Predicting Pulmonary Complications Following Upper and Lower Abdominal Surgery: ASA vs. ARISCAT Risk Index

Objective

Postoperative pulmonary complications (POPC) account for a substantial proportion of risk related to surgery and anaesthesia. The American Society of Anesthesiologists (ASA) classification and the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk index correlate well with POPC. Here, we compared their accuracy in predicting pulmonary complications following upper and lower abdominal surgery.

Methods

We retrospectively reviewed the medical records of patients undergoing upper and lower abdominal surgery. We collected patients’ demographic data, comorbidities, preoperative pulmonary risk score, laboratory results, surgical data, respiratory tract infection history within one month before surgery, surgical urgency, ASA scores and pulmonary complications within one month after the surgery.

Results

We evaluated 241 patients [upper abdominal surgery (UAS) n=121; lower abdominal surgery (LAS) n=120; mean age 55.7±3.1 years]. In the UAS, 55.8% of the patients were male. In LAS, all patients were female. In both groups, the most common POPC was pleural effusion with compressive atelectasis (CA). Regarding risk score, in both groups, patients with high-risk developed a higher rate of pulmonary complications [UAS (50%), LAS (40%)]. In patients with low-risk scores, the rate of pulmonary complications was significantly lower than the intermediate and high-risk groups (p<0.001). A positive correlation was observed between preoperative risk score and complications (UAS r=0.34; LAS r=0.35 p<0.05). No association was observed between the ASA scores and POPC (p=0.8).

Conclusion

The ASA classification was found to be a weaker modality than ARİSCAT risk index to predict pulmonary complications after the upper and lower abdominal surgeries.

[Determination of anthropometric measurements in obstructive sleep apnea syndrome in Turkish population]

Introduction

In this study, we aimed to determine the values of anthropometric measurements and rates used in the evaluation of obstructive sleep apnea syndrome (OSAS) in our country.

Materials and Methods

Twenty accredited sleep centers in thirteen provinces participated in this multicenter prospective study. OSAS symptoms and polysomnographic examination and apnea-hypopnea index (AHI) ≥ 5 cases OSAS study group; patients with AHI < 5 and STOP-Bang < 2 were included as control group. Demographic characteristics (age, sex, body mass index-BMI) and anthropometric measurements (neck, waist and hip circumference, waist/hip ratio) of the subjects were recorded.

Result

The study included 2684 patients (81.3% OSAS) with a mean age of 50.50 ± 0.21 years from 20 centers. The cases were taken from six geographical regions of the country (Mediterranean, Eastern Anatolia, Aegean, Central Anatolia, Black Sea and Marmara Region). Demographic characteristics and anthropometric measurements; age, neck, waist, hip circumference and waist/ hip ratios and BMI characteristics when compared with the control group; when compared according to regions, age, neck, waist, hip circumference and waist/hip ratios were found to be statistically different (p< 0.001, p< 0.001, p< 0.05, respectively). When compared by sex, age, neck and hip circumference, waist/hip ratio, height, weight and BMI characteristics were statistically different (p< 0.001, respectively). Neck circumference and waist/hip ratio were respectively 42.58 ± 0.10 cm, 0.99 ± 0.002, 39.24 ± 0.16 cm, 0.93 ± 0.004 were found in women.

Conclusions

The neck circumference was lower than the standard value in men, but higher in women. The waist/hip ratio was above the ideal measurements in both men and women. In this context, the determination of the country values will allow the identification of patients with the possibility of OSAS and referral to sleep centers for polysomnography.

Acute Respiratory Failure in Renal Transplant Recipients: A Single Center Experience

OBJECTIVES

We evaluated the frequency and cause of acute respiratory failure in renal transplant recipients.

MATERIALS AND METHODS

Our single-center retrospective observational study included consecutive renal transplant recipients who were admitted to an intensive care unit for acute respiratory failure between 2011 and 2017. Acute respiratory failure was defined as oxygen saturation < 92% or partial pressure of oxygen in arterial blood < 60 mm Hg on room air and/or requirement of noninvasive or invasive mechanical ventilation.

