Hypersensitivity reactions to ibuprofen and acetaminophen: A report of case with literature review

The higher the use of nonsteroidal anti-inflammatory drugs (NSAIDs), the more reports of adverse drug reactions, especially in children than in adults. As patients with fever take several NSAIDs alternatively, suspected symptoms allergic to drugs with different chemical structures are also experienced in the clinical field. This is because it appears not only through immunological mechanisms but also through cross-intolerant reactions. Therefore, when hypersensitivity to one or more NSAIDs is present, it is important to distinguish between the 2 mechanisms for future treatment planning. Although it is difficult to distinguish between the 2 mechanisms by clinical history, drug provocation test with aspirin is helpful in diagnosis. A 4-year-old patient who had urticaria/angioedema and shortness of breath after taking ibuprofen and acetaminophen visited Kangwon National University Hospital for a treatment plan using antipyretics and/or analgegics forward. We propose a diagnosis and treatment protocol for such patients with a brief literature review.

Anaphylaxis-related interventional demand and the response status of pediatric and youth educational institutions in Gangwon-do Province, South Korea: A school nurse and childcare teacher survey

Purpose@#Anaphylaxis may be life-threatening, and thus requires early recognition and a rapid response. We investigated current demands imposed by anaphylaxis and the responses of pediatric and youth educational institutions. We surveyed school nurses and childcare teachers in Gangwon-do Province, South Korea. @*Methods@#The online survey featured 2 questionnaires: one exploring demands imposed by anaphylaxis and the current response status and the other evaluating awareness of anaphylaxis among school nurses and childcare teachers. @*Results@#A total of 105 school nurses and 263 childcare teachers responded, of whom 16.2% and 1.9% reported that they had encountered anaphylaxis at work, and 6.7% and 11.0% had epinephrine auto-injectors (EAIs) available, respectively. Furthermore, 7.6% of school nurses and 3.0% of childcare teachers had been requested by parents to obtain institutional EAIs. Screening for anaphylaxis at the beginning of each school year was performed in 81.9% of schools and 41.1% of childcare institutions, and 55.2% of schools and 44.5% of childcare institutions had formulated action plans for anaphylaxis. Anaphylaxis education had been received by 72.4% of school nurses and 38.8% of childcare teachers. However, anaphylaxis awareness and coping skills seemed to be lacking in most participants. @*Conclusion@#Given the nontrivial numbers of pediatric patients with anaphylaxis and thus the demand for assistance, the lack of institutional prevention and management systems (screening, action plans, and coping skills) is of concern. In addition to increasing teacher awareness, institutional changes are required.

Effects of Maternal Diet during Pregnancy or Lactation on the Development or Prevention of Allergic Diseases in Offspring

The increasing prevalence of allergic diseases in the past decades has been caused by environmental rather than genetic factors. Recent research has focused on the relationship between the mother’s environmental exposure, especially during pregnancy, and allergic outcomes in the offspring. Intervention studies to prevent allergic diseases have also been conducted. Environmental factors, such as diet induce changes in the mother's intestinal flora, and the signals generated have a permanent effect on the fetal immune development through an epigenetic mechanism, which may be involved in disease development. This review outlines whether dietary patterns in mothers are related to allergic diseases, and it summarizes whether supplementation with micronutrients, such as omega-3 unsaturated fatty acids, vitamin D, and folic acid can prevent allergic diseases. Studies have found that a westernized diet is associated with an increase in the prevalence of allergic diseases; however, intervention studies conducted with micronutrients or probiotics do not provide clear results regarding its preventive effect. A mother’s diet during pregnancy or lactation may affect the health of the child. Well-designed intervention studies are warranted to attempt to prevent allergic diseases. Consequently, good dietary patterns based on high-quality evidence are recommended for pregnant and lactating mothers.

