in the NST group. The D-dimer level significantly decreased in both groups. Means of AT III, PC and protein S increased in the SST and decreased in the NST group, but only the decrease in PC in the NST group was meaningful. Compared with the controls, AT III levels in the NST group and activated PC resistance in the SST group were significantly decreased. Thrombocyte aggregation tests suggested an incline after 10 days in both groups. Conclusions: We suggest that in patients with COPD exacerbation, addition of systemic corticosteroids to treatment results in better outcome in normalization of PAPs, hemostasis, pulmonary functions and blood gases.

Peripheral blood gamma-delta T cells in advanced-stage cancer patients

Gamma-delta T (γδ T) cells form a subgroup which has been reported to play a role in both natural and acquired immunity. Their levels have been found to increase in some tumour tissues. The aim of this study was to investigate the ratio of γδ T cells to all T cells in the peripheral blood of advanced-stage cancer patients; the level of γδ T cells expressing the Vδ2-T-cell receptor (TCR) chain; NKG2D receptor expression; and apoptotic (Annexin-V) γδ T-cell levels. Twenty patients with advanced-stage cancer and 13 healthy controls were included. No statistical differences were found between control and patient groups in terms of the γδ T/total T-cell ratio (P=0.53), the Vγ2-TCR expressing γδ T-cell ratio (P=0.19) or the Annexin-V ratio (P=0.48). However, NKG2D expression in γδ T cells was significantly different between the control and patient groups (P=0.014). In summary it was shown that the levels of NKG2D receptors, which are responsible for the cytolytic effect of γδ T cells, were lower in cancer patients than in healthy adults. However, no significant differences were observed in the other parameters studied between groups.

Acute Myeloblastic Leukemia Achieving Complete Remission with Amifostine Alone

Amifostine, a phosphorylated thiol-amine, is known as a cytoprotective agent especially for cisplatin containing chemotherapies. Apart from the cytoprotective role, Amifostine could also be used in the treatment of hematologic malignancies such as myelodysplastic syndrome (MDS) and acute myeloblastic leukemia (AML), as a treatment option or for potentiating the effects of cytotoxic agents. We tried to use Amifostine in a patient with AML, which did not respond to conventional cytotoxic chemotherapy and aimed to publish the results. The patient was a 77-year-old male patient, he was diagnosed as AML by peripheral blood smear and bone marrow aspiration. Treatment commenced with low dose cytosine arabinoside (Ara-C) but the therapy should have ceased due to patient intolerance. The patient refused further therapy and he was offered to have Amifostine treatment. Amifostine was administered 200 mg/m 2 three times a week, with ciprofloxacin, pentoxifyllin and dexamethasone. Dramatic response was obtained after 8 weeks of administration. Blast rate was reduced from 35 to 7% in bone marrow aspiration; pancytopenia was restored to normal levels. This remission was maintained through 8 more weeks. Amifostine treatment was restarted after he relapsed but this time he did not respond to the treatment and died of gastrointestinal bleeding on the 8th week of treatment.

Ambulatory Blood Pressure Measurement Provides True and Prognostic Information on Blood Pressure Variability in Hypertensive Patients.

