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.

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.

The effect of emotion recognition and mindfulness on depression symptoms: A case-control study.

Abnormalities in emotion recognition (ER) are frequently reported in depression, with lower recognition accuracy in patients with major depressive disorder (MDD) when compared to healthy individuals. Mindfulness was found to directly impact the severity of depressive symptoms, by recognizing negative cognitions and dysfunctional reactions. The aims of this study were to compare ER and mindfulness levels between MDD patients and healthy controls (HCs), as well as to examine whether ER and mindfulness are related to symptom severity in MDD patients. Sixty-eight patients with MDD and 93 HCs participated in the study. A sociodemographic form, reading the mind in the eyes test (RMET), five facet mindfulness questionnaire-short form (FFMQ-S) and the Montgomery-Asberg depression scale (MADRS) were administered. Group comparison in ER and mindfulness was performed using the multivariate analysis of covariance (MANCOVA). Bivariate correlations and hierarchical linear regression analyses were performed to assess the associations between depression severity, ER and mindfulness in the patient group. Higher level of mindfulness was found in HCs relative to MDD group, however, no ER difference was present between the groups. A positive association between depression severity and the non-reactivity facet of mindfulness was found. On the other hand, ER was not significantly associated with symptom severity among individuals with MDD. Non-reactivity, unlike other dimensions of mindfulness, seems to increase with the severity of depressive symptoms among MDD patients. A particular focus on this subdimension in mindfulness techniques may yield better outcomes in alleviation of depressive symptoms.

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.

Lung ultrasound findings in children with foreign body aspiration.

OBJECTIVES: Foreign body aspiration (FBA) has a wide clinical spectrum, patients may be asymptomatic or present with cardiopulmonary arrest. Radiological imaging methods are used in addition to history and physical examination findings for certain diagnosis. Lung ultrasonography (LUS), whose usage area is increasing year by year, can be included in these. This study aimed to investigate ultrasonography findings in FBA and hypothesized that LUS may have a standard place in FBA diagnosis. METHODS: Patients who administered to the pediatric emergency department between August 2019-August 2021, considered according to the clinical findings and physical examination possible FBA, and who undergone rigid bronchoscopy by pediatric surgery were included in the study. RESULTS: Thirty-two patients were included in the study. According to the results of bronchoscopy, FBA was detected in 25 patients. The most common finding in radiography was hyperinflation on one side, while LUS findings were confluent-B lines in eight patients, barcode-sign in five patients, pleural line abnormalities in two patients, and pleural consolidation in two patients. CONCLUSION: This study is the first study aiming to evaluate LUS findings in FBA to the best of our knowledge. The B-lines, barcode sign, pleural line abnormalities and consolidation are seen findings in LUS of the patients with FBA. Although it is far from replacing chest radiography in these patients, it is possible to say that it has an equivalent value with chest radiography.

The role of metacognitions in cyberbullying and cybervictimization among adolescents diagnosed with major depressive disorder and anxiety disorders: A case-control study.

Cyberbullying is becoming increasingly widespread as individuals use technology more widely and frequently. Recent studies have shown a growing vulnerability for cyberbullying and cybervictimization, particularly in the adolescent population. We argue that dysfunctional metacognitions, which have been found to be prominent in various psychiatric disorders, may also play a role in predicting cyberbullying and cybervictimization over and above a variety of established factors including daily Internet use, social media use, depression and anxiety. For this purpose, we recruited 121 adolescents diagnosed with major depressive disorder (MDD) and 122 adolescents diagnosed with anxiety disorders (AD) from the child and adolescent psychiatric department of 'Çankiri State Hospital' along with age and gender matched healthy controls (n = 120). Participants completed the DSM-5 Depression and Anxiety Severity Scales, the Social Media Disorder Scale (SMDS), the Metacognitions Questionnaire for Children (MCQ-C) and the Revised Cyberbullying Inventory-II (RCBI-II). Cybervictimization scores were found to be higher in the MDD and AD groups when compared with healthy controls. Cyberbullying scores in the MDD group were higher than healthy controls. Additionally, the Superstition, Punishment and Responsibility subdimension of the MCQ-C was a significant predictor of cybervictimization in the AD group while controlling for daily Internet use, social media use and anxiety. However, metacognitions were not associated with cyberbullying in the MDD and AD groups, as well as with cybervictimization in the MDD group. We concluded that dysfunctional metacognitions may be a preventive therapeutic target in reducing the impact of cyberbullying in adolescents with AD.

