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IntroductionCoronary artery ectasia (CAE) is localized or diffuse enlargement of the coronary artery more than 1.5 times in diameter in comparison with the adjacent normal coronary artery. The etiology and pathophysiology of CAE are not fully elucidated. Resistin is a newly identified adipocyte secreted hormone belonging to a cysteine-rich protein family. Recently it has been found to be relevant to inflammation-related disease and correlated with serum C-reactive protein (CRP). This research aimed to investigate whether the resistin level has a role in CAE etiopathogenesis.Material and methodsA hundred and three patients with diagnosis of CAE and 122 with normal coronary anatomy (NCA) were included. Details of baseline clinical characteristics and angiographic findings were recorded. Other necessary biochemical parameters were measured with an autoanalyzer. Blood was collected and stored for serum resistin level analysis.ResultsSerum resistin levels in CAE were higher than in the NCA group and were statistically significant (p = 0.001). Hypertension (OR = 1.006, 95% CI: 1.002–1.008, p = 0.025), tobacco use (OR = 1.089, 95% CI: 1.055–1.124, p < 0.001), serum resistin levels (OR = 2.431, 95% CI: 1.100–4.696, p = 0.01), hyperlipidemia (OR = 1.005, 95% CI: 1.000–1.014, p = 0.004), triglyceride (OR = 1.006, 95% CI: 1.001–1.010, p = 0.012) remained as independent factors for CAE. In the subgroup analysis of the CAE group, in patients with ectasia in three coronary arteries, resistin levels were significantly higher and statistically significant (p = 0.001). In ROC analysis, the sensitivity of serum resistin was 67.6% and specificity was 86.7% (AUC = 0.749, 95% CI: 0.621–0.877, p = 0.0001).ConclusionsSerum resistin level was significantly higher in CAE. In addition this study showed that serum resistin levels are directly proportional to the number of coronary arteries with ectasia. We think that this study will shed light on this subject and encourage further studies in this field.

Coronary artery ectasia (CAE) is localized or diffuse enlargement of the coronary artery more than 1.5 times in diameter in comparison with the adjacent normal coronary artery. The etiology and pathophysiology of CAE are not fully elucidated. Resistin is a newly identified adipocyte secreted hormone belonging to a cysteine-rich protein family. Recently it has been found to be relevant to inflammation-related disease and correlated with serum C-reactive protein (CRP). This research aimed to investigate whether the resistin level has a role in CAE etiopathogenesis.A hundred and three patients with diagnosis of CAE and 122 with normal coronary anatomy (NCA) were included. Details of baseline clinical characteristics and angiographic findings were recorded. Other necessary biochemical parameters were measured with an autoanalyzer. Blood was collected and stored for serum resistin level analysis.Serum resistin levels in CAE were higher than in the NCA group and were statistically significant (Serum resistin level was significantly higher in CAE. In addition this study showed that serum resistin levels are directly proportional to the number of coronary arteries with ectasia. We think that this study will shed light on this subject and encourage further studies in this field.

Background/aims Most important cause of mortality in chronic obstructive pulmonary disease (COPD) patients is known to be cardiovascular disease (CVD). The objective of the present study was to evaluate the echocardiographic parameters in COPD patients with or without pre-diagnosed CVD and to investigate the relationship between echocardiographic parameters and systemic inflammation markers. Methods A total of 60 stable COPD patients (23 patients with CVD, group 1; 37 patients without CVD, group 2) and 21 healthy controls (group 3) were included in the study. Six-minute walking test (6MWT), COPD assessment test (CAT), and Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index results were recorded. High-sensitivity C-reactive protein (HsCRP), interleukin 8 (IL-8), fetuin-A, Clara cell protein (CCL-16), N-terminal pro-brain natriuretic peptide levels were studied in serum. Parameters of left and right ventricular systolic and diastolic function were measured by echocardiography. Results Patients with COPD had higher levels of systemic inflammation markers and lower level of inflammation inhibitor fetuin-A. When three groups were compared, group 1 had lower 6MWT result. HsCRP was highest in group 2 while other inflammatory markers were similar in groups 1 and 2. Regarding echocardiographic parameters, left ventricular ejection fraction (LVEF) was lower and left ventricle end-diastolic diameter (LVED), left ventricle end-systolic diameter (LVES) diameters were higher in group 1. The aortic diameter was higher in COPD patients. Fetuin-A was correlated with diameter of aorta and LVES. LVEF, LVED, and LVES were found to be correlated with functional parameters of COPD cases. Conclusion In COPD, left ventricular functions are affected as well as right ventricle before prominent clinical findings of cardiac disease and these echocardiographic parameters correlate with functional parameters of COPD patients.

The Global Initiative classification (GOLD) for chronic obstructive pulmonary disease (COPD), which relies on the practical issues of treatment of this complex and heterogeneous disease, may not be reliable in predicting disease severity and prognosis as the term of inflammation is excluded from the definition.The aim of this study was to determine systemic inflammatory markers in GOLD ABCD groups and to compare these parameters according to clinical and functional features.The study included 60 COPD patients and 59 healthy subjects. Comparisons were made with the pulmonary function test, transthoracic echocardiography and the six-minute walk test (6MWT). The COPD assessment test (CAT), modified Medical Research Council (mMRC), and index scores of body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) were recorded. The systemic inflammatory state was assessed using C-reactive protein, fibrinogen, tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-8 and IL-18.The levels of all serum inflammatory markers were higher in the COPD group than in the control group. TNF-α and IL-6 were significantly higher in the symptomatic groups (B and D) than in the less symptomatic groups (A and C) (P0.05). Spirometric parameters were more severe in Group D, followed by groups C, B and A, respectively. The 6MWT and the BODE scores were worst in Group D, followed by groups B, C and A.The results suggest that bronchodilator treatment alone might be insufficient in Group B patients, as the systemic inflammatory markers in addition to exercise capacity and mortality predictors were at the worst level in Groups D and B.

