Metabolic Syndrome as a Factor Affecting Systemic Inflammation in Patients with Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is a systemic disease which may be associated with other comorbidities. The aim of the study was to estimate the incidence of metabolic syndrome (MS) in COPD patients and to assess its impact on systemic inflammation and lung function. MS was diagnosed in accordance with the recommendations of the Polish Forum for the Prevention of Cardiovascular Diseases. The study group consisted of 267 patients with stable COPD in all stages of severity. All patients underwent spirometry with bronchial reversibility testing and 6 min walk test (6MWT). The following blood tests were evaluated: lipid profile, glucose and C-reactive protein as well as serum concentration of IL-6, leptin, adiponectin, and endothelin. MS was diagnosed in 93 patients (35.8%). No differences were observed in the incidence of MS in relation to airflow limitation severity (mild; moderate; severe and very severe: 38.9; 36.3; 35.2 and 25.0%, respectively). FEV1 (% predicted), FVC (% predicted), 6MWT distance (6MWD), age, and the number of pack-years were similar in patients with and without MS. MS was more frequent in males than females (38.7 vs. 28.4%, p > 0.05). Serum concentrations of IL-6, endothelin, leptin, and CRP were higher in the MS group, contrary to adiponectin concentration which was lower (p < 0.01). MS was more frequent in male COPD patients, but there were no differences in its frequency between patients with different severity of airflow limitation. We conclude that MS, as a comorbidity, occurs in all COPD stages and affects systemic inflammation. MS incidence does not depend on COPD severity.

Exacerbations of Chronic Obstructive Pulmonary Disease and Quality of Life of Patients.

Exacerbations of chronic obstructive pulmonary disease (COPD) are one of the most important factors which influence the course of disease and quality of life in COPD patients. The aim of the study was to assess the exacerbation frequency in COPD patients in relation to COPD severity and to evaluate the impact of the number of exacerbations on quality of life. The study included 445 COPD patients in all four progressive stages of the disease according to GOLD classification. The patients recorded exacerbations in diaries. Spirometry, St. George's Respiratory Questionnaire, and dyspnea score were assessed at baseline and after 12 and 24 months from enrollment. After 24 months, 261 diaries were returned. The mean number of exacerbations per year in the sequential GOLD 1-4 stages of COPD was as follows: 1.3 ± 2.1, 1.4 ± 2.0, 1.7 ± 1.8, and 3.4 ± 4.5. A statistical difference in the exacerbation frequency was noted for GOLD 4 and the remaining groups. A significant negative correlation was found between the number of exacerbations and functional status for GOLD 2 and 3 stages. We conclude that the number of exacerbations is the highest in the most severe stage of the disease. The quality of life of patients with moderate and severe COPD correlates negatively with the number of exacerbations.

Thyroid Hormone Levels and TSH Activity in Patients with Obstructive Sleep Apnea Syndrome.

Obstructive sleep apnea syndrome (OSAS) is characterized by complete cessation of inspiratory flow (apnea) or upper airway airflow limitation (hypopnea) with increased respiratory muscle activity, which is repeatedly observed during sleep. Hypothyroidism has been described as a rare cause of OSAS, but it is considered to be the main cause of breathing disorders during sleep in patients in whom an improvement of OSAS is observed after thyroid hormone replacement therapy. Nevertheless, euthyreosis due to thyroxine replacement in patients with OSAS often does not improve the breathing disorder and treatment with continuous positive airway pressure is usually applied. The aim of this study was to assess thyroid function in patients with OSAS. We studied 813 patients in whom severe OSAS was diagnosed; the mean apnea-hypopnea index was 44.0. Most of the patients were obese (mean BMI 33.1 ± 6.6 kg/m2) and had excessive daytime sleepiness (ESS 12.8 ± 6.6). With the thyroid stimulating hormone (TSH) concentration as the major criterion, hypothyroidism was diagnosed in 38 (4.7%) and hyperthyroidism was diagnosed in 31 (3.8%) patients. Analysis of basic anthropometric data, selected polysomnography results, and TSH, fT3, and fT4 values did not reveal any significant correlations. In conclusion, the incidence of thyroid function disorders seems to be no different in OSAS than that in the general population. We did not find correlations between TSH activity and the severity of breathing disorders during sleep.

