relation between noneacterial thrombotic endocarditis and thromboembolism in patients with cancer

Patients with cancer are in hypercoagulable state. Nonbacterial thrombotic endocarditis [NBTE] can complicate any cancer. The major clinical manifestations of NBTE result from systemic emboli rather than valvular dysfunction. To assess the frequency and echocardiographic characteristics and to determine whether the presence of valvular lesions correlate with thrombo-embolic manifestations [TEM]. A prospective study conducted on 60 patients with different histopathological types of cancer and 10 healthy volunteers. A full medical history taking and physical examination were done and according to the performance status using the WHO score, the patients were classified into two groups of patients; group one, patients with good performance [grade I and II] and group two those with poor performance [III and IV]. Doppler echocardiography, chest-x-ray, abdominal sonography, and laboratory study including complete blood count [CBC]; bleeding time [BT]; prothrombin time and concentration [PT and PC]; Activated partial thromboplastin time [APTT] and serum level of both fibrinogen and D-dimer were done for all participants. Blood culture was done only for patients with NBTE. Doppler study of extremities and computed tomography [CT] of the brain were done for suspected patients with deep venous thrombosis [DVT] and cerebrovascular [CV] stroke respectively, NBTE was detected in 16 out of 60 patients [26.66%]. 22valve lesions were found; the aortic and mitral valves were the commonest sites [12 and 7 lesions respectively]. Valvular regurgitation was found in 12/60 patients [20%]; tricuspid regurgitation [TR] was the commonest lesion [42%]. The incidence of NBTE was higher in patients with poor performance than in those with good performance [p<0.001], and the highest incidence was in patients with adenocarcinoma of pancreas [50%]. Serum level of D-dimer ms higher in patients with NBTE than in those without NBTE [p<0.001]. The incidence of TEM was higher in patients with NBTE than in those without [62.5% versus 6.8%, p<0.001]. NBTE is not uncommon in patients with cancer. Aortic valve was the most commonly affected. Adenocarcinoma was the most frequent histologic type of related cancer. The major clinical manifestations of NBTE result from systemic emboli rather than valvular dysfunction. NBTE should be suspected in any stroke patient with a known or suspected malignancy and anticoagulation with unfractionated or low molecular weight heparin should be used in cancer patients with NBTE

Inflammatory mediators in plasma and peritoneal fluid in cirrhotic patients with spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis [SBP] in cirrhotic patients is associated with an increased production and decreased metabolism of inflammatory mediators [cytokines] such as tumour necrosis factor a [TNF-alpha], interleukin 6 [IL-6] and interleukin 1-beta [IL-l beta]. The present study was designed to investigate the relationship between the development of SBP and the degree of inflammatory response in patients with liver cirrhosis and to assess the diagnostic value of the inflammatory mediators in cirrhotic patients with SBP. This study was carried out on 46 cirrhotic patients with SBP, 22 cirrhotic patients with ascites but without evidence of SBP, and 12 healthy subjects as a control group. All patients were subjected for history taking, clinical examination and abdominal ultrasound. Blood samples were collected for complete blood count [CBC], liver function tests and measurement of TNF-alpha, IL- l beta, and IL-6 levels [in patients and control]. Ascitic fluid samples were collected for measurement of TNF-alpha, IL- l beta, and IL-6 and for aerobic and anaerobic cultures [only in patients with SBP]. Cirrhotic patients with SBP showed significantly higher plasma and ascitic fluid levels of TNF-alpha, IL- l beta and IL-6 than cirrhotic patients without SBP [despite that severity of liver disease was similar in the two groups] and normal control subjects [p<0.001]. Ascitic fluid TNF-alpha, IL- l beta and IL-6 were also higher in the cirrhotic patients with SBP than in plasma, [p<0.001 for each]. Also the plasma levels of TNF-alpha, IL- l beta and IL-6 in cirrhotic patients with SBP were significantly higher than in healthy control subjects [p<0.001]. There was a strong direct correlation between plasma and ascitic fluid levels of TNF-alpha, [r=0.9624, p<0.001] IL-l beta [r=0.4024, p<0.01], and IL-6 [r=0.2890, p<0.05] at the time of diagnosis of SBP. A significant correlation was also observed between TNF-alpha, IL- l beta, and IL-6 in ascitic fluid [r=1.0000, p<0.001] and in plasma [r=0.8500, p<0.001]. PMN cell count in ascites correlated significantly with the ascitic fluid level of IL- l beta [r=0.3156, p<0.05], but did not correlate with both TNF-alpha [r-0.0953, p>0.05] and IL-6 [r=0.0702, p>0.05]. Patients with culture-positive SBP showed significantly higher plasma and ascitic fluid levels of TNF-alpha, IL- l beta, and IL-6 than patients with culture-negative SBP. The PMN cell count in the ascitic fluid was also significantly higher in the culture-positive vs culture-negative SBP patients [6.813 +/- 0.24 vs 1.36110.07, p<0.001]. Cirrhotic patients with SBP display a marked increase of TNF-alpha, IL- l beta, and IL-6 levels in ascitic fluid and plasma. Specificity and sensitivity of these cytokines detection of SBP in cirrhotic patients strongly favor its measurement during acute phase of the disease

