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OBJECTIVE The objective of this study was to detect variables associated with burnout syndrome (BS) in pediatric intensive care units (PICUs) and pediatric emergency medicine departments (PEDs) in high-volume centers from different parts of Turkey. METHODS An observational, cross-sectional multicenter study was performed. The Maslach Burnout Inventory scale was administered to all of health care providers working in PICUs and PEDs. In this study, health care providers were defined as physicians, nurses, and other staff (secretaries, cleaning and patient care staff) working in PICU and PEDs. RESULTS A total of 570 participants completed the survey. The major finding of this study was that 76.1% (n = 434) of PICU and PED health care professionals had BS. The most prominent subscale of BS was emotional exhaustion (62.5%). The rate of BS was higher among health care providers working in PEDs compared with PICUs (79.1% vs 73.7%, P = 0.04). The frequency of BS according to emotional exhaustion and depersonalization subscales was higher in health care providers of PEDs. The rate of BS was also significantly higher in younger employees, females, those working 51 or more hours totally in a week, those having a low monthly salary, those single or divorced, those without children, those with no childcare at home, those not owning a home, those not doing regular exercise and not having regular breakfast, those with total employment time of less than 1 year, and those not having a car or not having a hobby. In PEDs, when the daily evaluated number of patients was equal to or more than 44 (sensitivity, 88%; specificity, 66%), it predicted the occurrence of BS. In PICUs, when the number of patients cared for by 1 nurse was equal to or more than 3, it predicted the occurrence of BS (sensitivity, 78%; specificity, 62%). CONCLUSIONS By creating early intervention programs to prevent BS, shortages of health care professionals can be avoided and the costs of health care expenditures related to infections can be decreased.

To compare ketoprofen with acetaminophen in febrile children in terms of proportion of achieved temperatures below 37.8°C and time of temperature reduction. 316 patients (6 months–12 years) with fever were randomly assigned to receive a single dose of acetaminophen or ketoprofen orally. Tympanic temperature was measured at the time of antipyretic administration and at 15, 30, 60, 120,180, 240 min thereafter. A higher proportion of patients in the ketoprofen group achieved a temperature below 37.8°C during the 4 h follow up (95% CI, 3.03–12.99, p

Aim: To reveal the perceptions, knowledge and practices of our parents regarding children's fever and to discuss the differences between other populations. Methods: Parents of 200 febrile children aged 0–16 years were interviewed between October and November 2007 in the Pediatric Emergency Department at Dr Sami Ulus Children's Health and Diseases Training and Research Hospital. Questions about socio-demographical data, children's previous history about fever, parental beliefs and practices concerning fever were asked. Results: Of the parents, 56.5% stated that fever could be determined by touching the forehead. Of the parents, 43.5% determined children's fever by using thermometer. Only 27.5% of parents knew the correct temperature for fever. Mercury-in-glass thermometer was the preferred one to measure children's fever. The preferred route of measuring temperature was the axillary site. Maternal educational level was significantly associated with knowledge on correct definition of fever and proper use of thermometer (P 0.05), corroborating the findings of studies from different populations. Conclusion: Parental education about ‘fever in childhood’ in our population may positively effect parental knowledge and approach to fever. However, parental education may not be effective in removing parental fear of fever in our population.

Objective: To assess the prevalence of urinary tract pathogens and their resistance patterns against antimicrobial agents in a single center. Patients and Methods: In children Results: A total of 3,485 positive urine cultures were identified, of which 2,379 (68%) were from females and 106 (32%) from males. Their mean age was 63.5 ± 40.7 months. Escherichia coli was the most common causative agent both in total and among different age groups. Ampicillin had the highest resistance rate from all the pathogens isolated (63.8%), followed by piperacillin (51.8%) and trimethoprim-sulfamethoxazole (TMP-SMX; 48.6%). Cephalotin also had a high resistance rate (32.7%). The least resistance was for imipenem, amikacin, netilmicin and ciprofloxacin (0.13, 1.7, 2.4 and 7.5%, respectively). None of the Klebsiella and Pseudomonas isolates were resistant to imipenem. None of the Staphylococcus aureus isolates were resistant to teicoplanin and vancomycin. Vancomycin-resistant Enterococcus spp. were isolated from two cultures. Conclusion:E. coli was the most common causative agent of UTI in children. Ampicillin, TMP-SMX or cephalothin and piperacillin had the highest resistance rates against urinary tract pathogens in our center.

Inorganic mercury intoxication should be considered a potentially life-threatening condition that leads to widespread progressive gastrointestinal, renal, hepatic, hematologic, neuropsychiatric, and dermatologic system hazards. We report here a 10-year-old girl with severe inorganic mercury intoxication whose blood and urine mercury levels were 5,380 microg/L (normal, 0.6 to 59 microg/L) and 91 microg/L (normal, 0.1 to 20 microg/L), respectively, to reveal that life can be saved and complete recovery can be achieved even if the clinical situation is very severe. To our knowledge, this is the first report of a mercury intoxication being alive with such a high blood mercury level in children in English pediatric literature.