Incidence and aetiology of eosinophilic pleural effusion.

Although eosinophilic pleural effusion (EPE) has been a subject of numerous studies, its clinical significance still remains unclear. The aim of our study was to evaluate: 1) the relative incidence and aetiology of EPE; 2) the predictors of malignancy in patients with EPE; and 3) the relationship between repeated thoracentesis and pleural fluid eosinophilia. A retrospective analysis of 2,205 pleural fluid samples from 1,868 patients treated between 1995 and 2007 was performed. We identified 135 patients with EPE (7.2% of all patients with pleural effusion) and 153 EPE samples. The most common condition associated with EPE was malignancy (34.8%) followed by infectious (19.2%), unknown (14.1%), post-traumatic (8.9%) and miscellaneous (23.0%) pleural effusions. The incidence of malignancy was significantly higher in patients with a lower (< or =40%) pleural fluid eosinophil percentage. 40 patients with EPE underwent a second thoracentesis. In 16, eosinophilia was present in both pleural fluid samples, 14 revealed pleural fluid eosinophilia only after the second thoracentesis and 10 had eosinophilia only in the first pleural fluid sample. Pleural fluid eosinophilia should not be regarded as a predictor of nonmalignant aetiology. Probability of malignancy is lower in effusions with a high eosinophil percentage. The incidence of EPE in patients undergoing second thoracentesis is not different to that found during the first thoracentesis.

Nontuberculous mycobacterial infections among patients suspected of pulmonary tuberculosis.

The purpose of this study was to present a retrospective analysis of the frequency of nontuberculous mycobacteria (NTM)-related pulmonary infections among the AFB-positive and/or culture-positive patients in the Warsaw region who were suspected of tuberculosis (TB) and hospitalized in the university hospital between 1999 and 2005. All the AFB-positive pulmonary samples were examined with a molecular method using the Amplicor MTB test (Roche) for detection of Mycobacterium tuberculosis complex, and all mycobacterial isolates were speciated by high performance liquid chromatography (HPLC) analysis of mycolic acids. Patients who met clinical, radiological, and bacteriological criteria of mycobacteriosis were classified according to the American Thoracic Society (ATS) guidelines for diagnosis of NTM related disease. Among the 445 smear-positive or/and culture-positive patients, 142 subjects (31.9%) were found to be infected with M. tuberculosis. Among 303 non-TB patients, mycobacteriosis was found in 27 (8.9%) subjects. The frequency of NTM-related lung disease as compared to the bacteriologically-confirmed lung TB was estimated at 1:5. The rapid, precise methods of NTM speciation are necessary for progress in diagnostics of NTM related diseases.

Electrocardiographic changes in patients with spontaneous pneumothorax.

The aim of the study was to evaluate the prevalence of electrocardiography (ECG) abnormalities in subjects with spontaneous pneumothorax. Forty consecutive patients (mean age 43.7 +/-19.1 years) with spontaneous pneumothorax participated in the study. There were 22 cases of left-sided and 18 cases of right-sided pneumothorax. The mean relative volume of pneumothorax was 51.4 +/-24.7% according to the Light's index and 53.5 +/-22.9% according to the Rhea method. Heart rate was significantly higher in patients with pneumothorax than after lung re-expansion (91 +/-20 bpm vs. 72 +/-16 bpm; P<0.001). Abnormal left axis deviation was found in 3 patients with left-sided and in 1 with right-sided pneumothorax, while abnormal right axis deviation was found in 2 patients with left-sided pneumothorax. Relevant QRS abnormalities (incomplete RBBB and T-wave inversion) were found in 4 patients (10%). QRS amplitude in V2-V6 leads was significantly decreased in left-sided pneumothorax, while the right-sided pneumothorax was associated with an increase in QRS amplitude in V5-V6. We conclude that ECG in subjects with pneumothorax often reveals significant abnormalities. The most significant abnormalities were seen in patients with massive right-sided pneumothorax.

