How Approprıate are the Lengths of Syringe Needles Used for Subcutaneous Injections to the Children at School Age?

ABSTRACT Objectives: To define the normal ranges of the thicknesses of the skin and subcutaneous tissues via ultrasonography, and determine whether the current syringe needle-lengths used for the subcutaneous injections were appropriate. Methods: The thicknesses of the skin and subcutaneous tissues of 2244 students were measured at the left arm using ultrasonography. The patients were divided into three groups based on their age: 6-8, 9-12 and 13-17 years. Results: The thicknesses of the skin, subcutaneous tissue and skin-subcutaneous tissue were found to be positively correlated with their age, body mass index (BMI) and body surface area. All these were observed to be gender related. There was the possibility to make intramuscular injections for 50%, 25% and 25% of boys within the age groups of 6-8, 9-12 and 13-17 years, respectively. For girls, the risk of intramuscular injection was 25% for all the age groups. Conclusion: The study showed that the skin and skin-subcutaneous tissue thicknesses varied as a function of the patients' age, gender, BMIs and body surface areas.

Plasma amino acid profile in autism spectrum disorder (ASD).

OBJECTIVE: In our study, we aimed to reveal pathophysiologic mechanisms in ASD by comparing plasma amino acid levels between patients and healthy controls while considering vitamin B12 and D levels. PATIENTS AND METHODS: The study included 21 patients aged 2-18 years-old who were followed with a diagnosis autism spectrum disorder (ASD) and 21 age and sex-matched healthy children from our outpatient clinic as control group. RESULTS: The study included 42 children and adolescents aged 2-18 years-old (19 girls and 23 boys). There were no significant differences in terms of body weight and height between the groups. We found significant differences in levels of ammonium, phosphoethanolamine, histidine, homocysteine, carnosine, methionine, cystathionine, cystine, threonine, 3-methyl histidine and phenylalanine/tyrosine ratio between patient and control groups. Both vitamin B12 and D were significantly lower in the ASD group compared to controls. In the variance analysis with vitamin B12 and D as covariates, significant differences persisted for only phosphoethanolamine (p=0.04), cystathionine (p<0.001), cystine (p=0.006) and threonine (p=0.02). CONCLUSIONS: Further studies are needed on the amino acids that show variations in children with ASD in order to reveal their role in the etiology and therapeutic use in ASD.

Role of circulating nesfatin-1 in the underweight children with poor appetite.

OBJECTIVE: To investigate serum concentration of nesfatin-1 in underweight children who have poor appetite, and its association with anthropometric markers of malnutrition. PATIENTS AND METHODS: We recruited 50 underweight children and adolescents (aged 2-18 years) who presented with loss of appetite. Thirty age- and sex-matched controls were also included in the study. Fasting serum nesfatin-1 concentrations were measured by using Enzyme-Linked Immunosorbent Assay (ELISA) technique. RESULTS: Mean nesfatin-1 level was significantly higher in underweight children when compared to controls (p<0.001). There was no correlation between serum nesfatin-1 levels and anthropometrics markers. CONCLUSIONS: Our results suggest that nesfatin-1 might have an important role in regulation of food intake and pathogenesis of loss of appetite in children.

Cardiac syncope due to pain: report of a case responsive to duloxetine treatment.

Neurocardiogenic syncope comprises situations triggered by neurological reflexes resulting in abnormal responses of the neurocardiovascular system that cause loss of consciousness. A vast number of clinical conditions may cause this disorder including pain, defecation, micturition, swallowing, cough, sudden fear or excitement, exercise, and long-time standing. Treatment options for syncope prevention are not satisfactory. Several agents were used for pharmacological treatment without success. Selective inhibitors of neuronal norepinephrine transporter (NET) like duloxetine may play a role in neurally mediated syncope by increasing synaptic norepinephrine levels. Therefore, we report the effect of duloxetine in a patient with pain-induced syncope resistant to standard regimens.

Relationship between fragmented QRS complexes and left ventricular systolic and diastolic functions.

