Coagulation, Fibrinolytic System Activation and Endothelial Dysfunction in Patients With Mitral Stenosis and Sinus Rhythm

Anticoagulation treatment can prevent systemic embolism in patients with mitral stenosis (MS) and atrial fibrillation (AF), but this treatment is under debate if patients are in sinus rhythm. The authors aimed to determine the hemostatic changes in patients with MS and sinus rhythm. Forty-six patients (28 in sinus rhythm and 18 in AF) with mitral stenosis were enrolled in this study. They studied systemic venous fibrinogen, D-dimer, antithrombin-III, tissue plasminogen activator (tPA), plasminogen activator inhibitor-I (PAI-I), von Willebrand factor (vWF), and platelet factor 4 (PF 4) in these patients. The patients were first classified according to their rhythm as sinusal and AF, and then according to the presence of left atrial spontaneous echo contrast (LASEC). Fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly greater in patients with MS and sinus rhythm or atrial fibrillation compared to the control group (p<0.05). Whether the rhythm was sinus or AF, fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly higher in patients with LASEC than in the control group (p<0.05). Only PF 4 was higher in the AF group than in those with sinus rhythm (p<0.05). As to plasminogen activator and PAI-I levels, only tissue plasminogen activator levels were found to be higher in the AF group than in those with sinus rhythm and the control group (p<0.05). In patients with mitral stenosis and sinus rhythm, if LASEC is present, coagulation activation, platelet activation, and endothelial dysfunction are similar in patients with AF, and anticoagulation should be considered in these patients.

Increased Systemic and Regional Coagulation Activity in Patients with Mitral Stenosis and Sinus Rhythm

A hypercoagulable state has been reported in patients with mitral stenosis (MS) and sinus rhythm (SR). However it has been suggested that the coagulation activity may be increased only within the left atrium in MS, with normal peripheral blood levels. The aim of the present study was to assess regional left atrial and systemic coagulation activities by measuring PF 1 +2 in patients with severe mitral stenosis and sinus rhythm, normal blood clotting times, and no left atrial thrombus. The study was conducted in 25 consecutive patients with moderate-to-severe MS and sinus rhythm who underwent percutaneous balloon mitral valvu loplasty. Transesophageal echocardiography was performed before the valvuloplasty procedure in all patients to exclude the presence of left atrial thrombus and left atrial spontaneous echo contrast (LASEC). There were no statistically significant differences between LASEC-positive and LASEC-negative patients with respect to age, gender, fibrinogen levels, prothrombin time, mitral valve area, mean mitral gradient, pulmonary artery pressure (in all p> 0.05). Regional (left atrial) PF1+2 levels of both LASEC-positive and LASEC-negative patients were significantly elevated when compared to control subjects (p<0.01). Statistically significant elevated systemic level of PF 1 +2 was observed only in LASEC-positive patients when compared to control subjects (p<0.01, p>0.05, respectively). In conclusion patients with severe mitral stenosis and SR have increased regional coagulation activity in both LASEC-negative and LASEC-positive groups. Although this increased regional coagulation activity has been reflected in peripheral blood of LASEC-positive patients, it has not been reflected in peripheral blood of LASEC-negative patients.

Factors causing stress in women with babies 0-3 months old and their coping styles

This study was conducted in order to identify the factors that cause stress in women who have babies aged 0-3 months and the ways to deal with stress. This descriptive study was conducted in outpatient clinics for newborns. The sample consisted of 322 women. Data were collected through a questionnaire and Ways of Coping with Stress Inventory. It was found that most of the women became stressed because of problems regarding self-care, baby care and social life. Women mostly used ineffective coping styles to cope with stress.

Influence of blood collection systems on coagulation tests

Objective: Coagulation tests are influenced by pre-analytic conditions such as blood collection systems. Change of glass collection tubes with plastic ones will cause alteration of the test results.

The aim of this study was to compare three plastic blood collection tubes with a standard glass blood collection tube and each plastic collection tube with the other two for possible additional tube-to- tube differences.

Material and Methods: A total of 284 blood samples were obtained from 42 patients receiving warfarin during their routine controls, besides 29 healthy volunteers. Subgroup analyses were done according to health status.

Results: Our study demonstrated that different blood collection tubes have a statistically significant influence on coagulation tests. The magnitude of the effect depends on the tube used. However most of the tests performed on samples obtained from any tube correlated significantly with results obtained from other tube samples.

Conclusion: Although blood collection tubes with different brands or properties will have distinct effects on coagulation tests, the influence of these blood collection tubes may be relatively small to interfere with decision-making on dose prescription, therefore lack clinical importance. Correlations between the results showed that, one of these plastic blood collection tubes tested in our study, can be used interchangably for a wide variety of coagulation assays.

Conflict of interest:None declared.

Continuous active state of coagulation system in patients with nonthrombotic inflammatory bowel disease

This study was planned for searching possible changes of the total coagulation and fibrinolysis system in inflammatory bowel disease (IBD) in order to obtain some clues for explaining the relation between IBD and hypercoagulability. A total of 24 patients with ulcerative colitis, 12 patients with Crohn disease, and 20 healthy controls were studied. Platelets; prothrombin time (PT); partial thromboplastin time (PTT); fibrinogen; D-dimer; fibrinogen degradation products; protein C; protein S; antithrombin; thrombin time; von Willebrand factor; coagulation factors V, VII, VIII, IX, XI, and XIII; plasminogen; antiplasmin; tissue plasminogen activator; plasminogen activator inhibitor 1; and prothrombin fragments 1 + 2 were studied. Most of the procoagulants (platelets, fibrinogen, von Willebrand factor, coagulation factor IX, and plasminogen activator inhibitor 1) were found increased together with decreases in some anticoagulants (protein S and antithrombin) in IBD. Also the activation markers of coagulation (D-dimer, fibrinogen degradation products, and prothrombin fragments 1 + 2) were all increased. The parameters of the total coagulation-fibrinolysis system were increased in IBD, regardless of the form and the activity of the disease.

