Increased aortic root diameters in patients with acromegaly

ObjectiveThe clinical manifestations of acromegalic cardiomyopathy include arrhythmias, valvular regurgitation, concentric left ventricular (LV) hypertrophy, and LV systolic and diastolic dysfunction. At present, it is unknown whether acromegaly also affects the aortic root.DesignAortic root diameters were prospectively assessed in 37 acromegalic patients (18 patients with active disease and 19 with controlled disease) by conventional two-dimensional and Doppler echocardiography before, and after, an observation period of 1.9 years (range 1.5–3.0 years). Baseline parameters were compared with healthy controls.ResultsThe diameters of the aortic root at the sino-tubular junction and the ascending aorta were increased in patients with acromegaly: 30±4 vs 26±3 mm (P=0.0001) and 33±5 vs 30±4 mm (P=0.006) respectively. The diameter of the aortic root at the aortic annulus and aortic sinus were not different from controls. During follow-up, the aortic root diameters increased at the levels of the annulus and the sinotubular junction (P=0.025 and P=0.024 respectively), whereas there was no change in the diameters at the levels of the sinus and the ascending aorta during follow-up. Baseline aortic root diameters were not influenced by disease duration, current disease activity, or blood pressure. When patients with active and inactive disease were analyzed separately, only the diameter of the sinotubular junction increased in patients with inactive acromegaly during follow-up (P=0.031).ConclusionAortic root diameters are increased in patients with acromegaly compared with healthy controls.

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Early and mid-term outcomes of modified aortic root repair for acute stanford type A aortic dissection

European Heart Journal ◽

10.1093/eurheartj/ehab724.2007 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

L C Wang ◽

Y X Liu ◽

Y J Dun ◽

X G Sun

Keyword(s):

Aortic Valve ◽

Aortic Root ◽

False Lumen ◽

Ascending Aorta ◽

Aortic Sinus ◽

Root Repair ◽

Aorta Replacement ◽

Aortic Root Repair ◽

Ascending Aorta Replacement

Abstract Background Acute Stanford type A aortic dissection (ATAAD) is the most common catastrophic aortic event. Most ATAAD involves the aortic root which has many important anatomical structures such as aortic valve, so the proper treatment of dissected root can ensure a good prognosis for patients. However, there is still no consensus on root management strategies for ATAAD patients with aortic root involvement. Purpose This clinical study aimed to evaluate the therapeutic effect of modified aortic root repair in ATAAD. Methods From September 2017 to September 2020, Participants with root involvement of ATAAD were recruited who underwent modified aortic root repair as well as some additional procedure such as aortic valve junction suspension plasty based on the aortic sinus tear extent. During this novel procedure, the proximal anastomosis plane was at the level of the sinu-tubular junction and the false lumen below it was retained. We collected and analyzed the perioperative clinical data and follow-up imaging data of patients, and further evaluated the early and mid-term efficacy of this surgical approach. Results A total of 79 patients were enrolled, including 59 males and 20 females, the age was (52.4±11.3) years old (28–73 years), the diameter of aortic sinus was (38.6±4.1) mm, and the diameter of sinu-tubular junction was (41.8±4.8) mm. In this group, 75 patients (94.9%) received ascending aorta replacement, total arch replacement and frozen elephant trunk, 2 patients (2.5%) received ascending aorta replacement and hybrid total arch replacement, 2 patients (2.5%) received ascending aorta replacement and partial arch replacement. Cardiopulmonary bypass time was (197.2±58.6) min (118–455 min), blocking time was (132.6±38.9) min (73–323 min), circulatory arrest time was (10.3±7.0) min (0–27 min). There was no perioperative death, no paraplegia, one secondary thoracotomy, five renal failures needing hemodialysis treatment and two cerebral infarctions. Before patients discharged, aortic CTA showed that the residual false lumen in the sinus disappeared. And the diameter of the aortic sinus was (35.5±3.1) mm, the diameter of the junction of the aortic sinus was (30.0±3.0) mm. The patients were followed up for (18±12) months (3–35 months). There was one patient died during follow-up and no further surgical intervention at the root of the aorta. Follow-up aortic CTA showed no residual or new dissection in the aortic sinus and no significant difference in the diameters of aortic sinu-tubular junction (P=0.122) or aortic sinus (P=0.37) between postoperative period and follow-up period. Echocardiography showed that the structure and function of the aortic valve were normal. Conclusions The modified aortic root repair for ATAAD is relatively simple, easy to learn and safe in perioperative period. Early and mid-term follow-up image examination showed that the structure of aortic sinus returned to normal. The long-term clinical effect requires close attention. FUNDunding Acknowledgement Type of funding sources: None. Modified aortic root repair procedure Aortic root diameter change under CTA

