A silent scream in the pediatric emergency department: child abuse and neglect.

Child abuse and neglect includes any behavior that harms the child or hinders the child's development. The aim of this study was to determine the demographic and clinical characteristics of patients with suspected child abuse or neglect in the pediatric emergency department. Between July 2017 and July 2022, patients admitted to our pediatric emergency department and consulted to the medical social services unit with a preliminary diagnosis of neglect and/or abuse were retrospectively scanned through the registry system. The patients were divided into five groups according to their victimization: physical, sexual, and emotional abuse; neglect; and medical child abuse (MCA)-Munchausen by proxy. A total of 371 children were included in the study. Two hundred twenty-two (59.8%) of the patients were female and the median age was 161 months [IQR (46-192)]. Then, 56.3% of the patients were in the adolescent age group. The most common admission time period was between 16.00 and 24.00 (n 163, 43.9%). Then, 24.2% of the patients were exposed to physical abuse, 8.8% to sexual abuse, 26.1% to emotional abuse, 50.4% to neglect, and 3.2% to MCA. One hundred eight (29.1%) patients were followed up as inpatients in the pediatric intensive care unit. Four of the patients (1%) had out-of-hospital cardiac arrest, and the deaths were in patients under 2 years of age.  Conclusion: Pediatric emergency departments are one of the important units visited by child maltreatment patients. Victimized children may reflect their silent screams with various clinical presentations. Infants are at the greatest risk of suffering serious or fatal injuries. Health professionals working in the emergency department have an important role in detecting, treating, and preventing recurrence of child neglect and abuse. What is Known: • The pediatric emergency department is an important entry point in the health care system for children who experience maltreatment. • It has a wide spectrum of physical, sexual, emotional abuse and neglect. What is New: • A high index of suspicion is required to diagnose cases of child maltreatment. • Infants are at the greatest risk of suffering serious or fatal injuries.

Resistance Training to Muscle Failure with Variable Load Intensities: Implications for Post-Exercise Blood Pressure and Heart Rate Variability in Trained Men.

Background: The modulation of cardiac sympathovagal balance alters following acute resistance training (RT) sessions. Nevertheless, the precise influence of RT at varying load intensities on this physiological response remains to be fully elucidated. Therefore, the aim of this study was to compare the time course of recovery following low- (40%), moderate- (60%), and high- (80%) load-intensity RT protocols performed up to muscle repetition failure in resistance-trained men. Method: Sixteen young, resistance-trained men (mean age: 21.6 ± 2.5 years, mean height: 175.7 ± 8.9 cm, mean weight: 77.1 ± 11.3 kg) participated in a randomized crossover experimental design involving three sessions, each taken to the point of muscle failure. These sessions were characterized by different load intensities: low (40% of 1-repetition maximum, 1RM), moderate (60% of 1RM), and high (80% of 1RM). The exercise regimen comprised four exercises-back squat (BS), bench press (BnP), barbell row (BR), and shoulder press (SP)-with each exercise consisting of three sets. Throughout each session, heart rate variability (HRV) and blood pressure (BP) parameters were assessed both pre-exercise and during a 40 min post-exercise period, segmented into 10 min intervals for stabilization. Statistical analysis involved the use of a repeated measures ANOVA. Results: It was observed that the 40% and 60% RT sessions resulted in a significantly higher root mean square of successive R-R intervals (RMSSD) value compared to the 80% RT session in the post-exercise recovery process in 30 min (respectively, p = 0.025; p = 0.028) and 40 min (respectively, p = 0.031; p = 0.046), while the 40% and 60% RT sessions produced similar responses. The 40% RT session was significantly higher in the high frequency (HF) value post-exercise in 40 min compared to the 80% RT session (p = 0.045). Conclusions: Our findings suggest that engaging in resistance training (RT) sessions to muscle failure at an intensity of 80% induces acute increases in sympathetic activity, potentially leading to elevated cardiovascular stress. For individuals with normal blood pressure, it is advisable to opt for lighter loads and higher repetition volumes when prescribing RT, as heavier-load RT may carry an increased risk of cardiac-related factors.

