Four Cases of Congenital Depressed Skull Fractures in Neonates

Depressed skull fractures in newborn babies mainly result from birth injury and rarely occurr in intrauterine life without any definable etiology. We present 4 cases of congenital intrauterine depressed skull fractures which were discovered at birth in neonates. Three babies (case 1, 2, 3) had round shallow depressions without adjacent soft tissue injury except the last one (case 4), showing sharp angulation in the center of the depression. They had neither birth trauma nor forceps applications and they were healthy without neurologic symptoms. We performed nonsurgical reduction using vacuum extractor in all cases. Three cases were reduced successfully, but the last one failed due to sharp angulation in the center of the depression. It was reduced successfully by surgical elevation using a Freer elevator. Reduction should be performed in congenital depressed skull fractures without neurologic symptoms, because brain compression by depressed fracture results in brain injury or epileptic focus. Nonsurgical reduction should be prior to surgical reduction because of its technical feasability, safety and good results, but surgical reduction should be attempted in the case of sharp angulation in the center of the depression.

A Case of Hinman Syndrome Successfully Treated by Non-Surgical Measures

Hinman syndrome is a condition caused by an incoordination between the detrusor and external urethral sphincter during bladder contraction. Manifestations include day-and-night wetting, residual urine, infected urine, vesicoureteral reflux, christmas-tree shaped bladder-wall change, and upper tract damage without neurologic lesion or anatomical obstruction. Recently, this incoordination was postulated to be due to over-compensation of the external sphincter which compensates the uninhibitory detrusor contraction and pathological persistence of this "detrusor-sphincter dyssynergia" habit after brain cortical maturation. Accordingly, this syndrome is an acquired psychosocial-behavioral problem, reversible by bladder training and does not necessitate surgical intervention. We report a case of nonneurogenic neurogenic bladder who was successfully treated by biofeedback training, anticholinergic drugs and intermittent catheterization.

Expression of Several Cell Cycle Regulatory Genes in Cultured AT-1 Cardiomyocytes after Formation of Synchronously Beating Sheets

BACKGROUND AND OBJECTIVE: AT-1 cells have been derived from the left atrial tissue in which the ANF promoter targeted SV40 large T antigen expression. When cultured, clusters of spontaneously contracting cells were observed after 4-5 days and contiguous sheets of synchronously beating cardiomyocytes were formed after 10 days. In this study, expression of several cell cycle regulatory genes were monitored through Northern blot analyses in AT-1 cells during beating and after formation of beating sheets (BS). MATERIALS AND METHOD: AT-1 RNAs were obtained in 3 days after plating, during beating and after formation of BS, and used for Northern blot analyses. RESULTS: alpha-Cardiac myosin heavy chain expression was prominent in beating cells, as would be expected for this contractile protein isoform but ANF was decreased after beating. Gax was not expressed in cultured AT-1 cells but in AT-1 tumor and murine heart. p53 and p21 were decreased after beating which indicate transcription level of p53 and p21 correlated well in AT-1 cells. In contrast, pRB and p107 were increased after beating but p68 (2.4 kb) which arose by alternative splicing of p107 and lacks the pocket domain B was decreased in beating cells. pTCS2, murine tuberous sclerosis gene, represented similar levels during beating but a little was decreased after formation of BS. mRAD50, the murine homologue of yeast DNA recombinational repair gene RAD50, was increased in beating cells, a similar pattern to p107 and pRB. But the p50 arose by alternative splicing of mRAD50 and has 3' half of mRAD50 had unexpectedly appeared and maintained after beating. CONCLUSION: The expression of cell cycle regulatory genes after beating and formation of BS in AT-1 cells showed gene-specific pattern and the p50 which has homology to the mRAD50 may participate in differentiation of cardiomyocytes.

A Clinical Study on Factors affecting Spontaneous Resolution of Vesicoureteral Reflux in Children

We report a case of 53-year-old man with plasmacytoid transitional cell carcinoma of the urinary bladder, which may be confused with plasmacytoma. The patient initially presented with gross hematuria and dysuria for two months. Cystoscopy and radiologic studies revealed multiple intraluminal protruding masses on the urinary bladder invading perivesical fat tissue. After urinary cytologic examination and cystoscopic biopsy, radical cystectomy and pelvic lymph node dissections were done. Urine cytology showed single cells and poorly cohesive cells with round eccentric nuclei, bi-or multi-nucleation, indistinct nucleoli, coarse chromatin, and abundant basophilic cytoplasm within relatively clear background. The cytologic findings of tumor cells were similar to the plasma cells seen in plasmacytoma. The tumor of the bladder was composed of discohesive, individual cancer cells with diffuse pattern that simulated lymphoma or plasmacytoma. Immunohistochemical and electron microscopic studies clearly established the epithelial nature of the neoplasm. Recognition of this plasmacytoid type of transitional cell carcinoma of the urinary bladder can avoid the misdiagnosis.

