Potential role of matrix metalloproteinase-2,-9 and tissue inhibitors of metalloproteinase-1,-2 in exudative pleural effusions

PURPOSE

To investigate diagnostic values of pleural fluid matrix metalloproteinase-2 (MMP-2), MMP-9, tissue inhibitors of metalloproteinase-1 (TIMP-1) and TIMP-2 measurements in tuberculous pleurisy(TP) and malignat pleurisy (MP).

METHODS

The study included 24 patients with TP, 22 patients with MP and 15 patients with pleural effusion of non-tuberculous and non-malignant origin as controls. MMP-2,-9 and TIMP-1,-2 levels in pleural fluid were measured by ELISA method.

RESULTS

Pleural fluid MMP-2 and MMP-9 levels were higher (P < 0.001, P < 0.001, respectively) in TP than in MP and controls. MP patients have higher pleural fluid MMP-2 and MMP-9 levels (P < 0.01, P < 0.05, respectively) than controls. Pleural fluid TIMP-2 levels were higher (P < 0.01 and P < 0.001, respectively) in MP than in TP and controls. Pleural fluid MMP-9 levels were negatively correlated with pleural fluid TIMP-2 levels (r: 0.464, P=0.029) in patients with MP.

CONCLUSIONS

Determination of TIMP-2 in pleural fluid may contribute to differentiate TP from MP. These results suggest that overproduction of MMP-9 and TIMP-2 is associated with accumulation of the pleural effusion in malignancy. Further studies with a greater number of patients are needed to confirm this hypothesis.

Factors affecting survival of hospitalised patients with COPD

Factors determining in-hospital mortality and long-term survival of patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are not precisely understood. The aim of the present study was to assess the parameters related to in-hospital mortality and long-term survival after hospitalisation of patients with AECOPD. Clinical and epidemiological parameters on admission in 205 consecutive patients hospitalised with AECOPD were prospectively assessed. Patients were followed-up for 3 yrs. Factors determining short- and long-term mortality were analysed. In total, 17 patients (8.3%) died in hospital. In-hospital mortality was significantly associated with lower arterial oxygen tension (P(a,O2)), higher carbon dioxide arterial tension, lower arterial oxygen saturation and longer hospital stay. The overall 6-month mortality rate was 24%, with 1-, 2- and 3-yr mortality rates of 33%, 39% and 49%, respectively. Cox regression analysis revealed that long-term mortality was associated with longer disease duration (relative risk (RR) = 1.158), lower albumin (RR = 0.411), lower P(a,O2) (RR = 0.871) and lower body mass index (RR = 0.830). When the model was run for the time elapsed since first hospitalisation, it also appeared as statistically significant (RR = 1.195). These findings show that patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease have poor short- and long-term survival. Prediction of survival status may be enhanced by considering arterial oxygen tension, albumin, body mass index, disease duration and time elapsed since the first hospitalisation.

Evaluation of right and left ventricular function using pulsed-wave tissue Doppler echocardiography in patients with subclinical hypothyroidism

Previous studies showed that subclinical hypothyroidism (SH) was associated with cardiovascular disorders, such as endothelial dysfunction, atherosclerosis and myocardial dysfunction. Only one study investigated left ventricular (LV) function using pulsed tissue Doppler echocardiography (TDE) in patients with SH. However, no study has used this technique in the identification of right ventricular (RV) function in these patients. We aimed to investigate the effect of SH on RV and LV function using TDE technique. The present study included 36 newly diagnosed SH patients and 28 healthy controls. For each subjects, serum free T3 (FT3), free T4 (FT4), total T3 (TT3), total T4 (TT4), TSH, peroxidase antibody (TPOab) and thyroglobulin antibody (TGab) levels were measured, and standard echocardiography and TDE were performed. In patients with SH, TSH levels were significantly higher, and TPOab and TGab levels were significantly higher when compared to healthy controls. TDE showed that the patients had significantly lower early diastolic mitral and tricuspid annular velocity (Ea) and early/late (Ea/Aa) diastolic mitral and tricuspid annular velocity ratio (p<0.05, p<0.05 and p<0.001, p<0.001, respectively), and significantly longer isovolumetric relaxation time (IRT) of left and right ventricles (p<0.001 and p<0.001, respectively). However, Aa, Sa, and isovolumetric contraction time (ICT) and ET (ejection time) of left and right ventricle did not significantly differ (p=ns for all). In addition, a negative correlation between TSH and TD-derived tricuspid Ea velocity and Ea/Aa ratio, and a positive correlation between TSH and IRT of right ventricle were observed. Our findings demonstrated that SH is associated with impaired RV diastolic function in addition to impaired LV diastolic function.

