Impact of Pulmonary Hypertension on Renal Functions in Obstructive Sleep Apnea Syndrome.

OBJECTIVES: Pulmonary hypertension (PH) is common in obstructive sleep apnea syndrome (OSAS). This study aimed to evaluate the effect of PH on kidney functions in patients with OSAS. METHODS: The data of patients who were diagnosed as having OSAS after referral to the sleep center in the Gaziantep University Medical Faculty between January 2005 and June 2017 were evaluated. The estimated glomerular filtration rate was calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Renal functions of the subjects who had data after 5 years were included for long-term analysis. RESULTS: A total of 2152 patients with OSAS (n = 1540), PH (n = 49), OSAS and PH coexistence (n = 359), and the control group (n = 204) were included in the study. Pulmonary arterial pressure (PAP) was 44.51 ± 23.73 in the PH group; it was 37.1 ± 13.14 in the group with OSAS + PH (P = 0.001) Urea and uric acid were found to be higher in the association of OSAS + PH. CKD-EPI was lower in the presence of PH or OSAS + PH than in the presence of OSAS. PH was present in 16.06% of males and 25.10% of females (P = 0.000), and PAP was detected as 35.80 ± 13.23 and 40.96 ± 16.65, respectively (P = 0.001). PH was present in 15.99% of males and 25.84% of females with OSAS (P = 0.000). The PAP of males with OSAS was 36.03 ± 13.46, and the PAP of females was 38.68 ± 12.55 (P = 0062). Urea, creatinine, and uric acid were higher and CKD-EPI was lower in male subjects in the presence of OSAS and PH, whereas the same scenario also was present in the presence of PH alone in female subjects. Long-term comparisons (n = 343) revealed significant decreases in the CKD-EPI in those with OSAS and OSAS + PH and these decrease were more pronounced in the presence of OSAS and PH. The regression analysis revealed that female patients had lower CKD-EPI in the presence of PH, although the presence of PH had no effect on CKD-EPI in males. CONCLUSIONS: PH is a risk factor for the deterioration of renal function in OSAS and more prominent in the long term.

Obstructive sleep apnea is the triggering factor for massive hemoptysis : Obstructive sleep apnea and hemoptysis.

PURPOSE: The purpose of this study was to investigate the prevalence of obstructive sleep apnea (OSA) in patients with hemoptysis. METHODS: Files of patients who had undergone bronchial arterial embolization due to hemoptysis between 1 December 2009 and 2015 were evaluated and interviews of patients were conducted until 1 June 2016. Pittsburgh Sleep Quality Index (PSQI), STOP and STOP-BANG surveys were administered. OSA risk was determined with Berlin Questionnaire. RESULTS: Study group consisted of 53 patients and 58 control subjects. Mean age was 46.94 ± 14.36 and 41.97 ± 12.92 in patient and control group, respectively. Of these patients, seven had re-embolization procedure because of recurrence of hemoptysis. High OSA risk was more common among patients with hemoptysis (24.5%, n = 13) than the control group (8.6%, n = 5) (p = 0.023). Percentage of high risk OSA patients with massive hemoptysis, nonmassive hemoptysis, and control subjects was 29.7% (n = 11), 12.5% (n = 2), and 8.6% (n = 5), respectively (p = 0.022). There were more high OSA risk subjects among patients with idiopathic hemoptysis 44.4% (four out of nine), while 20.5% (nine out of 53) patients with a known etiology had high risk (p = 0.127). The number of patients with high OSA risk was also higher in patients who required a second embolization procedure (four out of seven, 57.1%), while 19.6% of patients without need for re-embolization had high risk (p = 0.031). CONCLUSIONS: OSA is found to be a risk factor for hemoptysis and also may provoke massive hemoptysis. It seems reasonable to consider OSA as an underlying condition in idiopathic hemoptysis. OSA may contribute to embolization failure.

An unusual course of aortic arch through an accessory fissure of left upper lobe of the lung: extramediastinal aortic arch.

In this case report, we present an unexpected, extramediastinal course of aortic arch through an accessory fissure of left upper lobe of the lung in a 19-year-old healthy man.

Tracheobronchomalacia as a Rare Cause of Chronic Dyspnea in Adults.