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Diseases of the aorta

10.1093/med/9780198726012.003.0053 ◽

2016 ◽

Author(s):

Arturo Evangelista ◽

Eduardo Bossone ◽

Alain Nchimi

Keyword(s):

Aortic Dissection ◽

Thoracic Aorta ◽

Aortic Root ◽

Imaging Techniques ◽

Transoesophageal Echocardiography ◽

Left Ventricular ◽

Ascending Aorta ◽

Emergency Setting ◽

Aortic Diseases

Echocardiography plays an important role in the diagnosis and follow-up of aortic diseases. Evaluation of the aorta is a routine part of the standard echocardiographic examination. Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly the aortic root and proximal ascending aorta. Transoesophageal echocardiography (TOE) overcomes the limitations of TTE in thoracic aorta assessment. TTE and TOE should be used in a complementary manner. Echocardiography is useful for assessing aorta size, biophysical properties, and atherosclerotic involvement of the thoracic aorta. TTE appears to suffice for aortic root assessment. TOE is the gold standard in thoracic aorta assessment. It provides excellent morphological information on aortic dissection and is superior to TTE in the diagnosis of intramural haematomas and aortic ulcers. TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade, and left ventricular function can be easily visualized by TTE. However, a negative TTE does not rule out aortic dissection and other imaging techniques must be considered. TOE should define entry tear location, mechanisms and severity of aortic regurgitation, and true lumen compression. In addition, echocardiography is essential in selecting and monitoring surgical and endovascular treatment and in detecting possible complications. Although other imaging techniques have a greater field of view and may yield complementary information, echocardiography is portable, rapid, accurate and cost-effective in the diagnosis and follow-up of most aortic diseases.

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Early safety performance of a modified technique of aorta replacement with sinotubular stabilization

Asian Cardiovascular and Thoracic Annals ◽

10.1177/02184923211015094 ◽

2021 ◽

pp. 021849232110150

Author(s):

Marco Moscarelli ◽

Nicola Di Bari ◽

Giuseppe Nasso ◽

Khalil Fattouch ◽

Thanos Athanasiou ◽

...

Keyword(s):

Artery Bypass ◽

Aortic Insufficiency ◽

Ascending Aorta ◽

Safety Performance ◽

Modified Technique ◽

Sinotubular Junction ◽

Aorta Replacement ◽

Valve Sparing ◽

Ascending Aorta Replacement

Background We sought to determine if a modified technique for ascending aorta replacement with sinotubular junction reduction and stabilization was safe. Methods This technique was performed by suspension of the three commissures, invagination of the aortic Dacron graft and advancing the graft into the ventricles. We included patients with dilatation of the ascending aorta, normal sinuses of Valsalva dimension (<45 mm), with or without aortic annulus enlargement (>25 mm) and with various degree of aortic insufficiency (from grade 1 to 3). Results From April to October 2019, 20 patients were recruited from two centers; mean age was 66.9 ± 12.8 years, 13 were male; grade 1, 2 and 3 was present in 12, 2 and 6 patients, respectively. All patients underwent ascending aorta replacement with modified technique; an additional open subvalvular ring was used in 8 patients with aortic insufficiency ≥ 2; cusps repair was performed in 6 patients (5 plicating central stitches/1 shaving); concomitant coronary artery bypass grafting was performed in 10 patients. There was no 30-day mortality. One patient was re-explored for bleeding. All patients completed six-month follow-up; at the transthoracic echocardiography, there was no aortic insufficiency ≥ 1 except one patient with aortic insufficiency grade 1 who underwent ascending aorta replacement and subvalvular ring; no patients underwent reintervention. Conclusions This modified technique for ascending aorta replacement and sinotubular junction stabilization was safe. It could be associated with other aortic valve sparing techniques. However, such remodeling approach has to be validated in a larger cohort of patients with longer follow-up.

