Recep Akgedik

Increased Exhaled 8-Isoprostane and Interleukin-6 in Patients with Helicobacter pylori Infection.

Helicobacter pylori (H. pylori) infection triggers both local inflammation, usually in gastric mucosa, and chronic systemic inflammation. It is assumed that this local and systemic inflammation is caused by extracellular products excreted by H. pylori. The aim of this study was to investigate the possible association between H. pylori infection and a local inflammatory response in the airway by using exhaled breath condensate technique.

Influence of obstructive sleep apnea on ischemia-modified albumin levels and carotid intima-media thickness

Obstructive sleep apnea (OSA) is associated with an increased risk of atherosclerosis. Carotid intima-media thickness (CIMT) is strongly associated with the presence of significant risk factors for cardiovascular disturbances. A disturbance in the oxidative/antioxidative balance is involved in the pathogenesis of OSA and cardiovascular diseases. Ischemia-modified albumin (IMA) is suggested as a novel marker of oxidative stress; IMA can be defined as decreased binding of transitional metal ions to serum albumin in oxidative status. The purpose of this research was to evaluate the influence of OSA on IMA levels and CIMT. In total, 61 individuals with OSA with no comorbidities and 24 healthy controls with a similar body mass index and age were enrolled in this study. Serum levels of IMA, CIMT (estimated radiologically), and polysomnographic parameters, were determined and interpreted. Serum IMA levels were significantly higher in individuals with OSA compared with the control group (p=0.0003). CIMT was significantly higher in the OSA group compared with the control group (0.88± 0.26 mm vs 0.75±0.17 mm, p=0.005). The CIMT and serum IMA levels were positively correlated with the apnea-hypopnea index (r=0.35 and r=0.32, respectively), and with the oxygen desaturation index (r=0.34 and r=0.29, respectively) at baseline. Increased IMA levels and CIMT may be related to increased oxidative stress and risk of atherosclerosis in individuals with OSA.

Spontaneous hemothorax due to dabigatran use in a patient with atrial fibrillation