Impact of type 2 diabetes mellitus on cardiac structure and function: the association with microalbuminuria and hyperinsulinemia

Early determination of myocardial manifestations of diabetes mellitus [DM] is of a major importance, since myocardial involvement considerably influence the prognosis of diabetic patients. Microalbuminuria [MA] and hyperinsulinemia [HI] have been shown to predict cardiovascular [CV] disease in patients with DM. However the relationship between these risk factors and both cardiac structure and function is still unclear. To assess the Echocardiographic evidence of cardiomyopathy in asymptomatic patients with type 2 DM; to relate these findings to MA and fasting plasma insulin level [FI]; and to investigate whether these observations are independent of glycemic control and other clinical CV risk factors. 63 type 2 diabetic patients without known cardiac diseases, duration of DM [mean 52.4 +/- 51.4 month], age [47.4 +/- 807 year], body mass index [BMI] [26.6 +/- 3.2], men [41/63], in addition to 20 healthy subjects matched for age, sex and BMI served as control were enrolled in the present study. Based on MA and FI, patients were subgrouped into [microalbuminuric and normoalbuminuric] and [hyperinsulinemic and normoinsulinemic] respectively. We compared Echo- derived indices of left ventricular [LV] structure and LV systolic and diastolic functions in patients versus control subjects and between the different patient subgroups. Diabetic patients had greater LV posterior wall thickness [PWT], interventricular septal thickness [IVST], and LV mass index [LVMI] [p<0.0001 for each]. LV diastolic dysfunction, manifested as reduction in E velocity and E/A ratio and prolongation in isovolumic relaxation time [IVRT] [p<0.001 for each], was documented in diabetic patients as compared with control subjects. MA was diagnosed in 15/63 [24%] patients. As compared with normoalbuminuric patients, MA was associated with higher fasting blood glucose [FBG] and FI [p<0.05 for each], greater LVPWT [p<0.05], and LVMI [p=0.02], and lower fractional shortening [FS], ejection fraction [EF], and E/A ratio [p<0.001, p=0.006 and p<0.05 respectively]. Patients with HI had lower FS [p=0.02] and lower E velocity [p=0.04] than in patients with normal FI. In multi-variate analysis, the associated findings either with MA or FI has been unchanged after adjusting for the duration of DM, glycemic control, age, gender, BMI, and BP. Type 2 diabetic patients without overt heart disease have increased LV wall thickness and LVMI and LV diastolic dysfunction suggesting subclinical diabetic cardiomyopathy [DCM]. MA and HI are independently associated with these changes, which may contribute to the relation of albuminuria and HI with increased rate of CV event among diabetics. Thus, screening of either MA or HI may identify patients at CV high risk

Anticardiolipin antibodies and left atrial thrombus as indicators for increased risk of thromboembolic events in patients with isolated mitral stenosis

