Ergenekon Karagoz

Mean platelet volume: an emerging diagnostic factor of recurrent aphthous stomatitis and behcet disease.

We read the article entitled ‘‘Mean Platelet Volume in Recurrent Aphthous Stomatitis and Behçet Disease.’’ by Ekiz et al with interest. The authors concluded that mean platelet volume (MPV) might be a diagnostic marker of Behçet disease (BD) and recurrent aphthous stomatitis but it could not differentiate these diseases. Mean platelet volume describes the size of platelets and is also a marker of inflammation. Furthermore, elevated MPVs were related to autoimmune disorders, thrombocytopenia, congestive heart failure, acute pulmonary emboli, and hepatitis B and C; lower MPVs have been described in patients with anemia, chronic renal failure, Crohn disease, and ulcerative colitis. Behçet disease is a multisystemic disorder of recurrent acute inflammation, characterized by major symptoms of oral aphthous ulcers, uveitis, skin lesions, and genital ulcers. Although the etiology of BD is still unknown, a high prevalence of HLAB51, increased expression of heat shock protein 60, and Type 1 T helper-dominant immune responses have been reported. Streptococcus sanguis, herpes simplex virus, increased blood levels of soluble thrombomodulin, E-selectin, vascular endothelial growth factor, and endocan (a novel endothelial and inflammatory marker) are also associated with BD. According to our knowledge, the prognosis of BD is related to young age, male sex, major organ involvement, and cranial nerve system diseases. In this context, the authors could have compared their cases according to these parameters affecting the severity of this disease. Medication may alter MPV in patients with BD, so it would have been useful if the patients were described in greater detail in terms of colchicine use and/or other medications. In addition, it would also be relevant, if the authors specified how much time elapsed between taking the blood samples and measuring MPV because a delay may affect the MPV value. We believe that the findings of Ekiz et al will lead to further research regarding the relationship between MPV and BD. Nevertheless, it should be kept in mind that MPV alone without other inflammatory markers (eg, C-reactive protein, sedimentation rate, and endocan) may not provide certain information about the inflammatory status of the patient.

Clinical usefulness of mean platelet volume and red blood cell distribution width to platelet ratio for predicting the severity of hepatic fibrosis in chronic hepatitis B virus patients.

Objective Hepatitis B virus infection is still one of the leading causes of cirrhosis and hepatocellular carcinoma worldwide. Liver biopsy is the gold-standard method to assess the severity of liver fibrosis, but the invasive nature of this method limits its usage. Currently, noninvasive parameters are utilized to estimate liver histology. In the present study, we aimed to investigate the relationship between the severity of fibrosis and red blood cell distribution width (RDW), platelet distribution width (PDW), mean platelet volume (MPV), and MPV and red blood cell distribution width to platelet ratio (RPR) in patients with chronic hepatitis B (CHB). Design A total of 229 biopsy-proven naïve CHB cases were included in the study. The complete blood count variables including white blood cell, hemoglobin, hematocrit value, platelet count, RDW, MPV and PDW, as well as aspartate aminotransferase, alanine aminotransferase, total bilirubin, albumin, and other routine biochemical parameters were tested. Liver biopsy samples were examined using the Ishak scoring system. Data analyses were carried out using SPSS 15 software. Statistical significance was set at a P-value of less than 0.05. Results Of the 229 cases, 210 (91.7%) were men and 19 (8.3%) were women. The mean age of the patients was 30.9 years, and 85 cases (37.1%) had HBeAg positivity. Fibrosis scores of 41 cases (17.9%) were greater than or equal to 3, whereas 188 cases (82.1%) had fibrosis scores less than 3. There was a significant difference between these two groups for MPV (group 1=7.98±1.20, group 2=8.77±1.44, P<0.05). There was also a significant difference between these two groups for RDW (P<0.05). The RDW value in group 1 patients was 11.83±0.89, whereas this value was 12.57±1.32 in group 2. Moreover, the RPR was significantly higher in group 2 than in group 1 (P<0.001). There was no significant difference between the groups for PDW. We have compared the receiver operating characteristic curves for the diagnostic performance of aspartate aminotransferase, alanine aminotransferase, platelet count, RDW, MPV, and RPR in identifying fibrosis in CHB and area under the curve values for these variables were 0.666, 0.463, 0.657, 0.672, 0.677, and 0.758, respectively. Conclusion MPV and RDW values are significantly higher in hepatitis B virus-infected patients, associated with severity, and can be defined as independent predicting factors in hepatic fibrosis. Further studies are required to determine the associations between MPV and the severity of fibrosis in hepatitis B patients.

