Evaluation of cardiac arrhythmia in pediatric patients with Left Ventricular Assist Device (L-VAD).

OBJECTIVE: Pediatric heart failure is an important cause of morbidity and mortality in childhood. Left ventricular assist devices (L-VAD) are used for bridging to transplantation in patients with indications for heart transplantation. PATIENTS AND METHODS: The children included in the study were patients who underwent implantation of an L-VAD due to advanced heart failure at Ege University Faculty of Medicine Hospital between January 2009 and January 2023. RESULTS: Of the 33 patients who underwent L-VAD implantation, 16 (48.5%) were female and 17 (51.5%) were male. The median age at surgery was 13 years (IQR, 9.5-15). The median weight was 44 kg (IQR, 25.65-52), the median height was 158 cm (IQR, 134.5-168.5), and the median body surface area was 1.37 m2 (IQR, 0.95-1.51). All patients who underwent L-VAD implantation had an echocardiographic diagnosis of dilated cardiomyopathy. The patients underwent a median of 16 (IQR, 9-21) ECGs, and the median number of 24-hour Holter ECGs obtained was 3 (IQR, 2-5). Arrhythmias that occurred after L-VAD implantation were classified as atrial and ventricular. Ventricular arrhythmia included ventricular tachycardia (VT) lasting for more than 30 seconds (sustained VT), VT lasting for less than 30 seconds (nonsustained VT), and ventricular fibrillation. Atrial arrhythmias included atrial flutter, atrial fibrillation, supraventricular tachycardia, and atrial ectopic tachycardia. During the follow-up, atrial or ventricular arrhythmias were observed in 11 (33%) patients. The most common rhythm disturbances before L-VAD implantation were ventricular arrhythmias, while after the surgery, atrial arrhythmias were found to be the most frequent. A total of 5 patients underwent cardioversion (n=2) or defibrillation (n=3) due to arrhythmia. CONCLUSIONS: In patients undergoing L-VAD implantation, rhythm disorders that could normally lead to hemodynamic instability are frequently encountered. In these rhythm disorders, medical therapy should be attempted before resorting to cardioversion or defibrillation, and subsequently, more aggressive treatment methods should be considered.

The impact of frailty on noninvasive mechanical ventilation in elderly medical intensive care unit patients.

AIM: Many factors affecting noninvasive ventilation (NIV) in critically ill patients have been reported in the literature, but there is no study about the effect of frailty. With this study, the frailty prevalence was evaluated with two different frailty scores among the NIV population of a medical intensive care unit (ICU). Besides, the impact of frailty on NIV success and mortality and its association with NIV application problems were evaluated. METHOD: A prospective observational cohort study was performed on patients who were over 50 years of age and assigned to NIV due to hypercapnic respiratory failure. For the assessment of frailty, Clinical Frailty Scale (CFS) and The Edmonton Frailty Scale (EFS) were used and the ones with CFS ≥5 and EFS ≥8 were considered as fragile. The study population was classified and compared according to NIV success, ICU outcome (discharge or exitus) and NIV application problems. RESULTS: A total of 103 patients with the mean age of 73 ± 11 years were included. The incidence of frailty was 41% with CFS ≥5 and 36% with EFS ≥8. The NIV failure occurred in 30 (29%) patients. Among them frailty and SOFA score was higher; Glasgow Coma Scale (GCS) was lower. In multivariate analysis GCS (OR: 1.2, p: 0.042) and frailty with EFS (OR: 2.8, p: 0.027) were identified as independent risk factors of NIV failure. Sixty-five (63%) patients had NIV application problems and frailty was higher among them with both CFS and EFS (p < 0.05). Mortality occurred in 18 (17%) patients; NIV failure and frailty according to CFS were independent risk factors of mortality. CONCLUSION: The frailty is associated with higher NIV application problems, failure and mortality risk in elderly ICU patients. The CFS and EFS frailty scores can be used to predict NIV success and outcomes in ICUs.

Is It Possible Using Handgrip Strength Instead of Body Mass Index in MNA-SF Test to Assess the Nutritional Status of Geriatric Patients?