Mobbing against nurses in the workplace in Turkey

AIM

The aim of the study was to determine whether the nurses have been exposed to mobbing or not, and to reveal the causes of the mobbing between 3 November 2008 and 31 December 2008.

METHODS

This research was a mixed method study involving survey and focus group interviews. The sample was calculated using sample calculation formula, and 206 nurses were included in the survey study. Four focus group interviews were later carried out with 16 nurses. The survey method and semi-structured question form were used to collect data. The percentage and chi-square were used to evaluate the quantitative data, and for the analysis of the qualitative data, descriptive analyses were made through direct quotations from the nurses' statements.

FINDINGS

According to the mobbing scale, 9.7% of the nurses had been exposed to mobbing, but according to their own declarations, 33% had been exposed. Some of the nurses (25.2%) who expressed that they had been exposed to mobbing reported that the executor of mobbing was the head nurse and 9.2% said that the reason for mobbing was 'communication problems'. Nurses under 25 years of age and those who work in intensive care units are apparently exposed to mobbing more frequently than others (P<0.05).

CONCLUSIONS

It is suggested that head nurses' mobbing behaviours should be determined and they should be educated about leadership. Nurses should be educated about assertiveness to prevent mobbing. The necessary measures should be adopted to solve the 'communication problems', which are shown as a major reason for mobbing.

Increased platelet activity in patients with isolated coronary artery ectasia

BACKGROUND

The common coexistence with coronary artery disease has led to the suggestion that coronary artery ectasia (CAE) is a variant of coronary artery disease. The mechanisms, however, responsible for CAE formation during the atherosclerotic process and the exact clinical significance are not well known. In this study, we aimed to investigate platelet activity in patients with isolated CAE by using specific markers of platelet activation as P-selectin, beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4).

METHODS

Thirty-two patients with isolated CAE without significant stenosis and 30 control participants with angiographically normal coronary arteries were included in this study. According to the angiographic definition used in the Coronary Artery Surgery Study, a vessel is considered to be ectasic when its diameter is > or = 1.5 times that of the adjacent normal segment in segmental ectasia. Plasma P-selectin, beta-TG and PF4 levels were measured in all patients and control participants using enzyme-linked immunosorbent assay method.

RESULTS

Patients with isolated CAE were detected to have significantly higher levels of plasma P-selectin, beta-TG and PF4 in comparison with control participants with angiographically normal coronary arteries (P-selectin: 248+/-46 vs. 154+/-32 ng/ml, respectively, P<0.001; beta-TG: 51+/-19 vs. 21+/-9 ng/ml, respectively, P<0.001; PF4: 58+/-23 vs. 33+/-11 ng/ml, respectively, P<0.001).

CONCLUSION

In conclusion, we have shown for the first time that patients with isolated CAE have raised levels of plasma P-selectin, beta-TG and PF4 compared with control participants with angiographically normal coronary arteries, suggesting increased platelet activation in patients with CAE.

Vascular endothelial growth factor receptor-1 levels in hepatocellular carcinoma and correlations with clinicopathological features

BACKGROUND/AIMS

To determine the serum vascular endothelial growth factor receptor-1 (VEGFR-1) levels in hepatocellular carcinoma patients and its correlations with the clinical and laboratory parameters.

METHODOLOGY

Serum VEGFR-1 levels were measured in 18 biopsy-proven treatment-naive hepatocellular carcinoma patients (female/male: 5/13; mean age: 59.22 +/- 13.15 years) and in age- and sex-matched healthy controls. Possible associations were also evaluated between serum VEGFR-1 levels and etiology and severity of chronic liver disease, serum alpha-fetoprotein levels, presence of ascites and portal vein thrombosis, and tumor number, size and stage.

RESULTS

Serum VEGFR-1 levels were undetectable in all healthy subjects, while all of the patients with hepatocellular carcinoma had increased VEGFR-1 (p < 0.001). Serum VEGFR-1 levels did not correlate with the clinical and laboratory parameters and tumor characteristics in hepatocellular carcinoma.

CONCLUSIONS

VEGFR-1 is involved in the regulation of carcinogenesis in hepatocellular carcinoma.

Plasma level of soluble P-selectin in patients with rheumatic mitral stenosis and sinus rhythm undergoing percutaneous mitral balloon valvuloplasty

OBJECTIVE

To determine whether plasma level of soluble P-selectin (sP-selectin) increases in rheumatic mitral stenosis (MS) patients with sinus rhythm, who have scheduled for percutaneous mitral balloon valvuloplasty (PMBV), and to examine the effect of PMBV on sP-selectin level.

METHODS

Twenty-six patients with MS and sinus rhythm (study group, 20 female, mean age 33 +/- 8 years) and a well-matched control group composed of 21 healthy volunteers (15 female, mean age 35 +/- 6 years) were enrolled in the study. In each patient left atrial (LA) thrombus was excluded by transesophageal echocardiography. sP-selectin levels were compared between study patients and controls, and between peripheral and LA blood. Changes in sP-selectin level 24 h and 4 weeks after PMBV were also analyzed.

RESULTS

A significantly higher basal sP-selectin level was noted in study group. After PMBV, the mitral valve area (MVA) increased and the transmitral mean gradient decreased significantly. At 24th hour after PMBV, sP-selectin level decreased from 1080.38 +/- 143.87 ng/ml to 960.00 +/- 103.26 ng/ml (p < 0.0001) and at 4th-week follow-up it was decreased from 960.00 +/- 103.26 ng/ml to 879.61 +/- 98.16 ng/ml (p < 0.0001). No significant difference was found between peripheral and LA blood regarding the sP-selectin level. Correlation analysis between the difference in MVA measured 24-hour after and before PMBV and the difference in sP-selectin level measured 24-hour after and before PMBV showed a significant direct relationship between these variables.

CONCLUSION

This study suggests that in patients with MS and sinus rhythm sP-selectin level increases probably due to turbulent flow across the stenotic valve. After PMBV sP-selectin shows a progessive decline, which is directly correlated with the increase in MVA.

Plasma levels of soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) in familial Mediterranean fever

AIMS

To assess the levels of soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) in patients with familial Mediterranean fever (FMF).

