The Relationship between Frontal QRS-T Angle and Vitamin D Deficiency.

Background and Objectives: A deficiency in serum 25-hydroxyvitamin D levels is associated with a number of cardiovascular situations, such as high blood pressure, heart failure, atherosclerotic heart disease, and peripheral artery disease. The frontal QRS-T angle has recently been proposed as a marker of ventricular repolarization. A wider frontal QRS-T angle has been positively correlated with adverse cardiac events. The objective of our study was to examine the association between serum 25-hydroxyvitamin D level and the frontal QRS-T angle. Materials and Methods: A total of 173 consecutive patients aged 18-60 years undergoing routine cardiology check-up evaluation, and not receiving concurrent vitamin D treatment were included in the study. Patients were classified in three groups, depending on their vitamin D levels, and categorized as follows: Group 1-deficient (<20 ng/mL), Group 2-insufficient (20-29 ng/mL), or Group 3-optimal (≥30 ng/mL). The frontal QRS-T angle was determined using the automated reports generated by the electrocardiography machine. Results: The average age of participants was 45.8 (±12.2) years, and 55.5% of participants were female (p < 0.001). Individuals with low vitamin D concentrations exhibited a wider frontal QRS-T angle. It was determined that vitamin D level is an independent predictive factor for the frontal QRS-T angle. Conclusions: As the levels of 25-hydroxyvitamin D decrease, repolarization time assessed by frontal QRS-T angle is widened. Our findings indicate that lower concentrations of vitamin D may increase the susceptibility to ventricular arrhythmia.

Effect of prior beta-blocker use on in-hospital atrial fibrillation development in patients with ST-elevation myocardial infarction.

BACKGROUND AND AIM: There are conflicting results about the early administration of beta-blockers (bb) on in-hospital mortality and arrhythmias. Here, we wanted to investigate the effects of chronic bb use on in-hospital Atrial Fibrillation (AF) development in ST-Elevation Myocardial Infarction (STEMI) patients. MATERIALS AND METHODS: A total of 814 consecutive patients with STEMI were included in the study. They were divided into two groups according to whether they are using bb on admission or not. They were followed for AF development in-hospital and predictors of AF were determined by multivariable logistic regression analysis. RESULTS: Of the 814 patients, 103 (12.67%) patients were already using bb, while 711 (87.3%) were not. There were no significant differences in the frequency of AF development [3 (%2.9) vs 30 (%4.2), p = .788] between the groups. Multivariable logistic regression analysis showed that left atrial (LA) diameter is the only independent predictor of in-hospital AF development. CONCLUSIONS: Our study showed that chronic bb use does not have an effect on in-hospital AF development in STEMI patients. Nevertheless, LA diameter was found to be an independent predictor of AF.

The association of plasma oxidative status and inflammation with the development of atrial fibrillation in patients presenting with ST elevation myocardial infarction.

Atrial fibrillation (AF) is the most common supraventricular arrhythmia following ST elevation myocardial infarction (STEMI). Oxidative stress and inflammation may cause structural and electrical remodeling in the atria making these critical processes in the pathology of AF. In this study, we aimed to evaluate the association between total oxidative status (TOS), total antioxidative capacity (TAC) and high-sensitivity C-reactive protein (hs-CRP) in the development of AF in patients presenting with STEMI. This prospective cohort study consisted of 346 patients with STEMI. Serum TAC and TOS were assessed by Erel's method. Patients were divided into two groups: those with and those without AF. Predictors of AF were determined by multivariate regression analysis. In the present study, 9.5% of patients developed AF. In the patients with AF, plasma TOS and oxidative stress index (OSI) values were significantly higher and plasma TAC levels were significantly lower compared to those without AF (p = .003, p = .002, p < .0001, respectively). Multivariate regression analysis results showed that, female gender (Odds ratio [OR] = 3.07; 95% Confidence Interval [CI] = 1.26-7.47; p = .01), left atrial diameter (OR =1.28; 95% CI =1.12-1.47; p < .0001), hs-CRP (OR =1.02; 95% CI =1.00-1.03; p = .001) and OSI (OR =1.10; 95% CI =1.04-1.18; p = .001) were associated with the development of AF in patients presenting with STEMI. The main finding of this study is that oxidative stress and inflammation parameters were associated with the development of AF in patients presenting with STEMI. Other independent predictors of AF were female gender, left atrial diameter and hs-CRP.

