Halil Ertuğ

Cytokines in acute rheumatic fever

Abstract Plasma concentrations of inflammatory cytokines (IL-1α, IL-1β, IL-6, IL-8 and TNFα) were determined by ELISA in 27 patients with acute rheumatic fever (RF), 12 with only arthritis (RFA) and 15 with rheumatic heart disease (RHD), before, during and after treatment. Altogether, significant increases in TNFα, IL-8 and IL-6 levels were observed in the acute phase as compared to the data found during and after treatment. No significant differences were observed for the other cytokines. Elevations of one or more of the inflammatory cytokines were observed in 9 of 12 patients with RFA, and 12 of 15 with RHD. Increase of TNFα (6/9) and IL-8 (5/9) levels were higher in RHD patients with cardiac failure. These cytokines were below the detection limits on day 7 of treatment in all 22 patients, except in two, and in all 10 days after treatment. Conclusions These findings suggest that inflammatory cytokines, as TNFα, IL-8 and IL-6, may play a patho‐genic role in rheumatic fever.

Heart rate variability and circadian variations in type 1 diabetes mellitus

Abstract:  Diabetic autonomic neuropathy (DAN) commonly complicates diabetes and is associated with increased mortality rates over 5 yr. This fact denotes the significance of DAN prevention, mainly with effective glycemic control. However, total prevention of autonomic neuropathy in diabetic patients is not achievable. Thus, the timely detection of DAN and the use of effective means to improve autonomic nervous system function or slow down its progression become of utmost significance. Heart rate variability (HRV) is a technique that measures the beat‐to‐beat variability in RR intervals, which reflects changes in autonomic activity and their impact on cardiovascular function. Circadian variation in time and frequency domains of heart variability has been shown to correlate with circadian rhythm of ambulatory ischemia and suggests that relative changes in vagal and sympathetic tone at different times during the day may have a direct relationship to the severity of clinical events. Forty‐seven (21 boys and 26 girls) type I insulin‐dependent diabetics and 46 control subjects (19 boys and 27 girls) were included in the study. Our investigation demonstrated that overall HRV is markedly depressed in diabetes mellitus (DM). All time domain parameters except standard deviation of all 5‐min mean RR intervals and all frequency domain indices maintain significant circadian variation. These changes in overall HRV and HRV circadian rhythms reflect significant reductions in cardiac parasympathetic activity and, possibly, increased sympathetic tone.

Heart Rate Variability in Patients with Thalassemia Major

Cardiac dysfunction, including congestive heart failure and fatal arrhythmia, is a frequent cause of death among children with thalassemia major (TM). Autonomic nervous system activity typically is measured by a series of cardiovascular autonomic function tests, but these tests are unsuitable for young patients because they are invasive or complex. Heart rate variability assessment is a technique that measures the beat-to-beat variability in R-R intervals. This variability reflects changes in autonomic activity and their impact on cardiovascular function. This study examined 32 patients with TM to evaluate heart rate variability (HRV) in a preclinical phase of cardiac involvement. The study patients showed no evidence of heart failure or signs of peripheral or autonomic neuropathy. All HRV parameters were significantly reduced in the TM patient group compared with the control group. The results of this study can be interpreted as evidence of early cardiac autonomic neuropathy in young thalassemic patients. Therefore, all TM patients should be screened using HRV analysis for that complication.

Investigation of endothelial dysfunction and arterial stiffness in children with type 1 diabetes mellitus and the association with diastolic dysfunction