Awareness of anaphylaxis among community and emergency responders in Korea

Purpose@#Anaphylaxis is life-threatening, so early recognition and proper response are critical. This study evaluated the awareness of anaphylaxis in Korean community including teachers, 119 rescue team, and doctors in public service. @*Methods@#A questionnaire of anonymously structured 9 items about anaphylaxis was administered to the teachers working in kindergartens or elementary schools, 119 rescue team, and public health physicians in Gangwon province in 2017. Additional questionnaire about knowledge on anaphylaxis management was administered to the physicians. @*Results@#A total of 415 people participated in the survey. About 4% of child care and health teachers experienced anaphylaxis within 1 year, but the overall awareness of anaphylaxis was very low, regardless of the educational level of anaphylaxis. 119 rescue teams experienced more anaphylactic patients, but they lacked knowledge of epinephrine administration and epinephrine autoinjector (EAI), independent of the educational level of anaphylaxis. Public health physicians had good knowledge of early treatment for anaphylaxis, but there was a lack of knowledge for epinephrine injection sites, observation plan, and EAI. @*Conclusion@#The awareness of anaphylaxis among community and emergency responders seems likely to be inadequate. Systematic and continuous education by anaphylaxis specialists is necessary for community health care providers.

Asthma and obesity: Is asthma a risk factor for obesity?

Many studies have shown that asthma and obesity are linked and affect each other. Although obesity is an important risk factor for asthma, it is controversial whether asthma is a risk factor for obesity vice versa. Recent United States and European cohort studies have published papers reporting that pediatric asthma is a risk factor for obesity in school-aged children or adolescents. Previous studies have shown inconsistent results, suggesting that the 2 diseases are highly complex and that the relationships between them are strong. In order to understand the relationships between the 2 diseases, it is necessary to approach them from a new point of view such as energy metabolism relevance or autonomic nervous system control.

A Delphi study for the application of Korean Triage and Acuity Scale to children

OBJECTIVE: We investigated the opinions of experts to identify problems and prepare an improvement plan when applying the Korean Triage and Acuity Scale (KTAS) to pediatric patients in the emergency department. METHODS: The experts comprised 15 researchers at a pediatric emergency center designated by the Ministry of Health and Welfare and research team members of the Korean Society of Pediatric Emergency Medicine. The first survey was an open-ended question about the problems, application results, and remedies of applying KTAS to children through e-mail. The problems were categorized by topic, and degree of agreement was presented using a 9-point Likert scale. RESULTS: In the first survey, 67% of experts participated and 18 problems were identified. In the second survey, 73% of experts participated and eight problems were identified in four categories, validity, reliability, feasibility and other opinions. All experts pointed out that resources were not considered during pediatric triage in the KTAS. Ninety-one percent of experts said that peak expiratory flow rate measurement and Glasgow Coma Scale evaluation were unlikely to be feasible. Moreover, 91% experts were concerned that the triage level could be distorted if KTAS was interlocked with medical costs. Eighty-two percent of the respondents pointed to the high triage result of febrile children and the difference in pain score between the evaluators, etc. CONCLUSION: Based on the problems pointed out by experts and the reality of Korea's emergency departments, it is necessary to consider revision of KTAS for children.

Drug eruption by antihistamine mistaken for chronic urticaria in a child / 소아과

Although rare, antihistamines can cause adverse effects, including drug-induced eruptions or anaphylaxis. A 4-year-old child visited the pediatric department of a hospital for skin eruptions after administration of antihistamines, (e.g., ucerax [hydroxyzine] or leptizine [levocetirizine]), for cholinergic rashes; he did not have pruritus. Skin prick, intradermal, and drug provocation tests were performed to determine the relationship between the antihistamines and eruptions. Levocetirizine induced wheals in the skin prick test and a rash in the oral drug provocation test. In contrast, ketotifen induced no reaction in the skin prick test but showed a positive reaction in the oral provocation test. Our case report highlights that children can experience the same types of adverse reactions as seen in adults, and cross-reactivity between various antihistamines can occur.