BACKGROUND: Fragmented QRS complexes (fQRS) have been associated with increased morbidity and mortality, sudden cardiac death, and recurrent cardiovascular events. The association between left ventricular systolic and diastolic functions and presence of fragmented QRS has not been comprehensively studied to date. We tested the hypothesis that the presence of fragmented QRS is associated with left ventricular systolic and diastolic dysfunction. METHODS: The study included 259 patients who were consecutively admitted to our outpatient clinic for cardiovascular risk factor management. Extensive echocardiographic parameters were obtained from all patients and these were compared with the presence and number of fQRS. RESULTS: Patients with fQRS were of older age (58 ± 12 vs. 55 ± 13 years, p = 0.03) and had prolonged QRS time (105 ± 12 vs. 93 ± 10 ms, p < 0.001) and a higher rate of Q waves on ECG (36% vs. 11%, p < 0.001). In addition, they had worse systolic (lower LVEF%, 44 ± 17 vs. 61 ± 12, p < 0.001) and diastolic functions (DT, 177 ± 77 vs. 211 ± 59 ms, p < 0.001; IVRT, 81 ± 27 vs. 92 ± 22 ms, p = 0.001; Em, 9 ± 4 vs. 10 ± 4 cm/s, p = 0.008; E/Em ratio, 11 ± 5 vs. 8 ± 4, p < 0.001) in comparison to patients with nonfragmented QRS. There was a significant negative correlation between the number of fQRS and left ventricle systolic functions (for LVEF%, r = - 0.595, p < 0.001). After adjustment for age and gender, the number of fQRS remained significantly negatively associated with left ventricular systolic and diastolic functions. CONCLUSION: We found that fQRS is related to left ventricular systolic dysfunction and diastolic dysfunction. fQRS, which may be the result of myocardial ischemia or scar on myocardial electrical parameters at the cellular level, may represent inadequate systolic and diastolic functions.

Increased serum resistin levels in patients with coronary slow-flow phenomenon.

BACKGROUND: Slow coronary flow (SCF) is an angiographic finding characterized by delayed opacification of the epicardial coronary arteries without obstructive coronary disease. Resistin, an adipocytokine, plays a major role besides low-grade inflammation in atherosclerotic vascular processes and may be of importance in other coronary pathologies such as SCF. METHODS: The present study was cross-sectional and observational, consisting of 70 individuals who underwent coronary angiography and had angiographically normal coronary arteries of varying coronary flow rates. The study included 50 patients with isolated SCF and 20 control participants with normal coronary flow (NCF). RESULTS: There were no statistically significant differences between the SCF and NCF groups with respect to age, gender, presence of hypertension or diabetes mellitus, and smoking habit, except for increased creatinine levels (p = 0.014). The serum resistin level was significantly higher in the SCF group than in the NCF group (8.4 ± 7.2 vs. 5.4 ± 2.6 ng/ml, p = 0.014). Ln-transformed resistin levels correlated positively with left anterior descending (LAD) coronary artery TIMI frame count (TFC) (r = 0.408, p < 0.001) as well as with glucose (r = 0.340, p = 0.004), creatinine (r = 0.248, p = 0.044), and C-reactive protein (CRP; r = 0.283, p = 0.023) levels, and negatively with LAD coronary flow velocity (r = - 0.314, p = 0.009). When multivariate analyses were performed, in linear regression analysis, ln-resistin was associated with a longer TFC [beta (standardized regression coefficient): 0.404, p = 0.001] and lower coronary flow velocity (beta: - 0.280, p = 0.035); in logistic regression analysis, ln-resistin was an independent predictor of the presence of SCF (OR: 6.692, 65 %CI: 1.117-40.1, p = 0.037). CONCLUSION: We demonstrated, for the first time, a significant increase in serum resistin levels in patients with SCF compared to subjects with NCF. We believe that further studies are needed to clarify the role of resistin in patients with SCF.

Aortic valve sclerosis is a high predictive marker of systemic endothelial dysfunction in hypertensive patients.

BACKGROUND: Aortic valve sclerosis (AVS) is closely related to hypertension and is an important predictor of coronary artery disease as well as cardiovascular morbidity and mortality. However, the mechanisms causing AVS have not yet been clarified. Therefore, we planned to investigate the influence of atherosclerosis-related risk factors including C-reactive protein (CRP), epicardial adipose tissue (EAT), carotid intima-media thickness (CIMT), pulse wave velocity (PWV), left ventricular hypertrophy, and the conventional risk parameters as well as endothelial dysfunction in untreated hypertensive patients. METHODS AND RESULTS: Our study was cross-sectional and observational, and included 107 consecutive untreated hypertensive patients. All patients underwent vascular evaluation by CIMT, PWV, flow-mediated dilation (FMD%), as well as echocardiographic examinations. Age (OR = 1.180, p < 0.001), male sex (OR = 3.056, p = 0.019), waist circumference (OR = 1.082, p = 0.004), EAT (OR = 1.419, p = 0.001), smoking status (OR = 3.161, p = 0.014), FMD% (OR = 0.649, p < 0.001), mean CIMT (OR = 2.481, P < 0.001), and carotid plaque (OR = 4.692, P = 0.001) were associated with AVS in univariate analyses. Multivariate analyses revealed only age (OR = 1.144, P = 0.006) and FMD% (OR = 0.691, 0.001) as independent predictors of AVS. The presence of AVS had a high positive predictive value (100 %) but a low negative predictive value (51 %) for endothelial dysfunction (FMD < 12 %) in hypertensive patients. CONCLUSION: Our study supports the theory that systemic endothelial dysfunction has an initial and independent effect on AVS pathogenesis. Moreover, we demonstrated that the presence of AVS in patients with hypertension predicts endothelial dysfunction, with a high positive predictive value. Thus, AVS in hypertensive patients may urge clinicians toward aggressive risk factor modification and intensive treatment.

