Mehmet Aydogan

Red cell distribution width is a predictor of mortality in patients undergoing coronary artery bypass surgery

We read with interest the article ‘Red cell distribution width and coronary artery bypass surgery’, by Warwick et al., [1]. They aimed to investigate the effect of red cell distribution width (RDW)—after adjustment for the haemoglobin level—on in-hospital mortality, long-term survival, myocardial damage as assessed by creatine kinase muscle–brain (CKMB) isoenzyme release and the length of hospital and intensive care unit (ICU). They concluded that the RDW was a significant factor determining in-hospital mortality and long-term survival, but that it had no significant effect on CKMB release or length of stay in ICU or hospital. Confounding factor analysis revealed that, in the absence of anaemia, the RDW was still a significant factor determining in-hospital mortality and long-term survival. They suggested that the RDW may be a significant factor determining in-hospital mortality and long-term survival in patients undergoing isolated coronary artery bypass graft (CABG). We believe that these findings will enlighten further studies on the relationships between RDW and coronary artery bypass surgery. Thanks to the authors for their contribution. RDW has recently been identified as an independent predictor of all-cause, long-term mortality in patients with coronary artery disease [2]. Sometimes conditions like the differential diagnosis of anaemias might affect the RDW parameter and so this parameter might be changed in any such abnormality in thyroid function tests, renal or hepatic dysfunction (creatinine >1.5 mg/dl, aspartate aminotransferase and alanine transaminase more than twice the upper limit of normal, respectively), inflammatory diseases and any medication. On the other hand, it is also reported that an increased RDW may be associated with ethnicity and nutritional deficiency (i.e. iron, vitamin B12 and folic acid). Reduced glomerular filtration rate (GFR) may also be associated with adverse outcomes in patients with cardiovascular disease. In a previous study, pre-operative GFR was predictive of all-cause mortality, cardiovascular mortality and combined cardiovascular mortality and morbidity. GFR may be useful in identifying those patients undergoing CABG with subclinical chronic kidney disease [3]. For this reason, it would be better if the authors mentioned any of these possible conditions. Present studies have shown that elevated levels of inflammatory molecules are markers of atherosclerotic disease activity. These molecules also indicate an increased risk of the progression of CABG and they can be reduced by medications such as antihypertensive therapy and acetylsalicylic acid treatment [4, 5]. Additionally, not only RDW but also neutrophil lymphocyte ratio, gamma-glutamyltransferase, C-reactive protein, mean platelet volume and uric acid are markers easily used to assess the cardiovascular disease of the patients [6]. These markers might be useful in clinical practice. RDW itself, alone without other inflammatory markers, may not give information to clinicians about the inflammatory condition and prognostic indication of the patients. So we think that it should be evaluated together with other serum inflammatory markers. Finally, it would be better if the authors defined their timescale for measuring RDW levels, because delay in blood sampling can cause abnormal results in RDW measurements.

Omalizumab as a Steroid-Sparing Agent in Chronic Eosinophilic Pneumonia

Chronic eosinophilic pneumonia (CEP) is an idiopathic eosinophilic pulmonary disease characterized by an abnormal and marked accumulation of eosinophils in the lung. Common presenting complaints include cough, fever, dyspnea, wheezing, and night sweats. Common laboratory abnormalities are peripheral blood and BAL eosinophilia. The pathognomonic radiographic finding is bilateral peripheral infiltrates. Corticosteroids are the mainstay of therapy, and dramatic improvement follows treatment. Relapses are common, and most patients require prolonged therapy. Side effects associated with chronic corticosteroid therapy must be monitored. Our case was that of a 36-year-old woman who had characteristic clinical and radiologic features. She was treated with corticosteroids but she needed prolonged therapy, and side effects occurred. Because the patient had high IgE levels and a positive skin prick test result, we used omalizumab for the treatment. The patient responded well. To our knowledge, this is the first CEP case in the literature successfully treated with omalizumab.

