Assessment of Cost-Effectiveness of Computerized Cranial Tomography in Children with Mild Head Trauma.

PURPOSE: Pediatric head traumas constitute the majority of admissions to emergency departments (ED) due to trauma. This study aims to draw attention to the use of cranial computerized tomography (CT) scans in the evaluation of children with head trauma under the age of 18, and to determine CT scans' usefulness in terms of cost-effectiveness. MATERIALS AND METHODS: Age, gender, mechanism of trauma and Glasgow Coma Scale (GCS), diagnosis, time of admission to hospital, hospitalization and operation, cranial computerized tomography and hospitalization costs of all cases were retrospectively analyzed. RESULTS: A total of 26,412 patients younger than 18 years old who were admitted to the emergency department due to head trauma and who had a cranial tomography were analyzed. They had a mean age of 7.74 ± 5.66 years. In total, 26,363 (99.8%) of these patients had a GCS greater than 14. Out of these patients, only 402 (1.5%) had brain injury revealed by cranial CT, 41 (0.2%) of these patients were operated and 3 of the patients lost their lives. The total cost of patients admitted to the emergency department with a head injury amounts to USD 583,317. Furthermore, 75.78% of this cost comes from negative cranial CTs. A cost analysis according to different age groups did not show a meaningful difference between 0-2 years and 3-5 years (p = 1.000), but there was a meaningful difference for all the other age groups. CONCLUSION: Our findings show that applying algorithms to predict traumatic brain injury in children with mild head injury rather than scanning all patients with cranial CT will enable more reliable and cost-effective patient care. Current practices should be reviewed to avoid unnecessary radiation exposure and expense in the ED. It is also necessary to inform and educate parents about the risk/benefit ratio of cranial CT scans.

Evaluation of Asymmetric Dimethylarginine Levels in Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary embolism, and pulmonary endarterectomy (PEA) is the surgical treatment. Asymmetric dimethylarginine (ADMA) levels are increased in pulmonary hypertension. This study aimed to investigate serum ADMA levels in patients with CTEPH, the effect of PEA on ADMA, and its prognostic value in long-term mortality. METHOD: Eighty (80) patients with CTEPH and 32 healthy controls were included. Preoperative serum ADMA levels, determined using an enzyme-linked immunosorbent assay, were compared between patients with CTEPH and controls. Of 80 patients, 64 had PEA. Pre- and 6-month postoperative serum ADMA levels, 6-minute walk distance (6MWD), and haemodynamic parameters were collected from patients undergoing PEA. Patients were followed-up for survival analysis. RESULTS: Mean ± standard deviation serum ADMA levels were significantly higher in patients with CTEPH compared with controls (0.79±0.32 µmol/L vs 0.52±0.12 µmol/L; p=0.0001). Statistically significant differences were observed between preoperative and postoperative serum ADMA levels (0.78±0.30 µmol/L vs 0.62±0.22 µmol/L; p=0.0001), 6MWD (p=0.0001), and pulmonary vascular resistance (p=0.0001) in 60 patients who underwent and survived PEA. The decrease in serum ADMA levels and increase in 6MWD were significantly correlated (r=-0.286, p=0.027). No other correlation was found. Perioperative mortality was 6.3%, and the survival rate with a mean follow-up of 34.57±8.20 months was 93.3%. Patients with serum ADMA levels >0.8 µmol/L had a significantly lower survival rate (logrank: 5.86; p=0.015). CONCLUSIONS: Levels of circulating ADMA might add diagnostic and prognostic information in CTEPH. Pulmonary endarterectomy is associated with an improvement in serum ADMA levels. Preoperative serum ADMA levels may be useful for estimating the outcome of PEA.

Evaluation of the Relationship Between Transcutaneous Bilirubin Measurement and Total Serum Bilirubin in Neonatal Patients Followed for Jaundice.