OBJECTIVE: To emphasize the importance of a careful clinical evaluation to prevent unnecessary interventions and treatments. CLINICAL PRESENTATION AND INTERVENTION: A 76-year-old female patient had been diagnosed with asthma during previous admissions to different hospitals. She had also undergone fiberoptic bronchoscopy (FOB) on 2 occasions for evaluation of right middle lobe atelectasis observed on computed tomography. A repeated FOB revealed tracheobronchomalacia and nodular bronchial amyloidosis. A silicone Y stent was inserted, but the dyspnea increased. Excessive granulation tissue developed, and the patient died despite ventilatory support. CONCLUSION: The stenting technique used did not prevent the development of respiratory failure and death in this patient. Hence, a surgical procedure could be considered as an alternative to stenting in such cases.

Renal functions in obstructive sleep apnea patients.

PURPOSE: The aim of this study is to investigate possible factors influencing glomerular filtration rate (GFR) in obstructive sleep apnea (OSA). METHODS: Data of OSA patients admitted to Gaziantep University sleep clinic from January 2005 to January 2010 were retrospectively evaluated. GFR is calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Patients younger than 18 years old were excluded. RESULTS: The mean age of OSA (n = 634) and control group (n = 62) were 51.13 ± 11.61 and 50.69 ± 13.88 years, respectively (p = 0.81). The mean estimated GFR (eGFR) was 90.73 ± 19.59 ml/min/1.73 m(2) in OSA patients and 94.14 ± 18.81 ml/min/1.73 m(2) in control subjects (p = 0.19). GFR was 84.25 ± 20.87 ml/min/1.73 m(2) in patients with left ventricular hypertrophy (LVH) while it was 93.94 ± 18.44 ml/min/1.73 m(2) in patients without LVH (p = 0.00). GFR of male subjects was 92.1 ± 19.23 in OSA and 95.84 ± 20.08 ml/min/1.73 m(2) in controls (p = 0.33). GFR of female and male patients in the OSA were 87.45 ± 20.10 and 92.91 ± 18.02 ml/min/1.73 m(2), respectively (p = 0.13). Serum creatinine was higher in OSA patients compared to controls (p = 0.01). GFR was 92.30 ± 19.27 in male and 88.33 ± 19.84 ml/min/1.73 m(2) in female subjects (p = 0.01). GFR was 84.86 ± 19.95 in hypertensive patients while it was 95.11 ± 18.20 ml/min/1.73 m(2) in normotensive subjects (p = 0.00). GFR was 89.30 ± 19.96 in patients with metabolic syndrome (MetS) and it was 93.46 ± 18.68 ml/min/1.73 m(2) in patients without MetS (p = 0.00). CONCLUSIONS: GFR values were lower in sleep apneic patients with MetS as well as in patients with hypertension and LVH.

An update on cardiovascular effects of obstructive sleep apnoea syndrome.

Obstructive sleep apnoea syndrome is an important health problem which may cause or worsen systemic diseases. Chronic intermittent hypoxia during repetitive airflow cessations may cause endothelial dysfunction. Sleep apnoea is also shown to be associated with hypercoagulability which may be due to decreased nitric oxide levels and impaired vasodilatation. Endothelial dysfunction, increased systemic inflammation, sympathetic nervous system activation, increased oxidative stress and dysglycaemia may all contribute to cardiovascular processes such as hypertension, arrhythmia, stroke, heart failure and coronary artery disease in patients with obstructive sleep apnoea. Treatment approaches in patients with obstructive sleep apnoea mainly focus on maintaining upper airway patency either with positive airway pressure devices or upper airway appliances. Strategies involving positive airway pressure therapy are associated with decreased morbidity and mortality. Obstructive sleep apnoea should be suspected as an underlying mechanism in patients with cardiovascular disease and warrants appropriate treatment.

Relationship between head posture and the severity of obstructive sleep apnea.