Evaluation of autonomic activity in patients with subclinical hypothyroidism

It has been shown that impaired cardiac autonomic activity is closely related with lethal arhythmias. Heart rate variability (HRV), analysis of beat-to-beat variations, is an important and widely used non-invasive method to assess autonomic function. Impaired cardiac autonomic activity and altered sympathovagal balance were previously documented in patients with hypothyroidism. However, the effect of subclinical hypothyroidism (SH) on autonomic function has not been studied yet. We aimed to investigate the effect of SH on sympathovagal balance using the HRV method. The study included 31 patients with SH and 28 healthy volunteer controls. Patients with cardiac, metabolic, neurological disease or any other systemic disease that could affect autonomic activity were excluded from the study. HRV time domain and frequency domain parameters were determined over a period of 24 h. All time and frequency domain measures of HRV in patients with SH were not significantly different compared to those of healthy control group (p > 0.05). Additionally, we compared SH subgroups (TSH level > or =10 and TSH level <10 mU/l) with each other and the controls. A statistically significant difference was observed only in time domain parameters of SD of normal-to-normal intervals (SDNN) and SD of all 5-min mean normal NN intervals (SDANN) between subgroup with TSH level > or =10 and controls (p < 0.05, p < 0.05, respectively). In correlation analysis with TSH, there was positive relationship between TSH and the root mean square of successive differences between adjacent R-R intervals (rMSSD). These findings indicate that SH may affect cardiac autonomic activity in correlation with TSH levels.

Metformin versus flutamide in the treatment of metabolic consequences of non-obese young women with polycystic ovary syndrome: a randomized prospective study

In addition to the reproductive consequences, polycystic ovary syndrome (PCOS) is characterized by a metabolic disorder in which hyperinsulinemia and insulin resistance are central features. The effects and possible benefits from insulin-sensitizing drugs are not well known, especially in non-obese women with PCOS. This study was designed to evaluate the effects of metformin and flutamide on metabolic parameters and insulin resistance in non-obese women with PCOS. Thirty non-obese women newly diagnosed with PCOS and 15 age- and weight-matched healthy volunteers as controls were included in the study. Patients were assigned randomly to receive flutamide 250 mg daily or metformin 850 mg three times daily. Glucose, insulin, insulin resistance, androgen levels and glucose and insulin responses to an oral glucose tolerance tests (OGTT) were assessed before and after a 4-week therapy period. A positive correlation was found between body mass index and insulin level in patients with PCOS and controls. Follicle stimulating hormone, luteinizing hormone, free testosterone and dehydroepiandrosterone sulfate levels decreased significantly, but insulin resistance levels were not changed after flutamide therapy. Body weight, free testosterone, insulin and insulin resistance levels decreased significantly after metformin therapy. In conclusion, metformin treatment improved insulin sensitivity and decreased androgen levels, and flutamide decreased androgen levels but failed to improve insulin sensitivity in the non-obese women with PCOS.

Comparison of the effects of amlodipine and verapamil on autonomic activity in hypertensive patients

Background: Many studies have shown that autonomic activation is one of the major factors in the etiology of hypertension. Furthermore, sympathovagal imbalance may be responsible for arrhythmias and sudden cardiac death. The aim of the present study was to compare and to evaluate the effects of short-term therapy with amlodipine and verapamil on heart rate variability (HRV) in patients with essential hypertension. Methods: Forty patients with essential hypertension (11 men and 29 women, mean age 50.5+/-10.4 years) were included in the study. Patients with cardiac, metabolic, or any other systemic disease were excluded. Patients were randomized to receive either amlodipine (10 mg; n=20) or verapamil (240 mg; n=20). Patients underwent 24-h Holter monitoring assessment before treatment and after the 4-week treatment period. Standard deviation of normal RR intervals (SDNN), standard deviation of all 5-min mean normal RR intervals (SDANN), square root of the mean of the sum of the squares of differences between adjacent RR intervals (r-MSSD), and pNN50 (time domain variables) and TF, high-frequency power (HF), low-frequency power (LF), and sympathovagal balance (LF/HF; frequency domain variables) were analyzed before and after treatment. Results: Blood pressure (BP) was reduced to a similar degree, from 182/104 to 128/85 mmHg with verapamil and from 174/100 to 124/86 mmHg with amlodipine (verapamil p<0.001; amlodipine p<0.001). This study revealed that amlodipine had no significant effect on any of the time or frequency domain parameters. In contrast, in patients on verapamil, there were significant increases in all time domain parameters, and the LF/HF ratio was significantly decreased (p<0.05). Conclusions: These results suggest that verapamil may have additional positive effects on sympathico-parasympathetic control beyond lowering blood pressure compared with amlodipine, even after short-term treatment in hypertensive patients.