OBJECTIVES: Jaundice is a physiological condition caused by hyperbilirubinemia, which is common in neonatal period. However, severe hyperbilirubinemia can cause kernicterus, which is a serious condition that leads to neurological problems. In this study, we aimed to investigate whether it is safe to use transcutaneous bilirubin (TcB) instead of blood for the evaluation of jaundice by comparing TcB measurement with standard total serum bilirubin (TSB) measurement values. METHODS: A total of 105 term and early term infants with gestational ages between 37 and 42 weeks were included in the study. MBJ20 TcB measuring device was used for TcB measurement. TcB was measured from the forehead and sternum. To evaluate the relationship between TcB measurements and TSB measurements, we performed Pearson correlation, Spearman correlation, linear regression analysis, and Bland-Altman analysis in which we evaluated the scatter plot of the differences between the average values of the measurements. RESULTS: There was a positive and statistically significant correlation between TcB forehead and TSB measurements and TcB sternum and TSB measurements (p<0.001). Linear regression analysis showed a positive directional correlation between TcB forehead and TSB measurements (R²=0.85) and TcB sternum and TSB measurements (R²=0.87). Bland-Altman analysis showed a good consistency between TSB and TcB forehead measurement methods (mean difference: 0.39±1.46, 95% CI: [-2.47]-[3.26]), and between TSB and TcB sternum measurement methods (mean difference: 0.49±1.32 95% CI: [-2.1]-[3.07]). CONCLUSION: As a result of our study, we found that TcB measurement can be reliable instead of taking blood for jaundice evaluation.

Is Cord Blood Bilirubin Level a Reliable Predictor for Developing Significant Hyperbilirubinemia?

OBJECTIVE: We aimed to investigate whether cord blood bilirubin (CBB) level could be used to identify the newborns at a high risk of developing hyperbilirubinemia. STUDY DESIGN: Total and direct serum bilirubin level were evaluated from umbilical cord blood of newborns. We checked blood groups and Rh status of all mothers and determined blood groups and direct Coombs test (DC) of newborns born to mothers whose blood group was O type or Rh negative to determine the maternal-fetal blood group or Rh incompatibility. RESULTS: A total of 418 newborns were included, and phototherapy (PT) was required in 17 newborns. The cutoff value of CBB for predicting the occurrence of significant hyperbilirubinemia requiring PT was 1.67 mg/dL, with a sensitivity of 82% and specificity of 99%. The mean CBB level in babies receiving PT was 2.4 ± 0.9 mg/dL. When blood group, CBB level, DC, gender, and mode of delivery were assigned as possible risk factors, multivariate analysis showed ABO, Rh incompatibility, and CBB level increased the risk of PT requirement. CONCLUSION: CBB could be useful to determine newborns at a risk of developing hyperbilirubinemia and prevent developing severe complications due to delay in diagnosis.

The follow-up results of newborn hearing screening of Gaziosmanpasa Taksim Research and Training Hospital.

AIM: This study aimed to present the results of newborns who were referred to advanced audiology centers after newborn hearing screening, and to determine concordance of our results with the American Academy of Pediatrics guidelines about the ages of hearing loss, aid fitting, and cochlear implantation. MATERIALS AND METHODS: A total of 7502 newborns were screened in Gaziosmanpasa Taksim Research and Training Hospital between March 2014 and June 2016 using the transient otoacustic emissions test as the first two steps and automated auditory brainstem response test for the third step. Newborns who had risk factors were screened using the automated auditory brainstem response only. Newborns who failed the screening tests were referred to advanced audiology centers. RESULTS: Of the 7502 newborns, 6736 (90%) completed the screening. The ratio of hearing loss was 0.08%. Six of 62 newborns who failed auditory brainstem response test and were referred to advanced audiology centers had severe bilateral hearing loss. One of the patients was not fitted with a hearing aid because the family refused it. The other one was not fitted an aid and did not undergo cochlear implantation because of severe and treatment-resistant acute otitis media. The age of diagnosis for the rest was before three months, and except for one patient, hearing aid fitting was before six months. The age of cochlear implantation was 12 months for two patients and 14 months for two patients. CONCLUSION: Ninety percent of patients completed the screening, the age of diagnosis for hearing loss was before three months and aid fitting was before six months, except for one patient. The results of the study were compatible with the diagnosis and treatment guidelines of the American Academy of Pediatrics.

Familial clustering of HBV in families with children who are diagnosed as chronic hepatitis B or inactive carriers of HBV.