RESULTS

Of 187 renal transplant recipients, 35 (18.71%) required intensive care unit admission; 11 of these patients (31.4%) were admitted to the intensive care unit with acute respiratory failure. Six of these patients (54.5%) had pneumonia and had shown infiltrates on chest radiography, which were shown in a minimum of 3 zones of the lung (2 with Klebsiella pneumonia, 1 with Acinetobacter species, 1 with Proteus mirabilis, 2 with no microorganisms). The other reasons for acute respiratory failure were cardiogenic pulmonary edema (2 patients), acute respiratory distress syndrome (2 patients, due to acute pancreatitis and acute cerebrovascular thromboembolism), and exacerbation of chronic obstructive pulmonary disease (1 patient). Six patients (54.5%) needed invasive mechanical ventilation because of pneumonia (3 patients), cardiogenic pulmonary edema (2 patients), and cerebrovascular thromboembolism (1 patient). Hemodialysis was administered in 5 patients (45%). Six of 11 patients died due to pneumonia (3 p atients), cardiogenic pulmonary edema (2 patients), and cerebrovascular thromboembolism (1 patient). Among the 5 survivors, 3 (60%) had recovered previous graft function.

CONCLUSIONS

Acute respiratory failure is associated with high mortality and morbidity in renal transplant recipients. Main causes of acute respiratory failure were bacterial pneumonia and cardiogenic pulmonary edema in our study population. Extended chemoprophylaxis for bacterial and fungal infection and early intensive care unit admission of patients with acute respiratory failure may improve outcomes.

Smoking Is Related to Postoperative Pulmonary Complications and Graft Outcomes in Renal Transplant Patients

OBJECTIVES

Renal transplant is an important treatment option for end-stage renal disease. A successful kidney transplant improves the quality of life and reduces the mortality risk compared with maintenance dialysis in patients with end-stage renal disease. Several immunologic and nonimmunologic factors are responsible for graft outcomes in renal transplant patients. Our study was performed to evaluate the role of smoking on postoperative pulmonary complications and graft outcomes in renal transplant patients.

MATERIALS AND METHODS

Our study retrospectively analyzed 1740 patients who had renal transplants between 1987 and 2014 at Baskent University. Patients with smoking data were included in the study. Patient demographic, smoking status, comorbid diseases, postoperative pulmonary complications, graft outcomes, and clinical features were recorded. The relation between postoperative pulmonary complications and risk factors was investigated.

RESULTS

Our study included 131 adult renal transplant recipients who had smoking data. The incidence of postoperative pulmonary complications was 16% (21 patients) in the first month after surgery. Smoking history was found in 52 patients (39.7%). There was a statistically significant relationship between the presence of atelectasis and smoking history (P = .004). A positive and statistically significant correlation was detected between atelectasis and pack-years smoking (r = 0.424; P = .001). We evaluated graft rejection within 1 month after transplant regardless of being acute cellular or humoral rejection. The relation between smoking history and graft rejection within 1 month after transplant was significant (P = .011).

CONCLUSIONS

Renal transplant patients who are smokers have an increased risk for early postoperative pulmonary complications. Furthermore, cigarette smoking contributes to allograft loss in renal transplant patients. Smoking cessation before surgery can reduce the risk of early postoperative complications.

Association Between Preoperative Pulmonary Risk Scores and Postoperative Complications in Renal Transplant Recipients

OBJECTIVES

Patients who are being considered for renal transplant must undergo thorough preoperative pulmonary evaluation to determine risk of postoperative pulmonary complications. The aim of this study was to determine the relation between the preoperative pulmonary risk factor score and pulmonary complications in patients undergoing renal transplant.

MATERIALS AND METHODS

Medical records of patients who underwent renal transplant at our institution between 2004 and 2015 were retrospectively reviewed. Patient demographics, smoking history, comorbidities, and preoperative pulmonary risk factors (age, oxygen saturation, hemoglobin level, type of incision, duration of surgery, history of lower respiratory tract infection 1 month before surgery, urgency of surgery), and type of pulmonary complications within 1 month after transplant were recorded.

