The Early Response to Dietary Therapy can Predict the Late Outcome in Children with Intractable Epilepsy

Background@#and Purpose Dietary therapy (DT), including the ketogenic diet (KD), is one of the nonpharmacological treatment options for patient with drug-resistant epilepsy. However, maintaining DT in patients without seizure reduction is very difficult, so it is critical for clinicians to decide when to stop this intervention. @*Methods@#We retrospectively analyzed early clinical and laboratory findings and the clinical characteristics of children who received DT. The maintenance of DT and the clinical seizure frequency were assessed at 1, 3, 6, 12, and 24 months after KD initiation. Responders were defined as patients showing an overall reduction in seizure frequency of >50% relative to the baseline. @*Results@#We included 67 patients who received DT, but only 23 (34.3%) of these patients remained on DT at 6 months. Only 1 (5%) of the 20 responders at 1 month became a nonresponder at 6 months. The response rate at 6 months was significantly higher among patients under 2 years of age (15/17, 88.2%) than older patients (2/6, 33.3%; p=0.021). Moreover, the 6-month responders were significantly younger (29.4±38.6 months, mean±SD) than the nonresponders (98.9±84.6 months, p=0.012) at the initiation of the diet. A high blood β-hydroxybutyrate (BHB) level at 1 month predicted a good DT response at 6 months. @*Conclusions@#Most 1-month responders maintained their response on DT for up to 6 months.The blood BHB level at 1 month was significantly correlated with the 6-month seizure outcome.Confirming clinical and laboratory biomarkers for the efficacy of DT requires further studies with larger cohorts.

Lymph Node Ratio as a Good Prognostic Factor for Patients with Pathologic N3a Breast Cancer with 10 or More Metastatic Axillary Lymph Nodes

Purpose@#Pathologic N3a breast cancer is defined as having 10 or more metastatic axillary lymph nodes and metastases to the infraclavicular (level III axillary lymph) node. This study aimed to determine clinicopathological factors and assess the importance of lymph node ratio (LNR) as a prognostic factor for patient with N3a breast cancer treated with surgery without neoadjuvant chemotherapy. @*Methods@#Medical records of 154 patients who underwent surgery were retrospectively analyzed. Patients were pathologically diagnosed with N3a breast cancer between May 2004 and December 2014. LNR was defined as the number of metastatic lymph nodes divided by the total number of resected lymph nodes. It was calculated using the receiver operating characteristic (ROC) curve. The median follow up period was 94 months (range, 10–205 months). @*Results@#Among 154 patients with N3a breast cancer, 70 (45.5%) had recurrence and 40 (26.0%) died during the follow-up period. The 5-year disease free survival (DFS) and overall survival (OS) rates after surgery were 63.0% and 85.9%, respectively. LNR>0.82 (hazard ratio [HR]: 2.271; 95% confidence interval [CI]: 1.413–3.649; p=0.001) was a prognostic factor significantly associated with DFS. LNR>0.68 (HR: 2.156; 95% CI: 1.146–4.044; p=0.017) and invasive ductal carcinoma (HR: 0.125; 95% CI: 0.017–0.915: p=0.041) were significantly associated with OS. @*Conclusion@#Although LNR values associated with DFS and OS are slightly different, LNR is a good prognostic factor for patients with N3a breast cancer.

Nipple Adenoma Treated with Nipple Preservation in Young Female Patient: A Report of 2 Cases

Adenoma of the nipple is a rare benign type of breast that occurs most often in middle-aged women with nipple discharge, skin erosion in addition to crusting, inflammation, and pain. It can be clinically confused with Paget’s disease or breast cancer precursor lesions, such as ductal carcinoma in situ low grade. The treatment of choice for nipple adenoma is complete excision of the tumor. However in younger women, nipple preservation is required. We present two cases of nipple adenoma that were completely removed with nipple preservation.

