GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}.

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21} M_{⊙} and 66_{-18}^{+17} M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65 M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28} M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4} Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30} Gpc^{-3} yr^{-1}.

Assessment of atrial fibrillation and ventricular arrhythmia risk in patients with asthma by P wave/corrected QT interval dispersion.

OBJECTIVE: Although the relationship between obesity-asthma, obesity-atrial fibrillation (AF) and obesity-sudden cardiac death is clearly known, the risk of AF and ventricular arrhythmia has not been clearly determined in asthmatic patients. The aim of this study was to investigate whether AF, ventricular arrhythmia, and sudden cardiac death risk were increased in asthmatic patients using P wave dispersion (PWD) and corrected QT interval dispersion (CQTD). PATIENTS AND METHODS: The study was designed as a cross-sectional study. A total of 164 participants (88 patients with asthma and 76 healthy volunteers) were enrolled into the study. PWD and CQTD were measured and recorded in both groups. The statistical difference between the two groups was examined. RESULTS: PWD was higher in the asthma patients than in control subjects (31.53 ± 3.18 vs. 30.33 ± 3.53, p = 0.023). However, there was no statistically difference between the groups in terms of CQTD measurement (43.9 ± 1.84 vs. 43.63 ± 2.06, p = 0.385). In comparison between control group and asthma subgroups (mild, moderate and severe), there was a statistically significant difference among these four groups in terms of PWD (p = 0.017). Subgroup analyses showed that this difference was mainly due to patients with severe asthma. CONCLUSIONS: PWD value was elevated in asthmatic compared to the control group. The CQTD was not statistically significant between the groups. These results indicate that the risk of developing AF in asthmatic patients might be higher than in the normal population. Ventricular arrhythmia and sudden cardiac death risk may not be high in asthmatic patients.

Evaluation of pulmonary infections in solid organ transplant patients: 12 years of experience.

BACKGROUND: Recipients of solid organ transplants (SOTs) are at higher risk to develop pulmonary infections (PIs) owing to their immunocompromised state. Flexible bronchoscopy (FB) is frequently performed to diagnose nature of these infections. The aim of 12-year review was to evaluate the demographic characteristics of SOT recipients with PIs and to study diagnostic utility of FB in this group of patients. METHODS: Medical records of patients who underwent SOT as well as FB between 2000 and 2012 were retrospectively reviewed. Patients' demographics, type of transplantation, primary diagnoses, thoracic computed tomography (CT) findings, total blood count and chemistry, indication for FB, FB results, specimen culture results, and suspected and final diagnoses were all recorded. If the bronchoscopy findings altered medical management and produced improvement in PI, the procedure was considered diagnostic. RESULTS: Ninety of 998 liver, heart, or kidney transplant recipients underwent FB (73 renal, 16 liver, and 1 heart; mean age, 42.3 ± 12.1 years) during the study period. CT findings were as follows: Consolidation (49.4%), lymphadenopathy (3.4%), nodular infiltrates (5.6%), and cavitary lesion (1.1%). FB was unremarkable in 29, but showed increased secretions in 33 patients (36.7%), chronic mucosal changes in 9 (10%), edema in 7 (7.8%), mucosal plaque in 7 (7.8%), friable mucosa in 3 (3.3%), and endobronchial lesion in 2 (2.2%). A total of 29 bronchial washings (BW; 32.6%) and 10 bronchoalveolar lavages (BAL; 11.2%) were performed. PI was diagnosed in 82% of the patients (n = 73). In 32 patients (36%), micro-organism growth was observed on either BW or BAL. Mycobacterium tuberculosis was detected in 6 (6.7%), Staphylococcus aureus in 4 (4.4%), Moraxella catharralis in 4 (4.4%), Candida albicans in 6 (6.7%), Klebsiella pneumonia in 2 (2.2%), Escherichia coli in 2 (2.2%), Streptococcus pneumoni in 2 (2.2%), Stenotrofomonas maltofilia in 1 (1.1%), Aspergillus fumigatus in 4 (4.5%), and Pseudomonas aeruginosa in 1 (1.1%). Final diagnosis was established by FB (n = 33) with a diagnostic yield of 36%. No significant finding was observed between the type of the transplant and the culture results (P > .05). CONCLUSION: Suspected PI is the most common indication for FB in SOT recipients. It may identify the causative organism in >30% of patients. Tuberculosis was found to be the most frequent agent, which is not surprising from such an endemic area. Bacteria were more common than fungal or viral micro-organisms. FB should be considered in SOT recipients presenting with lung infiltrates and suspected to have PI.

