The Insidious Enemy of the Liver: The Situation in Childhood Acetaminophen Poisoning and Early N-AC Treatment.

METHODS: This study was designed as a cross-sectional, observational, retrospective study. The variables of the study were paracetamol overdose, demographic information, poisoning mechanisms, clinical, laboratory findings, and clinical progression of the cases. The cases compared in whom treatment was initiated within the first 8 hours after poisoning and those in whom it was not. χ 2 , t test, and logistic regression analyses were conducted at appropriate facilities. RESULTS: Three hundred forty-eight cases were included in the study. N-AC treatment was initiated within the first 8 hours after poisoning in 322 cases (92.5%), and 26 cases received N-AC treatment after 8 hours after poisoning. Liver toxicity developed in 6 cases (1.7%), and indications for liver transplantation were met in 36 cases (10.3%). Among the 26 cases for which treatment was not initiated within the first 8 hours, 18 cases (69.2%) had indications for liver transplantation ( P < 0.01). It was found that N-AC within the first 8 hours reduced the risk by 43 times ( P = 0.02) and being older than 6 years, being admitted to the intensive care unit, and having alanine aminotransferase values above 1000 U/L increased the risk significantly ( P = 0.009, P = 0.005, P < 0.001). When a receiver operating characteristic curve was plotted for the 4th-hour blood acetaminophen level to predict liver transplantation, a value of 684.5 µg/mL emerged with 89% sensitivity and 93% specificity (area under the curve, 0.951). CONCLUSIONS: As a result, this study demonstrates the protective effect of early-initiated N-AC therapy on liver toxicity in pediatric acetaminophen poisoning cases. It also highlights a significant impact of gastrointestinal decontamination methods.

Variability of the optic nerve sheath diameter on brain computed tomography in Turkish children based on sex and age.

BACKGROUND: Optic nerve sheath diameter (ONSD) measurement is a noninvasive method that can be used for intracranial pressure monitoring. Several studies have investigated normal ONSD values in children, but no general consensus has been reached yet. OBJECTIVES: The aim of our study was to reveal normal ONSD, eyeball transverse diameter (ETD), and ONSD/ETD values on brain computed tomography (CT) in healthy children aged 1 month to 18 years. METHODS: Children admitted to the emergency department with minor head trauma and had normal brain CT were included in the study. The demographic characteristics of the patients (age and sex) were recorded, and the patients were divided into four age groups: 1 month to 2 years, 2 to 4 years, 4 to 10 years, and 10 to 18 years. RESULTS: The images of 332 patients were analyzed. When the median values of all measurement parameters (right and left ONSD, ETD, and ONSD/ETD) were compared between the right and left eyes, no statistically significant differences were found. When the same parameters were compared according to age group, the ONSD and ETD values differed significantly (values of males were found to be higher), but the ONSD proximal/ETD and ONSD middle/ETD values did not differ significantly. CONCLUSION: In our study, normal ONSD, ETD, and ONSD/ETD values were determined according to age and sex in healthy children. As the ONSD/ETD index did not statistically significantly differ according to age and sex, diagnostic studies for traumatic brain injuries can be performed using the index.

Use of the pleth variability index in children with obstructive respiratory disease.

