The effectiveness of thrombolytic therapy in patients with massive and submassive pulmonary thromboembolism

Thrombolytic therapy is the most effective therapy for massive pulmonary embolism (PTE). In this study we evaluated the symptoms, clinical and radiologic features and response to thrombolytic therapy in patients who had massive or submassive PTE. Thrombolytic therapy was administered for a mean period of 3 (1-5) hours to 19 patients with a mean age of 63.7 years who had the diagnosis of PTE based on symptoms which lasted for an average of 72 (2-240) hours and findings of echocardiography, spiral computed tomography (CT) angiography and perfusion scan. The patients to whom heparin infusion and oral anticoagulant treatment were given after thrombolytic therapy were evaluated. Bleeding as a complication was noted in six patients after thrombolytic therapy. Two patients died due to this complication. Control spiral CT angiography was performed to 12 of 15 (80%) patients who were initially diagnosed PTE by spiral CT angiography. While marked regression was noted in 5 (41.7%) patients in the early phase (second week), in 7 (58.3%) patients in the late phase (sixth month) PTE findings were completely disappeared. The median value of pulmonary artery pressure was 65 (45-70) mmHg before and 39.5 (30-45) mmHg after the treatment. Of the genetic factors studied before thrombolytic therapy, antithrombin III deficiency was found as the most common one. This study demonstrates that spiral thorax CT angiography is a very accurate diagnostic tool for the definitive diagnosis and transthoracic echocardiography is very useful for the rapid diagnosis and to decide for thrombolytic therapy, in especially patients who are not hypotensive and have submassive to massive PTE, and support the idea that thrombolytic therapy is life saving after reaching the certain diagnosis.     

First description of the alpha lipoic acid intoxication in an adult patient worldwide following oral administration

Alpha lipoic acid (ALA), which is an anti-oxidant acting as a scavenger for reactive oxygen species, is especially used to improve glycemic control and prevent polyneuropathies associated with diabetes mellitus. ALA is considered to be a safe drug and intoxication with ALA is extremely rare. However, this paper reports a 38-year-old young woman who was admitted to the emergency department after she had ingested ten pills of 600 mg ALA belonging to her diabetic parent, which led to delirium, metabolic acidosis, thrombocytopenia, and rhabdomyolysis. To the best of our knowledge, there are only four cases of ALA intoxication reported in the literature and all were observed in children. This report aims to present the first case of ALA related intoxication worldwide in an adult patient.     

Can d-dimer become a new diagnostic parameter for acute appendicitis?

Introduction

In this study, we investigated d-dimer serum level as a diagnostic parameter for acute appendicitis.

Materials and Methods

Forty-nine patients were enrolled in the study. Patients were classified according to age; sex; duration between the beginning of pain and referral to a hospital or clinic; Alvarado scores; and in physical examination, presence of muscular defense, the number of leukocytes, preoperative ultrasonography, and d-dimer levels of histopathologic study groups were analyzed.

Results

Of the patients enrolled in the study, 26.5% were females and 73.5% males. The average age was 21 years (range, 16-38 years) and 81.7% acute appendicitis (AA). According the duration of pain, 63.2% of the patients were referred to the hospital within the first 24 hours, 26.5% of the patients were referred to the hospital within 24 to 48 hours, and 10.3% were referred to the hospital within a period of more than 48 hours. No statistically significant difference was determined regarding d-dimer levels between the histopathologic study groups (P > .05). Alvarado scores lower than 7 were found in 36.7% and 7 or higher in 63.3% of the patients. There was no statistically significant difference related with d-dimer levels between histopathologic study groups (P > .05). The ratio of cases with a number of leukocytes below the upper limit were determined respectively as 32.7% and 67.3%, and no statistically significant difference was found regarding d-dimer levels between histopathologic study groups (P > .05).

Conclusion

Increased d-dimer levels should not be considered as a diagnostic parameter in diagnosis of acute appendicitis.     

Malignant mesothelioma due to environmental exposure to asbestos: follow-up of a Turkish cohort living in a rural area

STUDY OBJECTIVES: This study examines the incidence of malignant pleural mesothelioma (MPM) in a rural population of Turkey with environmental exposure to asbestos-contaminated soil mixtures (white soil). DESIGN: A field-based epidemiologic study. SETTING AND SUBJECTS: A cohort of villagers (the "Eskisehir" cohort) from 11 villages around Eskisehir in central Anatolia, who had been environmentally exposed to asbestos due to the use of white soil. MEASUREMENTS: The mineral content and asbestos contamination of the white soil used in these villages was determined, as well as airborne fiber concentrations. Cohort members' details of age, sex, ambient exposure data, duration of residence in the villages, and hospital records, including pathologic diagnosis, were recorded. RESULTS: The Eskisehir cohort consisted of 1,886 villagers. During the observation time, 377 deaths occurred and 24 MPM cases were diagnosed. Average annual mesothelioma incidence rates were 114.8/100,000 for men and 159.8/100,000 for women. CONCLUSIONS: These data indicate that the risk of mesothelioma is 88.3 times greater in men and 799 times greater in women, respectively, in comparison to world background incidence rates.     