Evaluation of the skeletal and dental effects in orthodontic patients with maxillary lateral incisor agenesis.

OBJECTIVE: The purpose of this study was to evaluate the transverse dimension of the dentoalveolar and skeletal widths in both unilateral (UMLIA) and bilateral (BMLIA) maxillary lateral incisor agenesis groups. MATERIALS AND METHODS: The study sample consisted of 59 patients (34 females and 25 males) divided into three groups as UMLIA group (16 patients; 14.94 ± 1.37 years), BMLIA group (21 patients; 14.46 ± 1.53 years) and control group (22 patients; 15.28 ± 1.70 years) without tooth agenesis. Transversal measurements (maxillary and mandibular intercanine, interpremolar, intermolar, intercanine alveolar, interpremolar alveolar, intermolar alveolar widths) were done on dental casts. Craniofacial skeletal measurements were done with posteroanterior cephalometric radiographs. Statistical testing was performed with the one-way variance analysis, Kruskal-Wallis and post hoc tests. RESULTS: UMLIA and BMLIA groups had statistically significantly narrower skeletal apical base of the maxilla, maxillary intercanine and intercanine alveolar widths compared with the control group (P < .05). Moreover, UMLIA and BMLIA groups had statistically significantly similar dental, alveolar and skeletal features (P > .05). CONCLUSIONS: The UMLIA and BMLIA groups showed statistically significantly smaller values for maxillary intercanine, maxillary intercanine alveolar and skeletal maxillary widths compared with the control group. CLINICAL SIGNIFICANCE: This study provides information the transverse dimension of the dental, alveolar and skeletal widths with maxillary lateral incisor agenesis patients. Knowledge of transverse dimension of the dental, alveolar and skeletal widths with maxillary lateral incisor agenesis patients is important for diagnosis and treatment planning.

Association between the use of renin-angiotensin system blockers and development of in-hospital atrial fibrillation in patients with ST-segment elevation myocardial infarction.

BACKGROUND AND AIM: Atrial fibrillation (AF) is the most common supraventricular arrhythmia following ST-segment elevation myocardial infarction (STEMI). We evaluated the association between use of previous angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers (renin-angiotensin system [RAS] blockers) and started RAS blockers after MI and development of AF in patients presenting with acute STEMI. MATERIALS AND METHODS: This retrospective study enrolled 1000 patients with acute STEMI who were admitted to the coronary care unit. Patients were divided into groups according to the use of RAS blockers before MI and development of AF rates was compared. Predictors of AF were determined by multiple logistic regression analysis. RESULTS: Of the 1000 patients presenting with STEMI, 247 received and 753 did not receive RAS blockers. The incidence of AF was 7.9%. The incidence of AF in patients receiving RAS blockers and did not receiving RAS blockers before MI were similar (5.7% vs. 8.6% respectively, P=0.13). On the other hand, AF rate was lower in patients in whom RAS blockers were administered during MI as compared to those in whom these agents were not administered (7.2% vs. 28.6%, P<0.001). Multiple regression analysis results showed that administration of RAS blockers or statins during hospitalization and left atrial diameter were associated with development of AF in patients with acute STEMI. CONCLUSIONS: Previous therapy with RAS blockers does not reduce the incidence of AF in STEMI. Administration of RAS blockers at the hospital may decrease the AF rate in STEMI.

The effects of good glycaemic control on left ventricular and coronary endothelial functions in patients with poorly controlled Type 2 diabetes mellitus.

