Descending Aorta Blood Flow Characteristics before the Development of Necrotizing Enterocolitis in Preterm Neonates

PURPOSE: To investigate the hemodynamic risk factors for necrotizing enterocolitis (NEC), we analyzed the characteristics of descending aorta (DA) blood flow in preterm neonates, who later developed NEC. METHODS: This was an observational case-control study on 53 preterm neonates at a tertiary referral center. Clinical and echocardiographic data were collected from 23 preterm neonates with NEC (NEC group), and compared with those of 30 preterm neonates without NEC (control group). Echocardiography was done at a median (interquartile range) of 5 (3–9) days after birth and 2 (1–2.5) days before the diagnosis of NEC. RESULTS: Basic clinical characteristics including gestational age, birth weight, Apgar score, breast feeding status, use of umbilical catheters, and mode of invasive ventilator care were similar between the groups. Compared with the control group, the lowest diastolic velocity of DA was significantly decreased, whereas the diastolic reverse flow and the ratio of diastolic reverse to systolic forward flows were significantly increased in the NEC group. In addition, the resistive index (RI) of DA was significantly increased in the NEC group and showed a positive association with the development of NEC. Multivariate logistic regression analysis showed that increasing RI of DA was an independent risk factor for the development of NEC (P=0.008). CONCLUSION: Significant changes in DA flow characteristics including decreased diastolic velocity and increased diastolic reverse flow along with increased peripheral vascular resistance were observed before the development of NEC in preterm neonates. These findings may help clinicians stratify in advance neonates at a risk of developing NEC and may help improve outcomes in these neonates.

The successful clinical outcomes of pregnant women with advanced chronic kidney disease

BACKGROUND: Successful pregnancy outcomes in patients with advanced chronic kidney disease (CKD) are increasingly common in Western countries. However, in Korea, the available literature addressing this clinical issue is scarce. METHODS: We reviewed 5 successful parturitions [1 patient with Stage 5 CKD and 4 with maintenance hemodialysis (HD)] at Seoul St. Mary's Hospital over 3 years and investigated changes in dialysis prescription, anemia management, and the incidence of maternal and neonatal complications. RESULTS: There were no maternal or neonatal deaths in this cohort. The mean age at the time of conception and delivery was 35.8 ± 3.7 and 36.2 ± 3.5 years, respectively. Dialysis patients received more frequent and intensified HD during pregnancy, 20.0 ± 5.7 h/wk of HD over 5 visits with the ultrafiltration dose maintained between 1 and 2 kg per session. All patients received erythropoietin-stimulating agents and iron replacement therapy during pregnancy. The mean hematocrit was 33.1 ± 1.9% before pregnancy and was well maintained during gestation (33.9 ± 3.8% at the first trimester, 29.2 ± 4.2% at the second trimester, and 33.6 ± 8.7% at delivery). The mean gestation period was 32.7 ± 4.7 weeks, with 60% of patients experiencing premature delivery. The primary maternal complication was pre-eclampsia; 3 women developed pre-eclampsia and underwent emergency cesarean sections. Most neonatal complications were related to preterm birth. CONCLUSION: Dialysis-related care and general clinical management improved the clinical outcome of pregnancy for patients with advanced CKD.

Usefulness of Abdominal Sonography in Accurate Diagnosis for Necrotizing Enterocolitis

PURPOSE: The purpose of this study was to examine the usefulness of abdominal sonography in the diagnosis of necrotizing enterocolitis (NEC). METHODS: We reviewed the medical records of 51 neonates who were diagnosed with NEC in the neonatal intensive care unit at Yeouido St. Mary's Hospital of the Catholic University in Korea between January 2008 and December 2012. The neonates underwent abdominal ultrasonography on the day of their diagnosis and on the third day after diagnosis. Simple abdominal radiography was performed on the same day as the sonography. The neonates were diagnosed with NEC in accordance with the abdominal sonographic findings. Abdominal radiography and sonography were used to assess the NEC stages in the neonates. RESULTS: On the day of NEC diagnosis by abdominal sonography, 50 neonates were diagnosed with stage II NEC and 1 was diagnosed with stage III NEC. However, simple radiography diagnosed 49 neonates with stage I NEC, 1 with stage II NEC, and 1 with stage III NEC. On the third day after NEC diagnosis by abdominal sonography, 48 neonates were diagnosed with stage II NEC and 3 were diagnosed with stage III NEC. On the other hand, simple radiography diagnosed 26 neonates with stage I NEC, 24 with stage II NEC, and 1 with stage III NEC. CONCLUSION: Abdominal sonography can be used as a tool for accurately diagnosing NEC and treating neonates showing ambiguous symptoms during the early stages of NEC.

