Turgay Celikel

Analysis of pleural effusions using flow cytometry.

Flow cytometry allows a rapid and accurate analysis of the cells in serous fluids. The aim of this study was to evaluate the use of flow cytometric analysis in malignant pleural effusions. 26 patients (13 females, 13 males; mean age 52 +/- 19 years; range 16-82) were included in the study. 15 had malignant pleural effusions (7 adenocarcinoma, 2 lymphoma, 2 chronic myeloid leukemia, 1 ovarian carcinoma, 1 small cell lung carcinoma, 1 squamous cell lung carcinoma and empyema, and 1 malignant mesothelioma) with positive cytology. 2 had benign effusions associated with malignancy (1 squamous cell lung carcinoma and congestive heart failure, and 1 neuroblastoma and hypoproteinemia). 9 had benign effusions (3 tuberculosis, 1 congestive heart failure, 3 parapneumonic pleural effusion, 1 benign mesothelioma, and 1 pulmonary embolism). Flow cytometric analysis of pleural effusions revealed an increased DNA index in malignant effusions: 1.32 +/- 0.44 versus 0.88 +/- 0.23 in benign effusions (p < 0.04). The cell cycle distribution of cells such as G1/G0 and S in malignant effusions did not differ from that of benign pleural effusions; however G2+M increased significantly in malignant effusions (p < 0.03). Using analysis of mononuclear immunophenotyping, CD3+, CD4+, and CD8+ cells did not show any significant difference between the two groups. The lymphocyte activation marker CD38 was positive in 57.6 +/- 11.5% of malignant fluid cells and 38.5 +/- 6.2% of benign fluid cells (p < 0.04). The mean carcinoembryonic antigen levels in malignant and benign pleural effusions were 98.7 +/- 157.3 and 0.9 +/- 1.2 ng/ml, respectively (p < 0.03). In conclusion, the results of our study indicate that finding cells with an abnormal DNA content strongly supports the diagnosis of malignant pleural effusions. Additionally, mononuclear cell phenotypes have to be taken into consideration for malignant pleural effusions, particularly activated T cells. We recommend that flow cytometry should be performed if the cytology is equivocal.

IL-8 in pleural effusion.

Interleukin-8 (IL-8) is a recently described potent chemotactic factor that may be involved in the pathogenesis of pleural effusions. To understand the actual mechanisms mediating the inflammatory response, changes in cellular components and IL-8 level in pleural fluid of different aetiologies were evaluated. Thirty-four patients (19 male, 15 female) with a mean age of 46 +/- 22 years (range 16-92) were included in the study. Of these, 13 had tuberculous pleural effusion, seven had empyema/parapneumonic pleural effusion, and 14 had malignant pleural effusion (seven adenocarcinoma, three ovarian carcinoma, two lymphoma, one chronic myeloid leukaemia, and one small cell carcinoma) with positive cytology. Differential cell counts in the pleural fluid were obtained using cytocentrifuge preparations. The concentrations of IL-8 in pleural fluid were measured by the ELISA method. Interleukin-8 was detected in all 34 pleural fluid samples. The serum IL-8 level was analysed only in the empyema/parapneumonic pleural effusion group. The mean IL-8 levels of tuberculous, empyema/parapneumonic, and malignant pleural effusions were 1420 +/- 1049 pg ml-1, 4737 +/- 2297 pg ml-1, and 1574 +/- 1079 pg ml-1, respectively. The IL-8 levels in the empyema/parapneumonic group were significantly raised over malignant and tuberculous groups (P < 0.02). The mean pleural fluid neutrophil counts in tuberculous, empyema/parapneumonic and malignant pleural effusions were 315 +/- 575 cells mm-3, 11,136 +/- 12,452 cells mm-3, and 635 +/- 847 cells mm-3, respectively (P < 0.003). There was a significant positive correlation between pleural IL-8 levels and neutrophil counts (r = 0.46, P < 0.006). The levels of IL-8 in paired samples of serum and pleural fluid in the empyema/parapneumonic effusion group were compared, and the concentration of IL-8 was higher in the pleural effusion than serum (means, 4737 +/- 2297 pg ml-1 and 130.0 +/- 62.5 pg ml-1, respectively, P < 0.03). There was a significant negative correlation between IL-8 concentrations in serum and pleural fluid (r = -0.80, P < 0.03). This data suggests that production of IL-8 in pleural effusion may play a key role in initiation and maintenance of inflammatory reactions, especially in empyema/parapneumonic pleural effusions. It may offer the basis for introduction of novel anti-inflammatory agents in treatment.

C-reactive protein in acute pulmonary embolism.