A 72-years-old male patient admitted to our clinic with the complaint of increasing dyspnea in the last 1 week. He had a medical history of atrial fibrillation and chronic obstructive pulmonary disease. He had been under treatment of 50 mg metoprolol daily and 110 mg dabigatran twice daily for 1.5 years. There was no respiratory sound on the right lower lung field in anterior and posterior aspect. Dullness and decreased thoracic vibration were prominent on the same lung field. Heart rate was 110 beats/min, respiratory rate was 18/min and oxygen saturation was 93% in the room air. Other systemic examination findings were normal. Moderate pleural effusion was detected in the chest X-ray in the right lung (Fig. 1A). Computed tomography scans of the chest also revealed pleural effusion with lobulated contour and 7 cm in diameter in the right hemithorax (Fig. 2). Laboratory findings were as follows; WBC: 12.6 3 10 (4.6–10.2), HGB: 12.9 g/dL (12.2–18.1), Htc: 40.3% (37.7–53.7), Plt: 256 3 10, CRP: 29 mg/dL, ESR: 86 mm/h, PT: 16.9 s (11– 16), INR: 1.27 (0.8–1.25), APTT: 39.5 s (24–34). Dabigatran was discontinued for 24 h and thoracentesis was performed resulting with drainage of significant hemorrhagic material. Blood count findings of pleural fluid were as follows; HGB: 10.8 g/dL (12.2–18.1), Htc: 32.3% (37.7–53.7). Hemothorax was diagnosed considering the ratio of blood/pleural fluid hematocrit which was above 80%. History of trauma was questioned again. However, the patient did not define any history of trauma. The patients was inserted an 8F pleural catheter (Plastimed-ThoracathVR ). An amount of 1100 cc hemorrhagic material was drained in the first day and 250 cc in the second. In the third day, the amount of the fluid was less than 100 cc and it was light-colored. Control chest X-ray demonstrated complete resolution of the fluid and the drain was removed at the fifth day (Fig. 1B). The patient did not have any other reason that would cause hemorrhage except dabigatran use. Dabigatran and B-blocker were discontinued due to life-threatening hemorrhage in the lungs and acetyl salicylic acid in addition to diltiazem therapy was started at the fifth day. New hemorrhage was not observed under these drugs and the patient was discharged asymptomatically. The most common cause of hemotorax is blunt or penetrating trauma. Spontaneous hemothorax develops in the absence of any traumatic reason and is quite rare. Spontaneous hemothorax often accompanies pneumothorax. It occurs due to rupture of vascularized adhesions between parietal and visceral pleura. Isolated hemothorax often develops secondary to coagulopathies, neoplasms, vascular ruptures and pleural endometriosis (1). The main goal of anticoagulant use is to reduce risk of systemic thromboembolic events and stroke. Warfarin has been used quite effectively for this purpose. However, it is subject to increased risk of bleeding and management of dosing is quite difficult. New oral anticoagulants (rivaroxaban, dabigatran and apixaban) are direct thrombin inhibitors and do not require dose management. Dabigatran was found to be superior to warfarin in terms of stroke and systemic embolism prevention in a study who were followed up for 2 years. Major and minor bleeding rates were observed to be significantly lower in dabigatran group with the dose of 110 mg (2). The literaure includes reports about spontaneous hemothorax due to warfarin use. However, INR value was not in the therapeutic range in these cases and warfarin overdose was the main problem (3, 4). Spontaneous hemotorax cases have also been reported in patients using low molecular weight heparin (5, 6). Likewise, unfractioned heparin has also been reported to cause spontaneous hemothorax (7). Unlike, spontaneous hemothorax due to new oral anticoagulants has not been reported previously. Traetment of spontaneous hemothorax is drainage with large chest tube while urgent surgery may be required in massive cases in addition to blood and fluid replacement. In our case, vital signs were stable. There was no clot in the pleural fluid and a total of 1400 cc hemorrhagic fluid was drained. To our knowledge, our case is the first report of a spontaneous hemotorax due to dabigatran use. Our case was treated nonsurgical therapeutic approach via Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article and have no relevant financial disclosures.

Lung damage due to low-voltage electrical injury

Contact with high- or low-voltage electricity can cause injury. Low-voltage damage is more common and widespread, although there is little information on it in the literature. Exposure to an electrical current can effect every organ system in the body. The degree of damage is related to many factors, including the duration of exposure, type of current, and nature of the affected tissue. An unusual low-voltage electrical injury with a serious pulmonary lesion is presented, including the clinical intervention and imaging findings. We present a 20-year-old male electrician who sustained direct electrical damage to the pulmonary parenchyma, with no signs of chest wall damage, when exposed to a 380 V shock while working. Imaging demonstrated an electrical burn of the posterior right lower lobe. This case demonstrates that a low-voltage electric current can cause lung damage. A timely diagnosis is required for treatment.

Swyer–James–Macleod syndrome mimicking an acute pulmonary embolism: A report of six adult cases and a retrospective analysis

In patients with pulmonary embolism (PE), a pulmonary radiograph may reveal oligemic fields (the Westermark sign) associated with sites of occlusion of the pulmonary arteries, interruption or loss of the artery line (the knuckle sign), and even unilateral hyperlucency attributable to reduced overall lung vascularity. In Swyer–James–Macleod syndrome (SJMS), which develops as a result of bronchiolitis obliterans, unilateral hyperlucency is evident because of emphysema and hypoplasia of the pulmonary artery and its branches. Therefore, SJMS cases with clinical and laboratory data compatible with PE may in fact be confused with PE. The cases of six adult patients who were initially presumed to have PE but on further investigation were diagnosed with SJMS are presented in this report, which thus can serve as a guide for diagnosis of similar cases in future.

