Nurettin Ünal

Etanercept for therapy‐resistant macrophage activation syndrome

Macrophage activation syndrome (MAS) is a severe, potentially fatal complication of childhood rheumatic diseases, especially systemic onset juvenile idiopathic arthritis (SoJIA). We report a 4‐year‐old girl with probable SoJIA who presented with MAS. She did not respond to pulse methyl prednisolone and Cyclosporine A (CsA). She also failed to respond to intravenous immunoglobulin (IVIG) therapy. Etanercept was started, based on the observation of increased serum levels of tumor necrosis factor‐alpha (TNF‐α) in patients with MAS. Her condition improved following etanercept, suggesting that etanercept might have a therapeutic role in resistant MAS. Pediatr Blood Cancer 2008;50:419–421.

Metoclopramide induced dystonia in children: two case reports.

Metoclopramide is a dopamine antagonist that is widely used in gastroesophageal disease and chemotherapy-induced emesis in the paediatric population. It is also prescribed in nausea and vomiting caused by respiratory tract infections and enteritis in practice. The primary side-effect of the drug is extrapyramidal reactions with incidences as high as 25% in children. We report two cases, one of which was referred to our emergency department as encephalitis and the other as tetany, but which were just acute dystonic reactions caused by metaclopramide, even though the patients had used the drug in the recommended dosages. The adverse effects of the drug can be seen at normal doses. These dystonic reactions caused by metaclopramide can easily be confused with other diseases, because dystonia is not seen frequently in paediatric practice whatever the cause.

Evaluation of serum lipids and carotid artery intima media thickness in epileptic children treated with valproic acid

The aim of this study is to evaluate the carotid artery intima media thickness and serum lipids in pediatric patients with epilepsy treated with valproic acid. The study included 44 pediatric epileptic and 40 healthy children. Intima media thickness of left common carotid artery and fasting lipid profile (total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol) were assessed. Although we did not observe any differences regarding serum lipid profiles, intima media thickness of common carotid artery was significantly higher in epileptic patients treated with valproic acid. We suggest that this increase in intima media thickness of common carotid artery may be due to epilepsy and/or valproic acid treatment.

Platelet activation in congenital heart diseases

The research presented here investigated platelet activation in cyanotic and acyanotic congenital heart diseases (CHD). Children with cyanotic CHD are prone to both thrombosis and hemorrhage. However, patients with acyanotic CHD may also have a mild bleeding disorder. The platelet activation in CHD was investigated in support of a hypothesis that platelet activation may play a role in the hemostatic abnormalities reported in these patients. Platelet activation was determined by using flow cytometry with anti‐CD62 monoclonal antibody (mAb), which has been shown to be a specific marker of platelet activation. Thirteen children with cyanotic CHD, 33 children with acyanotic CHD and 17 healthy children serving as controls were studied. Platelet activation was significantly higher in the cyanotic group and also in the acyanotic group compared with the healthy children (P = 0.0000 and P = 0.019, respectively). In the cyanotic group, platelet activation showed a direct correlation with arterial O2 saturation (SaO2) (P = 0.014). There was no correlation between platelet activation and erythrocyte related parameters in either group. Platelet activation occurs in CHD, particularly in patients with cyanotic CHD (even in patients with no evidence of clinical thrombosis) and it may play a role in the pathogenesis of thrombotic disorders seen in these patients.

Asymptomatic intracranial sewing needle: An unsuccessful infanticide attempt?

Infanticide attempts may appear in various clinical scenarios. Although very rarely reported, insertion of foreign objects through the cranial sutures may sometimes be used as a method of infanticide. In the present report, a 10-year-old orphaned girl who was brought to the emergency department because of minor head trauma and diagnosed to have a sewing needle in her brain parenchyma is investigated.

