Clinical characteristics and outcomes of continuous renal replacement therapy performed on younger children weighing up to 10 kg.

BACKGROUND: This study aimed to investigate the clinical features, modality, complications, and effecting factors on the survival of children weighing up to 10 kg who received continuous renal replacement therapy (CRRT). METHODS: This study was a retrospective observational study conducted in five pediatric intensive care units in tertiary hospitals in Turkey between January 2015 and December 2019. RESULTS: One hundred and forty-one children who underwent CRRT were enrolled in the study. The median age was 6 (range, 2-12)months, and 74 (52.5%) were male. The median weight of the patients was 6 (range, 4-8.35) kg and 52 (36.9%) weighed less than 5 kg. The most common indication for CRRT was fluid overload in 75 (53.2%) patients, and sepsis together with multiorgan failure in 62 (44%). The overall mortality was 48.2%. DISCUSSION: Despite its complexity, CRRT in children weighing less than 10 kg is a beneficial, lifesaving extracorporeal treatment modality.

A multicentered study on efficiency of noninvasive ventilation procedures (SAFE-NIV)

Background/aim: To characterize the clinical course of noninvasive positive pressure ventilation (NIPPV) and high flow humidified nasal cannula ventilation (HFNC) procedures; perform risk analysis for ventilation failure. Material and methods: This prospective, multi-centered, observational study was conducted in 352 PICU admissions (1 month-18 years) between 2016 and 2017. SPSS-22 was used to assess clinical data, define thresholds for ventilation parameters and perform risk analysis. Results: Patient age, onset of disease, previous intubation and hypoxia influenced the choice of therapy mode: NIPPV was preferred in older children (p = 0.002) with longer intubation (p < 0.001), ARDS (p = 0.001), lower respiratory tract infections (p < 0.001), chronic respiratory disease, (p = 0.005), malignancy (p = 0.048) and immune deficiency (p = 0.026). The failure rate was 13.4%. sepsis, ARDS, prolonged intubation, and use of nasal masks were associated with NIV failure (p = 0.001, p < 0.001, p < 0.001, p = 0.025). The call of intubation or re-intubation was given due to respiratory failure in twenty-seven (57.5%), hemodynamic instability in eight (17%), bulbar dysfunction or aspiration in 5 (10.6%), neurological deterioration in 4 (8.5%) and developing ARDS in 3 (6.4%) children. A reduction of less than 10% in the respiration within an hour increased the odds of failure by 9.841 times (OR: 9.841, 95% CI: 2.0021­48.3742). FiO2 > 55% at 6th hours and PRISM-3 >8 were other failure predictors. Of the 9.9% complication rate, the most common complication was pressure ulcerations (4.8%) and mainly observed when using full-face masks (p = 0.047). Fifteen (4.3%) patients died of miscellaneous causes. Tracheostomy cannulation was performed on 16 children due to prolonged mechanical ventilation (8% in NIPPV, 2.6% in HFNC) Conclusion: Absence of reduction in the respiration rate within an hour, FiO2 requirement >55% at 6th hours and PRISM-3 score >8 predict NIV failure.

A homozygote frameshift mutation in OCLN gene result in Pseudo-TORCH syndrome type I: A case report extending the phenotype with central diabetes insipidus and renal dysfunction.

Intrauterine infections with the pathogens, including toxoplasmosis, other (syphilis, varicella, mumps, parvovirus, and HIV), rubella, cytomegalovirus, and herpes simplex (TORCH) in susceptible individuals during pregnancy, result in microcephaly, white matter disease, cerebral atrophy, and calcifications in the fetus. Pseudo-TORCH syndrome is an umbrella term, consisting of several syndromes, resultant from different genetic alterations and pathogenetic mechanisms. Band-like calcification with simplified gyration and polymicrogyria (BLC-PMG) is one of these conditions, resultant from biallelic mutations in the OCLN gene, located in the chromosome 5q13.2. OCLN gene encodes occludin, a tight junction protein, which is expressed in the endothelia. The absence of occludin in the developing brain subsequently results in abnormal blood-brain barrier, thus immune-cell mediated tissue damage and cortical malformation. Herein, we present a pediatric patient who had progressive microcephaly, spasticity, multi-drug resistant epilepsy, PMG and intracranial band-type calcifications, accompanied by central diabetes insipidus and renal dysfunction. Whole exome sequencing revealed a homozygote W58Ffs*10 (c.173_194del) frameshift mutation in the OCLN gene. Of 34 BLC-PMG cases with demonstrable OCLN mutations, only three had renal manifestations, which is responsible for the majority of the demises. This is the first case diagnosed as having central diabetes insipidus and responded to desmopressin treatment to the best of our knowledge, however, this clinical improvement could not prevent the patient from renal dysfunction. The patient deceased at four years of age from sepsis, therefore early diagnosis, optimal follow-up for renal involvement and infection prevention measures are necessary for the patients with BLC-PMG.