The study population consisted of 113 non-anticoagulated patients with Mitral stenosis [MS] and 20 healthy control subjects. Serum levels of IgG and IgM anticardiolipin antibodies [ACLs] were determined in all patients and control subjects. Transthoracic echocardiographic [TTE] and transesophageal echocardiographic [TEE] studies were performed in all patients to measure cardiac chambers, mitral valve area [MVA] and left ventricular ejection fraction [EF%] and to examine left atrial [LA] appendage [LAa] and LA for the presence of thrombi. In conclusion, anticardiolipin antibodies either IgG or IgM was commonly detected in patients with MS. There was a significant association between +ve ACLs and LA thrombi detected by TEE. So, these antibodies could be considered as a warning tool for thrombus formation and seem to be considered an independent risk factor for thrombembolic events in patients with mitral stenosis

Soluble adhesion molecules for prediction of cardiac dysfunction in chronic renal failure patients

Beside cell-bound adhesion molecules, which are of fundamental importance to a large number of physiological and pathological processes, soluble forms of adhesion molecules have been detected in the circulating blood in recent years. Circulating soluble adhesion molecules appear to be biologically active, and raised levels have been reported in a variety of disorders. In the present study, we measure the serum levels of the soluble [s] molecules included vascular cell adhesion molecule 1 [sVCAM- 1] and sE-selectin in 26 patients on chronic hemodialysis [HD], 16 undialyzed patients with chronic renal failure [CRF], and 10 healthy controls having a similar mean and distribution of ages. The presence of hypoalbuminemia, inflammation [C-reactive protein,CRP] and dyslipidemia were assessed together with echocardiographic evaluation of cardiac dimensions, systolic and diastolic function in all studied groups. sVCAM-1 was found to be elevated in patients with chronic hemodialysis and undialyzed CRF [P < 0.001 each] compared with the controls but levels did not differ between both groups of patients. sE-selectin was also raised in both groups of CRF patients compared with controls [P < 0.001 each] with higher significant level in the undialyzed group [P < 0.05] compared with HD group. Both adhesion molecules are correlated positively to each other [r = 816, P<0.001]. The presence of hypoalbuminemia, inflammation, dyslipidemia together with left ventricular hypertrophy [LVH] and low ratio of E/A peak early LV filling velocity [E] /peak atrial filling velocity [A] by echocardiography were associated with higher sVCAM-1 and sE-selectin than in CRF patients without these findings. Both sVCAM and sE-selectin correlated significantly positive with CRP [P<0.01, P<0.001 respectively], left ventricular mass index [LVMI] [P<0.001, P<0.05 respectively], and significantly negative with high-density lipoprotein [HDL] [P<0.001 each], serum albumin levels [P<0.001 each] and with E/A ratio [P<0.001 each]. Elevated serum concentrations of soluble adhesion molecules [sVCAM-l and sE-selectin] are found in undialyzed and chronic hemodialysis patients who are malnourished inflamed, dyslipidemic and have echo findings of cardiac diastolic dysfunction and LVH

Pleural effusion: criteria for distinction between transudates and exudates

This study aimed to assess the diagnostic value of the new biochemical criteria proposed to discriminate pleural transudates from exudates and to compare their efficiency with those of Light's criteria as well as to study the effect of diuretics on different biochemical parameters among cases with transudative pleural effusion. A total of 110 patients with pleural effusion was included in the study. All patients were subjected to history taking, clinical examination, chest X-ray and ultrasound and Doppler echocardiography. Pleural fluid and blood samples were examined for the measurement of total proteins, albumin, lactate dehydrogenase [LDH], cholesterol, cholinesterase, bilirubin and serum pleural fluid albumin gradient [SPAG]. Forty patients had transudative effusion, while 70 had exudative effusion. Among patients with transudates, the biochemical criteria were reevaluated after diuretic therapy. SPAG was the most specific biochemical parameter in identifying exudates, while pleural/serum cholinesterase ratio was the most sensitive one. Moreover, both parameters were more accurate than Light's criteria in the differentiation between transudates and exudates. Diuretics had a significant effect on Light's criteria with a conversion of transudates into pseudo-exudates in many cases; in contrast, diuretics had no significant effect on SPAG, cholinesterase ratio, bilirubin ratio, pleural cholesterol and pleural/serum cholesterol ratio

