Publications by authors named "Nazan Dalgic"

47 Publications

Multicenter prospective surveillance study of viral agents causing meningoencephalitis.

Sci Rep 2021 Mar 30;11(1):7216. Epub 2021 Mar 30.

Department of Microbiology, Faculty of Medicine, Istanbul University, Istanbul, Turkey.

The frequency of bacterial factors causing central nervous system infections has decreased as a result of the development of our national immunization program. In this study, it is aimed to obtain the data of our local surveillance by defining the viral etiology in cases diagnosed with meningoencephalitis for 1 year. Previously healhty 186 children, who applied with findings suggesting viral meningoencephalitis to 8 different tertiary health centers between August 2018 and August 2019, in Istanbul, were included. The cerebrospinal fluid (CSF) sample was evaluated by polymerase chain reaction. The M:F ratio was 1.24 in the patient group, whose age ranged from 1 to 216 months (mean 40.2 ± 48.7). Viral factor was detected in 26.8%. Enterovirus was the most common agent (24%) and followed by Adenovirus (22%) and HHV type 6 (22%). In the rest of the samples revealed HHV type 7 (10%), EBV (6%), CMV (6%), HSV type 1 (6%), Parvovirus (4%) and VZV (2%). The most common symptoms were fever (79%) and convulsions (45.7%). Antibiotherapy and antiviral therapy was started 48.6% and 4% respectively. Mortality and sequela rate resulted 0.53% and 3.7%, respectively. This highlights the importance of monitoring trends in encephalitis in Turkey with aview to improving pathogen diagnosis for encephalitis and rapidly identifying novel emerging encephalitis-causing pathogens that demand public health action especially in national immunisation programme.
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http://dx.doi.org/10.1038/s41598-021-86687-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010096PMC
March 2021

The role of intraventricular antibiotic therapy in the treatment of ventriculo-peritoneal shunt infection in children.

Childs Nerv Syst 2021 Mar 17. Epub 2021 Mar 17.

Department of Neurosurgery, Health Science University (HSU) Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.

Background: In this study, the effectiveness of intraventricular (IVT) antibiotic administration was evaluated in the treatment of ventriculo-peritoneal (VP) shunt infection by comparing patients who received only systemic antibiotic treatment with patients who received antibiotics added to systemic therapy by IVT route.

Methods: From July 2009 to July 2019, 78 shunt infection episodes of 74 pediatric patients with bacterial growth in cerebrospinal fluid (CSF) culture who were treated with the diagnosis of VP shunt infection were retrospectively analyzed. The demographic data, clinical and laboratory parameters, antimicrobial management, and treatment outcomes of patients with VP shunt infections were recorded.

Results: Thirty-eight of 78 shunt episodes received only systemic antibiotic treatment, and 40 had received IV plus IVT treatment. The mean age of the entire patient group was 16.7±21.3 months (range, 1 to 95 months). There was no significant difference between the two treatment groups in terms of mean age. The most common microorganism grown in CSF culture was coagulase-negative Staphylococcus. However, in the group that received IV plus IVT treatment, gram-negative bacteria were predominant (42.1% versus 20%), and this group had carbapenem-resistant and ESBL positive gram-negative bacteria growth. In the duration of CSF sterilization, hospital stay was statistically significantly shorter in the group receiving IV plus IVT treatment (p=0.000, p=0.000, respectively).

Conclusion: Our study shows that IVT administration of antibiotics shortens the duration of CSF sterilization, duration of antibiotic use, and the duration of hospital stay. For the treatment of VP shunt infection, the usage of IVT treatment in a particular group of a pediatric age is promising. However, further efforts should be done for supporting the current results by randomized controlled studies.
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http://dx.doi.org/10.1007/s00381-021-05116-9DOI Listing
March 2021

Munchausen by Proxy Syndrome Associated with Fecal Contamination: A Case Report.

Turk Psikiyatri Derg 2020 ;31(3):212-215

Factitious disorder imposed on another, also known as Munchausen Syndrome by Proxy (MSBP), is a serious form of child abuse that is difficult to diagnose. In general, signs and symptoms are fabricated or produced by the mother or the caregiver. Delay in diagnosis may cause serious morbidity and mortality. Here, we present the case of an 18-month-old boy who was admitted to the Paediatric Infection Clinic with a diagnosis of acute gastroenteritis. When on intravenous fluid therapy, he developed high fever and subsequently, polymicrobial growth was determined in his blood. He was later diagnosed with MSBP. Despite being a rare condition, MSBP is a disorder that is often overlooked and may have fatal outcomes. Early diagnosis is very important in this disorder, which is considerably difficult to diagnose. In suspected cases, interdisciplinary team work is necessary to prevent adverse consequences.
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January 2020

Comparison of non-burn-specific systemic inflammatory response syndrome criteria and burn-specific American Burn Association systemic inflammatory response syndrome criteria in paediatric burned patients.

J Paediatr Child Health 2020 10 25;56(10):1623-1628. Epub 2020 Aug 25.

Faculty of Pharmacy, Department of Clinical Pharmacy, Marmara University, Istanbul, Turkey.

Aim: We aim to investigate the diagnostic value of newly defined criteria for the systemic inflammatory response syndrome (SIRS) for paediatric burn patients by the American Burn Association (ABA) by comparing the non-burn-specific SIRS criteria for children.

Methods: A total of 147 paediatric burn patients were included in this study. Patients diagnosed with sepsis were included in the sepsis group. Clinical parameters were obtained from the electronic medical records at the time of preliminary sepsis diagnosis. Both the non-burn-specific SIRS criteria and the burn-specific ABA SIRS criteria were applied to both the sepsis group and the non-sepsis group.