Emergency medical service use at a pediatric center in Turkey, during the COVID-19 pandemic period.

AIM: This study aimed to evaluate aspects of pediatric patients presenting to a hospital in Turkey via emergency ambulance services, including incidence of visits to the hospital, acuity of illness and most common diagnoses, during the one-year period before and after the onset of the coronavrrus dsease 2019 (COVID-19) pandemic. METHODS: This was a retrospective and single center analysis of children, transported by Emergency Medical Services to the Emergency Department (ED) of a children's hospital in Turkey, between 10 March 2019 and 11 March 2021. RESULTS: Percentage of high acuity group (68.1% vs.76.9%) during pandemic period was significantly lower than prepandemic period (p < 0.001). On the contrary, the percentage of patients using emergency ambulance service with a low level of acuity increased during the pandemic period compared to the prepandemic period (31.9% vs. 23.1%) (p < 0.001). A significant decrease was observed in the cases of lower respiratory tract infections, febrile status epilepticus and excessive alcohol use during the pandemic period. No significant differences were found hospitalizations requiring PICU and mortality in ED during the pandemic period. CONCLUSION: During the COVID-19 pandemic; also, a decrease in admissions was observed for those with high-risk conditions. On the contrary, an increase was detected in patients with low acuity levels. Efforts should be made to ensure access to safe and quality emergency care during the pandemic.

Social, Emotional and Behavioral Problems in Children With Foreign Body Ingestion: A Case Control Study.

OBJECTIVES: To compare the social, emotional, and behavioral status between the patients aged 1 to 4 years with foreign body ingestion and healthy individuals. METHODS: A case control study was conducted in a tertiary level hospital over 32 months. Children, aged 1-4 years, admitted to the pediatric emergency department with foreign body ingestion were included as cases. Patients with known autism spectrum disorders, cerebral palsy and incomplete evaluation were excluded. A matched control group constituted healthy individuals. Both groups were evaluated with Aberrant Behavior Checklist (ABC) and Brief Infant-Toddler Social Emotional Assessment (BITSEA) scales. Logistic regression was performed to determine the predictors of foreign body ingestion. RESULTS: Cases and controls included 150 children each. All ABC subscale scores (mean irritability, hyperactivity/dissonance, lethargy/social withdrawal, stereotypical behavior, and inappropriate speech) and problem area scores of BITSEA were significantly higher in the cases (P < 0.001). Hyperactivity was significantly predictive of foreign body ingestion [OR (95% CI) 1.37 (1.21, 1.55), P < 0.001]. CONCLUSION: Younger children with foreign body ingestion screened significantly higher for behavioral and emotional problems compared to controls. Hyperactivity was an important predictor factor for foreign body aspiration.

Evaluation of Neurosurgical Emergencies in the Pediatric Emergency Department: Clinical Warning Signs.

BACKGROUND: We aimed to evaluate the patients who underwent neuroimaging with suspicion of neurosurgery pathology and identify the clinical warning signs for the early recognition of neurosurgical emergencies. METHODS: Patients aged one month to 18 years who underwent neuroimaging with a preliminary diagnosis of intracranial pathology requiring emergency surgery and symptom duration less than one month were included in the study. Patients were divided into three groups according to their definitive diagnosis as neurosurgical emergencies, neurological emergencies, and nonurgents. RESULTS: A total of 140 patients were included in the study (the median age was 8 [interquartile range IQR 3 to 13] years and 52.8% were male). Neurosurgery emergency group and neurological emergency group were significantly younger than the nonurgent group (P < 0.001). Vomiting, meningeal irritation findings, and papilledema (grade 2 and above) were more common in the neurosurgical emergency group (P 0.029, 0.023, and < 0.001, respectively). For neurosurgical emergencies, in the presence of papilledema (grade 2 and above) and focal neurological deficit, the specificity was 99.2%, positive predictive value (PPV) 83.3%, negative predictive value (NPV) 88.1%, and odds ratio (OR) 36.8 (P < 0.001, confidence interval [CI] 4.04 to 336.0); in the presence of altered consciousness and focal neurological deficit, the specificity was 97.5%, PPV 50%, NPV 86.6%, and OR 6.4 (P = 0.014, CI 1.20 to 34.4). CONCLUSIONS: Younger age, presence of vomiting, signs of meningeal irritation, papilledema grade 2 and above, and altered consciousness are the crucial "warning signs" of a potential neurosurgical emergency.