Diagnostic utility of flexible bronchoscopy in recipients of solid organ transplants.

BACKGROUND: Solid organ transplant (SOT) recipients are prone to develop pulmonary complications (PC) due to their immunocompromised state. Flexible bronchoscopy (FB) is frequently performed to diagnose the nature of these complications. The aim of this study was to evaluate the diagnostic utility of FB in SOT recipients with suspected PC. METHOD: We examined the medical records of patients who underwent FB between 2000 and 2010; patients who received SOT were included patient demographics, transplantation type, primary diagnoses, thorax computed tomography results, total blood count and chemistries, immunosuppressant therapies, indication, results, specimen cultures, as well as suspected and final diagnoses were recorded. RESULTS: Among 1368 either liver or kidney transplant recipients 61 subjects including 49 male patients of overall mean age 42.8±12 years underwent FB. FB was performed for lung infiltrates (n=42), lung nodules (n=2), atelectasis (n=1), bronchopleural fistula (n=1), stridor (n=1), mediastinal lymphadenopathy (n=2), pleural effusion (n=1), fever (n=9), and/or hemoptysis (n=2). FB was unremarkable in 17. Other findings were as follows: increased secretions (n=24), chronic mucosal changes (n=7), endobronchial lesion (n=1), edematous mucosa (n=3), submucosal narrowing (n=1), necrotic plaque (n=2), hemorrhage (n=2), tracheal stenosis (n=1), and/or friable mucosa (n=3). We performed bronchial washings (n=56) and/or bronchoalveolar lavage (n=5). In 24 patients the microorganisms were Mycobacterium tuberculosis, Staphylococcus aureus, Moraxella catharralis, Candida albicans, Klebsiella pneumonia, Escherichia coli, Streptococcus pneumonia, Stenotrofomonas maltofilia, Aspergillus fumigatus, and Pseudomonas aerigunosa. In 34 patients a final diagnosis was established using FB (diagnostic yield, 55.7%). Thirty-one patients had received tacrolimus (10.5±5.3 ng/ng/mL); 22 cyclosporine (187.1±79.3 ng/mL); and 8, sirolimus (6.2±2.2 ng/mL). No significant difference was observed between high versus low drug levels and the culture results (P>.05). CONCLUSION: Suspected pulmonary infection is the most common indication for FB in SOT recipients. It may identify the causative organism in more than 30% of patients and should be considered in the presence of a lung infection.

Pulmonary complications in renal recipients after transplantation.

BACKGROUND: Renal transplantation is the most common type of solid organ transplantation. Recipients are susceptible to a variety of pulmonary complications, in particular during intense immunosuppression therapy. OBJECTIVE: To evaluate pulmonary complications during the first year after renal transplantation. MATERIALS AND METHODS: Medical records were reviewed retrospectively for all patients who underwent renal transplantation between 2007 and 2010. Data pertinent to pulmonary complications were obtained including patient demographics, findings at chest radiography and pulmonary function testing, concentrations of C-reactive protein and albumin, and white blood cell count. RESULTS: The study included 136 patients (71.3% men), with mean (SD) age of 36.3 (12.2) years. The most frequently prescribed immunosuppression therapy included prednisolone plus cyclosporine, tacrolimus, or rapamycin. Fifteen patients developed complications during the first year after surgery including respiratory infections in 12 (80%), namely, bacterial pneumonia in 10 (66.6%), and tuberculosis (caused by Mycobacterium tuberculosis) in 2 (33.3%). Pneumonia developed within the first 5 months after transplantation in 6 patients, and tuberculosis after the third month. Microbiologic agents were detected in 3 of the 6 patients (20%), and empyema, postoperative atelectasis, and pulmonary embolism, respectively, in the other 3 patients. No association was observed between complications and baseline pulmonary function test results. C-reactive protein concentration was significantly increased in patients with pulmonary complications. No invasive procedures were performed to diagnose complications, all of which resolved with appropriate treatment. CONCLUSION: Pulmonary infections are a primary complication in renal transplant recipients, and are observed most frequently in the first 6 months after surgery. Immunosuppression therapy is the most likely cause of these complications, and rigorous monitoring of drug concentrations is essential. An invasive diagnostic approach may not always be necessary to determine the early specific therapy.

