Predictive value of fibrinogen-to-albumin ratio in acute coronary syndrome.

BACKGROUND: We aimed to investigate the predictive value of the fibrinogen-to-albumin ratio (FAR) regarding the development of major cardiovascular events (MACE) in patients treated with percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). METHODS: This was a prospective, observational cohort study that included 261 consecutive patients who were treated with PCI. The patients were grouped according to the occurrence of MACE during the follow-up period. RESULTS: During follow-up, MACE occurred in 68 (26%) patients. The FAR was independently predictive of MACE (HR: 1.017, 95% CI: 1.010-1.024, p < 0.001). In addition, left ventricular ejection fraction (LVEF) and a diagnosis of ST-segment elevation myocardial infarction (STEMI) were independent predictors of MACE. The area under the curve (AUC) of the multivariable model, including LVEF and diagnosis of STEMI, was 0.707 (95% CI: 0.631-0.782, p < 0.001). When the FAR was added to the multivariable model, the AUC was 0.770 (95% CI: 0.702-0.838, z = 2.820, difference p = 0.0048). CONCLUSION: The FAR could be used for the prediction of MACE in patients with ACS who have undergone PCI.

The effect of bilirubin on long-term mortality in patients with chronic total coronary occlusion.

AIM: We intended to investigate the association of bilirubin with total mortality in patients with chronic total coronary occlusion (CTO). METHODS: We included 172 patients who underwent coronary angiography due to stable angina pectoris and had CTO. We checked the viability of patients after 9 years of follow-up. RESULTS: Direct bilirubin levels were significantly lower in the non-viable group. We revealed age (OR = 1.045, 95% C.I: 1.009‒1.083; p = 0.015) and direct bilirubin concentrations (OR = 0.029, 95% C.I: 0.002‒0.435; p = 0.029) as independent predictors of mortality. Direct bilirubin value of > 0.2 mg/dL was associated with decreased mortality with a sensitivity of 85 %, and a specificity of 46 %. CONCLUSION: Serum direct bilirubin concentrations independently predict total mortality in patients with chronic total occlusion over 9 years of follow-up (Tab. 1, Fig. 2, Ref. 23).

Relationship of osteoprotegerin to pulse wave velocity and carotid intima-media thickness in rheumatoid arthritis patients.

OBJECTIVE: Osteoprotegerin (OPG) is considered an important biomarker in cardiovascular (CV) disease. CV disease is the most common cause of mortality in patients with rheumatoid arthritis (RA), a consequence of accelerated atherosclerosis. The present study aimed to evaluate the relationship of serum OPG levels to arterial stiffness, carotid intima-media thickness (CIMT), and clinical and laboratory indices in RA patients. PATIENTS AND METHODS: Included in the study were 68 RA patients with no history or signs of CV disease and 48 healthy subjects Disease activity was assessed by the 28-joint disease activity score (DAS28) in RA patients. Serum OPG level was measured using enzyme-linked immunosorbent assay (ELISA). Carotid femoral pulse wave velocity (PWV) was measured as an index of arterial stiffness and CIMT was evaluated by carotid ultrasonography. RESULTS: The mean serum OPG level was significantly higher in RA patients than controls (p < 0.001). Mean PWV and CIMT were also significantly increased in RA patients compared to controls (both p < 0.001). In RA patients, serum OPG level was significantly correlated with PWV and CIMT, as well as rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody; but not with DAS28, high-sensitivity C-reactive protein (hsCRP), or erythrocyte sedimentation rate. CONCLUSION: Serum OPG levels were increased and correlated with CIMT and PWV in RA patients. In addition to PWV and CIMT, OPG may be a useful biomarker for CV risk management in RA patients.

Comorbid diseases in aspirin-exacerbated respiratory disease, and asthma.