INTRODUCTION: The objective of this study was to compare the head posture of patients with obstructive sleep apnea (OSA) having different levels of severity with that of control subjects. METHODS: One hundred subjects participated in this study. Seventy-five subjects underwent overnight polysomnography in a sleep laboratory and were allocated into "mild," "moderate," or "severe" OSA groups, and 25 subjects with no complaints regarding OSA were allocated into 1 group and served as the controls. Cephalometric radiographs were obtained from all participants in natural head position. Craniocervical, craniovertical, and cervicovertical angles were measured in the groups. Data were analyzed using the least significant difference. RESULTS: The results showed significant differences between the OSA groups and the control group, and among the test groups, in all craniocervical, craniovertical, and cervicovertical angles (P <0.05), except for 1 craniovertical measurement (P >0.05). There were no significant differences in this measurement among the test groups and in any measurement between the mild and moderate OSA groups (P >0.05). CONCLUSIONS: Head posture showed significant differences in patients with OSA. In general, the more severe the OSA, the more extended the natural head position as indicated by increases in the craniocervical angles. The cervical posture parameters may indicate existing OSA.

Pelvic inflammatory myofibroblastic tumour mimicking scrotal mass: an extremely rare case.

Inflammatory myofibroblastic tumour (IMT) is a rare benign mesenchymal tumour. However, IMT may arise from a wide variety of tissues and is very rare in the elderly. IMT may mimic the mass in which it originates. Although IMT has been defined as uncertain behaviour, it is treated surgically. We present a-65-year old man whose mass was diagnosed as IMT extending from scrotum to pelvis. The mass was independent of any surrounding anatomic structures. According to our best knowledge this is the first case in the literature that pelvic IMT was diagnosed in an elderly man and successfully treated surgically with a long term follow-up period. Aetiology of IMT is still unknown, and more studies are needed for exact continuum of IMT.

Obstructive sleep apnea is prevalent in patients with pulmonary embolism.

PURPOSE: Obstructive sleep apnea (OSA) syndrome causes systemic consequences due to hypoxia and endothelial dysfunction. The purpose of this study was to investigate whether OSA is more common in subjects with pulmonary embolism (PE). METHODS: This prospective study was conducted between November 2009 and December 2010 in the Department of Pulmonary Medicine of Gaziantep University. Twenty-eight patients with PE were included in the study group along with forty-five subjects with OSA as the control group. The control group was selected from among subjects who were referred to the sleep clinic. Full night polysomnography was performed for each subject. RESULTS: Mean apnea-hypopnea index (AHI) was found to be higher in the PE group compared with the control group (p=0.010). Severe OSA was detected in 21.4% of the PE group but in no controls (p=0.015). Sleep stage 2 was longer in control group whereas stage 1 and rapid eye movement (REM) sleep was longer in the PE group. Snoring and excessive daytime sleepiness were more common in the control group compared with the study group. AHI severity and thrombus localization were not significantly different between the groups (p=0.350). CONCLUSION: Our study findings suggest that OSA is more prevalent and severe in subjects with PE compared with control subjects. The clinical significance of less prevalent excessive daytime sleepiness and snoring in subjects with PE should be evaluated in further studies.

Comparison of metabolic syndrome with growing epidemic syndrome Z in terms of risk factors and gender differences.

PURPOSE: The aim of this study is to compare metabolic syndrome with syndrome Z growing epidemic in terms of risk factors, demographic variables, and gender differences in our large cohort at southeastern area in Turkey. METHODS: Data of patients admitted to sleep clinic in University of Gaziantep from January 2006 to January 2011 were retrospectively evaluated. ATP III and JNC 7 were used for defining metabolic syndrome and hypertension. RESULTS: Data of 761 patients were evaluated. Hypertension, diabetes mellitus, coronary artery disease, pulmonary hypertension, and left ventricular hypertrophy were more common in patients with syndrome Z than in patients without metabolic syndrome. Age, waist/neck circumferences, BMI, triglyceride, glucose, and Epworth sleepiness scale score were detected higher, whereas the minimum oxygen saturation during sleep was lower in patients with syndrome Z. Metabolic syndrome was more common in sleep apneic subjects than in controls (58 versus 30 %). Female sleep apneics showed higher rate of metabolic syndrome than those of males (74 versus 52 %). Hypertension, diabetes mellitus, coronary artery disease, and left ventricular hypertrophy were detected higher in males with syndrome Z than in males without metabolic syndrome. Snoring and excessive daytime sleepiness were detected higher in females with syndrome Z than in females without metabolic syndrome. Systemic/pulmonary hypertension, diabetes mellitus, and left ventricular hypertrophy were more common in females with syndrome Z than in females without metabolic syndrome. Complaints of headache and systemic/pulmonary hypertension were more common among females than males with syndrome Z. Female syndrome Z patients had lower minimum oxygen saturation than male patients with syndrome Z. CONCLUSIONS: Metabolic syndrome in sleep apneic patients is more prevalent than in controls. All metabolic syndrome parameters were significantly different among obstructive sleep apneic patients with respect to gender with more severe coronary risk factors in males.