An analysis of cardiology consultation requests in infants presented to the pediatric emergency department of a tertiary children's hospital.

INTRODUCTION: Cardiological emergencies are reported to constitute almost 15% of all emergency department visits. This study aimed to characterize the main signs and symptoms of the infants that necessitated pediatric cardiology consultation and to analyze the characteristics of patients diagnosed with a cardiological disorder. MATERIAL AND METHODS: Patients aged 1 month to 1 year who were consulted to the pediatric cardiology service during a 4-year period were retrospectively evaluated. Patients' age, sex, nationality, complaints at PED, physical examination findings, reason for echocardiography (echo) and final diagnosis were recorded from the hospital medical record system for further analysis. Patients were divided into two groups according to the severity of the echo findings (patients with significant cardiovascular issues and patients without significant cardiovascular issues). RESULTS: Of the 200 patients included in the study, 19 were in the significant cardiovascular issues, and 181 were in the without significant cardiovascular issue group. The leading complaints of the patients who were consulted to cardiology were cyanosis (22.5%), seizure (22.5%), cough (22%), and fever (19.5%). In emergency presentations, jaundice (16%), nutritional problems (21%), and cardiomegaly (21%) on x-rays were higher in patients with significant cardiovascular issues (p < 0.05). CONCLUSION: In conclusion, congenital heart disease is usually diagnosed in the neonatal period, but some patients may be missed due to a variety of symptoms and findings. Infants with feeding problems and jaundice, especially those with cardiomegaly on chest radiographs, should be carefully evaluated for underlying serious congenital heart disease.

Evaluation of Acute Ataxia in the Pediatric Emergency Department: Etiologies and Red Flags.

BACKGROUND: We aimed to evaluate patients with acute ataxia and to determine the warning clinical factors in the early prediction of neurological emergencies. METHOD: Patients with a history of balance and gait coordination disorder and clinically diagnosed as acute ataxia in pediatric emergency department were included in the study. As a result of final diagnosis, the characteristics of patients with and without clinically urgent neurological pathology (CUNP) were compared. CUNP was defined as any nervous system disorder requiring early diagnosis and prompt medical or surgical treatment and/or intensive care unit admission to prevent disabling or life-threatening evolution. RESULTS: Eighty-eight patients with a median age of 5 years were included in the study (37 [42%] patients with CUNP and 51 [58%] without CUNP). In the CUNP group, the median age of patients and symptom duration were significantly higher (P < 0.001 and P = 0.011, respectively). The most common etiologies were acute post/parainfectious cerebellar ataxias (n = 40 [45.4%]), acute cerebellitis (n = 9 [10.2%]), and Guillain-Barré syndrome (n = 8 [9%]). Hyporeflexia/areflexia and dysmetria were associated with a higher risk of CUNP. Headache, loss of consciousness, and visual dysfunction were the findings appearing exclusively in patients with CUNP. CONCLUSIONS: The most common etiologies in acute ataxia are benign and transient, whereas life-threatening conditions may occur rarely and may require urgent intervention. Older age; prolonged symptom duration; focal neurological deficits such as hemiparesis, hyporeflexia, and visual impairment; and nonspecific findings such as loss of consciousness and headache are the most striking "red flags" of a potential neurological emergency and should alert clinicians to CUNP.

