Muzaffer Kursat Fidanci

Prevalence and risk factors of onychomycosis in primary school children living in rural and urban areas in Central Anatolia of Turkey

BACKGROUND Onychomycosis is a world-wide public health concern in children, requiring epidemiological data for different regions for control and prevention. AIM The aim of this study was to evaluate the predominant pathogens and risk factors for onychomycosis in school children living in Kayseri, Turkey. METHODS This study included 8122 school children, aged 5-16 years, living in the rural and urban areas around Kayseri. Onychomycosis was clinically classified as distal and lateral subungual (DLSO), proximal subungual, superficial white, endonyx and totally dystrophic onychomycosis. Nail samples from children with clinically diagnosed onychomycosis were collected, examined by direct microscopy and inoculated for culture study. The demographic features and possible risk factors were recorded and assessed by logistic regression models. RESULTS We clinically diagnosed onychomycosis in 152 out of 8,122 (0.18%) school children. DLSO was the most frequent clinical diagnosis (120/152, 78.9%). Culture-positive onychomycosis was detected in 27/152 (17.7%) children. The prevalence of culture-positive onychomycosis was determined as 0.33%. All culture-positive samples were only from toenails. The onychomycosis causative agents were dermatophytes in 17/27 cases (62.9%), including Trichophyton rubrum 12 (44.4%), Trichophyton mentagrophytes 1 (3.7%), Trichophyton tonsurans 1 (3.7%) and Trichophyton spp. 3 (11.1%) and yeasts in 10/27 cases (37.1%), including Candida glabrata 4 (14.8%), Candida parapsilosis 1 (3.7%), Trichosporon 2 (7.4%) and Rhodotorula 3 (11.1%). Age, fathers occupation, number of siblings and rooms were statistically associated with the frequency of onychomycosis. CONCLUSIONS Although to be prevalence of onychomycosis in school children in central Anatolia of Turkey seems very low degree, pediatric onychomycosis is a growing public health concern all over the world. Children having more siblings or unemployed fathers and children living in small house as well as older children should be examined carefully for onychomycosis.

Heart rate variability can be affected by gender, blood pressure, and insulin resistance.

We really read with a great interest the paper by Durakoğlugil et al. (1) entitled “The effect of irritable bowel syndrome on carotid intimamedia thickness, pulse wave velocity, and heart rate variability” published in the September issue of Anatol J Cardiol 2014; 14: 525-30. They purposed to investigate a possible association between irritable bowel syndrome and autonomic dysfunction using heart rate variability (HRV) parameters in their study population. They concluded decreased parasympathetic modulation in patients with constipation-predominant irritable bowel syndrome. One of the best non-invasive methods to evaluate the autonomic dysfunction is to measure HRV, defined as the RR interval variability beat-by-beat, and provide us quantitative data about the autonomic nervous system (2). However, HRV parameters can be affected by various variables, including age, gender, nutrition, obesity, hyperlipidemia, diabetes mellitus, hypothyroidism, heart failure, hypertension, coronary artery disease, chronic obstructive pulmonary disease, renal failure, chronic liver disease, and drugs (2-5). It is well known that there is a relationship between gender and HRV measurements (3). Recently, Hillebrand et al. (5) reported an association between body fat and HRV and concluded that insulin resistance might be a reason for this relationship. In the study by Durakoglugil et al. (1), I think that it would be more helpful to present whether there was no statistically significant difference between the patients and control subjects in terms of gender, blood pressure, and insulin resistance, because the study population included overweight or obese people and the frequency of diabetes mellitus and hypertension is higher in the control group. We believe that the results of the study will be stronger with these additional data and whether irritable bowel syndrome really has an effect on autonomic dysfunction, which predicts survival, can be more comprehensible.