Determination of cerebral edema with serial measurement of optic nerve sheath diameter during treatment in children with diabetic ketoacidosis: a longitudinal study.

Background Cerebral edema is a fatal complication that can occur in children with diabetic ketoacidosis (DKA). Its clinical signs are generally not explicit, and subclinical cerebral edema can occur. This study is one of the few longitudinal studies conducted to identify cerebral edema in patients with DKA by measuring the optic nerve sheath diameter (ONSD). The aim of this study was to investigate cerebral edema in children with DKA with serial measurement of ONSD, which is an early and reliable indicator of cerebral edema, and to monitor changes in ONSD during therapy. Methods The study was conducted by measuring ONSD ultrasonographically at baseline and during the course of therapy in patients with DKA. All participants were diagnosed and received therapy at our unit between May 2016 and June 2017. The study was registered with the Clinical Trials database, with a study number of NCT02937441. Measurements were obtained while the patients were in the supine position with their eyes closed, and axial transbulbar images of both eyes were obtained with a 6-15-MHz linear probe. Results The ONSD values of children with DKA changed during the treatment, reaching the highest values at 12-16 h of therapy, and the greatest ONSD was observed in children who had moderate and severe DKA. Conclusions During treatment of children with DKA, it is possible to predict cerebral edema by measuring ONSD, and this may contribute to clinical management, especially fluid treatment.

Appraisal of the "pediatric ARDS: consensus recommendations from the pediatric acute lung injury consensus conference" with the AGREE II instrument

Background/aim: The ″Pediatric Acute Lung Injury Consensus Conference″ (PALICC) was convened in order to develop a taxonomy to define pediatric acute respiratory distress syndrome (ARDS). The Appraisal of Guidelines for Research and Evaluation (AGREE) assesses the quality of guidelines. The aim of this study is to evaluate the new pediatric ARDS guideline using the AGREE II instrument. To the best of our knowledge, this is the first assessment of the new pediatric ARDS clinical practice guideline in the English literature. Materials and methods: Four appraisers assessed the new pediatric ARDS guideline with the AGREE II instrument. At the end of the evaluation each appraiser rated the overall quality of the guidelines. Results: Results of the assessment were editorial independence 100%, clarity of presentation 94%, scope and purpose 89%, stakeholder involvement 78%, rigor of development 78%, and applicability 78%. Conclusion: The new pediatric ARDS guideline received good scores especially with respect to editorial independence and clarity of presentation. Our overall AGREE II review of the PALICC guideline indicates that it has been created using high quality methodology and should be recommended for use and implementation as currently published.

Neuroinfluenza: evaluation of seasonal influenza associated severe neurological complications in children (a multicenter study).