Success of the acute renal angina index in the early prediction of acute kidney injury in the emergency department.

INTRODUCTION: It is mentioned that the acute renal angina index (aRAI), a new concept, can be used in emergency departments to calculate and accurately predict the risk of developing acute kidney injury (AKI). The aims of the study included: to evaluate the predictive performance of the aRAI (AKI risk classification tool) in predicting AKI in the pediatric emergency department. METHOD: Patients who met the criteria for systemic inflammatory response syndrome were examined. AKI was defined with creatinine N1.5× baseline 24-72 hours after hospitalization. aRAI and original RAI scores were calculated for patients and were shown as renal angina positive (RA+) above a population-derived threshold. The performance of aRAI in predicting AKI compared to changes in creatinine and original RAI was evaluated. RESULTS: In total, 241 eligible subjects were enrolled. The median age of the patients was 17 months (min-max 1-192). AKI developed in 60 (24.8%) of the patients. According to the aRAI, 76 (31.5%) of 241 patients were RA(+). The aRAI had an NPV of 1.00 and an AUC of 0.948 (0.914-0.983) for the prediction of AKI. Sensitivity was 95% for the aRAI as compared to 48% for an elevation in SCr noted to be at least two times greater than the baseline while in the PED and 61% for original RAI. CONCLUSIONS: The aRAI is easily computable, does not depend on complex computational or derivation methods, and is universally accessible. We confirm and extend the findings of previous study reporting the performance of RAI for early prediction of AKI.

A Novel Marker for Predicting Fulminant Myocarditis: Systemic Immune-Inflammation Index.

In myocarditis, the search for effective and appropriate prognostic biomarkers can help clinicians identify high-risk patients in a timely manner and make better medical decisions in clinical practice. The prognostic value of systemic immune-inflammatory index (SII), an innovate biomarker of inflammation, in fulminant myocarditis in children has not been assessed. This study aims to (1) determine the effect of SII and other inflammatory markers on the prognosis of patients with myocarditis, and (2) characterize other factors affecting adverse outcomes in myocarditis. All patients aged between 1 months and 18 years who admitted to Pediatric Emergency Department between January 1, 2015 and October 1, 2021 and were diagnosed with myocarditis were retrospectively analyzed. 106 Eligible subjects were enrolled (67% male, 12.5 years (IQR 6-16). Fulminant myocarditis developed in 16 (15%) of the patients. The median SII was 1927 (1147.75-3610.25) in the fulminant myocarditis group and 351 (251.75-531.25) in the non-fulminant group (p < 0.001). In estimation of fulminant myocarditis, AUC was 0.87 for WBC [95% confidence interval (CI) 0.72-1.00, p = 0.002], 0.94 for ANC (95% CI 0.85-1.00), p = 0.000), 0.92 for SII (95% CI 0.82-1.00, p = 0.000). Spearman's correlation analysis showed a significant negative correlation between SII and LVEF (r = 0.576, p < 0.001). The highest AUC values were associated with ANC, SII, and WBC levels to predict fulminant myocarditis. SII, a readily available biomarker from routine blood parameters, allows early recognition of negative outcomes and can independently predict the prognosis of myocarditis in children.

Benign acute childhood myositis: Factors associated with muscle symptoms and resolution.