Elevated serum YKL-40 level predicts myocardial reperfusion and in-hospital MACE in patients with STEMI.

BACKGROUND: Macrophages in atherosclerotic plaques secrete YKL-40, a new biomarker of acute and chronic inflammation in patients with stable CAD. We hypothesized that YKL-40 may be a specific marker reflecting the burden of localized inflammation in myocardium and a predictor in patients with STEMI. In this study, we investigated the relationship of YKL-40 to in-hospital major adverse cardiac events (MACE), reperfusion parameters and its predictors in patients with STEMI. METHODS: In total, 80 patients with STEMI and no history of prior coronary artery disease (CAD), who underwent primary percutaneous coronary intervention (p-PCI), were enrolled consecutively. In addition, 30 patients with normal coronary arteries (NCA) were enrolled as a control group. Cardiac biomarker levels including creatinine kinase-MB fraction (CK-MB), troponin-I, admission glucose and inflammatory markers including leukocytes and YKL-40 levels were measured as admission values. RESULTS: In our study, YKL-40 levels correlated to high-sensitivity CRP levels (r = 0.333, p = 0.003), TIMI risk score (r = 0.445, p < 0.001), age (r = 0.477, p < 0.001), pain to balloon time (r = 0.432, p < 0.001), leukocyte and neutrophil count (r = 0.386, p < 0.001 and r = 0.430, p < 0.001, respectively), hemoglobin (r = - 0.345, p = 0.002), admission and fasting blood glucose (r = 0.388, p < 0.001 and r = 0.427, p < 0.001), creatinine levels (r = 0.395, p < 0.001) and myocardial blush grade (r = - 0.334, p = 0.004). When the patients were divided into two groups determined by presence or absence of MACE, the patients with MACE had significantly higher levels of YKL-40 in comparison to the patients without MACE and the control group (194 ± 104, 114 ± 61 and 110 ± 53 µg/L, p < 0.001, respectively). In multivariate logistic regression analysis in STEMI patients, only YKL-40 level (OR: 1.011, 95%CI: 1.002-1.019, p = 0.011) and leukocyte count (OR: 1.264, 95%CI: 1.037-1.540, p = 0.020) were the independent predictors for MACE. Sensitivity and specificity of YKL-40 to predict MACE, when 125 µg/l was accepted as a cut-off value, were 84% and 70%, respectively. CONCLUSION: We found that serum YKL-40 is related to older age, increased admission glucose levels, leukocyte counts and decreased hemoglobin levels; YKL-40 level and leukocyte count independently predicted MACE.

Independent relationship of serum uric acid levels with leukocytes and coronary atherosclerotic burden.

BACKGROUND AND AIM: Epidemiological studies have shown that increased serum uric acid (SUA) level is associated with coronary artery disease (CAD). Leukocytes have been shown to play an important role in the atherosclerotic process. The aim of the study was to investigate whether there is any relationship among SUA, leukocyte counts and coronary atherosclerotic burden in patients who are suspected of having CAD. METHOD AND RESULTS: We enrolled 690 eligible patients who had undergone coronary angiography between October 2005 and June 2006 in a consecutive manner. The relationship of SUA with total and differential leukocyte counts and CAD was investigated. Serum uric acid levels (5.57+/-1.64 vs 4.63+/-1.27 mg/dl, p<0.001) and leukocytes were higher in patients with CAD than those with normal coronary arteries (NCA). When we divided the patients into four groups according to the quartiles of SUA, we found that the monocyte count was prominently related with SUA (478+/-165, 553+/-177, 565+/-199 and 607+/-229 mm(-)(3), Q1-Q4, p<0.001). In multivariate analysis, SUA was an independent predictor of CAD (OR, 1.270; 95% CI, 1.087-1.484, p=0.003). When we performed multiple linear regression analyses to determine the independent predictors of inflammatory cells in blood, we found a strong, positive and independent relationship between SUA with neutrophils (beta+/-SE: 206+/-60, p=0.001) and monocytes (beta+/-SE: 35+/-7, p<0.001). CONCLUSION: Our study results demonstrated that neutrophils and monocytes which play an important role in inflammation and atherosclerosis were independently related with SUA. This finding suggests an important epidemiologic relation and may provide a possible causative mechanism of SUA in atherosclerotic process.