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Surgery for Aortic Root Abscess: A 15-Year Experience

Texas Heart Institute Journal ◽

10.14503/thij-14-4747 ◽

2016 ◽

Vol 43 (1) ◽

pp. 20-28 ◽

Cited By ~ 18

Author(s):

Kaan Kirali ◽

Sabit Sarikaya ◽

Yucel Ozen ◽

Hakan Sacli ◽

Eylul Basaran ◽

...

Keyword(s):

Valve Replacement ◽

Aortic Root ◽

Survival Rates ◽

Prosthetic Valve Endocarditis ◽

Composite Graft ◽

Left Ventricular ◽

Surgical Reconstruction ◽

Pericardial Patch ◽

Aortic Root Abscess

Aortic root abscess is the most severe sequela of infective endocarditis, and its surgical management is a complicated procedure because of the high risk of morbidity and death. Twenty-seven patients were included in this 15-year retrospective study: 21 (77.8%) with native- and 6 (22.2%) with prosthetic-valve endocarditis. The surgical reconstruction of the aortic root consisted of aortic valve replacement in 19 patients (70.4%) with (11) or without (8) a pericardial patch, or total aortic root replacement in 7 patients (25.9%); 5 of the 27 (18.5%) underwent the modified Bentall procedure with the flanged conduit. Only one patient (3.7%) underwent subaortic pericardial patch reconstruction without valve replacement. A total of 7 patients (25.9%) underwent reoperation: 6 with prior valve surgery, and 1 with prior isolated sinus of Valsalva repair. The mean follow-up period was 6.8 ± 3.7 years. There were 6 (22.2%) in-hospital deaths, 3 (11.1%) of which were perioperative, among patients who underwent emergent surgery. Five patients (23.8%) died during follow-up, and the overall survival rates at 1, 5, and 10 years were 70.3% ± 5.8%, 62.9% ± 6.4%, and 59.2% ± 7.2%, respectively. Two of 21 patients (9.5%) underwent reoperation because of paravalvular leakage and early recurrence of infection during follow-up. After complete resection of the perianular abscess, replacement of the aortic root can be implemented for reconstruction of the aortic root, with or without left ventricular outflow tract injuries. Replacing the aortic root with a flanged composite graft might provide the best anatomic fit.

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P6496Endovascular reconstruction from aortic valve to aortic arch by one-piece valved-fenestrated-bifurcated endografting in animal experiments

European Heart Journal ◽

10.1093/eurheartj/ehz746.1086 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

Z P Jing ◽

J X Feng ◽

X H Bao ◽

T Li ◽

Y Zhao ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Arch ◽

Aortic Root ◽

Animal Experiments ◽

Proximal Part ◽

Minimal Invasive ◽

Left Ventricular ◽

Technical Success Rate

Abstract Aims The possibility of endovascular reconstruction of aortic valve, sinus of Valsalva, and ascending aorta by a minimal-invasive single endograft has not been proven in vivo. Combining our own long-term experiences from transcatheter aortic valve replacement (TAVR) and Thoracic Endovascular Repair (TEVAR) for ascending and arch dissection, we designed the special endo-graft: a novel one-piece valved-fenestrated-bifurcated endografting, and tried to endovascularly reconstruct the area from Left ventricular outflow tract to aortic arch in animal experiments. Methods and results For 20 healthy adult female pigs weighed between 62.3±2.2 kilograms, we did aortic compute tomography angiography (CTA) examinations and measured morphologic parameters of aortic root. Then we accordingly customized the valved-fenestrated-bifurcated endograft. The endograft was delivered through transapical access and endovascularly reconstructed the segment from aortic valve to proximal part of aortic arch. The overall technical success rate was 95% because of one case of delivery system failure. Instant transesophageal echography (TEE) and aortic CTA confirmed ideal position of the endograft, satisfactory function of aortic valve, and the patency of coronary arteries in all subjects. During follow-up, 12 subjects were sacrificed according to the plan and seven were followed up for 8.1±3.6 months. There was one unplanned death of cardiac infection (unplanned mortality: 5.3%). Follow-up re-examinations (aortic CTA, cardiac ultrasound, and electrocardiogram) found no adverse events. Among 12 sacrificed subjects, there was no evidence of fenestrations alignment lost and no myocardial ischemia according to the pathological analysis. Conclusion The novel one-piece valved-fenestrated-bifurcated endografting might be feasible for minimal-invasive reconstruction of aortic root in animal models, thus provided a prospect to simultaneously treat pathologies involving aortic valve and aortic root in endovascular way.