Results: Of 147 patients, 50 had sepsis according to the non-burn-specific sepsis criteria. When the 50-patient sepsis group was compared to the 97-patient non-sepsis group, the sepsis group had a significantly higher duration of hospitalisation, burn percentage, burn state and abbreviated burn scoring index (ABSI) (P < 0.05). The specificity of the two scales was 29.9% for the non-burn-specific SIRS and 74.2% for the burn-specific ABA SIRS. The sensitivity for the burn-specific ABA SIRS was calculated as 58%, the sensitivity for the non-burn-specific SIRS was 100%. While positive predictive value was calculated as 42.4% for the non-burn-specific SIRS, this value was found as 53.7% for the burn-specific ABA SIRS criteria. The correlation coefficient between the non-burn-specific SIRS and the burn-specific ABA SIRS was 0.378 (P < 0.001).

Conclusions: Our study underlines the need for widespread use of more specific and sensitive burn-specific clinical criteria to early diagnosis of infection in burn patients to prevent unnecessary antibiotic usage.
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http://dx.doi.org/10.1111/jpc.15060DOI Listing
October 2020

Preseptal Cellulitis in Children: A Single-Center Experience.

Sisli Etfal Hastan Tip Bul 2019 19;53(4):409-412. Epub 2019 Nov 19.

Department of Pediatric Infectious Diseases, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.

Objectives: Preseptal cellulitis is an infection that affects the palpebra and the periorbital superficial tissue. This study is an evaluation of the clinical findings, treatment, and complications of patients hospitalized with preseptal cellulitis in a single clinic.

Methods: The records of 29 patients with preseptal cellulitis who were hospitalized in the Şişli Hamidiye Etfal Education and Research Hospital Pediatric Infection Clinic between November 2012 and November 2017 were analyzed retrospectively.

Results: Of the 29 cases, 34.5% (n=10) were female and 65.5% (n=19) were male. The mean age was 61.76±46.95 months, and the mean length of hospital stay was 4.03±2.04 days. Periorbital swelling (72.4%) was the most common cause of complaint at hospital admission, and periorbital hyperemia and edema were observed in 93.1% of the clinical findings. Nine (52.9%) of 17 cases with predisposing factors were sinusitis-related. A blood culture was obtained in 21 (72.4%) cases. Imaging methods were used in 9 (31%) cases to support the diagnosis. All of the patients received broad-spectrum intravenous antibiotic therapy during hospitalization. The mean duration of antibiotic use was 10.10±3.41 days, including after discharge. None of the patients developed complications related to preseptal cellulitis.

Conclusion: Preseptal cellulitis is a very common orbital infection, especially in childhood. Although it generally has a good prognosis, it can progress rapidly to the orbita and intracranial structures. An accurate clinical approach and rapid treatment can prevent the spread of infection and avoid serious complications.
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http://dx.doi.org/10.14744/SEMB.2018.75010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192284PMC
November 2019

Evaluation of QuantiFERON tuberculosis Gold In-Tube assay for diagnosis of active tuberculosis in children.

J Paediatr Child Health 2020 Apr 12;56(4):581-585. Epub 2019 Nov 12.

Duzen Laboratories Group, Department of Microbiology, Division of Tuberculosis Laboratory, Istanbul, Turkey.

Aim: Tuberculin skin test (TST) is still used in diagnostic algorithms of childhood tuberculosis (TB). QuantiFERON TB Gold In-Tube assay (QFT-GIT) is an alternative test to TST based on the detection of interferon-gamma release upon in vitro induction of peripheral mononuclear cells by TB antigens. In this study, we aimed to determine the diagnostic value and performance of QFT-GIT for active childhood TB.

Methods: This retrospective study was conducted between January 2005 and December 2011 in three referral hospitals in Turkey with 124 children who were diagnosed with definite active TB. Sensitivity values of TST and QFT-GIT were determined by accepting the microbiological confirmation as the gold standard of diagnosis of TB.

Results: In our study, sensitivity of QFT-GIT and TST was found to be 65 and 66% respectively. However, combined usage of QFT-GIT and TST was found to be more sensitive (85%) than TST or QFT-GIT alone (P < 0.0001). Although negative results of QFT-GIT or TST did not exclude the diagnosis of active TB in children, their positivity supported the diagnosis. Specificity could not be measured as only microbiologically confirmed cases of Mycobacterium tuberculosis disease were enrolled in the study.

Conclusion: Although sensitivities of TST and QFT-GIT are too low to exclude active TB, their positivity supports diagnosis of active TB in children concomitant with signs and symptoms. QFT-GIT and TST should be used together to enhance diagnostic sensitivity and could help exclude a diagnosis of TB if the pretest probability is low.
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http://dx.doi.org/10.1111/jpc.14687DOI Listing
April 2020

Intraventricular Plus Intravenous Tigecycline for the Treatment of Daptomycin Nonsusceptible Vancomycin-Resistant Enterococci in an Infant with Ventriculoperitoneal Shunt Infection.

World Neurosurg 2019 Oct 11;130:470-473. Epub 2019 Jul 11.

Department of Pediatric Infectious Diseases, University of Health Sciences, Sisli Hamidiye Etfal Research and Education Hospital, Istanbul, Turkey.

Background: Ventriculoperitoneal (VP) shunt infection, which is 1 of the most important complications of VP shunt is observed at a rate of 4%-17%. Staphylococcus epidermidis is the most common causative agent. Vancomycin-resistant Enterococcus (VRE) is an increasingly common nosocomial pathogen that rarely causes central nervous system infections globally. Current treatment options that have shown appreciable activity against various VRE infections include daptomycin, linezolid, inquinupristin/dalfopristin, and tigecycline. Daptomycin has a particular mode of action and a potent bactericidal activity, making it a useful addition to the clinician's antibiotic collection. Global surveillance data indicate <1.0% rates of daptomycin resistance in enterococci.

Case Description: Here, we describe, to the best of our knowledge, the first case of successful intraventricular plus intravenous use of tigecycline to treat VP shunt infections caused by daptomycin resistant VRE faecium.