OBJECTIVE: Diabetics are at risk for developing overt heart failure and subclinical left ventricular (LV) dysfunction. Also, impaired coronary flow reserve (CFR) reflecting coronary microvascular dysfunction is common in diabetics. However, no substantial data regarding the effects of good glycaemic control on subclinical LV dysfunction and CFR are available. CONTEXT: To investigate whether good glycaemic control had favourable effects on subclinical LV dysfunction and CFR. DESIGN: Prospective, open-label, follow-up study. PATIENTS: Diabetics (n = 202) were classified based on baseline HbA1C levels: patients with good (group 1) (<7·0%) and poor glycaemic control (≥7·0%). MEASUREMENTS: All patients underwent echocardiographic examination at baseline evaluation, and it was repeated at months 6 and 12. Based on HbA1C levels obtained at month 6, the patients with poor glycaemic control were divided into two groups: achieved (group 2) and not achieved good glycaemic control (group 3). RESULTS: The groups were comparable with respect to diastolic function parameters including left atrium diameter, mitral E/A, Sm , Em /Am , E/E' and Tei index, and these parameters did not significantly change at follow-up in the groups. At baseline, CFR was slightly higher in group 1 than in group 2 and group 3, but it did not reach statistically significant level. At follow-up, CFR remained unchanged in group 1 (P = 0·58) and group 3 (P = 0·86), but increased in group 2 (P = 0·02: month 6 vs baseline and P = 0·004: month 12 vs baseline). CONCLUSIONS: Diabetics with poor and good glycaemic control were comparable with respect to echocardiographic parameters reflecting subclinical LV dysfunction, and good glycaemic control did not affect these parameters. However, good glycaemic control improved CFR.

A Case Series of Obstructive Prosthetic Mitral Valve Thrombosis, Successfully Treated with Low-Dose, Slow Infusion Tissue-Type Plasminogen Activator.

BACKGROUND AND AIM OF THE STUDY: Prosthetic valve thrombosis (PVT) is a rare but serious complication of the prosthetic heart valve. Although recent guidelines generally recommend surgical treatment as the main option for patients with obstructive left-sided PVT, thrombolytic therapy (TT) may offer another attractive approach. There is also no consensus on the type, dose and route of administration of thrombolytic agents. The present study included a small series of patients with low-dose, slow infusion tissue-type plasminogen activator (tPA) to treat PVT in the mitral position. METHODS: Eight consecutive episodes of mitral PVT (one woman was pregnant) in seven patients were treated with low-dose (25 mg), slow infusion (within 6 h) tPA, if needed, with repeat sessions of TT (with the same protocol up to a total dose of 150 mg) until a satisfactory result was achieved. RESULTS: The cause of PVT was inadequate anticoagulation with warfarin or low-molecular-weight heparin in all patients on admission. A complete resolution of hemodynamic instability and echocardiographic abnormalities was observed in all cases, without mortality. In addition, there were no thromboembolic and major hemorrhagic complications in the case series. CONCLUSION: These findings suggest that low-dose, slow infusion tPA may be applicable to bileaflet mitral PVT in relatively stable patients, and may represent a therapeutic option to surgery.

Mean platelet volume is increased in infective endocarditis and decreases after treatment.

OBJECTIVES: The aim of this study was to assess the mean platelet volume (MPV), an indicator of platelet activation in patients with infective endocarditis. SUBJECTS AND METHODS: Twenty-nine patients with infective endocarditis and 29 healthy subjects were studied. Plasma MPV values in patients and control subjects were measured on admission and after 2 weeks of specific treatment of infective endocarditis. RESULTS: The MPV was significantly higher among patients with infective endocarditis when compared with the control group (9.86 ± 1.1 vs. 8.0 ± 1.0 fl, respectively; p < 0.01). The MPV values of patients with infective endocarditis decreased significantly after treatment from 9.86 ± 1.1 to 7.86 ± 1.0 fl (p < 0.01). Total platelet counts increased significantly after treatment from 193.4 ± 96.5 × 10(9) to 243.7 ± 92.4 × 10(9) (p = 0.04). CONCLUSION: MPV values were higher in patients with infective endocarditis and decreased significantly after treatment. Elevated MPV values indicate that patients with infective endocarditis have increased platelet activation and infective endocarditis treatment decreases this platelet activation by decreasing MPV.

Increased plasma neopterin and hs-CRP levels in patients with endemic fluorosis.