KAAACI Evidence-Based Clinical Practice Guidelines for Chronic Cough in Adults and Children in Korea

Chronic cough is common in the community and causes significant morbidity. Several factors may underlie this problem, but comorbid conditions located at sensory nerve endings that regulate the cough reflex, including rhinitis, rhinosinusitis, asthma, eosinophilic bronchitis, and gastroesophageal reflux disease, are considered important. However, chronic cough is frequently non-specific and accompanied by not easily identifiable causes during the initial evaluation. Therefore, there are unmet needs for developing empirical treatment and practical diagnostic approaches that can be applied in primary clinics. Meanwhile, in referral clinics, a considerable proportion of adult patients with chronic cough are unexplained or refractory to conventional treatment. The present clinical practice guidelines aim to address major clinical questions regarding empirical treatment, practical diagnostic tools for non-specific chronic cough, and available therapeutic options for chronic wet cough in children and unexplained chronic cough in adults in Korea.

Asthma Severity and the Controller Prescription in Children at 12 Tertiary Hospitals

PURPOSE: Guidelines need to be tailored to where they are applied. We aimed to describe the distinctive asthma severity profile and the pattern of controller prescription in Korean children. METHODS: Twelve pediatric allergists from tertiary medical centers reviewed medical records of all asthmatic children who visited their clinics between September 1 and November 30 of 2013. Controller prescriptions were re-classified into 4 categories, then the prevalence of each asthma severity category and the controller prescription patterns according to asthma severity assessed by a Western (Global Initiative for Asthma, GINA) and an Asia-Pacific (Japanese Pediatric GuideLine, JPGL) guideline were evaluated. RESULTS: A total of 840 cases were reviewed. Both GINA and JPGL revealed that 328 (39.0%) and 249 (29.6%) subjects had intermittent asthma whereas 24 (2.9%) and 21 (2.5%) subjects had severe persistent asthma, respectively. Although higher category controllers tended to be prescribed to those who had more severe asthma, there was much overlap in categories of prescribed controllers between groups with regard to asthma severities. Leukotriene receptor antagonists (LTRA) was the most frequently prescribed as a single controller (40%) or as an add-on medication (19%) in the group of asthmatic children <6 years. CONCLUSIONS: Korean children have distinctive patterns of asthma severity and management strategies with a lower prevalence of severe asthma and a preference toward LTRA rather than low dose inhaled corticosteroids (ICS) alone or add-on long-acting beta-agonist (LABA) in the group of <6 year-old asthmatics that has not been predicted in Western countries. Thus, strategies tailored to regional situations need to be developed and recommended.

Safety of ultrarush allergen subcutaneous immunotherapy in children with allergic disease

PURPOSE: Ultrarush immunotherapy (ultra-RIT) is more convenient and higher compliant than conventional immunotherapy, but it has rarely used in clinical practice due to severe systemic reactions. This study aimed to determine the safety of ultra-RIT in children and adolescents. METHODS: We investigated 19 patients who received ultra-RIT with the same schedule between January 2011 and May 2016. They were sensitized to house dust mites (HDMs) and/or pollen and had their symptoms associated with positive allergens. Over a 1-day hospitalization period, all patients received ultra-RIT subcutaneously 3 times, increasing at hourly intervals. Systemic reactions were classified according to the World Allergy Organization grade system. RESULTS: Systemic reactions occurred in 14 patients (73.7%). The mean time to adverse reactions after the last injection was 36 minutes, and the majority of systemic reactions were pruritus and urticaria. In addition, the injection of HDM alone or HDM plus pollen caused more than grade 2 systemic reactions in about 50% each of the patients. CONCLUSION: Since ultra-RIT caused a higher incidence of systemic reactions in children and adolescents, it should be carried out cautiously in the hospitalization rather than the office.