Levosimendan versus dobutamine in heart failure patients treated chronically with carvedilol

Introduction : Although beta‐blockers are highly effective in the treatment of heart failure (HF), many patients with HF receiving a beta‐blocker continue to become decompensated and require hospitalization for worsening HF. Levosimendan and dobutamine are used to manage decompensated HF, but their comparative effects on left ventricular (LV) function in patients prescribed beta‐blockers are unknown. Aims : The aim of this study was to compare the effects of dobutamine and levosimendan on LV systolic and diastolic functions in chronic HF patients treated chronically with carvedilol. Forty patients with chronic HF who had NYHA class III to IV symptoms, a LV ejection fraction (LVEF) <40%, and ongoing treatment with carvedilol were enrolled in this randomized (1:1), dobutamine controlled, open‐label study. Before and 24 h after treatment, LVEF, mitral inflow peak E and A wave velocity, E/A ratio, the deceleration time of the E wave (DT), isovolumic relaxation time (IVRT), peak systolic (Sm) and early diastolic (Em) mitral annular velocity, and systolic pulmonary artery pressure (SPAP) were measured by echocardiography. Results : Levosimendan produced a statistically significant increase in LVEF (28 ± 5% vs. 33 ± 3%), Sm (6.5 ± 1.2 cm/s vs. 7.4 ± 0.9 cm/s), DT (120 ± 10 ms vs. 140 ± 15 ms), and Em (7.5 ± 0.4 cm/s vs. 8.1 ± 0.5 cm/s) and significant decrease in E/A ratio (2.1 ± 0.3 vs. 1.7 ± 0.4) and SPAP (55 ± 5 mmHg vs. 40 ± 7 mmHg). No significant change occurred in LV systolic and diastolic function parameters, or SPAP with dobutamine treatment. Levosimendan did not significantly alter the heart rate (72 ± 4 bpm vs. 70 ± 3 bpm), systolic (105 ± 5 mmHg vs. 102 ± 4 mmHg), or diastolic blood pressure (85 ± 5 mmHg vs. 83 ± 5 mmHg) whereas with dobutamine treatment, all these parameters significantly increased. Conclusions : Dobutamine and levosimendan have different effects on LV functions in patients treated chronically with carvedilol. These differences should be considered when selecting inotropic therapy for decompensated HF receiving long‐term carvedilol.     

Combined transbronchial needle aspiration and PET/CT for mediastinal staging of lung cancer

In this study, we aimed to evaluate the performance of transbronchial needle aspiration (TBNA) combined with positron emission tomography/computed tomography (PET/CT) for the staging of lung cancer. Twenty-five patients having lymphadenopathies greater than 1 cm on thorax CT and maximum standardized uptake value (SUVmax) ≥ 2.5 on PET/CT were included in this prospective study performed between March 2006 and March 2008. Forty-three lymphnode stations were sampled by using TBNA. Surgical histology, as confirmed by mediastinoscopy, was accepted as the "gold standard". The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of combined TBNA and PET/CT for correct lymph node staging were 67%, 100%, 100%, 76% and 84%; respectively. The initial clinical staging was downstaged after TBNA in 13/19 (69%) patients with adequate TBNA samples, whereas staging was correct in 17/19 (89%) patients assessed by combined TBNA and PET/CT. Staging was completed by TBNA, without mediastinoscopy, in 6/25 (24%) patients. Among the clinical factors that were assessed, only the PET SUVmax was associated with positive TBNA results [odds ratio (OR) 1.27, 95% CI 1.004-1.61, p= 0.046]. A PET SUVmax ≥ 5 was eleven times more likely in patients with positive TBNA results [OR 10.68, 95% CI 1.91-59.62, p< 0.01]. In conclusion, the combination of TBNA with PET/CT increased the sensitivity of TBNA. Combined TBNA and PET/CT may also allow adequate mediastinal staging of lung cancer in most patients with enlarged lymph nodes, and reduce the need for mediastinoscopy. The SUVmax cut off point for a positive TBNA result was ≥ 5.     

Takayasu arteritis in children

OBJECTIVE: To retrospectively evaluate the clinical features, angiographic findings, and outcomes of children with Takayasu arteritis (TA) in Turkey. METHODS: Clinical, laboratory, and angiographic findings and outcomes of 19 children with TA were evaluated with a retrospective chart review. The criteria for inclusion were those proposed by the American College of Rheumatology. RESULTS: Mean followup period was 35.89 +/- 40.75 months (range 1-168, median 30). There were 14 girls and 5 boys. The mean age at diagnosis was 12.84 +/- 2.69 years (range 8-17, median 13). The most common complaints on admission were headache (84%), abdominal pain (37%), claudication of extremities (32%), fever (26%), and weight loss (10%). One patient presented with visual loss. Examination on admission revealed hypertension (89%), absent pulses (58%), and bruits (42%). Angiography revealed type I in 13 patients (aortic arch, descending thoracic, and abdominal aorta), type II in 4 (descending thoracic aorta and abdominal aorta), and type IV in 2 (diffuse aortic and pulmonary artery). The most commonly involved vessels were the renal, subclavian, and carotid arteries. All patients received corticosteroid therapy, and further immunosuppressive therapy was added in 15 patients. Fourteen of the 17 hypertensive patients had renal artery stenosis and 9 underwent surgery or interventional therapy. Thoraco-abdominal bypass graft was performed in 2 patients who had abdominal aortic stenosis. CONCLUSION: Hypertension is the most common clinical feature at presentation. Corticosteroid and immunosuppressive therapy was effective in the control of disease activity. Angioplasty or bypass grafting was successfully performed when needed.     