METHODS

Plasma levels of sVEGFR-1 were investigated in 33 FMF patients in an attack-free period (mean age 30.8 years; males/females 10/23), in 15 patients with acute FMF attack (mean age 32.7 years; males/females 7/8), and 19 healthy controls (mean age 32 years; males/females 11/8). Levels of sVEGFR-1 were also compared among patients who were receiving colchicine and those who were not.

RESULTS

Plasma sVEGFR-1 levels were 3.49+/-1.10, 3.53+/-1.02, and 0.37+/-0.28 ng/ml for FMF patients in the attack-free period, FMF patients with acute attack, and healthy controls, respectively. Plasma sVEGFR-1 levels were significantly higher in FMF patients with and without acute attack compared to the control group (p<0.05). sVEGFR-1 levels were not statistically significant between patients with acute attack and attack-free FMF patients (p>0.05). The plasma levels of sVEGFR-1 were also comparable in colchicine treated and untreated patients.

CONCLUSION

Our data suggest that sVEGFR-1 may have a role in the ongoing inflammatory cascade in FMF.

Serum transforming growth factor beta 1 levels in multiple myeloma patients

Cytokinesis plays an important role in the etiology of multiple myeloma. The transforming growth factor (TGF) beta 1 levels in 82 sera from 60 patients with multiple myeloma were analyzed by ELISA. Fourty one sample were obtained before treatment from newly diagnosed patients, 22 after treatment from the same patients and 19 from relapsed/refractory patients. Serum median TGF level of newly diagnosed patients was 769.5 ng/mL (126-1853), and the relapsed/refractory patients had similar levels. TGF levels after chemotherapy were not different between patients that reached plateau phase and those who remained refractory. We found a negative correlation between TGF and C-reactive protein and blood urea nitrogen and a positive correlation between TGF and hemoglobin level in newly diagnosed patients. After treatment, it was determined that TGF levels at diagnosis were higher in patients who reached plateau phase than in the refractory patients. Elevated serum TGF concentration at diagnosis in multiple myeloma patients may be a favorable predictor of response.

Serum level of lipoprotein (a) is inversely associated with the development of coronary collateral circulation

BACKGROUND

This study sought to determine the relationship between serum lipoprotein (a) levels and angiographically visible coronary collateral circulation and to evaluate whether lipoprotein (a) exerts any effect on vascular endothelial cell growth factor.

METHODS

The study population included 60 patients (39 men, mean age 59+/-13 years) with angiographically documented total occlusion in one of the major coronary arteries. Development of collaterals was classified by Rentrop's method. Patients were defined as having poorly developed collaterals for grades 0 and 1 (group 1), or well-developed collaterals for grades 2 and 3 (group 2). Serum lipoprotein (a) and vascular endothelial cell growth factor levels were determined by enzyme-linked immunosorbent assay.

RESULTS

In group 1, lipoprotein (a) levels were significantly higher and vascular endothelial cell growth factor levels were significantly lower than in group 2 (34+/-19 vs. 20+/-12 mg/dl, P<0.001, and 2.5+/-0.7 vs. 3.4+/-0.8 ng/dl, P<0.001, respectively). Poorly developed collaterals were significantly more frequent in patients with lipoprotein (a) levels >or=30 mg/dl than in patients with levels <30 mg/dl (72 vs. 37%, P=0.008). A strong negative correlation was observed between lipoprotein (a) and vascular endothelial cell growth, factor (r=-0.708, P<0.0001). Multivariate analysis revealed that a high level of lipoprotein (a) negatively affected the development of collaterals, whereas the duration of angina had a positive effect.

CONCLUSION

This study demonstrated for the first time that the high level of lipoprotein (a) negatively affects the formation of coronary collateral vessels in human beings. Reduced production or bioactivity of vascular endothelial cell growth factor caused by high levels of lipoprotein (a) may be the possible responsible mechanisms of hyperlipoprotein (a)-related poor collateral formation.

The plateled-derived growth factor level (PDGF) in Hodgkin's disease and non-Hodgkin's lymphoma and its relationship disease activation

The research reported in this paper was designed to study the role of plateled-derived growth factor (PDGF) in Hodgkin's disease (HD) and non-Hodgkin's lymphomas (NHL). The PDGF levels in 9 patients with HD and 12 NHL and in a control group consisting of 20 people, was measured by ELISA method. The PDGF values in the disease group of 19 patients were raised. The values of PDGF in the control group were 28.977+/-9 pg/ml, but were measured at 147.083+/-54 pg/ml in HD group and 131.487+/-56 pg/ml in NHL group (p < 0.01). The observation of a 5-fold increase in PDGF values in the disease group when compared to the control group suggests that PDGF could itself be considered as a possible factor in the pathogenesis of HD and NHL. In order to support this, there is a need to design additional studies monitoring PDGF in larger number of patients at various stages of the disease.

Increased plasma soluble adhesion molecules; ICAM-1, VCAM-1, and E-selectin levels in patients with slow coronary flow

BACKGROUND

Inflammation has been reported to be a major contributing factor to many cardiovascular events. In the present study, we aimed to evaluate plasma soluble adhesion molecules; intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin as possible indicators of endothelial activation or inflammation in patients with slow coronary flow.

METHOD

Study population included 17 patients with angiographically proven normal coronary arteries and slow coronary flow in all three coronary vessels (group I, 11 male, 6 female, mean age=48+/-9 years), and 20 subjects with angiographically proven normal coronary arteries without associated slow coronary flow (group II, 11 male, 9 female, mean age=50+/-8 years). Coronary flow rates of all patients and control subjects were documented by Thrombolysis In Myocardial Infarction frame count (TIMI frame count). All patients in group I had TIMI frame counts greater than two standard deviation above those of control subjects (group II) and, therefore, were accepted as exhibiting slow coronary flow. Serum levels of ICAM-1, VCAM-1, and E-selectin were measured in all patients and control subjects using commercially available ELISA kits.