Does cardiopulmonary bypass alter plasma level of tumor markers? CA 125 and carcinoembryonic antigen

BACKGROUND

In addition to malignant diseases, acute and chronic inflammations may elevate plasma levels of tumor markers CA 125 and carcinoembryonic antigen (CEA). Cardiopulmonary bypass (CPB) causes a generalized inflammatory response. In this study, we have investigated the effect of CPB on plasma levels of CA 125 and CEA.

METHODS

We measured plasma levels of CA 125 and CEA in patients undergoing coronary artery bypass grafting (CABG) with CPB (Group 1, n = 21), and in patients who underwent off-pump CABG, that is, without CPB (Group 2, n = 16). Blood samples were collected preoperatively, and on postoperative days 1, 6, and 12.

RESULTS

Within both groups, CEA plasma levels were not significantly influenced in any samples. Comparing with preoperative values, CA 125 values elevated significantly on postoperative days 6 and 12 within both groups. It was observed that the elevation of CA 125 plasma levels in these samples were significantly higher in Group 1.

CONCLUSIONS

The results indicate that CPB elevated plasma level of CA 125. However, clinical importance of this finding needed further evaluation.

Spirometric predictors for the exclusion of severe hypoxemia in chronic obstructive pulmonary disease

BACKGROUND

Controversy has existed over the need for routine arterial blood gas (ABG) analysis in patients with chronic obstructive pulmonary disease (COPD). Some authors recommend it in all patients with COPD, but others find it unnecessary if the forced expiratory volume in 1 s (FEV(1)) is 50% of predicted or greater.

OBJECTIVES

To clarify this controversy, and to investigate correlations between severe hypoxemia and multiple spirometric parameters in patients with COPD with FEV(1) 50% of predicted or greater.

PATIENTS AND METHODS

In 103 consecutive patients with COPD with FEV(1) 50% of predicted or greater, and without any other cardiopulmonary disorder, the incidence of severe hypoxemia (partial pressure of arterial oxygen less than 60 mmHg) was established by ABG analysis. Positive and negative predictive values (PPVs and NPVs, respectively) for severe hypoxemia for multiple spirometric parameters (FEV(1), FEV(1)/forced vital capacity [FVC], peak expiratory flow [PEF], maximal midexpiratory flow rate [FEF(25-75)]) were evaluated in a stepwise manner.

RESULTS

Twenty-two patients (21%) were found to be severely hypoxemic. In the severely hypoxemic group, the mean values for FEV(1), FEV(1)/FVC, PEF and FEF(25-75) were 59.0+/-8.19%, 53.6+/-11.3, 50.6+/-9.3 and 34.4+/-14.2% of predicted, respectively. The mean values for the same parameters in the other patients were 58.0+/-4.6%, 52.7+/-7.8, 51.5+/-7.5 and 39.1+/-7.7% of predicted, respectively. Comparing these parameters between the two groups, only the difference in FEF(25-75) was statistically significant (P<0.01). Valid PPVs and NPVs could not be established for any of the parameters at any level, except for the NPV for FEF(25-75) 50% of predicted or greater, which was 92%. This threshold value resulted in a false negative finding in less than 5% of the patients with hypoxemia.

CONCLUSIONS

The results of the present study showed that one in five patients with COPD with FEV(1) 50% of predicted or greater was severely hypoxemic. In such patients, hypoxemia may be excluded, and ABG analysis may not be needed when the FEF(25-75) is also 50% of predicted or greater. The FEV(1), FEV(1)/FVC and PEF parameters failed to predict or exclude severe hypoxemia.

Increased levels of soluble adhesion molecules, E-selectin and P-selectin, in patients with infective endocarditis and embolic events

AIMS

Inflammation-induced procoagulant changes and endothelial cell activation appear to play an important role in thromboembolic complications of infective endocarditis. Hence, the aim of this study was to compare the plasma levels of soluble adhesion molecules E- and P-selectin in infective endocarditis patients with and without embolic events, and healthy subjects.

METHODS AND RESULTS

The study group consisted of 76 consecutive patients (mean age=26 years old, range from 8 to 64 years) with definite infective endocarditis according to the Duke criteria. Thirteen of the patients (17.1%) had embolic events. Transoesophageal echocardiographic examinations were performed on all patients within 3 days of initiation of antimicrobial therapy. Although there was a trend towards a higher rate of vegetations detected in those with embolic events than in those without, this did not reach statistical significance (84.6% vs 80.9%, P>0.05). Significantly larger vegetations were observed in patients with embolic events as compared to those without embolic events (1.4 cm vs 1.0 cm, P=0.03). The mean plasma concentrations of P-selectin were elevated in patients with embolic events as compared to both patients without embolic events and control subjects (58.69+/-7.49 ng x ml(-1)vs 29.65+/-5.69 ng x ml(-1), P=<0.001 and 58.69+/- 7.49 ng x ml(-1) vs 25.82+/-5.38 ng x ml(-1), P<0.001). Similarly, the patients with embolic events had increased plasma levels of E-selectin compared to those without embolic events and the control group (73.15+/-11.47 ng x ml(-1) vs 42.84+/-8.77 ng x ml(-1), P<0.001 and 73.15+/- 11.47 ng x ml(-1) vs 34.23+/-5.92 ng x ml(-1), P<0.001).