Abdominal Drainage in the Prevention and Management of Major IntraAbdominal Complications after Total Gastrectomy for Gastric Carcinoma

Purpose@#The role of prophylactic abdominal drainage in total gastrectomy is not wellestablished. This study aimed to evaluate the efficacy of abdominal drainage in the prevention and management of major intra-abdominal complications after total gastrectomy for gastric carcinoma. @*Materials and Methods@#We retrospectively reviewed the data of 499 patients who underwent total gastrectomy for gastric carcinoma in a high-volume institution. The patients were divided into drainage and non-drainage groups and compared for the development and management of major intra-abdominal complications, including anastomotic leak, abdominal bleeding, abdominal infection, and pancreatic fistulas. @*Results@#The drainage group included 388 patients and the non-drainage group included 111 patients. The 2 groups showed no significant differences in clinicopathological characteristics or operative procedures, except for more frequent D2 lymphadenectomies in the drainage group. After surgery, the overall morbidity (drainage group vs. non-drainage group: 24.7% vs. 28.8%, P=0.385) and incidence of major intra-abdominal complications (6.4% vs. 6.3%, P=0.959) did not significantly differ between the two groups. The nondrainage group showed no significant increase in the incidence rate of major intra-abdominal complications in the subgroups divided by age, sex, comorbidity, operative approach, body mass index, extent of lymphadenectomy, and pathological stage. Abdominal drainage had no significant impact on early diagnosis, secondary intervention or reoperation, or recovery from major intra-abdominal complications. @*Conclusions@#Prophylactic abdominal drainage showed little demonstrable benefit in the prevention and management of major intra-abdominal complications of total gastrectomy for gastric carcinoma.

Abdominal Drainage in the Prevention and Management of Major IntraAbdominal Complications after Total Gastrectomy for Gastric Carcinoma

Purpose@#The role of prophylactic abdominal drainage in total gastrectomy is not wellestablished. This study aimed to evaluate the efficacy of abdominal drainage in the prevention and management of major intra-abdominal complications after total gastrectomy for gastric carcinoma. @*Materials and Methods@#We retrospectively reviewed the data of 499 patients who underwent total gastrectomy for gastric carcinoma in a high-volume institution. The patients were divided into drainage and non-drainage groups and compared for the development and management of major intra-abdominal complications, including anastomotic leak, abdominal bleeding, abdominal infection, and pancreatic fistulas. @*Results@#The drainage group included 388 patients and the non-drainage group included 111 patients. The 2 groups showed no significant differences in clinicopathological characteristics or operative procedures, except for more frequent D2 lymphadenectomies in the drainage group. After surgery, the overall morbidity (drainage group vs. non-drainage group: 24.7% vs. 28.8%, P=0.385) and incidence of major intra-abdominal complications (6.4% vs. 6.3%, P=0.959) did not significantly differ between the two groups. The nondrainage group showed no significant increase in the incidence rate of major intra-abdominal complications in the subgroups divided by age, sex, comorbidity, operative approach, body mass index, extent of lymphadenectomy, and pathological stage. Abdominal drainage had no significant impact on early diagnosis, secondary intervention or reoperation, or recovery from major intra-abdominal complications. @*Conclusions@#Prophylactic abdominal drainage showed little demonstrable benefit in the prevention and management of major intra-abdominal complications of total gastrectomy for gastric carcinoma.

Effects of Parenteral Nutrition in Pediatric Patients with Hematopoietic Stem Cell Transplantation

PURPOSE: This study examined the effects of parenteral nutrition (PN) on the nutritional status, clinical improvement, and PN-related complications in pediatric patients who had undergone hematopoietic stem cell transplantation (HSCT). METHODS: A retrospective audit of 110 pediatric patients (age≤18), who underwent HSCT from March 2015 to February 2017 was undertaken. The patients were divided into 3 groups based on the ratio of daily calorie supplementation to the daily calorie requirement (ROCS). The clinical factors related to the nutritional status, such as difference in body weight (BW), body mass index (BMI), percent ideal body weight (PIBW), total protein (T.protein), and albumin; the early clinical outcome, such as PN-duration, length of hospitaliaztion (LOH), engraftment day (ED), graft-versus-host disease, sepsis, pneumonia and mucositis; and PN-related complications, including elevation of total bilirubin (T.bil), direct bilirubin (D.bil), aspartate aminotransferase, alanine aminotransferase, glucose and cholesterol levels, and hepatic veno-occlusive disease were analyzed using the electronic medical records. Additional analysis subject to auto-HSCT and allo-HSCT patients was also performed. RESULTS: The very-low-ROCS, low-ROCS, and satisfied-ROCS group were 30 (27.3%), 47 (42.7%), and 33 (30.0%) patients, respectively. The PN-duration (P=0.005, z=−2.271), LOH (P=0.023, z=−2.840), ED (P < 0.001, z=−3.695), T.bil elevation (P < 0.001, z=−3.660), and D.bil elevation (P=0.002, z=−3.064) tended to decrease with increasing ROCS. The difference in the PN-duration (P=0.017), ED (P=0.001), T.bil elevation (P=0.001), and D.bil elevation (P=0.011) in the 3 groups was statistically significant. In the auto-HSCT patients, the change in BW (P=0.031, z=+2.154), PIBW (P=0.029, z=+2.187), and BMI (P=0.021, z=+2.306) tended to increase. In the allo-HSCT patients, the change in T.protein (P=0.022, z=+2.286) increased but the ED (P=0.021, z=−2.304) decreased. CONCLUSION: Aggressive PN supplementation has an effect on maintaining the nutritional status and achieving better early outcomes in pediatric HSCT patients, whereas it has no effect on increasing the PN-related complications.