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Characteristics and long-term outcomes of aortico-left ventricular tunnel

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivaa241 ◽

2020 ◽

Author(s):

Jing Sun ◽

Hongxia Qi ◽

Hongyuan Lin ◽

Wenying Kang ◽

Shoujun Li ◽

...

Keyword(s):

Aortic Valve ◽

Valve Replacement ◽

Surgical Repair ◽

Mechanical Valve ◽

Left Ventricular ◽

Ascending Aorta ◽

Aortic Orifice ◽

The Right

Abstract OBJECTIVES Aortico-left ventricular tunnel (ALVT) is an extremely rare, abnormal paravalvular communication between the aorta and the left ventricle. Few studies have identified the characteristics and long-term prognosis associated with ALVT. METHODS The data of 31 patients with ALVT from July 2002 to December 2019 were reviewed. Echocardiography was performed in all patients during the follow-up period. RESULTS The median age of the patients was 11.5 years. Bicuspid aortic valve and dilatation of the ascending aorta were found in 13 patients, respectively. The aortic orifice in 20 patients showed a close relation to the right sinus and the right–left commissure. Of the 31 patients, 26 were operated on. Mechanical valve replacement was performed in 4 patients and aortic valve repair, in 6 patients. Ascending aortoplasty was performed in 5 patients and aortic replacement was done in 2 patients. One patient died of ventricular fibrillation before the operation. Follow-up of the remaining 30 patients ranged from 1 to 210 months (median 64 months). There were 4 deaths during the follow-up period: 1 had mechanical valve replacement and 3 did not undergo surgical repair. In the 26 patients without aortic valve replacement, 6 had severe regurgitation and 2 had moderate regurgitation. In the 28 patients without replacement of the ascending aorta, 11 had continued dilatation of the ascending aorta, including those who had aortoplasty. CONCLUSIONS The aortic orifice of ALVT showed an association with the right sinus and the right–left commissure. For patients who did not have surgery, the long-term survival rate remained terrible. Surgical closure should be done as soon as possible after ALVT is diagnosed. The main long-term complications after surgical repair included aortic regurgitation and ascending aortic dilatation.

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Diseases of the aorta

10.1093/med/9780199599639.003.0023 ◽

2011 ◽

Author(s):

Arturo Evangelista ◽

T. González-Alujas

Keyword(s):

Aortic Dissection ◽

Thoracic Aorta ◽

Imaging Techniques ◽

Cost Effective ◽

Transoesophageal Echocardiography ◽

Left Ventricular ◽

Ascending Aorta ◽

Emergency Setting ◽

Aortic Diseases

Evaluation of the aorta is a routine part of the standard echocardiographic examination, because echocardiography plays an important role both in the diagnosis and follow-up of aortic diseases. In particular, echocardiography is useful for assessing aorta size, biophysical properties, and atherosclerotic involvement of the thoracic aorta.Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly the aortic root and proximal ascending aorta. Transoesophageal echocardiography (TOE) overcomes the limitations of TTE in thoracic aorta assessment, so TTE and TOE should be used in a complementary manner.Although TOE is the technique of choice in the diagnosis of aortic dissection, TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade, and left ventricular function can be easily visualized by TTE. However, a negative TTE does not rule out aortic dissection and other imaging techniques must be considered. TOE should define entry tear location, mechanisms of aortic regurgitation, and true lumen compression.In addition, echocardiography is essential in selecting and monitoring surgical and endovascular treatment and in detecting possible complications. Although other imaging techniques have a greater field of view, echocardiography is portable, rapid, accurate, and cost-effective in the diagnosis and follow-up of most aortic diseases.