Conclusion: Tigecycline is a life-saving option in the treatment of resistant nosocomial infections but it has not yet been approved for use and there are not enough data in terms of dose and side effects associated with its use in children.
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http://dx.doi.org/10.1016/j.wneu.2019.07.045DOI Listing
October 2019

Intravenous and intraventricular daptomycin plus intravenous linezolid treatment of an infant with Vancomycin-Resistant Enterococci induced ventriculoperitoneal shunt infection.

World Neurosurg 2019 Jan 24. Epub 2019 Jan 24.

Departments of Pediatric Infectious Diseases, University of Health Sciences, Sisli Hamidiye Etfal Research and Education Hospital, Istanbul, Turkey.

The rate of ventriculoperitoneal (VP) shunt infection is reported between 3% and 20%. Vancomycin-Resistant Enterococci (VRE) are increasingly prevalent nasocomial pathogens worldwide and they rarely cause infections to the central nervous system. Daptomycin is a cyclic lipopeptide effective antibiotic due to its rapid bactericidal effect. It is a life-saving treatment option for meningitis, bacteriemia, sepsis, endocarditis and urinary system infections caused by VRE. Here, we presented a 2.5-month-old male patient diagnosed with ventriculoperitoneal shunt infection caused by VRE faecium. This is the first pediatric VP shunt infection caused by VRE and treated with a combination of intravenous (IV) linezolid IV and intraventricular (IVT) daptomycin. The patient was admitted to the medical center with the complaint of umbilical discharge and shunt revision was applied with the thought of shunt dysfunction. Intermittent umbilical cerebrospinal fluid (CSF) leakage continued and the patient developed fever 2 weeks after the operation. VRE growth in his CSF culture was treated by meropenem and linezolid treatment. Upon continuation of the growth afterwards, the patient who was referred to our hospital underwent extra ventricular drainage (EVD), and IV linezolid, IV daptomycin (8 mg/kg day) and IVT daptomycin (2.5 mg/kg day) was scheduled as treatment. On the 5th day of treatment, there was no growth in the culture and no side effects were observed during the treatment. VP shunt was placed in the patient for the 15 days of daptomycin IV plus IVT treatment, and 36 days of linezolid. No infection was observed in the 8-month follow-up period.
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http://dx.doi.org/10.1016/j.wneu.2019.01.065DOI Listing
January 2019

Intraventricular tigecycline for the treatment of shunt infection: a case in pediatrics.

J Neurosurg Pediatr 2018 11;23(2):247-250

3Microbiology, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey.

Ventriculoperitoneal (VP) shunt infections are seen in 3%-17% of patients with VP shunts. These infections may cause severe morbidity and mortality. Staphylococci are the most common cause of CSF shunt-associated infections, although gram-negative bacteria (especially multidrug-resistant [MDR] and extensive drug-resistant [XDR] bacteria) also play an important role. Due to increased antibiotic resistance, sometimes off-label usage of antibiotics is considered. Tigecycline is one of these antibiotics. It should not be used unless there are no other antibiotic treatment options available, especially in children. It belongs to the glycylcycline class of antibiotic agents and inhibits protein translation in bacteria by binding to the 30S ribosomal subunit. The authors describe the case of a patient who had an XDR Klebsiella pneumoniae-positive VP shunt infection. After removal of his VP shunt, an external ventricular drain was inserted, and the patient was treated with a combination of intravenous (1.2 mg/kg/day) and intraventricular (4 mg/day) tigecycline in addition to his meropenem (120 mg/kg/day) treatment. On the 7th day of the combined therapy, his CSF culture was sterile. Because tigecycline distribution into the tissues is not sufficient with intravenous administration, combining it with intraventricular infusion can provide new treatment methods. However, further studies are needed for its use as a treatment method in children.
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http://dx.doi.org/10.3171/2018.9.PEDS18470DOI Listing
November 2018

Time Series Analysis of the Microbiota of Children Suffering From Acute Infectious Diarrhea and Their Recovery After Treatment.

Front Microbiol 2018 12;9:1230. Epub 2018 Jun 12.

Institute for Integrative Systems Biology, Catedrático José Beltrán, Valencia, Spain.

Gut microbiota is closely related to acute infectious diarrhea, one of the leading causes of mortality and morbidity in children worldwide. Understanding the dynamics of the recovery from this disease is of clinical interest. This work aims to correlate the dynamics of gut microbiota with the evolution of children who were suffering from acute infectious diarrhea caused by a rotavirus, and their recovery after the administration of a probiotic, CNCM I-745. The experiment involved 10 children with acute infectious diarrhea caused by a rotavirus, and six healthy children, all aged between 3 and 4 years. The children who suffered the rotavirus infection received CNCM I-745 twice daily for the first 5 days of the experiment. Fecal samples were collected from each participant at 0, 3, 5, 10, and 30 days after probiotic administration. Microbial composition was characterized by 16S rRNA gene sequencing. Alpha and beta diversity were calculated, along with dynamical analysis based on Taylor's law to assess the temporal stability of the microbiota. All children infected with the rotavirus stopped having diarrhea at day 3 after the intervention. We observed low alpha diversities in the first 5 days (-value < 0.05, Wilcoxon test), larger at 10 and 30 days after probiotic treatment. Canonical correspondence analysis (CCA) showed differences in the gut microbiota of healthy children and of those who suffered from acute diarrhea in the first days (-value < 0.05, ADONIS test), but not in the last days of the experiment. Temporal variability was larger in children infected with the rotavirus than in healthy ones. In particular, class was found to be abundant in children with acute diarrhea. We identified the microbiota transition from a diseased state to a healthy one with time, whose characterization may lead to relevant clinical data. This work highlights the importance of using time series for the study of dysbiosis related to diarrhea.
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http://dx.doi.org/10.3389/fmicb.2018.01230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6005867PMC
June 2018

A Case Report of a 4-Year-Old Boy with Intradural Spinal Cord Abscess Successfully Treated with Adjuvant Hyperbaric Oxygen Therapy.