INTRODUCTION: The phenomenon of pulsus paradoxus (PP) develops at varying rates in relation to the severity of the disease in obstructive respiratory tract disease. The Pleth Variability Index (PVI) is the measurement value of perfusion index changes that occur with ventilation, which are determined during at least one respiratory cycle. Therefore, noninvasive measurement of PVI can help in the measurement of PP. The current study aims to determine the role of PVI measurements before and after bronchodilator therapy during admission to the hospital in children with obstructive respiratory tract disease. METHODS: Age, gender, Pulmonary Index Score (PIS), and PVI data of patients aged 2-18 years who applied to the pediatric emergency department with signs of obstructive respiratory tract disease were recorded in triage. The PVI and PIS scores of the patients, who were divided into three groups according to their clinical severity scores, were recorded before and after bronchodilator treatment, and they were compared to the PVI values according to the disposition results. RESULTS: A total of 133 patients were included in this prospective, single-center study. The PVI values before and after treatment were significantly higher in patients with severe disease compared to the mild and moderate groups (p < 0.001). Post-treatment PVI values were significantly lower than pre-treatment values in all clinical severity groups (p < 0.001). While a total of 95 (71.43%) patients were discharged from the emergency department, 31 (23.31%) patients were admitted to the relevant department, and seven (5.26%) patients were admitted to the pediatric intensive care unit. The PVI values before and after treatment were significantly higher in the hospitalized group compared to the group discharged from the emergency department (p < 0.001). The areas under the ROCs were 0.940, 0.865, and 0.843 for the PVI measurements in patients with severe disease, moderate disease, and hospitalization (p< 0.001). CONCLUSIONS: Automated PVI measurement can be used as a noninvasive, rapid, and objective tool in the emergency department triage of patients admitted to the pediatric emergency department with signs of asthma attack or reactive respiratory tract disease.

Direct kidney injury or lower extremity ischemia induced indirect kidney injury: Which one is more harmful for kidneys?

OBJECTIVES: The aim of this study was to investigate and compare the severity of kidney damage following lower limb ischemia-reperfusion and direct kidney ischemia-reperfusion. METHODS: Thirty Sprague Dawley male rats were randomly divided into three groups; lower extremity ischemia-reperfusion group (Group 2), renal ischemia-reperfusion group (Group 3) and control (anesthesia and median laparotomy only) (Group 1). In group 3, 1-h ischemia was performed on the kidney and in group 2, 1-h ischemia was performed on the left lower extremity. This procedure was followed by reperfusion for 24 h. Renal tissues were removed after the reperfusion period and the groups were evaluated for glutathioneperoxidase activity, malondialdehyde and GSH levels, and furthermore, their histolopathological scores were calculated. RESULTS: Renal malondialdehyde levels were significantly higher in Group 2 and Group 3 than they were in the Control group. There was no significant difference in renal malondialdehyde levels between Group 2 and Group 3. Kidney glutathione (GSH) levels were statistically lower in Group 2 and Group 3 than in the Control group. No statistically significant difference was found between Group 2 and Group 3 regarding their GSH levels. In histological evaluation, there was no statistically significant difference between Group 2 and Group 3 in terms of kidney damage score. CONCLUSIONS: This study has identified that lower extremity ischemia induces remote kidney damage with similar features to kidney injury, occurring after direct kidney ischemia-reperfusion.

The association between low vitamin D levels and suicide attempts in adolescents.

BACKGROUND: Psychiatric disorders are the most common cause of suicide attempts. Some studies have shown there is a relationship between low vitamin D levels and psychiatric disorders. In this study, we examined the relationship between suicidal behavior and vitamin D levels in adolescents. METHOD: This study included 215 patients who presented to the pediatric emergency department due to a suicide attempt (patient group) and 200 healthy individuals (control group). Demographic and clinical features of both groups were recorded, and serum vitamin D, calcium, and phosphorus levels were measured. The groups were compared in terms of these factors. All data were analyzed using the SPSS 20.0 (SPSS Inc., Illinois, USA) software program. RESULTS: The mean vitamin D level was 19.4 ± 10 ng/mL in the control group and 12.3 ± 6 ng/mL in the patient group (t = 8.8 and P = .01). The mean serum total calcium level was 9.9 ± 0.3 mg/dL in the control group and 9.4 ± 0.5 mg/dL in the patient group (P < .01). CONCLUSIONS: Vitamin D deficiency, which is a treatable condition, may be one of the causes of suicidal behavior in adolescents. Therefore, we believe that physicians who treat adolescents should consider vitamin D levels in routine examinations.

The association between low vitamin D levels and suicide attempts in adolescents.