The aim of this study was to assess and compare the spread of HBV infection in families with children who are diagnosed as chronic hepatitis B or are inactive carriers of HBV. A total of 570 patients aged 2-16 years and 2358 family members were included in the study. Patients were classified as inactive carriers (Group 1, 350 patients) or patients diagnosed as chronic active hepatitis B (Group 2, 220 patients). Demographic features of the families, HBV serological markers and routes of transmission were evaluated. Parental transmission was lower compared to nonparental transmission (34.8% and 65.1%, respectively). HBsAg positivity rate was found to be highest among mothers in both of the groups. HBeAg positivity and anti-HBs positivity were significantly higher in family members of Group 2. Transmission rates were significantly higher in families consisting of five or more members compared to families consisting of less than five members. HBsAg positivity of siblings was lowest when both parents were HbsAg negative and highest when both parents were HBsAg positive in both groups. A high risk of HBV transmission among mothers of HBsAg carriers and patients with chronic hepatitis B was demonstrated.

Description of pediatric tuberculosis evaluated in a referral center in istanbul Turkey.

PURPOSE: Diagnosis of tuberculosis (TB) in children is more challenging than in adults. This study aimed to describe demographical, clinical and laboratory findings of children diagnosed with tuberculosis in Turkey, including the issues of contact tracing, culture positivity and forms of the disease. MATERIALS AND METHODS: Clinical and laboratory data of 51 children with a mean age of 8.0±4.6 years who were diagnosed with TB were retrospectively reviewed. Main diagnostic tools included tuberculin skin test, chest X-ray, sputum/gastric aspirate culture with sensitivity testing, and direct microscopy for acid-fast bacilli on available samples. Clinical characteristics and outcomes of the patients were examined. RESULTS: Thirty-six (70.6%) children were diagnosed with intra-thoracic and 15 (29.4%) with extra-thoracic tuberculosis. Twenty-eight of the patients had a positive Bacillus Calmette-Guérin vaccine scar (28/51, 54.9%) and 23/51 (45.1%) had a positive tuberculin skin test. An adult TB contact was identified in 27 (52.9%) of the cases. On direct microscopy, acid-fast bacilli were found in nine (17.6%) patients and positive culture for Mycobacterium tuberculosis was found in 19 (37.3%). Drug resistance to isoniazid was detected in four (7.8%). One patient with nephrotic syndrome and miliary tuberculosis died during follow-up. All other patients responded well to the treatment. CONCLUSION: Focusing on active contact tracing among all household contacts of tuberculous cases may be helpful in early identification and controlling childhood disease, even in regions with low disease prevalence. Adopting a suspicious and proactive approach in this particular age group is warranted.

Serum gastrin levels and gastroduodenal lesions in children with chronic renal failure on continuous ambulatory peritoneal dialysis: a single-center experience.

OBJECTIVE: The aim of this study was to determine serum gastrin levels and gastroduodenal lesions in children with chronic renal failure (CRF) on continuous ambulatory peritoneal dialysis (CAPD). METHODS: A total of 19 patients (mean age: 11.7±3.9 years, M/F: 1.37) with CRF on CAPD and 20 age-matched and sex-matched patients (mean age: 10.2±1.4 years, M/F: 1.5) with peptic ulcers were included in the study. Serum gastrin, creatinine, phosphate, and parathormone levels were determined. Upper gastrointestinal endoscopy was performed in all patients. RESULTS: The basal gastrin concentrations of CAPD patients were significantly higher than those of patients with peptic ulcer disease without CRF (124.2±59.1 and 53.0±9.4 pg/ml, respectively) (P<0.001). A significant correlation was found between age, duration of uremia, and serum gastrin levels (r=0.59, P<0.01; r=0.60, P<0.01, respectively). No correlation was found between the duration of CAPD and serum gastrin levels in the patient group. Of the patients, 73.6% had abnormal upper gastrointestinal endoscopic findings. The gastroduodenal lesion observed was hemorrhagic gastritis (31.5%), followed by hemorrhagic gastroduodenitis (26.3%), gastric nodular gastritis (10.5%), and polyps (10.5%). CONCLUSION: On the basis of our findings, such as higher serum gastrin levels in patients with CRF than those of the control group and the frequent endoscopic findings of gastroduodenal lesions in most of the patients, we recommend that an endoscopic examination should be considered for all the children with CRF on CAPD awaiting renal transplantation even if they are asymptomatic.

A case report of malignant infantile osteopetrosis.