Objective:This study investigated the cardiotoxicity of cisplatin (CIS) on rat heart by using the oxidative damage of the rat myocardium, troponin I and serum S100A1 levels. Previous studies have reported that cell-protective effect of Pycnogenol® (PYC) depended on its antioxidant and anti-inflammatory properties. Hence, the myocardial protective effect of PYC was investigated in this study.Materials and Methods:Rats were randomly grouped to four with 5 rats in each group. The groups were consisted of control group, PYC group: 10 mg/kg PYC for 7 days, CIS group: 15 mg/kg single injection of CIS on the 5th day, CIS + PYC group: 10 mg/kg PYC for 7 days, plus 15 mg/kg single injection of CIS on the 5th day. Heart and serum samples were acquired subsequently.Results:CIS and PYC co-treatment group had increased catalase level (from 43.61±15.16 to 60.80±21.36, p

Aims. Cardiovascular diseases are the primary cause of premature morbidity and mortality in early breast cancer patients after treatment with cardiotoxic chemotherapeutic agents. Arterial stiffness is an independent risk factor for future cardiovascular diseases and can be used as a predictive marker of subclinical cardiac damage. The aim of this study is to analyze the arterial stiffness in breast cancer patients who are in the follow-up period after receiving anthracycline-based chemotherapy regimens with trastuzumab. Methods and Material. We enrolled 45 HER2-positive breast cancer patients who are on follow-up at least for six months after completion of adjuvant chemotherapy with trastuzumab, and cardiovascular risk matched 30 control volunteers. The measurements were done with pulse wave analyzing machine. Results. Mean pulse wave velocity was higher in breast cancer patients compared to controls. The pulse wave velocity was significantly higher in patients receiving aromatase inhibitors compared to patients under tamoxifen. It was also significantly higher in postmenopausal breast cancer patients than postmenopausal controls. Conclusions. Arterial stiffness measurements may predict the breast cancer survivors with higher risk for cardiovascular events earlier in the follow-up period, and necessary preventive approaches and/or treatments can be applied.

Anticoagulant therapy of the patients with mechanical heart valve prosthesis (MHV) in the course of pregnancy requires careful monitorization and well estimation of each step regarding benefits and handicaps of each treatment strategy in the particular trimester. Unfractioned heparin with close monitoring of activated thromboplastin time (APTT), low molecular weight heparin with close monitoring of anti Xa levels or warfarin with close monitoring of INR are the main options. It may be challenging most of the sometimes because of the procoagulant nature of pregnancy as well as physiological changes like increased glomerular filtration rate. During the follow up, any recent onset symptom should call prompt and careful investigation beginning with transthoracic echocardiography and planning further transesophageal echocardiography and fluoroscopic studies if needed. If MHV thrombosis is detected, management of patients differs due to the presence of obstruction, critical illness, thromboembolic events or thrombus size. Thrombolytic therapy and the surgical thrombectomy are the options for critically ill patients. International guidelines suggest surgical approach as a first line therapy if the risk of surgery is not too high. However, the complication and success rates of studies with fibrinolytic agents are encouraging. Each strategy comes with its own particular risk and regardless of the selected strategy MHV thrombosis during the pregnancy is a high risk situation. In this paper, we report a 26 year old patient presented with recent onset dyspnea due to MHV thrombosis in the mitral position. After the failure of unfractioned heparin, and because of hemodynamic deterioration she was referred for urgent surgery. She recovered after the surgery, however baby was found to have congenital diaphragmatic hernia and is still monitored in the intensive care unit. This report includes, treatment strategies of anticoagulant medication for the pregnant patients with MHV prosthesis and management of MHV thrombosis during the pregnancy.

Objectives: We aimed to compare right and left ventricular functions by echocardiography (ECHO) according to chronic obstructive pulmonary disease (COPD) groups, and to determine their associations...

Aims Pulse wave velocity (PWV) is an accepted evaluation method to assess vascular changes and determine cardiovascular disease risk in type 1 diabetes (T1D) patients. The aim of this study was to identify atherosclerosis risk by using oscillometric device in pediatric patients who had T1D but no end organ impairment and no cardiovascular disease findings. Materials and methods Pediatric patients with T1D and no determined end organ impairment and cardiovascular disease were involved in the study. Results A total of 72 patients with T1D containing 32 males and 40 females were included in the study. A total of 77 patients including 39 males and 38 females were evaluated as healthy control group. The average age of patients with T1D was 12.8 ± 3.7 years, their average weight was established as 43.8 ± 16.7 kg. The average age of control group was 12.3 ± 1.6 years and average weight was determined as 46.8 ± 12.8 kg. When the results obtained by pulse wave method were compared; PWV and Alx_75 values in T1D patients (respectively, 4.63 ± 0.40 and 22.9 ± 6.7) were determined significantly higher than those of control group (respectively, 4.42 ± 0.34 and 16.6 ± 6.6). A positive correlation was identified between diabetes duration and HbA1c (instant and mean) levels in patients with T1D with respect to PWV and Alx_75 values. Conclusions Arterial stiffness was impaired in children with T1D with no end organ impairment using oscillometric method. This impairment was related to high HbA1c levels and diabetes duration.

SUMMARY AIM: Uremic toxins and excess fluid contributes to increased cardiovascular (CV) risk. We aimed to determine the body fluid status in patients who are just starting hemodialysis (HD) and to determine the effects of excess fluid removed by HD on the CV system. METHODS: A total of 52 patients with chronic kidney disease (CKD) who had just started HD were included. Before the HD, the left atrial diameter was measured, the volumes were calculated, the pulse wave velocity (PWV) and the augmentation index (AIx) were measured, the bioimpedance analysis (BIA) was performed, the blood was taken for brain natriuretic peptide (BNP). When patients reached their dry weight with HD, the same measurements were repeated. RESULTS: Measurements were made to determine the volume status, and all parameters except the fat tissue index decreased significantly after HD. With the removal of fluid by HD, there was an average weight reduction of 4.38 kilograms. Positive correlations between PWV and age and cardiothoracic ratio (CTR) before HD were determined. Negative correlations were found between PWV and lean tissue mass (LTM) and intracellular water (ICW) before HD. At the end of the last HD, PWV was positively correlated with age, CTR, central pulse pressure Correlation between pulse wave velocity and LTI was negative CONCLUSIONS: HD significantly improves PWV in patients reaching dry weight. Reduction of fluid excess by ultrafiltration in HD patients may reduce CV mortality by reducing arterial stiffness. RESUMO INTRODUÇÃO: Em pacientes com doença renal crônica (DRC), toxinas urêmicas e hipervolemia contribuem para aumentar o risco cardiovascular. Nosso objetivo foi determinar o estado de hidratação em pacientes com DRC iniciando hemodiálise (HD) e avaliar os efeitos da correção da hipervolemia sobre o sistema cardiovascular. MÉTODOS: Foram incluídos 52 pacientes que haviam acabado de iniciar HD. Antes do início da sessão, foram determinados o diâmetro e o volume atrial esquerdo, a velocidade de onda de pulso (VOP) e o índice de amplificação sistólica (“augmentation index”, AI). Além disso, realizamos análise da composição corporal por bioimpedância elétrica (BIA) e mensuramos os níveis plasmáticos de peptídeo natriurético tipo B. Os mesmos procedimentos foram repetidos após os pacientes alcançarem o “peso seco”. RESULTADOS: O peso corporal dos pacientes foi reduzido, em média, em 4,38 kg. Na BIA, todos os parâmetros, exceto o índice de gordura corporal, foram significativamente reduzidos após a hemodiálise. Antes da HD, a VOP se correlacionou positivamente com idade e razão cardiotorácica (RCT), e negativamente com a massa magra e a água intracelular. Ao final da hemodiálise, a VOP se correlacionou positivamente com idade, RCTe pressão de pulso central, correlacionando-se negativamente com a Lean Tissue Index (LTI). CONCLUSÃO: A hemodiálise melhora a VOP por meio da redução da volemia. O controle da hipervolemia via ultrafiltração pode reduzir a mortalidade cardiovascular por meio da redução da rigidez arterial.