BACKGROUND: Psychiatric disorders are the most common cause of suicide attempts. Some studies have shown there is a relationship between low vitamin D levels and psychiatric disorders. In this study, we examined the relationship between suicidal behavior and vitamin D levels in adolescents. METHOD: This study included 215 patients who presented to the pediatric emergency department due to a suicide attempt (patient group) and 200 healthy individuals (control group). Demographic and clinical features of both groups were recorded, and serum vitamin D, calcium, and phosphorus levels were measured. The groups were compared in terms of these factors. All data were analyzed using the SPSS 20.0 (SPSS Inc., Illinois, USA) software program. RESULTS: The mean vitamin D level was 19.4 ± 10 ng/mL in the control group and 12.3 ± 6 ng/mL in the patient group (t = 8.8 and P = .01). The mean serum total calcium level was 9.9 ± 0.3 mg/dL in the control group and 9.4 ± 0.5 mg/dL in the patient group (P < .01). CONCLUSIONS: Vitamin D deficiency, which is a treatable condition, may be one of the causes of suicidal behavior in adolescents. Therefore, we believe that physicians who treat adolescents should consider vitamin D levels in routine examinations.

Which Distant Organ is Most Affected by Lower Extremity Ischemia-Reperfusion?

BACKGROUND: It has been experimentally shown that reperfusion injury occurs in many remote organs after ischemia-reperfusion (I/R) of the lower extremity. However, which distant organ is affected more after I/R of the lower extremity has not been investigated. In this study, we investigate which remote organ is predominantly affected after lower extremity I/R. METHODS: Twenty male Sprague-Dawley rats were randomly divided into 2 groups: sham (group 1) and lower extremity I/R (group 2). In group 2, 1 hr of ischemia of the left lower extremity was followed by 24 hr of reperfusion of the limb. After reperfusion, the lung, liver, kidney, heart, and small intestine tissues were harvested in both groups. RESULTS: In the I/R group, the malondialdehyde levels were significantly higher in the heart and small intestine tissues than those in other tissues (P < 0.05). In addition, in the I/R group, the glutathione and glutathione peroxidase activities were also higher in the heart tissues than those in other tissues (P < 0.05). However, these results were not significant because the malondialdehyde, glutathione, and glutathione peroxidase levels of the heart tissues in the control group were higher than those of the other tissues. Therefore, no statistically significant difference was found between the tissues in terms of the histological damage score we created and the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling-positive cell numbers. CONCLUSIONS: There was no difference in the severity of reperfusion injury between the tissues we examined after lower extremity I/R. This suggests that every distal organ should be carefully monitored after lower extremity I/R.

Preemptive high-flow nasal cannula treatment in severe bronchiolitis: Results from a high-volume, resource-limited pediatric emergency department.

BACKGROUND: The aims of this study were to evaluate the outcomes of patients with severe bronchiolitis who received preemptive high-flow nasal cannula (HFNC) treatment according to the authors' protocol, and to identify potential baseline characteristics that might predict patients who will not benefit from HFNC. METHODS: This was a retrospective chart review of patients with severe bronchiolitis, who received preemptive HFNC treatment according to the authors' protocol and who were admitted to the pediatric emergency department between January 1, 2015, and December 31, 2016. RESULTS: Eighty-four patients in total were enrolled over the 2 year period. Twenty-three patients (27.3%) failed HFNC. Of these, four responded to non-invasive mechanical ventilation and 19 required subsequent invasive ventilation. According to logistic regression analysis, existence of a chronic condition, significant tachycardia, existence of dehydration, and a venous pH <7.30 at admission were found to be predictors of HFNC failure. There were no cases of pneumothorax or any other reported adverse effects related to HFNC therapy. CONCLUSIONS: Preemptive HFNC treatment, complying with a preestablished protocol, might be a safe way to support patients with severe bronchiolitis in high-volume, resource-limited pediatric emergency departments. The existence of a chronic condition, significant tachycardia, dehydration, and a venous pH <7.30 at admission could be risk factors for preemptive HFNC treatment failure in severe bronchiolitis.

A Rare Cause of Metabolic Acidosis: Fatal Transdermal Methanol Intoxication in an Infant.

