Abdullah Baris Akcan

Peripherally inserted central venous catheters in critically ill premature neonates

Purpose To evaluate the safety of peripherally inserted central venous catheters (PICCs) and their complications in critically ill premature neonates. Methods A retrospective collection of data of infants with very low birth weight (VLBW) who underwent PICC placement over a 2-year period. Gestational age, birth weight (BW), sex, site of catheter placement, reason for catheter removal, duration of the catheter use, proven sepsis, type of the reported organism and the rate of complications were collected. The infants were classified into two groups according to BWs: Group 1–-VLBW infants (BW between 1,000 and 1,500 g) and Group 2–-BW <1,000 g (extremely low birth weight, ELBW group). Results During the study period, 90 VLBW infants were admitted to the neonatal intensive care unit. PICCs were attempted in 71 patients. A PICC was successfully inserted into 62 patients (87.3%). Totally, 68 PICCs were inserted into 62 infants. PICCs placed in either the upper or the lower extremity have no differences in complication rates. The median time of catheter insertion was 10 (1-22) days for Group 1 and 16 (1-47) days for Group 2 (p=0.001). The median duration of PICCs was 9 (2-18) and 12.0 (3-30) days, respectively (p=0.012). There were no significant differences between groups for the reasons for removal (p=0.859). Conclusions PICCs are convenient for the administration of long course antibiotics and parenteral nutrition for both VLBW and ELBW infants. The risk of catheter complications did not increase in ELBW infants. Although the technique of insertion is easy and using PICCs has many benefits, serious and fatal complications may occur in premature neonates in critical states.

The use of chloride–sodium ratio in the evaluation of metabolic acidosis in critically ill neonates

Acid–base disturbances have been usually evaluated with the traditional Henderson–Hasselbach method and Stewart’s physiochemical approach by quantifying anions of tissue acids (TA). It is hypothesized that an increase in tissue acids during metabolic acidosis would cause a compensatory decrease in the plasma chloride (Cl) relative to sodium (Cl–Na ratio) in order to preserve electroneutral balance. Therefore, we aimed to investigate the use of Cl–Na ratio as a bedside tool to evaluate the identifying raised TA in neonates as an alternative to complex calculations of Stewart’s physiochemical approach. This retrospective study was conducted between January 2008 and December 2009. Infants were included in the study when blood gas analysis reveals a metabolic acidosis; pHxa0<7.25 and sHCO3 concentration was <22xa0mEq/L. The Cl–Na ratio, sodium–chloride difference (DiffNaCl), anion gap (AG), albumin-corrected AG (AGcorr), strong ion difference (SID), unmeasured anions (UMA), and TA were calculated at each episode of metabolic acidosis. A total of 105 metabolic acidosis episodes occurred in 59 infants during follow-up. Hypochloremic metabolic acidosis occurred in 17 (16%) of samples, and all had increased TA. The dominant component of TA was UMA rather than lactate. There was a negative correlation between the Cl–Na ratio and SID, AGcorr, UMA, and TA. Also, there was a positive correlation between DiffNaCl and SID, AGcorr, UMA, and TA. Base deficit and actual bicarbonate performed poorly in identifying the TA. In conclusion, our study suggested that DiffNaCl and Cl–Na ratio are simple and fast, and may be an alternative method to complex Stewart’s physiochemical approach in identifying raised UMA and TA in critically ill neonates.

Mean platelet volumes in babies of preeclamptic mothers.

The aim of this study was to compare the mean platelet volume (MPV) in babies of preeclamptic and normal pregnant women and to investigate the correlation between thrombocytopenia and MPV in the babies of preeclamptic mothers. A total of 63 newborns with similar gestational ages were included in this retrospective study. They were divided into three groups as 21 babies of preeclamptic mothers with thrombocytopenia (Group A), 21 without thrombocytopenia (Group B), and 21 babies of normal pregnant women without thrombocytopenia (Group C). Hematologic data of these patients, obtained in the first 72 h of their life, were obtained from their medical records. Groups were compared according to their birth weights, platelet counts, and MPV. Gestational ages and birth weights of all groups were similar. The platelet count of group A was significantly lower (P < 0.001). MPV seemed to increase as platelet counts decreased when the groups were compared. However, no significant correlation was found between MPV and platelet counts and no significant difference between MPVs (P = 0.052). Increase in MPV is accepted as a sign of platelet destruction and decrease as a sign of platelet production insufficiency. Our results showed that the cause of thrombocytopenia in babies of preeclamptic mothers cannot be explained with the help of MPV.