Background Contrast-induced nephropathy (CIN) is an important complication of vascular interventions. Ozone therapy can induce tolerance to ischemic insults, a phenomenon known as ozone oxidative preconditioning (OOP). The aim of this study was to investigate the effects of OOP on CIN. Materials and methods Thirty-two Wistar rats were randomized into four groups (n = 8). The control group had intravenous saline injection. The contrast media (CM) group had intravenous meglumine/sodium diatrizoate injection to form CIN. The ozone (O3) group received intraperitoneal ozone for 5 d before the induction of CIN. The oxygen (O2) group was given an equal amount of oxygen for 5 d before the induction of CIN. The animals were sacrificed 48 h after the administration of contrast agent or saline. Kidneys were harvested, and blood samples were obtained. Renal function tests, serum and renal tissue malondialdehyde (MDA), and nitric oxide (NO) levels and renal oxidant system parameters were determined. Histologic examination was performed for renal injury. Results Serum blood urea nitrogen (BUN), creatinine, and serum and renal MDA were increased after contrast exposure. Renal NO was decreased, and there was prominent tubular necrosis in the CM group. Serum BUN, creatinine, serum and renal MDA, and grade of tubular necrosis were decreased in the O3 group as compared with those in the CM group. The levels of serum and renal NO and renal total antioxidant system in O3 group were higher than the levels in the CM group. Conclusions OOP attenuates experimental CIN. This effect is suggested to be mediated by reinforcement of renal antioxidant defenses and maintenance of renal NO levels.

OBJECTIVE There is still a group of patient that have unpredictable risk for the development of contrast nephropathy (CN). There is also an effort to find more effficient strategies to prevent CN. Carvedilol, metoprolol and nebivolol seem to have theoretical potentials for the prevention of CN. In this study, we aimed to investigate their effects on the prevention of CN. We also aimed to define the risk factors associated with the development of CN in our study group. METHODS In this prospective, cross-sectional study, the patients were divided into four groups according to whether they were taking 25 mg/day carvedilol (n:56), 5 mg/day nebivolol (n:60), 50 mg/day metoprolol (n:68) or none (n:63). We made analysis to determine the agents' efficiency on the prevention of CN. We also performed multiple logistic regression analysis including all groups to define the risk factors associated with CN. RESULTS The incidents of CN were the lowest in the carvedilol group (4%) while the worst performance occurred in those taking metoprolol (10%). The difference between the groups in terms of the development of CN did not reach statistical significance (p>0.05). Multiple logistic regression analysis showed age (p=0.003), higher triglyceride levels (p=0.011) and family history of coronary artery disease (p=0.038) to be the predictors of CN. CONCLUSION In this study, we didn't find any relation between the development of CN and carvedilol, metoprolol or nebivolol usage. We found age, higher levels of triglyceride and family history of coronary artery disease to be risk factors for predicting CN.

Aim We aimed to determine the predictors of early death in the course of acute pulmonary embolism (APE). Materials and methods We included 206 patients who had been admitted to our hospital between January 2011 and April 2013 with the diagnosis of APE. We derived a new model including corrected QT interval dispersion (QTcd) and P wave dispersion (Pd), echocardiographic findings, laboratory markers, and blood cell count indices to predict early death in patients with APE. Results Thirty patients (14.5%) died; 176 patients (85.5%) lived after diagnosis of APE. Logistic regression (LR) analysis found that troponin I (odds ratio [OR], 1.084 [95% confidence interval {CI}, 1.009-1.165]), creatinine (OR, 4.153 [95% CI, 1.375-12.541]), mean platelet volume (OR, 1.991 [95% CI, 1.230-3.223]), neutrophil to lymphocyte ratio (NLR) (OR, 1.079 [95% CI, 1.005-1.160]), QTcd (OR, 1.084 [95% CI, 1.043-1.127]), Pd (OR, 1.049 [95% CI, 1.004-1.096]) were associated with early death in APE. New LR model (area under the curve [AUC], 0.970) performed better than the simplified pulmonary embolism severity index (sPESI) score (AUC, 0.859) in predicting early death in APE ( P = .021). The predictivity of the sPESI score significantly improved after its single combination with creatinine, QTcd, or troponin I. When the combined model was constructed together with these 6 independent variables and sPESI score, stepwise LR model automatically excluded Pd and NLR, and the AUC from the rest of the combined model was 0.976, which is significantly different from the AUC of sPESI (0.859) ( P = .0031). Conclusions Creatinine, troponin I, and QTcd significantly improves sPESI score. A new model with troponin I, creatinine, mean platelet volume, NLR, QTcd, and Pd seems to have greater prognostic power than the sPESI scoring system.