Effectiveness of double-dose oseltamivir for pediatric patients with severe 2009 pandemic influenza A H1N1

PURPOSE: We aimed to evaluate the use and safety of double dose oseltamivir for patients manifesting severe respiratory symptoms or showing no improvement of clinical symptoms after 72 hours' treatment with the usual oseltamivir dosage. METHODS: We analyzed the clinical features of 2009 influenza A H1N1 inpatients who had been admitted to a university hospital's Department of Pediatrics between August 2009 and January 2010. The Influenza A H1N1 diagnoses were confirmed by real-time reverse transcriptase polymerase chain reaction. RESULTS: The study participants numbered 157 (mean age, 5.0 years; male-to-female ratio, 1.1:1). Among them, twenty (mean age, 5.2 years) were administered double dose oseltamivir. This double dose group showed higher peak body temperatures and more abnormal radiologic results than the other, usual-dose group. The mean time duration between high fever and afebrile status after initiation of double-dose oseltamivir administration was 2.1 days, whereas that within the usual-dose group was 1.7 days. There were no adverse effects in the patients treated with double-dose oseltamivir. CONCLUSION: Double-dose oseltamivir was well tolerated in patients with severe 2009 influenza A H1N1 infection.

Can the multiple mini-interview predict academic achievement in medical school? / 한국의학교육

PURPOSE: The purpose of this study was to determine whether the multiple mini-interview (MMI) predicts academic achievement for subjects in a medical school curriculum. METHODS: Of 49 students who were admitted in 2008, 46 students finished the entire medical education curriculum within 4 years. We calculated the Pearson correlation coefficients between the total MMI score of the 46 graduates and their academic achievements in all subjects of the curriculum. RESULTS: The correlation coefficients between total MMI score and academic achievement in Medical Interview and History Taking, Problem-Based Learning, Doctoring I, and Clinical Practice of Surgery ranged from 0.4 to 0.7, indicating that they were moderately related. The values between total MMI score and achievement in Research Overview, Technical and Procedural Skills, Clinical Performance Examinations 1 and 3, Clinical Practice of Laboratory Medicine and Psychiatry, Neurology, and Orthopedics ranged from 0.2 to 0.4, which meant that they were weakly related. CONCLUSION: MMI score can predict medical student' academic achievement in subjects in the medical humanities and clinical practice.

A Case of Extreme Uterine Hypotrophy in Hypogonadotropic Hypogonadism with Partial GH Deficiency

Congenital hypogonadotropic hypogonadism is one of the causes of pubertal failure and primary amenorrhea, it is related to uterine hypotrophy. If the uterus is extremely hypotrophied, it is difficult to identify in imaging studies and can be misdiagnosed as a structural anomaly of internal genitalia. We report a case of extreme uterine hypotrophy in 18-year-old girl with primary amenorrhea that was finally diagnosed as hypogonadotrophic hypogonadism. The patient was initially suspected of Mullerian agenesis owing to the invisible uterus. After 4 months of treatment with estrogen, she showed significant growth of the uterus.

A Case of Extreme Uterine Hypotrophy in Hypogonadotropic Hypogonadism with Partial GH Deficiency

Congenital hypogonadotropic hypogonadism is one of the causes of pubertal failure and primary amenorrhea, it is related to uterine hypotrophy. If the uterus is extremely hypotrophied, it is difficult to identify in imaging studies and can be misdiagnosed as a structural anomaly of internal genitalia. We report a case of extreme uterine hypotrophy in 18-year-old girl with primary amenorrhea that was finally diagnosed as hypogonadotrophic hypogonadism. The patient was initially suspected of Mullerian agenesis owing to the invisible uterus. After 4 months of treatment with estrogen, she showed significant growth of the uterus.

