Funda Coskun

Low Level of IGF-1 in Obesity May Be Related to Obstructive Sleep Apnea Syndrome

The aim of this study was to compare serum insulin-like growth factor (IGF-1) levels in patients with obstructive sleep apnea syndrome (OSAS) with those of nonapneic controls and to determine the risk factors of low IGF-1 levels in patients with OSAS. The study included 39 newly diagnosed moderate-to-severe OSAS patients and 36 nonapneic controls. Overnight polysomnography (PSG) was performed in all patients. The circulating levels of IGF-1 in the OSAS group were significantly lower than those of the control group (p < 0.05). There was a significant negative correlation between IGF-1 and logarithmic transformation (Ln) of the apnea-hypopnea index (AHI), duration of apnea-hypopnea, arousal index, average desaturation, and oxygen desaturation index (ODI). The result of stepwise regression analyses showed that OSAS (p = 0.001) was a risk factor for a low IGF-1 level, independent of age, gender, and body mass index (BMI). Our findings demonstrated that there was a significant negative correlation between IGF-1 and Ln AHI and that OSAS reduced the circulating levels of IGF-1.

Impaired left ventricular systolic and diastolic functions in patients with early grade pulmonary sarcoidosis

AIMS Cardiac sarcoidosis is symptomatic in only 5% of patients, and it is an independent predictor of mortality and carries a very poor prognosis. In our study, we aimed to assess left ventricle (LV) systolic and diastolic functions with tissue Doppler imaging (TDI) in patients with early grade pulmonary sarcoidosis. METHODS AND RESULTS The study population included 55 patients with Grade I-II sarcoidosis (41 females, 14 males, mean age: 47.9 ± 10.1) and 22 healthy subjects. LV lateral and septal wall early myocardial peak velocity (E(m)), late myocardial peak velocity (A(m)), E(m) to A(m) ratio, myocardial relaxation time (RT(m)), myocardial systolic wave (S(m)) velocity, isovolumic acceleration (IVA), myocardial pre-contraction time (PCT(m)), contraction time (CT(m)), and the PCT(m) to CT(m) ratio were measured. No statistically significant difference was detected between the groups according to age, gender, body mass index, systolic and diastolic blood pressure, or heart rate. LV systolic parameters, LV septal, and lateral wall IVA, were significantly lower, and the PCT(m) to CT(m) ratio (P = 0.026) was higher at the septal annulus as compared with control group. E(m), a LV diastolic parameter, was significantly lower at the septal annulus. CONCLUSION Cardiac sarcoid involvement is not rare and is treatable. It should be identified at an early stage. TDI, especially IVA, may be a suitable tool for the early detection of subclinical LV sarcoid involvement.

Catheter-Directed Therapy in Acute Pulmonary Embolism with Right Ventricular Dysfunction: A Promising Modality to Provide Early Hemodynamic Recovery

Background Catheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure. Material/Methods Medical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed. Results The study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2±16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04–0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2–98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure. Conclusions CDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

Combination and comparison of two models in prognosis of pulmonary embolism: Results from TUrkey Pulmonary Embolism Group (TUPEG) study☆

BACKGROUND Clinical parameters, biomarkers and imaging-based risk stratification are widely accepted in pulmonary embolism(PE). The present study has investigated the prognostic role of simplified Pulmonary Embolism Severity Index (sPESI) score and the European Society of Cardiology (ESC) model. METHODS This prospective cohort study included a total of 1078 patients from a multi-center registry, with objectively confirmed acute symptomatic PE. The primary endpoint was all-cause mortality during the first 30days, and the secondary endpoint included all-cause mortality, nonfatal symptomatic recurrent PE, or nonfatal major bleeding. RESULTS Of the 1078 study patients, 95 (8.8%) died within 30days of diagnosis. There was no significant difference between non-low-risk patients ESC [12.2% (103 of 754;)] and high-risk patients as per the sPESI [11.6% (103 of 796)] for 30-day mortality. The nonfatal secondary endpoint occurred in 2.8% of patients in the the sPESI low-risk and 1.9% in the ESC low-risk group. Thirty-day mortality occurred in 2.2% of patients the sPESI low-risk and in 2.2% the ESC low-risk group (P=NS). In the present study, in the combination of the sPESI low-risk and ESC model low-risk mortality rate was 0%. CONCLUSIONS The sPESI and the ESC model showed a similar performance regarding 30-day mortality and secondary outcomes in the present study. However, the combination of these two models appears to be particularly valuable in PE.