Oxidative stress and vasoconstriction appear to be important components of contrast nephropathy (CN) pathogenesis, and both carvedilol and nebivolol are known to have vasodilatory and antioxidant effects.This study aimed to investigate whether carvedilol and nebivolol play preventive roles against developing CN and to compare the effects of each.Wistar albino rats were divided into control (C, n = 6), contrast material (CM, n = 6), carvedilol (CV, n = 7), carvedilol + contrast material (CV + CM, n = 7), nebivolol (N, n = 7), and nebivolol + contrast (N + CM, n = 7) groups. Following 3 days of dehydration, 6 mL/kg diatrizoate was administered to each rat. Carvedilol was given at a dose of 2 mg/kg and nebivolol at a dose of 1 mg/kg by way of oral gavage. After scarification, total antioxidant capacity (TAC), malondialdehyde (MDA), and superoxide dismutase (SOD) were studied in renal tissue. Histopathological findings were graded as mild (+), moderate (++), and severe (+++).Most of the histopathological findings and MDA levels were significantly higher in the CM group than that in the C, CVCM, and NVCM groups, whereas there was no significant difference between the C, CVCM and NVCM groups. TAC level in the CM group was significantly lower than in all other groups. There was no difference in SOD among groups.Carvedilol and nebivolol both prevent development of nephropathy related to CMs by decreasing oxidative stress. Neither is superior to the other.

The aim of this study was to investigate the association between HATCH score and atrial fibrillation (AF) after coronary artery bypass graft (CABG) surgery. 369 patients (103 patients with AF and 266 patients without AF) undergoing isolated CABG surgery were analyzed. Complete medical records were retrospectively collected to investigate HATCH score. The median age of patients with AF was significantly higher than the median age of non-AF group (60.8±10.0 years vs 67.8±9.5 years, P1 (two or more), with a sensitivity of 42% and specificity of 70%. Patients with elevated preoperative HATCH score may have higher risk for AF after CABG surgery.

Objective There are still contradictory data in the literature whether patients with acromegaly are under risk in terms of atherosclerotic heart disease. Increased arterial stiffness develops before atherosclerosis and is evaluated to be a risk factor for atherosclerosis. Mean platelet volume (MPV) is currently gaining interest as a new independent cardiovascular risk factor. There are contrasting views about arterial stiffness in patients with acromegaly. There is no report in literature studying MPV in acromegaly patients. The aim of this study was to evaluate MPV and arterial stiffness in patients with acromegaly. Methods This study was designed as an observational cross-sectional, case-controlled study. Twenty-eight patients with acromegaly and 22 healthy volunteers were recruited for the study. The arteriography device Mobil-O-Graph® (IEM GmbH. Stolberg, Germany) which can perform oscillometric measurements was used to measure arterial stiffness. The Mann-Whitney U test, Student's t-test, Spearman's nonparametric correlation analysis and the chi-square test were used to statistical analyze. Results Aortic pulse wave velocity (PWV) value was found to be 6.41 ± 2.12 m/s in the patient group with active acromegaly and 5.24 ± 1.04 m/s in the healthy control group. The difference was statistically significant (p=0.03). The mean MPV value was found to be 9.68 ± 1.11 in the patient group with active acromegaly and 8.53 ± 1.18 in the healthy control group. There was a statistically significant difference between the two groups (p=0.004). In patients with acromegaly, a positive correlation was found between MPV and insulin-like growth hormone-I (IGF-1) level (p=0.021, r=0.434). Conclusion We determined an increase in aortic PWV and MPV in patients with acromegaly. In conclusion, evaluation of MPV and arterial stiffness in future studies could be beneficial in determining the risks for cardiovascular disease in patients with acromegaly.

We aimed to investigate the prophylactic effects of trimetazidine (TMZ) against contrast-induced nephropathy (CIN) in rat kidneys.28 Wistar rats were divided into 4 groups of 7 rats each (control (C), contrast media (CM) TMZ, trimetazidin+contrast media groups (TMZ + CM). The administration of TMZ solution was done on d2, d3 and d4. Fifth day, contrast media was administered at a single dose. On d6 scarification was performed. The oxidant/antioxidant parameters were measured and histopathological scores were performed in kidney tissues. Most of the histopathological scores were significantly higher in the CM group as compared to other groups. Moreover, the scores of the TMZ + CM and C groups were not statistically different. CM group, had significantly higher levels of MDA compared to the C and CM + TMZ groups (562.82 ± 38.15 vs. 419.15 ± 49.01 and 507.34 ± 14.16 01 nmol/mg protein respectively) (p0.001). CM group had significantly lower levels of SOD as compared to C, CM + TMZ and TMZ groups (p0.05).To the best of our knowledge, this study for the first time, histopathologically demonstrated the effectiveness of TMZ for the prevention of CIN.

Free fl oating right atrial thrombi are associated with high mortality. Although trombolysis and surgical trombectomy are recommended, their management is still the subject of debate. A 78 year old woman with a history of stroke a month ago, presented to the emergency department with palpitation. Transthoracic echocardiography revealed a large free-fl oating right atrial thrombus. After intravenous bolus of 5000 IU unfractional heparin she was prepared for cardiac surgery because of contraindications for trombolytic therapy. About 90 minutes after unfractional heparininfusion, we decided to check the thrombus, and realised that it was not there anymore, but there was a slight enlargement in right cardiac chambers. Patient was hemodynamically stabil. Contrast enhanced computerized tomography demonstrated multiple small fi lling defects in the subsegmental branches of pulmonary tree. Surgery was cancelled and Doppler ultrasonography revealed deep venous thrombosis in the left lower limb. After 72 hours of continuous unfractional heparin infusion, warfarin was started. During the hospitalization there was not any complication. Patient was stabil for the following three months. This is a report of free fl oating right atrial trombus origined from deep lower extremity veins and treated by unfractional heparin without any clinical deterioration. In this particular case we think that unfractional heparin might have partly worked because of fresh, unorganised and fragil thrombus. In patients with right atrial free fl oating thrombus, especially when thrombolytic therapy is contraindicated and surgical mortality is high, it may be an alternative to start unfractional heparin and check the thrombus after several hours before the surgery.

Many drugs are known to cause lengthening of the QT interval. Ibandronic acid is a frequently used agent in the treatment of osteoporosis and is known to cause prolongation of the QT interval due to hypocalcaemia. However, no cases of long QT syndrome associated with ventricular tachycardia (VT) with a serum calcium level within the normal limits have been reported in the literature. We report on a case of a VT-based long QT syndrome associated with the use of ibandronic acid.