Nanoduct Sweat Conductivity Measurements in 2664 Patients: Relationship to Age, Arterial Blood Gas, Serum Electrolyte Profiles and Clinical Diagnosis

Background The Nanoduct® device has acceptable diagnostic accuracy, but there is not enough systematic data supporting its usage in the diagnosis of cystic fibrosis (CF). Methods A retrospective review of patients with an indication for the sweat test was conducted. The conductivity test was repeated in patients who had values higher than 60 mmol/L, and they were referred for sweat chloride measurements. Associations between sweat conductivity measurements and age, gender, (pH, HCO3, pCO2, Na, K, Cl), family history, consanguinity, indications for the test and number of hospitalization were studied. Results Among 2,664 patients, 16 children had sweat conductivity values higher than 80. The median age of patients diagnosed with CF was 4 months old. Age, pH, HCO3, Na, Cl, K and the sweat conductivity test were statistically related (P < 0.001). The ROC curve showed very high agreement between the 2nd conductivity test and the sweat test. Conclusions Patients suspected to have CF can be screened using the Nanoduct® conductivity device in non-qualified centers.

The efficacy of cardiac findings in assessing the outcome in preterms with bronchopulmonary dysplasia.

ObjectivesTo evaluate if cardiac dysfunctions are important in assessing the outcome in newborns with Bronchopulmonary Dysplasia (BPD), by evaluating cardiac functions with N-terminal prohormone of brain natriüretic peptide (NT-proBNP) levels, M-mode and tissue doppler echocardiography at 6–12xa0mo of age.MethodsTwenty eight patients were retrospectively classified as mild, moderate and severe according to the diagnostic criterias for BPD. All cases were assessed with standard M-mode, tissue doppler echocardiography and NT-proBNP levels. Control group consisted of 28 healthy infants, having similar postnatal ages as patients and were assessed with standard M-mode and tissue doppler echocardiography.ResultsThe age of patients with BPD was 9.8u2009±u20092.3xa0mo and control group was 9.5u2009±u20092.6xa0mo. There was no significant difference between the postnatal ages of two groups (pu2009>u20090.05). Neither pulmonary hypertension nor pulmonary/tricuspid regurgitation was detected. The M-mode echocardiography measurements did not differ between patients and control group (pu2009>u20090.05). Tissue doppler echocardiography, tricuspid valve medial segment early diastolic myocardial relaxation velocity (TME’) measurements of patients were found significantly lower, peak transtricuspid filling velocity in the early diastole (TE)/TME’ ratios and isovolumetric relaxation time (IVRT) measurements were found significantly higher than control group (pu2009<u20090.05). Tricuspid E, TE/TLE’ (Tricuspid valve lateral segment early diastolic myocardial relaxation velocity), TE/RVLE’(Right ventricular lateral segment early diastolic myocardial relaxation velocity), TE/TME’ levels were also found as significantly abnormal in patients with severe BPD. A significant correlation was found between right ventricular diastolic disfunctions and severity of BPD (pu2009<u20090.05). No statistically significant difference was found between NT-proBNP levels, BPD stages and tissue doppler echocardiography measurements (pu2009>u20090.05).ConclusionsThis is the first study evaluating cardiac findings in patients with BPD by tissue doppler echocardiography and NT-proBNP at the same time. On the basis of cardiac evaluations, tissue doppler echocardiography measurements were found as significant and specific for the early assessment of right ventricular diastolic disfunctions.

Effect of breastfeeding on serum zinc levels and growth in healthy infants.

BACKGROUNDnThis study investigated the association among breastfeeding, serum zinc levels, and nutritional status of children.nnnSUBJECTS AND METHODSnOne hundred healthy infants were included in the study. Anthropometric measurements of the children were taken, and their plasma zinc levels were determined. The mothers were interviewed about the duration of breastfeeding and nutrition pattern of the children at the time of zinc measurement.nnnRESULTSnLow zinc levels were associated with lower weight measurements (r=0.49, p<0.001), but the association between height and zinc level was not statistically significant (r=0.18, p>0.05). There was a negative correlation between breastfeeding duration and weight-for-age percentile (r=-0.2, p<0.05), height-for-age percentile (r=-0.3, p<0.05), and serum zinc level (r=-0.3, p=0.002). The pattern of nutrition correlated only with the weight of the infant (r=0.2, p<0.05) and not with either height or serum zinc levels (p>0.05).nnnCONCLUSIONSnExclusive breastfeeding beyond 6 months of age has negative effects on serum zinc levels and can be associated with low weight gain, which will be especially important in developing countries.