Association between self reported snoring, STOP questionnaire and postoperative pulmonary complications in patients submitted to ortophaedic surgery

BackgroundObstructive sleep apnea (OSA) may increase perioperative complications. The aim of this study was to determine the relationship among postoperative pulmonary complication, snoring and STOP questionnaire in patients with ortophaedic surgery.Methods1,406 consecutive records of patients who had undergone elective ortophaedic surgery during the period January 2005-December 2008 were investigated retrospectively. Demographic information, sleep symptoms, STOP questionnaire, comorbidities and outcome data were collected.ResultsThere were 289 (20.5%) snorers and 1,117 (79.5%) non-snorers in the study group. There was no significant difference between snorer and non-snorer patients (p > 0.05) in the prevalence of pneumonia and respiratory failure. But in snorer patients the rate of postoperative atelectasis was significantly higher than in non-snorer group (p < 0.0001). The STOP Questionnaire was given to 1,406 patients and 147 (10.4%) out of them were classified at high risk of OSA. There was no significant difference in the prevalence of pneumonia and respiratory failure between low and high risk group (p > 0.05). However, in high risk patients the occurrence of postoperative atelectasis was significantly higher than in low risk group (p < 0.0001).ConclusionPostoperative atelectasis was significantly more prevalent in the high risk group according to STOP questionnaire.

Relationship between disease severity and D-dimer levels measured with two different methods in pulmonary embolism patients

Pulmonary embolism (PE) is diagnosed with increasing frequency nowadays due to advances in the diagnostic methods and the increased awareness of the disease. There is a tendency to use non invasive diagnostic methods for all diseases. D-dimer is a fibrin degradation product. We aimed to detect the relationship between disease severity and the D-dimer levels measured with two different methods. We compared D-dimer levels in cases of massive vs. non-massive PE. A total of 89 patients who were diagnosed between 2006 and 2008 were included in the study. Group 1 included patients whose D-dimer levels were measured with the immunoturbidimetric polyclonal antibody method (D-dimerPLUS®), while Group 2 patients made use of the immunoturbidimetric monoclonal antibody method (InnovanceD-DIMER®). In each group, the D-dimer levels of those with massive and non-massive PE were compared, using the Mann Whitney U test. The mean age of Group 1 (25 F/26 M) was 56.0 ± 17.9 years, and that of Group 2 (22 F/16 M) was 52.9 ± 17.9 years. There was no statistical difference in gender and mean age between the two groups (p > 0.05). In Group 1, the mean D-dimer level of massive cases (n = 7) was 1444.9 ± 657.9 μg/L and that of nonmassive PE (n = 34) was 1304.7 ± 350.5 μg/L (p > 0.05). In Group 2, the mean D-dimer level of massive cases (n = 6) was 9.7 ± 2.2 mg/L and that of non-massive PE (n = 32) was 5.9 ± 1.3 mg/L (p < 0.05). The mean D-dimer levels of massive cases as measured with the immunoturbidimetric monoclonal antibody method were significantly higher. Pulmonary embolism patients whose D-dimer levels are higher (especially higher than 6.6 mg/L) should be considered as possibly having massive embolism. Diagnostic procedures and management can be planned according to this finding.RiassuntoLa diagnosi di embolia polmonare (EP) viene posta oggi giorno con sempre maggiore frequenza grazie ai passi avanti della metodologia diagnostica e alla maggiore consapevolezza di malattia. In tutte le patologie si tende a ricorrere a metodi non invasivi per giungere alla diagnosi. Il D-dimero è un prodotto di degradazione della fibrina. Scopo di questo studio è valutare il rapporto tra gravità di malattia e livelli di D-dimero misurati con due metodiche differenti. Abbiamo comparato i livelli D-dimero in casi di EP massiva e in casi non gravi di EP. Sono stati selezionati 89 pazienti in cui è stata posta diagnosi di EP tra il 2006 e il 2008. Al Gruppo 1 sono stati allocati i pazienti ai quali il D-dimero era stato misurato mediante un metodo immunoturbidimetrico con anticorpi policlonali (D-dimer PLUS®), al Gruppo 2 i pazienti valutati mediante metodo immunoturbidimetrico con anticorpi monoclonali (InnovanceD-DIMER®). La comparazione tra i due gruppi è stata effettuata con il Mann Whitney U test. L’età media del gruppo 1 (25F/26M) era 56,0 ± 17,9 anni, nel Gruppo 2 (22F/16M) era 52,9 ± 17,9 anni. Non vi era una differenza statisticamente significativa tra i due gruppi per sesso o età (p > 0,05). Nei pazienti più gravi del gruppo 1 (n = 7) il livello medio di D-dimero era 1444,9 ± 657,9 μg/L, nei non gravi (n = 34) era 1304,7 ± 350,5 μg/L (p > 0,05). Nel gruppo 2 il livello medio di D-dimero nei gravi (n = 6) era 9,7 ± 2,2 mg/L e nei non-gravi (n = 32) era 5,9 ± 1,3 mg/L (p < 0,05). Il livello medio di D-dimero nei casi gravi in cui è stata utilizzata la metodica con anticorpo monoclonale è risultato significativamente più elevato rispetto ai pazienti meno gravi. Nei pazienti con embolia polmonare il cui D-dimero è più elevato (specie se superiore a 6,6 mg/L con la metodica ad anticorpi monoclonali) dovrebbe essere considerata la possibilità di una embolia massiva. I protocolli diagnostici e di gestione dei pazienti potrebbero perciò essere riformulati sulla base di questi risultati.