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Variations in the Left Coronary Artery

Chattagram Maa-O-Shishu Hospital Medical College Journal ◽

10.3329/cmoshmcj.v16i1.34986 ◽

2017 ◽

Vol 16 (1) ◽

pp. 42-47

Author(s):

Sultana Ruma Alam

Keyword(s):

Coronary Artery ◽

Left Coronary Artery ◽

Artery Bypass ◽

Clinical Manifestations ◽

Coronary Arteriography ◽

Ascending Aorta ◽

Main Stem ◽

Aortic Sinus ◽

Circumflex Artery ◽

Left Circumflex Artery

Background : There is a large spectrum of variations in the disposition of coronary arteries. Many of these variations are 'normal' and not considered as 'anomalous'1. These variations mainly occur in the Left Coronary Artery (LCA)2. While some of these are benign and have no clinical consequences, other variants can cause important clinical manifestations including sudden death of the individual3. Lack of knowledge of such variations can pose difficulties in percuteneous coronary arteriography, coronary artery bypass surgery or prosthetic valve replacement. A cadaveric study in unsuspected population can help to understand the variations that will be useful to determine the prevalence of certain variations. Thus the objective of this study was to analyze the characteristics of LCA that may be used in the diagnosis and treatment of its pathologies.Methods: The study was carried out in the Department of Anatomy, Chittagong Medical College (CMC) Chittagong over a period between Jan 2012 to Dec 2013 with ethical clearance. A detailed dissection of LCA and its branches in 50 cadaveric human hearts, fixed in 10% formalin was carried out to study normal and variant anatomy of LCA. The length of the main stem of LCA was measured by slide calipers.Results: The LCA was found to arise from the Left Posterior Aortic Sinus (LPAS) of the ascending aorta in 100% cases. The level of the ostia (Opening of coronary artery) was above the free margin of the aortic cusps in 98% cases. In all samples ostia were present below sinutubular ridge (A slight circumferential thickening separating bulbar aortic sinus and proximal ascending aorta). The length of the main stem of LCA (From origin to the point of termination into main branches) was found to range from 0.5-2 cm. The LCA showed bifurcation in 74%, trifurcation in 26% of cases. Left Anterior Descending artery (LAD) was found to terminate at the apex of the heart in 68% and at the posterior interventricular groove in 32% cases. The Left Circumflex artery (LCx) was terminated at the crux of the heart in 52%, near the crux in 44% and by crossing the crux in 4% cases. The Left Marginal Artery (LMA) which was present only in 34% cases, found to terminate nearer to the apex of the heart. 0% Left dominance of heart was observed.Conclusion: Simple attention to potential variations in the origin, number, level of ostia, length of the main stem, branching pattern, termination and distribution of LCA can greatly enhance clinical outcomes.Chatt Maa Shi Hosp Med Coll J; Vol.16 (1); Jan 2017; Page 42-47

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Enalapril Therapy Prevents Cardiac Remodelling of Sickle Cell Disease Patients.

Blood ◽

10.1182/blood.v108.11.3792.3792 ◽

2006 ◽

Vol 108 (11) ◽

pp. 3792-3792

Author(s):

Sara T. Saad ◽

Carmen S. Passos Lima ◽

Osvaldo M. Ueti ◽

Adriana A. Ueti ◽

Kleber G. Franchini ◽

...

Keyword(s):