Necrotizing Enterocolitis among Very-Low-Birth-Weight Infants in Korea

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency and remains a major cause of mortality for very-low-birth-weight infants (VLBWI) requiring surgery. To date, there have been no large-scale studies evaluating the incidence, associated clinical factors and outcomes of NEC for VLBWI in Korea. The 2,326 VLBWI of a total 2,386 Korean Neonatal Network (KNN) cohort born with a birth weight below 1,500 g between January 2013 to June 2014 were included in this analysis. The overall incidence of NEC (stage > or = 2) among VLBWI in Korea was 6.8%; 149 infants had NEC stage > or = 2 and 2,177 infants did not have NEC. Surgery was performed for 77 (53%) of the infants in the NEC group. NEC was related to lower gestational age (GA) and birth weight (P < 0.001). Multivariate logistic regression analysis demonstrated that NEC was consistently related to hypotension within one week after birth (OR 2.0, 95% CI 1.0-3.9). With respect to outcome, the NEC group had longer times to reach 100 mL/kg/day feeding (P < 0.001), longer TPN duration (P < 0.001) and hospitalization (P = 0.031) and higher PVL (P < 0.001) and mortality rate (P < 0.001). When the medical and surgical NEC groups were compared, GA was significantly lower and PDA was more found in the surgical NEC group. The overall incidence of NEC in Korea is similar to that of other multicenter studies. In addition to GA and birth weight, hypotension within a week of life is significantly related to NEC.

Risk Factors for Severity of Intraventricular Hemorrhage in Very Low Birth Weight Infants and Neurodevelopmental Outcomes / 대한주산의학회잡지

PURPOSE: The purpose of this study is to investigate the perinatal risk factors for severity of intraventricular hemorrhage (IVH) in very low birth weight infants (VLBWIs) and to study the following neurodevelopmental outcomes depending on the degree of IVH severity. METHODS: The retrospective study included 145 VLBWIs who were admitted at Seoul St. Mary's Hospital between May of 2009 and April of 2013. Prenatal, obstetric and postnatal risk factors for IVH were investigated. VLBWIs were divided into the group of IVH grade 1-2 and IVH grade 3-4. During this study period, 26 VLBWIs were died and 11 VLBWIs were lost to followed up, thereby 108 infants were included in the final analysis. They were regularly followed up and assessed for presence of major neurodevelopmental impairments including cognitive impairment, cerebral palsy, visual deficit, hearing deficit, and epilepsy. Among 108 infants, 23 (21.3%) patients had neurodevelopmental impairments. RESULTS: The lower gestational age and birth weight were significant prenatal risk factors for severe IVH. Lower Apgar score at 1 and 5 min, hypotension/shock, higher levels of partial pressure of carbon dioxide, presence of patent ductus arteriosus, pneumothorax, thrombocytopenia, necrotizing enterocolitis, and bronchopulmonary dysplasia were significant postnatal risk factors for severe IVH. After multiple logistic regression analysis, gestational age, birth weight, and hypotension/shock were independent risk factors for severe IVH. The incidence of major neurodevelopmental impairments were also significantly higher in VLBWIs who survived after severe IVH. CONCLUSION: In addition to preterm birth, minimizing hypotension/shock, the risk factor of severe IVH, is important to prevent major neurodevelopmental impairments in VLBWIs.