Causes of sleep disturbance in human immunodeficiency virus-infected individuals: Is it depression or obstructive sleep apnea?

OBJECTIVES: To examine the possible association of obstructive sleep apnea (OSA) and depression on sleep quality in people living with human immunodeficiency virus (PWLHIV). METHODS: Adult PWLHIV were included in this prospective, cross-sectional, case-control study. Our study was completed with 99 patients and 80 control subjects. To investigate sleep quality, the Pittsburgh Sleep Quality Scale and Stanford Sleepiness Scale were used; to determine the risk of OSA, the Berlin and STOP-BANG questionnaires were used; and to evaluate the existence and degree of depression, the Beck Depression Inventory was applied. RESULTS: Patients had significantly higher daytime sleepiness (p=0.002) and absent-mindedness (p=0.004). The rate of being able to concentrate on one's work was significantly higher in the control group compared with the patient group (p=0.000). More participants in the patient group had poor sleep quality (57% versus [vs.] 47.5%). The sleep quality score was significantly higher in the patient group (6.32 vs 5.23; p=0.032). Daytime dysfunction was significantly higher in the patient group (p=0.004). The rate of OSA risk was similar between the patient group and the control group on both the Berlin and STOP-BANG questionnaires (p=0.443 and p=0.581). Rates and numbers of depression the patient group were significantly higher (p=0.007). CONCLUSION: The results suggest that depression may be the most likely cause of sleep disorders in PWLHIV, regardless of OSA.

Factors influencing compliance with continuous positive airway pressure ventilation in obstructive sleep apnea syndrome.

INTRODUCTION: Positive pressure ventilation is considered first line therapy in obstructive sleep apnea syndrome however compliance is limited by various factors. We aimed to investigate possible factors influencing compliance. MATERIALS AND METHODS: One hundred and forty patients were prescribed positive pressure ventilation for obstructive sleep apnea during June 2006-June 2008. Of these patients, 77% (n= 108) were reached by telephone and a questionnaire was administered regarding factors influencing treatment compliance. Airway passage was measured with C2 vertebrae level and narrowest airway passage on lateral skull radiographs. RESULTS: The mean age was 52.2 ± 12.3 years. Seventy one percent (n= 77) of subjects obtained the prescribed device. There was no difference in sex, age, marital status, educational level, symptoms, co-morbid conditions, and social security coverage between the subjects who have received the prescribed devices and who have not (p> 0.05). No difference was detected between these two groups of patients in view of Epworth sleepiness scale (ESS) and apnea hypopnea index (AHI). Mean duration of device usage was 6.3 ± 2.3 hours. The device use compliance was not affected by any of the following factors: age, gender, level of education, co-morbid diseases, ESS score, AHI, airway passage measurements, application of humidification and education concerning the device (p> 0.05). Patient (p= 0.057) and bed partners (p= 0.001) satisfaction about the device yielded higher compliance rates. CONCLUSION: Factors influencing compliance rates in obstructive sleep apnea syndrome seems to be related to satisfaction about the device use however upper airway morphology measured with C2 vertebrae level and narrowest airway passage has no impact on treatment compliance.

Churg-Strauss syndrome related to montelukast.

A young male with complaints of cough, dyspnea and hemoptysis was admitted. He was using fluticasone propionate and salmeterol for two years for his asthma. Leukotriene receptor antagonist was prescribed two weeks prior to his admission and no reduction of his inhaled steroid therapy was performed. Eosinophil count was detected as 1460/mm³ (15%) and immunoglobulin E level was 547 IU/mL. Thorax computerized tomography revealed patchy infiltration. Increased eosinophilic inflammation were detected in bronchoalveolar lavage fluid and transbronchial biopsy. He received prednisolone treatment for Churg-Strauss syndrome. Improvement was observed on three months follow up period. He has no complaint in his follow up.