Observation of zeroth-order band gaps in negative-refraction photonic crystal superlattices at near-infrared frequencies.

We present the first observations of zero-n[over ] band gaps in photonic crystal superlattices consisting of alternating stacks of negative-index photonic crystals and positive-index dielectric materials in the near-infrared range. Guided by ab initio three-dimensional numerical simulations, the fabricated nanostructured superlattices demonstrate the presence of zeroth-order gaps in remarkable agreement with theoretical predictions across a range of different superlattice periods and unit cell variations. These volume-averaged zero-index superlattice structures present a new type of photonic band gap, with the potential for complete wave front control for arbitrary phase delay lines and open cavity resonances.

Relationship between N-terminal pro-B type natriuretic peptide and extensive echocardiographic parameters in mild to moderate aortic stenosis.

CONTEXT: The N-terminal pro-B type natriuretic peptide levels (NT pro-BNP) are increased in cases of volume or pressure overload. AIMS: To examine NT pro-BNP levels and enclose whether any relationship is present between the levels of NT pro-BNP and extensive echocardiographic parameters in asymptomatic patients with mild to moderate aortic stenosis (AS). SETTINGS AND DESIGN: A cross-sectional study about the NT pro-BNP levels was conducted in 37 asymptomatic AS patients and compared with 40 controls. METHODS: Patients < 70 years old with mild to moderate AS with a peak transaortic gradient > 20 mm Hg in transthoracic echocardiogram were included in our study. Extensive echocardiographic parameters and NT pro-BNP levels were obtained from these patients and these indices were compared with the control population selected from the patients who had similar clinical characteristics with the AS patients. STATISTICAL ANALYSIS: NT-proBNP values were found to be distribution free. Spearman correlation coefficient was used for correlation analysis. Mean values were compared by the Kruskal-Wallis test. RESULTS: The NT pro-BNP levels were increased in patients with AS (median; interquartiles range: 686 [449-855] pg/mL vs. 140 [116-150] pg/mL, P < 0.001). Among patients with AS, when correlation analysis was performed mean transaortic gradient, aortic valve area index, myocardial performance index, E(m)/A(m) ratio, left-ventricular mass index (LVMI) and E/E(m) ratio had correlations (r=0.38, P = 0.026; r=-0.46, P =0.008; r=0.19, P =0,049; r=-0.22, P =0.04, r=0.49, P =0.003 and r=0.53, P <0.001 respectively) with plasma NT pro-BNP levels. The LVMI (r = 0.49, P = 0.003) and E/E(m) ratio (r = 0.53 P < 0.001) have the strongest correlations when compared to other parameters. CONCLUSION: Plasma NT pro-BNP levels are increased in even asymptomatic patients with AS and correlated with several echocardiographic parameters related to severity of AS and degree of diastolic dysfunction. As a result, NT pro-BNP levels may be used in the follow-up of asymptomatic patients having mild to moderate AS.

Complications of subduroperitoneal shunting.

OBJECTS: Subduroperitoneal (SP) shunts have been widely used in the management of pediatric subdural fluid collections. METHODS: We retrospectively reviewed the complications of SP shunting in 73 boys and 24 girls, who ranged in age from 1 to 180 months (median 7 months). Subdural fluid collection was bilateral in 75 and unilateral in 22 patients. The most common complication was shunt obstruction (13 patients). Shunt migration was seen in 8 patients. Migration occurred only with unishunts without a reservoir and with peritoneal catheters. However, the shunts with a reservoir or flushing valve led to skin necrosis in 4 patients (P=0.003). Unilateral drainage though bilateral collections were present, infection, bowel perforation, and ileus occurred in 5, 4, 1 and 1 patients respectively. CONCLUSIONS: These SP shunt complications, some of which are avoidable, should be kept in mind.