Superior herniation of normal mediastinal thymus into the anterior neck is a rare cause of neck masses in children. It is defined as intermittent migration of the broadest part of the normal thymus out of the thorax into the suprasternal region during Valsalva maneuver with an increase in the intrathoracic pressure. The fact that the mass apparent only during Valsalva maneuver and typical ultrasound characteristics usually allow the diagnosis but computerized tomography scan or magnetic resonance imaging is necessary to assess the extent of the mass. We report the first and the only siblings with the most dramatic degree of superior herniation of normal mediastinal thymus. We discuss the findings of imaging and the differential diagnosis. We try to remind this entity to avoid unnecessary biopsy or surgery and their potential risk of altering immune function.

Objective: It was the aim of our study to present a case of Rubinstein Taybi syndome (RTS) associated with hepatic hemangioma. Clinical Presentation and Intervention: A 6.5-year-old boy was diagnosed with RTS. He had large areas of cutaneous capillary hemangiomas. Radiological examination revealed a hepatic hemangioma. A multidisciplinary follow-up program was commenced and hepatic ultrasound examinations were performed periodically. No progression and complication have since occurred. Conclusion: This case shows an association between RTS and hepatic hemangioma, and hence, we recommend regular hepatic ultrasound examination when RTS is suspected or diagnosed.

To reveal the perceptions, knowledge and practices of our parents regarding children's fever and to discuss the differences between other populations.Parents of 200 febrile children aged 0-16 years were interviewed between October and November 2007 in the Pediatric Emergency Department at Dr Sami Ulus Children's Health and Diseases Training and Research Hospital. Questions about socio-demographical data, children's previous history about fever, parental beliefs and practices concerning fever were asked.Of the parents, 56.5% stated that fever could be determined by touching the forehead. Of the parents, 43.5% determined children's fever by using thermometer. Only 27.5% of parents knew the correct temperature for fever. Mercury-in-glass thermometer was the preferred one to measure children's fever. The preferred route of measuring temperature was the axillary site. Maternal educational level was significantly associated with knowledge on correct definition of fever and proper use of thermometer (P0.05) in accordance with the literature. If fever was untreated, of the parents, 84% believed febrile convulsions occur and 10.5% believed brain damage occur if fever was untreated. Parental age, parental educational status, parental knowledge about fever, median number of children in family and children's previous febrile convulsion history did not significantly effect parents' interventions and beliefs about fever (P0.05), corroborating the findings of studies from different populations.Parental education about 'fever in childhood' in our population may positively effect parental knowledge and approach to fever. However, parental education may not be effective in removing parental fear of fever in our population.

Carpal tunnel syndrome, an entrapment neuropathy of the median nerve, is rarely seen in childhood. Familial carpal tunnel syndrome, an even more exceptional entity, is frequently associated with inherited systemic disorders. Rarely it can be presented as a primary familial form with Mendelian autosomal dominant inheritance. We report the occurrence of carpal tunnel syndrome in two generations of a family in which the index case was a 6-year-old boy with bilateral hand pain and paresthesias. Our report demonstrates an interesting inheritance pattern of carpal tunnel syndrome in a family transmitted by an autosomal dominant gene with variable expressivity and reduced penetrance. To our knowledge, it is the first report of familial bilateral carpal tunnel syndrome in a family with possible skipped generation.

Objective: To evaluate the accuracy of urine sample collection methods among children suspected of having urinary tract infections. Subjects and Methods: Four methods for urine sample collection were evaluated in 1,067 children aged 0–16 years with suspected urinary tract infections over 2 months at Dr. Sami Ulus Children’s Hospital. Within 30 min of collection, all specimens were sent to the laboratory, refrigerated and processed according to standard hospital microbiological procedures. Urine samples were analyzed using routine culture techniques. Results: At initial sending of the urine culture, 617 (57.8%) had negative culture results, 145 (13.6%) had positive culture results, and 305 (28.6%) had evidence of bacterial contamination. Clean catch specimens showed a contamination rate of 14.3% and urethral catheterization specimens showed a similar contamination rate (14.3%). However, urethral catheterization was preferred in only a small number of cases (n = 7). Suprapubic aspiration was also used in a small number of cases (n: 11) and the contamination rate for suprapubic aspiration was 9.1% (n: 1/11). The contamination rate for sterile urine bag was 43.9%, significantly higher than the other methods (p < 0.001). Conclusion: Suprapubic aspiration showed the lowest contamination rate and sterile urine bag showed the highest contamination rate among 4 methods of urine sample collection. Contaminated specimens, needed to be repeated and this procedure increased the cost of urine culture. In conclusion, measures should be taken to reduce the contamination rate in our center. This is an area where further investigation is required.

Our objective in this retrospective study was to assess the hippocampal abnormalities, associate them with various congenital brain malformations, and define the frequency of the association in specific anomaly subgroups. A total of 62 patients with congenital malformations of the brain who had thin-slice coronal T2-weighted, fluid attenuated inversion recovery, IR, or T1-weighted 3D gradient echo images were retrospectively evaluated for the type of congenital brain malformation and morphological or rotational hippocampal abnormalities. Medical records were reviewed for age, sex, and symptoms. Hippocampal abnormalities are found in 55.8% of all patients with different kinds of congenital brain malformations that are mostly associated with cortical dysplasia, lissencephaly, and total agenesis of the corpus callosum. The severity of the injury may have an effect on the extent of the involvement of the brain.