Turk Neurosurg 2019 ;29(5):789-792

University of Health Sciences, Sisli Hamidiye Etfal Research and Education Hospital, Pediatric Infectious Diseases Clinic, Istanbul, Turkey.

Intradural spinal cord abscesses are rare infections in early childhood and usually result from pre-existing congenital anomalies of the spinal column. The formation of abscess may be the result of hematogenous spread. It is treated by surgical and parenteral antibiotic treatment, but some special cases may require additional treatments. This article presents a 4-year-old male patient who was previously operated on for spina bifida (meningocele and tethered cord syndrome) at another hospital. Upon complaints of not being able to walk after one month, he was operated on with the diagnosis of spinal intradural abscess and referred to our clinic to continue his treatment. The patient underwent an emergency operation when his new spinal magnetic resonance imaging (MRI) at our hospital showed progression of intradural abscess. Due to no regression of neurological deficits in the follow-up and the risk of another operation, antimicrobial treatment as well as hyperbaric oxygen therapy (HBOT) was planned. At the end of 20 HBOT treatment sessions, the patient started to walk with support and the antibiotic treatment was completed in six weeks. In cases where surgical and antimicrobial treatments have failed, HBOT should be considered as an additional treatment method in children with spinal abscess.
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http://dx.doi.org/10.5137/1019-5149.JTN.22971-18.2DOI Listing
December 2019

Ventriculoperitoneal shunt infections and re-infections in children: a multicentre retrospective study.

Br J Neurosurg 2018 Apr 28;32(2):196-200. Epub 2018 Apr 28.

a Marmara University School of Medicine , Istanbul , Turkey.

Purpose: Ventriculoperitoneal shunt (VPS) is the most common treatment modality for hydrocephalus. However, VPS infection is a common and serious complication with high rates of mortality and morbidity. The objective of this study was to investigate causative agents and the management of VPS infections and to identify risk factors for re-infection in children.

Materials And Methods: Retrospective, multicentre study on patients with VPS infection at paediatric and neurosurgery departments in four tertiary medical centres in Turkey between January 2011 and September 2014.

Results: A total of 290 patients with VPS infections were identified during the study period. The aetiology of hydrocephalus was congenital malformations in 190 patients (65.5%). The most common symptom of shunt infection was fever in 108 (37.2%) cases. At least one pathogen was identified in 148 VPS infections (51%). The most commonly isolated pathogen was coagulase-negative staphylococci, which grew in 63 cases (42.5%), followed by Pseudomonas aeruginosa in 22 cases (14.9%), Klebsiella pneumoniae in 15 cases (10.1%), and Staphylococcus aureus in 15 cases (10.1). The median duration of VPS infection was 2 months (range, 15 days to 60 months) after insertion of the shunt, with half (49.8%) occurring during the first month. VPS infection was treated by antibiotics and shunt removal in 211 cases (76.4%) and antibiotics alone without shunt removal in 65 patients (23.5%). Among the risk factors, CSF protein level greater than 100 mg/dL prior to VPS insertion was associated with a potential risk of re-infection (OR, 1.65; p =.01).

Conclusion: High protein levels (>100 mg/dL) before the re-insertion of a VPS may be a risk factor for VPS re-infection.
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http://dx.doi.org/10.1080/02688697.2018.1467373DOI Listing
April 2018

First Case of Bacteremia Caused by Kytococcus schroeteri in a Child With Congenital Adrenal Hyperplasia.

Pediatr Infect Dis J 2018 12;37(12):e304-e305

Pediatric Intensive Care Department, Health Science University (HSU) Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey.

Kytococcus schroeteri is a commensal organism of the human skin, which may cause serious infections in immunocompromised patients. We report the first case of K. schroeteri bacteremia in a child with congenital adrenal hyperplasia, identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (Bruker Daltonics, Germany). İdentification was confirmed by 16S rRNA gene sequencing.
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http://dx.doi.org/10.1097/INF.0000000000002014DOI Listing
December 2018

Magnusiomyces capitatus Peritonitis in a Child With Acute Lymphocytic Leukemia as a Breakthrough Infection During Caspofungin Therapy.

Pediatr Infect Dis J 2017 Dec;36(12):e351-e353

From the University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Clinical Microbiology Laboratory, Istanbul, Turkey.

Magnusiomyces capitatus is an emerging opportunistic fungal pathogen particularly in immunocompromised patients. We report a case of a M. capitatus peritonitis in child with acute lymphocytic leukemia as a breakthrough infection during caspofungin therapy. The possibility of breakthrough infections caused by M. capitatus must be taken into consideration, particularly in immunosupressed patients being treated for systemic fungal infections by caspofungin. Although there are no defined breakpoints for susceptibility testing of M.capitatus, minimal inhibitory concentration results can be helpful for therapy. Antifungal treatment with amphotericin B lipid complex plus flucytosine can be effective against infections caused by M. capitatus.
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http://dx.doi.org/10.1097/INF.0000000000001720DOI Listing
December 2017

Candida-Related Immune Response Inflammatory Syndrome Treated with Adjuvant Corticosteroids and Review of the Pediatric Literature.

Turk J Haematol 2017 03 18;34(1):109-111. Epub 2016 Oct 18.

Şişli Hamidiye Etfal Training and Research Hospital, Clinic of Pediatric Oncology, İstanbul, Turkey Phone: +90 212 373 66 57 E-mail:

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http://dx.doi.org/10.4274/tjh.2016.0237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5451675PMC
March 2017

Epidemiologic and microbiologic evaluation of nosocomial infections associated with Candida spp in children: A multicenter study from Istanbul, Turkey.

Am J Infect Control 2016 10 20;44(10):1139-1143. Epub 2016 Jun 20.

Department of Pediatric Infectious Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey.

