Perran Boran

Impact of obesity on ventilatory function

OBJECTIVE Although obesity was found to be associated with severe impairment of ventilation, most of the study population has been morbidly obese adults. We aimed to explore the effects of mild obesity on ventilatory function in the pediatric age group. METHODS In a cross-sectional controlled study, 80 patients (M/F: 35/45), who were evaluated in our outpatient clinic with the complaint of excess body weight, with no history of asthma or other atopic diseases were studied and compared to a control group of 50 normal weight children controlled for age and sex. The mean age of patients was 9.7+/-2.5 years (7 to 15 years). Anthropometric measurements and spirometry were performed in all subjects. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were used as measures of ventilatory function. RESULTS There were no significant differences in FEV1%, FVC% and FEV1%/FVC% by study group (p > 0.05). Only three patients had obstructive abnormalities documented on their pulmonary function tests (two had moderately severe and one had mild obstructive abnormalities). No correlation was observed between pulmonary function parameters and anthropometric measurements. CONCLUSION These data demonstrate that pulmonary function test parameters of the mildly obese children were similar to those of the normal weight children. Anthropometric measurements had no significant effect on spirometric measurements in children as they did on adults.

Evaluation of Mild Head Injury in a Pediatric Population

Approximately 5 million children present to emergency departments, seeking care for head injuries, each year, and 80% of these children are classified as cases of mild head injury. Due to the huge number of patients and low frequency of intracranial lesions in this group, obtaining a computed tomography scan for each and every patient is a significant economic problem. This study was conducted to identify the clinical parameters and the radiographic findings that may be associated with intracranial lesions in children with mild head injury. 421 patients, with a Glasgow Coma Scale score of 15 and without any focal neurological deficit, were studied. Intracranial lesion was noted in 37 cases (8.8%). Sensitivity of a plain radiogram was 43.2%, and specificity was 93%. An intracranial pathology was demonstrated in 28.9% of the patients with a linear skull fracture. The only clinical parameters associated with an increase in the frequency of detection of intracranial lesions were posttraumatic seizures and loss of consciousness. Age, sex, headache, vomiting and scalp lacerations were not associated with a higher frequency. Even when patients with a history of loss of consciousness or posttraumatic seizure were subtracted from the study group, intracranial lesions were noted in 4.1% of the cases, and in 1.8% neurosurgical intervention was required. Computed tomography is the gold standard in the evaluation of pediatric patients with mild head trauma, and every child who has experienced a head injury should undergo a cranial computed tomography evaluation, even if he or she appears in perfect health.

Methemoglobinemia due to application of prilocaine during circumcision and the effect of ascorbic acid.

Local anesthesia with prilocaine has become a routine part of ambulatory circumcision procedures. Methemoglobinemia is a rare but potentially lethal complication of local anesthetics. We report the case of a 42-day-old boy who presented with cyanosis after receiving local anesthesia with prilocaine. Methemoglobin level revealed severe methemoglobinemia (methemoglobin=44.5%). His cyanosis promptly resolved after intravenous administration of ascorbic acid. Cases of local anesthetic-induced methemoglobinemia in urology are under recognized. Although the association between prilocaine use and methemoglobinemia has generally restricted prilocaine use in infants, it is still widely used in ambulatory procedures, especially during circumcision in the neonatal period. Prilocaine should not be used in infants less than 3 months of age because of the risk of methemoglobinemia and alternative local analgesics should be considered among this age group. We also discuss the use of ascorbic acid during treatment in light of the literature.

Intracerebral hematoma as a complication of intrathecal methotrexate administration

Neurotoxicity of methotrexate is a well‐documented issue, but development of an intracerebral hematoma following administration of intrathecal methotrexate is an extremely rare entity. A 6‐year‐old male with the diagnosis of non‐Hodgkin lymphoma was put on a treatment regimen, including intrathecal methotrexate. Six days following the last intrathecal methotrexate administration, the patient developed a deteriorating state of consciousness. There was no history of trauma. Coagulation studies and platelet count were normal. Magnetic resonance imaging of the brain demonstrated a large left frontoparietal hematoma. Intracerebral hematoma may be a very rare, but serious, complication of intrathecal methotrexate administration. Pediatr Blood Cancer 2008;50:152–154.