Evaluation of children with lympadenopathy

AIM To examine children who present with enlargement of lymph nodes in terms of demographic, clinical, serological and radiological aspects. MATERIAL AND METHODS Ninety-eight patients who presented with a complaint of enlargement of lymph nodes were examined in terms of demographic, clinical, serological and radiological aspects by screening file data retrospectively. The character of lymph nodes (reactive, malign) was evaluated according to the distribution, number, sizes and blood supply determined in ultrasonographic measurements. Fishers Exact test and Mann-Whitney U Test were used in comparison of the groups. Kappa value was used in assessment of compatibility between the two groups. RESULTS Cervical lymphadenomegaly was found most frequently in accordance with the complaint of swelling in the neck. Erythrocyte sedimentation rate, ultrasonography, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) IgM were not found to be statistically significatly different between the normal and abnormal physical examination groups (erythrocyte sedimentation rate; p=0.623, USG; p=0.753, EBV and CMV; p=1.00). Cytomegalovirus and EBV IgM were not found to be statistically significatly different between the normal and abnormal ultrasonography groups (CMV; p=0.35, EBV; p=0.36). There was no compatibility between physical examination and ultrasonography (=0.32). CONCLUSION Lymphadenopathy is a common problem in the childhood and necessitates a careful physical examination and follow-up. Laboratory and imaging methods should be used when necessary. Although lymphadenopathy is mostly related with infections, care should be taken in terms of malignancy and malignancy should be eliminated. The important point is systemic evaluation and follow-up of the patient. It is important to note physical examination findings and clinical follow-up findings, because frequent ultrasonographic investigations may confuse physicians and families with high values of lymph node measurements despite normal physical examination. Therefore, using our fingertips with a good physical examination is still our most sensitive diagnostic tool instead of ultrasonography.

Radiofrequency ablation and predictors for faster recovery for tachycardia-induced cardiomyopathy in the pediatric population

We read with great interest the paper by Rodríguez-Mañero et al. entitled ‘‘Permanent junctional reciprocating tachycardia in a patient with an atypically located accessory pathway in the left lateral mitral annulus’’ published in the January 2016 issue of the Journal. We congratulate the authors on the successful management of this patient. We had an experience with a premature newborn who had multi-drug resistant permanent junctional reciprocating tachycardia (PJRT) resulting in tachycardia-induced cardiomyopathy. At the age of 29 days, she underwent radiofrequency ablation, after which sinus rhythm was established. Ablation was repeated at the age of 56 days because of recurrence. Medical treatment including amiodarone, propranolol and propafenone was stopped after the ablation. The patient has had no symptoms or medication for two years. PJRT is a rare form of reentrant supraventricular tachycardia featuring a long R-P interval and incessant tachycardia ranging from 120 to 250 bpm. Inverted P waves in the inferior leads on the surface electrogram and an accessory pathway with slow, decremental retrograde conduction can be seen on electrophysiological study during the tachycardia. The diagnosis of PJRT is usually incidental or due to tachycardia-induced cardiomyopathy, as in our case. PJRT usually does not respond to antiarrhythmic drugs. Femenia et al. described successful radiofrequency ablation of PJRT in a newborn. Vaksmann et al. reported

Delayed diastolic recovery and more prevalent psychiatric disorders in Takotsubo cardiomyopathy

We read with great interest the paper by Menezes et al. entitled ‘‘A rare case of concomitant stress (takotsubo) cardiomyopathy and acute myocardial infarction’’ published in the July 2015 issue of the Journal. They presented a rare adult case of concomitant stress cardiomyopathy and myocardial infarction. We congratulate the authors for their successful clinical management of the case. If we may, we have a few comments. Takotsubo cardiomyopathy (TC) or stress cardiomyopathy is characterized by transient left ventricular (LV) wall motion changes, which usually occur after a stressful event, with excellent long-term prognosis despite the fact that TC can very rarely result in fatal arrhythmias or ventricular rupture. The diagnosis of TC is currently established according to the Mayo Clinic diagnostic criteria, which consist of (1) typical wall-motion changes; (2) no obstruction or acute plaque rupture of a coronary artery; (3) new ECG changes or mild elevation of cardiac troponin; and (4) no evidence of myocarditis or pheochromocytoma. Ahtarovski et al. described two stages of LV recovery in TC. The first stage involves rapid systolic recovery in 4--6 days with diastolic dysfunction. In the second stage there is delayed but complete diastolic recovery with almost normal LV systolic function. Although LV systolic dysfunction in TC is completely reversible by three months, diastolic impairment requiring treatment in symptomatic patients despite preserved ejection fraction may still be

Body mass index may be an influential factor in heart rate variability.