The Impact of Anticonvulsants on Neurologic Outcomes in Neonatal Seizures / 대한주산의학회잡지

PURPOSE: Although neonatal seizures can cause epilepsy, neurodevelopmental disability, and mortality with high frequency, the use of anti-epileptic drug is limited and the side effect of the drug is unidentified. Thus, authors investigated the prognosis of the neonatal seizures related with anti-epileptic drugs and electroencephalography. METHODS: Retrospective medical records of 37 infants with neonatal seizures under 44 weeks of gestational age who were hospitalized at neonatal intensive care unit in Seoul St. Mary' Hospital from January to June 2012 were analyzed. RESULT: The mean gestational age was 32.5+/-1.9 weeks and the mean birth weight was 2,010+/-82 g. Seizures occurred in 65% in infants within 7 days of birth and subtle seizures were most common type. Hypoxic ischemic encephalopathy was the most common cause of seizures and 62% showed abnormal electrographic findings. Among 37 of patients, seizures of 57% were able to be controlled by levetiracetam, but 19% were controlled by co-administration of more than three anti-epileptic drugs. After 6 months of treatment, epilepsy was diagnosed in 6% and developmental delay occurred in 19% among patients controlled by one anti-epileptic drug. Epilepsy and developmental delay occurred in 29% and 86%, respectively, among patients with more than three anti-epileptic drugs. In addition 86% of patients with normal electroencephalographic findings show normal development, but 3 patients with severe abnormalities showed abnormal development. CONCLUSION: Neurologic outcome was not good when the number of anti-epileptic drugs were added due to uncontrolled seizures, and the result of electroencephalography showed severe abnormalities.

Allergic Proctocolitis Resembling Ulcerative Colitis of Infancy in a 3-day Old Neonate

Allergic proctocolitis (AP) can be hard to differentiate and diagnose in neonates who manifested watery diarrhea and failure to thrive. The initial symptoms are not specific and colonoscopic findings share similar ulcerated and erythematous lesions as in ulcerative colitis of infancy and infectious colitis. A 3-day-old infant was admitted to the hospital due to loose, blood-tinged stools. An initial workup, including abdominal ultrasound and hepatobiliary scan, was performed, and all results were negative. The patient subsequently required readmission due to pervasive watery diarrhea, severe weight loss, and lethargy. After further investigation, he was eventually diagnosed of allergic proctocolitis by rectosigmoidoscopy and biopsy. Treatment was started with a corticosteroid (prednisone 2 mg/kg/day) due to severe symptoms. After 7 days of steroid therapy, the stools slowly normalized, and the patient started to gain weight. He was discharged home and followed regularly at the outpatient clinic.

Follow-up of Full-term Neonatal Seizures: Prognostic Factors for Neurodevelopmental Sequelae

PURPOSE: The objectives of this study were to observe the major neurodevelopmental sequelae of the full-term neonatal seizures, and to identify the risk factors associated with the poor neurodevelopmental outcomes. METHODS: A retrospective review of the medical records of full-term newborns who had clinical and/or electrographic seizures in neonatal intensive care unit of St. Mary's Hospital between June 1994 to July 2007 was performed. To assess the risk factors associated with poor neurological outcome, various factors were analyzed with univariate analysis and multiple regression analysis (SAS for Windows version 9.2). RESULTS: The most common etiology of seizures in full-term infants was hypoxic ischemic encephalopathy (76.2%). The most common type of seizure was subtle (50.9%), followed by multifocal clonic (41.8%), and the seizure type had no significant correlation to the prognosis. Moderate to major EEG abnormalities were significantly related to poor clinical outcome. Additional factors related to neurodevelopmental outcome were Apgar score at five minute, evidence of HIE on brain MRI, Sarnat stages of HIE, number of anticonvulsant drugs used for seizure control and duration for normalization of EEG abnormalities. CONCLUSION: The risk factors observed in this study may be helpful to predict the neurological outcomes in full-term neonates with seizures.