Objective: The pathophysiology of glaucoma is still undisclosed. Cardiovascular hemodynamic changes are hypothesized to contribute to glaucoma. This study aimed to determine the differences in the diurnal blood pressure (BP) of patients with normal tension glaucoma (NTG), primary open angle glaucoma (POAG), and controls without glaucoma. Methods: A total of 129 patients were included in this study. The day–night average systolic and diastolic BPs, the day–night average pulse pressures (PPs), the day–night average heart rates, and the percentage of BP decline at night were obtained from the Holter devices and compared. Study design: Prospective, randomized, case-control study. Results: This study included 43 NTG patients (Group 1), 44 POAG patients (Group 2), and 42 healthy subjects without glaucoma (Group 3). The age (p=0.138) and sex (p=0.216) distributions between the groups were similar. The average day–night PP values of Group 1 were 49.17±9.90 and 46.07±10.84 mm Hg, respectively, while their total average PP was 48.48±9.60, their total average systolic BP was 120.02±12.65, and their night average systolic BP was 111.93±15.87 mm Hg. In Group 2, the average day and night PP values were 54.83±10.35 and 51.73±9.10 mm Hg, respectively, their total average PP was 54.00±9.87, their total average systolic BP was 126.75±11.50, and their night average systolic BP was 119.21±12.38 mm Hg. These differences were statistically significant and the corresponding p values were 0.040, 0.040, 0.037, 0.033, and 0.038. Conclusion: NTG patients have low diurnal BP parameters, which may reduce their optic nerve perfusion and may be responsible for their glaucomatous visual field damage.

Acromegaly is a rare condition caused by a pituitary adenoma that secretes growth hormone. The mortality rate is 72 % higher in patients with acromegaly than in the general population according to meta-analyses. Mortality analysis has shown as many as 60 % of acromegalic patients die due to cardiovascular disease. Sudden cardiac death may occur in patients with acromegaly and malignant ventricular arrhythmia may play an important role in this fatal complication; however, the precise mechanism is not fully known. QT dispersion (dQT) is an electrophysiological factor known to be associated with a tendency for ventricular arrhythmia and sudden cardiac death. This study aimed to evaluate dQT as an early predictor of ventricular tachyarrhythmia, as sudden cardiac death commonly occurs in acromegalic patients. This cross-sectional case–control study enrolled 20 patients (10 female and 10 male) with acromegaly and 20 healthy controls (11 female and 9 male) after exclusion criteria were applied. Each participant underwent 12-lead electrocardiography, including ≥3 QRS complexes, at a speed of 25 mm/s after a 15-min rest. In each participant, the QT interval (beginning of the Q wave to the end of the T wave) was corrected (QTc) for heart rate using Bazett’s formula $$ \left( {\text{QTc\, =\, QT}}/\sqrt {R}-R {\text{ s}} \right) $$ QTc dispersion (dQTc) (QTc max – QTc min) was also calculated. There was no significant difference in median dQTc between the acromegalic patients (0.79 s) and the controls (0.45 s) (p > 0.05). Active acromegalic patients (n = 14) were estimated to have a median dQTc of 0.82 s, after excluding from the analysis six patients that were under full biochemical control, and that had randomly obtained growth hormone levels

a Adnan Menderes University, Medical Faculty, Department of Pediatric Cardiology, Turkey b Adnan Menderes University, Medical Faculty, Department of Cardiology, Turkey c Adnan Menderes University, Medical Faculty, Department of Pediatrics, Turkey d Adnan Menderes University, Medical Faculty, Department of Pediatric Allergy and Immunology, Turkey e Aydin Zubeyde Hanim Maternity and Children Hospital Department of Pediatrics, Turkey

The “single coronary artery” anomaly arises from the aortic root by a single coronary ostium and in the absence of another ostium mostly has an asymptomatic course. However, some types of this congenital anomaly may cause various clinical manifestations like chest pain and even sudden death. In this presentation, a 51-year-old woman, who had complaints of typical chest pain increasing with hypertension was presented. Angiography was performed due to chest pain complaints, revealed that all coronary system was giving off branches from a main single coronary artery, which arose from the right sinus of valsalva. There weren’t any blocking coronary lesions that might cause ischemia. Multislice computed tomography examination was performed in order to describe the symptoms and it was observed that this main coronary artery arose from right sinus of valsalva as well as it followed a retroaortic course. Because of symptoms of myocardial ischemia, further evaluation of the coronary ostium with intravascular ultrasound (IVUS) was suggested. However the patient refused further invasive examination and a medical treatment was arranged. After a month, under a medical treatment and while her blood pressure was under control, she experienced atrial fibrillation attack that had begun after typical chest pain. Medical cardioversion with sotalol was succesfull. At that time further evaluation was again suggested but the patient refused again. The patient having Canadian Cardiovascular Society (CCS) class II angina pectoris is being followed up in our clinic for the last six months without experiencing any coronary events or arrhythmia.

Objective: The aim of this study was to evaluate the expression levels of cardiac-related circulating microRNAs (miRNAs) in ST-elevation myocardial infarction (STEMI) patients. Methods: This study has a prospective experimental cohort design. A total of 12 consecutive patients with acute chest pain within 12 h admitted to emergency department (STEMI group) and 13 adult patients with normal coronary angiography during the same period were enrolled (control group) in this study. Changes in the expression of miR-122, miR-208, miR-375, miR-22, miR-133b, miR-92b, miR-21, miR-133a, miR-423-5p, miR-27b, miR-30a-3p, miR-17, miR-30d, miR-642, and miR-95 were analyzed using quantitative reverse transcription-polymerase chain reaction. Blood samples were collected before angiography and 24 h after angiography. Data were analyzed using the Statistical Package for the Social Sciences v19. Results: The STEMI group included 12 patients (7 males) with an average age of 56.5±8.3 (range, 44–69) years. The control group included 13 patients (9 males) with an average age of 59±11 (range, 42–80) years. When fold differences were calculated for the miRNA expression values, only miR-30d and miR-423-5p expression levels in STEMI patients showed significant differences in expression levels compared with control patients. The miRNA levels were 2.3-fold higher for miR-30d (p=0.034) and 6.9-fold higher for miR-423-5p (p=0.017). There was no significant correlation between troponin I and miR-30d or miR-423-5p levels (p>0.05). Conclusion: In this study, the expression levels of miRNAs related to cardiac disease were evaluated in peripheral blood. The circulating miR-423-5p and miR-30d levels in peripheral blood were found to be higher in STEMI cases than in the control group. Further studies should be conducted to evaluate their potential use as biomarkers in STEMI cases. (Anatol J Cardiol 2016; 16; 392-6)

