Emine Suskan

Establishment of interdisciplinary child protection teams in Turkey 2002–2006: Identifying the strongest link can make a difference!

OBJECTIVES The University of Iowa Child Protection Program collaborated with Turkish professionals to develop a training program on child abuse and neglect during 2002-2006 with the goals of increasing professional awareness and number of multidisciplinary teams (MDT), regional collaborations, and assessed cases. This paper summarizes the 5-year outcome. METHODS A team of instructors evaluated needs and held training activities in Turkey annually, and provided consultation when needed. Descriptive analysis was done via Excel and SPSS software. RESULTS Eighteen training activities were held with 3,570 attendees. Over the study period, the number of MDTs increased from 4 to 14. The MDTs got involved in organizing training activities in their institutions and communities. The number of medical curriculum lectures taught by MDTs to medical students/residents, conferences organized by the MDTs, and lectures to non-medical professional audiences increased significantly (R(2)=91.4%, 83.8%, and 69.2%, respectively). The number of abuse cases assessed by the MDTs increased by five times compared to pre-training period. CONCLUSIONS A culturally competent training program had a positive impact on professional attitudes and behaviors toward recognition and management of child abuse and neglect in Turkey. The need to partner with policy makers to revise current law in favor of a greater human services orientation became clear. PRACTICE IMPLICATIONS Pioneers in developing countries may benefit from collaborating with culturally competent instructors from countries with more developed child protection systems to develop training programs so that professional development can improve recognition and management of child abuse and neglect.

Selective Immunoglobulin M Deficiency Presenting with Recurrent Impetigo: A Case Report and Review of the Literature

Selective immunoglobulin M (IgM) deficiency is a rare disorder defined by a decreased serum level of IgM and normal levels of other immunoglobulin classes. The disease has not been well described and the cause remains unknown. Patients with IgM deficiency may present with a wide spectrum of clinical manifestations, from asymptomatic to life-threatening infections, including recurrent respiratory and gastrointestinal infections, allergy and autoimmunity. Here, we report a 6.5-year-old otherwise healthy boy with selective IgM deficiency who presented with multiple recurrent impetigo. We reviewed the published data regarding selective deficiency of IgM.

Late Presentation of a Traumatic Rupture of the Diaphragm with Gastric Volvulus in a Child: Report of a Case

Rupture of the diaphragm following blunt trauma is rare in children. A late presentation of a left diaphragmatic rupture with gastric volvulus is also highly exceptional. The authors report the case of a 5-year-old boy with a left diaphragmatic rupture, who presented with acute respiratory distress and volvulus of the herniated stomach 6 months after injury. The features of this uncommon entity are discussed with special emphasis on early diagnosis. It is concluded that repeated chest radiographs during hospitalization, as well as some days after discharge, should be obtained in trauma patients to detect a slowly increasing herniation.

The validity of diagnostic criteria for streptococcal pharyngitis in Integrated Management of Childhood Illness (IMCI) guidelines.

The WHOs Integrated Management of Childhood Illness (IMCI) programme is being implemented in Turkey with an additional section relating to throat problems for our countrys adaptation. The aim of this study is to evaluate the validity of this additional part and suggest new combinations for the diagnosis of streptococcal pharyngitis to improve the guidelines. Throat swabs were obtained from 245 children between 0 and 17 years of age with signs and symptoms of upper respiratory tract infections. Considering the throat culture based diagnosis as the gold standard, the validity of the symptoms alone and in combinations were calculated. The combination in Turkeys IMCI guideline was found to be 36.9 per cent sensitive and 68.3 per cent specific. Sensitivities of combinations including at least two of the following three symptoms, namely sore throat, pharyngeal erythema, and pharyngeal exudates or sore throat, pharyngeal erythema, and fever, were 76.9 and 87.7 per cent, respectively. Specificities of the same combinations were 49.4 and 30.6 per cent. We concluded that new combinations with a higher sensitivity may be considered as a criterion for antibiotic treatment.

Masturbation mimicking seizure in an infant.

A 3.5-month-old boy was referred to our hospital with the diagnosis of infantile spasm. His developmental milestones and physical examination were normal. During the follow-up we recorded about six to nine attacks a day and the duration of attacks was changed between 15 seconds–1.5 minutes. During the episodic attacks he was flushed and had tonic posturing associated with crossing of thighs, without loss of consciousness and his eye movements were normal. Routine and long-term electroencephalogram (EEG) were normal during attack. The patient was diagnosed as masturbation according to the clinical and EEG findings. In conclusion, we would like to stress that masturbation should also be considered in infants who were admitted with complaint of seizure, and aside from EEG monitoring a detailed history and careful observation are very important factors in differential diagnosis of these two different conditions.

Intracardiac thrombosis associated with acquired protein C deficiency.

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ISOLATED DEFICIENCY OF GLUCOCORTICOIDS PRESENTING WITH CHOLESTASIS

Abstract Background: Isolated deficiency of glucocorticoids is characterized by elevated levels of adrenocorticotropin (ACTH) and normal aldosterone production. It is rare for isolated deficiency of glucocorticoids to be associated with liver involvement. A case of an infant with isolated deficiency of glucocorticoids presenting with cholestasis is presented in this article. A male infant on his 39th postnatal day was referred to our hospital for evaluation of prolonged jaundice and convulsion. He had two episodes of hypoglycemic convulsion on postnatal 8th and 39th day, after which he was admitted to our hospital.