INTRODUCTION: In Mini-Nutritional Assessment-Short Form (MNA-SF) test, a practical and reliable alternative parameter is still necessary for patients with difficult body mass index evaluation. We aimed to show whether or not handgrip strength may be used instead of body mass index (BMI) in MNA-SF test. MATERIALS AND METHODS: MNA-SF test scores, calf circumferences (CC), handgrip strength (HGS), and BMI of 191 patients were evaluated. The first one of calculated MNA-SF tests was with BMI, the second one with CC, and the last one with HGS. Zero point was given if CC was <31 cm and 3 points were given if CC was ≥31 cm. Zero, 1, 2, and 3 points were given if the loss of HGS when compared to expected HGS were ≥%60, from ≥%30 to <%60, from ≥%10 to <%30, and <%10 or greater than expected HGS, respectively. MNA-SF scores and nutritional status according to these three measures were compared. RESULTS: Mean age and median MNA-SF scores of the patients were 75±7.6 years and 12 points (min-max: 0-14) respectively. There were strongly positive correlations between MNA-SF scores with BMI and CC, with BMI and HGS, and with CC and HGS (r=0.938 p<0.001, r=0.938 p<0.001, r=0.914 p<0.001, respectively). Substantial agreement in nutritional status of the patients were seen between MNA-SF groups with BMI and CC, with CC and HGS, and with BMI and HGS (kappa: 0.795 p<0.001, kappa: 0.709 p<0.001, and kappa: 0.760 p<0.001, respectively). CONCLUSIONS: HGS might be considered instead of BMI in MNA-SF test to assess nutritional status of geriatric patients.

Tumour necrosis factor-alpha, interleukin-10, interferon-gamma and vitamin D receptor gene polymorphisms in patients with chronic hepatitis delta.

No data exist to assess certain polymorphisms that have a potential effect on the immune response in patients with chronic hepatitis delta (CHD). The aim of this study was to investigate polymorphisms in 6 polymorphic sites: IL-10 -1082 (rs1800896), IL-10 -627 (rs1800872), IFN-γ +874 (rs62559044), TNF-α -308 (rs1800629), vitamin D receptor (VDR) FokI (rs2228570) and VDR TaqI (rs731236). The genotypes of 67 patients with CHD and 119 patients with chronic hepatitis B (CHB) were compared. In addition, 56 individuals with resolved hepatitis B virus (HBV) infection were used as a control group for patients with CHB. Polymorphisms in TNF-α, IL-10, and VDR genes were analysed using polymerase chain reaction/restriction fragment length polymorphism methods. The IFN-γ gene polymorphism was detected by allele-specific polymerase chain reaction (PCR). Patients with CDH were more likely to have advanced liver disease compared with patients with CHB (P < 0.0001). IL-10 -1082 and VDR TaqI polymorphisms showed significant differences between patients with CHD and CHB. The high secretory IL-10 -1082 genotype GG was less frequent in CHD compared with patients with CHB and resolved HBV (17.7%, 37.4% and 47.1%, respectively (P < 0.05 for CHD vs CHB and resolved HBV). The frequency of the high secretory VDR TaqI TT genotype was 86.6% in patients with CHD, 62.7% in patients with CHB and 62.5% in resolved HBV individuals (CHD vs CHB: P < 0.05). None of the polymorphisms analysed had an effect on HBV persistence. IL-10 -1082 and VDR TaqI polymorphisms may contribute to the more severe liver disease associated with CHD compared with CHB.

Sarcopenia assessment project in the nursing homes in Turkey.