BACKGROUND: Asthma, persistent rhinosinusitis, and/or nasal polyposis accompanying non-steroidal anti-inflammatory drug (NSAID) intolerance is defined as aspirin-exacerbated respiratory disease (AERD). Although the literature includes considerable data on comorbidities in asthma, data on comorbidities in AERD have not been previously published. OBJECTIVE: This study aimed to determine the prevalence of comorbidities in AERD and compare the findings to those in asthmatic patients. MATERIALS AND METHODS: The records for 330 AERD patients that presented to our allergy clinic were reviewed. Patients with urticaria/angio-oedema type reactions to NSAIDs were included in the pseudo Samter's group (n=83) and 338 randomly selected NSAID-tolerant asthma patients constituted the control group. RESULTS: Gender, age at presentation, age at onset of asthma, and follow-up periods were similar in all groups. Hypertension (P=0.035), diabetes mellitus (P=0.323), gastro-oesophageal reflux (P<0.001), psychological disorders (P=0.099), obesity (P=0.003), and hyperlipidaemia (P=0.002) were significantly more prevalent in the asthma group. Interestingly, coronary artery disease (CAD) and congestive heart failure (CHF) were more common in the AERD group (P=0.178); CAD/CHF was associated with AERD (OR: 4.5; 95% CI: 1.206-16.93). CONCLUSION: AERD and asthma are associated with several comorbidities. Even though systemic steroid dependency and severe asthma were significantly more common in the AERD group, comorbidities occurred more frequently in the asthma group. Additional longitudinal studies are needed to more clearly discern if the risk of CAD/CHF is increased in AERD.

Aspirin 300 mg/day is effective for treating aspirin-exacerbated respiratory disease.

BACKGROUND: Aspirin desensitization (AD) treatment at doses of up to 1300 mg/day improves outcomes in aspirin-exacerbated respiratory disease (AERD). The aim of this study was to investigate the efficacy of aspirin 300 mg/day in the treatment of patients with AERD. METHODS: The study included 40 patients diagnosed in our clinic as AERD that were desensitized and treated with aspirin 300 mg/day between December 2005 and December 2012. Changes from the baseline status were analyzed at 1 year and at 3 years of follow-up. RESULTS: Of the 40 patients included, 24 (60%) were female and median (interquartile range [IQR]) age was 45 (40-51) years. Median (IQR) duration of AD was 31.5 (10.5-48.5) months. In total, 29 patients continued treatment for at least 1 year and 18 patients for at least 3 years. The annual rate of use of systemic corticosteroid regimens, episodes of sinusitis, and surgery was significantly lower both at 1 year (P = 0.002, P = 0.01, and P < 0.001, respectively) and at 3 years (P = 0.001, P = 0.03, and P = 0.002, respectively). Significant improvement was observed in the nasal congestion score (P = 0.01) and sense of smell score (P = 0.05) at 1 year and in the postnasal drainage score (P = 0.01) at 3 years. CONCLUSION: Daily treatment with aspirin 300 mg had beneficial effects in patients with AERD, especially for the control of upper airway disease.

Immediate-type hypersensitivity reactions to proton pump inhibitors: usefulness of skin tests in the diagnosis and assessment of cross-reactivity.

BACKGROUND: Data are limited about the value of skin tests in the diagnosis of proton pump inhibitor (PPI)-induced hypersensitivity reactions and the cross-reactivity between PPIs. We aimed to assess the role of skin testing in the diagnosis of PPI-related immediate hypersensitivity reactions and the cross-reactivity patterns among PPIs. METHODS: The study was designed in a prospective, national, multicentre nature. Sixty-five patients with a suggestive history of a PPI-induced immediate hypersensitivity reaction and 30 control subjects were included. Standardized skin prick and intradermal tests were carried out with a panel of PPIs. Single-blind, placebo-controlled oral provocation tests (OPTs) with the PPIs other than the culprit PPI that displayed negative results in skin tests (n = 61) and diagnostic OPTs with the suspected PPI (n = 12) were performed. RESULTS: The suspected PPIs were lansoprazole (n = 52), esomeprazole (n = 11), pantoprazole (n = 9), rabeprazole (n = 2), and omeprazole (n = 1). The sensitivity, specificity, and negative and positive predictive values of the skin tests with PPIs were 58.8%, 100%, 70.8%, and 100%, respectively. Fifteen of the 31 patients with a hypersensitivity reaction to lansoprazole had a positive OPT or skin test result with at least one of the alternative PPIs (8/52 pantoprazole, 6/52 omeprazole, 5/52 esomeprazole, 3/52 rabeprazole). CONCLUSION: Considering the high specificity, skin testing seems to be a useful method for the diagnosis of immediate-type hypersensitivity reactions to PPIs and for the evaluation of cross-reactivity among PPIs. However, OPT should be performed in case of negativity on skin tests.

Comparision of inflammatory biomarkers for detection of coronary stenosis in patients with stable coronary artery disease.