Gender differences with respect to psychiatric comorbidity in obstructive sleep apnea syndrome.

OBJECTIVES: Psychiatric disorders are common in obstructive sleep apnea syndrome (OSAS); however, interrelating factors influencing psychiatric comorbidity (PC) in OSAS are unclear. The aim of this study is to investigate gender related differences with PC in OSAS. METHODS: Data of patients diagnosed as OSAS in University of Gaziantep from January 2006 to January 2010 were retrospectively evaluated. Polysomnographic data were recorded with Viasys Sleep Screen (Viasys Healthcare, Germany). Patients younger than 18 years old were excluded. RESULTS: PC was present in 53.1% of OSAS patients. The rate of male subjects with PC was 42.6%; however, 76.26% of females had PC (P = 0.00). Age (P = 0.00) and body mass index (BMI) (P = 0.00) were higher in patients with PC. Ferritin levels were lower in patients with PC (P = 0.00). Male subjects with PC were older and had lower sleep efficiency and longer rapid eye movement latency than males without PC. BMI was the only contributory factor to PC in female subjects. CONCLUSION: PC in OSAS is common, especially in females. Apnea hypopnea index does not seem to influence probability of PC.

[Pulmonary manifestations of polyvinyl chloride exposure]. / Polivinil klorür maruziyetinin pulmoner sisteme etkileri.

There is currently no national data on the effects of polyvinyl chloride (PVC) exposure on pulmonary function. In this study we recruited workers and administrative staff from two PVC plants between July 2008 and July 2009. A questionnaire, pulmonary function tests, carbon monoxide diffusion capacity, and peak flows were recorded. Particulate matter analyses were performed by the Adana Central Laboratory of the Directorate of Occupational Health and Safety. Data were analyzed with SPSS 13.0 software. Nine of the 147 subjects were female. The incidence of a cough was more common in the administrative group. Of the study population, 59.1% were smokers. Tobacco addiction significantly increased cough and dyspnea [OR= 1.10 (1.00-1.20, 95% CI) p= 0.007 and OR= 1.08 (1.02-1.14, 95% CI), p= 0.008, respectively]. Dust exposure was correlated with the incidence of a cough [OR= 0.20 (0.04-0.80, 95% CI) p= 0.008]. The period of work correlated with sputum production [OR= 1.00 (1.00-1.02, 95% CI) p= 0.044]. The FVC% was significantly higher in the administrative group, and FEV1/FVC and DLCO were higher in the exposed group. Tobacco addiction increased the risk of airflow limitation, as evaluated by FEV1/FVC < 70% and FEF25-75 < 50% [OR= 1.15 (1.06-1.25, 95% CI) p= 0.001 and OR= 1.09 (1.02-1.17, 95% CI) p= 0.010, respectively]. Tobacco addiction and increasing duration of work had a negative influence on DLCO in the exposed group (r= -0.270, p= 0.025 and r= -0.210, p= 0.037). In the exposed group PEF variability was significantly greater on workdays, compared with rest days. This study shows that tobacco consumption has a greater affect on the airways than PVC dust exposure. A median of 36 months exposure to PVC dust had no significant impact on pulmonary function parameters, except for DLCO and PEF variability.

Treatment of acute chronic obstructive pulmonary disease exacerbation improves right ventricle function.

AIMS: It was shown that cardiac function is impaired in chronic obstructive pulmonary disease (COPD) patients who have severe pulmonary hypertension (PHT). However, no previous reports have evaluated cardiac function in COPD patients before and after medical therapy for acute COPD exacerbation. In this study, we evaluated the cardiac function of COPD patients during acute COPD exacerbation. METHODS AND RESULTS: Thirty-two patients (27 men and 5 women; mean age 59 +/- 8.7 years) with acute COPD exacerbation without PHT were included in the study. Thirty-two age- and sex-matched control subjects (22 men and 10 women; mean age 57 +/- 10 years) were also examined. Right ventricular (RV) and left ventricular (LV) functions were assessed using both conventional and tissue Doppler imaging methods before and after therapy, which were performed according to accepted guidelines. Medical therapy included inhaled beta(2)-agonists, inhaled anticholinergic agents(,) oxygen, systemic corticosteroids, and antibiotics. The systolic tissue Doppler velocity (TSm) in the RV was increased after therapy (13.7 +/- 2.4 vs. 14.4 +/- 2.4 cm/s, P = 0.027). The function of the RV and LV during diastole was also improved, and pulmonary artery pressures decreased after therapy (34 +/- 5.2 vs. 28.2 +/- 4.7 mmHg, P < 0.0001). However, there was no change in LV function during systole. CONCLUSION: We have demonstrated that treatment of patients with acute COPD exacerbation according to guidelines improves not only pulmonary function, but also RV and LV function and PHT.

