Risk of vasovagal syncope and cardiac arrhythmias in children with mitral valve prolapse

OBJECTIVE: Postural phenomena, cardiac arrhythmias and autonomic dysfunction are responsible for presyncope and syncope in patients with mitral valve prolapse (MVP). In this study, arrhythmia and vasovagal syncope incidence were investigated in children with MVP. METHODS: Between April 2005 and December 2006, 37 children with MVP and 26 healthy children were evaluated.Telecardiography, electrocardiography (ECG), echocardiography, Holter monitoring, exercise test and head-up tilt test were performed. RESULTS: The MVP group consisted of 19 boys and 18 girls with a mean age of 11.8 years. The control group was similar with respect to age and gender. Telecardiography, ECG, Holter monitoring, exercise test and QTc of all children were within normal limits.There was a statistically significant difference between the two groups in terms of QT dispersion. The tilt table test was positive in 11 of 37 (29.7%) children with MVP and in 1 of 26 (3.8%) normal healthy children. This difference was statistically significant (P < 0.01). CONCLUSION: Arrhythmia and syncope frequency was found to be higher in children with MVP than in the normal population. The risk of vasovagal syncope indicated by a positive tilt test was found to be increased in children with MVP. Therefore, patients and families must be informed about the conditions that may predispose to vasovagal syncope and caution should be recommended in these patients.     

Aortic pulse wave velocity in subjects with aortic valve sclerosis

Background: Aortic stiffness is an independent risk factor for cardiovascular events and mortality. The measurement of pulse‐wave velocity (PWV) is the most simple, noninvasive, and robust method to determine aortic stiffness. Whether aortic stiffness contributes to aortic valve sclerosis (AVS) remains unknown. The aim of the present study was to examine the relationship between PWV and AVS in subjects free of clinically evident atherosclerotic disease. Methods: We enrolled 62 patients (48 men; age 65 ± 8 years) diagnosed with AVS and an additional 62 age‐, hypertension‐, diabetes mellitus‐, and history of smoking‐matched subjects without AVS. Applanation tonometry was applied to assess the augmentation index and aortic PWV. The subjects with symptomatic vascular disease were excluded from the study. AVS was defined by echocardiography as thickening and calcification of the normal trileaflet aortic valve without obstruction to the left ventricular outflow. Results: There was no significant difference between the two groups regarding the aortic PWV and augmentation index (11.7±3.3 vs 11.8±3.7, P=0.85; 28.0±9.4 vs 25.0±8.6, P=0. 17, respectively). The presence of AVS was significantly correlated with ejection fraction (r=0.211, P=0.011), male gender (r=0.362, P=0.0001), and age (r=0.200, P=0.026). Conclusions: The lack of an association between the aortic PWV and AVS suggests that AVS is a complex phenomenon consisting of several distinct processes, related to both atherosclerotic and nonatherosclerotic processes.     

Is it possible that direct rigid laryngoscope-related ischemia–reperfusion injury occurs in the tongue during suspension laryngoscopy as detected by ultrasonography: a prospective controlled study

Abstract

Background: Tongue-related complications can be seen in suspension laryngoscopy (SL) procedures.

Aims/objectives: This study aimed to detect tongue edema associated with the pressure exerted by a rigid direct laryngoscope by measuring the tongue area using ultrasonography (USG) in patients undergoing SL procedures.

Material and methods: The study group included 31 patients and the control group consisted of 33 patients. Submental USG examinations of the tongue in the coronal plane were performed. In the study and control groups, the first examination (TA¹) was done immediately after intubation and the second examination (TA²) was done after the surgery procedure but before extubation. The USG results regarding tongue area for both the groups were compared.

Results: The study and control groups significantly differed in terms of the postoperative tongue area measurements (TA²), as well as tongue edema (based on the TA²???TA¹) values.

Conclusions and significance: Direct rigid laryngoscopes may cause tongue edema in SL procedures which was demonstrated by the USG. This tongue edema can be a result of ischemia–reperfusion injury in the tongue due to the pressure exerted by a direct rigid laryngoscope. This study is the first to demonstrate the possible role of USG examination in determining the side effects of SL procedures on the tongue.