Blood Pressure ◽

Sickle Cell Disease ◽

Sickle Cell ◽

Ace Inhibitors ◽

Aortic Root ◽

Fetal Hemoglobin ◽

Treated Group ◽

Left Ventricular ◽

Cell Disease

Abstract Angiotensin-converting enzyme (ACE) inhibitors are capable of decreasing cardiac remodelling in patients with cardiac dysfunction, however their effects on sickle cell disease (SCD) are unknown. Thus, this study aimed to investigate the cardiac effects of enalapril on SCD patients. Thirteen adult patients with sickle cell disease (SCD) and microalbuminuria (3M/10F); 11 sickle cell anemia patients (SCA), 1 Sβ thalassemia patient (Sβ) and 1 patient with hemoglobin SC (SC) were treated with enalapril. Thirteen other SCD patients (4M/9F) without microalbuminuria, matched according to age, diagnosis (11 SCA, 1 Sβ and 1 SC), and levels of hemoglobin, hematocrit and fetal hemoglobin, did not receive enalapril and were followed up as the control group in the same period of study. In the treated group, enalapril (5mg) was administered to 9 SCD patients during the entire study period. One patient did not complete follow-up, and higher doses (7.5mg to 20mg) were administered to 3 patients who developed systolic BP over 120 mmHg during the study period. Median age (28.5 vs 29.0; P= 0.580), baseline values of hemoglobin (8.5 vs 8.4g/dL, P= 0.600), hematocrit (25.0 vs 23.5%, P= 0.500), fetal hemoglobin (4.4 vs 4.1%, P=0.720) and mean blood pressure (MBP; 80 vs 93mmHg, P= 0.13) were similar in treated and untreated patients Echocardiograms were performed before the study entry and once a year in patients and controls. Comparisons of groups were performed at the beginning of the study and after 36 months of follow-up using the Wilcoxon-signed rank test and Spearman coefficient. At 36 months of follow-up, MBP was lower than the baseline value (93 mmHg vs 87 mmHg, P= 0.018) in the treated group. Significant increases in left ventricular mass (192 vs 231g, P= 0.005), posterior left ventricular wall thickness in end-diastole (8.5 vs 10.0mm, P= 0.013), left ventricular mass index (114.4 vs 131g/m2, P= 0.043), interventricular septal wall thickness in end-diastole (9.0 vs 9.5mm, P= 0.036) and aortic root dimension (28 vs 32mm, P= 0.009) values were seen in untreated, but not in enalapril treated patients. No major changes were seen in left ventricular ejection fraction, left ventricular systolic diameter, left ventricular diastolic dimension and left atrial diameter, in both groups, along the observational period. No significant correlation was detected between the data here presented. At the end of the study, no symptoms or signals related to cardiac failure were found in any of the enrolled patients. These results indicate a trend toward cardiac and aortic root remodeling in untreated SCD patients and suggest that long-term treatment with ACE inhibitors has beneficial effects on the cardiac remodeling of SCD patients and could be indicated for adult patients, if an increase in baseline blood pressure occurs.

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Effect of Proinflammatory Cytokines (IL-6, TNF-α, and IL-1β) on Clinical Manifestations in Indian SLE Patients

Mediators of Inflammation ◽

10.1155/2014/385297 ◽

2014 ◽

Vol 2014 ◽

pp. 1-8 ◽

Cited By ~ 43

Author(s):

Vinod Umare ◽

Vandana Pradhan ◽

Milind Nadkar ◽

Anjali Rajadhyaksha ◽

Manisha Patwardhan ◽

...

Keyword(s):

Proinflammatory Cytokines ◽

Lupus Erythematosus ◽

Clinical Manifestations ◽

Serum Levels ◽

Organ Damage ◽

Inactive Disease ◽

Control Group ◽

Healthy Controls ◽

Sledai Score ◽

Active Disease

Systemic lupus erythematosus (SLE) is an inflammatory rheumatic disease characterized by production of autoantibodies and organ damage. Elevated levels of cytokines have been reported in SLE patients. In this study we have investigated the effect of proinflammatory cytokines (IL-6, TNF-α, and IL-1β) on clinical manifestations in 145 Indian SLE patients. One hundred and forty-five healthy controls of the same ethnicity served as a control group. Clinical disease activity was scored according to SLEDAI score. Accordingly, 110 patients had active disease and 35 patients had inactive disease. Mean levels of IL-6, TNF-α, and IL-1βwere found to be significantly higher in SLE patients than healthy controls (P<0.001). Mean level of IL-6 for patients with active disease (70.45±68.32 pg/mL) was significantly higher (P=0.0430) than those of inactive disease patients (43.85±63.36 pg/mL). Mean level of TNF-αwas44.76±68.32 pg/mL for patients with active disease while it was25.97±22.03 pg/mL for those with inactive disease and this difference was statistically significant (P=0.0161). Similar results were obtained for IL-1β(P=0.0002). Correlation between IL-6, TNF-α, and IL-1βserum levels and SLEDAI score was observed (r=0.20,r=0.27, andr=0.38, resp.). This study supports the role of these proinflammatory cytokines as inflammatory mediators in active stage of disease.

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