BACKGROUND: Benign acute childhood myositis (BACM) is associated with several viral infections. The aim of this study was to evaluate the progression of myositis symptoms, laboratory findings and oseltamivir treatment in children with influenza- and non-influenza-associated BACM. METHODS: Patients aged 0-18 years old, admitted to the pediatric emergency department in the seasonal influenza period between 2018 and 2020 were retrospectively analyzed. Patients with acute onset calf tenderness, pain, difficulty in walking and elevated serum creatine phosphokinase were included and were grouped according to influenza rapid test kit results as influenza (A and B) positive, and influenza negative. The time to symptom resolution, laboratory data and the oseltamivir treatment were compared between the groups. RESULTS: There were 94 patients (67 male, 27 female) with a mean age of 77 ± 22 months. Influenza A was detected in 21, influenza B in 27, and neither were detected in 46 patients. Time to symptom resolution of BACM was shorter in the influenza-positive patients than in influenza-negative patients (2.9 ± 1.4 days and 3.5 ± 1.5 days, respectively, P = 0.027). Oseltamivir did not reduce the symptom resolution time in influenza patients. All children had normal hemoglobin and platelet counts, elevated creatine phosphokinase and 76% of them had leukopenia. Neither clinical recurrence nor metabolic disease were reported. CONCLUSION: Symptoms of BACM tended to resolve slightly earlier in influenza-positive patients and the duration of symptoms was not affected by oseltamivir treatment.

Evaluation of chronic cough etiology, quality of life, and anxiety level in children.

Introduction: To evaluate the quality of life and anxiety level of school-age children with chronic cough, and changes with treatment. Materials and Methods: Patients aged between 6-18 years with a chronic cough were included in this study. A control group was designed, and the scale scores were compared with each other. Result: The mean age of the 82 patients was 10.9 ± 3.8 years, 62 (75.6%) had at least one specific cough marker. Forty patients (48.8%) were diagnosed with asthma. At their first visit, the psychosocial health scores and the total scale scores (sum of physical and psychosocial total scores) were lower than the control group for both patients and parents. After the resolution of cough, their scores increased to the same level with the control group. It was also found that the level of anxiety was significantly higher than in the control group both before treatment and after the resolution period (p<0.001 and =0.008, respectively). Conclusions: Asthma was the leading cause of chronic cough. Quality of life is impaired in children with chronic cough. Anxiety level in these patients increases and after symptoms improve, continues to be higher than that of healthy children.

COVID-19 Infection in Well-Appearing 30- to 90-Day-Old Infants with Fever without a Source.

Fever without a source (FWS) is common clinical status in the young infants. The aim of this study was to evaluate the clinical and laboratory findings of coronavirus disease (COVID-19) infection in well-appearing infants with FWS. Well-appearing febrile infants between 30 and 90 days who were evaluated as FWS in the pediatric emergency department and tested for COVID-19 were divided into two groups: COVID-19 (+) and (-). The clinical and laboratory findings of the patients were compared. The study included 95 febrile infants with FWS, and the mean age was 59.62 ± 16.82 days. The nasopharyngeal COVID-19 polymerase chain reaction test results of 29/95 (30.5%) patients were positive, while 66/95 (69.5%) were negative. The complaints of irritability and nasal congestion were found to be significantly more common in COVID-19-positive patients (p = 0.04 and p = 0.041, respectively). The hospitalization rate (p = 0.009), length of hospital stay (p = 0.026), initiation of antibiotic treatment (p < 0.001) and duration of antibiotic treatment (p = 0.036) were significantly lower in the COVID-19 (+) patients. The C-reactive protein (CRP, p < 0.001), absolute neutrophil count (ANC, p < 0.001), absolute lymphocyte count (ALC, p = 0.015), white blood cell (WBC, p < 0.001) and systemic immune-inflammation index (SII, p < 0.001) were found to be significantly lower in the COVID-19 (+) patient group. There was no significant difference between the groups in terms of neutropenia, lymphopenia or leukopenia.COVID-19 infection may present as an FWS. During the pandemic period, testing for COVID-19 among infants who were evaluated as FWS may reduce unnecessary hospitalizations and antibiotic treatments, and shorten hospital stays and duration of antibiotics.

Utility of the systemic immune-inflammation index to predict serious bacterial infections in infants with fever without a source.