Exercise capacity in patients with obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is a common disease characterized by repetitive partial or complete closure of the upper airway during sleep. Cardiovascular disturbances are the most important complications responsible for increased morbidity and mortality. It is suggested that daytime somnolence, chronic fatigue, and nocturnal hypoxemia may further impair muscle function and decrease exercise fitness. The aim of this study was to evaluate cardiopulmonary response to exercise in OSAS patients. One hundred and eleven middle aged (50.2+/-10 yr), obese (BMI 31.0+/-4.6 kg/m2) patients (109 M, 2F) with severe OSAS (AHI 47.2+/-23.1 h(-1)) were enrolled into the study. OSAS was diagnosed with overnight polysomnography and a symptom-limited cardiopulmonary exercise test was performed on a treadmill using Bruce protocol. The results showed that the most frequent reason for exercise termination were: muscle fatigue and/or dyspnea (66+/-), increase in systolic blood pressure>220 mmHg (20%), ECG abnormalities, and chest pain (6%). Although the mean VO2 peak was within the reference value (29.6+/-6 mlO2/kg/min), in 52 patients (46%) VO2 peak was <84% of predicted. Hypertensive response to exercise was diagnosed in 39 of patients (35%). Patients with severe sleep apnea (AHI40>or=h(-1)) were characterized by higher mean blood pressure at rest, at 25%, 50% of maximal work load, at peak exercise and at post-exercise recovery. Several significant correlations between hemodynamic responses to exercise and sleep apnea severity were also noted. We conclude that exercise tolerance can be limited due to hypertensive response in about 20% of patients. Patients with severe OSAS have exaggerated hemodynamic response to exercise and delayed post-exercise blood pressure recovery. Cardiopulmonary response to exercise seems to be related to sleep apnea severity.

The effect of fiberoptic bronchoscopy on exhaled nitric oxide.

Nitric oxide has been extensively studied as a noninvasive marker of airway inflammation. Assuming that bronchoscopy can produce not only systemic but also local inflammatory response, we hypothesized that bronchofiberoscopy can be responsible for an increase in nitric oxide synthesis with resulting increase in fractional concentration of exhaled nitric oxide (FE(NO)). Fifty five subjects (F/M-23/32; mean age 53.9 +/-17.3 yr) undergoing diagnostic bronchoscopy participated in the study. The indications for bronchoscopy were as follows: interstitial lung diseases (n=13; 23.6%), lung cancer (n=11; 20.0%), hemoptysis (n=10; 18.2%), differential diagnosis of asthma/dyspnea (n=9; 16.4%), pulmonary infections (n=7; 12.7%), and others (n=5; 9.1%). During bronchoscopy bronchial washing (n=18), bronchoalveolar lavage (BAL) (n=26), and bronchial biopsies (n=24) were performed. FE(NO) was analyzed on-line with chemiluminescence analyzer (NIOX, Aerocrine, Sweden) according to the ATS guidelines, before and at 1, 2, 3 and 24 h after bronchoscopy. The mean FE(NO) before bronchoscopy was 21.0 +/-3.31(SE) ppb, it decreased to 14.8 +/-2.10 ppb 1 h after bronchoscopy, reached a nadir at 2 h (14.4 +/-2.28 ppb; P<0.05), and was not different from baseline 24 h after bronchoscopy (22.8 +/-2.90 ppb). There were no differences in the FE(NO) profile in BAL patients compared with those in whom only the bronchial washing was performed. We conclude that bronchoscopy leads to a decrease in FE(NO). The underlying mechanisms are at present unclear.

Gas exchange abnormalities in patients listed for liver transplantation.