BACKGROUND: The objective of the current study was to evaluate the role of various inflammatory biomarkers in detection of coronary stenosis in patients with stable coronary artery disease (CAD) and healthy people. METHODS: A total of 111 patients with stable coronary artery disease, and 66 healthy subjects were enrolled in the study. Serum levels of lipoprotein-associated-phospholipase A2 (Lp-PLA2), high-sensitivity C-reactive protein (hs-CRP), and myeloperoxidase (MPO) were measured to compare patient and control groups. RESULTS: Baseline characteristics were similar between healthy and patient groups, with the exception of age. ANCOVA and log-transformed data of inflammatory biomarkers revealed that, Lp-PLA2 (p < 0.001) and hs-CRP (p < 0.05) levels in all patient groups were significantly higher than in the control group. Conversely, there was no significant difference in MPO levels among groups. CONCLUSIONS: In stable CAD patients, serum Lp-PLA2 levels are more compatible than hs-CRP and MPO levels in the detection of coronary stenosis.      

Aortic valve sclerosis is a high predictive marker of systemic endothelial dysfunction in hypertensive patients.

BACKGROUND: Aortic valve sclerosis (AVS) is closely related to hypertension and is an important predictor of coronary artery disease as well as cardiovascular morbidity and mortality. However, the mechanisms causing AVS have not yet been clarified. Therefore, we planned to investigate the influence of atherosclerosis-related risk factors including C-reactive protein (CRP), epicardial adipose tissue (EAT), carotid intima-media thickness (CIMT), pulse wave velocity (PWV), left ventricular hypertrophy, and the conventional risk parameters as well as endothelial dysfunction in untreated hypertensive patients. METHODS AND RESULTS: Our study was cross-sectional and observational, and included 107 consecutive untreated hypertensive patients. All patients underwent vascular evaluation by CIMT, PWV, flow-mediated dilation (FMD%), as well as echocardiographic examinations. Age (OR = 1.180, p < 0.001), male sex (OR = 3.056, p = 0.019), waist circumference (OR = 1.082, p = 0.004), EAT (OR = 1.419, p = 0.001), smoking status (OR = 3.161, p = 0.014), FMD% (OR = 0.649, p < 0.001), mean CIMT (OR = 2.481, P < 0.001), and carotid plaque (OR = 4.692, P = 0.001) were associated with AVS in univariate analyses. Multivariate analyses revealed only age (OR = 1.144, P = 0.006) and FMD% (OR = 0.691, 0.001) as independent predictors of AVS. The presence of AVS had a high positive predictive value (100 %) but a low negative predictive value (51 %) for endothelial dysfunction (FMD < 12 %) in hypertensive patients. CONCLUSION: Our study supports the theory that systemic endothelial dysfunction has an initial and independent effect on AVS pathogenesis. Moreover, we demonstrated that the presence of AVS in patients with hypertension predicts endothelial dysfunction, with a high positive predictive value. Thus, AVS in hypertensive patients may urge clinicians toward aggressive risk factor modification and intensive treatment.

Relationship between fragmented QRS complexes and left ventricular systolic and diastolic functions.

BACKGROUND: Fragmented QRS complexes (fQRS) have been associated with increased morbidity and mortality, sudden cardiac death, and recurrent cardiovascular events. The association between left ventricular systolic and diastolic functions and presence of fragmented QRS has not been comprehensively studied to date. We tested the hypothesis that the presence of fragmented QRS is associated with left ventricular systolic and diastolic dysfunction. METHODS: The study included 259 patients who were consecutively admitted to our outpatient clinic for cardiovascular risk factor management. Extensive echocardiographic parameters were obtained from all patients and these were compared with the presence and number of fQRS. RESULTS: Patients with fQRS were of older age (58 ± 12 vs. 55 ± 13 years, p = 0.03) and had prolonged QRS time (105 ± 12 vs. 93 ± 10 ms, p < 0.001) and a higher rate of Q waves on ECG (36% vs. 11%, p < 0.001). In addition, they had worse systolic (lower LVEF%, 44 ± 17 vs. 61 ± 12, p < 0.001) and diastolic functions (DT, 177 ± 77 vs. 211 ± 59 ms, p < 0.001; IVRT, 81 ± 27 vs. 92 ± 22 ms, p = 0.001; Em, 9 ± 4 vs. 10 ± 4 cm/s, p = 0.008; E/Em ratio, 11 ± 5 vs. 8 ± 4, p < 0.001) in comparison to patients with nonfragmented QRS. There was a significant negative correlation between the number of fQRS and left ventricle systolic functions (for LVEF%, r = - 0.595, p < 0.001). After adjustment for age and gender, the number of fQRS remained significantly negatively associated with left ventricular systolic and diastolic functions. CONCLUSION: We found that fQRS is related to left ventricular systolic dysfunction and diastolic dysfunction. fQRS, which may be the result of myocardial ischemia or scar on myocardial electrical parameters at the cellular level, may represent inadequate systolic and diastolic functions.