INTRODUCTION: This study analyzed the utility of the systemic immune-inflammation index (SII) in predicting serious bacterial infections (SBIs) in infants with fever without a source (FWS). METHODS: Infants (aged 1-4 months) evaluated in the pediatric emergency department for FWS were divided into two groups: with SBI and without SBI. The efficacy of inflammatory markers in predicting SBI was compared. RESULTS: The study included 223 infants with a mean age of 76.65 ± 25.42 days; 62 (27.8%) of them were included in the SBI group, and all of them were diagnosed with a urinary tract infection (UTI). The hospitalization rate and length of hospital stay were significantly higher in UTI patients (p < 0.001 for each). The mean SII was 795.76 ± 475.85 in the SBI group and 318.24 ± 300.70 in the non-SBI group, and there was a significant difference between the groups (p < 0.001). In diagnosis of SBI, the area under the curve values were found to be 0.89 [95% confidence interval (CI): 0.85-0.94] for C-reactive protein (CRP), 0.86 (95% CI: 0.81-0.91) for absolute neutrophil count (ANC), 0.84 (95% CI: 0.78-0.89) for the SII, and 0.81 (95% CI: 0.74-0.87) for WBC. In the multivariate logistic regression analysis, high CRP and SII values were found to be predictive factors for UTI without bacteremia (p < 0.001 and p = 0.008, respectively). CONCLUSION: We found that high CRP and SII values could be predictive for UTI without bacteremia in infants with FWS. The SII may be preferred because it can be easily calculated using the hemogram results, is not accompanied by extra costs, and does not require further blood collection.

Is the Early Diagnosis of Pediatric Stroke Possible in the Emergency Department?

BACKGROUND AND PURPOSE: Pediatric stroke is a neurological emergency. Knowing the predictive clinical markers for childhood stroke will help in early diagnosis and patient management. This study aims to (1) evaluate patients admitted to the pediatric emergency department (PED) with acute neurological signs and/or symptoms who underwent neuroimaging and (2) determine the clinical warning signs for the early recognition of stroke. METHODS: One hundred one patients aged 1 month to 18 years who were admitted with stroke-related neurological signs and symptoms and underwent neuroimaging in the PED were retrospectively analyzed using the file record system. As a result of these imaging tests, the characteristics of patients with stroke and nonstroke were compared. RESULTS: The mean age of the 92 included patients was 10.7 (SD, 4.5) years. Among the admission symptoms of the patients, a significant difference was observed only in terms of speech disorder, whereas a significant difference was found in the examination results for altered consciousness and dysarthria. The incidences of hemiplegia and hemiparesis were higher in the stroke group, but they were not statistically significant. The median duration of time from symptom onset to PED admission was 240 minutes (interquartile range, 30-1440 minutes). The mean time from PED admission to magnetic resonance imaging in the stroke group was 2.3 (SD, 0.7) hours, which was significantly shorter than for the nonstroke group (4.9 [SD, 1.2] hours, P = 0.002). CONCLUSIONS: Childhood stroke is a neurological emergency that requires a multidisciplinary approach. Early stroke diagnosis is vital for treatment and prognosis. With respect to sudden neurological deficits, particularly dysarthria, altered consciousness, hemiplegia, and hemiparesis, should alert clinicians to stroke. In addition, interdepartmental cooperation is essential both in the rapid recognition of stroke and the treatment and follow-up processes.

Evaluation of the efficiency of the systemic immune-inflammation index in differentiating parapneumonic effusion from empyema.