HRCT findings of pulmonary sarcoidosis; relation to pulmonary function tests

BackgroundChest-X-ray has several limitations in detecting the extent of pulmonary disease in sarcoidosis. It might not reflect the degree of pulmonary involvement in patients with sarcoidosis when compared to computed tomography of the thorax. We aimed to investigate the HRCT findings of pulmonary sarcoidosis and to find out the existence of possible relations between HRCT findings and PFTs. In addition, we aimed to investigate the accordance between HRCT findings and conventional chest-X-ray staging of pulmonary sarcoidosis.Method45 patients with sarcoidosis with a mean age 29.7+/− 8.4 years were evaluated. Six of them were female and 39 were male. The type, distribution and extent of the parameters on HRCT/CTs were evaluated and scored. Chest-X-rays were evaluated for the stage of pulmonary sarcoidosis. Correlations were investigated between HRCT/CT parameter scores, Chest X-Ray stages and pulmonary function parameters.ResultsNodule, micronodule, ground glass opacity and consolidation were the most common HRCT findings. There were significant correlations between pulmonary function parameters, HRCT pattern scores, and chest-X-ray stages. A significant correlation between chest-x-ray score and total HRCT score was found.ConclusionsPulmonary sarcoidosis patients might have various pulmonary parenchymal changes on HRCT. Thorax HRCT was superior to chest-X-ray in detecting pulmonary parenchymal abnormalities. The degree of pulmonary involvement might be closely related to the loss of pulmonary function measured by PFTs. Chest-X-ray is considered to have a role in the evaluation of pulmonary sarcoidosis.

Pentraxin 3: An early marker of severity in higher mortality disease

this debilitating and often manageable condition. Further research is needed to examine the relationship between urinary incontinence, its severity and effect with type and duration of heart failure diagnosis, history of prior incontinence, exercise and lifestyle factors, medications and other medical conditions such as diabetes and hypertension. Further research is also required to investigate optimal management strategies with people with heart failure.

Assessment of the role of serum ischemia-modified albumin in obstructive sleep apnea in comparison with interleukin-6

ABSTRACT Objectives: There is limited and contradictory information regarding the role of serum ischemia-modified albumin (IMA) in obstructive sleep apnea (OSA). In this study we examine the effects of OSA and obesity on IMA and interleukin-6 (IL-6), and detect whether IMA and IL-6 may be potential biomarkers in OSA. Methods: Fifty-one males who underwent all night polysomnography test were included into the study. Body-mass index (BMI) and apnea-hypopnea index (AHI) of all patients were determined. Serum IMA and IL-6 levels, erythrocyte sedimentation rate (ESR), complete blood count, routine blood biochemistry and thyroid function tests were performed. Results: Mean IMA [0.36 (± 0.04) U/ml, 0.89 (± 0.15) U/ml], mean IL-6 [1.01 (± 0.19) pg/ml, 2.02 (± 1.19) pg/ml] and mean ESR [4.14 (± 2.5) mm/h, 14.35 (± 13.7) mm/h] levels showed significant difference between non-OSA and OSA groups (P = 0.005, P < 0.001, P < 0.001, respectively). Sensitivity of IMA in distinction of non-OSA/OSA was equal to IL-6 and higher than ESR. IMA was also a stronger predictive factor than IL-6 and ESR in the evaluation of OSA groups (severe/mild/moderate OSA and non-OSA). IMA was the sole distinctive biomarker in assessment of obese and non-obese cases. IMA correlated with IL-6, AHI and ESR. Conclusion: Serum IMA may be a valuable oxidative stress indicator for OSA and could act as a better biomarker than IL-6 for reflecting the presence and the severity of OSA.

Red cell distribution width without additional cost compared with a relatively expensive test measurement in clinical practice