Increased serum resistin levels in patients with coronary slow-flow phenomenon.

BACKGROUND: Slow coronary flow (SCF) is an angiographic finding characterized by delayed opacification of the epicardial coronary arteries without obstructive coronary disease. Resistin, an adipocytokine, plays a major role besides low-grade inflammation in atherosclerotic vascular processes and may be of importance in other coronary pathologies such as SCF. METHODS: The present study was cross-sectional and observational, consisting of 70 individuals who underwent coronary angiography and had angiographically normal coronary arteries of varying coronary flow rates. The study included 50 patients with isolated SCF and 20 control participants with normal coronary flow (NCF). RESULTS: There were no statistically significant differences between the SCF and NCF groups with respect to age, gender, presence of hypertension or diabetes mellitus, and smoking habit, except for increased creatinine levels (p = 0.014). The serum resistin level was significantly higher in the SCF group than in the NCF group (8.4 ± 7.2 vs. 5.4 ± 2.6 ng/ml, p = 0.014). Ln-transformed resistin levels correlated positively with left anterior descending (LAD) coronary artery TIMI frame count (TFC) (r = 0.408, p < 0.001) as well as with glucose (r = 0.340, p = 0.004), creatinine (r = 0.248, p = 0.044), and C-reactive protein (CRP; r = 0.283, p = 0.023) levels, and negatively with LAD coronary flow velocity (r = - 0.314, p = 0.009). When multivariate analyses were performed, in linear regression analysis, ln-resistin was associated with a longer TFC [beta (standardized regression coefficient): 0.404, p = 0.001] and lower coronary flow velocity (beta: - 0.280, p = 0.035); in logistic regression analysis, ln-resistin was an independent predictor of the presence of SCF (OR: 6.692, 65 %CI: 1.117-40.1, p = 0.037). CONCLUSION: We demonstrated, for the first time, a significant increase in serum resistin levels in patients with SCF compared to subjects with NCF. We believe that further studies are needed to clarify the role of resistin in patients with SCF.

Elevated serum YKL-40 level predicts myocardial reperfusion and in-hospital MACE in patients with STEMI.

BACKGROUND: Macrophages in atherosclerotic plaques secrete YKL-40, a new biomarker of acute and chronic inflammation in patients with stable CAD. We hypothesized that YKL-40 may be a specific marker reflecting the burden of localized inflammation in myocardium and a predictor in patients with STEMI. In this study, we investigated the relationship of YKL-40 to in-hospital major adverse cardiac events (MACE), reperfusion parameters and its predictors in patients with STEMI. METHODS: In total, 80 patients with STEMI and no history of prior coronary artery disease (CAD), who underwent primary percutaneous coronary intervention (p-PCI), were enrolled consecutively. In addition, 30 patients with normal coronary arteries (NCA) were enrolled as a control group. Cardiac biomarker levels including creatinine kinase-MB fraction (CK-MB), troponin-I, admission glucose and inflammatory markers including leukocytes and YKL-40 levels were measured as admission values. RESULTS: In our study, YKL-40 levels correlated to high-sensitivity CRP levels (r = 0.333, p = 0.003), TIMI risk score (r = 0.445, p < 0.001), age (r = 0.477, p < 0.001), pain to balloon time (r = 0.432, p < 0.001), leukocyte and neutrophil count (r = 0.386, p < 0.001 and r = 0.430, p < 0.001, respectively), hemoglobin (r = - 0.345, p = 0.002), admission and fasting blood glucose (r = 0.388, p < 0.001 and r = 0.427, p < 0.001), creatinine levels (r = 0.395, p < 0.001) and myocardial blush grade (r = - 0.334, p = 0.004). When the patients were divided into two groups determined by presence or absence of MACE, the patients with MACE had significantly higher levels of YKL-40 in comparison to the patients without MACE and the control group (194 ± 104, 114 ± 61 and 110 ± 53 µg/L, p < 0.001, respectively). In multivariate logistic regression analysis in STEMI patients, only YKL-40 level (OR: 1.011, 95%CI: 1.002-1.019, p = 0.011) and leukocyte count (OR: 1.264, 95%CI: 1.037-1.540, p = 0.020) were the independent predictors for MACE. Sensitivity and specificity of YKL-40 to predict MACE, when 125 µg/l was accepted as a cut-off value, were 84% and 70%, respectively. CONCLUSION: We found that serum YKL-40 is related to older age, increased admission glucose levels, leukocyte counts and decreased hemoglobin levels; YKL-40 level and leukocyte count independently predicted MACE.