BACKGROUND/OBJECTIVES: Sarcopenia and sarcopenic obesity (SO) are geriatric syndromes leading to physical disability, poor quality of life and death. The aim of this study was to investigate the prevalence of sarcopenia and SO in nursing homes in Turkey and to define local disparities for diagnosing sarcopenia and SO. SUBJECTS/METHODS: This cross-sectional multicenter study was performed in 711 patients in 14 nursing homes. Comprehensive geriatric assessment tests, handgrip strength and calf circumference (CC) measurements were carried out. Sarcopenia was both defined by handgrip strength and CC criteria. RESULTS: According to handgrip strength measurement, 483 (68%) of patients were sarcopenic (male: 72%, female: 63.8%), 228 were non-sarcopenic. The prevalence of SO was 22% (13.7% in men, 30.2% in women). Patients (82.5%) who were diagnosed as sarcopenic by the handgrip strength test were not sarcopenic according to CC sarcopenia criteria. Therefore, we tried to determine the optimal CC value for diagnosing sarcopenia in our population. CONCLUSIONS: Both sarcopenia and SO were prevalent among Turkish nursing home elderly residents. Most of the patients with sarcopenia were obese or overweight. We showed that diagnosing sarcopenia with CC measurement underestimated the sarcopenia prevalence assessed by handgrip strength. So we concluded that, although different assessment methods are recommended for the diagnosis of sarcopenia local disparities should be considered.

An alternative way for the evaluation of zinc status in the elderly; nail zinc levels and relationship with Alzheimer's disease.

BACKGROUND: Zinc is one of the most important elements for human body. Zinc deficiency can occur in any age, if it is seen in elderly its clinical results can be more harmful due to already diminished functions. Some studies showed zinc deficiency has an important role in the pathogenesis of Alzheimer disease. In this study we measured the nail zinc levels and aimed to show its clinical implications in geriatric patients, especially Alzheimer disease. PATIENTS AND METHODS: 43 patients with Alzheimer disease and 89 patients with normal cognitive function were evaluated. The diagnosis of Alzheimer disease was made according to DSM-IV and NINCDS-ADRDA criteria after cognitive assessment and neuroimaging performed using magnetic resonance. Hand fingernail samples are obtained from the patients. RESULTS: Mean zinc level from fingernail samples was 117.99 ± 73.44 ppm in Alzheimer Disease patients, 123.86 ± 77.98 ppm in control group (p: 0.680). CONCLUSIONS: This is the first study measuring nail zinc levels in elderly patients with and without Alzheimer disease. Our data reveal no significant difference in nail zinc levels between two groups. However, fingernail zinc may be a useful biomarker in elderly population.  

Malnutrition in Turkish nursing homes: a correlate of short term mortality.

OBJECTIVE: Elderly nursing home residents are under high risk of malnutrition. Early interventions to prevent malnutrition may play a critical role in malnutrition-mortality correlation. This study aimed to obtain insight into the prevalence of malnutrition in nursing homes in the capital city of Turkey and the role of malnutrition in predicting the risk for short-term mortality. DESIGN: This study was conducted in seven different residential care facilities in Ankara. MEASUREMENTS: Nutritional status was evaluated by Mini Nutritional Assessment-Short Form. RESULTS: The mean age of the 534 participants was 79.46±7.22 years. Nutritional assessment revealed that 15.9% of all older adults suffered from malnutrition and another 53.6% were at risk of malnutrition. The mortality rate for all subjects was 118 (22.1%) over 18 months, which was significantly higher in participants with malnutrition. CONCLUSIONS: We noted a high prevalence of malnutrition and a strong correlation of increased mortality with malnutrition in nursing home residents. Given the negative impact of malnutrition on mortality and morbidity, an emphasis should be placed on an effective nutritional policy in nursing homes.

Iron deficiency can cause cognitive impairment in geriatric patients.