Partial Seizures Manifesting as Apnea Only in Preterm Infant

PURPOSE: Extremely-low-birth-weight infants (ELBWIs), especially those or =26-GW (n=65) infants nursed in 60% humidity. RESULTS: Survival rate until discharge was 33%, 82%, 75%, and 89.3% in 22-GW, 23-GW, 24-GW, and > or =26-GW infants, respectively. Fluid intake and IWL was higher in 22-GW and 23-WG, but not different in 24-GW, than in > or =26-GW infants. At postnatal days (P) 3-5, the urine output was significantly lower in > or =26-GW infants than in the other age groups. Serum sodium level was significantly higher in 22-, 23-, and 24-GW (P1-2) than in > or =26-GW infants. Hypernatremia (>150 mEq/dl sodium) was more frequent in 22-GW (71%), 23-GW (41%), and 24-GW (21%) than in > or =26-GW infants (14%). CONCLUSION: High-humidity environments significantly decreased fluid intake and improved electrolyte imbalance in 24-GW, but not 22- and 23-GW, infants. Increased IWL in the latter might be related to more immature skin, and implicates the need for additional nurturing conditions.

Parental concerns about their premature infants' health after discharge from the neonatal intensive care unit: a questionnaire survey for anticipated guidance in a neonatal follow-up clinic / 소아과

PURPOSE: The aim of this study was to develop an appropriate nursing information guideline according to corrected age, after investigating parents' concerns about the growth, development, and diseases of their premature infants after discharge from the neonatal intensive care unit (NICU). METHODS: The parents of premature infants (birth weight, <2,500 g; gestational age, <37 weeks) who went to a neonatal follow-up clinic after NICU discharge at Seoul St. Mary's Hospital from January 2005 to December 2009, were asked with regard to their concerns about their infants through a questionnaire survey. The results of physical examinations, including body measurements and neurodevelopmental status at 4, 8, 12, and 18 months of corrected age, were retrospectively reviewed in 390 infants. RESULTS: The most common parental concerns were developmental delay, poor growth, and feeding and nutritional problems. Parental concerns about developmental delay, growth failure in improvement in body weight and length, and overweightness were high in specificity but very low in sensitivity. After NICU discharge, 30% of premature infants experienced infectious diseases before 18 months of corrected age, the most common of which was respiratory tract infection. CONCLUSION: For guiding of premature infants in outpatient day clinics after NICU discharge, it is necessary to identify the parents' highest concerns, to educate them about the possibilities of growth and neurodevelopmental disabilities in their infants and to provide them with handouts containing guidelines on the management of infectious diseases, especially respiratory infections.

Neonatal Seizures in Preterm Infants / 대한소아신경학회지

PURPOSE: Neonatal seizures are the most prominent feature of neonatal neurologic dysfunction, and the lifespan risk for seizures is highest in the neonatal period, especially in preterm infants. This study was aimed to find and analyze the risk factors and clinical profiles of seizures in preterm infants. METHODS: Sixteen cases of preterms with seizures were retrospectively reviewed between Mar. 2009 and Feb. 2012. RESULTS: The average gestational age was 30.3+/-4.1 weeks and 11 patients (68.7%) experienced seizures within 1 week after the birth. Eight cases (50%) had a perinatal asphyxia during the delivery and 7 cases (43.8%) had a history of perinatal maternal illness. Various types of seizures were observed of which subtle seizures were the most common (50%). Electroecephalographies were performed in 12 cases, which showed abnormal findings in 9 cases (75%). Neuroimaging studies were performed in 16 cases and showed abnormal findings in 10 cases (62.5%). Thirteen patients were discharged in the improved state and 3 patients expired. Eight cases had normal outcome, while 3 cases showed developmental delay. Prognosis was unknown in 2 cases due to follow up loss. CONCLUSION: Neonatal asphyxia is the most important risk factor. Furthermore, infants with a history of perinatal maternal illness appear to be at risk for neonatal seizures. EEG is a sensitive method for assessing seizure activity and prognosis. Monitoring high risk infants with asphyxia and a history of perinatal maternal illness, and early postnatal tracing with EEG is required to detect and manage high risk preterms.