Objective: Our aim was to present 2 children with visual hallucinations possibly associated with clarithromycin administration at therapeutic dosage. Subjects and Methods: Two children were admitted to our hospital with sudden onset of visual hallucinations after taking clarithromycin at therapeutic dosage by mouth. Physical examination, laboratory investigations and imaging studies were normal. The symptoms gradually disappeared once the clarithromycin therapy had been discontinued, making us suspect clarithromycin as the agent responsible for the visual hallucinations. They were observed monthly for a year without any symptoms or further treatment. Conclusion: This report highlights hallucinations due to therapeutic doses of clarithromycin therapy as a possible new side effect in children.

Objective: To demonstrate the epidemiological features, clinical presentation, clinical courses and outcomes in critically ill children with pandemic influenza (H1N1) 2009 in pediatric intensive care units (PICU). Design and setting: Prospective, observational, multi-center study and 13 tertiary PICUs. Patients: 83 children with confirmed infection due to pandemic influenza (H1N1) 2009, detected by RT-PCR between November 1 and December 31, 2009 who required PICU. Results: In two months period, 532 children were hospitalized with pandemic influenza (H1N1) 2009 and 83 (15.6%) of them needed critical care. For the 83 patients requiring critical care, the median age was 42 months. Twenty of these patients (24.1%) had no underlying illness. The PICU admission indications were respiratory distress/respiratory failure in 66 (79.5%), neurologic deterioration in 6 (7.2%) and gastrointestinal symptoms in 5 (6.0%) of the patients. Acute lung injury was diagnosed in 23 (27.7%), acute respiratory distress syndrome in 34 (41%) of the critically ill children and 51 (61.4%) patients needed mechanical ventilation (MV). Oseltamivir was used in 80 (96%) patients. During the study period, overall mortality rate was 13.7%, however, mortality rate was 30.1% (n=25) in children with pandemic influenza A (H1N1) 2009 (p=0.0016) in PICUs. Cause of death was primary H1N1 infection in 16 (64%), nosocomial infection in 4 (16%) and primary disease progression in 5 (20%) patients. Conclusion: Severe disease and high mortality were seen in children with pandemic influenza (H1N1) 2009. Death occurred in all age groups of children with or without underlying illness.

Background and Aim The most cause of cardiopulmonary arrest (CPA) is respiratory system disorders. Usually the surive from CPA is 30% in hospital and under 10% in out of hospital. The aim of this study, the cause of CPA, applications and results of CPA in pediatric ICU and emergency care in Turkey. Methods This study conducted between January 15 and July 15, 2011, multicenter, prospective, observational from Turkey. Results We enrolled 239 children whose CPA developed. Fifty-four percent of all patients were boy and their mean age were 42.4±58.1 months. The causes of CPA were respiratory failure in 49.8%, sepsis in 301.%, cardiac disease in 21.3% and rhythm disorders in 8.8%. The place of CPA occurred were PICU in 68.6%, services in 18%, out of hospital in 10% and emergency care in 3.3% of patients whose CPA developed. Adrenalin was performed in 221, defibrillation in 16 and automatic external defibrillation in patients. Mean resuscitation time was 30.7±23.6 minutes. Return percent after first resuscitaiton application was 44.8%. We check to mortality rate after first resuscitation 43.3% in PICU, 41.9% in services, 50% in Emergency Care, 41.7% at out of hospital (p=0.539). The 83% of them were unconsciousness, renal replacement therapy was applicated in 16 patients. After first resuscitation, 54.2 patient survived and neurologic sequele was in 32% of them. Conclusion Mortality and morbidity are higher either hosptial and out of hospital CPA, therefore prevention to CPA and well resuscitation applications are very important.

Acyclovir is an antiviral agent against herpes virus. Its local adverse effects are common and typically consist of inflammation or phlebitis at the site of intravenous infusion. Here we present a child with bullous eruptions away from infusion site due to acyclovir administration. It is exceptionally rare with only one adult case has been reported to date.

Dear Editor, I wish to thank Dr. Guzzi and colleagues for their valuable comments on our paper [1]. Both inorganic (Hg+2) and organic (methylmercury) mercurials cause rapid hemolysis [2]. In a study performed by Mojzis and Nicak, it was shown that hemolysis progressively declined in relation to the increased concentrations of Hg+2 [3]. We suspected inorganic mercury poisoning because our patient's blood mercury level was very high (5,380 μg/L), and the disappearance of hemolysis was rapid. Moreover, the clinical features suggested acute inorganic mercury intoxication. Unfortunately, the technical equipment for the assessment of mercury red blood cell/plasma distribution that provides more accurate evidence to distinguish the inorganic mercury from the organic one is not available in our hospital. Although DMPS is more specific for the treatment of inorganic mercury intoxication, we used DMSA because DMPS is not commercially available in our country, and our patient's G6PD test was normal.