Trend of Tuberculous Meningitis since 1970

PURPOSE: The incidence of tuberculous meningitis has reportedly decreased from 4.2% in 1970 to 1.8% in 1990 in Korea; however, tuberculous meningitis, which spreads hematogenously, claiming majority of mortality in childhood tuberculosis, still poses serious problems. This study was performed to evaluate the recent trend of tuberculous meningitis. METHODS: We compared with three groups of tuberculous meningitis, two were our previous reports on tuberculous meningitis, 106 cases1) from 1971 to 1979 were assigned as group I, 60 cases2) from 1982 to 1988 as group II and we reviewed medical record of 16 cases from 1989 to 1994 as group III. RESULTS: 1) The incidence of tuberculous meningitis among the total admitted patients in groups I, II, and III were 0.92, 0.27, and 0.06%, decreasing with a slope of -0.063% per year, and a correlation coefficient of -0.892. 2) The age proportion among children under age 1 year were 17.9, 8.3, and 6.3%, espectively for three groups and those over age 9-10 years were 11.3, 13.4, and 43.8%, indicating that proportion of under age 1 year declined, whereas it increased in older aged children. 3) The overall male to female ratio was 1.43 : 1, and peak seasonal incidence was not noted. 4) There was no differences in tuberculous family history with 41.5% in group I, and 43.8% in group III; BCG vaccination rate was increased significantly from 16.0% in group I up to 68.6% in group III(p<0.001); and the positive tuberculin skin test reactivity significantly increased from 29.6% in group I to 68.8% in group III(p<0.01). 5) On chest X-ray, the rate of finding tuberculous lesion did not significantly change among 3 groups with 69.8, 58.3, and 87.5%, while the rate of associated miliary tuberculosis was significantly reduced with 36.8, 28.3, and 0%(p<0.05). 6) The cure rate was 65.1, 68.4, and 87.5%, respectively and the cure rate of clinical stage 3 improved from 36.1% in group I to 66.7% in group III, but they showed no significant difference between groups(p<0.05). The mortality rate was 5.7, 14.9, and 12.5%, respectively and there was no significant difference between groups(p<0.05). 7) Hospital days under 14 days were 67.9, 23.3, and 6.3%, respectively; those over 21 days were 3.8, 45.0, and 68.8%, respectively, indicating the hospital days became prolonged(p<0.001). 8) Brain CT was performed in group III(13/16), with abnormal findings found in 84.6%. The abnormal findings were hydrocephalus in 5 cases(26.3%, ventriculoperitoneal shunt was done in 3 cases); and basal cisternal enhancement, and infarction 3 cases each. Complication rate was not improved with 35.0% in group I and 31.2% in group III. CONCLUSIONS: During 25 years, the incidence of tuberculous meningitis significantly decreased with the increased BCG vaccination rate; and the age of the affected children tended to increase. It is noted, however, that the mortality rate and neurologic complication of the affected children were not substantially improved, stressing early diagnosis and vigorous treatment on tuberculosis in children.