Is combination of neutrophil to lymphocyte ratio and platelet lymphocyte ratio a useful predictor of postoperative survival in patients with esophageal squamous cell carcinoma

Dear editor We read with interest the recent article entitled “Combination of neutrophil to lymphocyte ratio and platelet lymphocyte ratio is a useful predictor of postoperative survival in patients with esophageal squamous cell carcinoma” by Feng et al.1 In their study, authors aimed to investigate the usefulness of a novel inflammation-based prognostic system, using the combination of neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR), for predicting survival in patients with esophageal squamous cell carcinoma (ESCC). Finally, they concluded that combination of NLR and PLR is a useful predictor of postoperative survival in patients with ESCC and combination of these parameters is superior to NLR or PLR as a predictive factor in patients with ESCC. We would like to thank the authors for their contribution. PLR has been recently suggested to be a marker of thrombotic and inflammatory condition, mainly in patients with malignancies.2,3 NLR is a readily available and inexpensive laboratory marker which is used to assess systemic inflammation. In literature, it was shown that diabetes mellitus, thyroid functional abnormalities, essential hypertension, valvular heart diseases, acute coronary syndromes, renal and/or hepatic failure, metabolic syndrome, and many inflammatory diseases may potentially affect the NLR.4–7 Thus, it would be more relevant if Feng et al had mentioned these NLR-affecting factors while evaluating the predictive role of NLR in postoperative survival of patients with ESCC. Besides, medication may alter NLR and/or PLR, so it would have been useful if the patients were described in greater detail in terms of antibiotic, anti-diabetic, anti-hypertensive drug use and/or other medications. In addition, it would also have been better if the authors indicated the elapsed time between taking the blood samples and measuring NLR and PLR, since waiting period prior to analysis may affect these parameters. We believe that the findings of Feng et al1 will lead to further studies concerning the predictive role of NLR and PLR for postoperative survival of patients with ESCC. But, it should be clearly kept in mind that NLR or PLR itself alone without other variables may not secure true information about postoperative survival of patients with ESCC. Finally we concluded that these parameters should be evaluated with other variables as mentioned above.

Predictive role of the neutrophil-to-lymphocyte ratio in patients with advanced hepatocellular carcinoma receiving sorafenib.

We read the recently published article entitled ‘The Blood Neutrophil-to-lymphocyte Ratio Predicts Survival in Patients with Advanced Hepatocellular Carcinoma Receiving Sorafenib’ by Zheng et al. (2013), with interest. In the mentioned article authors aimed to determine the prognostic significance of the blood neutrophil-to-lymphocyte ratio (NLR) in patients with advanced hepatocellular carcinoma (HCC) who received sorafenib monotherapy. At the end of the article, the authors concluded that elevated NLR is associated with worse overall survival (OS) and time to progression (TTP) for the patients with advanced HCC receiving sorafenib monotherapy. We would like to thank the authors for their contribution. NLR is a readily available and inexpensive laboratory marker which is used to measure systemic inflammation. In previous researches, it was shown that renal and/ or hepatic failure, acute coronary syndromes, valvular heart diseases, diabetes mellitus, metabolic syndrome, essential hypertension, thyroid functional abnormalities, inflammatory diseases and many drugs may potentially affect the NLR (Balta et al., 2013; Karaman et al., 2013; Stotz et al., 2013). Thus, it would be more relevant if Zheng et al. had mentioned these NLR-affecting factors while evaluating the prognostic significance of the NLR in patients with advanced HCC receiving sorafenib. And also, as a limitation of study, it would be more objective if a large number of patients were included in the research. We believe that the findings of Zheng et al. (2013) will lead to further studies concerning predicting role of NLR in patients with HCC. Besides NLR, age, sex, tumor size, tumor number, capsule state, cell differentiation, location of tumor, presence of major blood vessel invasion, functional status of the liver (synthetic function), existence of portal hypertension/cirrhosis, TNM stage are previously described prognostic factors of hepatocellular carcinoma (Qin and Tang, 2002; Mulcahy, 2005; Song et al., 2011). Thus, it should be clearly kept in mind that NLR itself alone without other prognostic variables may not secure true information about the prognosis advanced HCC. Finally we concluded that, in terms of NLR’s predictive role in HCC, NLR should be evaluated with other prognostic variables as mentioned above. LETTER to the EDITOR

Red Blood cell distribution width: an emerging diagnostic factor of acute appendicitis?

Acute appendicitis is the most common surgical abdominal emergency. Immidiate diagnosis of this disease is crucial, because this condition can lead to appendiceal perforation, potential peritonitis, and even death. We read with great interest the article ‘The role of red cell distribution width (RDW) in the diagnosis of acute appendicitis: a retrospective case-controlled study’ by Narci et al. and wanted to discuss whether RDW alone provide certain information about the inflammatory status of the patient with acute appendicitis.

Cytomegalovirus-associated transverse myelitis: a review of nine well-documented cases

Abstract Cytomegalovirus-associated transverse myelitis is a rare disease. We found 12 cases in the medical literature, 8 of which met our criteria for being well documented. Our aim was to review this clinical entity using information from our own clinical experience as well as published cases.

Mean platelet volume: An emerging prognostic factor of infective endocarditis?