Cerebral hydatid cysts in children.

A parasitic tapeworm, called Taneia Echinococcus, causes hydatid disease. Hydatid disease is endemic in sheep and cattle-raising areas of the world. Hydatid disease of the central nervous system constitutes 2%-3% of all reported cases of hydatid cysts. In our institution, 23 children underwent surgery for intracranial hydatid cysts between 1979 and 1995. There were 14 boys and 9 girls, aged between 3 to 16 years (mean 8.8 years). Signs and symptoms were related to the site and size of the cyst. Headache and vomiting due to increased intracranial pressure were the most common presenting symptoms. A round cystic lesion without perifocal edema and rim enhancement is the characteristic appearance on a computed tomography (CT) scan. A magnetic resonance image visualizes cyst location better than CT. Associated systemic hydatidosis in four of our patients involved kidney, liver, lung, and liver and lung, respectively. Intact cyst removal was achieved in 14 patients. In three patients with infected or inflamed hydatid disease, the ruptured cyst capsule was totally resected. Aspiration and extirpation were performed in only one patient. Eleven patients were treated with chemotherapeutic agents such as albendazole or mebendazole due to cyst rupture during surgery or associated systemic hydatid disease. Hydatid disease can also be seen in Western countries because of travel and migration. Cerebral hydatid cyst should be kept in mind for the differential diagnosis of cystic lesions.

Split spinal cord malformations in children.

OBJECT: The authors reviewed and analyzed information on 74 patients with split spinal cord malformations (SSCMs) treated between January 1, 1980 and December 31, 1996 at their institution with the aim of defining and classifying the malformations according to the method of Pang, et al. METHODS: Computerized tomography myelography was superior to other radiological tools in defining the type of SSCM. There were 46 girls (62%) and 28 boys (38%) ranging in age from less than 1 day to 12 years (mean 33.08 months). The mean age (43.2 months) of the patients who exhibited neurological deficits and orthopedic deformities was significantly older than those (8.2 months) without deficits (p = 0.003). Fifty-two patients had a single Type I and 18 patients a single Type II SSCM; four patients had composite SSCMs. Sixty-two patients had at least one associated spinal lesion that could lead to spinal cord tethering. After surgery, the majority of the patients remained stable and clinical improvement was observed in 18 patients. CONCLUSIONS: The classification of SSCMs proposed by Pang, et al., will eliminate the current chaos in terminology. In all SSCMs, either a rigid or a fibrous septum was found to transfix the spinal cord. There was at least one unrelated lesion that caused tethering of the spinal cord in 85% of the patients. The risk of neurological deficits resulting from SSCMs increases with the age of the patient; therefore, all patients should be surgically treated when diagnosed, especially before the development of orthopedic and neurological manifestations.

Continuous external subdural drainage in the management of infantile subdural collections: a prospective study.

Continuous external subdural drainage (CESD) was suggested as a treatment step to be inserted prior to SP shunting, primarily because it makes it possible to avoid shunt placement in a significant number of patients. Thirty-three patients with symptomatic chronic subdural collection confirmed by computed tomography were included in this study. Unilateral CESD was performed in all cases, using a lumbar drainage set. The drains were left in place for no more than 10 days. A subduroperitoneal (SP) shunt was inserted in those patients in whom re-accumulation of the subdural collection had occurred. Of 33 patients, 17 were definitively treated by CESD and 16 subsequently needed an SP shunt. The cost of treatment with CESD was just less than half the cost of treatment with SP shunting. CESD can be used as a step before SP shunting in the management of chronic infantile subdural collections, since it is effective without further treatment in half the patients and safer than subdural tapping.

Immunoglobulin prophylaxis in shunt infections: a prospective randomized study.

Cerebrospinal fluid shunt infection is serious and one of the most frequent complications of shunt implantation. Age has been one of the most significant host factors for the development of shunt infections. A relative deficiency of the immune response against bacteria in infants could partly explain the higher infection rate in the very young patients. This prospective-randomized study was conducted in two groups: group A (immunoglobulin group) and group B (control group). There were 30 patients in each group. The patients in group A received intravenous immunoglobulin (Sandoglobulin) at a dose of 1 g/kg in the night before surgery. Each patient was followed up to 6 months. No infection was seen in group A. In group B, infection rate per procedure were 5.1% (P = 0.494) and 6.6% (P = 0.492), respectively. Intravenous immunoglobulin prophylaxis in infants seems to reduce the shunt infections.