Relationship between Silent Gastroesophageal Reflux and Food Sensitization in Infants and Young Children with Recurrent Wheezing

It is known that early childhood wheezing associated with sensitization to allergens, including food, has an increased risk of developing asthma later during school age. Gastroesophageal reflux (GER) is well known to be associated with asthma. The purpose of this study was to determine whether there is an association between silent GER and food sensitization in infants and young children with recurrent wheezing. Eighty-five infants or young children with recurrent wheezing, and no gastrointestinal symptoms, underwent 24 hr esophageal pH monitoring, as well as total serum IgE and specific IgE testing for eggs and milk. Among the 85 subjects, 48.2% had significant GER. There was no significant difference in the GER between atopic and non-atopic recurrent wheezers (41.7% and 50.8%, respectively). The sensitization rate to food (eggs or milk) was 12.2% and 20.5% in the GER and non-GER groups, respectively and showed no statistically significant difference between the two groups (P=0.34). In conclusion, about half of infants and young children with recurrent wheezing and no gastrointestinal symptoms have silent GER. The silent GER may not contribute to food sensitization in infants and young children with recurrent wheezing.

Experience of Implementation of Objective Structured Oral Examination for Ethical Competence Assessment / 한국의학교육

PURPOSE: We developed an objective structured oral examination (OSOE) case to assess the medical ethics of students. The aim of this study was to assess the reliability of OSOE with generalizability theory. METHODS: One 10-minute OSOE that contained key questions was developed. The evaluation sheet consisted of 4 domains: moral sensitivity, moral reasoning, decision making, and attitude. The total number of items was 13. The numbers of checklist items and global rating items were 11 and 2, respectively. Items and key questions were validated by 6 professionals. Standardization of the raters and the pilot study was performed before the OSOE. Fifty-four third-year medical students participated in the OSOE. The OSOE was duplicated, and 2 professors assessed 1 student independently. Each station lasted 8 minutes and was followed by a 2-minute interval,during which raters completed the checklist forms. We analyzed the reliability of the OSOE with the GENOVA program. RESULTS: The reliability (generalizability coefficient) was 0.945, and the interrater agreement was 0.867. The type of item, checklist or global rating, was the largest variance component. The reliability of the checklist alone was 0.668 and that of the global rating alone was 0.363. CONCLUSION: The OSOE is reliable and can be used to assess ethics. More research should focus on achieving validity.

Microarray analysis of gene expression in mice ovaries exposed to a 1.765 GHz microwave in utero / 대한산부인과학회지

OBJECTIVE: The aim of this study was to evaluate the effects on murine fetal ovarian gene expression of prenatal exposure to 1.765 GHz of microwave irradiation. METHODS:Ten pregnant ICR mice were divided into two groups. At 5th days after mating, dam mice were exposed to microwave (SAR: 0.38~1.71 W/kg) in the insulated cage for 8 hours each day. The remaining mice were treated in the same way. Neonatal ovaries were removed for study 7 days after delivery. Microarray analysis was performed using total RNA extracted from the removed ovaries. We investigated the differences in ovarian gene expression between the groups. SPSS 12.0 was used for statistical analysis. P<0.05 was considered to be statistically significant. RESULTS: The mean birth weight of the offspring in the irradiated group was significantly lower than that in the sham group (1.54+/-.22 g vs. 1.60+/-.21 g, P=0.012). The mean number of offspring per pregnancy in the irradiated group was significantly higher than in the sham group (13.60+/-.70 vs. 11.40+/-.17, P=0.009). We detected that in the irradiated ovaries, 14 genes were expressed at levels 2-fold higher than in the sham ovaries and 74 genes were expressed at levels 2-fold lower than in the sham ovaries. CONCLUSION: We found differences in fetal ovarian gene expression between the irradiated and sham groups. In the irradiated group, the Tnfaip8, TNFsf 12, Cfd, CCL 11, and Zfp74 genes were down-regulated and the Brd 3 gene was up-regulated.