Zonulin and claudin-5 levels in multisystem inflammatory syndrome and SARS-CoV-2 infection in children.

AIM: SARS-CoV-2 infection in children is generally asymptomatic or mild; however, it can lead to a life-threatening clinical condition, multisystem inflammatory syndrome in children (MIS-C), days or weeks after the infection. Increased intestinal permeability isa possible triggering factor at the onset of the hyperinflammation associated with MIS-C. Zonulin and claudin-5 are involved in intestinal permeability. In this study, we aimed to investigate serum zonulin and claudin-5 levels in SARS-CoV-2 infection and MIS-C disease. METHODS: The study group consisted of children diagnosed with MIS-C or SARS-CoV-2 infection who presented to a university hospital paediatric emergency or infectious diseases departments. The control group included well patients seen at the General Pediatrics units for routine follow-up. Serum zonulin and claudin-5 levels were measured at the time of diagnosis. RESULTS: Fifteen patients were included in the MIS-C group, 19 in the SARS-CoV-2 infection group and 21 in the control group. The mean zonulin level in the MIS-C group was significantly higher than in the control group (P < 0.001). Mean Claudin-5 levels were Psignificantly lower in the SARS-CoV-2 infection group than in the control group (P < 0.001). CONCLUSION: These results indicate that increased intestinal permeability may be involved in the pathogenesis of SARS-CoV-2 infection and MIS-C disease. Larger clinical trials are needed to clarify the role of serum zonulin and claudin-5 on intestinal permeability in MIS-C and SARS-CoV-2 infection in children.

Examining the roles of cognitive flexibility, emotion recognition, and metacognitions in adult Attention Deficit and Hyperactivity Disorder with predominantly inattentive presentation.

The evaluation of cognitive functions in Attention Deficit and Hyperactivity Disorder (ADHD) is fundamental to improve the efficacy of therapeutic interventions. However, the role of specific higher-order cognitive functions in adult ADHD, including cognitive flexibility, emotion recognition, and metacognitions, remains unclear. Therefore, in the current study, we aimed to examine these three distinct higher-order cognitive functions among adult ADHD individuals. Forty patients with ADHD with predominantly inattentive presentation and 42 healthy controls participated in the study. The Adult Attention Deficit and Hyperactivity Disorder Scale (AADHDS), the Wisconsin Card Sorting Test (WCST), the Reading the Mind in the Eyes Test (RMET), and the Metacognitions Questionnaire-30 (MCQ-30) were administered. Results indicated that patients with ADHD had worse metacognitions scores, in specific subdimensions, relative to healthy controls. However, cognitive flexibility and emotion recognition did not differ between the groups. Moreover, the cognitive confidence subdimension of the MCQ-30 was found to be sole significant predictor in the attention deficit subdimension of the AADHDS. Our findings suggest that lack of cognitive confidence may contribute to ADHD symptomatology despite regularly functioning cognitive flexibility and emotion recognition. Therefore, metacognitions could be a suitable target to alleviate the severity of ADHD symptoms.

Genetic Architecture of Depression: Where Do We Stand Now?

The research of depression genetics has been occupied by historical candidate genes which were tested by candidate gene association studies. However, these studies were mostly not replicable. Thus, genetics of depression have remained elusive for a long time. As research moves from candidate gene association studies to GWAS, the hypothesis-free non-candidate gene association studies in genome-wide level, this trend will likely change. Despite the fact that the earlier GWAS of depression were not successful, the recent GWAS suggest robust findings for depression genetics. These altogether will catalyze a new wave of multidisciplinary research to pin down the neurobiology of depression.

Examination of plasma zonulin levels in bipolar I disorder: a case-control study with follow-up.