Glycemic control and cardiopulmonary dysfunction in asymptomatic patients with insulin dependent diabetes mellitus

The study was undertaken to evaluate the cardiopulmonary functions in asymptomatic patients insulin dependent diabetes Mellitus [IDDM] and also to investigate the relationship of cardiopulmonary dysfunction to chronic glycemic control and the duration of diabetes. Thirty-three diabetic patients with mean age 26 +/- 7 years, with no history or physical findings of ardiovascular or respiratory disease, were compared with fifteen healthy non diabetic control subjects. According to the level of glycosylated hemoglobin [HBA1c], patients were classified into hyperglycemic [group A n=17] with elevated HbA1c levels and normoglycemic [group B n=16] who had near normal HbA1c levels. Pulmonary function via spirometry and Doppler echocardiogram were performed in all patients and control subjects. The results revealed significant reduction in forced vital capacity [FVC] in patients versus control and in hyperglycemic than normoglycemic patients [58.9 +/- 8.6% vs 67.0 +/- 2.8% respectively'; forced expiratory volume in the first second [FEV1] was also significantly diminished in patients versus control and in hyperglycemic than normoglycemic patients [60.9 +/- 11.0% vs 72.1 +/- 2.9% respectively. Ejection fraction [EF] was significantly diminished in patients versus control and in hyperglycemic patients versus normoglycemics [64.3 +/- 2.4% vs 65.9 +/- 3.0%, respectively. Also fractional shortening [FS] was significantly diminished in hyperglycemic than normoglycemic patients [32.9 +/- 6.1% vs 33.4 +/- 5.6% respectively]

Plasma endothelin-1 and thrombomodulin: correlation with the extent of pulmonary hypertension in patients whith chronic hypoxic pulmonary disease

This study included 47 pulmonary hypertensive patients secondary to chronic hypoxia due to chronic obstructive pulmonary diseases [COPD] and interstitial pulmonary fibrosis [IPF]. They were sampled in the morning after an overnight fast, before medication and after termination of treatment. Endothelin-1 level was 1.45 +/- 0.32 pg/ml which was increased compared with the normal controls [0.5 +/- 0.02]; the difference was statistically significant. Endothelin-1 was significantly correlated with pulmonary pressure and its degree of severity, especially among chronic obstructive pulmonary disease patients. There was a significant reduction in the level of endothelin-1 after long-term oxygen therapy; whereas, it did not correlate with the level of PaO2 either before or after oxygen therapy. Plasma thrombomodulin level was measured to study its pathophysiological significance in pulmonary hypertension secondary to hypoxia. Patients with pulmonary hypertension had higher concentrations of thrombomodulin [15.25 +/- 1.5] than the age matched normal controls [4.8 +/- 0.5 ng/ml]. There was a significant reduction in thrombomodulin after oxygen therapy. Plasma concentrations of thrombomodulin were significantly correlated with time to peak velocity [TPV] as a strong echo parameter of pulmonary hypertension and its severity in mild PH thrombomodulin level was 10.46 +/- 0.56 ng/ml versus 15.82 +/- 3.08 ng/ml among patients with severe pulmonary hypertension. Moreover, thrombomodulin correlated with PaO2 after oxygen therapy especially with patients of IPF

Relation of spontaneous echocontrast to prethrombotic state in patients with dilated cardiomyopathy

This study investigates the occurrence rate and the association of intracardiac spontaneous echocontrast [SEC] to the hemostatic state and also examines whether the presence of mitral regurgitation [MR] affects SEC and/or thrombus formation in patients with dilated cardiomyopathy [DCM]. Transthoracic and transesophageal echocardiographic studies were performed in 61 hospitalized patients with DCM. Platelet aggregability, prothrombin time [PT], prothrombin concentration, international normalized ratio [INR], activated partial thromboplastin time [PTT], protein C and protein S were estimated in all patients and in 20 healthy control subjects. SEC was observed in 64% [39/61] of patients. Intracardiac thrombi were detected in 8% [5/61], all of them had SEC. Systemic embolism occurred in 13% [5/39] of patients with SEC. SEC showed correlation with increased platelet aggregability and reduced protein C and protein S [P<0.01 for each]. MR jet area and the ratio between MR jet area and left atrial area [which signifies severity of MR] were significantly lower in patients with SEC [P<0.04 and P<0.02 respectively]. In conclusion, among patients with DCM, SEC is a common echocardiographic phenomenon and associated with a hypercoagulable state, thus assessment of hemostate may be useful for evaluating the risk of thromboembolism. Also the presence of significant MR may be protective against SEC and/or thrombus formation in patients with DCM