Microarray analysis of gene expression in mice ovaries exposed to a 1.765 GHz microwave in utero / 대한산부인과학회지

OBJECTIVE: The aim of this study was to evaluate the effects on murine fetal ovarian gene expression of prenatal exposure to 1.765 GHz of microwave irradiation. METHODS:Ten pregnant ICR mice were divided into two groups. At 5th days after mating, dam mice were exposed to microwave (SAR: 0.38~1.71 W/kg) in the insulated cage for 8 hours each day. The remaining mice were treated in the same way. Neonatal ovaries were removed for study 7 days after delivery. Microarray analysis was performed using total RNA extracted from the removed ovaries. We investigated the differences in ovarian gene expression between the groups. SPSS 12.0 was used for statistical analysis. P<0.05 was considered to be statistically significant. RESULTS: The mean birth weight of the offspring in the irradiated group was significantly lower than that in the sham group (1.54+/-.22 g vs. 1.60+/-.21 g, P=0.012). The mean number of offspring per pregnancy in the irradiated group was significantly higher than in the sham group (13.60+/-.70 vs. 11.40+/-.17, P=0.009). We detected that in the irradiated ovaries, 14 genes were expressed at levels 2-fold higher than in the sham ovaries and 74 genes were expressed at levels 2-fold lower than in the sham ovaries. CONCLUSION: We found differences in fetal ovarian gene expression between the irradiated and sham groups. In the irradiated group, the Tnfaip8, TNFsf 12, Cfd, CCL 11, and Zfp74 genes were down-regulated and the Brd 3 gene was up-regulated.

Qualitative Assessment of Atopic Dermatitis-Related Websites / 소아알레르기및호흡기학회지

PURPOSE: This study aimed to investigate the current status of Internet websites dealing with atopic dermatitis and to evaluate the quality of their contents using an evaluation tool. METHODS: The words "atopic dermatitis" were searched with the four most commonly used Internet search engines between July and August of 2005. The searched websites included commercial medical instrument, oriental medicine, community (i.e., health portal), and medical institution sites. However, we assessed with the evaluation tool, the quality of the contents of only those sites that provided some description of atopic dermatitis-related symptoms, doctor consultations, and treatment and management. RESULTS: A total of 104 web sites were searched. Among them, commercial medical nstrument sites were the most common [53 sites (51%)], followed by oriental medicine sites [28 sites (26.9%)]. The quality of each of these 82 site's contents was analyzed. At the community sites, the purpose of the site's existence was clearer, but the reliability of information was relatively poor, as compared with the other site types. Among the various types of informations on atopic dermatitis, treatment and management, of the greatest interest to users, showed only a low-accuracy rating on the qualitative assessment. CONCLUSION: Commercial medical instrument sites predominated among the four types of site that providing atopic dermatitis-related information in internet. Having assessed the quality of contents of all of the four types of site, we showed that the accuracy of complementary alternative medical information was low. In this regard, it is deemed necessary to formulate a standard for finding and managing correct information.

Evaluation of Growth Information in Height on the Internet Web-sites / 대한소아내분비학회지

PURPOSE: The purpose of this study was to evaluate the problems and the quality of the Internet Web-sites for management of short stature in childhood and adolescent. METHODS: We evaluated 105 Web-sites identified from 5 search engines, Naver, Daum, Korean Yahoo, Nate and Empas, using the word of 'height and/or short stature'. According to Web-site author, total Web-sites were classified as academy & society, physician, commercials, portal site, oriental medicine, and unidentified. We accessed how well the Web-sites informed people about the diseases by of short stature. RESULTS: Of the 105 Web-sites, 98 were accessible. 45 Web-sites (46%) were operated by oriental medicine group. Difference in IS between oriental medicine group and non-oriental medicine groups was significant (P<0.001). CONCLUSION: A great portion of Web-sites on short stature was operating by oriental medicine group. Oriental medicine Web-sites had a tendency to be omitted essential information on short stature and occasionally even had unhealthy information. This investigation could have a adverse influence that internet navigators for short stature might miss a chance of managing in time and there were huge increasing medical expense. There was strongly demand for reliable national certification system to certify to exellent quality for medical and health Web-sites.