There is an accumulation in studies which strive to reveal zonulin's potential role in mental disorders. To date, one cross-sectional recent study examined zonulin in patients with bipolar disorders (BDs); however, its role still remains vague due to high fluctuation. Our aims are to determine plasma zonulin levels in exacerbation and treatment response periods, and to examine the associations between zonulin and symptom severity in BD. 30 patients with BD type I and 29 healthy controls participated in the current study. Socio-demographic form, Young Mania Rating Scale (YMRS), and Hamilton Depression Rating Scale (HAM-D) were administered. Enzyme-linked immune assay (ELISA) method was used to measure the plasma zonulin levels of the participants. The groups did not differ in plasma zonulin-level comparisons. Plasma zonulin did not alter between the exacerbation and treatment response periods of the patients. Besides, no associations were found between plasma zonulin-level and disease symptoms. Intestinal barrier integrity was not found to be altered among patients with BD type I. The lack of alterations in plasma zonulin level between different periods may be attributable to several factors. One possible factor might be the ELISA method which can detect other proteins (e.g., properdin) rather than zonulin. Therefore, it might fail to indicate direct observation of intestinal permeability. However, future study designs with more accurate estimation of zonulin in a larger sample may provide a different perspective on intestinal permeability's possible role in BD etiology.

The relationship between dysfunctional metacognitive beliefs and problematic social networking sites use.

Social networking sites (SNSs) enrol new subscribers each day. However, problematic SNS use has undesirable effects on psychological functioning. Therefore, it is important to identify the factors that contribute to the development of problematic SNS use. Very few studies have focused on revealing the underlying mechanisms of problematic SNS use. Although many past studies have examined the relationship between metacognitive beliefs and Internet addiction, the association between metacognitive beliefs and problematic SNS use has not been adequately explored. In this study, we aimed to explore the association between metacognitive beliefs and problematic SNS use among young adults. A total of 308 individuals participated in this study. A socio-demographic data form, the Metacognitions Questionnaire-30 (MCQ-30), and Social Media Addiction Scale (SMAS) were administered. Group comparisons were performed using multivariate analysis of covariance. Pearson's correlational and multiple linear regression analyses were conducted to examine the associations between metacognitive beliefs and problematic SNS use. The SNS addicts scored higher in all of the SMAS assessments. When compared to non-addicts, SNS addicts obtained higher scores on all the subtests of the SMAS and MCQ-30 except cognitive self-consciousness. The negative beliefs about the uncontrollability and danger of worry, cognitive confidence, and need for control thoughts were associated with SMAS mood modification, relapse and conflict subdimensions. Our findings revealed that dysfunctional metacognitive beliefs are related to problematic SNS use among young adults. These findings indicate that mental health workers should consider the modification of metacognitive beliefs in the treatment of problematic SNS use.

Development of Neuroimaging-Based Biomarkers in Psychiatry.

This chapter presents an overview of accumulating neuroimaging data with emphasis on translational potential. The subject will be described in the context of three disease states, i.e., schizophrenia, bipolar disorder, and major depressive disorder, and for three clinical goals, i.e., disease risk assessment, subtyping, and treatment decision.

The evaluation of metacognitive beliefs and emotion recognition in panic disorder and generalized anxiety disorder: effects on symptoms and comparison with healthy control.

Background: The impairments in metacognitive functions and emotion recognition are considered as liable factors in anxiety disorders. Aims: The better understanding of these cognitive abilities might lead to develop more accurate treatment methods for patients who suffer from anxiety. Methods: Forty-four patients with panic disorder (PD), 37 individuals with generalized anxiety disorder (GAD) and 44 healthy control (HC) were participated in our study. Metacognition questionnaire-30 (MCQ-30), Reading The Mind From The Eyes Test and symptom severity tests were administered. Results: Statistical analyses estimated the dysfunctional metacognitive beliefs and disrupted emotion recognition in patients relative to HC. The 'need to control thoughts' aspect of metacognitive beliefs was accounted for symptom severity in GAD. Improper metacognitive beliefs were significantly predicted the PD and GAD. In addition, impoverished emotion recognition predicted the GAD. Conclusions: Our study revealed the role of inconvenient metacognitive beliefs and distorted emotion recognition in PD and GAD. These findings might facilitate the treatment management in cognitive therapies of anxiety disorders via pointing out more reasonable targets across improper cognitive fields.