We thank Gomez et al. for their study entitled ‘‘Cardiovascular profile in myotonic dystrophy type 1: Analysis of a case series in a specialized center’’ published in the December 2014 issue of the Journal. They aimed to determine total cardiovascular risk and the risk of arrhythmias in patients with myotonic dystrophy type 1 (DM-1) and to compare these findings with the genetic results of patients in terms of CTG repeats. They concluded that altered heart rate variability (HRV) parameters, especially in the frequency domain (LF, HF and LF/HF ratio) in the study population and lower LF/HF ratio in females compared with males, indicated higher vagal tone in females. HRV is a well-established and valuable method for evaluation of cardiac autonomic function which has prognostic importance in various diseases. HRV, which can be defined as beat-to-beat RR interval variability, provides numerical data for further analysis. Nevertheless, HRV measurements may be affected by diverse factors including age, gender, ethnicity, nutrition, medication, blood pressure, hyperlipidemia, diabetes mellitus, hypothyroidism, heart failure, coronary artery disease, chronic obstructive pulmonary disease, renal failure and chronic liver disease. It is clear that HRV is affected by gender. Hillebrand et al. found a relationship between body fat and HRV, probably resulting from insulin resistance. In Gomez’s study, it is not surprising that a lower LF/HF ratio was found in women than in men, reflecting greater vagal activity in females, and mean body mass index was lower in men than in women (p<0.05). Blood lipid levels, blood pressure and insulin resistance in the study population were not mentioned in the article. We believe that the results of this study would be more reliable with these additional data and might be more valuable for demonstration of autonomic dysfunction in patients with DM-1 with and without ≤900 CTG repeats.

Is atrial septal defect alone able to affect the cardiac autonomic function or are there different factors that influence this function

We read with a great interest the paper by Özyılmaz et al. (1) entitled “Heart rate variability improvement in children using transcatheter atrial septal defect closure” published in the Anatol J Cardiol 2015 Mar 4. The authors aimed to evaluate cardiac autonomic functions in children who underwent transcatheter closure of atrial septal defect (ASD) using analysis of heart rate variability (HRV) parameters. They concluded recovery of HRV indices approximately 6 months after transcatheter ASD closure. ASD is a frequently seen congenital heart disease characterized with left-to-right shunting and dilation of the right cardiac chambers and pulmonary artery, which might result in heart failure, arrhythmia, and thromboembolic events as well as increased mortality. The enlarged right ventricle usually returns to normal size during the first 24 months after transcatheter device closure or surgical repair, although this normalization may persist for up to 5 years after defect closure (2). As mentioned in the article by Özyılmaz et al. (1), HRV impairment in patients with ASD has been attributed to right ventricular filling and right atrial tension due to left-to-right blood flow through ASD (3). However, in the study by Özyılmaz et al. (1), no data demonstrating dimensions of cardiac chambers before and after the transcatheter closure are available, and we do not know whether the initial dimensions are significantly different from those measured 6 months after transcatheter closure. In addition, the mean diameter of ASD as well as the range of the diameter of the defect in the study population is not mentioned in the article. With these additional data, we believe that readers of the journal can more easily understand whether the size of the defect and the dimensions of cardiac chambers have an effect on HRV parameters. The interpretation of HRV analysis is not as simple as thought because of various factors that influence HRV indices, which might be affected by many variables such as hyperlipidemia and blood pressure (3-5). We think that it would be more helpful to demonstrate blood pressure levels and blood lipid profiles of the study population in terms of showing no variable affecting HRV parameters rather than ASD. Thus, one can understand whether ASD alone really impairs the cardiac autonomic function, which has a prognostic importance for survival (5).

Balloon test occlusion, device selection, and extracorporeal membrane oxygenation in the transcatheter closure of coronary artery fistula

We read with a great interest the paper by Zoghi et al. (1) entitled “Coil embolization of iatrogenic coronary-pulmonary arterial fistula after heart transplantation” published in the July issue of the Anatol J Cardiol 2015; 15: 587-8. They presented a successful transcatheter coil embolization of iatrogenic coronary-pulmonary fistula after heart transplantation in a 20-year-old male. We congratulate the authors for the successful intervention and clinical management of the case. However, we have a few technical comments. Our major concern is that immediately after release of the coil in the coronary artery, some residual flow is expected, which might potentially mask the evaluation of blood flow in the small right coronary artery efferents regard with ischemia. Therefore, we think that the transient balloon test occlusion of the fistula before releasing the device should be performed in such cases (2). The Amplatzer vascular plug (St. Jude Medical, Austin, TX) device as user-friendly and is attached to a flexible delivery cable that allows us to deliver the device through a smaller delivery catheter. In addition, a single plug is usually enough for the closure of the fistula, and this makes the vascular plug advantageous compared with multiple coil usage, which may result in increased fluoroscopy time, more contrast volume, and higher embolization risk because of high flow in arterial vessels (3, 4). Recently, the use of extracorporeal membrane oxygenation (ECMO) in elective high-risk complex percutaneous coronary intervention has been reported as an alternative method for hemodynamic support (5). In our opinion, it would be more helpful to be prepared for ECMO in hearttransplanted patients with a low systolic ejection fraction and requiring pacemaker support, as in the patient presented by Zoghi et al. (1).