Serum CCL-18 level is a risk factor for COPD exacerbations requiring hospitalization

Introduction Chemokine (C-C motif) ligand 18 (CCL-18) has been shown to be elevated in chronic obstructive pulmonary disease (COPD) patients. This study primarily aimed to evaluate whether the serum CCL-18 level differentiates the frequent exacerbator COPD phenotype from infrequent exacerbators. The secondary aim was to investigate whether serum CCL-18 level is a risk factor for exacerbations requiring hospitalization. Materials and methods Clinically stable COPD patients and participants with smoking history but normal spirometry (NSp) were recruited for the study. Modified Medical Research Council Dyspnea Scale, COPD Assessment Test, spirometry, and 6-min walking test were performed. Serum CCL-18 levels were measured with a commercial ELISA Kit. Results Sixty COPD patients and 20 NSp patients were recruited. Serum CCL-18 levels were higher in COPD patients than those in NSp patients (169 vs 94 ng/mL, P<0.0001). CCL-18 level was significantly correlated with the number of exacerbations (r=0.30, P=0.026), although a difference in CCL-18 values between infrequent and frequent exacerbator COPD (168 vs 196 ng/mL) subgroups did not achieve statistical significance (P=0.09). Serum CCL-18 levels were significantly higher in COPD patients who had experienced at least one exacerbation during the previous 12 months. Overall, ROC analysis revealed that a serum CCL-18 level of 181.71 ng/mL could differentiate COPD patients with hospitalized exacerbations from those who were not hospitalized with a 88% sensitivity and 88.2% specificity (area under curve: 0.92). Serum CCL-18 level had a strong correlation with the frequency of exacerbations requiring hospitalization (r=0.68, P<0.0001) and was found to be an independent risk factor for hospitalized exacerbations in the multivariable analysis. Conclusion CCL-18 is a promising biomarker in COPD, as it is associated with frequency of exacerbations, particularly with severe COPD exacerbations requiring hospitalization, as well as with functional parameters and symptom scores.

Summary of Consensus Report on Preoperative Evaluation

INTRODUCTION The clinician has three aims in the preoperative evaluation: to determine the risk of preoperative complications, to decrease the risk of perioperative complications, and to eliminate the risk factors in patients who have a risk of complications in the postoperative period. For this purpose, an accurate preoperative evaluation would allow the patient to be operated on with minimum risk.