Background: The purpose of this study was to establish species distribution of Candida isolates from pediatric patients in Istanbul, Turkey, and to determine risk factors associated with nosocomial Candida infections.

Methods: This study was conducted between June 2013 and June 2014 by participation of 7 medical centers in Istanbul. Candida spp strains isolated from the clinical specimens of pediatric patients were included. Clinical features were recorded on a standardized data collection sheet.

Results: A total of 134 systemic Candida infections were identified in 134 patients. The patients were admitted in pediatric and neonatal intensive care units (41.8% and 9.7%, respectively) and in pediatric wards (48.5%). Candida albicans was the most prevalent species (47%), followed by Candida parapsilosis (13.4%), Candida tropicalis (8.2%), Candida glabrata (4.5%), Candida lusitaniae (3.7%), Candida kefyr (2.2%), Candida guilliermondii (1.5%), Candida dubliniensis (0.7%), and Candida krusei (0.7%). Types of Candida infections were candidemia (50.7%), urinary tract infection (33.6%), surgical site infection (4.5%), central nervous system infection (3.7%), catheter infection (3.7%), and intra-abdominal infection (3.7%). In multivariate analysis, younger age (1-24 months) and detection of non-albicans Candida spp was found to be risk factors associated with candidemia (P = 0.040; odds ratio [OR], 4.1; 95% confidence interval [CI], 1.06-15.86; and P = 0.02; OR, 2.4; 95% CI, 1.10-5.53, respectively).

Conclusions: This study provides an update for the epidemiology of nosocomial Candida infections in Istanbul, which is important for the management of patients and implementation of appropriate infection control measures.
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http://dx.doi.org/10.1016/j.ajic.2016.03.056DOI Listing
October 2016

Corynebacterium propinquum bronchopneumonia in a child with ataxia telangiectasia.

Turk J Pediatr 2016 ;58(5):558-561

Clinical Microbiology Laboratory, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.

Nondiphtherial Corynebacterium species isolated from clinical specimens are usually considered as contaminants by many clinicians when reported by microbiologists. However, an increasing number of studies have confirmed the importance of Corynebacterium spp. in the etiology of a variety of infectious processes. In this report, we present a case of bronchopneumonia caused by Corynebacterium propinquum. The infection occurred in a seven-year-old child who had a history of immunosuppression due to ataxia telangiectasia. The purulent sputum of the patient yielded a large number of polymorphonuclear leucocytes with abundant gram-positive coryneform bacilli in gram staining and pure growth of coryneform bacteria in culture. Definitive identification as C. propinquum was made by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene sequencing. C. propinquum should be recognized as a potential pathogen and included in the etiologic diagnostic algorithm, particularly in patients with immunosuppressive conditions.
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http://dx.doi.org/10.24953/turkjped.2016.05.018DOI Listing
September 2017

Pericardial Effusion and Adenosine Deaminase False Positivity Due to Parvovirus B19.

Pediatr Infect Dis J 2015 Sep;34(9):1033-4

From the *Division of Cardiology, Department of Pediatrics, †Department of Pediatrics, and ‡Division of Pediatric Infectious Diseases, Department of Pediatrics, Sisli Etfal Education and Research Hospital, Sisli, Istanbul, Turkey.

This case is presented to highlight that one of the causes for massive exudative pericardial effusion in a child may be parvovirus B19, and adenosine deaminase can be falsely positive in such patients.
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http://dx.doi.org/10.1097/INF.0000000000000784DOI Listing
September 2015

Children with breakthrough varicella infection requiring hospitalization in Turkey (VARICOMP Study 2008-2013).

Vaccine 2015 Jul 29;33(32):3983-7. Epub 2015 Jun 29.

Cukurova University, Faculty of Medicine, Department of Pediatrics, Adana, Turkey.

Introduction: Varicella in previously immunized individuals, known as "breakthrough varicella". While the majority of breakthrough cases are mild, some may be severe, requiring hospitalization in previously healthy children or children with an underlying condition.

Methods: This report, as a part of the prospective national pediatric varicella hospitalizations study (including 29 centers, represent 50% of pediatric population) in Turkey, is aimed to evaluate breakthrough varicella infection requiring hospitalization before the routine use of single-dose live varicella vaccine in national program from 2008 to 2013 (<10% of the pediatric age group received a single-dose vaccine).

Results: In the time period, 1939 children were hospitalized due to varicella infection in Turkey; 36 children (20 boys, 16 girls, mean age 68.0+37.6 months, all received single dose live varicella vaccine) with breakthrough varicella infection. Breakthrough varicella infection might be severe in previously healthy children (61.1%) and children with immune-compromising conditions (38.9%). The time elapsed between vaccination and hospitalization was approximately 5 years, and neurological complications, mainly encephalitis and meningitis, were the most common reason for hospitalization in previously healthy children.

Conclusion: Pediatric breakthrough varicella requiring hospitalization have been seen in Turkey, is mainly observed in previously healthy children at 5 years after a single-dose varicella vaccine. The varicella vaccine has been implemented as part of the National Immunization Program in Turkey in 2013 (a single dose at age 12 months). Further surveillance in the same settings could evaluate the effectiveness of national immunization with single-dose varicella vaccine at 12 months of age and potential need for second dose of vaccine.
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http://dx.doi.org/10.1016/j.vaccine.2015.06.029DOI Listing
July 2015

Lactobacillus reuteri DSM 17938 shortens acute infectious diarrhea in a pediatric outpatient setting.

J Pediatr (Rio J) 2015 Jul-Aug;91(4):392-6. Epub 2015 May 16.

Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.

Objective: Two randomized controlled clinical trials have shown that Lactobacillus (L) reuteri DSM 17938 reduces the duration of diarrhea in children hospitalized due to acute infectious diarrhea. This was the first trial evaluating the efficacy of L. reuteri DSM 17938 in outpatient children with acute infectious diarrhea.