Integration of GARD Turkey national program with other non-communicable diseases plans in Turkey.

For the prevention and control of non-communicable diseases (NCD), an action plan on NCDs is intended to support coordinated, comprehensive and integrated implementation of strategies and evidence-based interventions across individual diseases and risk factors, especially at the national and regional levels by World Health Organization (WHO). The Global Alliance against Chronic Respiratory Diseases (GARD) is making every attempt to align with WHO's non-communicable diseases action plan. GARD activities have been commenced in over 40 countries and in 11 countries an integrated NCD action plan is being prepared or has already been initiated. This integrated approach of GARD has also targeted to GARD Turkey project. The Turkish Ministry of Health has decided to apply this national control program in conformity with other NCD action plans. This article is intended to summarize these integration efforts of GARD Turkey (the National Control Program on Chronic Airway Diseases) with other NCD national programs.

The WHO global alliance against chronic respiratory diseases in Turkey (GARD Turkey).

In order to prevent and control non-communicable diseases (NCDs), the 61st World Health Assembly has endorsed an NCD action plan (WHA resolution 61.14). A package for essential NCDs including chronic respiratory diseases (CRDs) has also been developed. The Global Alliance against Chronic Respiratory Diseases (GARD) is a new but rapidly developing voluntary alliance that is assisting World Health Organization (WHO) in the task of addressing NCDs at country level. The GARD approach was initiated in 2006. GARD Turkey is the first comprehensive programme developed by a government with all stakeholders of the country. This paper provides a summary of indicators of the prevalence and severity of chronic respiratory diseases in Turkey and the formation of GARD Turkey.

Pulmonary hypertension in patients with end-stage renal disease undergoing renal transplantation.

INTRODUCTION: Pulmonary hypertension (PHT) has been reported to occur in a considerable proportion of patients with end-stage renal disease (ESRD). It is a progressive condition of the pulmonary circulation that poses prognostic importance. In this study, we sought to investigate the prevalence and the predictors of PHT among ESRD patients undergoing renal transplantation. PATIENTS AND METHODS: We retrospectively evaluated the records, clinical and demographic data as well as laboratory results of 500 adult patients who underwent renal transplantation at our institution. A comprehensive Doppler echocardiographic examination was performed in all patients as part of the preoperative assessment. Systolic pulmonary artery pressure (SPAP) was calculated using Bernoulli equation; a value of >30 mm Hg was accepted as PHT. RESULTS: The mean age of the study population was 31.6 +/- 10.2 years. The mean duration of dialysis was 40 months; 432 patients (86.4%) were on hemodialysis (HD) and 68 (13.6%) on peritoneal dialysis (PD). PHT was detected in 85 (17%) patients with a mean SPAP of 46.7 +/- 8.7 mm Hg (range = 35-75 mm Hg). The mean age, sex, and laboratory variables were similar between patients with versus without PHT (P > .05 for all). The mean duration of dialysis therapy was longer in the PHT group than those subjects with normal SPAP (50.8 vs 38.5 months; P = .008). Concerning the type of dialysis, the ratio of patients having PHT was higher in the HD compared with the PD group (18.8% vs 5.9%; P = .008). The prevalence of chronic obstructive pulmonary artery disease, asthma, smoking, hypertension, and diabetes mellitus did not differ between patients with versus without PHT (P > .05 for all). CONCLUSION: The findings of this study revealed that PHT was a common clinical condition among patients with ESRD evaluated for renal transplantation. The time on renal replacement therapy particularly HD as the treatment was associated with greater prevalences. Since it may be of prognostic importance in patients undergoing renal transplantation, a careful preoperative assessment including a comprehensive Doppler echocardiographic examination is needed to identify PHT.

The effect of pretreatment with renin-angiotensin-aldosterone system blockers on cardioversion success and acute recurrence of atrial fibrillation.