AIM: To evaluate the effectiveness of the systemic immune-inflammation index (SII) and other biomarkers in distinguishing parapneumonic effusion (PPE) and empyema. METHODS: Patients who were thought to have pleural effusion secondary to pneumonia in the pediatric emergency department (PED) between 2004 and 2021 were retrospectively evaluated. The patients were divided into two groups as empyema and PPE. The efficacy of infection markers in predicting empyema was compared. RESULTS: Fifty-nine patients (59.3% male) were included in the study. Forty-three (72.9%) patients were in the PPE and 16 (27.1%) were in the empyema group. Length of hospital stay and pleural fluid thickness measured with thoracic ultrasonography were significantly higher in the empyema group (p = 0.018 and p = 0.002, respectively). The mean SII was 1902.73 ± 1588.87 in PPE patients, while it was 6899.98 ± 6678 in empyema patients (p = 0.009). C-reactive protein (CRP), white blood cell (WBC) count, absolute neutrophil count (ANC), and neutrophil-lymphocyte ratio (NLR) ​​were significantly higher in the empyema group; absolute lymphocyte count (ALC) and lymphocyte-monocytes ratio (LMR) were significantly lower than the PPE group. When the best cut-off values of inflammation markers are determined according to the area under the curve, the highest odds ratios suggesting empyema were found in SII, LMR, CRP, and ANC, respectively. CONCLUSION: Inflammation markers can be useful in predicting empyema. The best markers were found to be SII, LMR, CRP, and ANC. High SII is one of the practical diagnostic markers that can be used differentiate empyema from PPE in PED.

Retrospective Evaluation of Acute Headache in Pediatric Emergency Department: Etiologies, Red Flags, and Neuroimaging.

BACKGROUND: The aims of this study were to describe the etiologies of acute headache presenting to the pediatric emergency department, determine their clinical characteristics, the prevalence of red flag findings and neuroimaging and identify predictors of headaches because of serious intracranial diseases. MATERIALS AND METHODS: Patients from 2 to 18 years of age who visited pediatric emergency department with a chief complaint of headache between January 1, 2016 and August 31, 2020 were retrospectively evaluated. RESULTS: The mean age of the 558 patients included in the study was 11.17±3.78 years, and 290 (52%) were female. The most common cause of acute headache was head and neck area infections (except central nervous system infections) in 355 (63.6%) patients. Forty patients (7.2%) had a headache because of serious intracranial diseases. According to binary logistic regression analysis, the findings that predicted a serious intracranial diseases were abnormal neurological physical examination [odds ratio (OR): 187.57; 95% confidence interval (CI): 32.67-1076.64], recent onset or suddenly severe headache (OR: 14.41; 95% CI: 3.14-65.91), and vomiting (OR: 9.42; 95% CI: 1.90-46.63). Neuroimaging was performed in 63 (11.3%) patients, and 7 (1.25%) had a pathology requiring emergency treatment. CONCLUSIONS: The majority of acute headaches were evaluated as secondary headache. The most common cause of acute headache was head and neck area infections. Abnormal neurological physical examination, recent onset or suddenly severe headache, and vomiting were the most useful red flags for predicting serious intracranial diseases. The requirement for neuroimaging should be evaluated individually for each patient.

Delta neutrophil index and C-reactive protein: a potential diagnostic marker of multisystem inflammatory syndrome in children (MIS-C) with COVID-19.

Multisystem inflammatory syndrome in children (MIS-C) is a life-threatening hyperinflammation syndrome emerging after COVID-19. The serum delta neutrophil index (DNI) reflects the fraction of circulating immature granulocytes and is evaluated in infection and inflammation. The aim of this study is to evaluate the usefulness of DNI as a diagnostic marker in patients with MIS-C and to assess its role in determining the severity of MIS-C. This retrospective, observational study included 83 patients with MIS-C and 113 patients with COVID-19, and 102 healthy controls. C-reactive protein (CRP), the absolute neutrophil count (ANC), absolute lymphocyte count (ALC), DNI, and the platelet count were recorded. The DNI levels were 4.60 ± 5.70% in the MIS C group, 0.30 ± 0.99% in the COVID group, and 0.20 ± 0.56% in the control group (p < 0.001). According to the severity of MIS-C, the DNI level was found to be 1.22% in mild MIS-C, 4.3% in moderate MIS-C, and 5.7% in severe MIS-C. There was a statistically significant correlation between DNI levels and the severity of MIS-C. The cutoff value of DNI for predicting MIS-C was 0.45%. In the analysis of the diagnostic performance of DNI compared with CRP, ANC, ALC and platelet counts, sensitivity, specificity, positive predictive value, and negative predictive value were found to be 79.5%, 97.1%, 95.7%, and 85.3%, respectively.Conclusions: The delta neutrophil index was identified as a diagnostic marker for MIS-C such as ANC, ALC, platelet count, and CRP. DNI levels in hemogram analysis may guide clinicians in determining the diagnosis and severity of MIS-C. What is Known: • Although CRP, sedimentation, ALC, ANC, platelet count, sodium, and albumin are used as first step tests, there is no specific laboratory marker used in the diagnosis of MIS C. • The serum delta neutrophil index (DNI) reflects the fraction of circulating immature granulocytes and is elevated in infection and inflammation. What is New: • DNI is a promising and easily accessible marker that can be used with other markers in the diagnosis and determines the severity of MIS C. • DNI is an easily accessible, inexpensive, and dynamic marker and its levels in simple hemogram analysis will guide pediatricians in determining the diagnosis and severity in MIS C.