Abnormalities of pulmonary gas exchange are common in patients with advanced liver disease. Since arterial blood hypoxemia is an important issue in the preoperative evaluation of liver transplant candidates, the study was undertaken to determine the incidence and severity of lung function impairment with a special emphasis on pulmonary gas exchange abnormalities in this group of patients. 104 consecutive patients (47 F and 57 M, mean age 46 +/-11 yr) listed for orthotopic liver transplantation participated in this prospective study. All patients underwent evaluation including: clinical assessment (Child-Pough and MELD classification), chest X-ray, chest sonography, lung function tests, arterial blood gases measurement, and transthoracic contrast enhanced echocardiography. There were 2 patients with acute hepatic failure, 6 patients with primary or metastatic liver carcinoma, and 96 patients with chronic liver disease. The mean PaO(2) and lung function parameters for the entire group were within normal limits. There were 29 hypoxemic patients (PaO(2)< 80 mmHg) and 40 patients with widened (>20 mmHg) P(A-a)O(2). DL(CO) was significantly lower in cirrhotic vs. non-cirrhotic patients (76.5 +/-19.3 vs. 92.4 +/-19.0% predicted; P<0.001). Hepatopulmonary syndrome (HPS) was recognized in 23 (24%) patients. 91% of patients with HPS showed mild to moderate stage of disease. There were significant difference between differences HPS patients and non-HPS patients in DL(CO) (69.0 +/-14.5 vs. 83.5 +/-20.7, P<0.01). In conclusion, all patients referred for OLT should be screened for gas exchange abnormalities. Such a workup should include not only PAO(2) but also DL(CO) and P(A-a)O(2) measurement together with contrast enhanced echocardiography.

[Anatomic abnormalities within upper airways in patients with obstructive sleep apnea syndrome]. / Nieprawidlowosci anatomiczne górnych dróg oddechowych u chorych z obturacyjnym bezdechem podczas snu.

In order to determine a proper method of the treatment of Obstructive Sleep Apnea Syndrome (OSAS) it is essential to demonstrate anatomical abnormalities of upper airways. In this study we would like to estimate how often these anatomical abnormalities occur and what is their influence on OSAS severity. 113 patients underwent laryngological examination, the nasal structure, palate and pharynx were evaluated. The anatomical abnormalities of upper airways were found in 86% patients. The most frequent abnormalities found were nasal disorders, however they were not correlated with OSAS severity. Anatomical abnormalities in more than one level of upper airways were found in 50% of the patients and in those patients OSAS symptoms were the most severe. This may explain why the most frequently performed operations in OSAS patients are not very effective.

[Obstructive sleep apnea and risk factors for coronary artery disease]. / Obturacyjny bezdech senny a czynniki ryzyka choroby niedokrwiennej serca.

STUDY AIM: Obstructive sleep apnoea (OSA) is strongly associated with obesity, especially abdominal obesity. Obesity in turn is a well-known risk factor for coronary artery disease (CAD). The aim of our study was to evaluate the relationship between OSA severity and CAD risk factors. MATERIAL AND METHODS: The sample consisted of 73 subjects (mean age +/- SE, 46.7 +/- 1 years) referred to a sleep laboratory. Subjects were either: 1. obese with OSA (O-OSA group n = 35; body mass index, BMI l 30 kg/m2; apnoea/hypopnoea index, AHI > 35), 2. non-obese with OSA (BO-OSA group n = 14; BMI < 27 kg/m2; AHI > 35), or 3. obese without OSA (O-Z group n = 24; BMI l 30 kg/m2; AHI < 5). All subjects underwent full overnight polysomnography. Blood samples were taken from all subject, for fasting levels of insulin (INS), glucose (GLU), total, HDL and LDL cholesterol, triglyceride (TG) and uric acid (UA). RESULTS: O-OSA had significantly higher INS and UA levels (p < 0.05) compared to BO-OSA and O-Z. GLU and lipid levels were comparable in the studied groups. GLU level correlated (p < 0.05) negatively to minimum oxyhemoglobin saturation (SAT-MIN) and positively to neck circumference. TG and UA levels were correlated (p < 0.05) positively to AHI and negatively to SAT-MIN. UA level was also positively correlated (p < 0.05) to BMI, waist/hip circumference ratio (WHR), and INS level. INS level correlated (p < 0.05) positively to AHI, T90, WHR and UA, and negatively to SAT-MIN and mean oxyhemoglobin saturation. After adjusting for the influence of OSA and obesity (multiple regression analysis), we found independent negative correlations (p < 0.05) between: GLU level and SAT-MIN, UA level and SAT-MIN, and INS level and SAT-MIN. An independent, positive correlation (p < 0.05) was found between TG level and AHI. CONCLUSIONS: Results of our study suggest that OSA increases the risk of coronary artery disease by increasing plasma levels of glucose, triglyceride and insulin, independent of obesity.