We read with great interest the article ‘‘Mean Platelet Volume and Mean Platelet Volume/Platelet Count Ratio in Infective Endocarditis’’ by Cho et al. [1]. The authors concluded that higher MPV level is associated with infective endocarditis (IE) and might be a diagnostic marker of this disease. MPV describes the size of platelets and is utilized as a marker of platelet activation and function [2]. MPV is an emerging marker of inflammation and also intensity of inflammation [3]. IE-related endothelial damage and hypercoagulability may be associated with inflammation and these conditions may lead to life-threatening complications such as thromboembolism and even death [1]. In previous studies, it was demonstrated that diabetes mellitus, peripheral artery disease, acute coronary syndromes, autoimmune disorders, thrombocytopenia, congestive heart failure, acute pulmonary emboli, thyroid functional abnormalities, local or systemic infections, malignancy, inflammatory diseases, and many drugs may potentially affect MPV levels [2]. Thus, it would have been better if the authors had mentioned these MPV-effecting factors while assessing the associations between MPV and IE. MPV may alter in subacute and acute IE. Subacute forms of IE or prosthetic valve IE may have different presentations because of biofilm and low-level inflammatory responses. Even though the number of the patients were limited in this study, it would also have been relevant if the authors had discriminated between subacute IE and acute IE. Recent studies have demonstrated that B-type natriuretic peptide (BNP), procalcitonin (PCT), cystatin C, and matrix metalloproteinase-9 levels are found to be associated with the infective endocarditis (IE) [4–6]. In this context, the authors could have compared their cases according to these parameters affecting the prognosis and severity of this disease. Medication may also alter MPV in patients with IE, so it would have been useful if the patients were described in greater detail in terms of antibiotic use and/or other medications. In addition, it would also have been better if the authors indicated the elapsed time between taking the blood samples and measuring MPV since waiting period prior to analysis may affect MPV value [7]. We believe that the findings of Cho et al. will lead to further research regarding the relationship between MPV and IE [1]. Anyway, it should be kept in mind that MPV alone without other variables (e.g., C-reactive protein, PCT, and BNP) may not provide certain information about the inflammatory status of the patient with IE.

Mean platelet volume and red cell distribution width to platelet ratio for predicting the severity of hepatic fibrosis in patients with chronic hepatitis C.

Objective We designed this study to investigate the relationship between the severity of fibrosis and mean platelet volume (MPV), red cell distribution width, and red cell distribution width to platelet ratio (RPR) in patients with chronic hepatitis C (CHC). Design Overall, 98 biopsy-proven naïve CHC cases were enrolled in the study. Complete blood count variables, including white blood cell, hemoglobin, platelet count, MPV, red cell distribution width, platelet distribution width as well as aspartate transaminase, alanine transaminase, total bilirubin, albumin, and other routine biochemical parameters, were tested. Liver biopsy samples were assessed according to the Ishak scoring system. Data analyses were carried out using SPSS-15 software. Statistical significance was set at a P-value of less than 0.05. Results Of the 98 cases, 80 (81.6%) were men and 18 (18.4%) were women. Fibrosis scores of 69 cases (70.4%) (group 1) were less than 3, whereas 29 cases had fibrosis scores at least 3 (29.6%) (group 2). Significant differences in MPV and RPR were observed between these two groups (MPV: 8.19±1.002 vs. 8.63±0.67 fl, P<0.05; RPR: 0.0526±0.02 vs. 0.0726±0.02, P=0.001). The areas under the curve of the RPR and MPV for predicting significant fibrosis were 0.705 and 0.670, which was superior to the aspartate transaminase-to-alanine transaminase ratio and aspartate transaminase-to-platelet ratio index scores of the study group. Cut-off values were calculated for diagnostic performance, and the cut-off values for MPV and RPR were 8.5 and 0.07 fl, respectively. Conclusion MPV and RPR values were significantly higher in patients with CHC, associated with severity, and can be used to predict advanced histological liver damage. The use of MPV and RPR may reduce the need for liver biopsy. Further studies are required to determine the relationship between these parameters and the severity of fibrosis in hepatitis C patients.

Predictive role of neutrophil to lymphocyte ratio in Henoch–Schonlein purpura related gastrointestinal bleeding

We read with interest the recent article ‘The relationship of neutrophil-to-lymphocyte ratio with gastrointestinal bleeding in Henoch–Schonlein purpura’ by Makay et al. (Rheumatol Int. doi:10.1007/s00296-014-2986-2, 2014). In their study, researchers aimed to evaluate the relationship between blood neutrophil to lymphocyte ratio (NLR) and gastrointestinal bleeding in children with Henoch–Schonlein purpura (HSP). In discussion part, the authors concluded that blood NLR may be considered as a useful marker for predicting gastrointestinal bleeding in HSP. We would like to thank Makay et al. for their valuable contribution.

Neutrophil-to-lymphocyte ratio: an emerging prognostic factor of cirrhosis?

We read with great interest the article ‘Blood neutrophilto-lymphocyte ratio independently predicts survival in patients with liver cirrhosis’ by Biyik et al. [1]. They aimed to evaluate the role of the neutrophil-to-lymphocyte ratio (NLR) in predicting long-term mortality in patients with liver cirrhosis. Finally, the authors concluded that NLR is a predictor of survival independent of Child–Turcotte– Pugh and Model for End-Stage Liver Disease scores in patients with liver cirrhosis. Its ready availability and the fact that it is inexpensive may strengthen its broad use in daily practice in the near future. We would like to thank the authors for their contribution.