Methods: This was a multicenter, randomized, single-blinded, case control clinical trial in children with acute watery diarrhea. A total of 64 children who presented at outpatient clinics were enrolled. The probiotic group received 1×10(8)CFU L. reuteri DSM 17938 for five days in addition to oral rehydration solution (ORS) and the second group was treated with ORS only. The primary endpoint was the duration of diarrhea (in hours). The secondary endpoint was the number of children with diarrhea at each day of the five days of intervention. Adverse events were also recorded.

Results: The mean duration of diarrhea was significantly reduced in the L. reuteri group compared to the control group (approximately 15h, 60.4±24.5h [95% CI: 51.0-69.7h] vs. 74.3±15.3h [95% CI: 68.7-79.9h], p<0.05). The percentage of children with diarrhea was lower in the L. reuteri group (13/29; 44.8%) after 48h than the control group (27/31; 87%; RR: 0.51; 95% CI: 0.34-0.79, p<0.01). From the 72nd hour of intervention onwards, there was no difference between the two groups in the percentage of children with diarrhea. No adverse effects related to L. reuteri were noted.

Conclusion: L. reuteri DSM 17938 is effective, safe, and well-tolerated in outpatient children with acute infectious diarrhea.
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http://dx.doi.org/10.1016/j.jped.2014.10.009DOI Listing
January 2016

Evaluation of thyroid hormones in children receiving carbamazepine or valproate: a prospective study.

J Child Neurol 2015 Jan 15;30(1):63-8. Epub 2014 Apr 15.

Department of Pediatrics, Sisli Etfal Training & Research Hospital, Istanbul, Turkey.

The aim of this study was to determine the alterations in thyroid function during carbamazepine or valproate monotherapy in a prospective study. Forty patients treated with valproate, 33 patients treated with carbamazepine, and 36 control patients, all aged between 2 and 18 years, were enrolled in our study. Serum levels of thyroid hormones were measured before the beginning of the antiepileptic therapy and at 6 and 12 months of treatment. Carbamazepine-treated patients showed mean serum thyroid hormone levels significantly lower than baseline evaluation and the control group. Thyroid-stimulating hormone levels at 6 and 12 months were not significantly different in carbamazepine treated patients. Serum hormone levels did not change during valproate treatment. Thyroid-stimulating hormone levels were significantly higher at the 12th month of valproate treatment. Our data suggest that although carbamazepine causes significant alterations in thyroid hormone levels, these changes do not lead to clinical symptoms at the follow-up period of 12 months.
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http://dx.doi.org/10.1177/0883073814529822DOI Listing
January 2015

Ertapenem versus standard triple antibiotic therapy for the treatment of perforated appendicitis in pediatric patients: a prospective randomized trial.

Eur J Pediatr Surg 2014 Oct 27;24(5):410-8. Epub 2013 Aug 27.

Division of Pediatric Surgery, Sisli Etfal Training and Research Hospital, Istanbul, Turkey.

Background: The primary objective of this study was to compare triple therapy with ertapenem treatments in pediatric patients with perforated appendicitis, especially in terms of postoperative infectious complications. The secondary objective of this study was to assess the relative impact of therapy with ertapenem and triple antibiotic regimen on the emergence of resistant bacteria in bowel flora in the patients.

Materials And Methods: Children aged 3 months to 17 years with perforated appendicitis were randomized 1:1 to receive ertapenem or triple therapy. Serial rectal cultures were obtained from participants enrolled in the study, allowing assessment of the relative impact of therapy with ertapenem and triple therapy on bowel colonization by resistant bacteria.

Results: In this study, 107 patients were included. No difference existed in time to full oral intake and regular diet, the length of antibiotic therapy, the length of the postoperative hospitalization, or the length of hospital stay between the two groups. Patients in the triple-therapy group were more likely to suffer from a postoperative infectious complication than those in the ertapenem group (6/54 vs. 2/53, p > 0.05). Bowel colonization with resistant organisms at the end of therapy in the triple-therapy group was significantly different than in the ertapenem group (35.2 vs. 11.3%, p < 0.05).

Conclusions: Bowel colonization with resistant bacteria was less likely to occur after ertapenem treatment than triple therapy. The results of this trial suggest that ertapenem may be a useful option that could eliminate the need for combination and/or multidosed antibiotic regimens for the empiric treatment of perforated appendicitis in children.
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http://dx.doi.org/10.1055/s-0033-1352524DOI Listing
October 2014

The effect of a multispecies synbiotic mixture on the duration of diarrhea and length of hospital stay in children with acute diarrhea in Turkey: single blinded randomized study.

Eur J Pediatr 2013 Apr 14;172(4):459-64. Epub 2012 Dec 14.

Department of Pediatrics, Pediatric Intensive Care and Infectious Disease Unit, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, TR26480, Turkey.

Probiotics have been successfully used for the treatment of acute diarrhea in children and this effect depends on the strains and dose. The aim of this study was to assess the effect of a synbiotic mixture on the duration of diarrhea and the length of hospital stay in children with acute watery diarrhea. This is a prospective randomized, multicenter single blinded clinical trial in hospitalized children with acute watery diarrhea. All children were treated with conventional hydration therapy with or without a daily dose of a synbiotic (2.5 × 10(9) CFU live bacteria including Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium bifidum, Bifidobacterium longum, Enterococcus faecium, and 625 mg fructooligosaccharide) for 5 days. The primary endpoint was duration of diarrhea and duration of hospitalization was the secondary endpoint. Among 209 eligible children, 113 received the synbiotic mixture and 96 served as a control. The duration of diarrhea was significantly shorter (∼36 h) in children receiving the synbiotic group than the controls (77.9 ± 30.5 vs. 114.6 ± 37.4 h, p < 0.0001). The duration of hospitalization was shorter in children receiving the synbiotic group (4.94 ± 1.7 vs. 5.77 ± 1.97 days, p = 0.002). The effect of synbiotic mixture on diarrhea started after 24th hours and stool frequency significantly decreased after 24th and 48th hours. The percentage of diarrhea-free children is significantly higher in synbiotic group at 48th and 72nd hours of synbiotic group. In conclusion, this study showed a reduction in diarrhea duration by approximately 36 h and a reduction in the duration of hospitalization with approximately 1 day in children with acute diarrhea with this synbiotic mixture.
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http://dx.doi.org/10.1007/s00431-012-1903-5DOI Listing
April 2013

Risk factors for recurrent shunt infections in children.