CONCLUSION

Determination of these membrane activation molecules may provide useful markers with which to identify patients at high thromboembolic risk from infective endocarditis.

Role of activated protein C resistance in left atrial thrombogenesis in patients with mitral stenosis

Activated protein C resistance (APC-R) is the most common inherited cause of clinically apparent venous thromboembolism. Previous data indicate that left atrial thrombus (LAT) formation is a common complication in mitral stenosis (MS) and a hypercoagulable state exists in these patients. The aim of this study was to invastigate the association between APC-R and LAT formation in patients with MS. Seventy-seven consecutive patients with rheumatic MS were included in this study. Transesophageal echocardiography was performed on all patients to assess the presence of any thrombus or spontaneous echo contrast (LASEC) in the left atrial cavity or appendage. Thirty four of the patients had LAT and 43 did not. Prevelance of APC-R was smiliar between the two groups of patients with and without LAT (23% vs 16%, p=0.425). LAT(+) patients had higher incidence of atrial fibrillation (AF, 74% vs 51%, p=0.046) and LASEC (71% vs 19%, p<0.001) compared to LAT(-) patients. On multivariate regression analysis, only the presence of LASEC achieved statistical significance as an independent risk factor for LAT formation (p=0.0001, odds ratio=9.589, 95% confidence interval [CI] =3.143-29.251). Because onunivariate analysis both LASEC and AF were associated with LAT, we also compared the prevelance of APC-R in the subgroups of patients who have these risk factors with and without LAT. There was a correlation between the presence of APC-R and LAT in the AF(+) subgroup of MS patients (p=0.033, odds ratio=8.167, 95% CI=1.001-72.812). However, the presence of APC-R was not associated with the increased risk of LAT in LASEC(+) patients (p=0.217, odds ratio=1.200, 95% CI=1.003-1.435). Although the presence of APC-R itself is not an independent risk factor for LAT formation in MS, it may increase the risk of LAT when present in combination with AF (as an additional risk factor) in these patients.

Thoracic involvement in Behçet's disease and its correlation with multiple parameters

In Behçet's disease (BD), controversy has existed over the incidence of thoracic involvement, which may be a direct threat to the patient's life. The aim of this study is to evaluate the incidence of thoracic involvement in BD and its correlation with the number of diagnostic BD criteria of The International Study Group (ISG), gender, disease duration, and the presence of symptoms. Forty-two BD patients, who had consecutively applied to different clinics in Turgut Ozal Medical Center Research Hospital, were included in the study. They were either newly diagnosed or already under treatment. All patients were examined by standard chest roentgenogram, spirometry, and thorax CT. Perfusion scintigraphies were obtained in patients with thoracic involvement. Thoracic pathologic conditions were found in five patients (11.9%). All thoracic pathologic conditions appeared in patients with at least four diagnostic criteria (26 patients) of the ISG for BD. In this subgroup, the rate of thoracic involvement was 19.2%. Also, 25% of the patients with pulmonary symptoms (12 patients) had thoracic lesions. Gender and the duration of the disease did not correlate with thoracic involvement. Our findings suggest that the rate of thoracic involvement in BD is greater than is generally believed. An increased number of diagnostic BD criteria of the ISG may indicate other organ system involvement and an increased risk of thoracic pathosis. All BD patients with at least four diagnostic criteria or any pulmonary symptoms should be evaluated for thoracic involvement, which is a major menace to life and necessitates early intervention.

Complications associated with percutaneous placement of intra-aortic balloon counterpulsation: can unsheathed insertion reduce limb ischaemia?

Complications related to percutaneous placement of intra-aortic balloon pump counterpulsation are still high despite major refinements in catheter design and techniques. One hundred and forty-eight patients in whom intra-aortic balloon pumping was inserted were classified into two groups on the basis of the insertion technique. Group I included 103 patients in whom the conventional percutaneous insertion was used. A sheathless insertion technique was used in group II (n = 45). The overall complication rate was 16.6% (25 of 150), in which lower limb ischaemia was the most common complication. The limb ischaemia was noted in 12 patients (11.5%) in group I and 4 patients (8.9%) in group II (statistically not significant). Peripheral vascular disease, diabetes mellitus and female gender were found to be significant predictors of limb ischaemia (p = 0.01, p = 0.02 and p = 0.03, respectively). In conclusion, sheathless insertion of intra-aortic balloon pump catheters does not reduce the incidence of limb ischaemia.