Hasim Olgun

The effects of ondansetron and granisetron on electrocardiography in children receiving chemotherapy for acute leukemia.

5-HT3 receptor antagonists, including granisetron and ondansetron, are widely used in the prophylactic treatment of chemotherapy-induced nausea and vomiting. Although the cardiac safety of granisetron and ondansetron has been investigated in several adult studies, there is no report investigating the effects of those agents on electrocardiography (ECG) in children. The effects of intravenously infused (over 30 seconds) 0.1 mg/kg ondansetron and 40 μg/kg granisetron on ECG were assessed in 22 children receiving high-dose methotrexate therapy for acute lymphoblastic leukemia. The ECG recording was obtained at before and just after the infusion, and repeated at 1, 3, 6, and 24 hours of treatment. Granisetron administration resulted in a statistically significant decrease of mean heart rate at 1 and 3 hours, and significant prolongation of mean QT and QTc dispersions at 1 hour of infusion. In patients treated with ondansetron, no meaningful change was observed. In conclusion, intravenous granisetron but not ondansetron causes clinically asymptomatic and transient changes on ECG measurements in children receiving high-dose methotrexate therapy.

Clinical, Electrocardiographic, and Laboratory Findings in Children With Amitriptyline Intoxication

Background: Amitriptyline is one of the major tricyclic antidepressants, and the data on amitriptyline poisoning in children are limited. Objectives: To present our experiences with amitriptyline poisoning in children, particularly with regard to its effects on electrocardiogram (ECG) and relation with clinical status. Methods: Clinical, laboratory, and electrocardiographic findings in 52 children admitted with amitriptyline poisoning were reviewed. Patients were divided into 2 groups according to age, as 6 years or younger (group A) and older than 6 years (group B). Results: Mean age was 4.6 ± 3.0 years. Thirty-one patients were male, and 41 were 6 years or younger. Ingested amitriptyline dose was known in 23 patients (range, 2.3 mg/kg-27 mg/kg). The most frequent findings were lethargy (76.9%), sinus tachycardia (57.7%), and coma (48.1%). Four patients had a history of convulsion. The most common laboratory abnormalities were hyponatremia (26.9%) and leukocytosis (25%). Elevated transaminase levels were observed in 4 patients. In ECG, 11 (22.4%) patients had QTc prolongation and in 4 (8.2%) of them, it was significant. In 4 patients (8.2%), the QRS duration was 100 ms or longer and in 15 patients, the R wave in aVR was 3 mm or longer. The frequencies of clinical, laboratory, and electrocardiographic findings were similar between the 2 age groups (P > 0.05). No clinically apparent arrhythmias were observed. The positive predictive value of a widened QRS was 100% in terms of coma. None of the patients with an R wave in aVR of less than 3 mm developed convulsion; thus, the negative predictive value of an R wave in aVR of 3 mm or longer was 100% in terms of convulsion. Conclusions: Amitriptyline poisoning may result in severe toxicity. Frequencies of clinical, laboratory, and ECG findings were similar in the 2 age groups. Amitriptyline overdose results in some ECG changes that can possibly help to predict the results of poisoning. Absence of an R wave in aVR of 3 mm or longer predicts seizures with a high negative predictive value, and a QRS duration of 100 or longer ms predicts coma with a high positive predictive value.

Intravenous Paracetamol for Patent Ductus Arteriosus in Premature Infants - A Lower Dose Is Also Effective