Fungi balls and treatment in infancy.

is approximately 57% in pediatric patients.1 Fungi balls are regarded as a complication of these infections. Preterm infants, especially infants with genitourinary abnormalities, with multiple indwelling catheters, patients treated with prolonged broad-spectrum antibiotics and immunocompromized patients are at a high risk for invasive candidiasis.2 Various treatment modalities have been recommended for urinary fungi balls, but there is no consensus due to the small number of cases.

Comparison of the levels of knowledge and approaches in relation with child abuse and neglect in residents of pediatrics, pediatricians and practitioners working in the province of Ankara.

AIM In this study, it was aimed to evaluate the levels of knowledge and approaches related with child abuse and neglect in pediatricians and practitioners who have a significant role in recognition and prevention of child abuse and neglect. MATERIAL AND METHODS Two hundred residents of pediatrics and 100 pediatricians working in university and education and research hospitals in the center of Ankara province and 250 practicioners working in primary health care centers were included in the study. A scale composed of five parts including history, physical examination, radiology, risk groups and symptoms was prepared to determine the level of knowledge of physician related with child abuse and neglect. The correct answers given to the questions included in the scale were added and knowledge scores for the subscales and the total score were calculated. Approval was obtained from Ankara University, Medical Faculty Ethics Committee for the study. The data were evaluated using Mann-Whitney U and Kruskal Wallis test. RESULTS A total of 550 physicians (339 female and 221 male) were included in the study. The mean total knowledge score related with child abuse and neglect was found to be 12.4±4.5 in residents of pediatrics, 13.7±2.8 in pediatricians and 13.6±2.8 in practitioners. The level of knowledge was found to be significantly higher in women, married physicians, physicians who received education before and after graduation, physician who confronted with cases of abuse or suspicious abuse and made a legal notice. CONCLUSION In the light of these findings, child abuse and neglect should be included in education programs before and after graduation for physicians who have a key role in the subject of child abuse and neglect.

New challenges of the pediatric emergency department: synthetic cannabinoids

To the Editor, In recent years, the frequency of use of synthetic cannabinoid (SC) has increased in the adolescent age group (1). While it is known as “K2”, “Spice”, “Aroma”, ”Mr.Smiley”, “Zohai”, “Eclipse”, “Black Mamba”, “Red X Dawn”, “Blaze”, the name “Bonzai” has come to the forefront in our country (2). Synthetic cannabinoids are sprayed on plants, are sold in packages with warnings including “natural plant mixture”, “incense”, ‘’not for human use” and is consumed like cigarette (3). It is important to recognize poisonings due to this kind of substances the content and dosage of which are unclear and to perform appropriate interventions. In this article, it was aimed to present a 17-year old male patient who presented to the pediatric emergency department after usage of SC after obtaining verbal consent and to draw attention of physicians working in pediatric emergency departments to this issue. A 17-year old male patient was brought to the pediatric emergency department by 112 ambulence because of headache, muscle aches, nervousness, restlessness and drowsiness following use of SC. The Glascow coma scale was found to be 15 and systemic examination and vital findings were found to be normal. It was learned that he was using depakin because of epilepsy and had no additional illness. In his history, it was learned that he started to use SC approximately 6 months ago, obtained the substance from street vendors and used SC like cigarette. He was not using any other illegal substance or alcohol. He did not attend the school and was working as an errand-boy in industry. Complete blood count, blood biochemistry and electrocardiography were found to be normal. It was thought that his complaints arised from SC. Nervousness and restlessness improved after 5 mg oral diazepam. No additional problem developed during the 6-hour follow-up period. He was discharged to be referred to the Alcohol and Substance Addicts Research and Treatment Center. A significant increase has occured in substance abuse and related mortality in recent years. In our country, 12 deaths related with substance abuse were reported in 2000, whereas this figure reached 147 in 2007 (4). The frequency is increasing in the adolescence because of low price and easy accessibility. The issue is in the news in visual and printed media almost everyday and a growing number of cases present to emergency departments. Adolescents may abuse substance because of many different reasons. Individual risk factors include antisocial personality, agressiveness, hyperacitivity and chronic diseases. Environmental risk factors include intra-familial violence, parents who abuse illegal substances, weak family bonds and exposure to abuse. Social risk factors include easy accessibility of illegal subtances, poverty, unemployment and a high rate of crime in the area of residence (5). In our case, presence of underlying epilepsy and working as an employee in industry instead of attending the school were thought to be risk factors. In the diagnosis, the most important clue is a history of usage of SC. In patients with cognitive, behavioral and mood disorders, usage of SC should be suspected, if sympatomimetic findings are present additionally. The signs and symptoms reported after use of synthetic cannaboid are shown in Table 1. The laboratory tests are generally within the normal limits, but they should be performed to find additional pathologies. SC can not be determined with standard toxicological screening tests. Table 1. Signs and symptoms reported after use of synthetic cannabinoid (1) The mainstay of treatment consists of supportive therapy. Patients should be monitored in a quiet and calm room at an appropriate temperature and treatment should be planned according to the clinical findings. It has been shown that agitation improves with long-acting benzodiazepines and dystonia improves with diphenhydramine (1). It is important to interrogate patients in terms of abuse of additional substances other than SC and to perform additional therapeutical interventions if necessary. Following urgent treatment and follow-up patients should be referred to appropriate psychiatry and substance addiction treatment centers.