OBJECTIVES: Deficiency of iron, which plays an important role in oxygen transport and storage, may lead to cerebral hypoxia and cognitive decline. This relationship which was studied in children and adults was not evaluated in the elderly. The objective of this study is to examine the effect of iron deficiency on cognitive function in the elderly. DESIGN, SETTING, PARTICIPANTS: This is a cross-sectional study conducted in a geriatric medicine outpatient clinic of a university hospital. Consecutive 2009 patients admitted to Geriatric Medicine outpatient clinic were examined and 622 patients who fulfilled the inclusion criteria were enrolled in the study. MEASUREMENTS: Comprehensive geriatric assessment, cognitive assessment and laboratory analysis including blood count, iron, total iron binding capacity, ferritin, and transferrin saturation were performed. RESULTS: Mean age of the study group was 72.5±6.5 and 439 (70.6%) were women. MMSE scores were moderately and significantly correlated with iron levels (r=0.33, p<0.001) and transferrin saturation (r=0.32, p<0.001). Transferrin saturation was significantly lower in the patients with dementia (p=0.040). It was found that patients with iron deficiency had lower MMSE scores (p<0.001) and this relationship was also present in patients without anemia (p=0.004). CONCLUSION: The results of this study revealed a negative influence of iron deficiency on cognitive function and this influence was independent from the presence of anemia. As iron deficiency can be easily diagnosed and treated, detecting its effect on cognitive function is of importance. Screening for iron deficiency and initiating appropriate treatment should be a routine part of comprehensive geriatric assessment.

Surgical therapy of end-stage heart failure in pediatric patients.

OBJECTIVE: We herein review our experience with ventricular assist device (VAD) implantation and heart transplantation in children with end-stage heart failure. METHODS: We performed a retrospective nonrandomized review of all patients who underwent insertion of a Berlin Heart Excor VAD or heart transplantation in our clinic. The study spans from July 2005 to July 2010. We transplanted 11 patients of mean age 11.8 ± 4.49 years, 3 of whom with critical hemodynamic situations were bridged to heart transplantation by VAD implantation. Despite the poor right ventricular systolic functions, they did not require right rVAD. In addition, 2 patients who underwent VAD implantation are still awaiting a donor heart. The mean follow-up was 825.27 ± 630.23 days (range, 21-1,888 days). RESULTS: There was no serious complication during VAD support. The overall heart transplantation mortality rate was 9.1% (1/11). In all patients, impaired end-organ functions were improved by VAD implantation before the heart transplantation. Cardiac biopsies revealed 4 grade 2R rejection episodes, which were successfully controlled in 3 patients. CONCLUSION: Heart transplantation is highly effective therapy for pediatric patients with end-stage heart failure. Pediatric VAD implantation provided satisfactory safe circulatory support for small children in poor condition on the waiting list. This option should be considered for all pediatric candidates who show a poor hemodynamic status.

Intra-erythrocyte magnesium levels and their clinical implications in geriatric outpatients.

OBJECTIVES: Magnesium deficiency has been implicated as a factor in numerous chronic diseases and previous studies suggest a greater prevalence of occult magnesium deficiency among older adults. Serum is the choice for the assessment of most analyses used in clinical medicine, although serum magnesium concentrations have been shown to be poor predictors of intracellular magnesium concentration. The aim of this study was to compare intracellular and extracellular magnesium concentrations in geriatric outpatients. Moreover, we examined whether a significant correlation between magnesium parameters and clinical outcome existed. DESIGN: Cross-sectional study. SETTING: Geriatric medicine outpatient clinic of a university hospital. PARTICIPANTS: A total of 246 patients with a mean age of 71.9 ± 5.7 years were involved. MEASUREMENTS: Intra-erythrocyte magnesium levels were analyzed with atomic absorption spectrophotometry. RESULTS: Serum magnesium levels were within normal range in all patients, whereas intra-erythrocyte magnesium measurements were low in 57% of the patients. Increase in serum levels were together with just only a slightly increase in intra-erythrocyte measurements and the relationship was very weak. Intra-erythrocyte Mg levels were not significantly correlated with many laboratory or clinical parameters. CONCLUSION: Our results confirm that intra-erythrocyte Mg does not correlate with serum levels and clinical parameters in geriatric outpatients, but further studies are needed to define the correlation.

Potential biomarkers for vascular damage in Alzheimer's disease: thrombomodulin and von Willebrand factor.