Validation of the World Health Organization Enzyme-Linked Immunosorbent Assay for the Quantitation of Immunoglobulin G Serotype-Specific Anti-Pneumococcal Antibodies in Human Serum

The World Health Organization (WHO) enzyme-linked immunosorbent assay (ELISA) guideline is currently accepted as the gold standard for the evaluation of immunoglobulin G (IgG) antibodies specific to pneumococcal capsular polysaccharide. We conducted validation of the WHO ELISA for 7 pneumococcal serotypes (4, 6B, 9V, 14, 18C, 19F, and 23F) by evaluating its specificity, precision (reproducibility and intermediate precision), accuracy, spiking recovery test, lower limit of quantification (LLOQ), and stability at the Ewha Center for Vaccine Evaluation and Study, Seoul, Korea. We found that the specificity, reproducibility, and intermediate precision were within acceptance ranges (reproducibility, coefficient of variability [CV] ≤ 15%; intermediate precision, CV ≤ 20%) for all serotypes. Comparisons between the provisional assignments of calibration sera and the results from this laboratory showed a high correlation > 94% for all 7 serotypes, supporting the accuracy of the ELISA. The spiking recovery test also fell within an acceptable range. The quantification limit, calculated using the LLOQ, for each of the serotypes was 0.05–0.093 μg/mL. The freeze-thaw stability and the short-term temperature stability were also within an acceptable range. In conclusion, we showed good performance using the standardized WHO ELISA for the evaluation of serotype-specific anti-pneumococcal IgG antibodies; the WHO ELISA can evaluate the immune response against pneumococcal vaccines with consistency and accuracy.

A New Neolignan Derivative, Balanophonin Isolated from Firmiana simplex Delays the Progress of Neuronal Cell Death by Inhibiting Microglial Activation

Excessive activation of microglia causes the continuous production of neurotoxic mediators, which further causes neuron degeneration. Therefore, inhibition of microglial activation is a possible target for the treatment of neurodegenerative disorders. Balanophonin, a natural neolignoid from Firmiana simplex, has been reported to have anti-inflammatory and anti-cancer effects. In this study, we aimed to evaluate the anti-neuroinflammatory effects and mechanism of balanophonin in lipopolysaccharide (LPS)-stimulated BV2 microglia cells. BV2 microglia cells were stimulated with LPS in the presence or absence of balanophonin. The results indicated that balanophonin reduced not only the LPS-mediated TLR4 activation but also the production of inflammatory mediators, such as nitric oxide (NO), prostaglandin E2 (PGE2), Interleukin-1β (IL-1β), and tumor necrosis factor-α (TNF-α), in BV2 cells. Balanophonin also inhibited LPS-induced inducible nitric oxide synthase (iNOS), and cyclooxygenase-2 (COX2) protein expression and mitogen activated protein kinases (MAPKs), including extracellular signal-regulated kinase (ERK1/2), c-Jun N-terminal kinase (JNK), and p38 MAPK. Interestingly, it also inhibited neuronal cell death resulting from LPS-activated microglia by regulating cleaved caspase-3 and poly ADP ribose polymerase (PARP) cleavage in N2a cells. In conclusion, our data indicated that balanophonin may delay the progression of neuronal cell death by inhibiting microglial activation.