RESULTS

Our study included 131 patients (94 male patients; mean age of 38.25 ± 12.96 y). Of total patients, 21(16%) developed complications during the first month after transplant, with 10 of the 21 (7.6% overall) developing pulmonary complications. These complications were pleural effusion (2 patients), pneumonia (3 patients), respiratory failure (2 patients), and pulmonary embolism (1 patient). There were no deaths directly attributed to the pulmonary complications. A significant correlation was observed between the preoperative pulmonary risk factor score and postoperative pulmonary complications in renal transplant recipients (P = .003). A positive correlation between the preoperative pulmonary scores and postoperative pulmonary complications existed among life-long nonsmokers (r = 0.371; P = .003).

CONCLUSIONS

Renal transplant is an established modality in treatment of chronic renal failure. Prevention of pulmonary complications is essential for successful outcomes following transplant. Health care professionals involved with renal transplant and transplant centers should be aware of preoperative pulmonary risk factors. Patients should be observed so that these risk factors can be reduced before planned transplant. Moreover, we also suggest that smoking history should be considered as a preoperative pulmonary risk factor as it was found to be a factor leading to postoperative pulmonary complications in our study.

Postoperative Pleural Effusions After Orthotopic Heart Transplant: Cause, Clinical Manifestations, and Course

OBJECTIVES

Postoperative pleural effusions are common in patients who undergo cardiac surgery and orthotopic heart transplant. Postoperative pleural effusions may also occur as postcardiac injury syndrome. Most of these effusions are nonspecific and develop as a harmless complication of the surgical procedure itself and generally have a benign course. Here, we investigated the cause and clinical and laboratory features of postoperative early and late pleural effusions in orthotopic heart transplant patients.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 50 patients who underwent orthotopic heart transplant between 2004 and 2015 at Baskent University. Patient demographics and clinical and laboratory data, including cause of heart failure, presence of pleural effusions at chest radiography in the first year after transplant, timing of onset, microbiologic and biochemical analyses of pleural effusions, and treatment strategies were noted.

RESULTS

Mean age of patients was 39.22 ± 13.83 years (39 men, 11 women). Reason for heart failure was dilated cardiomyopathy in most patients (76%). Nineteen patients (38%) had postoperative pleural effusions, with 15 patients (78.9%) with pleural effusion during the first week after transplant. Of these, 4 patients had recurrent pleural effusion. A diagnostic thoracentesis was performed in 10 patients, with 4 showing transudative effusion and 6 showing exudative effusion secondary to infection (2 patients), postcardiac injury syndrome (1 patient), and hemothorax (3 patients). Aspergillus fumigatus was detected by quantitative culture from pleural effusion in 1 patient. Tube thoracoscopy drainage was performed in 10 patients (25%), and 2 patients received antibiotic therapy.

CONCLUSIONS

Pleural effusions are frequent after cardiac transplant. Complications may occur in a small portion of patients, with most effusions being nonspecific and having a benign course with spontaneous resolution. Early diagnostic thoracentesis could improve postoperative outcomes in these patients.

Conventional transbronchial needle aspiration in community practice

Conventional transbronchial needle aspiration (C-TBNA) provides an opportunity to diagnose mediastinal lesions and stage bronchogenic carcinoma in a minimally invasive fashion. The procedure is easy to learn and requires zero upfront cost. Any community pulmonologist can acquire and maintain the skills of C-TBNA without undergoing formal interventional pulmonary fellowship training. Besides being used for the diagnosis and staging of lung cancer, C-TBNA can be used in patients suspected to have benign conditions such as sarcoidosis and tuberculosis. It also contributes in improving the diagnostic yield of flexible bronchoscopy while dealing with endobronchial, submucosal, peribronchial, or peripheral lesions. C-TBNA may be the only diagnostic modality that can be performed in patients in whom mediastinoscopy is contraindicated due to a bleeding diathesis. The procedure is safe and has great potential to augment the welfare of patients with pulmonary ailments. The learning curve of the procedure is short and steep. Every community pulmonologist should be able to perform C-TBNA.