RESULTS

Serum ICAM-1, VCAM-1, and E-selectin levels of patients with slow coronary flow were found to be significantly higher than those of control subjects with normal coronary flow (ICAM-1: 545+/-198 ng/ml vs. 242+/-113 ng/ml respectively, p<0.001, VCAM-1: 2040+/-634 ng/ml vs. 918+/-336 ng/ml respectively, p<0.001, E-selectin: 67+/-9 ng/ml vs. 52+/-8 ng/ml respectively, p<0.001). Average TIMI frame count was detected to be significantly correlated with plasma soluble ICAM-1 (r=0.550, p<0.001), VCAM-1 (r=0.569, p<0.001) and E-selectin (r=0.443, p=0.006).

CONCLUSION

Increased levels of soluble adhesion molecules in patients with slow coronary flow may be an indicator of endothelial activation and inflammation and are likely to be in the causal pathway leading to slow coronary flow.

Elevated level of plasma homocysteine in patients with slow coronary flow

BACKGROUND

Elevated plasma levels of homocysteine are currently considered a major, independent risk factor for cardiovascular diseases. Recently, several investigators have suggested that even mild elevation in plasma homocysteine level can severely disturb vascular endothelial function and subsequently impair coronary blood flow. Accordingly, we investigated plasma homocysteine level in patients with slow coronary flow.

METHOD

Study population included 53 patients with angiographically proven normal coronary arteries and slow coronary flow in all three coronary vessels (group I, 21 females, 32 males, mean age=48+/-9 years), and 50 subjects with angiographically proven normal coronary arteries without associated slow coronary flow (group II, 22 females, 28 males, mean age=50+/-8 years). Coronary flow rates of all patients and control subjects were documented by Thrombolysis In Myocardial Infarction frame count (TIMI frame count). All patients in group I had TIMI frame counts greater than two standard deviations above those of control subjects (group II) and, therefore, were accepted as exhibiting slow coronary flow. The mean TIMI frame count for each patient and control subject was calculated by adding the TIMI frame counts for each major epicardial coronary artery and then dividing the obtained value into 3. Plasma homocysteine level was measured in all patients and control subjects using commercially available homocysteine kits.

RESULTS

There was no statistically significant difference between two groups in respect to age, gender, hypertension, diabetes mellitus, hyperlipidemia and cigarette smoking (p>0.05). Plasma homocysteine level of patients with slow coronary flow were found to be significantly higher than those of control subjects (15.5+/-5.7 vs. 8.7+/-4.2 microM/l, respectively, p<0.001). Moreover, we found a significant positive correlation between plasma homocysteine level and mean TIMI frame count (r=0.660, p<0.001).

CONCLUSION

We have shown that patients with slow coronary flow have raised level of plasma homocysteine compared to control subjects with normal coronary flow. This data suggests that elevated level of plasma homocysteine may play a role in the pathogenesis of slow coronary flow.

[Thrombotic, fibrinolytic and proliferative activities of pulmonary vascular bed in secondary pulmonary hypertension]

OBJECTIVE

To determine whether pulmonary vascular bed contributes to the development of in situ thrombosis and vascular remodelling in secondary pulmonary hypertension (SPH) via changes in its local secretory activities.

METHODS

Seventy-one patients with the diagnosis of secondary pulmonary hypertension (38 females, mean age 40.36+/-1.05 years) were included in the study. Selective right and left heart catheterization was performed to each patient for diagnostic purposes. Blood samples obtained from left ventricle (LV) and pulmonary artery (PA) of each patient were analyzed for levels of plasminogen activator inhibitor-1 (PAI-1), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), D-dimer, von Willebrand factor (vWF), protein-C, antithrombin-III, fibrinogen, and plasminogen. Results were compared between LV and PA. Correlation analysis between each parameter and mean pulmonary artery pressure (MPAP) was performed.

RESULTS

Although mean level of VEGF in LV and PA were found to be in normal range, it was significantly higher in LV than in PA (p<0.001). Mean PDGF and D-dimer levels, which remained in normal range were also higher in LV (p<0.001 and p<0.001, respectively) than in PA;.vWF showed similar degree of elevation in both LV and PA. Only one parameter, PAI-1, was found to be significantly higher in PA than in LV (p=0.012). Antithrombin-III, protein C, plasminogen, and fibrinogen levels showed no significant differences between two chambers. They also remained in normal range, except for fibrinogen, which was slightly elevated in both LV and PA. Correlation analysis revealed strong positive correlation between D-dimer level in both LV and PA and MPAP (r=0.775, p<0.001 and r=0.649, p<0.001, respectively).

CONCLUSION

In SPH, pulmonary vascular bed shows increased thrombotic, hypofibrinolytic, and proliferative activities, which are partially related to the severity of illness.

Late saphenous vein graft occlusion in patients with coronary bypass: possible role of aspirin resistance

BACKGROUND

Late venous graft thrombosis, leading to recurrent ischemia, is frequently encountered in old, degenerated vein grafts with advanced atherosclerotic plaque formation. Aspirin has been indicated to maintain venous graft patency in the post-operative period. However, there is considerable evidence that aspirin resistance is of concern in patients with venous grafts.

MATERIAL AND METHOD

Prospectively enrolled 14 patients (11 male, 3 female, Group 1), who were shown to have at least one occluded saphenous vein graft on their late control coronary angiogram after bypass operation, were compared for the presence of aspirin resistance by PFA-100 with age- and sex-matched 14 patients (10 male, 4 female, Group 2), who were found patent and well-functioning vein grafts without wall irregularities on late post-operative coronary angiograms (mean 6.5+/-2.5 years), enrolled as a control group.

RESULTS

Mean CT of collagen/epinephrine cartridge in Group 1 was 197+/-85 s and significantly less than in Group 2 (279+/-44 s; p=0.011). It was found that 50% of patients in Group 1 were so-called aspirin resistant, whereas in Group 2, this ratio was 7.1% (p=0.033). BMI (p=0.038, Beta=-0.322), uric acid level (p=0.023, Beta=-0.355), and CT by collagen/epinephrine cartridge (p=0.008, Beta=0.431) were independently predicting late occlusion of saphenous vein graft.