J Clin Neurosci 2012 Jun 18;19(6):844-8. Epub 2012 Apr 18.

Department of Neurosurgery, Sisli Etfal Training and Research Hospital, Halaskargazi Street, Istanbul 34100, Turkey.

Risk factors for recurrent shunt-related cerebrospinal fluid (CSF) infections were analyzed. A total of 58 children were treated for initial shunt infections (ISI): all children were treated with antibiotics and CSF drainage, either by removal of the shunt system and insertion of an external ventricular drainage (EVD) catheter (44 children, 75.9%) or by externalization of the existing ventricular catheter (14 children, 24.1%). Recurrent shunt infections (RSI) were detected in 15 children: nine had been treated with shunt removal and insertion of a new EVD catheter and six had been treated with externalization of the existing ventricular catheter. There was a statistically significant increase in the number of RSI in children treated with externalization of the existing ventricular catheter. Thus, to reduce the risk of RSI, total shunt removal and insertion of a new EVD catheter is preferred.
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http://dx.doi.org/10.1016/j.jocn.2011.07.054DOI Listing
June 2012

The epidemiology and economic impact of varicella-related hospitalizations in Turkey from 2008 to 2010: a nationwide survey during the pre-vaccine era (VARICOMP study).

Eur J Pediatr 2012 May 16;171(5):817-25. Epub 2011 Dec 16.

Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey.

Varicella can cause complications that are potentially serious and require hospitalization. Our current understanding of the causes and incidence of varicella-related hospitalization in Turkey is limited and sufficiently accurate epidemiological and economical information is lacking. The aim of this study was to estimate the annual incidence of varicella-related hospitalizations, describe the complications, and estimate the annual mortality and cost of varicella in children. VARICOMP is a multi-center study that was performed to provide epidemiological and economic data on hospitalization for varicella in children between 0 and 15 years of age from October 2008 to September 2010 in Turkey. According to medical records from 27 health care centers in 14 cities (representing 49.3% of the childhood population in Turkey), 824 children (73% previously healthy) were hospitalized for varicella over the 2-year period. Most cases occurred in the spring and early summer months. Most cases were in children under 5 years of age, and 29.5% were in children under 1 year of age. The estimated incidence of varicella-related hospitalization was 5.29-6.89 per 100,000 in all children between 0-15 years of age in Turkey, 21.7 to 28 per 100,000 children under 1 year of age, 9.8-13.8 per 100,000 children under 5 years of age, 3.96-6.52 per 100,000 children between 5 and 10 years of age and 0.42 to 0.71 per 100,000 children between 10 and 15 years of age. Among the 824 children, 212 (25.7%) were hospitalized because of primary varicella infection. The most common complications in children were secondary bacterial infection (23%), neurological (19.1%), and respiratory (17.5%) complications. Secondary bacterial infections (p < 0.001) and neurological complications (p < 0.001) were significantly more common in previously healthy children, whereas hematological complications (p < 0.001) were more commonly observed in children with underlying conditions. The median length of the hospital stay was 6 days, and it was longer in children with underlying conditions (<0.001). The median cost of hospitalization per patient was $338 and was significantly higher in children with underlying conditions (p < 0.001). The estimated direct annual cost (not including the loss of parental work time and school absence) of varicella-related hospitalization in children under the age of 15 years in Turkey was $856,190 to $1,407,006. According to our estimates, 882 to 1,450 children are hospitalized for varicella each year, reflecting a population-wide occurrence of 466-768 varicella cases per 100,000 children. In conclusion, this study confirms that varicella-related hospitalizations are not uncommon in children, and two thirds of these children are otherwise healthy. The annual cost of hospitalization for varicella reflects only a small part of the overall cost of this disease, as only a very few cases require hospital admission. The incidence of this disease was higher in children <1 year of age, and there are no prevention strategies for these children other than population-wide vaccination. Universal vaccination is therefore the only realistic option for the prevention of severe complications and deaths. The surveillance of varicella-associated complications is essential for monitoring of the impact of varicella immunization.
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http://dx.doi.org/10.1007/s00431-011-1650-zDOI Listing
May 2012

Species distribution of the Mycobacterium tuberculosis complex in clinical isolates from 2007 to 2010 in Turkey: a prospective study.

J Clin Microbiol 2011 Nov 21;49(11):3837-41. Epub 2011 Sep 21.

Sisli Etfal Research and Training Hospital, Clinical Microbiology Department, Istanbul, Turkey.

The Mycobacterium tuberculosis complex (MTBC) consists of a group of closely related species that differ in their epidemiological profiles, host ranges, pathogenicities, geographic distributions, and drug resistances. Identification of members in the MTBC is essential for monitoring the epidemiology of tuberculosis (TB) and implementing appropriate public health control measures. In this study, 188 consecutive MTBC clinical isolates from 2007 to 2010 were evaluated to determine the prevalence of MTBC species in Turkey. PCR and restriction fragment length polymorphism analysis (PCR-RFLP) of the gyrB gene were used, and results for species other than M. tuberculosis were confirmed using the GenoType MTBC assay (Hain Lifescience, Nehren, Germany). Most of the strains were found to be M. tuberculosis (94.1%). The prevalences of M. bovis and M. caprae were 4.3% and 1.6%, respectively. Only one M. bovis BCG strain was identified. Overall, the frequency of bovine tuberculosis in humans was 5.3%. We had assumed that bovine TB infection was under control in animal herds, but primary M. bovis infections in humans caused by transmission from infected animals are still an issue in Turkey. Our results indicate that the frequent identification of M. bovis in routine mycobacteriological laboratory work has further importance due to the well-known resistance of this species to pyrazinamide.
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http://dx.doi.org/10.1128/JCM.01172-11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3209075PMC
November 2011

Clinical and epidemiological features of Turkish children with 2009 pandemic influenza A (H1N1) infection: experience from multiple tertiary paediatric centres in Turkey.