Long-term pulmonary infections in heart transplant recipients

OBJECTIVES

Pulmonary infections are life-threatening complications in heart transplant recipients. Our aim was to evaluate long-term pulmonary infections and the effect of prophylactic antimicrobial strategies on time of occurrence of pulmonary infections in heart transplant recipients.

MATERIALS AND METHODS

Patients who underwent heart transplantation between 2003 and 2013 at Baskent University were reviewed. Demographic information and data about immunosuppression and infectious episodes were collected.

RESULTS

In 82 heart transplant recipients (mean age, 33.85 y; 58 male and 24 female), 13 recipients (15.8%) developed pulmonary infections (mean age, 44.3 y; 9 male and 4 female). There were 12 patients who had dilated cardiomyopathy and 1 patient who had myocarditis before heart transplantation; 12 patients received immunosuppressive therapy in single or combination form. Pulmonary infections developed in the first month (1 patient), from first to third month (6 patients), from third to sixth month (1 patient), and > 6 months after transplantation (5 patients). Chest computed tomography showed consolidation (unilateral, 9 patients; bilateral, 4 patients). Multiple nodular consolidations were observed in 2 patients and a cavitary lesion was detected in 1 patient. Bronchoscopy was performed in 6 patients; 3 patients had Aspergillus fumigatus growth in bronchoalveolar lavage fluid, and 2 patients had Acinetobacter baumannii growth in sputum. Treatment was empiric antibiotics (6 patients), antifungal drugs (5 patients), and both antibiotics and antifungal drugs (2 patients); treatment period was 1-12 months in patients with invasive pulmonary aspergillosis.

CONCLUSIONS

Pulmonary infections are the most common cause of mortality in heart transplant recipients. A. fumigatus is the most common opportunistic pathogen. Heart transplant recipients with fever and cough should be evaluated for pulmonary infections, and invasive pulmonary aspergillosis should be suspected if these symptoms occur within the first 3 months. Immediately starting an empiric antibiotic is important in treating pulmonary infections in heart transplant recipients.

Long-term risk of pulmonary embolism in solid-organ transplant recipients

OBJECTIVES

Solid-organ transplant recipients can develop chronic hypercoagulation that increases the incidence of pulmonary embolism. Here, we evaluate the frequency of pulmonary embolism in solid-organ transplant recipients during the first 10 years after transplantation and evaluate the risk factors for its development.

MATERIALS AND METHODS

The medical records of solid-organ transplant recipients who were treated between 2003 and 2013 were retrospectively reviewed. The reviewed data included demographics, type of transplant, comorbidities, procoagulation factors, thromboembolism prophylaxis, and the timing and extent of pulmonary embolism.

RESULTS

In total, 999 solid-organ transplant recipients are included in this study (661 renal and 338 liver transplant recipients) (male: female ratio = 665:334). Twelve renal (1.2%) and 1 liver transplant recipient (0.3%) were diagnosed with pulmonary embolism. Pulmonary embolism developed 1 year after transplantation in 10 patients: 1 patient developed pulmonary embolism < 3 months after transplantation, and the other 9 patients developed pulmonary embolism within 3 to 6 months. No patients had a prior history of deep venous thrombosis or pulmonary embolism. Five patients received tacrolimus, 7 patients received sirolimus, and 1 patient received cyclosporine. Ten patients received prednisolone, and 8 patients received mycophenolate mofetil. All patients were homozygous normal for factor V Leiden and prothrombin genes. One patient was homozygous abnormal, and 1 patient had a heterozygous mutation in the methylenetetrahydrofolate reductase gene. Two patients were treated with low-molecular-weight heparin, while the remaining patients received warfarin. Eight patients were treated for 6 months, and the remainder received longer treatments.