A Case of Renal and Liver Abscesses Caused by Nalidixic Acid-Resistant Salmonella typhi / 대한내과학회지

Prompt antibiotic treatment reduces the incidence of complications such as liver abscesses, pyelonephritis, and osteomyelitis in patients with typhoid fever. Renal or liver abscesses are especially rare in patients without underlying disease or predisposing factors. The occurrence of both renal and liver abscesses in a patient with typhoid fever has not been reported. Although the prevalence of typhoid fever in Korea has decreased, it is still an important disease owing to increased opportunities for the occurrence of waterborne diseases with climate warming and group feeding, and the increased numbers of tourists and foreigners visiting Korea. We present a patient with no underlying disease or predisposing factors who developed both renal and liver abscesses caused by nalidixic acid-resistant Salmonella typhi after a trip to Nepal. He was treated successfully with percutaneous drainage of the renal abscess and high-dose ciprofloxacin.

A Case of Polyarthritis Associated with Reactivation of Chronic Hepatitis B Virus Infection

Hepatitis viruses (hepatitis B virus (HBV) and hepatitis C virus) have been associated with development of inflammatory arthritis. Approximately 400 million people worldwide have chronic HBV infection. HBV infection is the one of the most common causes of liver disease, and the prevalence of HBV infection in Korea is almost 6%. Arthritis in patients with HBV can be encountered in two settings: as a rheumatoid arthritis (RA)-like, acute, self-limited polyarthritis during the pre-symptomatic phase of acute hepatitis B, or, more rarely, as arthritis occurring in the context of HBV-associated polyarteritis nodosa (PAN). In both cases, the pathogenesis of arthritis is attributed to the deposition of immune complexes containing viral antigens (HBsAg or HBeAg) and their respective antibodies (anti-HBs and anti-HBe) in synovial tissues. Here we report on a case of polyarthritis associated with reactivation of chronic hepatitis B virus infection with a review of the literature.

Cross-reaction of 6B and 19F Specific Antibodies to Serotypes 6A, 6C, and 19A after Immunization with 7-valent Pneumococcal Conjugate Vaccine in Korean Children Aged 12-23 Months / 소아감염

PURPOSE: The cross-protection of 7-valent pneumococcal conjugate vaccine (PCV7) against vaccine-related serotypes has been controversial. We investigated the serological properties of cross-protective antibodies against vaccine-related serotypes 6A, 6C, and 19A induced in young children aged 12-23 months after booster immunization of PCV7. METHODS: IgG and IgM antibody concentrations and opsonic index (OI) against vaccine serotypes 6B and 19F and vaccine-related serotypes 6A, 6C, and 19A were measured by ELISA and opsonophagocytic killing assay (OPA) in 4 selected immunesera. The serological properties and antigenic specificity of protective antibodies were determined by IgM depletion of immunesera, OPA, and competitive OPA against serogroup 6 and 19 pneumococci. RESULTS: Compared to pre-IgM depleted immunesera, OI of IgM-depleted immunesera against 6B and 19F decreased and OI against 6A, 6C, and 19A decreased, too. In competition OPA, free 6B and 19F polysaccharide completely inhibited the immune protection against vaccine-related serotypes 6A, 6C, and 19A as well as vaccine types 6B and 19F. CONCLUSIONS: The booster immunization of PCV7 certainly induced cross-protective antibodies against vaccine-related serotypes 6A, 6C, and 19A with both IgG and IgM isotypes. Furthermore, IgM antibodies are more highly contributed to opsonophagocytic activity against vaccine-related serotypes as well as most of vaccine types than do IgG antibodies. Further studies are needed for the more immunized sera in the children as well as adults.

Incidence and Cinical Characteristics of Severe Community-Acquired Pneumococcal Pneumonia: Comparisons with Non-Pneumoccocal Pathogens / 대한내과학회지