Objective: The objective of this study is to investigate endothelial dysfunction (ED) and arterial stiffness (AS) and determine the association with diastolic dysfunction in children with type 1 diabetes mellitus (DM). Methods: A total of 42 patients without diabetic complications (mean age: 13.21 years) and 40 healthy (mean age: 13.07 years) children were included in this study. AS was assessed with ascending aorta M-mode measurements, diastolic dysfunction with pulsed wave (PW) Doppler and tissue Doppler echocardiography measurements and flow-mediated dilatation (FMD) and carotid intima–media thickness (CIMT) with high-resolution ultrasonography. Results: Results of diabetic group and healthy children were compared. In diabetic group, aortic strain (8.40 ± 2.98, 20.12 ± 5.04; p < 0.001), aortic distensibility (7.36 ± 2.92, 16.59 ± 4.25; p < 0.001) and FMD% (7.70 ± 2.83, 11.33 ± 2.85; p < 0.001) were found decreased, and CIMT (0.52 ± 0.09 mm, 0.47 ± 0.08 mm; p < 0.05) was found increased. Additionally, left ventricular lateral segment and right ventricular free-wall isovolumic relaxation time (IVRT) and myocardial performance index (MPI) were found increased. Correlation analyses demonstrated a negative correlation between FMD and IVRT and MPI. Conclusions: ED and AS were found in type 1 DM patients without diabetic complications. Additionally, correlation was shown between increased AS and ED and right and left ventricular diastolic dysfunctions.

Right Atrial Hydatid Cyst with Multiple Organ Involvement

Cardiac hydatid disease is uncommon, especially in children. A 13-year-old girl had pulmonary and renal hydatidosis diagnosed by chest radiography, computed tomography, and magnetic resonance imaging. Serologic tests for hydatidosis were positive. A right atrial hydatid cyst was diagnosed on two-dimensional echo-cardiography. Medical treatment with albendazole was started and the cyst was successfully removed.

Facial Nerve Palsy and Kawasaki Disease

Kawasaki Disease (KD) is a vasculitic disease and can affect any organ system in the body. The development of coronary artery aneurysms is the most common and life threatening complication of KD and makes this disease the leading cause of acquired heart disease in children in the developed world. Facial nerve palsy has been reported as a possible marker of more severe disease and increased risk of coronary artery involvement in KD. Herein, the authors report an 8-mo-old infant who had left sided facial nerve palsy and multiple coronary aneurysms associated with KD.

Endothelial dysfunction and atherosclerosis in children with irreversible pulmonary hypertension due to congenital heart disease.

Objective: To assess endothelial dysfunction and the risk for coronary atherosclerosis in children with irreversible pulmonary hypertension due to congenital heart disease (CHD). Methods: The study included 18 cyanotic patients (the mean age was 12.28 ± 3.26 years) who developed irreversible pulmonary hypertension due to cyanotic and acyanotic CHDs, and 18 control patients (the mean age was 11.78 ± 3.00 years). Study groups were compared for flow-mediated dilatation (FMD), carotid intima media thickness (CIMT) and atherosclerotic risk factors. Results: Compared to the control group, the mean FMD was significantly reduced in the cyanotic group (5.26 ± 2.42% and 9.48 ± 2.60%, respectively; P-value < 0.001). No significant difference was observed between the groups in CIMT (0.41 ± 0.08 mm and 0.39 ± 0.06 mm, respectively; P-value = 0.299). The levels of total cholesterol, low-density lipoprotein–cholesterol and very low-density lipoprotein–cholesterol were statistically significantly lower compared tothe control group (P-value = 0.001, 0.006 and 0.014, respectively), whereas no statistically significant difference was found in the levels of high-density lipoprotein–cholesterol and triglycerides (P-value = 0.113 and 0.975, respectively). Conclusions: Systemic endothelial dysfunction in children with irreversible pulmonary hypertension due to CHD was noted but there was no increased risk for atherosclerosis.

Assessment of atrial electromechanical delay in children with acute rheumatic fever

PURPOSE There may be an increase in the risk of atrial arrhythmia due to left atrial enlargement and the influence on conduction system in acute rheumatic fever. The aim of this study is to investigate atrial electromechanical delay and P-wave dispersion in patients with acute rheumatic fever. PATIENTS A total of 48 patients diagnosed with acute rheumatic fever and 40 volunteers of similar age, sex, and body mass index were included in the study. The study groups were compared for M-mode echocardiographic parameters, interatrial electromechanical delay, intra-atrial electromechanical delay, and P-wave dispersion. RESULTS Maximum P-wave duration, P-wave dispersion, and interatrial electromechanical delay were significantly higher in patients with acute rheumatic fever compared with the control group (p < 0.001). However, there was no difference in terms of intra-atrial electromechanical delay (p > 0.05). For patients with acute rheumatic fever, a positive correlation was identified between the left atrium diameter and the P-wave dispersion and interatrial electromechanical delay (r = 0.524 and p < 0.001, and r = 0.351 and p = 0.014, respectively). Furthermore, an important correlation was also identified between the P-wave dispersion and the interatrial electromechanical delay (r = 0.494 and p < 0.001). CONCLUSION This study shows the prolongation of P-wave dispersion and interatrial electromechanical delay in acute rheumatic fever. Left atrial enlargement can be one of the underlying reasons for the increase in P-wave dispersion and interatrial electromechanical delay.