Recurrent parotitis as a first manifestation in a child with primary Sjogren's syndrome.

Recurrent parotitis is an acute, severe inflammation of one or both parotid glands, the major salivary glands in young children. We report the case of a seven-year old boy with Primary Sjogrens syndrome (PSS) who presented with 15 episodes of painful recurrent bilateral swellings of the parotid glands over a four-year period.

Anorexia Is Independently Associated with Decreased Muscle Mass and Strength in Community Dwelling Older Adults.

OBJECTIVES: We aimed to investigate the association between anorexia and sarcopenia in community dwelling older adults. METHOD: Anorexia was assessed by Simplified Nutritional Appetite Questionnaire (SNAQ) and sarcopenia defined by EWSGOP criteria. Study participants consisted of 442 patients from Turkish validation study of the SNAQ. Study is designed as cross-sectional in community dwelling outpatients. MEASUREMENTS: Muscle mass was determined by using bioimpedance analysis. Skeletal muscle mass index (SMMI) was calculated as SMM (kg)/height (m)2. Muscle strength was evaluated by hand grip strength (HGS) with Jamar hydraulic hand dynamometer. Gait speed (GS) was assessed by usual 4 meters speed. Depression and quality of life were assessed by using Geriatric Depression Scale (GDS) and Euro-Quality of Life-5D(EQ-5D). Univariate analysis and multivariate regression analysis were run to evaluate the association between poor appetite and components of sarcopenia. RESULTS: Prevalences of low HGS, low gait speed and sarcopenia were higher in group with poor appetite (p=0.001, p<0.0001, p=0.036, respectively). Depression and constipation were more prevalent in participants with poor appetite (p<0.0001, p=0.033, respectively). SNAQ was correlated with SMMI and EQ-5D. Regression analysis showed that lower muscle mass, lower SMMI, and lower HGS were independently associated with poor appetite after adjustment for confounders. Neither gait speed nor diagnosis of sarcopenia was associated with poor appetite in regression analysis models. CONCLUSION: We observed poor appetite has independent association with lower skeletal muscle mass and decreased muscle strength. Prospective studies are needed to evaluate exact relationship between poor appetite and sarcopenia.

Recurrent parotitis as a first manifestation in a child with primary sjogren's syndrome / Parotitis recurrente como primera manifestación en un niño con el síndrome de sjögren primario

Recurrent parotitis is an acute, severe inflammation of one or both parotid glands, the major salivary glands in young children. We report the case of a seven-year old boy with Primary Sjogrens syndrome (PSS) who presented with 15 episodes of painful recurrent bilateral swellings of the parotid glands over a four-year period.

La parotitis recurrente es una inflamación aguda, severa y reiterada de una o ambas glándulas parótidas - la mayor de las glándulas salivares - en los niños pequeños. Se reporta el caso de un niño de siete años de edad con el síndrome de Sjögren primario (SSP). El niño presentó 15 episodios de dolorosas inflamaciones bilaterales recurrentes de las glándulas parótidas por un período de cuatro años.