Dear Editor: We read the article “Ambulatory Blood Pressure Monitoring to Assess the White-Coat Effect in an Elderly East African Population” written by Ivy and colleagues with great interest. They aimed to investigate the influence of the white-coat effect (WCE) on conventional blood pressure (BP) measurement (CBPM)– recorded hypertension rates in a cohort of elderly people living in rural Tanzania and found a significant difference between mean CBPM and ambulatory blood pressure monitoring (ABPM) readings in their study cohort. Thanks to the authors for their contributions to their country’s people. The results of studies investigating the effects of WCE on CBPM in elderly people living in rural Tanzania may be insufficient. BP is not a constant and during mental and physical activity and sleep, BP changes from moment to moment in response to autonomic, humoral, mechanical, myogenic, and environmental stimuli. BP measurement may be affected by several factors such as smoking, temperature, emotional stress, and environmental stimuli. In order to investigate the effects of these factors on BP levels, BP variability is a good tool obtained by visit-to-visit or ambulatory monitoring. ABPM not only provides information on BP level but also on the diurnal changes in BP. Both daytime and nighttime BP consistently predicted the composite endpoint of all cardiovascular events. Twenty-four–hour ABPM is the best way of excluding white-coat hypertension in laboring patients with higher BP measurements in the doctor’s office. It is also wellknown that 24-hour BP is superior to only one BP measurement in the association of target organ damage and in the prediction of future cardiovascular events and mortality. It is also currently recommended by the latest guidelines of the European Society of Hypertension. Through 24-hour BP monitoring, BP variability can be derived and provide significant prognostic information, independent of mean BP. Some parameters are often used for BP variability such as standard deviation day-night and 24-hour, coefficient of variation, variability independent of the mean, and average real variability derived from ABPM. In conclusion, the subject is important for firstly diagnosed hypertension. It would be useful in evaluating the BP variability parameters derived from both ABPM records and visit-to-visit BP measurements in the present study.

Pantoprazole Sodium–Induced Hyponatremia in a Frail Elderly Adult

elderly adult with an itchy, psoriasiform scalp eruption. Individuals at higher risks include those who are bedbound with multiple medical comorbidities and poor mobility. The prognosis in MF is worse in men, older adults, at a higher stage of disease, and with the folliculotropic variant of MF. This woman had at least T3N1M0B0 disease, compatible with Stage IIB, which is advanced. Overall survival at this stage is 37.8% to 63.2% at 5 years after diagnosis and 19.8% to 53.2% at 10 years. Systemic therapy is indicated because of extensive skin and lymph node involvement. Choices include retinoid (bexarotene), interferon, histone deacetylase inhibitors (e.g., romidepsin, vorinostat), chemotherapy (e.g., methotrexate, doxorubicin, gemcitabine, cyclophosphamide, chlorambucil, fludarabine, etoposide), and biologic agents (e.g., bortezomib, alemtuzumab). Because these treatments are expensive and not readily available, this woman was fortunate to receive the biological treatment and chemotherapy free of charge and had a good outcome.

Oesophageal aspergillosis in a case of acute lymphoblastic leukaemia successfully treated with caspofungin alone due to liposomal amphotericin B induced severe hepatotoxicity.

Aspergillosis is one of the most common invasive fungal infections in immunocompromised patients. Sinonasal region and upper respiratory tract are commonly involved regions whereas oesophagus is seldom involved. We present an 18‐year‐old male with acute lymphoblastic leukaemia with aspergillosis of oesophagus which is a rare region of involvement. The diagnosis was confirmed by the examination of the cultures of endoscopic biopsy material. The patient was already receiving empirical liposomal amphotericin B, due to severe hepatotoxicity the therapy was switched to another antifungal (caspofungin). Here we report a case of successful treatment of invasive oesophageal aspergillosis by caspofungin.

Blood Pressure Variability Provides Useful and Prognostic Information on the White-Coat Effect Among Older Patients.