CONCLUSION

Aspirin resistance is highly prevalent in patients with occluded venous grafts at a relatively late period.

Antineutrophil cytoplasmic autoantibodies and anti-Saccharomyces cerevisiae antibodies in inflammatory bowel diseases

BACKGROUND/AIMS

Perinuclear antineutrophil cytoplasmic autoantibody is a marker for ulcerative colitis, and anti-Saccharomyces cerevisiae antibody is known to be associated with Crohn's disease. The purpose of this study was to search the value of detecting perinuclear antineutrophil cytoplasmic autoantibody and anti-Saccharomyces cerevisiae antibody for the diagnosis of Turkish inflammatory bowel disease patients.

METHODS

Serum samples were obtained from 80 patients with ulcerative colitis, 61 patients with Crohn's disease and 40 healthy controls. Determination of both anti-Saccharomyces cerevisiae antibody and antineutrophil cytoplasmic autoantibody was performed with the standardized enzyme-linked immunosorbent assay.

RESULTS

In cases with ulcerative colitis, 65% tested seropositive for antineutrophil cytoplasmic autoantibody, whereas the controls showed 2.5% positivity. In cases with Crohn's disease, 63.9% tested seropositive for anti-Saccharomyces cerevisiae antibody, whereas the controls showed 2.5% seropositivity. The combination of a positive anti-Saccharomyces cerevisiae antibody test and a negative antineutrophil cytoplasmic autoantibody yielded a sensitivity and specificity of 32.0% and 97.5%, respectively. The combination of a positive perinuclear antineutrophil cytoplasmic autoantibody and a negative anti-Saccharomyces cerevisiae antibody test yielded a sensitivity and specificity of 44.2% and 97.5%, respectively.

CONCLUSIONS

Both serologic tests may aid in the differential diagnosis of inflammatory bowel disease.

Decreased platelet activation and endothelial dysfunction after percutaneous mitral balloon valvuloplasty

OBJECTIVE

This study was conducted to assess the changes in platelet activation and endothelial dysfunction in patients with mitral stenosis (MS) and sinus rhythm (SR) following percutaneous mitral balloon valvuloplasty (PMBV).

BACKGROUND

Systemic thromboembolism is a serious complication in patients with valvular heart disease, and its incidence is highest in those with mitral stenosis. A hypercoagulable state has also been reported in patients with mitral stenosis and sinus rhythm. A recent study has shown that patients with previous PMBV had a lower incidence of thromboembolism.

METHODS AND RESULTS

The study was conducted in 21 patients (two men, 19 women, mean age=34+/-6 years) with mitral stenosis and sinus rhythm (SR) who underwent percutaneous mitral balloon valvuloplasty and 17 healthy control subjects (two men, 15 women, mean age=33+/-6 years). Biochemical markers of platelet activity (beta thromboglobulin, BTG, and soluble P-selectin, sPsel) and endothelial dysfunction (von Willebrand Factor, vWF) were measured in both control subjects' and patients' serum samples taken immediately before PMBV and 24 h after PMBV procedure. All patients underwent successful PMBV. Significant improvement of mitral valve area, pulmonary artery pressure, mean mitral gradients, and left atrial diameter were achieved in all patients after PMBV. Compared with control subjects, patients with MS had higher plasma levels of BTG (66+/-26 ng/ml vs. 14+/-6 ng/ml, P<0.001), vWF (177+/-67 units/dl vs. 99+/-37 units/dl, P<0.0001), sPsel (226+/-74 ng/ml vs. 155+/-66 ng/ml, P<0.001). There was a significant reduction of plasma levels of BTG (66+/-26 ng/ml vs. 48+/-20 ng/ml, P=0.002), vWF (177+/-67 units/dl vs. 134+/-60 units/dl, P=0.001) and P-selectin (226+/-74 ng/ml vs. 173+/-71 ng/ml, P=0.008,) 24 h after PMBV.

CONCLUSION

We have shown that patients with severe MS and SR have increased platelet activation and endothelial dysfunction compared with control subjects and PMBV results in decreased platelet activity and improvement of endothelial injury.

Scintigraphic evaluation of paired renal allografts from the same cadaveric donor

The aim of this study was to compare the outcome of paired grafts in renal recipients from the same cadaveric donor using quantitative Tc-99m DTPA scintigraphy. Fifty recipients from 25 cadaveric donors were followed for a median period of 3 years. Serial Tc-99m DTPA scintigraphy was performed starting on the third posttransplant day and images evaluated quantitatively. The quantitative parameters included Hilson's perfusion index, time to maximum activity, time to half of maximum activity, the ratio of the graft activity at 20 to 3 minutes, and glomerular filtration rate. In the early postoperative period, 20 of 25 paired kidneys showed similar performances. At the end of the first year 22 of 25 pairs showed a similar evolution. At the end of the third year, the number was 21 of 25. We concluded that if cold ischemia time was prudent, there was no difference in graft outcome between the first and the second recipient of a renal transplant from the same cadaveric donor.

Relationship between control of ventricular rate in atrial fibrillation and systemic coagulation activation in patients with mitral stenosis

BACKGROUND AND AIM OF THE STUDY

Systemic thromboembolism is a major complication in patients with mitral stenosis (MS), especially in those who have atrial fibrillation (AF). It has been suggested that systemic coagulation activity may be increased in these patients. The study aim was to investigate the relationship between control of ventricular rate and systemic coagulation factors in patients with MS and AF by measuring plasma levels of prothrombin fragment (PF) 1+2, thrombin-antithrombin III complex (TAT) and plasminogen activator inhibitor-1.

METHODS

Fifty-four consecutive patients with moderate to severe MS and AF were included in the study. Patients with resting heart rates < 100 beats per min were considered as having a controlled ventricular response rate (group A; n = 28) and those with > 100 beats per min as an uncontrolled ventricular response rate (group B; n = 26).