OBJECTIVE There are various studies showing the cardiovascular benefits of the Mediterranean diet (MD), but, to the best of our knowledge, this is the first study which aimed to investigate the relation between adherence to the MD and severity of coronary artery disease (CAD). METHODS The study was a single centre, cross-sectional prospective study which included 200 consecutive patients (131 men [65.5%] and 69 women [34.5%], mean age 57±9) who were diagnosed with CAD by coronary angiography between January 2012 and April 2013. A food frequency questionnaire was administered to the patients. Compliance to the MD was evaluated by the MD score (MDS), which collects prominent diet characteristics under 10 main titles. Each patient's angiographic data was examined by a cardiologist, and Gensini scores (GS) were then calculated to evaluate the extensiveness of coronary atherosclerosis. RESULTS Forty-four percent of patients were in the third category of body mass index (BMI) (≥30 kg/m2) and 17.5% were in the first category (BMI

Bicuspid aortic valve (BAV) is a congenital anomaly associated with structural weakness of the aortic wall. Sudden onset of symptoms in patients with BAV, such as sudden severe back pain, and pulse inequality between the extremities or tension disparity should alert clinicians to acute aortic syndromes, as they require prompt diagnosis and management. Retrograde aortic dissection, which is a rare form of acute aortic syndrome, is an uncommon life-threatening entity and may produce atypical computed tomography (CT) or magnetic resonance imaging findings, leading to difficulty in diagnosis. We report on a 51-year-old male patient with BAV and spontaneous retrograde ascending aortic dissection. CT findings were confusing and the diagnosis was made via transoesophageal echocardiography. After the diagnosis, the patient was treated with a modified Bentall procedure. He did not have any complications and was stable four months after the operation.

Long QT syndrome is a pathology that may cause fatal arrhythmias and has congenital or acquired forms. Structural and functional defects of the membrane ion channels are thought to be the cause of congenital form of long QT syndrome. On the other hand, drugs, electrolyte disorders, some kind of toxins, myocardial ischemia, conduction abnormalities and endocrine disorders such as hypothyroidism are known to be the cause of acquired form of long QT syndrome. Bupropion, that is widely used for both as an anti-depressant or the relief of the symptoms of cigarette smoking cessation, is one of the drugs that may cause QT prolongation. However, QT prolongation under dosages less than 1.5 g/day bupropion is exteremely rare. In this report, we declare a 26 years old female patient, who experienced transient QT prolongation and generalized tonic clonic seizure after the fi rst dose of 600 mg slow-release bupropion., Uzun QT sendromu, doğumsal veya sonradan kazanılmış formları olan ve ölümcül ritm bozukluklarına sebep olabilen bir patolojidir. Doğumsal tip uzun QT sendromunun membran iyon kanallarındaki yapısal ve fonksiyonel bozukluklardan kaynaklanabileceği düşünülmektedir. Diğer taraftan ilaçlar, elektrolit bozuklukları, bazı toksinler, miyokart iskemisi, ileti anormallikleri ve hipotiroidi gibi endokrin bozukluklar ise sonradan kazanılmış uzun QT sendromunun günümüzde bilinen nedenleri arasında yer almaktadır. Gerek antidepresan olarak, gerekse sigara bağımlılığı tedavisinde yoksunluk semptomlarının giderilmesinde kullanılan bupropion, QT uzaması yapabilen ilaçlardandır. Ancak, bupropionun 1.5 g/gün altında kullanımına bağlı QT uzaması oldukça nadir görülen bir durumdur. Bu yazıda, ilk doz 600 mg yavaş salınımlı bupropion alımı sonrasında ortaya çıkan jeneralize tonik klonik nöbet ve geçici QT uzaması yaşayan 26 yaşındaki kadın hasta sunulmaktadır.

This study examined the value of blood marker S100A1 in detecting cardiotoxicity induced by chemotherapy agents; trastuzumab and lapatinib, in normal rat heart. The rats were divided into three groups: control (n = 8, no treatment), T (n = 8, one time ip treatment with 10 mg/kg trastuzumab) and L (n = 8, oral treatment with 100 mg/kg/day lapatinib for 7 days). The activities of oxidative stress parameters Malondialdehyde (MDA), Superoxide dismutase (SOD), Catalase (CAT) and Glutathione (GSH) were measured from the extracted cardiac tissues. The levels of troponinI and S100A1 expressions were measured from blood samples. All biomarkers responded to the treatments as they exhibited alterations from their normative values, validating the chemically induced cardiotoxicity. S100A1 expression attenuated significantly (75%), which made the sensitive detection of cardiotoxicity feasible. Assessment of cardiotoxicity with S100A1 may be a valuable alternative in clinical oncology of cancers in some organs such as breast and prostate, as they do not overexpress it to compete against.

We read with great interest the article entitled "Echocardiographic abnormalities in patients with sleep apnea syndrome", published online in Archives of Cardiovascular Imaging on January 12th, 2014 (1). The authors sought to determine the cardiovascular disorder at an early stage in patients with sleep apnea syndrome (OSA) with different echocardiographic parameters. They found both relative left ventricular systolic and diastolic dysfunction and dysfunction at some echocardiographic parameters of the right ventricle. We have some comments about this study. Firstly, there is a major concern about the methodology of the study. The study group consists of male subjects whose disease duration is not known. To our knowledge, the disease is frequently seen in woman patients too (2). Furthermore, the disease duration is not known for the subjects. Thus, comparison of the results is not appropriate: for example, suppose that there is a patient with mild OSA of 10 years' duration and there is also another patient with severe OSA of 3-4 years' duration. The authors have mentioned this point in the limitations section, but it should be written in the patients and methods section. Secondly, the fact that the study is not the first study in the literature on the subject was not mentioned in the references. Aslan et al. published their work in Cardiology Journal in 2013 (3). They studied 80 patients with the OSA syndrome while excluding those with hypertension, diabetes, or any known cardiac disease, which makes their study more reliable. They divided the patients into two groups of normal/mild OSA group and moderate/ severe OSA group. Their study, however, was not as comprehensive as the original study. Tissue Doppler echocardiography showed that early diastolic myocardial velocity was lower in the second group (21 ± 5.6/s in group 1 vs. 18.3 ± 5.3 cm/s in group 2; P = 0.01). They concluded that left ventricular (LV) diastolic dysfunction, hypertrophy, and left atrial dilatation occurred in the OSA patients even before the development of hypertension and other cardiovascular disease. In the original study, strain imaging was used and changes at the basal septum strain rate (P =0.005) were associated with OSA severity. We should note that strain imaging is a new and more reliable method in terms of diastolic function. Thirdly, Cicek et al. prospectively studied 64 patients in terms of echocardiographic and aortic parameters (4). Their study was not as comprehensive as the present one with respect to echocardiographic examinations. They found that the LV systolic function did not differ between groups, which was a different result from the present study. They also concluded that the LV diastolic function and aortic elastic parameters deteriorate with the severity of OSA. The different result in terms of the LV systolic function might be due to the small number of subjects in both studies. In conclusion, we thank our colleagues for their effort to encourage us to think about this disease. We believe that the methodology of the study is inappropriate for drawing a conclusion in terms of the LV and right ventricular function and future research is needed to make a strong conclusion. We may obtain better information on the cardiovascular function in OSA patients with another study. Indeed, future research should recruit female subjects and subjects with known disease duration and exclude individuals with hypertension, diabetes, and other cardiovascular diseases.