Prevalence of Neisseria meningitidis carriage: a small-scale survey in Istanbul, Turkey

INTRODUCTION The human nasopharynx is the main reservoir of Neisseria meningitidis, and asymptomatic carriage is common. N. meningitidis one of the common causes of bacterial meningitis in Turkey, especially after the implementation of the national immunization program that includes conjugated pneumococcal and Haemophilus influenzae type b vaccines. The purpose of this study was to evaluate the prevalence of meningococcal carriage and determine the leading serogroup, which may help authorities to adapt appropriate meningococal vaccine into the national immunization programme. METHODOLOGY The prevalence of oropharyngeal carriage of N. meningitidis in 1,000 healthy subjects, 0-79 years of age, was investigated. Oropharyngeal swabs were collected during an 18-month period. Samples obtained were inoculated onto Thayer-Martin agar. The API-NH test and VITEK-MS system were used for identification of colonies. Multiplex real-time polymerase chain reaction assay was used to determine serogroups with serogroup-specific genes. RESULTS N. meningitidis was isolated from 6 of 1,000 subjects (0.6%). Meningoccocal carriers were between 21 and 40 years of age. All isolates were serogrouped as B, except one that did not survive on subculture. N. lactamica was isolated from 13 of 1,000 subjects (1.3%). CONCLUSIONS Carriage rate of meningococci in our study was relatively low. However, we detected that serogroup B was the leading strain in meningococcal carriage in Istanbul; choosing an appropriate meningococcal vaccine containing serogroup B should therefore be considered. High absolute humidity throughout the year in Istanbul may explain the low prevalence of carriage in our study. This should be verified with a multicenter national survey.

Effectiveness of a sleep education program for pediatricians

The high prevalence of sleep problems in children and long‐term consequences point to the need for early effective interventions, but health‐care providers have limited training in pediatric sleep medicine. The aims of this study were therefore to assess the effectiveness of a sleep health‐care education program and to develop a Turkish acronym for brief sleep history taking for pediatric primary caregivers in the ambulatory setting.

Low- versus high-flow oxygen delivery systems in children with lower respiratory infection.

Delivery of supplemental oxygen is the initial vital management of hypoxemic acute lower respiratory infection (HALRI). Oxygen delivery systems include low‐flow and high‐flow devices. In high‐flow devices such as the Venturi mask, a constant mixture of oxygen is delivered. As a result, increased rate of breathing does not affect the concentration of oxygen delivered. In this study, we compared the efficacy of oxygen masks and Venturi masks in the management of hypoxemia in pediatric patients.

Epidermodysplasia Verruciformis Associated with Natural Killer/T Cell Lymphoma

Figure 3. Skin biopsy specimen showing a thickened cornified layer and epidermis along with aggregates of large, bluegray keratinocytes and a prominent granular layer. (HemaE pidermodysplasia verruciformis (EV) is an extremely rare genodermatosis characterized by verruca plana like warts that may undergo malignant transformation. We report a 12-year-old boy who had hypopigmented smooth macules and wart-like lesions for 10 years (Figure 1). He was referred for facial swelling and erythema of his right cheek. The right nasal cavity was completely filled with a smooth mass. A biopsy specimen obtained from the nasal cavity revealed high-grade malignant tumor infiltration (Figure 2). The immunophenotype of this tumor was CD56, CD3, and CD20, consistent with natural killer (NK)/T cell lymphoma. Weak staining for Epstein-Barr virus (EBV) was evident. A skin biopsy specimen from a representative lesion exhibited hyperkeratosis, acanthosis, and groups of large blue-gray keratinocytes with large nuclei and a prominent, granular layer with condensed keratohyaline granules (Figure 3). Various abnormalities of nonspecific cell-mediated immunity have been found in patients with EV. These include decreased absolute numbers of T lymphocytes and T helper cells with a reversed CD4/CD8 ratio, increased NK cell activity, and T cell–mediated cytotoxicity against human papillomavirus-harboring keratinocytes. Our patient had a normal absolute lymphocyte count. Flow cytometry demonstrated reversal of the CD4/CD8 ratio, but normal CD3 cells. Nasal NK/T cell lymphomas are almost always associated with EBV. In an immunocompromised host, EBV can proliferate and induce lymphoproliferative disorders or lymphoma. In our patient, the presence of both EV and EBV may have contributed to the development of nasal NK/T cell lymphoma. Pediatricians should be aware of this rare dermatosis, and EV should be suspected in the clinical setting of numerous verrucous lesions in early childhood. Patients should receive regular follow-up for possible cutaneous or extracutaneous malignancy. n

Evaluation of fontanel size variation and closure time in children followed up from birth to 24 months

OBJECTIVE Anterior fontanel size and closure time can be useful clinical signs for the early diagnosis of diseases. Knowing age-related normal variations is important to decide on further investigations. The authors of this study aimed to describe fontanel size variation according to age, determine fontanel closure time, and identify the optimal method for assessing fontanel size. METHODS For this prospective cohort study, 321 healthy term babies who fulfilled the inclusion criteria were consecutively recruited. Percentile charts for the mean anterior fontanel size and oblique measurements from birth to 24 months of age were created. RESULTS The mean fontanel closure time was 9.7 ± 5.0 months (girls 10.3 ± 4.7 months, boys 9.2 ± 5.1 months). No differences were observed between the traditional method and oblique measurements. Early fontanel closure was not associated with microcephaly. CONCLUSIONS Oblique measurements can be used because they are as accurate as the traditional method. Children with fontanels measuring above the 95th percentile should be monitored closely and investigated further for potentially associated diseases.