We have read the article “Red cell distribution width (RDW) is associated with physical inactivity and heart failure(HF), independent of established risk factors, inflammation or iron metabolism; the EPIC— Norfolk study” by Emans et al. [1]. They aimed to investigate in a healthy population whether this association is independent of cardiovascular risk factors and iron metabolism, and whether RDW associates with physical activity. They concluded that RDW is associatedwith HF events in an apparently healthy middle-aged population. They also showed that the underlying pathophysiology linking HFwith anisocytosis is not reflected by conventional risk factors, nor it is explained by iron metabolism or inflammation. Furthermore, RDW levels were associated with physical inactivity, but this did not influence the RDW-associatedrisk of HF. Inflammatory parameters such as cytokines, high-sensitivity Creactive protein, natriuretic peptides, neurohormones as well as indicators of endothelial dysfunction and oxidative stress could be useful for diagnosis and prognosis. Recently, elevated RDW has been identified and proposed to be of importance. RDW is a quantitative measure of anisocytosis, the variability in size of circulating erythrocytes. As several routine hematology instruments can analyze erythrocyte volume, RDW is available in most clinical settings [2]. RDW independently predicts 1-year mortality in acute HF [3]. Consequently, higher levels of RDW correlate to poorer survival in chronic HF [4]. Recently, a number of studies have reported that elevated RDW levels are associatedwith poor prognosis in the setting of coronary artery disease [5], coronary bypass surgery, stroke, peripheral arterial disease, and older age [6]. RDW has recently been defined to highly correlate with shortand long-term outcomes in different clinical settings [7]. However, a common underlying cause of high RDW is iron or B12/folate deficiency. A similar increase in RDW occurs during iron and B12/folate replacement therapy when the reticulocyte count increases. The correlation with bilirubin could also be due to liver damage and excessive alcohol intake, resulting in macrocytosis and increased RDW. RDW may be also affected by ethnicity, neurohumoral activation, thyroid disease, bone marrow dysfunction, inflammatory diseases, chronic systemic inflammation and use of any medications. In addition, the authors used the Modification of the Modification of Diet in Renal Disease(MDRD) formula for glomerular filtration rate (GFR). However, the MDRD formula might measure higher GFR in younger age groups compared to the Cockcroft–Gault equation, but it can measure lower GFR in older individuals in comparison with the Cockcroft–Gault equation [8]. Although the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) recently published an equation for GFR using the same variables (serum creatinine level, age, sex, and race) as the MDRD formula, the CKD-EPI equation more accurately categorized individuals with respect to long-term clinical risk compared with the MDRD formula [9]. For this reason, it may be useful, and the result of the study may be different, if the authors had used the CKD-EPI equation due to these factors. In conclusion, the value of RDW is an instrument-dependent and consequently, each laboratory reference values may be different. Additionally, finally, because the authors evaluated patients with HF retrospectively in their study [1], the authors might not accurately define how much time elapsed before measuring RDW levels; delaying blood sampling may lead to abnormal results in RDW measurements [10]. So, not only RDWbut also mean platelet volume, neutrophil lymphocyte ratio [11], CRP and uric acid are easy and routine methods to evaluate the prognosis of the patients [12]. These markers might be useful in clinical practice [13]. We strongly believe that those findings obtained from the current study will lead to further studies examining the relationship between RDW and HF. This study gives important information on this clinically relevant condition.

Heart failure: not only reduced left ventricular ejection fraction but also reserved ejection fraction!

authors aimed to evaluate the effect of inhaled bronchodilators on pulmonary function and dyspnea in patients with chronic heart failure (HF). They concluded that inhaled bronchodilators have the potential to improve pulmonary function in patients with chronic HF, especially in those with airway obstruction. However, improvement in dyspnea at rest after bronchodilation did not correlate to improvement in pulmonary function. They suggested that inhaled bronchodilators may have an additional role in the management of these patients. Heart failure is a common clinical syndrome characterized by dyspnea, fatigue, and signs of volume overload, which may include peripheral edema and pulmonary rales. 2 The most common

Further studies on diastolic dysfunction in patients with airway obstruction should be kept in mind

We read the article “Airway obstruction in systolic heart failure (SHF) — Chronic obstructive pulmonary disease (COPD) or congestion?” by Susanne Brenner et al. with interest [1]. The authors aimed to estimate the prevalence, correlates and prognostic impact of true COPD in patients with SHF. They concluded that COPD is over-diagnosed in SHF. Also, COPD has a pronounced impact on survival only when proven by pulmonary function testing (PFT) under stable conditions. Chronic obstructive pulmonary disease and heart failure are prevalent comorbidities affecting a huge proportion of the world population, responsible for significantmorbidity andmortality [2]. COPD is a cluster of heterogenic disorders, characterized by expiratory flow limitation that is not completely reversible and in most cases progressive. A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic coughor sputumproductionandhistoryof exposureof risk factors such as smoking. Spirometry is only one parameter for establishing the clinical diagnosis of COPD [3]. In the presented study [1], about half of the patients (45.6%) in the study population had never smoked. Similarly, the rate of never-smokers in patients with diagnosis of COPD was 28%. And there is no information on the presence of other risk factors. Since COPD is characterizedbyfixedairflowobstruction, thismay lead tomisdiagnosisof various diseases with fixed airflow obstruction such as tuberculosis, bronchiectasis and lung cancer [4]. For these reasons, in patients (28%) without any risk factors may had received the wrong diagnosis. At this point, radiological images are important for the differential diagnosis. Another reason for the continuation of fixed airway obstruction in patients with no history of exposure to risk factors may be the continuation of decompensated left heart failure. Although they found that the mean ejection fraction of patients with proven COPD was 41% [1], population-based studies show that approximately half of all patients with heart failure have preserved left ventricular systolic function (HF-PEF) [5]. So, the continuation of fixed airwayobstructionmaybe associatedwith not only SHF but alsoHF-PEF. Finally, we think that further studies will mention these factors in patients with airway obstruction.