PURPOSE: Although influenza primarily affects the respiratory system, in some cases, it can cause severe neurological complications. Younger children are especially at risk. Pediatric literature is limited on the diagnosis, treatment, and prognosis of influenza-related neurological complications. The aim of the study was to evaluate children who suffered severe neurological manifestation as a result of seasonal influenza infection. METHODS: The medical records of 14 patients from six hospitals in different regions of the country were evaluated. All of the children had a severe neurological manifestations related to laboratory-confirmed influenza infection. RESULTS: Median age of the patients was 59 months (6 months-15.5 years) and nine (64.3%) were male. Only 4 (28.6%) of the 14 patients had a comorbid disease. Two patients were admitted to hospital with influenza-related late complications, and the remainder had acute complication. The most frequent complaints at admission were fever, altered mental status, vomiting, and seizure, respectively. Cerebrospinal fluid (CSF) analysis was performed in 11 cases, and pleocytosis was found in only two cases. Neuroradiological imaging was performed in 13 patients. The most frequent affected regions of nervous system were as follows: cerebellum, brainstem, thalamus, basal ganglions, periventricular white matter, and spinal cords. Nine (64.3%) patients suffered epileptic seizures. Two patients had focal seizure, and the rest had generalized seizures. Two patients developed status epilepticus. Most frequent diagnoses of patients were encephalopathy (n = 4), encephalitis (n = 3), and meningitis (n = 3), respectively. The rate of recovery without sequelae from was found to be 50%. At discharge, three (21.4%) patients had mild symptoms, another three (21.4%) had severe neurological sequelae. One (7.1%) patient died. The clinical findings were more severe and outcome was worse in patients <5 years old than patients >5 years old and in patients with comorbid disease than previously healthy group. CONCLUSION: Seasonal influenza infection may cause severe neurological complications, especially in children. Healthy children are also at risk such as patients with comorbid conditions. All children who are admitted with neurological findings, especially during the influenza season, should be evaluated for influenza-related neurological complications even if their respiratory complaints are mild or nonexistent.

MyD 88 Polymorphisms in Children Diagnosed with Sepsis.

BACKGROUND: Myeloid differentiation primary response gene 88 (MyD 88) is an intracellular adapter protein that mediates the early immune response to pathogens. Toll-like receptors (except TLR-3) induce the immune response through a MyD 88-dependent signal pathway. AIMS: We aimed to investigate the MyD 88 polymorphisms that play important roles in the immune response in septic children and to evaluate whether or not they were risk factors in the development of sepsis. STUDY DESIGN: Case-control study. METHODS: Sixty-five patients diagnosed with sepsis in the Pediatric Intensive Care Unit during the period from April 2010 to January 2012 were included as the study group. Sixty-five children without sepsis were included as controls. After DNA was obtained from blood samples in the study and control groups, MyD 88 polymorphisms were analyzed. According to the genotype and allele frequencies, the distributions of MyD 88 polymorphisms [Single nucleotide polymorphism (SNP) - 938 C/A (rs4988453), MyD 88 SNP 1944 C/G (rs4988457)] were analyzed in both the study and control groups. RESULTS: The C/C genotype of MyD 88 SNP -938 was significantly more common than the C/A genotype in the patient group (p=0.002). No statistically significant difference in the frequency of the MyD 88 SNP 1944 genotype was found between the study and control groups (p=0.272). CONCLUSION: Gene polymorphism studies could elucidate our understanding of sepsis in terms of prevalence and the management of treatment. It was shown in this study that children with the MyD 88 SNP -938 C/C genotype had a greater tendency toward sepsis. However, additional studies should be performed.

Pediatric Lyme Neuroborreliosis: Different clinical presentations of the same agent; Single center experience.

OBJECTIVES: Lyme disease is a vector-associated infectious disease, caused by the agent, spirochete Borrelia burgdorferi. Neurologic findings are observed in approximately 12% of the cases and termed Lyme neuroborreliosis (LNB). Lyme neuroborreliosis may manifest with different clinical neurologic manifestations. METHODS: The study was conducted at tertiary training and research hospital. From January 2014 to September 2015, a total of 75 patients diagnosed with encephalitis, ataxia, Guillain Barre Syndrome (GBS), facial paralysis, acute disseminated encephalomyelitis (ADEM), pseudotumorcerebri were evaluated for inclusion to the study. Among these patients whom investigations of B. burgdorferi antibody IgM and/or IgG ELISA and Western Blot (WB) were detected to be positive, were assessed. Epidemiologic data, tick bite histories, duration of symptoms, clinical findings, radiologic findings, treatment durations and prognosis were investigated. RESULTS: Totally 7 patients had been treated with the diagnosis of Lyme neuroborreliosis. The mean age was 9.14±4.91 years; duration of symptoms before admission was 8.0±4.50 days; and the duration of antibiotic use was 2.85±0.89 weeks. All patients had received ceftriaxone and intravenous immunoglobulin (IVIG); 3 patients had received plasmapheresis (42.9%) and one patient had received pulse corticosteroid therapy. While the patient with the diagnosis of encephalomyeloneuritis and atypical GBS had partially improved, the other patients were completely cured. CONCLUSION: In this article, we report pediatric LNB patients, B. burgdorferi should also be considered in patients with atypical or severe neurologic involvement or a history of tick bite; it is known that the prognosis is good with appropriate and early treatment.