Progestin-inflammatory cytokine interactions affect matrix metalloproteinase-1 and -3 expression in term decidual cells: implications for treatment of chorioamnionitis-induced preterm delivery

CONTEXT: Chorioamnionitis (CAM)-elicited preterm delivery (PTD) is associated with elevated amniotic fluid levels of IL-1beta and TNF-alpha. We hypothesized that IL-1beta and TNF-alpha may induce matrix metalloproteinase (MMP)-1 and MMP-3 activity to promote PTD by degrading decidual and fetal membranes and cervical extracellular matrix. OBJECTIVE: Our objective was to evaluate: 1) MMP-1 and MMP-3 expression in decidual sections from uncomplicated term, idiopathic preterm, and CAM-complicated deliveries, and 2) the separate and interactive effects of IL-1beta, TNF-alpha, medroxyprogesterone acetate (MPA), and a p38 MAPK inhibitor (SB203580) on MMP-1 and MMP-3 expression in term decidual cells (DCs). INTERVENTIONS AND MAIN OUTCOME MEASURES: Decidua were immunostained for MMP-1 and MMP-3. Cultured term DCs were incubated with estradiol (E2) or E2 plus MPA with or without IL-1beta or TNF-alpha with or without SB203580. ELISA and Western blotting assessed secreted MMP-1 and MMP-3 levels, quantitative real-time RT-PCR assessed mRNA levels, and substrate gel zymography was used to determined MMP-1 and MMP-3 proteolytic activity. RESULTS: MMP-1 and MMP-3 immunostaining was more prominent in CAM-complicated decidua vs. control preterm and term decidual specimens (P < 0.05). Compared with basal outputs by DCs incubated with E2, TNF-alpha enhanced MMP-1 and MMP-3 secretion by 14 +/- 3- and 9 +/- 2-fold, respectively, and IL-1beta increased MMP-1 and MMP-3 secretion by 13 +/- 3- and 19 +/- 2-fold, respectively (P < 0.05). Addition of MPA lowered basal MMP-1 and MMP-3 outputs by 70%, whereas the TNF-alpha- and IL-1beta-enhanced MMP-1 and MMP-3 levels were blunted by more than 50% (P < 0.05). SB203580 suppressed TNF-alpha- and IL-1beta-induced MMP-1 and MMP-3 secretion by severalfold. Western blotting confirmed the ELISA results, and mRNA levels corresponded with MMP-1 and MMP-3 protein levels. MMP-1 and MMP-3 proteolytic activity was confirmed by substrate gel zymography. CONCLUSION: Augmented DC-expressed MMP-1 and MMP-3 in CAM-complicated pregnancies may promote PTD via decidual, fetal membrane, and cervical extracellular matrix degradation. Effects of progestin-p38 MAPK signaling inhibition on cytokine-enhanced MMP-1 and MMP-3 expression in term DCs suggest alternative mechanisms to prevent CAM-induced PTD.     

Ischemia modified albumin in the differential diagnosis of pleural effusions

The differential diagnosis of pleural effusion often requires invasive procedures. Up to 25 percent of pleural effusions can remain undiagnosed with an unclear pathogenesis. Therefore new biological markers may increase diagnostic yield and provide better understanding of pathogenesis of pleural effusion. We hypothesized that new ischemia biomarker, “ischemia modified albumin (IMA)” would help in both the differentiation of the underlying etiologies and provide a better understanding of pathogenesis of pleural effusions. This study was done between December 2009 and September 2010 in the Department of Pulmonary Diseases of Gaziantep University Hospital. One hundred and sixteen subjects with pleural effusion were included. Pleural and blood IMA levels were measured by ELISA. The underlying etiologies of pleural effusions were as follows: transudates (n = 50), malignancy (n = 32), tuberculosis (n = 12), pulmonary thromboembolism (n = 6), pneumonia (n = 16). The median pleural IMA levels were significantly different between the groups (p < 0.000). There were no such differences in the blood levels of IMA. The most striking difference in the median pleural IMA levels was between transudates and exudates (7986 (25–75%, 5145–56.505) ng/mL; 3376 (25–75%, 1935–4660) ng/mL; respectively, p = 0.000). The area under the ROC curve was 0.837 ± 0.038 for the cut-off level higher than 4711 ng l/mL for the differentiation of transudates from exudates (sensitivity, 82%; specificity, 78%; 95% CI, 0.76 to 0.91; p = 0.0000). In conclusion, the pleural IMA levels are higher in transudates compared to exudates. No such differences were observed in blood levels of IMA suggesting that there are reasons other than ischemia that cause an increase in pleural fluid IMA levels.