CONCLUSIONS

Here, the incidence of pulmonary embolism in solid-organ transplant recipients is 1.2%. Renal transplant recipients are at higher risk of developing pulmonary embolism than liver transplant recipients. The factors that increase the risk of pulmonary embolism in solid-organ transplant recipients appear to be multifactorial and include genetic predisposition.

Conventional transbronchial needle aspiration: From acquisition to precision

INTRODUCTION

Conventional transbronchial needle aspiration (C-TBNA) is a minimally invasive, safe, and cost-effective technique in evaluating mediastinal lymphadenopathy. Previously we reported that the skills for C-TBNA can be acquired from the books. We studied the learning curve for C-TBNA for a single bronchoscopist at a tertiary-care center where ultrasound technology remains difficult to acquire .

METHODS

We prospectively collected results of the first 99 consecutively performed C-TBNA between December 2009 and 2013. Patients were divided into 3 groups: (I): First 33, (II): Next 33 and (III): Last 33. Results were categorized as malignant, non-malignant or non-diagnostic. Diagnostic yield (DY), sensitivity (SEN), specificity (SPE), positive and negative predictive values (PPV, NPV), and accuracy (ACC) were calculated to learn the learning curve for C-TBNA.

RESULTS

Total 99 patients (M:F = 62:37), mean age 58.2 ± 11.5 years, mean LN diameter 26.9 ± 9.8 mm underwent C-TBNA. Sixty-nine patients had lymph nodes (LNs) >20 mm in diameter. Final diagnoses were established by C-TBNA in 44 (yield 44.4%), mediastinoscopy 47, transthoracic needle aspiration 5, endobronchial biopsy 2 and peripheral LN biopsy 1. C-TBNA was exclusively diagnostic in 35.4%. Group I: DY: 42.4%, 64.7% in malignancies, 19% in benign conditions (P = 0.008). SEN, SPE, PPV, NPV, ACC = 70%, 100%, 100%, 66.6%, 78.7%, respectively. Group II: DY: 54.5% (36.4% exclusive), 88.2% in malignancies and 19% benign conditions (P = 0.000). SEN, SPE, PPV, NPV, ACC=72%, 100%, 100%, 53.3%, 78.7%, respectively. Group III: DY: 36.3% (27% exclusive), 100% in malignancies and 16% in benign conditions. SEN, SPE, PPV, NPV, ACC = 92.3%, 100%, 100%, 95.2%, 97%, respectively. No difference was found in relation to LN size or location and TBNA yield.

CONCLUSION

C-TBNA can be easily learned and the proficiency can be attained with <66 procedures. In selected patients, its exclusivity could exceed 35%.

"Pills" and the air passages

Aspiration of a medication in the airways in any form produces a variety of adverse effects, both local and systemic. Furthermore, specific reaction of the airways to each type of pill strongly affects the outcome. It is crucial for pulmonologists and emergency medicine specialists to acknowledge this clinical entity. In addition, airways have been increasingly used to deliver medications such as insulin and prostacycline. These aerosolized medications can also cause local as well as systemic side effects. We review the local and systemic reactions of these "pills" accessing the airways either by incidental aspiration or iatrogenic administration. We address clinical presentation, mechanism of injury, diagnosis, and management of complications of these pills in the air passages.

[Bronchoscopy suite]

Flexible bronchoscopy is usually performed at a tertiary care facility in a general endoscopy unit or a specially designed bronchoscopy suite. The procedure can also be performed outside the designated facility if the qualified personnel and required equipment can be mobilized. In this review, we discuss the essentials of a modern bronchoscopy suite based on the available information from the literature.

Pleural effusion following ventriculopleural shunt: Case reports and review of the literature

Ventriculo-pleural shunt (VPLS) is an acceptable alternative in the management of hydrocephalus. Imbalance between the production and absorption of cerebrospinal fluid an lead to formation of pleural effusion in patient with VPLS and on occasion produce symptoms. Pleural effusion could be a transudate or a non-specific exudate. We report our experience with this modality in relation to formation of pleural effusion and review the literature to make recommendation for its management. Information related to patients’ demographics, smoking history, prior pulmonary and occupational history, indication, duration and complications of the VPLS and their management was gathered to substantiate current recommendation with our experience.