Red cell distribution width in patients with sarcoidosis

Dear Editor, We have read the article ‘Prognostic Value of Red Cell Distribution Width (RDW) in Patients with Sarcoidosis’ by Ozsu et al. (1). They aimed to investigate the role of RDW monitoring in predicting the prognosis and progression of sarcoidosis. They concluded that serial RDW follow up may be beneficial in predicting the progression of sarcoidosis. This study gives important information on this clinically relevant condition. The ready availability of this parameter at no additional cost may encourage its wider use in clinical practice in the future. Thanks to the authors for their contribution. Immunopathogenic mechanism is one of the most common factors causing organ damage in patients with sarcoidosis. Cytokines, soluble cytokine receptors, metabolites, enzymes, extracellular matrix components, soluble adhesion molecules and other serum components had been evaluated to serve as serological markers of sarcoidosis in a previous review (2). Additionally, in a previous study (3), the authors evaluated the diagnostic accuracy of inflammatory markers to predict respiratory severity in sarcoidosis. The authors concluded that some inflammatory markers appear to be useful for monitoring respiratory disease severity in sarcoidosis. In comparison of above markers, several routine, inexpensive, readily available haematology markers can analyse inflammatory conditions, RDW is available in most clinical settings. RDW is a quantitative measure of anisocytosis, the variability in size of circulating erythrocytes. RDW is frequently associated with nutritional deficiencies (i.e. iron, vitamin B12 and folic acid) and transfusion history. RDW independently predicts 1-year mortality in the setting of stable angina, acute coronary syndrome, coronary bypass surgery, heart failure, stroke, peripheral arterial disease, older age and in the patients with or without coronary artery disease (4). Furthermore, RDW may also reflect ethnicity, neurohumoral activation, renal dysfunction, thyroid disease, hepatic dysfunction, bone marrow dysfunction, inflammatory diseases, chronic or acute systemic inflammation (5) and use of some medications (6). Additionally, the value of RDW is instrument dependent, forcing each laboratory to establish its own reference values. Finally, it would be better if the authors might define how much time they specified on measuring RDW levels because of the delaying blood sampling that can cause abnormal results in RDW measurements (7). As a conclusion, we hardly believe that those findings obtained from the current study will lead to further studies examining the relationship between RDW and sarcoidosis. However, one should keep in mind that RDW itself, alone without other inflammatory indicators, may not give exact information to clinicians about the inflammatory status and prognostic indication of the patients. So, from that point of view, we think that it should be evaluated accompanied with other serum inflammatory markers.

Future studies should consider multiple predisposing conditions in predicting weaning failure from mechanical ventilation in patients after cardiac surgery

Dear Editor, We read the article titled “High levels of B-type natriuretic peptide (BNP) predict weaning failure from mechanical ventilation in adult patients after cardiac surgery” by Thiago Martins Lara et al. with interest (1). The authors aimed to evaluate whether serum levels of B-type natriuretic peptide are a predictor of weaning failure from mechanical ventilation after cardiac surgery. They concluded that high BNP levels are predictive of failure to wean from mechanical ventilation after cardiac surgery. Plasma levels of BNP are increased in disorders associated with intravascular volume overload, increased central venous pressure and left ventricular dysfunction. BNP secretion is directly proportional to left ventricular wall stress and blood volume. Because of these associations, there has been much interest in using BNP as a biomarker for heart failure (2). However, high levels of BNP are present in many cases for reasons unrelated to cardiac diseases. In several studies, BNP levels were higher in women than in men, independent of age. Although the reason for this difference is unknown, it is believed that estrogen may play a role. Furthermore, levels of BNP increase with age, and this difference is not associated with “age-related” diastolic dysfunction in either sex (3). Obese individuals have low circulating natriuretic peptide levels, and diabetes mellitus is also associated with low plasma levels of natriuretic peptide (4). In addition, elevated BNP levels may be observed in many diseases associated with hypervolemia, such as chronic renal failure, chronic liver disease and hyperaldosteronism (5). Furthermore, respiratory conditions, such as pulmonary embolism and chronic obstructive pulmonary disease, are associated with high levels of BNP in the absence of left heart failure. One of the most important conditions associated with elevated BNP levels is sepsis. Many studies have shown significantly higher BNP levels in patients with sepsis, and this effect was not related to myocardial dysfunction (6). In conclusion, high levels of BNP are presented as a predictive factor for failure to wean from mechanical ventilation after cardiac surgery in the study by Thiago Martins Lara et al. However, because BNP levels may be affected by many factors, the significance of those risk factors in weaning from mechanical ventilation after cardiac surgery should be considered in future large-scale prospective randomized clinical trials.