Right and left ventricular dysfunction and interaction in respiratory critically ill patients

This study was designed to determine the incidence of right ventricular [RV] and left ventricular [LV] dysfunctions and to relate the findings to possible mechanisms of interdependence between right and left ventricles during acute respiratory failure [ARF] in patients with chronic obstructive lung diseases [COLDs]. 58 hospitalized patients underwent pulmonary function tests and arterial blood gases. An echo-Doppler examination was performed for patients and 20-healthy subjects as control group to measure RV and LV end-diastolic and end-systolic diameters; RV and LV ejection fraction [EF], transmitral early [E] and late [A] peak flow velocities and their ratio [E/A]; isovolumic relaxation time [IRT]; trans-tricuspid early [E1] and late [A1] peak flow velocities and their ratio [E1/A1] and estimation of pulmonary artery pressure [PAP] by acceleration time [ACT] of the pulmonary systolic flow and tricuspid regurgitation [TR] jet velocity. The data showed dilated RV in 80% [50/58]; mild TR in 64% [37/58]; RV systolic dysfunction [EF<45%] in 28% [16/58] and RV diastolic dysfunction [decreased E1/A1 ratio] in 53% [31/58] of patients. On the other hand, LV systolic dysfunction [EF<45%] was found in 16% [9/58] of patients while LV diastolic dysfunction [low E, low E/A ratio and high IRT] in 72% [42/58] of patients. A linear regression analysis revealed that low E and low E/A ratio were significantly correlated with RV size [p<0.01 and p<0.05, respectively], while low E/A ratio and prolonged IRT were significantly correlated with PAP [p<0.05 and p<0.001, respectively]. No significant correlations were found between LV and RV dysfunctions or respiratory functional parameters. In conclusion, the prevalence of RV and LV dysfunctions is high in patients with ARF and LV dysfunction appears to be closely related to the RV size and the level of pulmonary hypertension

Some platelet disorders in chronic idiopathic thrombocytopenic purpura and chronic myloid leukaemia

Thirty in-patients in the Department of General Medicine of Assiut University Hospital with thrombocytopenia were studied before treatment, twenty patients with chronic idiopathic thrombocytopenic purpura and ten patients with chronic leukemia [nine had chronic myeloid leukemia and one with lymphocytic leukemia]. The study also included ten normal individuals served as controls. Careful history and clinical examination were carried out for every patient and normal individual complete blood picture, bleeding time, clot retraction, prothrombin time, kaolin cephalin clotting time, platelet volume study including mean platelet volume and platelet volume distribution and platelet factor-3 availability were done. Statistical analysis of the results showed that patients with chronic idiopathic thrombocytopenic purpura had significantly prolonged bleeding time and reduced clot retraction, but there was no significant difference in prothrombin and kaolin cephalin clotting times between patients and normal individuals. They also had significantly increased mean platelet volume which varied inversely in linear pattern with platelet count. This linear inverse relation in chronic idiopathic thrombocytopenic purpura was the same in the control group. There was significantly increased mean percentage of microplatelets [3-6 FL] and large platelets [13 FL]. Also, 60% of patients with chronic idiopathic thrombocytopenic purpura had diminished platelet factor-3 availability. This analysis showed that patients with chronic leukemia had significant prolongation in bleeding time and reduction in clot retraction. They also had significant prolongation in prothrombin time and platelet volume study. Patients with chronic myeloid leukemia revealed significant increase in the mean platelet volume and in the mean percentage of large platelets [13 FL]. There was also a linear inverse relation between the mean platelet volume and platelet count. Platelet factor-3 availability was diminished in 70% of patients