[Hypersensitivity pneumonitis]

Hypersensitivity pneumonitis is an immunologically induced lung disease caused by repeated inhalation of agents in sensitized individuals. It may present with an extensive variety of clinical abnormalities depending on the nature of the inhaled dust and the amount of exposure, the time of exposure to the antigen and the immunological response of the host. In this review, we discuss the characteristics of hypersensitivity pneumonitis based on the available information from the literature.

Metabolic syndrome is associated with increased risk of acute exacerbation of COPD: a preliminary study

Studies have confirmed correlation between metabolic syndrome (MetS) and chronic obstructive pulmonary disease (COPD). However, to date, no studies have analyzed correlation between exacerbations of COPD (ECOPD) and MetS. The aim of this preliminary study was to examine if presence of MetS increases the frequency and duration of ECOPD. Patients with COPD were prospectively enrolled and followed between March 2008 and September 2009. Medical records, pulmonary function tests, chest X-rays; laboratory test results were gathered to establish the presence of COPD and MetS. Patients were divided in two groups; with and without MetS. The ECOPD was defined as worsening of symptoms requiring increased use of rescue medications and/or need for either systemic steroids or antibiotics or that led to emergency room visit or hospitalizations during 12 months follow-up. A total of 106 patients were recruited, 29 with MetS and 77 without. The mean exacerbation of COPD frequency was 2.4 ± 0.8 in MetS group versus 0.68 ± 0.6 in the control group during the follow-up period (P < 0.001). Mean duration of each exacerbation was 7.5 ± 1.5 days in patients with MetS versus 5 ± 2.4 days in patients without. Serum C-reactive protein (r = 0.31, P = 0.001), fasting blood glucose (r = 0.55, P < 0.001), and triglycerides (r = 0.251, P = 0.01) were positively and significantly correlated with exacerbation frequency. This study demonstrates an association between ECOPD and its duration with the MetS. The systemic inflammation induced by common cytokines may explain the linkage between the two conditions.

Value of exercise testing to estimate post-operative complications and mortality in solid organ recipients: a preliminary study

BACKGROUND

The pre-operative pulmonary risk assessment of solid organ transplant recipients is crucial to decrease post-operative pulmonary mortality and morbidity. Spirometry is the most commonly utilized test to predict post-operative pulmonary complications. This study was performed to evaluate the role of Cardiopulmonary Exercise Testing (CPET) in both heart and kidney transplantation recipients.

MATERIAL/METHODS

Patients referred for pulmonary evaluation between August 2008 and June 2009 prior to solid organ transplantation were included in this study. Patients' history, demographics, and physical examination were recorded. All patients performed pulmonary function tests (PFTs) and symptom-limited CPET. Thirty-four subjects (21 with heart failure and 16 with chronic renal failure) awaiting solid organ transplantation were enrolled to this study prospectively.

RESULTS

No pulmonary complication was found in the renal transplantation recipients, and there were pulmonary complications in 10 heart transplantation recipients. There was no difference between spirometric parameters with post-operative early pulmonary complications and mortality (p>0.05) in heart and kidney transplantation recipients. Anaerobic threshold oxygen uptake (VO(2)@AT) was significantly decreased, while minute ventilation to carbon dioxide output (VE/VCO(2)@AT) was increased in heart recipients (p<0.05).

CONCLUSIONS

CPET parameters measured at anaerobic threshold could help predict surgical mortality and pulmonary complications following heart transplantation. However, our study demonstrated that CPET parameters could not predict post-operative mortality and pulmonary complications in renal recipients. Therefore, heart transplant candidates should be routinely evaluated with CPET and spirometry to estimate post-operative early mortality and pulmonary complications pre-operatively.