Background Right ventricular dysfunction and N-terminal proB-type natriuretic peptide (NT-proBNP) are established determinants of prognosis in acute pulmonary embolism (PE). The aim of the study was to investigate the prognostic value of C-reactive protein (CRP) in PE. Methods Fifty-six patients (mean age, 64.4 ± 14.8years; 22 male subjects) with acute PE were consecutively enrolled and followed for 36 months after discharge. Serum CRP, NT-proBNP, and troponin T levels were determined. Right ventricular function was evaluated by transthoracic echocardiography. Results Right ventricular dysfunction was present in 31 patients and was more frequent in patients with higher CRP and NT-proBNP levels (P = 0.020 and P = 0.045, respectively). During the 36-month follow-up, there were 15 terminal events (death due to recurrent PE). The mortality rate was 41.2% in patients with NT-proBNP levels greater than 1000 pg/mL, whereas it was 5.9% in patients with less than 500 pg/mL (P = 0.011). Mortality rates also were higher in patients with elevated CRP and troponin T levels, but the differences did not reach clinical significance. The survival rate of acute PE patients with lower NT-proBNP and CRP levels was better than that of patients with higher NT-proBNP and CRP levels. Receiver operating characteristic curve analysis demonstrated cutoff values for NT-proBNP as 1800 pg/mL (sensitivity, 93.3%; specificity, 68.2%; positive predictive values, 66.7%; and negative predictive values, 93.8%) and for CRP as 48mg/L (sensitivity, 72.7%; specificity, 61.9%; positive predictive values, 50.0%; and negative predictive values, 81.3%) to predict mortality in PE patients. Conclusions C-reactive protein is associated with right ventricular dysfunction, which is a predictor of prognosis in PE and may become a promising biomarker for risk stratification of PE, although CRP is not found superior to NT-proBNP.

Treatment of Laryngopharyngeal Reflux Improves Asthma Symptoms in Asthmatics

Objective. Laryngopharyngeal reflux (LPR) is defined as the movement of gastric content toward laryngopharynx and is a common occurrence in patients with asthma. This study aimed (1) to determine the incidence of LPR in patients with asthma by assessment of symptom scores and indirect laryngoscopy and (2) to determine the effect of LPR treatment on asthma symptom scores. Methods. A total of 28 patients with mild to moderate asthma (24 women, 4 men, mean age 46 ± 6 years) were included in the study, and after all patients completed LPR and asthma symptom questionnaires, indirect videolaryngoscopy was performed. In patients with LPR, daily treatment with 40 mg pantoprazole was administered for 3 months. Symptom score assessment and indirect videolaryngoscopic examination were repeated at the end of treatment. Results. A diagnosis of LPR was made in 21 of 28 patients (75%) by indirect laryngoscopy. A statistically significant improvement was observed in asthma and LPR symptoms in patients with LPR after the treatment (p = 0.001 and p < 0.001, respectively). Conclusions. LPR is a frequent condition in asthma patients. When the LPR symptom questionnaire and indirect laryngoscopy findings are suggestive of LPR, treatment with a proton pump inhibitor provides improvement in both asthma and LPR symptoms.

The endocrinologic changes in critically ill chronic obstructive pulmonary disease patients.

ABSTRACT Background: Alterations in the neuroendocrine system occur during critical illness. Chronic obstructive pulmonary disease (COPD) itself causes hormonal changes. The aim of this study was to determine neu roendocrine hormones of COPD patients with acute respiratory failure and to investigate the relationship between hormonal changes, mortality, and morbidity.Methods: We enrolled 21 patients (13 F/8 M) with COPD exacerbation requiring artificial airway support. Blood samples were collected on admission to the ICU, and on the day of hospital discharge. Eighteen healthy people were included as controls. Results: Female patients had lower luteinizing hormone (LH), follicle stimulating hormone (FSH), and free triiodothyronine (fT3), and higher prolactin (PRL) levels than controls on admission to the ICU (FSH: 70.3 vs. 29.3 mlU/mL; LH: 26.6 vs. 6.8 mlU/mL; fT3: 2.9 vs. 2.0 pg/mL; PRL: 12.4 vs. 21.3 ng/mL). Male patients had low testosterone and TSH and high PRL but only changes in TSH and PRL reached statistical significance (testosterone: 3.5 vs. 1.5 ng/mL, TSH: 1.1 vs. 0.5 ulU/mL, PRL: 9.7 vs. 14.2 ng/mL). Female patients had lower fT3 than males (fT3female: 2.7 vs. fT3male: 2.0 pg/mL). On follow-up, significantly elevated FSH and fT3 and decreased estradiol concentrations were documented among recovered women (FSH: 28.4 vs. 46.6 mlU/mL, fT3,: 2.0 vs. 2.6 pg/mL, E2: 27.7 vs. 19.0 pg/mL). Patients had high C-reactive protein levels and acute physiologic and chronic health evaluation II scores. Mortality rate was 9.5% and a negative correlation between E2 and duration of noninvasive mechanical ventilation and length of hospital stay was found in male patients. Conclusion: Men and women with acute respiratory failure in the presence of COPD develop significant changes in the neuroendocrine axis. Hormonal suppression vanishes with disease improvement.