Adverse Effects of Chloral Hydrate in Neonates: Frequency and Related Factors

PURPOSE: Chloral hydrate is a common drug frequently used for procedural sedation. But data on chloral hydrate use in the newborns are limited. This study examined the frequency of adverse effects of chloral hydrate and factors related to the adverse effects. We also examined if there were additional adverse effects when an additional sedative was used. METHODS: The medical records of 104 patients admitted to neonatal intensive care unit of Seoul St. Mary's Hospital from March 2010 to February 2011 who used chloral hydrate for procedural sedation were retrospectively reviewed. RESULTS: Adverse effects after administration of chloral hydrate were noted in 41.3% of the 104 patients. The adverse events included oxygen desaturation (18.8%), increase in apneic episodes (17.5%), increase in bradycardia (10%), and feeding intolerance (3.8%). Using oxygen at the time of chloral hydrate administration was independently associated with adverse effects (odds ratio [OR], 10.911; 95% confidence interval [CI], 2.082-57.178) and with the necessity for an additional sedative after administration of chloral hydrate (OR, 4.151; 95% CI, 1.455-11.840). Using one additional sedative agent after chloral hydrate showed no difference in adverse effects except feeding intolerance. CONCLUSION: Patients dependent on oxygen at the time of chloral hydrate administration may were found to be at higher risk for adverse effect of chloral hydrate and for an additional sedative. When an additional sedative is needed, it could be used with monitoring feeding intolerance after chloral hydrate administration.

Hematologic Characteristics of Intrauterine Growth Restricted Small for Gestational Age Infants

PURPOSE: Intrauterine growth retardation (IUGR) is the term used to designate a fetus that has not reached its growth potential. However it is difficult to make a distinction between infants who are constitutionally small and growth restricted small. In the present study, we focused on the clinical characteristics and the hematologic value in small for gestational age (SGA) infants and discussed how to distinguish intrauterine growth restricted infants from constitutionally small infants. METHODS: SGA infants that did not have any other risk factors for IUGR in the medical record except maternal hypertension (HTN) and diabetes mellitus (DM) and born at the Seoul St Mary's Hospital and Yeouido St Mary's Hospital from January 2007 to July 2010 were included. The frequency of IUGR is higher in the pregnancy with medical problem, and in preterm infants. Therefore, the data was categorized by maternal disease and gestational age. We assessed the clinical data and the hematologic value. RESULTS: The leukocyte count and the platelet count were lower in the SGA with maternal HTN group and the preterm SGA group. There was no difference in the clinical data and the prognosis resulted from maternal HTN and maternal DM. However, the hematologic difference was not found in the categorization of the preterm SGA group as maternal diasease. CONCLUSION: The results of this study showed that it is possible the low leukocyte count and the low platelet count are the characteristic hematologic features in growth restricted small for gestational age infants.

Clinico-epidemiologic Study of Nosocomial Rotaviral Gastroenteritis, 2001-2005 / 소아감염

PURPOSE: This study was performed to determine the clinical and epidemiologic characteristics of nosocomial rotavirus gastroenteritis. METHODS: We retrospectively analyzed 628 medical records of patients with rotavirus gastroenteritis between 2001 and 2005. The patients were divided into two groups (the community-acquired group [528 cases] and the nosocomial group [100 cases]. The epidemiologic and clinical indices between the groups were analysed. For clinical comparison, 100 age- matched cases were selected from the community-acquired group. RESULTS: The male-to-female ratio was similar (1.4:1 vs. 1.5:1), but the mean age was lower in the nosocomial group compared to the community-acquired group (21.9+/-15.5 months vs. 16.6+/-10.3 months, P20 mg/dL were more in the community-acquired group (16% vs. 4%, P=0.01). CONCLUSION: The clinical and epidemiologic charateristics of nosocomial rotavirus gastroenteritis were similar and correlated to those of the community-acquired gastroenteritis.