Although fluoride induced inflammatory reactions have been shown in animals and in vitro humans, there are few studies about fluoride induced inflammatory reactions in human beings at clinical setting. We aimed to measure the plasma neopterin, a marker of activation of the monocyte/macrophage system, and high sensitivity C-reactive protein (hs-CRP) levels in patients with endemic fluorosis to investigate the possible role of inflammatory processes (monocyte/macrophage activity) in the underlying pathophysiology of fluoride toxicity at clinical level. Plasma neopterin and hs-CRP levels were determined in endemic fluorosis patients and control subjects. Plasma neopterin levels were significantly higher among patients with endemic fluorosis when compared with control group (2.40 ± 0.66 vs. 1.63 ± 0.27 ng/mL respectively; p < 0.001) and plasma hs-CRP levels were also significantly higher among patients with endemic fluorosis when compared with control group (2.41 ± 1.23 vs. 1.93 ± 0.64 mg/L respectively; p < 0.001). Plasma neopterin levels were positively correlated with urine fluoride levels (r = 0.67, p < 0.001) and serum hs-CRP levels were positively correlated with urine fluoride levels (r = 0.36, p < 0.001). We have found that plasma neopterin and hs-CRP levels are increased in patients with endemic fluorosis. We have concluded that inflammation play an important role in the pathophysiology of fluoride toxicity in patients with endemic fluorosis.

Elevated carbohydrate antigen 125 levels in patients with aortic stenosis: relation to clinical severity and echocardiographic parameters.

OBJECTIVES: Carbohydrate antigen 125 (CA 125), known as a tumor marker for ovarian cancer, has been reported to increase in relation to disease severity in heart failure patients with systolic dysfunction. Aortic stenosis (AS) has a wide clinical spectrum that often includes heart failure symptoms. The purpose of the present study is to evaluate the serum levels of CA 125 in patients with AS and its relation to clinical severity and echocardiographic parameters. STUDY DESIGN: The study group consisted of 42 patients (20 males, 22 females, mean age 62.5 ± 14.9 years) with AS and 35 healthy controls (17 men, 18 women; mean age 59.0 ± 9.1 years). All patients and control subjects underwent chest X-ray and echocardiographic evaluation. We measured serum CA 125 values in patients with AS and control subjects. RESULTS: The median (interquartile range) CA 125 level was significantly higher among AS patients than in the control group in covariate analysis (9.4 [2.5-38.1] vs. 6.8 [4.4-13.9] U/ml respectively; p=0.001). Spearman correlation analysis in the whole group indicated that CA 125 was positively correlated with aortic mean gradient (p=0.007, r=0.30) and creatinine levels (p=0.02, r=0.26). CONCLUSION: We found that CA 125 levels were elevated in patients with AS and were correlated with mean gradient and creatinine levels.

Mean platelet volume is elevated in patients with myocardial infarction with normal coronary arteries, as in patients with myocardial infarction with obstructive coronary artery disease.

Although the majority of cases of acute myocardial infarction are caused by atherosclerotic coronary artery disease (CAD), it can also occur in people with normal coronary arteries. One of the possible mechanisms causing myocardial infarction with normal coronary arteries (MINC) is transient occlusion of the infarct-related artery owing to platelet hyperactivity and thrombosis. Mean platelet volume (MPV), an indicator of platelet activation, has been shown to be elevated in patients with unstable angina and myocardial infarction in the setting of obstructive CAD. However, the value of MPV in patients with MINC is not known. The aim of this study was to assess the MPV in patients with MINC. We retrospectively studied 47 patients with MINC, 63 patients with myocardial infarction resulting from single coronary artery disease (MISC) and 55 control subjects. MPV values were recorded in all study patients and control subjects. The MPV values of patients with MINC and MISC were significantly higher than those of the control group (9.1+/-1.8 and 9.4+/-1.0 versus 8.3+/-1.4 fl; p<0.05 and p<0.001, respectively). There were no significant differences in MPV values between the MINC and MISC groups. We show for the first time that MPV is significantly higher in patients with MINC compared with control subjects. Concurring with previous studies, we also show that MPV is significantly higher in patients with MISC compared to control subjects.

P-wave dispersion in patients with Guillain-Barré syndrome.