Noninvasive positive pressure ventilation in unplanned extubation

BACKGROUND: Unplanned extubation is quite common in intensive care unit (ICU) patients receiving mechanical ventilatory support. The present study aimed to investigate the effectiveness of noninvasive positive pressure ventilation (NPPV) in patients with unplanned extubation. MATERIALS AND METHODS: A total of 15 patients (12 male, age: 57 ± 24 years, APACHE II score: 19 ± 7) monitored at the medical ICU during the year 2004 who developed unplanned extubation were included in the study. NPPV was tried in all of them following unplanned extubation. Indications for admission to the ICU were as follows: nine patients with pneumonia, three with status epilepticus, one with gastrointestinal bleeding, one with cardiogenic pulmonary edema and one with diffuse alveolar bleeding. RESULTS: Eleven of the patients (74%) were at the weaning period at the time of unplanned extubation. Among these 11 patients, NPPV was successful in 10 (91%) and only one (9%) was reintubated due to the failure of NPPV. The remaining four patients (26%) had pneumonia and none of them were at the weaning period at the time of extubation, but their requirement for mechanical ventilation was gradually decreasing. Unfortunately, an NPPV attempt for 6–8 h failed and these patients were reintubated. CONCLUSIONS: Patients with unplanned extubation before the weaning criteria are met should be intubated immediately. On the other hand, when extubation develops during the weaning period, NPPV may be an alternative. The present study was conducted with a small number of patients, and larger studies on the effectiveness of NPPV in unplanned extubation are warranted for firm conclusions.

Serum-effusion Albumin Gradient in Separation of Transudative and Exudative Pleural Effusions

Communications to the Editor 5 Aoki T, Inoue H, Sasaki H, Shimura S. Maeda S, Tomioka M, et al. Relation between selective alveolo-bronchograms and pulmonary function tests in patients with chronic obstructive lung disease. Am Rev Respir Dis 1984; 129:465-72 6 Honda I, Shimura S, Sasaki T, Sasaki H, Takishima T, Nakamura M. Airway mucosal permeability in chronic bronchitis and bronchial asthmatics with hypersecretion. Am Rev Respir Dis 1998; 137:866-71 7 Aikawa T, Shimura S. Sasaki H, Takishima T, Yaegasi H, Takahashi T. Morphometric analysis of intraluminal mucus in airways in obstructive lung disease. Am Rev Respir Dis 1989; 140:477-82

Role of the Adhesion Molecule ICAM-1 in Asthma

Cells need to interact with one another for the inflammatory response to occur. The intercellular adhesion molecule-1 (ICAM-1), a member of the immunoglobulin supergene family, plays an important role in inflammation, and circulating ICAM-1 has been reported to be elevated in patients with some inflammatory disorders. To study the influence of asthma on circulating ICAM-1 levels, we measured concentrations of circulating ICAM-1 in patients with asthma. Fifteen patients (6 male, 9 female, mean age: 30 +/- 7 years) and 5 controls (2 male, 3 female, mean age: 25 +/- 6 years) were included in the study. Daily peak flow rates and symptom scores were monitored over a week in all patients and methacholine challenge tests were performed in 7 patients. The spirometric analysis of asthmatic patients demonstrated mean FEV1: 2.57 +/- 0.97 L (74.9 +/- 17.7% predicted), mean FEV1/FVC: 70.1 +/- 9.6%, mean bronchodilator response: 19.2 +/- 8.4%. The mean morning peak flow rate was 331.0 +/- 122.2 L/min, the mean evening peak flow rate 389.0 +/- 118.5 L/min, the mean peripheral eosinophil count 268 +/- 451/mm3, and the mean serum IgE level 327.4 +/- 238.2 IU/ml. The mean serum ICAM-1 levels of asthmatic patients and controls were 429 +/- 133 ng/ml and 405.0 +/- 81.0 ng/ml, respectively. There was no statistical difference between these levels. Furthermore, we could find no correlation between serum ICAM-1 levels and FEV1, serum IgE levels, peak flow rates, and symptom scores, or methacholine PD20 values in asthmatic patients. The results of this study suggest that serum ICAM-1 levels are not increased in asthmatic patients over controls and do not correlate with clinical asthma status.