Tracheobronchial variations in Turkish population

The tracheobronchial tree exhibits highly individualistic features and many variations. As the anatomic variations among Turkish population have not been studied previously, we aimed to evaluate the type and frequency of tracheobronchial variations (TBVs) in our bronchoscopy population. In a 3-year period, 1,114 patients underwent flexible bronchoscopy (FB). Among these, 780 (70%) were male. The mean age of the patients was 51.3 +/- 15.1 (range: 17-84) years. In 639 cases, no TBV were detected. A total of 999 TBV were observed in 475 patients. Of all, 71.3% (713) of the total TBV were detected in males. Forty-nine and six-tenths percent (49.6%) of the TBV were observed on the right bronchial system, 49.2% on the left, and 1.2% in the trachea. The five most frequently observed TBV were right lower lobe basal orifice with two subsegments, left lower lobe basal orifice with two subsegments, left upper lobe with three segments, right upper lobe with two segments, and right lower lobe with a subapical segment. In the same lobe bronchus, single variation and two different TBV were seen in 85% and 15% of patients, respectively. Number of TBV increased linearly with the number of lobes involved. The availability and popularity of FB in recent years has led to the increase in identification and reporting of TBV. TBV should be correctly identified and documented. This information is invaluable during follow-up bronchoscopies as well as lung resection.

Hyperhomocysteinemia due to pernicious anemia leading to pulmonary thromboembolism in a heterozygous mutation carrier

Pulmonary thromboembolism is a life-threatening condition resulting mostly from lower extremity deep-vein or pelvic-vein thrombosis. A 46-year-old woman was admitted to hospital with pain on the right side of the chest and hemoptysis. On laboratory analysis, D-dimer level was elevated. Computed tomographic pulmonary angiography revealed intravascular filling defects due to thrombi in right lower lobe pulmonary segmental arteries. Screening for thrombophilic states was normal except for heterozygous mutations of both prothrombin and methylene tetrahydrofolate reductase (MTHFR 677) genes. Homocysteine level was high, and vitamin B12 level and serum ferritin level were reduced. Serum antiparietal antibody was positive, and therefore, pernicious anemia was diagnosed along with iron-deficiency anemia. After the diagnoses were established, enoxaparin followed by warfarin was started in addition to oral vitamin B12, pyridoxine, thiamine, folic acid, and ferroglycine sulfate supplementation. At the end of 8 weeks of the replacement therapy, vitamin B12, folate, and homocysteine levels and red cell volume were found to be normal, with complete resolution of the thrombus confirmed by repeat computed tomographic pulmonary angiography. We conclude that hyperhomocysteinemia due to vitamin B12 deficiency associated with pernicious anemia might have decreased the threshold for thrombosis. In addition, the presence of heterozygous prothrombin and methylene tetrahydrofolate reductase mutations might serve as synergistic cofactors triggering pulmonary thromboembolism.

Bioassay-guided isolation of kaempferol-3-O-beta-D-galactoside with anti-inflammatory and antinociceptive activity from the aerial part of Calluna vulgaris L

Calluna vulgaris L. (Ericaceae) is used for the treatment of various inflammatory ailments in traditional medicines. In order to evaluate this ethnobotanical information, its anti-inflammatory and antinociceptive activities were studied using in vivo experimental models in mice. The ethanolic extract of the plant was first fractionated into five extracts; namely, n-hexane, chloroform, ethyl acetate (EtOAc), n-butanol, and water fractions. Among them, the EtOAc Fr. was found to be the most effective and was further subjected to bioassay-guided fractionation and isolation procedures. After successive column chromatography applications, on Sephadex LH-20 and silica gel, a component, which is responsible for the above-mentioned activities of this species of Turkish origin, was isolated and its structure was elucidated as kaempferol-3-O-beta-D-galactoside, a common flavonol derivative by means of spectral techniques.