Oral methanol intoxication is common, but dermal intoxication is rare. We report a previously healthy 19-month-old female infant admitted to the emergency department (ED) with vomiting and tonic-clonic seizure. On physical examination, she was comatose and presented signs of decompensated shock with Kussmaul breathing. Her left thigh was edematous, with purple coloration. Methanol intoxication was suspected due to high anion gap metabolic acidosis (pH, 6.89; HCO3, <3 meq/L) and exposure to spirit-soaked bandages (%96 methanol) for 24 hours and 3 days. The patient's serum methanol level was 20.4 mg/dL. She was treated with fomepizole and continuous venovenous hemodialysis (CVVHD) in the pediatric intensive care unit, and methanol levels decreased to 0 mg/dL after 12 hours. During follow-up, massive edema and subarachnoid hemorrhage in the occipital lobe were detected by computed tomography of the brain. The patient died after 7 days.Although methanol intoxication occurs predominantly in adults, it must be considered in children with high-anion gap metabolic acidosis. This case report demonstrates that fatal transdermal methanol intoxication can occur in children, and it is the second report in the English literature of transdermal methanol intoxication in an infant.

Factors affecting the decision to hospitalise children admitted to the emergency department due to non-fatal suicide attempts by pills.

OBJECTIVE: Suicide attempts (SAs) in the paediatric age group represent an important cause of morbidity and mortality. Our aim was to examine the factors affecting the decision to hospitalize children with a diagnosis of non-fatal SA by pills. METHODS: Children <18 years of age admitted with SA by pills during 2014 were evaluated retrospectively. Patients were divided into two groups: Group-I comprised hospitalised patients and Group-II included those who were discharged from the PED. These two groups were compared in terms of clinical and demographic characteristics recorded upon PED admission. RESULTS: A total of 196 patients were included in the study. The number of pills taken for self-poisoning in Group-I (median: 20 pills) was higher than that in Group-II (median: 12 pills) (p < 0.001), and the rate of pathological findings during the first paediatric psychiatric consultation was higher in Group-I (91.1%) than in the Group-II (54.8%) (p < 0.001). CONCLUSION: Factors affecting the disposition decision in cases of children who performed non-fatal SA via pills included the amount of medication taken for the suicide attempt and the presence of psychiatric disorders, as determined by a paediatric psychiatrist during the acute phase.

The importance of microalbuminuria in predicting patient outcome in a PICU.

OBJECTIVE: To evaluate the prognostic significance of microalbuminuria in critically ill children. DESIGN: Prospective study. SETTING: PICU of a teaching hospital. PATIENTS: Admitted critically ill children. INTERVENTIONS: The urine albumin-creatinine ratio was measured at admission and at 24 hours. Pediatric Risk of Mortality, Pediatric Index of Mortality II, Pediatric Logistic Organ Dysfunction, and Inotrope Score were calculated. MEASUREMENTS AND MAIN RESULTS: In total, 102 patients (median age, 19 mo) were included in the study, among whom were 30 mortalities. Microalbuminuria was identified in 62 patients (64%). The patients were classified into three groups: patients with sepsis, patients with noninfectious systemic inflammatory response syndrome, and patients without systemic inflammatory response syndrome. The highest clinical scores, albumin-creatinine ratio levels, mortality rate, and duration of mechanical ventilation were found in the sepsis group, and the lowest values were seen in patients without systemic inflammatory response syndrome (p < 0.05). Significant correlations were observed between the albumin-creatinine ratio levels and the clinical scores (p < 0.05). The receiver operating characteristics curve analysis showed that the areas under the curves were 0.818 and 0.781, respectively, for albumin-creatinine ratio measured at admission and at 24 hours to identify PICU mortality. At a cutoff value of 34.2 mg/g, albumin-creatinine ratio measured at admission may be able to discriminate between patients a with sensitivity of 63.3%, specificity of 93.3%, positive predictive value of 95%, and negative predictive value of 56%. CONCLUSIONS: Microalbuminuria is a simple, inexpensive, and useful tool for predicting mortality and morbidity in critically ill children in the PICU.