Trial Registration ClinicalTrials.gov Identifier: NCT04205253     

Evaluation of adrenomedullin and endothelin-1: Are they factors in the adaptation of maternal vascular system in normotensive pregnancy

INTRODUCTION: The aim of our study was to analyse the role of adrenomedullin (AM) and endothelin-1 (ET-1) in the adaptation of the maternal vascular system in normotensive pregnancy. METHODS: Twenty-eight pregnant women, who were normotensive throughout the duration of their pregnancy, were recruited into the study. Plasma levels of AM and ET-1 at each trimester were measured and the AM/ET-1 ratio was calculated. RESULTS: Our experiment showed a significant decrease in plasma concentrations of AM in the first trimester for the study group (n=28) compared with the non-pregnant control group (n=16). There was also a significant decrease in plasma concentrations of ET-1 in all three trimesters (P<0.05) and a significant increase in the AM/ET-1 ratio in all three trimesters (P<0.05) for the study group compared with the control group. CONCLUSION: An alteration in vascular equilibrium between AM and ET-1, favouring AM, may be a reason why the physiological adaptation of the maternal vascular system to pregnancy occurs during normotensive pregnancy.     

Bilateral choroidal infiltration from indolent non-Hodgkin's lymphoma: a rapid course with poor prognosis

A 42-year-old-woman, with a 2 year history of non-Hodgkin's lymphoma suffered sudden bilateral visual loss. This unusual patient presented with an unifocal choroidal tumor in the superionasal quadrant in both eyes. Fluorescein angiography revealed early and late intense subretinal fluorescence. Cytological examination of the anterior chamber and vitreous tap material revealed abnormal lymphocytes compatible with NHL. Diffuse choroidal infiltration was diagnosed and treated with radiotherapy. Radiotherapy did not provide local control and preservation of the vision. Non-Hodgkin's lymphoma can infiltrate to the choroid and radiotherapy may not be efffective in every case.     

Improvement of the clinical outcome in Ankylosing spondylitis by balneotherapy

AIMS: This study is designed to show the efficacy of balneotherapy and balneotherapy (BT) + nonsteroid antiinflammatory drug (NSAID) use in Ankylosing spondylitis (AS) patients. METHODS: In this prospective study, BT, BT+ NSAID and NSAID therapy in 61 patients with AS were evaluated by ASAS core set. BT group (21 patients) was treated only with BT for 20 min, once a day, 5 days a week, over a period of 3 weeks. BT+NSAID group (20 patients) was treated with 1000 mg naproxen as well as BT. NSAID group (20 patients) was treated with 1000 mg naproxen. All of the participants did respiratory and postural exercises for 20 min a day and for the whole study period. Each patient was evaluated on admission (before treatment), at the end of the therapy and 6 months after the treatment. RESULTS: At the end of the study, statistically significant improvement was observed in all the clinical parameters of the patients in BT (G1), BT+NSAID (G2) and NSAID (G3) groups. This significant symptomatic and clinical improvement was maintained even 6 months after the treatment. The changes from baseline to follow up were similar in G1 and G2 except duration of morning stiffness (DMS) and chest expansion (CE). Improvements in CE and DMS were better in G1 and G2, respectively. Improvements observed in G1 and G2 were superior to the improvements observed in G3 for the variables of morning pain, nocturnal pain, DMS, global well being of the patient, occiput-wall distance, CE, finger to floor distance and functional index. In Schober test, improvement observed in G1 was statistically superior to G3. CONCLUSION: We concluded that BT can be suggested as an effective symptomatic treatment modality in patients with AS. Furthermore, sufficient improvement in clinical parameters can be obtained by BT alone.     