[Drivers with obstructive sleep apnea as potential authors of car accidents]. / Kierowcy chorzy na obturacyjny bezdech podczas snu (OBPS) jako potencjalni sprawcy wypadków komunikacyjnych.

The aim of this work was to estimate excessive somnolence and frequency of episodes of dozing off during driving a car in patients with obstructive sleep apnea. Result of questionnaire and polysomnographic investigations were analysed in a group of 503 patients. Mean age for the whole group was 49.2 +/- 9.7 of years, BMI 32.1 +/- 1.4 kg/m2 and the value for apnea and hypopnea index 45.4 +/- 24.8. Excessive somnolence during driving was reported by 49.1% of patients. 31.2% of the group notified at least one episode of falling asleep while driving a car. Sleepy drivers (group A) were significantly younger (46.5 +/- 9.2 vs 50 +/- 9.8 years) and had higher values of BMI (34.1 +/- 7 vs 31.1 +/- 5.5 kg/m2) than the others (group B) Results of polysomnographic investigation showed more severe sleep apnea in the group A. Mean value of AHI for this group was 52.5 +/- 26.1 vs 41.6 +/- 23.5 in the group B. Besides, somnolence in many other practical situations was more often considered as a serious problem in the group A.

Obstructive sleep apnea syndrome in patient with Creutzfeldt-Jakob disease. Clinical and morphological report.

We report a case of Creutzfeldt-Jakob disease (CJD) which at the beginning of the disease presented clinical syndrome of progressive supranuclear palsy. Rapid intellectual deterioration, supranuclear palsy, postural instability and myoclonic jerks suggested clinical diagnosis of CJD. After five months suffering from the disease patient developed obstructive sleep apnea syndrome (OSAS) confirmed by serial polysomnograms. OSAS is discussed in the context of the localization of histopathological findings and possible involvement of central autonomic structures. The main structures affected by spongiosis and astrogliosis were cortex, thalamus, basal ganglia and midbrain. OSAS was found as another sleep disturbance in CJD apart from insomnia and sleep-wake cycle abnormalities.

[Effect continuous positive airway pressure (CPAP) on left ventricular diastolic function in patients with obstructive sleep apnea syndrome--OSAS]. / Wplyw oddychania powietrzem pod stalym dodatnim cisnieniem (CPAP) na funkcje lewej komory u chorych z obturacyjnym zespolem bezdechów sennych--OSAS.

22 patients with (OSAS) obstructive sleep apnea syndrome were divided into two groups: patients with OSAS and without arterial hypertension, and OSAS with hypertension. The effect of CPAP (continuous positive airway pressure) on the left ventricular function was evaluated using 2D and Doppler echocardiography. Systolic left ventricular function (ejection fraction) was normal in all patients. The decrease in peak mitral flow velocity during early diastole E (m/sec), the increase of atrio-systolic contraction A (m/sec), the increase in E/A and prolonged isovolumic relaxation time (IVRT) was observed in the both groups at the beginning of the study. After three month treatment with CPAP the increase in the ratio E/A, 1.38 + 0.23 m/sec vs 0.98 + 0.28 (p < 0.05) and a reduction in IVRT, 79 + 6.8 milisec vs 91.3 + 6.3 (p < 0.05) in the group with OSAS and hypertension was observed. In the group with OSAS and without hypertension only a statistically significant reduction in IVRT was observed, 77.8 + 5.4 vs 83.7 + 5.15 milisec p < 0.05.