Impact of CPAP treatment on cardiac biomarkers and pro-BNP in obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate the effect of continuous positive airway pressure (CPAP) therapy on pro-brain natriuretic peptide (BNP) and cardiac markers in patients with obstructive sleep apnea syndrome and normal cardiac function. METHODS: Thirty-three consecutive patients with sleep apnea syndrome were analysed for serum pro-BNP and cardiac markers prior to and after 6 months of CPAP therapy. RESULTS: Twenty five patients had normal (83.3%) while remaining five (16.7%) revealed high pro-BNP values. We did not detect any significant difference between severity of obstructive sleep apnea syndrome and serum pro-BNP levels (p = 0.534). A statistically significant difference was not observed between basal and sixth-month creatine kinase (CK), creatine kinase-MB (CK-MB), troponin I, pro-BNP, aspartate transaminase (AST), and CK levels in patients with sleep apnea syndrome (p > 0.05). CONCLUSION: Obstructive sleep apnea syndrome does not induce myocardial damage enough to increase serum pro-BNP, CK, CK-MB, troponin I, and AST levels. Markers sensitive to ischemia could be preferred to evaluate effect of obstructive sleep apnea syndrome.

Signet ring cell adenoma of the thyroid: a very rare entity.

OBJECTIVES: To report a case of signet ring cell adenoma of the thyroid which is an extremely rare thyroid lesion. CLINICAL PRESENTATION AND INTERVENTION: A 25-year-old female patient presented with a goiter and dysphagia that had been present for the last 1 year before admission. Physical examination revealed a palpable solitary nodule in the right lobe of the thyroid. The ultrasonogram demonstrated multiple nodules among which the most remarkable one was 15 x 24 mm in size, in the right lobe of the thyroid. After surgical excision, the lesion was found to be consistent withsignet ring cell adenomacharacterized by the presence of round to oval signet ring cells with large cytoplasmic vacuoles and hyperchromatic eccentric nuclei. Intracytoplasmic thyroglobulin, periodic acid-Schiff (PAS) with and without diastase and combined Alcian-blue-PAS were all positive. CONCLUSIONS: Pathologists should keep this rare primary tumor of the thyroid in mind when examining thyroid lesions and should not confound it with metastatic signet ring cell carcinoma of the thyroid.

Diffuse alveolar haemorrhage due to 5-nitroimidazole treatment.

Diffuse alveolar haemorrhage (DAH) is indicated by the presence of red blood cells, fibrin and haemosiderin deposits in the lung parenchyma. We present a case of DAH in a 25-year-old male following 5-nitroimidazole treatment. The first episode of haemoptysis occurred following metronidazole treatment 10 months previously. The second episode of haemoptysis occurred following ornidazole treatment 10 days before admission. During his first admission, the patients haemoglobin concentration decreased to 40 g/L. The CXR was normal, whereas high resolution CT of the lungs revealed a diffuse acinonodular pattern. Serological tests for connective tissue diseases were negative. The haemorrhagic appearance of the BAL fluid obtained during fibreoptic bronchoscopy was consistent with DAH. Microbiological analysis of the BAL fluid showed no evidence for bacterial or mycobacterial infection. Haemosiderin laden macrophages were detected in BAL fluid and lung biopsy specimens. DAH due to use of 5-nitroimidazole was diagnosed on the basis of the patient's previous history and complete recovery following treatment with corticosteroid. This is the first reported case of DAH due to use of 5-nitroimidazole. Physicians should be aware of this side-effect when prescribing this group of drugs to patients.