Effects of high-dose intravenous immunoglobulin on lipopolysaccharide-induced acute lung injury

PURPOSEnIntravenous immunoglobulin (IVIG) therapy is used in inflammatory diseases but the use of immunoglobulin as a treatment for acute lung injury (ALI) has not been previously studied. Transforming growth factor beta (TGF-β) plays a critical role in the pathogenesis of of ALI. Therefore we examined the levels of TGF-β and lung inflammation scores in IVIG treated ALI models.nnnMETHODSnIntratracheal lipopolysacccharide was given to rats. Groups 1 and 3 received saline, whereas group 2 received IVIG. 24h later saline was given to groups 1 and 2 and IVIG to group 3. Blood samples and bronchoalveolar lavage (BAL) fluids were obtained from each group and sacrificed for pathological evaluation.nnnRESULTSnBAL TGF-β levels of groups 2 and 3 on day 30, were lower compared to their levels of day 2 (p=0.01, p=0.01). BAL TGF-β levels of groups 2 and 3 were lower than the levels of group 1 on day 30 (p=0.002, p=0.001). Pathological examination revealed that the inflammation scores of groups 2 and 3 on day 30, were lower than the scores of day 2 (p=0.02, p=0.01). Inflammation scores of group 2 were lower than group 1 on day 30 (p=0.02). Moderate fibrosis was seen in half of the rats from group 1 and one rat from group 2.nnnCONCLUSIONnHigh-dose IVIG decreased lung inflammation scores and BAL TGF-β1 levels and this therapy would give even better results if it is given earlier.

Low-cost home-use light-emitting-diode phototherapy as an alternative to conventional methods.

BACKGROUNDnThe aim of our study was to evaluate whether a portable, light-weight, light-emitting-diode phototherapy unit designed for home use is as effective as conventional blue-light fluorescent phototherapy (CFP) for treating hyperbilirubinemia in neonates.nnnMETHODSnA total of 50 patients were recruited sequentially for treatment using CFP (n = 25) and the home-type phototherapy unit (n = 25).nnnRESULTSnThe average rate of decrease in bilirubin levels was 0.17 ± 0.02 and 0.20 ± 0.01 mg/dL/hours at the end of 24 hours in the groups receiving phototherapy by CFP and home-type phototherapy units, respectively. There was no statistically significant difference in the rate of the decrease in bilirubin levels between the groups (p = 0.104).nnnCONCLUSIONSnIt has been shown that the home-type phototherapy unit is as effective as CFP units in the treatment of neonatal hyperbilirubinemia and has the potential to become a standard of care for treatment of jaundiced neonates.

A Systemic-Onset Juvenile Idiopathic Arthritis Patient with Reduced Anakinra Treatment Admitted with an Attack

Interleukin-1 plays an important role in the pathogenesis of systemic-onset juvenile idiopathic arthritis (SoJIA), and the use of anti-interleukin-1 therapy has been increasing. We report a case of a 14-year-old male patient with SoJIA. He was in remission with anakinra treatment for almost 2 years. When we extended the therapeutic range and decreased the dose (1 mg/kg twice a week), he developed symptoms mimicking pulmonary embolism and cardiac ischemia. Increased cardiac enzyme levels and echocardiographic findings were interpreted as myopericarditis. Pulmonary computed tomography angiography revealed no thrombus. An SoJIA attack was considered because of high level of acute-phase reactants and clinical findings. Intensive immunosuppressive therapy with 2 mg/kg/day anakinra was reinitiated. Clinical and laboratory parameters began to improve on the fifth day of treatment. Thus, anti-interleukin-1 therapy is very important in patients with SoJIA. Although the treatment dose was gradually reduced and the therapeutic range was extended, it is noteworthy that the case progressed to a severe clinical condition. Broad prospective studies regarding whether, how long, and for what reasons the dosages of these drugs should be reduced in patients with SoJIA with no genetic disorders are required.

A CASE OF CEFTRIAXONE-INDUCED TOXIC EPIDERMAL NECROLYSIS IN GENITAL AREA

ABSTRACT We present a 2-year-old Turkish boy who was treated with ceftriaxone several days for acute tonsillitis, complicated with toxic epidermal necrolysis (TEN) that was initially diagnosed as drug eruption. The advantages of a long half-life, wide spectrum, high tissue penetration rate, and a good safety profile, make ceftriaxone, a thirdgeneration cephalosporin, a frequent choice in the treatment of childhood infections. To the best of our knowledge, this is the first case of ceftriaxone-induced toxic epidermal necrolysis in genital area in the English literature. Key words: Drug hypersensitivity, adverse drug reaction, toxic epidermal necrolysis, ceftriaxone