This study investigated the prophylactic effect of nebivolol against hyper-homocysteinaemia (hHcy) induced oxidative stress in brain, heart, liver and kidney tissues and histomorphometric changes in the thoracic aorta.Twenty-four adult male Wistar rats were divided into a control, nebivolol, hHcy and nebivolol+hHcy group. hHcy was induced by oral administration of L-methionine (1 g/kg/day) for 28 days. 10 mg/kg/day nebivolol was administered orally for 28 days. Malondialdehyde (MDA) and glutathione (GSH) levels and catalase (CAT) and superoxide dismutase (SOD) activities in the tissues were determined. The total cross-sectional area (TCSA), luminal cross-sectional area (LCSA) and intima-media thickness (IMT) were measured in the thoracic aorta.Homocysteine (Hcy) levels were lower in the nebivolol+hHcy group than in the hHcy group. Nebivolol treatment significantly decreased high MDA levels in the brain, heart and liver tissues. The level of GSH was higher in the brain, heart and kidney tissues of the nebivolol+hHcy group (P0.001). The activity of CAT increased only in the kidney tissue of the nebivolol+hHcy group (P0.01), and the activity of SOD was significantly increased in all the tissues in this group. Increased TCSA and IMT in the nebivolol+hHcy group were significantly decreased after nebivolol administration. The LCSA was significantly higher in the hHcy group than the control group, probably due to outward vascular remodelling.Nebivolol treatment may be useful in different clinical scenarios where hHcy affects physiopathological pathways.

We report a novel complication that arose while treating a 54 year old man with acute inferior ST elevation segment myocardial infarction. It was decided to perform thrombus aspiration prior to balloon angioplasty. However, after aggressive maneuvers to cross the tight lesion in order to suck the distal thrombus, a novel complication was encountered. The Thrombus Aspiration Catheter (TAC) got stuck in the coronary artery. When the whole apparatus was pulled out, it was realized that the guidewire cut the main shaft of TAC and catheter got twisted over the wire. To the best of our knowledge, this is the first report of a complication of this type.

OBJECTIVE: We aimed to demonstrate and compare to each other the relations of QT and P wave dispersions with early death in the course of acute pulmonary embolism (PE). MATERIALS AND METHODS: The archive data of 124 patients who had been hospitalized in our hospital with the diagnosis of acute PE between May 2012 and June 2013 was retrospectively reviewed. 93 patients who were in sinus rhythm and whose data were suitable for QT interval and P wave analyses were included to the study. Analyses of corrected QT interval dispersion (QTcd) and P wave dispersion (Pd) were performed for each patients. RESULTS: Among the study population, 12 patients (13%) died and 81 patients (87%) lived after the diagnosis of PE. PD values of deaths were significantly higher than those who survived (59.2±21.2 msec versus 44.8±13.5 msec respectively, p=0.04). Moreover, QTcd values of deaths were also significantly higher than the survivors (105.5 msec (99-119) versus 80msec (74-88) respectively, p64.5 msec for prediction of early mortality was found to be 58.3% with a specificity of 97.5% (p=0.017) where the sensitivity of Qtcd> 97 msec for prediction of early mortality was found to be 83.3% with a specificity of 82.7% (p64.5 msn için erken ölümü öngörme sensitivitesi %58,3, spesifitesi %97,5 (p=0.017) olarak bulunurken, düzeltilmiş QT dispersiyonunun >97 msn için erken ölümü öngörme sensitivitesi %83,3, spesifitesi %82,7 olarak bulundu (p

OBJECTIVES In this study, systolic and diastolic function parameters were measured with conventional and tissue Doppler echocardiography in coronary slow flow phenomenon (CSFP) patients and compared to those of a control group. STUDY DESIGN Sixty patients (49 male; mean age 52.4±12.1) in whom CSFP was detected during coronary angiography study and 30 volunteers with normal coronary arteries (21 males; mean age 50.2±12.1) were included in this study. CSFP was determined using the TIMI frame count (TFC) method. TIMI frame count was calculated in each coronary artery using the TFC method. Left ventricular systolic and diastolic function was assessed by conventional echocardiography and tissue Doppler imaging. TFC correlation between diastolic function parameters was measured. RESULTS Baseline demographic and laboratory results did not differ significantly between the groups. TIMI frame counts were greater in the CSFP group compared to controls (p