Are Mean Platelet Volume and Platelet Distribution Width Useful Parameters in Children With Acute Rheumatic Carditis

Rheumatic fever (RF) is an inflammatory disease caused by autoimmune response to a preceding group A streptococcal infection. Mean platelet volume (MPV) reflects the platelet size and the rate of platelet production in bone marrow, and it may be used as an indicator of platelet activation and severity of inflammation. Fifty-three consecutive patients diagnosed with acute rheumatic carditis and 53 control subjects were enrolled into this study. Leukocyte and platelet counts were significantly higher in patients with acute carditis before treatment compared with controls, whereas MPV and platelet distribution width (PDW) values were not significantly different between groups. Platelet counts, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) values were decreased significantly in patients with RF after treatment. There was not a significant difference in terms of platelet count between the controls and the patient group after treatment. ESR was found to be correlated with CRP in patients before and after treatment. In conclusion, the results of our study showed that MPV and PDW levels do not change during acute rheumatic carditis before and after treatment.

Clinical and epidemiological features of Turkish children with 2009 pandemic influenza A (H1N1) infection: Experience from multiple tertiary paediatric centres in Turkey

Abstract Background: In April 2009 a novel strain of human influenza A, identified as H1N1 virus, rapidly spread worldwide, and in early June 2009 the World Health Organization raised the pandemic alert level to phase 6. Herein we present the largest series of children who were hospitalized due to pandemic H1N1 infection in Turkey. Methods: We conducted a retrospective multicentre analysis of case records involving children hospitalized with influenza-like illness, in whom 2009 H1N1 influenza was diagnosed by reverse-transcriptase polymerase chain reaction assay, at 17 different tertiary hospitals. Results: A total of 821 children with 2009 pandemic H1N1 were hospitalized. The majority of admitted children (56.9%) were younger than 5 y of age. Three hundred and seventy-six children (45.8%) had 1 or more pre-existing conditions. Respiratory complications including wheezing, pneumonia, pneumothorax, pneumomediastinum, and hypoxemia were seen in 272 (33.2%) children. Ninety of the patients (11.0%) were admitted or transferred to the paediatric intensive care units (PICU) and 52 (6.3%) received mechanical ventilation. Thirty-five children (4.3%) died. The mortality rate did not differ between age groups. Of the patients who died, 25.7% were healthy before the H1N1 virus infection. However, the death rate was significantly higher in patients with malignancy, chronic neurological disease, immunosuppressive therapy, at least 1 pre-existing condition, and respiratory complications. The most common causes of mortality were pneumonia and sepsis. Conclusions: In Turkey, 2009 H1N1 infection caused high mortality and PICU admission due to severe respiratory illness and complications, especially in children with an underlying condition.

QTc dispersion in children with severe head trauma.

Objective: Corrected QT (QTc) interval prolongation has been described after subarachnoid hemorrhage and head injury in adults. Abnormal QTc prolongation is associated with a higher risk of ventricular arrhythmias. The aim of this study was to analyze QTc interval and QTc dispersion in children with severe head trauma. Methods: Forty-three patients with severe head trauma and 49 children with no or only mild head injury as controls were enrolled in the study. QT interval from standard 12-lead electrocardiogram immediately after admission was calculated. QT interval was corrected by heart rate according to Bazett formula, and then QTc dispersion was calculated. At the same time, levels of serum electrolytes were measured. Results: Although no significant difference in terms of age, sex, and R-R interval was found, QTc interval and QTc dispersion values were significantly increased in the patients with severe head trauma compared with those with no or only mild head injury (QTc, 447 ± 31 vs. 409 ± 27 milliseconds; QTc dispersion, 77 ± 22 vs. 52 ± 16 milliseconds, respectively). When the patients with severe head trauma were categorized as those with or without intracranial hemorrhage, both QTc interval and QTc dispersion were significantly greater in those with intracranial hemorrhage. These electrocardiographic parameters were inversely associated with Glasgow Coma Scale score, serum calcium levels, and, at a lesser degree, potassium levels. Conclusions: Children with severe head trauma, especially those with intracranial hemorrhage have longer QTc interval and greater QTc dispersion.