BACKGROUND/AIMS: Only limited data are available on severe community-acquired pneumonia (severe CAP or SCAP) caused by Streptococcus pneumoniae in Korea. METHODS: All patients who were admitted to a tertiary hospital for CAP from January 2007 to December 2008 were reviewed retrospectively, and SCAP was defined by 2007 Infectious Disease Society of America/American Thoracic Society criteria. RESULTS: In total, 94 patients were diagnosed with SCAP (mean age, 73.5 +/- 14.3 years; male, 70). Among them, pneumococcal SCAP (P-SCAP) accounted for 24.5%, and non-P-SCAP accounted for 18.1% (four with Pseudomonas aeruginosa, [4.3%]; four with Staphylococcus aureus, [4.3%]), and no organisms were identified in 57.4% of the patients. A history of neoplasm was less frequent, and the incidence of shock and pneumonia severity index (PSI) scores were lower in patients with P-SCAP than in those with non-P-SCAP or with SCAP with no organism identified (p = 0.012, 0.023 and 0.007, respectively). Patients with P-SCAP had a lower rate of treatment failure (p = 0.048) and tended to have lower in-hospital and 30-day mortalities compared with those with non-P-SCAP. In a multivariate analysis, the history of neoplasm was the strongest independent factor for predicting 30-day mortality (odds ratio, 9.068; 95% confidence interval, 1.856-44.309). CONCLUSIONS: P-SCAP accounted for 24.5% of SCAP cases. P-SCAP was associated with lower disease severity and a tendency toward better hospital outcomes compared with non-P-SCAP.

A Case of Multicentric Reticulohistiocytosis Misdiagnosed as Rheumatoid Arthritis / 고신대학교의과대학학술지

Multicentric reticulohistiocytosis (MRH) is a rare disease characterized by nodular skin lesions and severe erosive polyarthritis which is associated with malignancy in some cases. The diagnosis is confirmed by the presence of oncocytic histiocytes and multinucleated giant cells on histopathology of the cutaneous nodules and the synovial membrane. It usually remits spontaneously after 5-8 years but it can provoke destructive arthritis. We report a case of a 49-year-old female who presented with numerous nodules on the both hands, face and abdomen and progressive destructive polyarthritis of 3 years duration and has been diagnosed with rheumatoid arthritis. The lesion showed large histiocytes with ground-glass eosinophilic cytoplasm, typical of MRH. Clinical manifestation and radiological pattern of MRH may be misdiagnosed as other disease like rheumatoid arthritis and psoriatic arthritis, but histopathologic findings of our case can differentiate MRH from any other conditions.

A Case of Tuberculous Pericardial Abscess Mimicking Thymic Carcinoma / 결핵및호흡기질환

We report here an unusual case of pericardial tuberculoma that was misdiagnosed as thymic carcinoma on an imaging study. A 48-year-old woman was referred for evaluation of an anterior mediastinal mass. Computed tomography (CT) scans of the chest displayed cystic masses mimicking thymic carcinoma at the anterior mediastinum. Pericardiotomy and surgical drainage of the cystic masses were done, and pathologic examination of the excised pericardial specimen showed a chronic granulomatous inflammation with necrosis, compatible with tuberculosis. Acid-fast bacilli were also identified in the specimen. After treatment with anti-tuberculosis drugs and steroids, the patient showed clinical improvement. Although tuberculous pericarditis usually presents as pericardial effusion or constrictive pericarditis, it can also present as a pericardial mass mimicking thymic carcinoma on CT. Therefore, we suggest that tuberculous pericardial abscess should be included in the differential diagnosis of a mediastinal mass in Korea, with intermediate tuberculosis prevalence.

Immunogenicity of 7-valent pneumococcal conjugate vaccine related to booster immunization in Korean children / 소아과

PURPOSE: The purpose of this study was to evaluate the immunogenicity of the booster immunization with pneumococcal conjugate vaccine in Korean children. METHODS: Thirty-nine children aged 12-23 months who visited Kangnam CHA Hospital between September 2006 and December 2006 were enrolled. The children were divided into primary and booster groups depending on their vaccination status for the 7-valent pneumococcal conjugate vaccine. The anti-pneumococcal antibody levels of each serotype included in the vaccine (4, 6B, 9V, 14, 18C, 19F, 23F) were determined by third-generation ELISA. RESULTS: The geometric mean titer (GMT) of antibodies to each pneumococcal serotype in the booster group was higher than in the primary group (P or =0.35 microgram/mL was 90.5-100% for all serotypes in both the primary and booster groups. The percentage of subjects with pneumococcal antibodies > or =1.0 g/mL in the booster group was 94.4-100%, which was higher than the primary group except for serotypes 6B and 14 (P or =5.0 microgram/mL in the booster group was 50.0-94.4% which was higher than the primary group for all serotypes (P<0.05). CONCLUSION: The immunogenicity of a booster dose of the pneumococcal conjugate vaccine in Korean children was high and the immunogenicity of a primary series was also relatively high. To determine the feasibility of the introduction of the pneumococcal conjugate vaccine and the appropriate schedule for Korean children, further prospective investigation of the immunogenicity of the booster immunization is needed.