Prediction of right ventricular dysfunction from radiographic estimates of right descending pulmonary artery in hemodynamically stable pulmonary embolism patients

BACKGROUND The evaluation of right ventricular (RV) dysfunction by echocardiography is one of the most important established determinants of the prognosis of acute pulmonary embolism. The aim of the study was to investigate possible association between diameter of right descending pulmonary artery on chest X-rays and RV dysfunction by echocardiography in hemodynamically stable pulmonary embolism patients. METHODS Eighty-nine patients with the diagnosis of hemodynamically stable pulmonary embolism were included. RESULTS The frequency of RV dysfunction was significantly higher in patients with an enlarged right descending pulmonary artery on chest X-rays (p = 0.001). There was a significant positive correlation between the diameter of the right descending pulmonary artery on postero-anterior chest X-rays and the diameter of the RV (r = 0.469; p = 0.002). Diameter of right descending pulmonary artery on chest X-rays was also found as a significant predictor of RV dysfunction besides the troponin-T levels and systolic pulmonary arterial pressure (p < 0.05). CONCLUSIONS Diameter of right descending pulmonary artery on chest X-rays may provide information about the risk for pulmonary embolism patients and may be used as a prognostic radiological parameter for the appropriate management of acute pulmonary embolism.

Effect of Inhaled Ingredients of a Commercial Cyclosporin A Ampoule on Airway Inflammation

This article is also accessible online at: http://BioMedNet.com/karger Dear Sir, We have published a study documenting the effect of inhaled cyclosporin A (Cyc-A) on the rat airway inflammation in this issue [1]. Our approach to assess the effect of pure Cyc-A was not rigorous since we used a commercial Cyc-A ampoule (50 mg cyclosporin A, 278 mg ethanol and 650 mg castor oil in a 1-ml intravenous ampoule; Sandoz, Basel, Switzerland). We have recently studied 10 additional rats to evaluate the effect of the ingredients (ethanol, castor oil) on the airway inflammation of sensitized rats. Twenty-one days after the initial intraperitoneal ovalbumin injection (1 mg ovalbumin and 100 mg Al(OH)3 in 1 ml 0.9% NaCl), animals were administered a nebulized ethanol and castor oil solution (278 mg ethanol and 650 mg castor oil in 1 ml 0.9% NaCl, adjusted dose: 0.4 ml/kg diluted to 2 ml with 0.9% NaCl) 1 h prior to exposure to nebulized ovalbumin; the same procedure was repeated on the 2nd day. 18–24 h later, bronchoalveolar lavage (BAL), peripheral blood and lung tissue sampling were performed as previously described [2, 3]. There was a nonsignificant decrease in the percentage of neutrophils (26.3 B 26.8 vs. 7.4 B 2.1%; p ! 0.06), a significant decrease in macrophages (66.1 B 7.7 vs. 63.6 B 7.2%; p ! 0.02), a nonsignificant increase in lymphocytes (21.1 B 12.4 vs. 24.4 B 7.0%; p 1 0.05) and a significant increase in eosinophils (2.4 B 2.6 vs. 4.7 B 2.0%; p ! 0.02) in the BAL of the ingredient pretreated group as compared with the group pretreated with the commercial Cyc-A ampoule. On light microscopic examination of the lung tissue samples, a significantly higher eosinophil count per high-powered field (HPF) (!400) (0 B 0 vs. 2.6 B 3.9/HPF in trachea, p ! 0.05; 4.3 B 9.4 vs. 16.1 B 12.4 in bronchi, p ! 0.008; 19.4 B 38.4 vs. 35 B 2.2 in bronchioles, p ! 0.02 was obtained in the ingredient-pretreated group compared to the group pretreated with the commercial Cyc-A ampoule. The percentage of peripheral blood eosinophil was significantly decreased in the ingredient-treated group (6.9 B 4.7 vs. 2.2 B 2.7%; p ! 0.004) compared with the group treated with the commercial Cyc-A ampoule. Our former study published in this issue demonstrated that commercial Cyc-A ampoule inhalation inhibits eosinophilia nonsignificantly in BAL and significantly in lung tissue in sensitized rat airway walls, with an increase of neutrophils in BAL and increase of peripheral blood eosinophils. This second part of the study showed that ingredients have no effect on BAL and lung tissue eosinophilia. It is likely that the immunosuppressive effect of the commercial Cyc-A ampoule is not mediated by the ingredients. Interestingly, we were unable to find neutrophilia in BAL and lung tissue or eosinophilia in the peripheral blood in rats pretreated with the ingredients. We postulate that eosinophils migrate from the lung to the peripheral blood with pure Cyc-A; however, we are unable to explain the pulmonary neutrophilia due to pure Cyc-A and this should be tested prospectively. Nevertheless, the definitive suggestions as to the most appropriate Cyc-A therapy in asthma still await the results of pure Cyc-A solution studies.