To the Editor: We read the article “White-Coat Effect Among Older Adults: Data From the Jackson Heart Study” written by Tanner and colleagueswith great interest. They aimed to determine thewhite-coat effect (WCE) and investigate the prevalence of white-coat hypertension (WCH) among younger and older adults. The authors concluded that clinic systolic blood pressure (SBP) was higher than outof-clinic SBP among participants 60 years and older vs those younger than 60 years and that clinic SBP ≥150 mm Hg vs <150 mm Hg was associated with a larger white-coat effect. According to the results, the authors provide suggestions about the role of ambulatory blood pressure (BP) monitoring in guiding antihypertensive treatment, elevated clinic BP, lower out-of-clinic BP, and white-coat effect among older adults. Ambulatory BP monitoring not only provides information on BP level but also on the diurnal changes in BP. Both daytime and nighttime BP consistently predicted the composite endpoint of all cardiovascular events. Twenty-four-hour ambulatory BP monitoring is the best way of excluding white-coat hypertension in patients with higher BP measurements in the doctor’s office. It is also known that 24-hour BP is superior to only one BP measurement in the association of target organ damage and in the prediction of future cardiovascular events and mortality, which is currently recommended by the latest guideline of the European Society of Hypertension. Through 24-hour BP monitoring, BP variability (BPV) can be derived and provide significant prognostic information, independent of mean BP. BP is not a constant condition so it may be affected by mental and physical activity and sleep. BP changes from moment to moment in response to autonomic, humoral, mechanical, myogenic, and environmental stimuli should be noted. BP measurement may be affected by several factors such as smoking, temperature, emotional stress, and environmental stimuli. In order to investigate the effects of these factors on BP levels, BPV is a good tool obtained by visit-to-visit or ambulatory monitoring. There are some parameters needed in order to define BPV such as standard deviation (SD) of day-night and 24-hour BP, coefficient of variation (CV), variability independent of the mean (VIM), and average real variability (ARV) derived from ambulatory BP monitoring. There are some reports and meta-analyses on the relationship between BPV and all-cause mortality. In a recent study, it was shown that visit-to-visit systolic BP variability, independent of age and mean systolic BP, was a predictor of cardiovascular and all-cause mortality and stroke. In an another study, the predictive value of visit-to-visit systolic BPV namely SD, CV, VIM, and ARV for cardiovascular events and all-cause mortality was shown. It was reported that a 1 mm Hg increase in SD was significantly associated with a 3% higher risk of all-cause mortality, a 10% higher risk of cardiovascular mortality, and a 2% higher risk of stroke. A 1% increase in CV was significantly associated with a 4% higher risk of all-cause mortality, a 1% higher risk of cardiovascular mortality, and a 5% higher risk of cardiovascular events. In conclusion, it would be useful to evaluate BPV parameters derived from ambulatory BP monitoring in the study population of the present study in order to evaluate the predicting mortality.

Inter-Arm Blood Pressure Differences May Be Important for Predicting Mortality

Dear Editor: We read the article “Inter-Arm Blood Pressure Difference in Hospitalized Elderly Patients Is Not Associated With Excess Mortality” written by Weiss and colleagues with great interest. They concluded that a more than 10 mm Hg inter-arm BP difference (IAD) for both systolic and diastolic blood pressure (BP) was not associated with mortality in hospitalized elderly individuals. Thanks to the authors for their contributions. But, it is well-known that IAD is associated with peripheral vascular disease and associated with cardiovascular mortality, especially in elderly patients with hypertension, diabetes mellitus, and ischemic heart disease. The measurement of BP in both arms and legs is very important in case of vascular disease such as peripheral vascular disease, aortic coarctation, and subclavian artery disease. The BP differences in both arms at the initial evaluation may lead to underdiagnosis of hypertension; therefore, it is recommended to not only measure BP in one arm. The impact of IAD during BP measurements has been a subject of extensive research in recent years. There may be a relationship between IAD and increased risk of cardiovascular morbidity in older patients. In the present study, the characteristics of vascular disease in the patients were not emphasized. We did not know about the subclavian stenosis of the patients. It would be useful to perform Doppler ultrasonography of the upper extremities to identify the vascular disease and actual IAD of these elderly patients. The atherosclerosis of the subclavian arteries may predict the total arterial system atherosclerosis. Therefore, this condition may be related with morbidity and mortality, especially in very elderly patients. The results of studies about the effects of IAD in very elderly patients might be controversial. Currently, coronary risk factors, eg, hypertension, obesity, and diabetes, are increasing in the elderly population. Higher systolic and diastolic BP may be one of the features of excessive cardiovascular risk not only for elderly patients but also younger patient. Additionally, the measurement of BP must be very sensitive. While some centers can do it automatically, measurements are usually performed manually. Twenty-four– hour ambulatory BP monitoring is the best way of excluding white-coat hypertension in laboring patients with higher BP measurements in the doctor’s office, even if elderly. There are some reports about IAD and increased mortality in elderly patients. It is expected that very old patients likely have a higher prevalence of atherosclerosis. IAD >10 mm Hg has been found to predict cardiovascular morbidity and mortality, especially in patients with diabetes, stroke, and hypertension. In conclusion, the subject is very important and we need further studies to better evaluate and understand BP measurements in both arms to exclude some cases of vascular disease and detect IAD in elderly and young patients. The very elderly with atherosclerotic vascular disease may have more IAD and may have increased cardiovascular morbidity and mortality.