BACKGROUND: Malignant infantile osteopetrosis (MIOP) presents early in life with extreme sclerosis of the skeleton and reduction of bone marrow spaces. Since there is a defect in the bone marrow, the disease can cause anemia, extramedullary hematopoiesis secondary to anemia leading to hepatosplenomegaly, cranial nerves compression and severe growth failure. This disorder is often lethal within the first decade of life because of secondary infections. Stem cell transplantation (SCT) remains the only curative therapy. CASE PRESENTATION: We report a two-month old male infant, diagnosed as MIOP while investigating the cause of hepatosplenomegaly. The patient was referred for stem cell transplantation. CONCLUSION: Malignant infantile osteopetrosis should be kept in mind as a rare cause of hepatosplenomegaly and the patient should be referred for stem cell transplantation before neurologic or visual impairment develops.

Relations between human leukocyte antigens and autoimmune hepatitis in Turkish children.

BACKGROUND/AIMS: We aimed to identify the genetic factors associated with increased tendency toward autoimmune hepatitis, a chronic and progressive inflammatory condition. METHODS: A total of 32 children diagnosed with autoimmune hepatitis were included in the present study, and 160 healthy adult blood donors served as controls. In both groups, HLA phenotypes were examined (HLA-A, B, C, DR, DQ) and compared. In addition, the association between the type of autoimmune hepatitis and HLA status was explored. RESULTS: Compared to controls, patients with autoimmune hepatitis had increased frequencies of the following class 1 HLA antigens: A24.9 (28% vs. 9%, p=0.007), A26 (25% vs. 3%, p<0.001), A32 (34% vs. 4%, p<0.001), B38 (9% vs. 0.6%, p=0.015), and B51 (16% vs. 0%, p<0.001). Among class II HLA antigens, DRB1*04 (22% vs. 0%, p<0.001), DRB1*07 (9% vs. 0%, p=0.004), DRB1*11 (12% vs. 0%, p=0.001), DRB1*15 (25% vs. 0%, p<0.001), DRB1*14 (31% vs. 0%, p<0.001), and DR11.5 (9% vs. 0%, p=0.004) were more frequent in patients compared to controls. Type 1 autoimmune hepatitis was associated with high frequencies of A24.9, A26, A32, and DRB1*15, whereas type 2 autoimmune hepatitis was associated with high frequencies of A26, B51, B38, and DRB1*11. On the other hand, frequencies of A32 and DRB1*04 were high among patients with unclassified autoimmune hepatitis. CONCLUSIONS: There seem to be associations between certain HLA antigens and susceptibility to autoimmune hepatitis, but variations among different geographical locations suggest a role for environmental factors.

[Case report: the efficacy of amphotericin B in visceral leishmaniasis]. / Olgu Sunumu: Visseral Leishmaniasisde Amfoterisin B'nin Etkinligi.

Leishmaniasis is a zoonotic disease which may be difficult to diagnose in children. Successful results have been achieved with amphotericin B in treatment. Here, we present a 7 month old girl who lives in Istanbul. She was given a diagnosis of kala-azar and treated with liposomal amphotericin B. Our case, born in Istanbul, had had fatigue for 3 weeks and pallor and abdominal distention for 2 days. History of travel was absent. In physical examination, paleness, malaise and hepatosplenomegaly were found. In laboratory findings there was pancytopenia and her albumin level was low. A peripheric smear and other laboratory findings were normal. Her first bone marrow aspiration was normal. Because of persistent fever and increase in hepatosplenomegaly, a second bone marrow aspiration was done on the tenth day after admission and Leismania amastigotes were seen. She was given a diagnosis of kala-azar and, clinical and microbiological responses were achieved by treatment with amphotericin B. In our country, visceral leishmaniasis should be considered in all age groups who live in western regions and have no history of travel and contact, that present with pancytopenia or bicytopenia, even if massive splenomegaly is absent.

Hepatitis a with pleural effusion, ascites and acalculous cholecystitis.

BACKGROUND: Hepatitis A virus (HAV) infection constitutes an important health problem in developing countries. It is usually a benign self-limiting disease, but may present with atypical clinical findings. CASE PRESENTATION: A twelve-year-old male with ascites, pleural effusion, and acalculous cholecystitis during the course of HAV infection is reported. He was managed conservatively and clinical improvement was observed with resolution of HAV infection. CONCLUSION: To our knowledge, this is the first case in which all these three rare complications were observed in a single patient in the early period of disease.