Management strategies for patients with nipple discharge

BACKGROUND AND AIMS: The aim of this study was to assess management strategies for patients with nipple discharge (ND). PATIENTS AND METHODS: The records of 13,443 women with breast-related complaints who were examined by the same surgeon between 1 January 1960 and 31 December 2000 were retrospectively assessed. Patients with ND were grouped according to whether they had had a spontaneous or provoked discharge. The parameters investigated in each group were age, physical findings, number of pregnancies, duration of lactation, duration of discharge, colour of discharge, and histopathological features. Chi-square and Mann-Whitney U-tests were used for statistical analysis. RESULTS: ND was the presenting symptom in 603 (4.5%) of the cases. Two hundred and eighty-seven (48%) of the 603 patients showed spontaneous nipple discharge (SND group) and the other 316 (52%) showed provoked nipple discharge (PND group). In the SND group, 124 (43%) tissue specimens were obtained by either biopsy or sub-areolar exploration. Histopathological examination revealed that the most frequent causes of ND in these cases were intraductal papilloma (49 patients; 40%), intraductal carcinoma (35 patients; 28%), and cystic disease (15 patients; 12%). Twenty tissue specimens were obtained from the group with PND. In these cases, the most frequently identified causes of ND were cystic disease (seven patients; 35%), intraductal papilloma (six patients; 30%), ductal ectasia (two patients; 10%), and carcinoma (one patient; 5%). The SND and PND groups differed significantly with respect to age (P = 0.001) and duration of ND (P = 0.008). The incidence of cancer was higher in the SND specimens than in the PND specimens (28% vs 5%, respectively; P = 0.01). The number of pregnancies was significantly higher and the duration of lactation was significantly longer in the SND group (P = 0.03 and P = 0.02, respectively). CONCLUSION: The study confirms previous reports that patients with SND have a higher incidence of carcinoma than those with PND. The results suggest that older age, higher number of pregnancies, and longer duration of lactation may predispose to cancer development in patients with SND. The possibility of breast cancer should also be kept in mind when one is assessing patients with PND. Careful physical examination and close follow-up is the optimal management strategy for patients with any type of ND.     

Plasma testosterone response at 1st and 4th day after short- and long-term hCG stimulation test

Human chorionic gonadotropin (hCG) stimulation test is a reliable dynamic test for the evaluation of testicular function during childhood. Several protocols have been recommended but their reliability is controversial. In order to decide the best timing to measure stimulated testosterone levels in short- and long-term hCG protocols, we evaluated 83 prepubertal patients in two group. In group A, 34 patients with isolated micropenis and in group B, 49 inguinal cryptorchidic patients were enrolled. In group A short-term hCG protocol (3000 IU/m2/im/3 days) and in group B long-term hCG protocol (1500 IU/m2/im; thrice a week for 3 weeks) was administered. Blood samples were drawn at the initiation of the test and then at the 1st and 4th days after the last hCG injection. Each case's peak stimulated testosterone (Tmax) and the incremenet in plasma testosterone (deltaT) were calculated and compared with the 1st and 4th day responses within the group. In the short-term protocol the 4th day responses were higher than the 1st day responses (p<0.01). Interestingly, while four patients had insufficient responses at the 1st day, three had sufficient Leydig cell response at the 4th day. In the long-term protocol group, in contrast to the short-term group, the 1st day responses were higher than the 4th day (p<0.01). According to our results, while performing hCG test in a patient, if a short-term protocol is planned, it is more convenient to check the 4th day testosterone response. On the other hand, in a long-term protocol it is best to check the 1st day response. We suggest that even if a patient's 1st day response is inadequate, the 4th day response should be checked in order to avoid misdiagnosis.     

Latent autoimmune diabetes mellitus in children (LADC) with autoimmune thyroiditis and Celiac disease

Latent autoimmune diabetes mellitus in adults (LADA) is characterized by clinical presentation as type 2 diabetes mellitus after 25 years of age, initial control achieved with oral hypoglycemic agents for at least 6 months, presence of autoantibodies and some immunogenetic features of type 1 diabetes mellitus. An 8.3 year-old girl was referred to our pediatric endocrinology department because of incidental glucosuria. She did not complain of polyuria, polydipsia, or weight loss. Her body mass index (BMI) was at the 80th percentile. Fasting glucose was 126 mg/dl, and OGTT glucose level at 120 min was 307 mg/dl. Although C-peptide levels were normal, her first phase insulin response (FIR) was lower than the 1st percentile. Anti-insulin antibody (AIA), islet cell antibody (ICA), and anti-glutamic acid decarboxylase (antiGAD) were negative. According to the clinical and laboratory findings, she was diagnosed as having type 2 diabetes mellitus. She was started with oral anti-diabetic treatment for a period of 1 year. Insulin had to be initiated for worsening of HbA1c levels. In the fourth year of follow-up, she was admitted to our hospital with diabetic ketoacidosis although she was on an intensive insulin regimen. At this time, C-peptide levels were low, antiGAD and AIA were positive with HLA DR3/DQ2 haplotype. In addition, her thyroid peroxidase antibody and endomysium antibody were found to be high at follow-up. Small intestinal biopsy revealed celiac disease. This patient may represent the first case of latent autoimmune diabetes mellitus in children (LADC) with autoimmune thyroiditis and celiac disease.