RESULTS

Group A patients had a lower mean mitral gradient and pulmonary artery pressure than group B patients (11 +/- 6 versus 15 +/- 5 and 35 +/- 7 versus 39 +/- 8; p < 0.05, respectively). Plasma concentrations of PF 1+2 (4.17 +/- 2.1 versus 2.95 +/- 1.21; p < 0.01) and TAT III (4.61 +/- 1.75 versus 3.12 +/- 1.01; p < 0.01) were elevated in group B compared with group A. Similarly, group B patients had higher plasminogen activator inhibitor-1 levels than group A patients (7.87 +/- 3.8 versus 5.8 +/- 2.9; p < 0.05). A significant correlation was found between heart rate and plasma PF 1+2 and TAT levels. Multiple logistic regression analysis revealed that heart rate and mean mitral gradient were independent predictors of systemic coagulation activation.

CONCLUSION

Besides contributing towards hemodynamic and symptomatic relief, the control of AF rate in MS patients induces a drastic decline in coagulation activation, and may also reduce the incidence of thromboembolism.

Predictors of left ventricular thrombus formation in patients with dilated cardiomyopathy: role of activated protein C resistance

OBJECTIVES

The aim of this study was to investigate the association between left ventricular thrombus formation and natural anticoagulant systems including the protein C, protein S and antithrombin in patients with dilated cardiomyopathy.

MATERIALS AND METHODS

Sixty patients with dilated cardiomyopathy who met the inclusion criteria were included in the study. Patients were divided into two groups: group I consisted of 22 patients with left ventricular thrombus and group II consisted of 38 patients without left ventricular thrombus. Our main inclusion criteria were ejection fraction </= 35% and left ventricular end-diastolic diameter >/= 6.0 cm. These two groups were compared for clinical and hematologic parameters (activated protein C resistance, protein S and antithrombin).

RESULTS

There were no statistically significant differences between patients with or without left ventricular thrombi with respect to left ventricular end-diastolic and end-systolic dimensions, ejection fraction, fractional shortening and left atrial diameter. There were no statistically significant differences between patients with and without left ventricular thrombus with respect to platelet count (252 +/- 64/mm3 x 10(3) compared with 260 +/- 74/mm3 x 10(3) respectively, P=0.68), prothrombin time (12.94 +/- 1.9 s compared with 12.86 +/- 1.3 s respectively, P=0.82), activated partial thromboplastin time (32 +/- 5 compared with 30 +/- 4 s respectively, P=0.32) and fibrinogen levels (36 +/- 9 mg/dl compared with 34 +/- 8 mg/dl respectively, P=0.41). None of the patients had protein S and antithrombin deficiency. Activated protein C resistance was found in 12 patients (12 out of 22, 54%) in group I and four patients (four out of 38, 9.5%) in group II (P < 0.01). It was also shown to be an independent predictor of left ventricular thrombus (P < 0.05).

CONCLUSION

Activated protein C resistance is found to be an independent predictor of left ventricular thrombus in patients with dilated cardiomyopathy who have ejection fractions less then 35% and left ventricular end-diastolic dimensions > 6.0 cm.

Protein C, S and antithrombin III levels in patients with acute mechanical valve thrombosis

BACKGROUND

Mechanical prosthetic heart valve thrombosis is a serious complication with an incidence of 1-6%. The reduction in active vitamin-K dependent protein C and S levels caused by warfarin treatment also results in a prothrombotic state. This study was conducted to investigate the connection between protein C (PC), protein S (PS), antithrombin III (ATIII) deficiency and prosthetic mechanical valve thrombosis.

METHODS

Twenty-nine of the 283 patients who underwent valve replacement with St. Jude medical prosthesis had mechanical valve thrombosis (group 2). The rest were considered as group 1. Twelve of the 29 patients (41.4%) had isolated aortic valve replacement, 12 had isolated mitral valve replacement (41.4%) and 5 patients had double valve replacement (17.2%). Most of the patients had rheumatic valve disease at their 1st operation. The mean time of occurrence for mechanical valve occlusion was 4.1+/-1.0 years following surgery.

RESULTS

The values of PC, PS and ATIII were obtained when the mechanical valves stuck or at routine follow-up. PC, PS and ATIII levels were significantly lower in the mechanical valve thrombosis group. PC levels were 75.4+/-37.6% and 49.9+/-32.2% in group 1 and 2, respectively (p=0.001). PC, PS and ATIII values were mostly lower in the 2nd group but this difference only became significant after at least 2 years of warfarin usage.

CONCLUSIONS

Natural anticoagulant levels can be low during the use of warfarin. In which case the dose can be increased in order to hold the international normalized ratio (INR) at 3-3.5. However, more frequent follow-up is required and patients should be investigated for hypercoagulation states or deficiency in anticoagulant proteins. Patients referred to hospital with any mechanical valve thrombosis or recurrent thromboembolism should be evaluated for hypercoagulant proteins.

Comparison of metabolic responses to deep hypothermic total circulatory arrest and retrograde cerebral perfusion in an experimental model

An experimental study was designed to search the effectiveness of retrograde cerebral perfusion which is presently used as cerebral protection method for the surgery of arcus aorta. Twelve dogs were subjected to the study. Six of them were remained in total circulatory arrest at 20 degrees C for 60 min. Retrograde cerebral perfusion was done again at 20 degrees C for 1 h for the other six dogs. Tumor necrosis factor (TNF), P-selectin, Intracellular Adhesion Molecule (ICAM), Creatine Phosphokinase (CPK-BB) and tissue Adenosine triphosphate (ATP) levels were measured, before the cardiopulmonary bypass at 37 degrees C and during perfusion period at 5, 60 min and 4 h. Tissue ATP level for retrograde cerebral perfusion group was 3.99+/-0.7 mcmol/g tissue and 2.86+/-0.1 mcmol/g tissue for total circulatory arrest group at fourth hour (p<0.05). TNF level was significantly higher in total circulatory arrest group than retrograde cerebral perfusion group (p<0.05). The samples taken at fourth hour of reperfusion showed the TNF level was, 162.55+/-13.1 pcg/ml for total circulatory arrest group and this value was 12.5+/-3.4 pcg/ml for retrograde cerebral perfusion group.ICAM (Intracellular Adhesion Molecule) level was higher in total circulatory arrest group (18.75+/-3.6 ng/ml) when compared to retrograde cerebral perfusion group (8.75+/-1.8 ng/ml) (p<0.05). All parameters showed that retrograde cerebral perfusion preserved the brain functions better comparing with total circulatory arrest. The time necessary for aortic surgery may be provided by the retrograde cerebral perfusion technique.