Imipenem-cilastatin versus piperacillin-tazobactam as monotherapy in febrile neutropenia.

BACKGROUND: In view of the recent trend toward monotherapy in the treatment of febrile neutropenia, we evaluated the clinical efficacy and safety of imipenem-cilastatin versus piperacillin-tazobactam as an empiric therapy for febrile neutropenia in children with malignant diseases. METHODS: Febrile neutropenic patients received either imipenem-cilastatin or piperacillin-tazobactam randomly. Improvement without any changes in the initial antibiotic treatment was defined as "success" and improvement with modification of the initial treatment and death was defined as "failure". RESULTS: Over 12 months, 99 febrile neutropenic episodes were treated with monotherapy in 63 patients with a median age of 5 years. At admission, median absolute neutrophil count was 50/mm(3) and in 67% of episodes, neutrophil count was under 100/mm(3). Median duration of neutropenia was 5 days. In 22% of episodes, neutropenia persisted for more than 10 days. Piperacillin-tazobactam was used in 52 episodes and imipenem-cilastatin was used in 47 episodes. There was no difference between groups in terms of age, sex, primary diseases, neutrophil count or duration of neutropenia. In the whole group, the success rate was 67% and the failure rate was 33%, whereas in the piperacillin-tazobactam group, the rates were 71% and 29%; and in the imipenem-cilastatin group they were 62% and 38%, respectively (P > 0.05). There were no deaths. No major adverse effects were seen in either group. CONCLUSIONS: Although failure was slightly higher in the imipenem-cilastatin group, this was statistically insignificant. Both of these antibiotics can be used safely for initial empirical monotherapy of febrile neutropenia.

Interferon and ribavirin treatment results of patients with HBV-HCV co-infection cured of childhood malignancies.

OBJECTIVES: We aimed to investigate the virological and clinical characteristics and the results of combination therapy in six oncology patients with hepatitis B virus (HBV)-hepatitis C virus (HCV) co-infection. METHOD: Six patients (five male and one female; age range 8-14 years), diagnosed with HBV-HCV infections during follow-up at the oncology outpatient clinic during 2000-2001 were included in the study. They had received an average of 25.8 units of blood by transfusion per patient during their treatment for malignancies. Positive serological HBV indicators were determined 20-40 months after the end of chemotherapy. HCV RNA positivity was determined together with HBV at an average of 3.3 months after hepatitis B infection. Patients received interferon-alpha-2b and ribavirin for 12 months. RESULTS: Both HBV DNA and HCV RNA became negative, and anti-HBe became positive in one patient. One patient had decreased HBV DNA levels and negative HCV RNA and HBeAg, but HBeAg became positive again at 18-months following treatment. Another patient had decreased serum HBV DNA and HCV RNA levels with normal ALT levels at the end of treatment; however, two months after therapy was ceased these values returned to pretreatment levels. CONCLUSION: We observed that combined treatment is effective in HBV-HCV infection. The effectiveness of combined treatment should be researched with larger groups of co-infected patients.

The effect of ribavirin on bone density in patients with chronic hepatitis C treated with interferon-ribavirin therapy.

OBJECTIVE: The objective of this study was to investigate the effects of ribavirin on bone mineral metabolism in patients with chronic hepatitis C who had been treated with interferon and ribavirin. METHODS: Twenty patients (3 female, 17 male) with chronic hepatitis C were enrolled. Age range was 6 to 15 years (mean+/-SD, 11.15+/- 2.3 years). Thirteen patients received combined interferon alpha-2b and ribavirin therapy (Group 1), and 7 patients received only interferon alpha-2b (Group 2). Both groups were treated for 12 months. Bone mineral density, z-scores and biochemical bone markers were evaluated in both groups before and after treatment. RESULTS: There were no significant differences between the groups in age or gender. Mean lumbar vertebral bone mineral density and mean z-scores in groups 1 and 2 before and after treatment were not significantly different. In both groups, serum and urinary biochemical values and bone markers were all normal and there were no differences between the pretreatment and post-treatment values. CONCLUSION: Contrary to studies in adults, we did not find any ribavirin-dependent changes related to bone mineral metabolism in our pediatric study groups. Further studies are needed to obtain more detailed information about the effects of ribavirin on bone mineral density.