Cardiac autonomic dysfunction assessed by the presence of arrhythmia, by the methods, such as heart rate variability or blood pressure variability, and by the electrocardiographic abnormalities is common in Guillain-Barré syndrome (GBS). The goal of present study was to analyze the P-wave dispersion (PWD), which is the non-invasive marker of atrial arrhythmia, in GBS patients and to compare those with healthy individuals. Thirty-five patients with GBS (mean age 53.6 ± 15.5 years) and 35 healthy controls (mean age 49.2 ± 14.1 years) were included to this study. Demographic and clinical information of the patients with GBS were assessed retrospectively. A 12-lead surface electrocardiogram was acquired from all participants. Minimum and maximum P-wave duration and PWD were measured in the patients with GBS and healthy controls. Maximum P-wave duration and PWD were significantly longer, and minimum P-wave duration was significantly lower in the patients with GBS rather than the control group (p = 0.037, p < 0.001, p = 0.007, respectively). GBS disability scores were positively correlated with the maximum P-wave duration (p = 0.015, r = 0.406) and PWD (p = 0.001, r = 0.525). We found that PWD was significantly prolonged in GBS patients compared with the controls. The increased PWD which is cheap, quick, non-invasive and feasible electrocardiographic marker may be related to increased risk for atrial fibrillation in patients with GBS.

Gamma glutamyltransferase, inflammation and cardiovascular risk factors in isolated coronary artery ectasia.

INTRODUCTION AND OBJECTIVE: There are conflicting data on the prevalence of cardiovascular risk factors in coronary artery ectasia (CAE). It is unclear whether CAE is associated with high-sensitivity C-reactive protein (hs-CRP) and gamma glutamyltransferase (GGT). We therefore investigated major cardiovascular risk factors, serum GGT and hs-CRP levels in a large population of patients with CAE. METHODS: A total of 167 patients with isolated CAE and 150 controls with normal coronary arteries were selected from 10505 patients undergoing coronary angiography. Serum GGT and hs-CRP levels were evaluated in addition to cardiovascular risk factors including family history, obesity, smoking, diabetes, hypertension and hyperlipidemia. RESULTS: Hypertension and obesity were slightly more prevalent in CAE patients than in controls, whereas diabetes was slightly less frequent in CAE patients. Other risk factors were similar. Serum GGT (22 [17-42] vs. 16 [13-21] U/l, p=0.001) and hs-CRP (2.9 [1.9-3.6] vs. 1.4 [1.1-1.8] mg/l, p=0.001) levels were higher in CAE patients than in controls. The presence of CAE was independently associated with diabetes (OR: 0.44, 95% CI: 0.20-0.95, p=0.04), obesity (OR: 2.84, 95% CI: 1.07-7.56, p=0.04), GGT (OR: 1.08, 95% CI: 1.03-1.12, p=0.001) and hs-CRP levels (OR: 3.1, 95% CI: 2.1-4.6, p=0.001). In addition, GGT and hs-CRP levels were higher in diffuse and multivessel ectasia subgroups than focal and single-vessel ectasia subgroups (each p<0.05). CONCLUSIONS: Our findings show that CAE can be independently and positively associated with obesity, GGT and hs-CRP levels, but inversely with diabetes. Moreover, its severity may be related to GGT and hs-CRP levels.

Increased Mean Platelet Volume in Familial Hypercholesterolemia.

Familial hypercholesterolemia (FH) is a genetic disorder of lipoprotein metabolism and increases the risk of premature cardiovascular diseases. In patients with FH, platelet function may be activated; however, the extent of this activation and its etiology are unclear. We aimed to evaluate the mean platelet volume (MPV), a marker of platelet activation, in patients with FH. The study group consisted of 164 patients with FH and 160 control patients. Controls were matched for age, gender, hypertension, and smoking. The MPV was significantly higher in patients with FH than in controls (9.2 ± 0.4 vs 7.9 ± 0.6 fL, respectively; P < .001). Platelet count was significantly lower among patients with FH when compared to control patients (259 ± 51 vs 272 ± 56 × 10(3)/L, respectively; P = .03). In linear regression analysis, MPV was independently associated only with total cholesterol (ß = .6, 95% confidence interval: 0.004-0.008, P < .001). We have shown that MPV was increased in patients with FH and that it was independently associated with total cholesterol level.