Antibody prsistence after Haemophilus influenzae type b (Hib) primary vaccination and response to boosters in Korean children / 소아과

PURPOSE: Antibody persistence after primary series of Haemophilus influenzae type b (Hib) vaccine and responses to boosters are seldom studied in Korean children. We performed this study to evaluate the antibody titer in relation to booster immunization of Hib vaccine in Korean children. METHOD: One hundred forty four children aged 12-23 months were enrolled in three university hospitals. The immunogenicity of boosters with Hib vaccine was assessed in children previously primed with Hib vaccine. Antibody persistence was also assessed in children who had received 3 doses of Hib vaccine without a booster. Anti-polyribosylribitol phosphate (PRP) IgG antibody levels and bactericidal titers were determined by enzyme immunoassay and bactericidal assay at the Center for Vaccine Evaluation and Study, Medical Research Institute, Ewha Womans University. RESULTS: Prior to a booster in the second year of life, geometric mean antibody concentrations were 2.39 microgram/mL and the percent of subjects who had a anti-PRP antibody level > or =1 microgram/mL was 68.6%. After boosting, antibody concentration was 19.09 microgram/mL and the percent of subjects who had a anti- PRP antibody level > or =1 microgram/mL was 96.5%, which reflects previous immune priming. In subjects who had finished primary immunization only, the bactericidal titer was 3,946 and in subjects who had a booster, it was 11,205. Anti-PRP antibody level was correlated with serum bactericidal titer. CONCLUSION: Many children aged 12-23 month old still had protective antibodies after recommended primary immunization only. A booster dose seemed to induce good anamnestic antibody responses in Korean children.

Validation of enzyme immunoassay for the quantitative measurement of human IgG antibodies specific for Haemophilus influenzae Type b capsular polysaccharide / 소아과

PURPOSE: This study was conducted to validate enzyme immunoassay (EIA) for the quantitative measurement of human IgG antibodies specific for Haemophilus influenzae type b (Hib) capsular polysaccharide. METHOD: We evaluated specificity, repeatability, intermediate precision, accuracy, lower limit of quantification (LLOQ), and stability to validate standardized EIA for the quantitative measurement of human anti-polyribosylribitol phosphate (PRP) IgG antibodies. RESULTS: The results indicated that this EIA showed specificity to HbO-HA antigen and repeatability and intermediate precision were within acceptance criteria (repeatability: CV < or =15%, intermediate precision: CV < or =20%). The EIA-derived results from this laboratory were equivalent to those obtained by the standard radioactive antigen binding assay (RABA) for quantitation of anti-PRP antibodies in the 28 sera. Spiking recovery result was within acceptance criteria (100+/-20%). The precision and accuracy of samples in LLOQ were from -14.7 to -4.7% in nominal values, which were within acceptance criteria (precision: CV < or =25%, accuracy: +/-25%). Freeze-thaw stability and short term temperature stability were within +/-20% of acceptance criteria. CONCLUSIONS: The EIA which is performed at the Center for Vaccine Evaluation and Study Ewha Medical Research Institute, is an appropriate serologic assay which can be used for quantitation of anti-PRP IgG antibodies in human sera.

A Case of Tuberculous Mesenteric Lymphadenitis Clinically Presenting as Abdominal Mass

No abstract available.

Evaluation of Fever Reducing Methods in Children

The efficacy of acetaminophen, sponging plus acetaminophen, and sponging alone as method of lowering body temperature was compared in 108 children aged 8 weeks to 5 years who presented with an axillary temperature of 38.5degrees C or greater during the period from January 1993 to April 1993. The following results were obtained. 1) The male to female ratio was 2.5:1 and clinical diagnosis in the order of frequency were upper respiratory infection, gastroenteritis, pneumonia, urinary tract infection, cellulitis, chickenpox and hand-foot-mouth disease. 2) At thirty minutes after treatment, there was no significant difference on the decrement of temperature among the three groups. 3) At sixty minutes, the temperature decrement was the greatest in the group of sponging plus acetaminophen and that was statistically significant (P<0.01). But there was no significant difference between the group of acetaminophen and that of sponging.

A study on comparison of referral content and outcome in out patient department of family medicine according grade

No abstract available.