Comorbid diseases in aspirin-exacerbated respiratory disease, and asthma

BACKGROUND: Asthma, persistent rhinosinusitis, and/or nasal polyposis accompanying non-steroidal anti-inflammatory drug (NSAID) intolerance is defined as aspirin-exacerbated respiratory disease (AERD). Although the literature includes considerable data on comorbidities in asthma, data on comorbidities in AERD have not been previously published. OBJECTIVE: This study aimed to determine the prevalence of comorbidities in AERD and compare the findings to those in asthmatic patients. MATERIALS AND METHODS: The records for 330 AERD patients that presented to our allergy clinic were reviewed. Patients with urticaria/angio-oedema type reactions to NSAIDs were included in the pseudo Samter's group (n = 83) and 338 randomly selected NSAID-tolerant asthma patients constituted the control group. RESULTS: Gender, age at presentation, age at onset of asthma, and follow-up periods were similar in all groups. Hypertension (P = 0.035), diabetes mellitus (P = 0.323), gastro-oesophageal reflux (P < 0.001), psychological disorders (P = 0.099), obesity (P = 0.003), and hyperlipidaemia (P = 0.002) were significantly more prevalent in the asthma group. Interestingly, coronary artery disease (CAD) and congestive heart failure (CHF) were more common in the AERD group (P = 0.178); CAD/CHF was associated with AERD (OR: 4.5; 95% CI: 1.206-16.93). CONCLUSION: AERD and asthma are associated with several comorbidities. Even though systemic steroid dependency and severe asthma were significantly more common in the AERD group, comorbidities occurred more frequently in the asthma group. Additional longitudinal studies are needed to more clearly discern if the risk of CAD/CHF is increased in AERD

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All-fiber wavemeter and Fourier-transform spectrometer.

An all-fiber Fourier-transform spectrometer is proposed and demonstrated, based on the diffraction of light through the side of a standard optical fiber by a UV-induced fiber grating. The interference pattern, whose Fourier transform yields the optical spectrum, is formed by light diffracted from counterpropagating modes in the fiber. The device is simple and compact and functions as a wavemeter, a fiber-optic network monitor, or a tool for fabrication and testing of long fiber Bragg gratings.

Radiation-mode coupling loss in tilted fiber phase gratings.

We demonstrate that grating tilt is an important adjustable parameter that can be utilized in addition to the more familiar parameters of grating length and index change to tune the spectral shapes of fiber phase gratings designed to perform demanding filter applications through guided-mode to radiation-mode coupling loss. A comparison is made between calculated transmission spectra obtained from a coupled-mode-theory analysis and measured spectra obtained from strong gratings written by ultraviolet irradiation of deuterium-sensitized fiber with grating tilt angles ranging from 0 degrees to 15 degrees . We show that good agreement is obtained between the experimental measurements and the theoretical predictions.

Dispersion control with use of long-period fiber gratings.

Chirped long-period fiber gratings are analyzed for management of dispersion in optical fiber communications systems. A ray model is used to derive simple analytic expressions that describe the transmission, chromatic delay, and dispersion properties of chirped long-period fiber gratings. A numerical model based on coupled-mode theory is used to verify the accuracy of the analytic expressions and explore design issues of the chirped long-period grating. With certain reasonable restrictions, chirped long-period gratings are found to be a viable and desirable alternative to existing dispersion compensation techniques.

Solgel-derived photosensitive germanosilicate glass monoliths.

We demonstrate volume gratings written in solgel-derived, Ge-doped silica monoliths. Glass was fabricated both with and without germanium oxygen deficient center (GODC) defects. The UV absorption and UV-induced index changes of these glasses, with and without hydrogen loading, are reported. The presence of GODC defects greatly enhances the photosensitivity of Ge-doped silica with and without the presence of hydrogen.

Fiber mode coupling in transmissive and reflective tilted fiber gratings.

Whereas core-mode reflection and core-mode-to-radiation-mode coupling in tilted fiber Bragg gratings is well understood, as is coupling between a core mode and higher-order core and cladding modes in untilted gratings, here we analyze in detail the coupling among core modes and cladding modes in reflective and transmissive tilted fiber gratings. We show that strong coupling between an LP(01) core mode and the exact (1m) cladding modes occurs in a transmissive tilted grating for nearly any tilt angle except angles close to 90 degrees, whereas the LP(01)-to-(lm) cladding mode coupling (l not equal 1) is appreciable only for tilt angles just below 90 degrees (approximately 88 degrees). In a reflective grating, strong coupling between the LP(01) core mode and the exact (1m) cladding modes occurs only for angles less than approximately 5 degrees, whereas coupling to (1m) cladding modes for m > 1 occurs only for angles greater than approximately 5 degrees. Coupling among bound core modes exhibits a similar behavior, except that in general the coupling is stronger. Experimentally we show coupling to both higher-order bound core modes and cladding modes in a transmissive tilted grating at visible and near-infrared wavelengths.