Circulating interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, and soluble ICAM-1 in patients with chronic stable angina and myocardial infarction

The changes in serum concentrations of cytokines such as interleukin-1 (IL-1) beta, interleukin-6 (IL-6), tumor necrosis factor (TNF) alpha and a soluble-intercellular adhesion molecule (sICAM-1) has been investigated in patients with stable angina and acute myocardial infarction. Thirty-four patients with stable angina (SA), 15 with acute myocardial infarction (AMI), and 20 subjects in the control (C) group were included in the study. The mean serum concentrations of sICAM-1, IL-1-beta, IL-6, and TNF-alpha differed significantly among the three groups. Serum concentrations of IL-1 beta, sICAM-1, and TNF-alpha were comparable in the AMI and SA groups and higher than those found in the C group (p < 0.001). The serum concentration of IL-6 was more than twice as high in the AMI group as compared to the other two groups (p < 0.001). The mean serum concentrations of IL-1 beta, TNF-alpha, and IL-6 were comparable in the AMI and SA groups and higher than in the C group.

Beneficial effects of iloprost during experimentally induced hemorrhagic shock

BACKGROUND

The aim of the study was to evaluate the efficacy of iloprost on myocardial insufficiency associated with hypovolemic shock in dogs. We designed the study as a controlled randomized study.

METHODS

Sixteen mixed-breed dogs were included into the study and divided into two equal groups as the control and iloprost groups. Mean arterial pressure was reduced to 45 mmHg by withdrawing the arterial blood into citrated bags. The control group did not receive any drug but the other group received iloprost at a rate of 20 ng/kg/min by an infusion pump. Iloprost infusion was started 30 min after the blood pressure was reduced to 45 mmHg. All measurements were made before removal of blood, 45 min after exsanguination and at 1 hour intervals for 3 hours. Left ventricular stroke work index was measured 72 hours after the study. The hemodynamic and biochemical parameters and blood gas analysis were obtained.

RESULTS

After hemorrhage, cardiac index (CI) decreased significantly from 132 +/- 14 to 51 +/- 8 ml/kg/min in the control group and from 128 +/- 11 ml/kg/min to 47 +/- 13 ml/kg/min in the iloprost group, respectively but at the end of the third hour it was 81 +/- 8 ml/kg/min in the control group and 105 +/- 6 ml/kg/min in the iloprost group (p < 0.05). Tumor necrosis factor-alpha (TNF alpha) was 41 +/- 8 pg/ml in the control group and 18 +/- 6 in the iloprost group 3 hours after bleeding (p < 0.05). Tumor necrosis factor-alpha concentration was significantly higher in the control group than in the iloprost group. There was no significant difference in pH between the groups but actual bicarbonate concentrations were different between the groups (p < 0.05). At the end of the third hour total body oxygen consumption was 105 +/- 11 ml/min in the control group and 132 +/- 12 ml/min in the iloprost group (p < 0.05). Oxygen delivery 3 hours after hemorrhage was 201 +/- 19 ml/min in the control group and 252 +/- 24 ml/min in the iloprost group (p > 0.05). Left ventricular stroke work index was higher in the iloprost group (p < 0.05).

CONCLUSIONS

Hemorrhagic shock causes tumor necrosis factor-alpha release which may lead to multiple organ failure. Organ dysfunction still persists even after the appropriate treatment. Iloprost attenuates the release of tumor necrosis factor-alpha which may improve the adverse effects of hemorrhagic shock.

Predictors of left ventricular thrombus formation in patients with anterior myocardial infarction: role of activated protein C resistance

BACKGROUND

Left ventricular mural thrombus formation is a well-recognised consequence of acute anterior myocardial infarction. The vast majority of left ventricular thromboses occur in patients with anterior myocardial infarction and depressed left ventricular function.

OBJECTIVE

To evaluate the factors predicting left ventricular thrombus formation in patients similar for left ventricular function and left ventricular score indexes.

METHODS

We evaluated 45 consecutive patients who met the inclusion criteria of anterior myocardial infarction resulting in apical, anterior or septal asynergy (akinesia, dyskinesia), without non-Q-wave myocardial infarction, dilated cardiomyopathy, or renal or hepatic dysfunction. Patients were divided into two groups: group I with, and group II without, left ventricular mural thrombus. The groups were compared for clinical, echocardiographic and hematologic parameters (activated protein C resistance (APC-R), protein S and antithrombin III).

RESULTS

Smoking and ACP-R were significantly greater in group I than in group II (P < 0.05 and P < 0.005 respectively). Multivariate regression analysis showed that APC-R was an independent risk factor for left ventricular thrombus formation in the patient group selected. Antithrombin III and protein S concentrations were not statistically different between two groups. All other clinical and echocardiographic characteristics of the patients were similar in both groups.

CONCLUSION

APC-R is an independent risk factor for left ventricular thrombosis in patients with anterior myocardial infarction resulting in septal or anterior and apical akinesia or dyskinesia.

Can flow cytometry detect successful ticlopidine treatment in patients with VVI pacemakers?

An increased platelet activation status is present in patients with VVI pacemakers. With platelet activation, there is modulation of platelet surface molecule expression. In the current study, the expression of platelet surface markers in VVI patients before and after ticlopidine treatment and control subjects was investigated by means of flow cytometry. The study group consisted of 25 patients with VVI pacemaker, and 15 control subjects. CD42b, CD61, and CD62p expression were significantly increased in VVI patients compared with control subjects (CD42b p < 0.001, CD61 p< 0.005 and CD62p p < 0.001). In addition, after ticlopidine treatment, platelets showed a significant fall in expression of all these markers in VVI patients (CD42b p < 0.001, CD61 p < 0.005 and CD62p p< 0.001). Our data suggest an increase of the surface expression of all these markers on platelets and demonstrate the efficacy of ticlopidine in reducing them.