The diagnostic significance of signal peptide-complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein-1 levels in pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is a common and potentially life-threatening disorder. Patients with PE often have nonspecific symptoms, and the diagnosis is often delayed. AIM: The aim of our study was to investigate the role of signal peptide-complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 (SCUBE1) used in the diagnosis of PE. METHODS: The study was designed prospectively. A total of 57 patients who were admitted to emergency service with clinically suspected PE were included in the study. The patients diagnosed with PE were defined as PE group (n = 32), and the patients with undetectable embolism on computerized tomographic pulmonary angiography were defined as non-PE group (n = 25). Twenty-five age- and sex-matched healthy cases were chosen for the study. Routine biochemical analysis, complete blood count, D-dimer, SCUBE1, and arterial blood gas analysis were performed early after admission. RESULTS: Mean SCUBE1 levels were higher in the PE group (0.90 ng/mL) than in the non-PE (0.38 ng/mL) and control groups (0.47 ng/mL) (P < 0.01). A cutoff point of 0.49 ng/mL for SCUBE1 indicated 100% sensitivity and 64% specificity in patients with PE. Mean D-dimer levels were not different between PE and non-PE groups (P = 0.591). A multivariable logistic regression analysis (with dichotomous PE groups as the response variable; age, gender, chest pain, syncope, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, D-dimer, neutrophil-lymphocytes ratio, and SCUBE1 variables as predictors) showed that the significant and independent predictors of PE diagnosis were SCUBE1 and chest pain. CONCLUSION: This study suggests that serum SCUBE1 measurement might be used as a diagnostic biomarker in PE.

Late perforation of anterior mitral leaflet after surgical resection of the subaortic membrane.

A 54-year-old woman who underwent surgical resection of the subaortic membrane 10 years earlier presented with new onset dyspnea. Cardiovascular examination revealed 3-4/6 pansystolic murmur at the apex. She was found to have severe mitral regurgitation (MR) with transthoracic echocardiography; 2D and real-time-3D transesophageal echocardiography demonstrated severe MR through anterior mitral leaflet perforation with precise localization. The patient was treated with surgery in which the perforated segment was closed by direct suture technique and discharged on postoperative 5th day. .

Increased mean platelet volume in hypertrophic cardiomyopathy.

Thromboembolic events may be seen in patients with hypertrophic cardiomyopathy (HCM). We investigated the mean platelet volume (MPV), an indicator of platelet activation in patients with HCM. This study included 112 patients with HCM, in which 40 were patients with hypertrophic obstructive cardiomyopathy (HOCM), and 106 were control participants. The MPV was significantly higher in patients with HCM than in controls (9.1 ± 0.3 vs 7.9 ± 0.3 fL, P = .01). In the subgroup analyses, MPV was also higher in patients with HOCM compared to those with hypertrophic nonobstructive cardiomyopathy (HNCM; 9.3 ± 0.3 vs 9.0 ± 0.2 fL, P = .01). Similarly, patients with HNCM had higher MPV values than controls (9.0 ± 0.2 vs 7.9 ± 0.3 fL, P = .01). The MPV was significantly and positively correlated with left ventricular outflow tract (LVOT) obstruction (r = .42, P = .001) and septal thickness (r =.62, P = .001). In linear regression analysis, MPV was independently associated only with septal thickness (ß = .07, 95% confidence interval: 0.04-0.09, P = .001). The MPV can be elevated in patients with HCM regardless of the obstruction of LVOT and may be associated with the severity of septal thickness.

Mean platelet volume may be elevated in mitral valve prolapse and associated with the severity of prolapse.

Thromboembolic events can be seen in patients with mitral valve prolapse (MVP). It is unclear whether platelet activation may contribute to these events in patients with MVP. Thus, we aimed to evaluate mean platelet volume (MPV) in patients with MVP and its association with the severity of MVP. This study included 312 patients with MVP and 240 control participants. Mean platelet volume was significantly higher in patients with MVP than in controls (8.9 ± 0.7 vs 7.9 ± 0.6 fL, P = .001). In linear regression analysis, MPV was independently associated with the degree of mitral regurgitation (ß = .23, 95% confidence interval (CI): 0.14-0.32, P = .001), maximal leaflet displacement (ß = .24, 95%CI: 0.17-0.31, P = .001), and mean thickness of the anterior (ß = .47, 95%CI: 0.27-0.61, P = .001) and posterior leaflets (ß = .22, 95%CI: 0.03-0.41, P = .02). Our findings show that MPV can be elevated in patients with MVP and may be independently associated with severity of mitral regurgitation, leaflet displacement, and thickness of the leaflets.