Comparison of Clinical, Demographic Features, and Costs in Respiratory Syncytial Virus, Rhinovirus, and Viral Co-infections in Children Hospitalized with Viral Infections of the Lower Respiratory Tract.

Viruses are the most common cause of lower respiratory tract infections (LRTIs) in children. Our study aimed to shed light on co-infection by comparing it with the most common single agents, such as respiratory syncytial virus (RSV) and rhinovirus (RV), in terms of epidemiological, clinical, laboratory findings, and cost. This retrospective study analyzed medical records pertaining to infants aged below 5 years, hospitalized with a diagnosis of LRTI with RSV, RV, or co-infection. The study group consisted of 199 children, RSV was detected in 116 patients (58.3%), RV in 46 (23.1%), and co-infections in 37 (18.6%). The average age of patients infected with RV was higher (P = 0.006), and the length of hospital stay of patients infected with RSV was longer (P = 0.03) than that with other agents. There was no significant difference between the groups in terms of oxygen requirement, intensive care unit admission, intubation, and development of complications. The cost was significantly higher in the RSV group (P = 0.02) compared to the other groups. Viral co-infections, RSV, and RV constitute an important part of the etiology in patients aged below 5 years; co-infections do not cause more severe clinical findings compared to single viral agents.

Mosquito hypersensitivity may be associated with atopic background in children.

BACKGROUND: Many children encounter unusual or "exaggerated" reactions such as large local, atypical or systemic reactions after mosquito bites. OBJECTIVE: The aim of this study was to document the clinical features of children with mosquito allergy and investigate the possible associations between demographic features and type of reactions in this population. METHODS: Children with large local or unusual reactions after mosquito bites who attended to our outpatient pediatric allergy department were enrolled in the study along with control subjects. RESULTS: A total of 180 children (94 with mosquito allergy and 86 age and sex-matched control subjects) with a median age of 6.8 years (IQR 5.5-9.3) were enrolled. Atopy (35.1% vs. 11.6%, p < 0.001) and grass pollen sensitization (28.7% vs. 8.1%, p < 0.001) were significantly more frequent in children with mosquito allergy. Skin prick test with mosquito allergen was positive in only 6 children (6,4%). Grass pollen sensitization was most common in children (28.7%) followed by sensitization to house dust mite (9.6%). 30 children (31.9%) had an accompanying atopic disease such as allergic rhinitis, asthma or atopic dermatitis. Bullae were significantly more frequent in children with asthma (41.7% vs.15.9, p = 0.034). The median duration of symptoms after onset were significantly longer in patients with ecchymosis, with immediate wheals and in children whose symptoms start in 20 min to 4 hours after mosquito bites. CONCLUSION: There is an association between unusual, large local or exaggerated reactions after mosquito bites and allergic diseases in children. The severity of reactions increases with age and particularly in children with atopic background.