Circulating cytokines and complements in chronic heart failure

Elevated levels of cytokines and complements have been reported in patients with advanced heart failure, but the exact clinical significance remains unclear. Therefore, assessments correlated with hemodynamic and clinical variables may provide important insight into the actions of cytokines and complements in chronic heart failure. The authors evaluated the clinical significance of cytokines and complements. The study included 60 subjects (50 men, 10 women); 34 had idiopathic dilated cardiomyopathy (DCM) and 26 had ischemic heart disease (IHD). Tumor necrosis factor alpha and interleukin-2 receptor concentrations in chronic heart failure were greater than in control subjects (20.0 +/- 0.4 vs 18.0 +/- 0.5 pg/mL, p<0.05 and 817.23 +/- 63.50 vs 642.75 +/- 27.31 pg/mL, p<0.05, respectively). There was no significant difference between DCM and IHD patients in circulating levels of the cytokines and the components complements (p=NS). Additionally, although functional classes III and IV heart failure patients showed a tendency to increase the levels of the cytokines and the component complements, these differences were not statistically significant (p=NS). Similarly, correlation analysis showed that the levels of the circulating cytokines and the component complements had independent value for mortality. These results suggest that humoral and cellular immunity abnormalities may play an important role in the pathogenesis of heart failure and dilated cardiomyopathy.

Plasma leukocyte elastase concentration and coronary artery disease

It has previously been shown that leukocyte elastase is involved in the pathogenesis of atherosclerosis. Few studies have addressed the relation between leukocyte elastase concentrations and coronary artery disease (CAD). The authors investigated (1) the clinical significance of leukocyte elastase determination in the diagnosis of CAD and (2) the relation between plasma leukocyte elastase concentration and lesion morphology. The study included 185 subjects (140 men, 45 women) who underwent coronary angiography during investigation of chest pain; 135 had coronary stenosis (Group I) and 50 had nonstenotic coronaries (Group II). Among Group I patients, those with simple atheromatous plaques were distinguished from those with complex plaques. Elastase concentrations in Group I were greater than in Group II (57.1 +/- 1.16 micrograms I[-1] vs 27.6 +/- 1.0 microgram, I[-1], P<0.001), and greater in complex plaque patients than in those with simple plaques (64.5 +/- 1.24 micrograms I[-1] vs 45.9 +/- 1.01 micrograms I[-1], P<0.001). Logistic regression analysis showed (1) that elastase concentration, age, and sex had independent value for prediction of CAD and (2) that among Group I patients, the risk of complex plaques was greatest for those with high elastase concentration. These results suggest that plasma leukocyte elastase concentration is a sensitive diagnostic marker of CAD and that high values of elastase may indicate the presence of complex atheromatous plaques.

Iloprost added to the cardioplegic solutions improves myocardial performance

A total of 12 mongrel dogs were divided into two equal groups. Six animals received IIoprost and the other 6 animals did not receive any additional treatment. In the Iloprost group, Iloprost was added to the cardioplegic solution (25 ng). Also, Iloprost was used (10 ng/kg/min.) 5 min. before and after cross-clamping. All cardiac output and biochemical measurements were evaluated before cross-clamp and 15 min., 1 h, and 4 h after cross-clamp. The measured dp/dt shows that the hearts treated with Iloprost preserved left ventricular function. Comparison of contractility indices between the groups revealed that contractile recovery was 59% in the control group and 71% in the Iloprost group (p < 0.05). Tumor necrosis factor (TNF) alpha level was significantly elevated in the control group (p < 0.001). Its level was 22.2 +/- 2.2 pg/mL in the control group and 13.8 +/- 1.0 pg/mL in the Iloprost group. E- and P-selectin levels were elevated in the control group (p < 0.001). ICAM-1 level was also elevated in the control group. ICAM-1 level was 17.7 +/- 1.8 ng/mL in the control group and 8.5 +/- 1.8 ng/mL in the Iloprost group. The Iloprost that was added to the cardioplegic solution and low dose administration during the pre- and post-ischemic period inhibits the toxic mediator release from endothelium-leukocyte interaction and reduces the severity of ischemia-reperfusion injury.

Effects of Prostacyclin on Hemodynamics after Intestinal Ischemia-Reperfusion

Ten rabbits underwent 30 minutes of superior mesenteric artery occlusion to assess the release of tumor necrosis factor, subcellular damage, and hemodynamic changes after intestinal ischemia-reperfusion injury. Five were treated with prostacyclin 5 ng/kg/min 5 minutes before the arterial occlusion. It was increased to 25 ng/kg/min during occlusion, decreased to 5 ng/kg/min for the first 5 minutes of reperfusion, and then discontinued. A control group of 5 rabbits did not receive any pharmacological agent. Specimens were obtained from the small intestine for electron microscopy after 10 minutes and after 60 minutes of reperfusion, while simultaneous blood samples were collected for measurement of tumor necrosis factor. Minimal changes were seen in tissue from the prostacyclin group but severe mitochondrial damage and vacuolation occurred in the control group. The tumor necrosis factor level was 11.97 ± 3.17 U/mL in the control group and 5.06 ± 2.19 U/mL in the prostacyclin group, one hour after the end of mesenteric occlusion ( p < 0.05). Hemodynamic status, assessed by central venous and arterial pressures, was much more affected in the control group than in the prostacyclin group. Mean arterial pressure was 71 ± 5 mm Hg in the control group, and 91 ± 6 mm Hg in the prostacyclin group ( p < 0.05). Central venous pressure was 5.3 ± 0.9 mm Hg in the control group and 2.3 ± 0.7 mm Hg in the prostacyclin group ( p < 0.05). We conclude that intravenous prostacyclin reduced the severity of reperfusion injury occurring during the early period of reperfusion by inhibiting the release of the toxic mediator tumor necrosis factor, thus decreasing distant organ injury.