Assessing the relationship between attachment, parental attitude and plasma oxytocin in schizophrenia patients and their unaffected siblings.

BACKGROUND: It is widely acknowledged that schizophrenia patients tend to have insecure attachment styles and improper parenting. However, the biological processes related to these adversities remain unclear and that the disturbance in oxytocin system is considered as one of the strongest predictors of such adversities. METHODS: Thirty-four patients with schizophrenia and their unaffected thirty-four healthy siblings were recruited for the study and they were compared with thirty-one healthy controls. We examined attachment styles via Experience in Close Relationship-Revised Test and perceived parental attitudes with the My Memories of Upbringing-Short Version Test. In addition, we evaluated plasma oxytocin levels across groups. RESULTS: The patients with schizophrenia had lower plasma oxytocin levels and obtained higher levels for attachment anxiety and avoidance with more parental rejection and over protection. There was a significantly negative relationship between the levels of plasma oxytocin in blood and parental over protection in the healthy sibling and healthy control groups. In contrast, there was a significantly positive relationship between the levels of plasma oxytocin in blood and parental over protection in the schizophrenia group. Results of the regression analyses revealed that the plasma oxytocin levels and over protection were notable factors in discriminating the groups from each other. CONCLUSION: Our findings suggested that disturbance in oxytocin is associated with susceptibility to schizophrenia predisposition. In sum, therapeutic interventions that address oxytocin and over protection may influence the outcomes in this severe mental disorder.

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.

The Aftermath of COVID-19: Exploring the Long-Term Effects on Organ Systems.

BACKGROUND: Post-acute sequelae of SARS-CoV-2 infection (PASC) is a complicated disease that affects millions of people all over the world. Previous studies have shown that PASC impacts 10% of SARS-CoV-2 infected patients of which 50-70% are hospitalised. It has also been shown that 10-12% of those vaccinated against COVID-19 were affected by PASC and its complications. The severity and the later development of PASC symptoms are positively associated with the early intensity of the infection. RESULTS: The generated health complications caused by PASC involve a vast variety of organ systems. Patients affected by PASC have been diagnosed with neuropsychiatric and neurological symptoms. The cardiovascular system also has been involved and several diseases such as myocarditis, pericarditis, and coronary artery diseases were reported. Chronic hematological problems such as thrombotic endothelialitis and hypercoagulability were described as conditions that could increase the risk of clotting disorders and coagulopathy in PASC patients. Chest pain, breathlessness, and cough in PASC patients were associated with the respiratory system in long-COVID causing respiratory distress syndrome. The observed immune complications were notable, involving several diseases. The renal system also was impacted, which resulted in raising the risk of diseases such as thrombotic issues, fibrosis, and sepsis. Endocrine gland malfunction can lead to diabetes, thyroiditis, and male infertility. Symptoms such as diarrhea, nausea, loss of appetite, and taste were also among reported observations due to several gastrointestinal disorders. Skin abnormalities might be an indication of infection and long-term implications such as persistent cutaneous complaints linked to PASC. CONCLUSIONS: Long-COVID is a multidimensional syndrome with considerable public health implications, affecting several physiological systems and demanding thorough medical therapy, and more study to address its underlying causes and long-term effects is needed.

Evaluating the requirement of ultrasonography for children with their first urinary tract infection.