OBJECTIVES: Evidence regarding the vascular basis of Alzheimer's disease (AD) is growing. In vascular damage thrombomodulin tears of the cell wall and its level increases in the plasma. von Willebrand factor (vWF) is also thought to be a biomarker for vascular damage. The aim of this study was to examine the levels of vWF and thrombomodulin in AD as possible markers for vascular damage and to test their utility as an early biomarker in AD. DESIGN: Case-control study. SETTING: Geriatric medicine outpatient clinic of a university hospital. PARTICIPANTS: Twenty Alzheimer's disease patients free from vascular risk factors and 20 controls were enrolled in the study. MEASUREMENTS: Thrombomodulin and VWF levels of 20 AD patients and 20 controls were analyzed by commercial kits. RESULTS: Thrombomodulin levels were not different between Alzheimer's disease and control groups [median (range) = 4.25 (2.27-37.00) ng/ml in Alzheimer's disease and 3.55 (2.27-14.00) in control group, p=0.15]. Von Willebrand Factor antigen (%) levels were 188.5 (96-306) in Alzheimer's disease, and 181 (112- 284) in control group (p=0.74). CONCLUSION: Although vascular damage is thought to play role in the pathogenesis of AD, vWF and thrombomodulin failed to demonstrate the vascular damage in AD. Their utility to be used as early biomarkers of AD could not be shown.

Cardiac tamponade as a first manifestation of possible systemic lupus erythematosus in a 3-year-old female child.

Cardiac manifestations of pediatric systemic lupus erythematosus (SLE) usually occur as an initial manifestation of the disease or within six months after the diagnosis of SLE. Pericarditis is the most frequent cardiac manifestation of SLE, but pericardial effusion causing tamponade, which has a very serious prognosis, rarely occurs, and it is even less frequent for the pericardial tamponade to be the presenting feature of SLE. In the present case which is the youngest case in the literature we report a 3 year old girl who presented to the emergency room with solely pericardial effusion causing tamponade, bilateral pleural effusion and diagnosed "possible SLE" based on American College of Rheumatology criteria.

Advanced age is associated with endothelial dysfunction in healthy elderly subjects.

BACKGROUND: Aging is associated with an increased risk for atherosclerosis in which endothelial dysfunction is an early marker. OBJECTIVE: The purpose of this study was to determine if endothelial function is altered with increasing age in healthy subjects. METHOD: The study population consisted of 30 elderly and 36 younger subjects free from major cardiovascular risk factors. Transthoracic echocardiography was performed for each subject to rule out structural heart disease. Endothelial function was evaluated by flow-mediated dilation (FMD) of the brachial artery via ultrasound. RESULTS: Baseline characteristics of the elderly and the younger group were similar, except for age (mean age: 71.3 +/- 5.8 vs. 26.5 +/- 7.2). Transthoracic echocardiography was normal in all subjects. FMD of the elderly group was significantly lower than the younger group (7.9 +/- 3.1 in the elderly, 10.8 +/- 1.9 in the younger group, p < 0.001). A negative relationship was found between FMD and age (r = -0.528, p < 0.001). CONCLUSION: It can be concluded that endothelial function detected by FMD declines with increasing age in healthy human subjects. Advanced age is a predictor of impaired endothelial function.

Liver transplantation of a child with child a cirrhosis and severe hepatopulmonary syndrome.

Hepatopulmonary syndrome (HPS) is a clinical state defined by a chronic hepatic disorder, intrapulmonary vascular dilatation, and altered gas exchange resulting in hypoxemia. Cirrhosis of the liver is the most common condition associated with HPS. A 3-year-old boy who presented with end-stage liver disease and severe hepatopulmonary syndrome underwent orthotopic liver transplantation (OLT). The findings of HPS resolved immediately after OLT. His status is within normal limits at 6 months after liver transplantation.

A de novo t (X;8)(p11.2;q24.3) demonstrating Cornelia de Lange syndrome phenotype.

Cornelia de Lange syndrome is a rare syndrome of hitherto unknown etiology. We present a 9-months old female patient with de novo t (X;8) (p11.2;q24.3) and Cornelia de Lange Syndrome phenotype. De novo t (X;8)(p11.2;q24.3) was not reported so far in Cornelia de Lange syndrome.