A 41-year-old female was admitted to our hospital with an unidentified source of fever, dyspnea and dizziness. Transthoracic echocardiography demonstrated severe mitral valve regurgitation, and further examination with transesophageal echocardiography (TEE) revealed a 7 mm vegetation on the anterior mitral leaflet. Blood cultures were negative, and after 45 days of empiric 12 g/day ampicillin-sulbactam therapy, the vegetation was shown to have disappeared. However, due to ongoing severe mitral regurgitation and valve deformity, a prosthetic metallic mitral valve replacement was performed. After the operation, TEE was performed again due to subfebrile fever; however, the valve was normal and blood cultures were negative. Because of the probable relapse risk of infective endocarditis, the preoperative intravenous antibiotherapy was continued for 21 days and then orally for one week. Then, she was placed on follow-up by our outpatient clinic. As her INR was highly unstable during this period and she developed new-onset subfebrile fever, she was hospitalized again, and the TEE demonstrated vegetation. Blood cultures were still negative, and a combination of vancomycin-rifampicin-gentamicin was started. While under that therapy, first stroke and after a few days recurrent trans-ischemic attack developed, and the vegetation was seen to have enlarged. Urgent valve operation was performed with a bioprosthetic mitral valve, and ampicillin-sulbactam therapy was added to her previous antibiotherapy at the suggestion of the Microbiology Department. Oral anticoagulant therapy was planned for three months; however, during the postoperative period, her INR levels were highly unstable and could not be maintained in therapeutic ranges for even two consecutive days. Adjusted dosage of dabigatran to 110 mg/bid according to renal clearance in combination with 150 mg/day aspirin was started. However, valve thrombosis and a massive stroke developed under this therapy. The thrombosis disappeared after continuous heparin infusion, and she was discharged with neurological sequelae on 150 mg/day aspirin 55 days after her last operation. During the follow-up period of four months, no other clinical events occurred.

AIM Coronary collateral circulation (CCC) helps to protect and preserve myocardium from episodes of ischemia, and reduce angina symptoms, arrhythmia, and cardiovascular events. Atrial fibrillation (AF) is the most frequent form of arrhythmia after coronary artery bypass graft (CABG) surgery. The aim of this study was to investigate the association between CCC and the development of AF in patients undergoing CABG surgery. METHODS A total of 165 patients (mean age 63±10 years, 74% men, 26% women) who were undergoing CABG surgery at our department were enrolled into this study. Patients were categorized into two groups according to preoperative CCC using the Rentrop method. RESULTS Of the patients, 79 had poor CCC and 89 had good CCC. The AF incidence rate in the poor collateral group was significantly higher than that in the good collateral group [37 (49%) vs. 12 (14%), P

This study was conducted to investigate the prophylactic effects of carnitine against contrast-induced nephropathy (CIN) and its relation to oxidant/antioxidant status in kidney, liver, heart, spleen and lung tissues in a CIN rat model. Twenty-eight adult male Wistar rats were divided into 4 groups, the control, contrast media (CM), carnitine and contrast media+carnitine (CM+carnitine) groups. Animals were placed in individual metabolism cages, and on the 2nd day, rats were deprived of water for 24 hr. On the 3rd day, contrast media were administered to groups CM and CM+carnitine. L-carnitine was administered on days 2, 3 and 4. Histopathological changes were evaluated in the right kidney after euthanization. Superoxide dismutase (SOD) and catalase (CAT) activities and glutathione (GSH) and malondialdehyde (MDA) levels were measured in renal, liver, heart, spleen and lung tissues. The SOD activities in the renal (P

C artery anomalies are seen in 0.6–5.6% of patients undergoing coronary angiography [1]. The overall incidence of single coronary artery is between 0.024 The coronary angiography was performed immediately. Angiography demonstrated a single coronary artery arising from the right sinus of valsalva, which gave off three and 0.044% [2]. The incidence of a left main coronary artery (LMCA) originating from the ostium of the right coronary artery (RCA) is very low and was detected in four cases out of a series of 50,000 coronary angiograms [3]. Life threatening symptoms, such as sudden death, arrhythmias, syncope and myocardial infarction, can occur in up to 20% of patients [2]. A 43 year-old man was referred to our hospital due to cardiac arrest after ischaemic ventricular fibrillation with successful defibrillation. Risk factors included smoking and family history. Physical examination revealed a blood pressure of 100/60 mmHg with a regular pulse of 50 beats per minute, heart murmurs were absent and there were no signs of heart failure. The electrocardiogram (ECG) showed ST-segment elevation in the leads II, III, aVF and V 4–6, and ST-segment depression in aVL (Fig. 1A). branches (Fig. 1B) and a rudimentary coronary artery originating from the left sinus of valsalva (Fig. 1C). A thrombotic total occlusion was observed in the distal part of posterior descending artery (Fig. 2). After administration of heparin, clopidogrel and acetyl salicylic acid, the patient was transferred to the intensive care unit with tirofiban infusion. The patient was discharged with isosorbide mononitrate, diltiazem, atorvastatin, clopidogrel and acetyl salicylic acid uneventfully. Coronary artery anomalies are asymptomatic and are usually detected as coincidental findings during coronary angiography or autopsy [2]. Findings can vary according to subtype of anomalous origin from asymptomatic patients to those who present with arrhythmia, myocardial ischaemia, angina pectoris, syncope, and sudden cardiac death.

Objective -Acute coronary syndromes (ACS) encompass a continuum of cardiac ischaemic events, ranging from unstable angina pectoris (UA) to ST-segment elevation myocardial infarction (STEMI). Oxidative stress may play an important role in the pathogenesis of acute coronary diseases. In the present study, we examined the associations between lipid and protein susceptibility to oxidation and total sialic acid (SA) and antioxidant status and the severity of ACS as determined by having UA, non-STEMI or STEMI. Methods and results - The study sample consisted of 102 patients with ACS and 45 controls. Malondialclehyde (MDA) as a marker of lipid peroxiclation and protein carbonyls as a marker of protein oxidation were measured to show the susceptibility to oxidation. Antioxidant status was determined by measuring the carotenoids, vitamin C and vitamin E levels and paraoxonase and arylesterase activities. In addition to conventional lipid and lipoprotein analysis, MDA and vitamin E were quantitated by high-performance liquid chromatography. Total SA and other oxidant and antioxidant parameters were studied spectrophotometrically. As expected, patients had significantly higher total cholesterol, triacylglycerol, low-density lipoprotein cholesterol, lipoprotein (a), apolipoprotein (apo) B values and lower high-density lipoprotein cholesterol and apoAl values than controls. Our results demonstrated significant increases both in total SA levels and in indicators of oxidative stress in patients with ACS compared with the controls. However, antioxidant parameters were decreased in patients with ACS. When the patients were divided into groups with UA, non-STEMI and STEMI, respectively, total SA and oxidant parameters were significantly increased and antioxidant parameters were significantly decreased in going from UA to STEMI. Conclusions - Our study shows gradually increased lipid and protein oxidation and total SA and gradually decreased antioxidant status when the conditions advance from UA to STEMI. These results indicate that these markers may be useful both in understanding plaque destabilization and in determination of risk stratification of patients. Also, measurement of these markers may provide a non-invasive window to study atherosclerotic lesions.