Usefulness of Neutrophil to Lymphocyte Ratio in Prediction of Coronary Artery Lesions in Patients with Kawasaki Disease

BACKGROUND Kawasaki disease is an inflammatory condition. Neutrophil to lymphocyte ratio is a marker reflecting inflammation. AIMS The aim of the study is to evaluate usefulness of neutrophil to lymphocyte ratio in diagnosis of Kawasaki disease and in prediction of coronary artery lesions. STUDY DESIGN Retrospective cross-sectional study. METHODS Seventy-five children with Kawasaki disease and 66 controls were retrospectively enrolled. Their leukocyte, neutrophil, and lymphocyte counts were recorded. Abnormally distributed data were shown as median (interquartile range). Cases having coronary artery diameter two standard deviation above mean were diagnosed to have coronary artery lesions. RESULTS Median age of Kawasaki disease patients was 34 months. Twentyfive of those (33.33%) had incomplete Kawasaki disease and twenty-six (34.66%) had coronary artery lesions. Leukocyte [12.61 (6.09)×10(3)/µL vs. 8.48 (5.58)×10(3)/µL], neutrophil [6.73 (4.10) ×10(3)/µL vs. 4.62 (5.47)×10(3)/µL], and lymphocyte [4.04 (2.91)×10(3)/µL vs. 3.02 (2.57) ×10(3)/µL] counts were significantly higher in Kawasaki disease patients compared to controls (all p values <0.01). However, there was not significant difference between patients and controls regarding neutrophil to lymphocyte ratio [1.72 (1.22) vs. 1.71 (1.88)]. Findings of Kawasaki disease and incomplete Kawasaki disease cases did not differ, while comparison of patients with and without coronary artery lesions revealed significantly higher neutrophil to lymphocyte ratio values in former group [2.02 (1.63) vs. 1.50 (1.28), p=0.01]. The cut-off neutrophil to lymphocyte ratio value for prediction of coronary artery lesions was determined as 1.32. CONCLUSION Neutrophil to lymphocyte ratio values in Kawasaki patients with coronary lesions were significantly higher than the ones without and values greater than 1.32 were useful in prediction of coronary lesions.

Clinical accuracy of tympanic thermometer and noncontact infrared skin thermometer in pediatric practice: an alternative for axillary digital thermometer.

Introduction The aim of this study was to compare the body temperature measurements of infrared tympanic and forehead noncontact thermometers with the axillary digital thermometer. Methods Randomly selected 50 pediatric patients who were hospitalized in Dr Behcet Uz Children’s Training and Research Hospital, Pediatric Infectious Disease Unit, between March 2012 and September 2012 were included in the study. Body temperature measurements were performed using an axillary thermometer (Microlife MT 3001), a tympanic thermometer (Microlife Ear Thermometer IR 100), and a noncontact thermometer (ThermoFlash LX-26). Results Fifty patients participated in this study. We performed 1639 temperature readings for every method. The average difference between the mean (SD) of both axillary and tympanic temperatures was −0.20°C (0.61°C) (95% confidence interval, −1.41°C to 1.00°C). The average difference between the mean (SD) of both axillary and forehead temperatures was −0.38 (0.55°C) (95% confidence interval, −1.47°C to 0.70°C). The Bland-Altman plot showed that most of the data points were tightly clustered around the zero line of the difference between the 2 temperature readings. With the use of the axillary method as the criterion standard, positive likelihood ratios were 17.9 and 16.5 and negative likelihood ratios were 0.2 and 0.4 for tympanic and forehead measurements, respectively. Discussion The results demonstrated that the infrared tympanic thermometer could be a good option in the measurement of fever in the pediatric population. The noncontact infrared thermometer is very useful for the screening of fever in the pediatric population, but it must be used with caution because it has a high value of bias.