BACKGROUND: Renin-angiotensin-aldosterone system (RAS) may be activated during atrial fibrillation (AF). It is unclear whether RAS inhibition may facilitate cardioversion from AF and may prevent acute recurrence of AF (ARAF). We thus investigated the effect of pretreatment with RAS blockers on cardioversion success and ARAF in patients with AF scheduled for elective cardioversion. METHODS: This observational study included 356 patients with AF undergoing elective pharmacological or electrical cardioversion. Of these patients, 135 were not included based on exclusion criteria and the remaining 221 patients were divided into RAS group (n = 116, 69 male) or non-RAS group (n = 105, 58 male) based on precardioversion use of any RAS blocker. RESULTS: Hypertension, coronary heart disease and heart failure were more frequent in the RAS group. Cardioversion from AF was more successful in the RAS group than in the non-RAS group (%92 vs. %82, p = 0.026). The rate of ARAF was lower in RAS group compared with that in non-RAS group (17% vs. 31%, p = 0.026). In multivariate analysis, pretreatment with RAS blockers in addition to shock number and enlarged left atrium, independently predicted ARAF (OR: 0.33, 95% CI: 0.15-0.75, p = 0.008). Independent predictors of cardioversion success were shock number and left atrial dilatation, but not use of RAS blocker. CONCLUSION: Precardioversion use of RAS blockers may reduce ARAF following successful cardioversion of AF, but did not improve electrical cardioversion.

Bloodstream infections in a medical-surgical intensive care unit: incidence, aetiology, antimicrobial resistance patterns of Gram-positive and Gram-negative bacteria.

In the present study, the incidence and antimicrobial resistance patterns of the microorganisms that caused bloodstream infections (BSIs) in a medical-surgical intensive care unit during the years 2005-2007 were determined. The mean BSI incidence density was 6.56 per 1000 patient-days. The incidence density increased linearly during the study period (from 3.57 to 9.60 per 1000 patient-days). Staphylococcus aureus was most frequently isolated (47.3%), followed by Enterococcus spp. (10.8%) and Candida spp. (10.1%). There was a high rate of resistance to several of the prescribed antimicrobials among the bacteria isolated from patients with BSIs.

Pleural effusion in long-term hemodialysis patients.

As a consequence of the expanded use of long-term hemodialysis and extended life spans, complications of chronic renal failure are encountered with an increased frequency among uremic patients. Such patients may develop many thoracic and extrathoracic problems--most frequently uremic pleuritis and pericarditis, uremic pneumonia, infection, and metastatic pulmonary calcification. We retrospectively analyzed the medical records of 257 patients who had received long-term hemodialysis between 1990 and 2006 to better understand the incidence, causes, and clinical features of pleural effusions in this population. The incidence of pleural effusion in hospitalized patients receiving long-term hemodialysis was 20.2% (n=52; mean age, 55.83 +/- 16.56 years; male-to-female ratio, approximately 3:2). Pleural effusion resulted from hypervolemia in 61.5% and was bilateral in 68.8% of patients. Unilateral effusion was present in 25 of 52 (48%) patients. The most frequent causes of unilateral effusion were hypervolemia (n=9) and parapneumonic effusion (n=5). Thoracenteses were performed in 14 of the 52 patients in the study group. Of thoracenteses performed, 64.3% of the patients had transudative pleural effusion and 35.7% had exudative effusion. Transudative pleural effusion resulted from hypervolemia in 66.7% and heart failure in 22.2%. Of the patients with transudative effusion, 85.7% were bilateral. The most frequent cause of exudative pleural effusion was uremic pleuritis, which occurred in 40% of the patients. The most common symptom was dyspnea, which occurred in 53.8% of patients. In conclusion, pleural effusions are common in patients receiving chronic hemodialysis. Thoracentesis may be performed in patients with unilateral pleural effusion. Since hypervolemia was the most common cause of pleural effusion, this complication should not be considered an obstacle in renal transplant recipients.

Iodine status, thyroid function, thyroid volume and thyroid autoimmunity in patients with type 1 diabetes mellitus in an iodine-replete area.