babies with hsPDA. The first patient was a 29-week premature infant (birth weight 1,045 g, postnatal age 3 days). Oral ibupro-fen was contraindicated in this patient due to suspected necrotizing enterocolitis (NEC). We started IV paracetamol with the dose regimen suggested by Oncel et al. [1] . After the first 4 doses, transaminase levels were checked and a significant increase was detected compared to pretreatment levels (aspartate aminotransferase (AST) 43 vs. 260 U/l, alanine aminotransferase (ALT) 11 vs. 180 U/l). The drug was ceased and transaminase levels normalized over the following 4 days. After this experience, we decreased each dose to 10 mg/kg (3 doses/day). An echocardiographic study was per-formed after each of the 3 doses. If the duc-tal shunt had disappeared, treatment was stopped, but if it persisted, an additional 3 doses were given, for a maximum of 4 days. In 6 additional patients, IV paracetamol was used with this dosing regimen. All were very low birth weight infants. The gesta-tional ages were <28 weeks (1 patient) and 28–31 weeks (5 patients). Oral ibuprofen could not be given to 2 patients due to Dear Sir, We read with great interest the recent article by Oncel et al. [1] entitled ‘Intrave-nous paracetamol treatment in the man-agement of patent ductus arteriosus in ex-tremely low birth weight infants’. It is the first study to report the results of intrave-nous (IV) paracetamol in premature in-fants where a 3-day treatment (15 mg/kg dose, 4 doses/day) is offered. In the case of treatment failure at the end of the third day, a second course is administered. Palmer et al. [2] reported the following dose regimen for IV acetaminophen to be safe in premature infants: 28–32 weeks, 10 mg/kg; 32–36 weeks, 12.5 mg/kg, and 36 weeks, 15 mg/kg. Although the gestational ages of the patients in the study of Oncel et al. [1] were low, they used a higher dose; no side effect related to IV paracetamol was re-ported. In our clinical practice, prematures with hemodynamically significant patent ductus arteriosus (hsPDA) and contraindi-cations for oral ibuprofen present a great challenge. For these patients, IV para ce ta-mol seems to be a good alternative. We ad-ministered IV paracetamol in 7 preterm

Patient- and lead-related factors affecting lead fracture in children with transvenous permanent pacemaker

AIMS Fracture in transvenous pacing leads is one of the most common reasons for lead abandonment. Although the factors affecting lead failure rates have been investigated, there is no study evaluating the clinical parameters that affect lead fracture in children. We report our experience with lead fracture in children with transvenous pacemakers. METHODS AND RESULTS The follow-up results of 264 leads from 184 patients were evaluated using pacemaker follow-up data. Underlying conditions, implant data, and lead features were evaluated for the analysis of lead fracture. During a mean follow-up of 72.8 +/- 39.7 months (range 3.2-160.6, median 70), lead fracture developed in 19 leads (7.2%) from 18 patients. The mean duration between implantation and lead fracture was 57.3 +/- 35 months (range 6.8-130, median 51). All fractures occurred in the leads implanted by the infraclavicular subclavian approach. Cumulative survival at the end of 5 years was 92.7% in terms of lead fracture. None of the patient-related risk factors correlated with lead fracture. Multivariate analyses of lead-related risk factors revealed a significant correlation only between lead fracture and fixation mechanism (P < 0.05). CONCLUSION Our results indicated that none of the patient-related risk factors was correlated with lead fracture. Among lead-related risk factors, only the fixation mechanism was found to be correlated with lead fracture; thus, it seems that passive fixation mechanism is safer in terms of lead fracture. Although all fractures occurred in the leads implanted by the intrathoracic subclavian approach, statistical analysis revealed no significance for this parameter. The effect of the extrathoracic approach should be investigated in a large group of patients.

Dilated cardiomyopathy secondary to rickets-related hypocalcaemia: eight case reports and a review of the literature.

INTRODUCTION Dilated cardiomyopathy is usually idiopathic and may arise secondary to infections or metabolic or genetic causes. Another rare cause is hypocalcaemia. Owing to the fact that calcium plays an essential role in excitation and contraction of myocardial muscle, myocardial contractility may decline in patients with hypocalcaemia. MATERIALS AND METHODS Patients with symptoms of congestive heart failure and rickets-related hypocalcaemia were assessed clinically and by echocardiography in a paediatric cardiology clinic. Echocardiography was performed for all patients. Rickets was diagnosed according to the clinical, laboratory, and radiologic findings. Maternal lifestyle and living conditions were investigated, and the maternal 25-OH vitamin D3 blood level was measured. RESULTS We evaluated eight patients who developed heart failure as a result of severe hypocalcaemia associated with rickets between August, 1999 and June, 2012. The age distribution of the patients was 3-12 months. Laboratory results were consistent with advanced-stage rickets. Severe hypocalcaemia was detected in all patients. The maternal 25-OH vitamin D3 levels were low. Echocardiography revealed increased pre-treatment left ventricle end-systolic and end-diastolic diameters for age and reduced ejection fraction and fractional shortening. After clinical improvement, the patients were discharged. CONCLUSIONS Severe hypocalcaemia associated with rickets must always be kept in mind among the causes of dilated cardiomyopathy and impaired cardiac function in infants. If diagnosed and treated in time, dilated cardiomyopathy and severe heart failure related to rickets respond well.