Our patients followed up with a diagnosis of neurogenic pulmonary edema.

Neurogenic pulmonary edema is a clinical situation which developes as a result of central nervous system injury. It is rare in the childhood. Neurogenic pulmonary edema is a clinical diagnosis. Although the pathogenesis is not elucidated well, there is increase in pulmonary interstitial and alveolar fluid. The main principle in treatment of neurogenic pulmonary edema is supportive treatment and decreasing intracranial pressure as in acute respiratory distress syndrome. In this article, clinical properties of our two patients diagnosed with neurogenic pulmonary edema developed as a result of central nervous system injury are presented.

Molecular epidemiology and antibiotic susceptibility pattern of Acinetobacter baumannii isolated from children in a Turkish university hospital.

The aim of the present study is to investigate the types of healthcare-associated infections (HC-AIs) caused by Acinetobacter baumannii and the related antibiotic susceptibility patterns as well as the genotypic characteristics of the Acinetobacter baumannii isolates from our center. Sixty-nine Acinetobacter baumannii isolates originating from various samples collected from 69 pediatric patients during their hospital stays were included in the study. The types of healthcare-associated infections caused by these isolates were evaluated, and the antibiotic susceptibility pattern and the genotypic characteristics of the isolates were determined using the pulsed-field gel electrophoresis (PFGE) method. Fifty of the 69 children were observed to have HC-AIs, and 19 children had Acinetobacter baumannii colonization. Healthcare-associated pneumonia (58%) was the most common type of these infections. The rate of carbapenem resistance was found as 91.3%, while tigecycline resistance was found as 18.84%. No colistin resistance was observed in any of the isolates. A total of 10 groups, comprising eight major and two minor groups, were determined using the pulsed-field gel electrophoresis method. Acinetobacter baumannii isolates are the leading cause of healthcare-associated infections, and they show high rates of multidrug antibiotic resistance. Molecular epidemiological evaluation using PFGE plays an important role in preventing healthcare-associated infections.

Screening tools for bacteraemia in a selected population of febrile children.

INTRODUCTION: This is a prospective, observational study. The aims of the study were to determine the rate of bacteraemia in febrile children in Turkey, and to evaluate the usefulness of white blood cell (WBC) count and manual differential counts of peripheral blood smears and a RISK score in predicting bacteraemia among these children. MATERIALS AND METHODS: A total of 377 febrile children aged 3 to 36 months were included in the study. Complete blood cell (CBC) count, manual differential counts and blood cultures were performed in all patients. The main outcome measures used to evaluate the usefulness of the RISK score were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), odds ratio (OR), posterior probability, areas under receiver operator characteristic curves (AUC) and miss-to-diagnosis ratio (MDR). RESULTS: Among the patients, 4.4% had bacteraemia and the predominant pathogen was Streptococcus pneumoniae. The Yale Observation Scale scores, percentages of neutrophil and bands, band-neutrophil ratio, absolute neutrophil count and absolute band count were found to be statistically significant predictors of bacteraemia. When the RISK score was 2 or higher, sensitivity was 93.8%, false positive ratio 35.8%, PPV 10.6%, NPV 99.5%, OR 26.2 (95% CI, 3.4 to 200.8), MDR 0.066 and posterior probability value 10%. CONCLUSIONS: We conclude that determination of the RISK score will significantly decrease unnecessary blood culture sampling, antibiotherapy and hospitalisation among febrile patients aged 3 to 36 months without an identifiable focus of infection.