Changes in Maternal Age and the Incidence of Down Syndrome

PURPOSE: The incidence of Down syndrome, the most common chromosoaml anomaly, increases with the advanced maternal age. Recently, however, the incidence of Down symdrome was reported to have decreased with wide acceptance of prenatal diagnosis and planned parenthood, prompting us to re-evaluate the incidence of Down syndrome in relation to changes in maternal age. METHODS: Subjected to study were 296 Down cases: 26 newborn Down's among the 58,479 deliveries undergone in our hospital (KCH) during the period over 2 decades from April 1974 through December 1994; and 270 cases, whose maternal age at delivery could be traced with certainty, among 366 Down cases confirmed by genetic counseling. The observation period was divided into three: Period I, before 1979 (n=66); Period II, from 1980 to 1989 (n=127); and Period III, after 1990 (n=103). RESULTS: 1) The change in maternal age at delivery Of total 58,479 deliveries, 0.5% were born to mothers younger than 20 years, 21.3% were aged 20-25 years; 57.7% (33,722) were aged 26-30 years; 16.9% fell between 30-35 years; and 3.6% were above 35 years. Deliveries of old mothers (>35 ys) were 4.9% in Period I, which significantly decreased to 2.8% in Period II, increased again to 4.1% in Period III. 2) Changes in Down incidence among those delivered in KCH Overall Down incidence among those delivered in KCH was 0.44/1000 (26/58,479); however, it was 0.93/1000 in Period I, 0.16 in II, significantly lower; and 0.59/1000 in Period III. Of the 26 Downs born in KCH 18 were born to mothers younger than 35 years (0.03%), whereas 8 were born to mothers older than 35 years (0.8%). The Down incidence among mothers younger than 35 years did not significantly differ among the periods, while for the mothers aged over 35 years it decreased from 1.0% (6/576) in Period I to 0% (0/825) in Period II, and back to 0.3% (2/698) in Period III, indicating that Down incidence among old mothers significantly decreased recently, compared with the early period. 3) Changes in maternal age and Down incidence among those confirmed by genetic counseling. Of those 270 Down cases, 226 were born to mothers younger than 35 years, whereas 44 were delivered by old mothers aged above 36 years. Old mothers had Down babies in 23.6% (13/55) in Period I, but it significantly decreased to 11.5% (14/122) in Period II, but it recovered to 18.2% (17/93) in Period III. 4) Relationship between karyotype pattern and maternal age Of total 296 Down cases 260 (87.8%) had typical pattern of 21-trisomy, 32 (10.8%) translocation, 4 (1.4%) mosaicism. Those with typical trisomy had mean age (+/-S.D.) of 30.3 (+/-6.0) year and those with mosaicism 30.8 (+/-6.2) year, whereas those with translocation were significantly younger with the mean age of 26.6 (+/-2.5) year. CONCLUSIONS: During the last 2 decades, the deliveries by old mothers tended to decrease, and also the overall incidence of Down syndrome has significantly decreased, especially among those born to mothers older than 35 years. Recently, however, maternal age tends to increase for various reasons, necessitating due emphasis on prenatal diagnosis.

Clinical Evaluation of Unmarried Maternal Neonates Admitted to NICU

PURPOSE: This study was done to see whether neonates born to unmarried mothers have higher rates of prematurity, low birth weight, perinatal morbidity and mortality than normal married group. METHODS: 88 neonates of unmarried mothers who were admitted in our NICU during the 5-year period from January 1987 through December 1991 were evaluated, and as the control group served 276 neonates of married mothers in 12 randomly selected weeks extended over the year during the same period. In statistical analyses, all data were analyzed by x2 test, Student t-test, and regression equation. RESULTS: 1) Unmarried mothers were 19.9+/-2.5(SD) year-old, with the majority(64.8%) falling into to age group between 16 and 20 years, whereas the control group was significantly older with 28.8+/-3.9 years. 2) Sex ratio was 1.38 : 1, with male prepondering, mean gestational age 35.5+/-3.7 weeks and mean birth weight 2,240+/-640g, in the unmarried group, differing significantly from the control group with 38.5+/-37 weeks and 2,910+/-750g. 3) Incidences of prematurity and low birth weight (LBW) were 70.5% and 75.0%, and total mortality was 28.4%. These values were significantly higher than in the control group, with 22.5%, 32.2%, 7.2%, respectively, and prematurity and LBW rate were also significantly higher in both groups of the same maternal age. Birth weight of unmarried group was significantly lower than control group in the same gestational age. Gestational age, birth weight, mortality rate were not significantly correlated to maternal age in both unmarried and control groups. 4) For the neonates of unmarried mothers, the majority was delivered either by midwife or in local obstetric clinics, and most of them(57.9%) were delivered by induction. 5) Neonatal diseases were jaundice, respiratory distress syndrome(RDS) and infection in the decreasing order, and incidence of RDS was significantly higher than in control group. But the death rate of RDS only tended to be higher in the unmarried-group. CONCLUSIONS: The neonates born to unmarried mothers have significantly higher rates of prematurity, LBW and mortality, and lower birth weight than the control group in the same gestational age. For neonatal diseases, incidence of RDS was significantly higher, and its mortality was significantly higher in the unmarried-group. Awareness on the seriousness of the problems leading to preventive measures against juvenile and unmarried child births, along with improved managements of babies born to unmarried mothers are urgently advocated.