Clinical characteristics of neonates With VACTERL association

Background:  The VACTERL association (VA) is the non‐random co‐occurrence of vertebral anomalies, anal atresia, cardiovascular malformations, tracheoesophageal fistula and/or esophageal atresia, renal anomalies, and/or limb anomalies, and is referred to by the first letters of its components. Studies investigating the clinical characteristics of VA patients and probing of the observed current six component types are limited, and none of them is focused on neonates. We investigated the clinical characteristics of our patients diagnosed as having VA in the newborn period.

Significance of bone marrow examination in the diagnostic process of paraspinal mass in children: a case report.

Spinal cord compression is a rare but serious complication of non-Hodgkin lymphoma or leukemia. Biopsy of the mass with or without laminectomy would be necessary for diagnosis in patients presenting with isolated paraspinal mass in the absence of other overt clinical symptoms or findings or laboratory abnormalities that would specifically suggest leukemia or lymphoma. The authors describe a 6-year-old girl with symptoms of spinal cord compression due to a paraspinal mass who had undergone surgical intervention; she was later shown to have acute B-cell lymphoblastic leukemia. A bone marrow aspiration should be considered in such patients to avoid unnecessary surgical intervention.

Congenital cardiac malformations in neonates with apparently isolated gastrointestinal malformations

Background:  The association of congenital cardiac malformations (CCM) with malformations of the gastrointestinal tract/abdominal wall is known. Nevertheless, the data presently available are derived from patient populations that include some special conditions known to be associated with a high rate of CCM. The aim of the present study was therefore to determine the incidence of cardiac malformations among neonates with apparently isolated malformations of the gastrointestinal tract/abdominal wall.

Comparison of safety and effectiveness of two different transfusion rates in children with severe anemia.

We compared the safety and efficacy of 2 transfusion regimens in children with severe anemia (hemoglobin <5 g/dL) and without overt signs of congestive heart failure requiring transfusion of packed red blood cells (PRBCs). Forty-three patients were randomly divided into 2 groups: group A and group B. The transfusion regimens consisted of continuous infusion of PRBC at a rate of 1 mL/kg/h for group A and 3 mL/kg/h for group B. The patients were closely monitored for any clinical signs of heart failure throughout transfusion. Heart and respiratory rate, and arterial blood pressure were measured hourly for 6 hours during transfusion. None of the patients developed any signs of cardiac failure during or after the transfusion. The mean heart rate, respiratory rate, diastolic and systolic blood pressure were similar in both groups throughout transfusion. Group A needed significantly more PRBC units than group B to attain the same hemoglobin increase. Transfusion of PRBC at a rate of 3 mL/kg/h, and at a rate of 1 mL/kg/h, is a safe regimen for children with severe anemia of gradual onset requiring transfusion therapy.

Intravenous paracetamol with a lower dose is also effective for the treatment of patent ductus arteriosus in pre-term infants.

INTRODUCTION Haemodynamically significant patent ductus arteriosus is a significant cause of morbidity and mortality in pre-term infants. This retrospective study was conducted to investigate the usefulness of lower-dose paracetamol for the treatment of patent ductus arteriosus in pre-term infants. MATERIALS AND METHODS A total of 13 pre-term infants who received intravenous paracetamol because of contrindications or side effects to oral ibuprofen were retrospectively enrolled. In the first patient, the dose regimen was 15 mg/kg/dose, every 6 hours. As the patient developed significant elevation in transaminase levels, the dose was decreased to 10 mg/kg/dose, every 8 hours in the following 12 patients. Echocardiographic examination was conducted daily. In case of closure, it was repeated after 2 days and when needed thereafter in terms of reopening. RESULTS A total of 13 patients received intravenous paracetamol. Median gestational age was 29 weeks ranging from 24 to 31 weeks and birth weight was 950 g ranging from 470 to 1390 g. The median postnatal age at the first intravenous paracetamol dose was 3 days ranging from 2 to 9 days. In 10 of the 13 patients (76.9%), patent ductus arteriosus was closed at the median 2nd day of intravenous paracetamol ranging from 1 to 4 days. When the patient who developed hepatotoxicity was eliminated, the closure rate was found to be 83.3% (10/12). CONCLUSION Intravenous paracetamol may be a useful treatment option for the treatment of patent ductus arteriosus in pre-term infants with contrindication to ibuprofen. In our experience, lower-dose paracetamol is effective in closing the patent ductus arteriosus in 83.3% of the cases.