Is Decreased Mean Platelet Volume in Allergic Airway Diseases Associated With Extent of the Inflammation Area

Objective The aim of this study was to determine the relationship between mean platelet volume (MPV) level and the extent of airway inflammation in allergic airway diseases and in subgroups by comparison of inflammatory markers. Materials and Methods A retrospective examination was made of 250 patients with allergic airway disease in the symptomatic phase, who had been newly diagnosed or who had abandoned treatment for at least 6 months. These patients were separated into 3 groups of asthma without allergic rhinitis (A − AR, n = 107), asthma with allergic rhinitis (A + AR, n = 83) and allergic rhinitis without asthma (AR − A, n = 60). Results The MPV values of the study groups were found to be significantly lower than those of the control group (P < 0.001). MPV was determined to be negatively correlated with white blood cells, neutrophil count, platelet count and immunoglobulin E level in the study groups. The lowest MPV value was determined in the A + AR group (8.035 ± 1.05 fL), which had the most extensive airway involvement, and the highest MPV value was determined in the AR − A group (8.109 ± 1.11 fL) with the least airway involvement. MPV level sensitivity and the specificity of the best cutoff level were 74.5% and 40.8%, respectively. The cutoff level of 8.18 fL for MPV level was found to have moderate sensitivity and low specificity for predicting pulmonary embolism. Conclusions The results of this study showed that MPV is lower in allergic airway diseases and a negative correlation was determined between MPV and inflammation markers but no statistically significant difference was determined between MPV and extent of the inflammation area.

The effects of treatment in patients with childhood asthma on the elastic properties of the aorta

Summary Introduction: The study aimed to investigate the effects of treatment in patients with childhood asthma on the elastic properties of the aorta and cardiovascular risk. Methods: The study was performed in 66 paediatric patients diagnosed with bronchial asthma (BA). All patients were administered the β2 agonist, salbutamol, for seven days, followed by one month of montelukast and six months of inhaled steroid treatment. All patients underwent conventionaltransthoracic echocardiographic imaging before and after treatment. Aortic elasticity parameters were considered to be the markers of aortic function. Results: Aortic elasticity parameters, including aortic strain (15.2 ± 4.8 and 18.8 ± 9.5%, p = 0.043), aortic distensibility (7.26 ± 4.71 and 9.53±3.50 cm2/dyn, p = 0.010) and aortic stiffness index (3.2 ± 0.6 and 2.8 ± 0.5, p = 0.045 showed significant post-treatment improvement when compared to pre-treatment values. Tricuspid annular plane systolic excursion (TAPSE) was also observed to improve after treatment (1.81 ± 0.38 and 1.98 ± 0.43, p = 0.049). Conclusion: The study demonstrated that when provided at appropriate doses, medications used in BA may result in an improvement in aortic stiffness.

Recurrent pneumonia due to olive aspiration in a healthy adult: a case report

Foreign body aspiration (FBA) of healthy adults is an extremely unusual condition due to functional swallowing reflex. It may be seen more common in patients who have primary underlying causes such as neurological diseases, mental retardation, alcohol or sedative misuse. FBA in adults can be difficult to diagnose because the symptoms are nonspecific and chest X-rays may be normal. Occult FBA may lead to a mistaken clinical diagnosis of asthma, bronchitis, chronic pneumonia, recurrent pneumonia and bronchiectasis (1, 2). In Turkey, olive consumption at breakfast is very common particularly among adults. We presented a case of olive aspiration which is extremely rare. A 64-year-old female adult patient was admitted to our clinic with a 1-week history of fever, productive cough and shortness of breath. Vital signs on admission revealed a pulse of 80 beats/min, blood pressure of 120/80 mmHg, respiratory rate of 14 breaths/min and a temperature of 37.5°C. Chest examination revealed crackles on the right lower area. The rest of the systemic examination was unremarkable. Chest X-ray revealed pneumonic infiltrates in the right middle and lower lung zones. The laboratory tests on admission showed a leucocyte count of 12 300/μL (4.0–10/μL) with 72% neutrophils. C-reactive protein was at 18 μmol/L (0–0.5 mg/dL). She was diagnosed with community acquired pneumonia involving the right lower lobe and parenteral antibiotic therapy was initiated. As learned from the patient medical history, she had been hospitalized because of right lower lobe pneumonia