A Case of Abdominal Epilepsy Diagnosed by 24-hour Electroencephalogram Monitoring / 대한소아신경학회지

Abdominal epilepsy is an infrequent syndrome which occurrs with gastrointestinal complaints caused by a seizure activity. It is characterized by paroxysmal onset of abdominal pain without visceral disorders, but comes along with the alteration of awareness during the attack and abnormal electroencephalogram(EEG) findings. Like other epilepsies, this abdominal epilepsy is improved with anticonvulsant medication. We present a 14 year-old boy who had recurrent episodes of abdominal pain for 2 months, accompanied by hyperventilation and alteration of awareness. His interictal EEG findings were normal, but 24 hour EEG monitoring showed multifocal spikes and generalized epileptiform discharges when abdominal pain developed. After the medication with valproate, he became free of symptoms and signs.

The effects of a sealant resin on enamel demineralization in orthodontic bracket bonding / 대한치과교정학회지

The purpose of this study was to evaluate the effects of a sealant resin on enamel demineralization in orthodontic bracket bonding. The forty eight extracted sound bovine teeth were subdivided into four groups and treated with Phase II(R) (Reliance, Itasca, Ill) on the surface. Group 1 was not treated. Group 2 was acid etched with 37% phosphoric acid for 30 seconds. Group 3 was applied with sealant after acid etching. Group 4 was applied with resin paste after acid etching and sealant application. Each group was demineralized in artificial caries solution. Demineralized enamel depth was measured by confocal laser scanning microscopy. The results were as follows: the mean demineralized enamel depth was 47.4 micrometer (Group 1), 61.8 micrometer (Group 2), 13.9 micrometer (Group 3), 8.2 micrometer (Group 4); the demineralized enamel depth was increased in Group 2 than in Group 1 (p < 0.05); the demineralized enamel depth was reduced in Group 3 than in Group1 and Group 2 with statistically significant differences (p < 0.05); and demineralization in Group 4 was very little. The results of the present study indicate that sealant application is useful for reducing enamel demineralization in orthodontic bracket bonding.

The three dimensional finite element analysis of stress distribution in three treatment options of implant restoration for the posterior single tooth missing

Agar-alginate combined impression technique and dimensional change resulting from idophor disinfection / 대한치과보철학회지

STATEMENT OF PROBLEM: Because dental impression can be a cross-infection source, disinfection, such as immersion disinfection is nessecary. However, the disinfection process may change the volume of the impression cast. PURPOSE: The purpose of this study is to find out the effects on dimensional change of different storage times and methods, of agar-alginate impression when immersed in a 5% idophor disinfectant. MATERIAL AND METHODS: An agar-alginate impression was made from a mandible model and then was disinfected and stored according the experimental conditions and a stone model was produced. Measurements were taken between reference points on the original mandible model and they were compared to measurements taken between reference points on the stone model. The study was divided into 4 groups. In group 1, the impression was stored in a 100% humidor for 30 minutes, 1 hour, 2 hours, 3 hours, 4 hours, 6 hours, 12 hours and 24 hours and stone models were made at each time. In group 2, the impression was immersed in 5% idophor disinfectant and then stored in a 100% humidor for the same length of times as group 1, and stone models were made at each time. In group 3, the impression was stored in extend-A-pourR, a special storage solution for 30 minutes, 1 hour, 2 hours, 3 hours, 4 hours, 6 hours, 12 hours, 24 hours 3 days, and 7 days and stone models were made at each time. In group 4, the impression was immersed in 5% idophor disinfectant and then stored in stored in extend-A-pourR, a special storage solution for the same length of times as group 3, and stone models were made at each time. 5 impressions and stone models were made at each time to make a total of 180. The Student-t test (P < .05) was used to do a statistical analysis of the measurements of the mandible model and stone models. The repeated-measure 2-way analysis of variance (P < .05) was used to do a statistical analysis of the difference in the 4 groups. RESULTS: The percent liner dimensional change was from 0.25+/-0.03% (group 1, 30 minutes) to 0.34+/-0.06% (group 4, 7 days). No significant change was noticed between the 4 groups. CONCLUSION: According to the above study, in both methods, least dimensional change was recorded when the storage times were short and in both methods, immersion in 5% idophor disinfectant did not effect dimensional change in the agar-alginate impression.