OBJECTIVE: To analyze the prevalence and clinical significance of thyroid autoimmunity, thyroid volume and iodine status in patients with type 1 diabetes mellitus compared with age and sex matched healthy controls, in an iodine-deficiency improved area. METHOD: Fifty-eight patients with type 1 DM, 30 female and 28 male, who attended the pediatric endocrinology clinic of Karadeniz Technical University Hospital were included into the study. They were compared with 58 healthy children matched for sex and age. Routine thyroid function parameters, thyroid autoantibodies (TPOAb, TGAb and TRAb) and urinary iodine excretion were measured and thyroid volume was determined by ultrasonography (US). RESULTS: Twenty-six patients (44.8%) in diabetic patients and 20 subjects (34.5%) in the control group had thyroid autoantibody positivity. TPOAb and TGAb positivity were significantly high in diabetic patients (P=0.01 and P=0.032, respectively). Thyroid US revealed a thyroid volume of 6.6+/-3.5 ml (median 6.4 ml, range 1.117.2 ml) in the diabetic patients compared with 3.7+/-2 ml (median 3.1 ml, range 0.8-8.6 ml) in the control group (P=0.0001). Median urinary iodine levels of both groups were clearly above the threshold level for iodine deficiency, but 26 patients with type 1 DM (44.8%) and 16 controls (27.5%) had urinary iodine excretion below 100 microg/L, and 21 (36.2%) of diabetic patients and two subjects (3.4%) of the control group were consistent with severe iodine deficiency. No significant differences were noted in diabetic patients in terms of age, duration and metabolic control of the disease and thyroid volume when compared according to the autoantibody presence. Additionally, there were no significant differences between the iodine deficient and iodine sufficient diabetic patients in terms of age, sex, duration of disease, HbA1c, thyroid hormones and thyroid volumes. Thyroid autoimmunity was lower in patients with iodine deficiency (38.4% vs. 50%), but not statistically significant. CONCLUSION: We found that type 1 DM patients had larger thyroid volume compared with healthy control groups, and a large portion of them had the markers of autoimmune thyroid disease and iodine deficiency. Surprisingly, we found that a large portion of the healthy children had TRAb positivity. We proposed that TRAb must be considered in community surveys or prevalence studies of autoimmune thyroid disorders in iodine-replete areas. Additionally, prospective longitudinal studies are needed to determine the clinical significance of TRAb positivity in diabetic patients.

Acute interstitial pneumopathy associated with docetaxel hypersensitivity.

BACKGROUND: Acute pulmonary toxicity in cancer patients treated with docetaxel has been reported in previous phase II studies and case reports. Unlike transient pulmonary infiltrates, it is demonstrated that docetaxel-induced interstitial pneumopathy is a severe clinical condition that generally leads to respiratory failure. CASE REPORT: We report a patient with breast cancer who received 2 cycles of docetaxel in 3-week intervals and developed respiratory failure. The clinical, pathologic, and radiographic data supported pulmonary toxicity caused by a hypersensitivity reaction to docetaxel as the most likely etiology. The patient developed the same symptoms and radiological findings after 1 cycle of paclitaxel administration. Unlike other more severe examples in the literature, this patient's condition did not require mechanical ventilation, and she recovered after corticosteroid treatment. CONCLUSION: The present case raises the possibility that taxanes, as a group of chemotherapeutic agents, may cause the same type of adverse reaction in the pulmonary parenchyma. The authors recommend that any patient who develops a taxane-induced pulmonary toxic reaction, not be rechallenged or treated with another agent of the same class.

Effect of pulse steroid therapy in a patient with Langerhans' cell histiocytosis.

Langerhans' cell histiocytosis (LCH) is a condition in which granulomas form in various tissues through the accumulation of abnormal histiocytes (Langerhans' cells), granulocytes and lymphocytes. An important distinction between LCH and primary pulmonary histiocytosis (PPH) is that smoking cessation is known to often lead to spontaneous improvement in PPH patients, while this has not been demonstrated in patients with multisystem LCH. In this case report, we describe the case of a 20-year-old man who presented with cough and palpably enlarged lymph nodes in his neck. An inguinal lymph node biopsy led to the diagnosis of multisystem LCH in the lungs, the cervical, intra-abdominal, and inguinal lymph nodes and the spleen. The patient was a smoker, and had averaged 30 cigarettes per day for 7 years. To address the multisystem involvement, intravenous pulse steroid therapy was administered (30-40 mg/kg daily) in two 3-day treatment periods separated by 3-4 weeks. The patient was also advised to stop smoking, and did so. Serial follow-up examinations confirmed an objective improvement with complete remission. The patient was still healthy at 18 months post-treatment, reflecting a dramatic and positive response to pulse steroid therapy. This encouraging result makes this case an important one to highlight.