BACKGROUND: Management of urinary tract infection (UTI) in children remains important. It may be the first sign for a possible underlying congenital abnormalities for the kidney and urinary tract (CAKUT). This study examined whether performing renal and bladder ultrasonography (RBUS) only for children who have a pathogen other than E. coli during their first urinary tract infection (UTI), or who experience UTI recurrence, would result in more missed diagnoses of kidney anomalies. METHODS: Patients aged between 2 months and 2 years who were seen in a tertiary pediatric hospital during a 2-year period and diagnosed with UTI were included. RBUS and voiding cystourethrography (VCUG) were performed according to American Academy of Pediatrics (AAP) guidelines. Afterwards, we looked back and evaluated how often we found kidney problems when we only did a RBUS on patients who had an atypical cause of their first UTI or who had multiple UTIs. RESULTS: One hundred and seventy-eight patients who were followed up with UTI were included in this study. The isolated pathogen was E. coli in 104 cases (58.4 %) and atypical in 74 cases (41.6 %). VCUG was conducted on 40 patients, and vesicoureteral reflux (VUR) was discovered in 16 cases and ureteropelvic junction obstruction (UPJO) was discovered in 1 case. A different diagnostic approach that required the presence of an atypical pathogen at the first UTI or a fUTI recurrence to perform the RBUS would have missed just two severe kidney anomalies. It was observed that there could be a decrease of 40.4 % in RBUS and at least 20 % in VCUG. CONCLUSIONS: A diagnostic approach that necessitates the presence of an abnormal pathogen during the initial UTI or a second UTI episode for the RBUS to be carried out would lead to fewer negative ultrasounds with minimal risk of overlooking kidney anomalies.

Clinical features and management of animal bites in an emergency department: a single-center experience.

OBJECTIVES: This study aimed to evaluate the clinical features, management, and outcomes of patients with animal bites presented to the pediatric emergency department of a tertiary center. METHODS: Patients with ICD-10 code W54 (contact with dog) and W55 (contact with other mammals) between March 1st, 2017, and July 1st, 2021, were included in the study. Demographic characteristics of the patients, type of contacted animal, wound characteristics (muscle involvement, soft tissue defect, vascular injury, type of nerve injury, and Lackmann's classification), wound care measurements, tetanus prophylaxis, administration of rabies immunoglobulin and antibiotics, location of the injury, existing fractures, suturing, splinting, surgical consultations and hospitalization status were recorded. RESULTS: Four hundred and nineteen incidents of animal bites (240 males and 179 females) occurred over a four-year period. 51% was due to a dog bite; 47% was by a cat. The median age was nine years (IQR: 5-14 years). Most bites (91.6%) involved only a single anatomical site. The extremities were the commonly involved part (right upper limb [35.3%], left upper limb [21.2%], right lower limb [12.6%], left lower limb [16%]). Head-neck and face injury ratio was 17.6%. Torso (5.7%) and genitalia (5.2%) were uncommonly involved. A consultation was requested from at least one surgical department for 8% of the patients. 97.1% of patients received a rabies vaccine. Most attacks were trivial and did not require hospitalization. CONCLUSION: Animal bites often cause minor injuries. However, multiple dog attacks can be seen related to a high number of stray animals in our country. Therefore, these patients may present with major traumas. Surgical intervention and hospitalization may be required. Emergency physicians play an essential role in acute management and rabies prophylaxis in these patients.

Dyskinesia due to mexiletine overdose: a rare presentation.

BACKGROUND: Mexiletine, a class IB antiarrhythmic, is a structural analog of lidocaine. Our knowledge of mexiletine overdose is based on lidocaine overdose reports. Only a few cases of mexiletine overdose have been reported, including fatal overdoses. Mexiletine toxicity primarily affects the central nervous, cardiovascular, and gastrointestinal systems. CASE: A 16-year-old female was brought to our hospital by ambulance after taking an unknown dose of mexiletine in a suicide attempt. Ventricular fibrillation developed while in the ambulance; cardiopulmonary resuscitation was started and spontaneous circulation returned within 1 min. The patient had been taking oral mexiletine for 1 month to treat primary erythromelalgia. Her vital signs were normal, but she was unconscious. Following gastric lavage she was transferred to the pediatric intensive care unit. Midazolam and levetiracetam were required due to uncontrolled seizures. During the first hour of hospitalization, severe dyskinesia characterized by abnormal involuntary large hyperkinetic movements in all 4 extremities was observed and successfully treated with 2 doses of intravenous biperiden. The patient was discharged on day 6 of hospitalization. CONCLUSIONS: Mexiletine overdose can be life-threatening. In addition to rapid and effective resuscitation, rapid identification and management of cardiovascular and central nervous system manifestations are key to preventing morbidity and mortality. The presented case had severe dyskinesia that was successfully treated with repeated doses of biperiden. Biperiden did not cause arrhythmia. Based on the presented case, we think biperiden should be considered for the treatment of movement disorders in cases of mexiletine overdose.

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.