Pulmonary artery sling and tracheal bronchus in an infant with severe respiratory distress.

A 19-month-old girl was admitted to our clinic with complaints of dyspnea and cough. Her medical history revealed that she had been hospitalized with a diagnosis of bronchiolitis and/or bronchopneumonia for five times during the last year. On physical examination her weight was 8 kg (<3rd percentile), height was 78 cm (10th percentile), she was tachypneic, tachycardic, and she had stridor, suprasternal retractions and coarse crackles over both hemithorax. Echocardiography revealed that the left pulmonary artery (LPA) was originating distal to its normal position, which was consistent with pulmonary artery sling (Fig. 1). Multislice computed tomography demonstrated that the LPA arose from the posterior aspect of the right pulmonary artery and encircled the trachea (Fig. 2). Also, right-upper-lobe bronchus was arising from the right lateral wall of the trachea above the carina (tracheal bronchus, Fig. 3). Because the sling structure was compressing the trachea and causing severe respiratory distress, she underwent left pulmonary arteriopexy operation. The patient’s postoperative course was uneventful and all the respiratory symptoms resolved after the operation. Echocardiography indicated a mild stenosis of LPA which was causing 17 mmHg peak gradient at the level of anastomosis (Fig. 4).

Penicillin Therapy in Children with Acute Rheumatic Fever: Side Effects, Malpractice and Anaphylactic Reactions

Akut romatizmal ates ARA gelismekte olan ulkelerde daha siktir. ARA sistemik bir hastalik olup cocuklarda grup A streptokok GAS farenjitinden sonra gelisir. Romatizmal kapak hastaligi otoimmun cevap sonucu olusur. Penisilin GAS ile olusan tonsillofarenjitin tedavisinde, ARA’nin primer ve sekonder proflaksisinde kullanilmaktadir. Primer proflakside tek doz intramuskuler IM benzatin penisilin veya oral penisilin V fenoksimetilpenisilin 10 gun sure ile verilir. Romatizmal kapak hastaligi mevcut ise en az 40 yasina kadar veya yasam boyu benzatin penisilin ile sekonder proflaksi uygulamak gerekir. Penisilin IM enjeksiyonu cocuklarda korkuya ve agriya neden olabilir. IM enjeksiyon sirasinda agriyi azaltmak icin lidokain veya lidokain-prilokain EMLA krem kullanilabilir. Penisilinin en ciddi yan etkisi anaflaktik reaksiyondur. Anaflaktik reaksiyon penisilinin major veya minor determinanti ile olusabilir. Penisiline bagli anaflaksiyi onlemek icin penisilin alerjisini iyi sorgulamak ve deri testini uygun olarak yapmak ve yorumlamak gerekir. Penisilin alerji suphesi varsa deri testi yapmadan hastalarin pediatrik alerji tarafindan major ve minor determinant kullanilarak yapilan testler ile degerlendirilmesi ve penisilin alerjisinin aydinlatilmasi gerekir. Penisilin allerjisi olanlarda alternatif ilac yoklugunda desensitizasyon yapilabilir. Penisilin uygulanirken deri testinin uygun sekilde yapilmasi ve yorumlanmasi, olasi anaflaksi reaksiyona mudahale icin gerekli malzemenin ve ilaclarin hazirda bulundurulmasi ve anaflaksiye uygun mudahalenin yapilmasi tibbi ve yasal acidan onemlidir. Penisilin pediatri ve pediatrik kardiyolojide sik kullanilan bir ilactir