Spontaneous Isolated Pericardial Tamponade Associated with Warfarin

To the Editor, An 83-year-old female patient was admitted to the emergency department with progressive dyspnea and orthopnea for 3 days. She was discharged with warfarin therapy (5 mg per day) due to pulmonary embolism 5 months previously. On admission she was orthopneic and tachypneic. Her arterial blood pressure was 90/60 mmHg and heart rate was 115/min with sinus rhythm. On cardiac auscultation, S1 and S2 intensity were decreased, and pathologic murmur and pericardial friction were not observed. Other physical examination findings were unremarkable. An increased cardio-thoracic ratio was revealed on chest X-ray (Figure 1a). Decreased QRS voltage and sinus tachycardia was evaluated on electrocardiogram. The internalised normalised ratio (INR) level was 8.6 and the prothrombin time was 70 seconds. Haemoglobin was determined to be 11.1 g/dL. The other laboratory findings were normal. An emergency thoracic computed tomography (CT) scan was performed to exclude recurrent pulmonary embolism, and surprisingly showed a massive pericardial effusion (Figure 1b). However, echocardiography revealed severe pericardial effusion that was compressing the right ventricle. Therefore, vitamin K and fresh frozen plasma infusion were administered promptly. As a result, the INR was decreased to 1.4 and 800 mL haemorrhagic fluid was drained percutaneously (P/S) with the apical approach. The patient’s blood pressure, orthopnoea and dyspnoea improved dramatically. There was no other source of bleeding except haemopericardium. Consequently, the cardiac tamponade in our patient, secondary to haemopericardium, was considered to be the result of the incorrect dosage of Warfarin. On control echocardiography, there was no recurrence of pericardial fluid and the patient was discharged on the 5th day. FIG. 1. a, b. Increased cardio-thoracic ratio due to pericardial effusion on chest X-ray (a). CT scan of chest showing large pericardial effusion (see arrow) (b) Cardiac tamponade is a life-threatening emergency condition. It is an acute type of pericardial effusion in which fluid accumulates in the intrapericardial space. This creates a mechanical pressure in the cardiac chambers which disrupts cardiac filling. (1). The common causes of pericardial effusion resulting in tamponade are pericarditis, malignancy, acute myocardial infarction, congestive heart failure, collagen vascular diseases, end stage renal disease, viral and bacterial infections (1). Cardiac tamponade secondary to haemopericardium is rarely seen and occurs with traumatic and non-traumatic causes. Non-traumatic causes are less common and associated with a number of conditions such as malignancy, infection, uraemia or coagulopathy (2). Today, warfarin sodium is still the most commonly used agent for anticoagulant therapy. The risk of spontaneous bleeding in patients using warfarin is less than 10%, whereas the risk of bleeding into the pericardial space is less than 1% (3). Echocardiography, which is the diagnostic test of choice, evaluates the haemodynamic consequences and guides transcutaneous drainage; CT is useful for further workup. These methods are superior to echocardiography for anatomical information, characterisation of the effusion, and providing information about the adjacent structures (2). The primary treatment of pericardial tamponade is pericardiocentesis.. Echocardiography-guided pericardiocentesis has been shown to be a safe and effective method which can be performed at the patient’s bedside (4). Isolated haemopericardium and cardiac tamponade secondary to warfarin are seen very rare. Haemorrhagic cardiac tamponade should be excluded in patients on warfarin with unexplained hypotension and excessive anticoagulation. Close monitoring of INR level is very important in the management of patients, especially in the elderly receiving warfarin treatment (5).