Inter‐Arm Blood Pressure Differences in Aviators: Is It Important?

Dear Editor, We read the article “Inter-Arm Blood Pressure Differences in Young, Healthy Patients” written by Grossman and colleagues with great interest. They concluded that there were no significant differences between right and left arm blood pressure (BP) measurements but interarm BP difference (IAD) was correlated with systolic BP. According to their results, significant IAD (>10 mm Hg) is common in young, healthy patients and so BP should be measured in both arms. We thank the authors for their contributions. The results of studies about the effects of IAD in young, healthy patients and aviators might be controversial. Currently, coronary risk factors, eg, hypertension, obesity, and diabetes, are increasing in prevalence among the young population. Higher systolic and diastolic BPs may be one of the features of excessive cardiovascular risk not only for older pilots but also young ones. Although all patients were completely healthy in the present study, the prevalence of IAD >10 mm Hg was 12.6% for systolic BP and 8.8% for diastolic BP and IAD was not correlated with age, body mass index, or heart rate, but was correlated with systolic BP. The impact of IAD during BP measurements has been the subject of extensive research in recent years. There may be a relationship between IAD and increased risk of cardiovascular morbidity in older patients. We do not know whether it is important in young patients, particularly cadet aviators. Additionally, measurement of BP must be very sensitive. While some centers can do it automatically, measurements are usually made manually. Therefore, analysis of intraobserver and interobserver differences are important. On the other hand, differential diagnosis of white-coat hypertension is a major concern, especially in young patients. The best way of excluding white-coat hypertension is 24-hour ambulatory BP monitoring in patients with higher BP measurements in the doctor’s office. The measurement of BP in both the arms and legs is very important in cases of vascular disease such as peripheral vascular disease, aortic coarctation, and subclavian artery disease. The differences that exist in the values measured in both arms provide us with a diagnosis. The patient is important and we need further studies to better evaluate and understand BP measurements in both arms to exclude vascular disease and detect IAD.

Does Bilirubin Level Have an Effect on Serum Lipid Parameters and Atherogenic Plaque Formation

We read the article entitled ‘‘Serum Bilirubin Level and Aortic Intima-Media Thickness in Patients Without Clinical Manifestation of Atherosclerotic Cardiovascular Disease’’ by Kalkan et al with interest. The cardioprotective effect of bilirubin has been reported in some studies. Kalkan et al showed that lower serum bilirubin level might be an independent predictor of subclinical thoracic atherosclerosis, and serum bilirubin level was negatively associated with high-sensitivity C-reactive protein and aortic intima–media thickness. There are some reports regarding the relationship between total bilirubin levels and atherosclerosis. However, the measurement of conjugated, unconjugated, or total bilirubin levels were not reported by Kalkan et al. In addition, patients with known atherosclerotic heart disease were excluded. If such patients were included, a comparison could have been made. There are different studies about the effects of bilirubin on cardiovascular parameters. For example, Cüre et al concluded that increased bilirubin levels are associated with decrease in noninvasive electrocardiographic parameters in Gilbert syndrome. The contribution of serum bilirubin level to the atherosclerotic process has not been fully clarified.