Scand J Infect Dis 2011 Dec 23;43(11-12):923-9. Epub 2011 Aug 23.

Department of Pediatrics, Ankara University Medical School , Ankara , Turkey.

Background: In April 2009 a novel strain of human influenza A, identified as H1N1 virus, rapidly spread worldwide, and in early June 2009 the World Health Organization raised the pandemic alert level to phase 6. Herein we present the largest series of children who were hospitalized due to pandemic H1N1 infection in Turkey.

Methods: We conducted a retrospective multicentre analysis of case records involving children hospitalized with influenza-like illness, in whom 2009 H1N1 influenza was diagnosed by reverse-transcriptase polymerase chain reaction assay, at 17 different tertiary hospitals.

Results: A total of 821 children with 2009 pandemic H1N1 were hospitalized. The majority of admitted children (56.9%) were younger than 5 y of age. Three hundred and seventy-six children (45.8%) had 1 or more pre-existing conditions. Respiratory complications including wheezing, pneumonia, pneumothorax, pneumomediastinum, and hypoxemia were seen in 272 (33.2%) children. Ninety of the patients (11.0%) were admitted or transferred to the paediatric intensive care units (PICU) and 52 (6.3%) received mechanical ventilation. Thirty-five children (4.3%) died. The mortality rate did not differ between age groups. Of the patients who died, 25.7% were healthy before the H1N1 virus infection. However, the death rate was significantly higher in patients with malignancy, chronic neurological disease, immunosuppressive therapy, at least 1 pre-existing condition, and respiratory complications. The most common causes of mortality were pneumonia and sepsis.

Conclusions: In Turkey, 2009 H1N1 infection caused high mortality and PICU admission due to severe respiratory illness and complications, especially in children with an underlying condition.
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http://dx.doi.org/10.3109/00365548.2011.598872DOI Listing
December 2011

Relationship between toll-like receptor 8 gene polymorphisms and pediatric pulmonary tuberculosis.

Dis Markers 2011 ;31(1):33-8

Sisli Etfal Training and Research Hospital, Division of Pediatric Infectious Diseases, Istanbul, Turkey.

Objectives: Genetic variants in Toll-like receptors (TLRs) are considered a potential indicator for host susceptibility to and outcome of several infectious diseases including tuberculosis. The aim of this study was to determine whether -129 C/G and Met1Val polymorphisms of TLR8 were associated with pediatric pulmonary tuberculosis in Turkish population.

Methods: The -129 C/G and Met1Val polymorphisms were studied in 124 children with pulmonary tuberculosis compared to 150 age-matched healthy control subjects.

Results: We did not identify any statistically significant differences between the patients with TB and control groups with regard to the frequency of genotypes GG or G/(-), CG, and CC or C/(-); and alleles G and C at rs3764879 (p> 0.05). We found a strong association with genotype A/(-) at rs3764880 with susceptibility to pulmonary TB in males (OR 2.87, 95%CI 1.38-5.98, p=0.007).

Conclusions: Our results provide evidence, for the first time, of a role for the TLR8 gene in susceptibility to pulmonary TB in male children. Additional research to verify our results are necessary. Tuberculosis in children presents particularly difficult challenges, but research priorities and advances in pediatric tuberculosis could provide wider insights and opportunities for tuberculosis control.
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http://dx.doi.org/10.3233/DMA-2011-0800DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3826908PMC
December 2011

Importance of NOD2/CARD15 gene variants for susceptibility to and outcome of sepsis in Turkish children.

Pediatr Crit Care Med 2012 Mar;13(2):e73-7

Institute of Forensic Sciences, Ankara University, Ankara, Turkey.

Objective: Severe sepsis remains a leading cause of morbidity and mortality in children. Given the link to pathogenesis, polymorphisms in genes involved in infection and inflammation may influence the outcomes in patients with sepsis and septic shock. The role of mutations within the innate immunity receptor NOD2/CARD15 has recently been demonstrated as a risk factor for bacteremia and mortality in adult patients with sepsis. The aim of this study was to evaluate the role of mutations of the NOD2/CARD15 gene in pediatric patients with sepsis.

Design: Prospective cohort study.

Setting: A tertiary care, ten-bed, pediatric intensive care unit.

Patients: One hundred twenty-eight patients with sepsis admitted to the pediatric intensive care unit and healthy control group were included.

Interventions: Venous blood from the children with sepsis and healthy controls was collected to investigate common polymorphisms (Arg702Trp, Gly908Arg, Leu1007fsincC) within the NOD2/CARD15 gene. Standard polymerase chain reaction restriction fragment length polymorphism technique was used to determine NOD2/CARD15 gene polymorphism.

Measurement And Main Results: R702W, G908R, and Leu1007fsinsC variants in the NOD2/CARD15 gene were determined as significant risk factors associated with susceptibility to sepsis (p = .025, p = .031, p = .014, respectively). Sepsis-related mortality was increased in children carrying the Leu1007fsinsC variant (p = .041).

Conclusions: The present article is the first report of clinical implications of NOD2/CARD15 gene variants in children with sepsis. Our findings suggest that common polymorphisms in the NOD2/CARD15 gene may play a major role in susceptibility to sepsis and the outcome of sepsis in children.
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http://dx.doi.org/10.1097/PCC.0b013e3182191c2eDOI Listing
March 2012