Bioassay-guided evaluation of anti-inflammatory and antinociceptive activities of pistachio, Pistacia vera L

The ethanolic and aqueous extracts prepared from different parts of Pistacia vera L. (Anacardiaceae) as well as its oleoresin were evaluated for their in vivo anti-inflammatory and antinociceptive activities. Among the extracts screened, only the oleoresin was shown to possess a marked anti-inflammatory activity against carrageenan-induced hind paw edema model in mice without inducing any gastric damage at both 250 and 500 mg/kg doses whereas the rest of the extracts were totally inactive. While the oleoresin was found to display significant antinociceptive activity at 500 mg/kg dose, the ethanolic and aqueous extracts belonging to fruit, leaf, branch and peduncle of Pistacia vera did not exhibit any noticeable antinociception in p-benzoquinone-induced abdominal contractions in mice. Fractionation of the oleoresin indicated the n-hexane fraction to be active, which further led to recognition of some monoterpenes, mainly alpha-pinene (77.5%) by capillary gas chromatography-mass spectrometry (GC-MS) as well as the oleoresin itself. alpha-Pinene was also assessed for its antinociceptive and anti-inflammatory activities in the same manner and exerted a moderate anti-inflammatory effect at 500 mg/kg dose.

Clues for the differential diagnosis of hypersensitivity pneumonitis as an expectant variant of diffuse parenchymal lung disease

Hypersensitivity pneumonitis, also called extrinsic allergic alveolitis, a type of diffuse parenchymal lung disease (DPLD), is an immunologically mediated pulmonary disease induced by inhalation of various antigens. As data on the frequency of hypersensitivity pneumonitis are lacking in Turkey, a retrospective analyses was performed in 43 patients with DPLD, followed up over seven years. The objective was to discover cases fulfilling the diagnostic criteria for hypersensitivity pneumonitis, to determine the frequency and/or the new characteristics of the disease, and to pick up clues for differentiating it from other DPLDs. The four subjects with hypersensitivity pneumonitis (9%) who lived in an urban area were studied in detail. The most common symptoms were dry cough and dyspnoea. According to the symptom duration, clinical features, radiological and pathological findings, three were diagnosed with chronic and one with subacute hypersensitivity pneumonitis. Patients with hypersensitivity pneumonitis and those with DPLD were compared by means of age, sex, smoking status, symptom duration, haematology, erythrocyte sedimentation rate, peripheral cell count, spirometric parameters, blood gases, and diffusion capacity. No statistically significant difference was detected in these parameters except for forced expiratory volume in one second (FEV(1)) and forced vital capacity (FVC). In conclusion, patients with a history of antigen exposure, with mild symptoms such as dry cough and dyspnoea, and who have diffuse interstitial lung involvement on radiology should be carefully evaluated for hypersensitivity pneumonitis. Moreover, among other DPLDs, stable FEV(1) or FVC values may be the clues for establishing the diagnosis of hypersensitivity pneumonitis. However, further studies are needed in larger series of patients.

Synthesis and Analgesic and Antiinflammatory Activity of Methyl 6-Substituted-3(2H)-pyridazinone-2-ylacetate Derivatives

A series of methyl 6-substituted-3(2H)-pyridazinone-2-ylacetates 9 were synthesized and their analgesic and anti-inflammatory effects were evaluated in the phenylbenzoquinone-induced writhing test (PBQ test) and carrageenan-induced paw edema method, respectively. Side effects of the compounds were examined on gastric mucosa. None of the compounds showed gastric ulcerogenic effect compared with reference nonsteroidal anti-inflammatory drugs. Methyl 6-(4-(4-fluorophenyl)piperazine)-3(2H)-pyridazinone-2-ylacetate 9e was found to be more active than acetylsalicylic acid (ASA). Methyl 6-(4-(2-ethoxyphenyl)piperazine)-3(2H)-pyridazinone-2-ylacetate 9c has shown an anti-inflammatory activity as compared to the standard compound indometacin at the carrageenan-induced paw edema method.A significant dependence of the anti-inflammatory effect on the substituents has been observed. The pharmacological study of these compounds confirms that modification of the chemical group at the position 6 of the 3(2H)-pyridazinone system influences analgesic and anti-inflammatory activities. The structures of these new pyridazinone derivatives were confirmed by their IR and (1)H-NMR spectra and elemental analysis.