Intermediate and Long-Term Results of Transcatheter Closure of Patent Foramen Ovale Using the Amplatzer Patent Foramen Ovale Occluder: One Case of Pulmonary Embolism Irrespective of Patent Foramen Ovale Closure

BACKGROUND AND OBJECTIVES: Patent foramen ovale (PFO) has been implicated in the pathogenesis of cryptogenic stroke or transient ischemic attack (TIA) due to paradoxical embolism, and in the pathogenesis of migraine. This paper reports the intermediate and long-term results of transcatheter closure of PFO associated with cerebrovascular accidents (CVAs), TIAs and migraine, using the Amplatzer PFO occluder. This paper also reports a case of pulmonary embolism which developed in one patient after PFO closure. SUBJECTS AND METHODS: From January 2003 to May 2010, 16 patients with PFO (seven males and nine females) with a history of at least one episode of cryptogenic stroke/TIA, CVA, or migraine and who underwent percutaneous transcatheter closure of PFO using the Amplatzer occluder. All the procedures were performed under general anesthesia and were assisted by transesophageal echocardiography. RESULTS: The device was implanted without any significant complications in all the patients, and the PFOs were effectively closed. At an average follow-up period of 54 months, the 15 patients with TIA/CVA had no recurrence of any thromboembolic event. The symptoms in one patient with migraine subsided after occlusion of the PFO. In this study, pulmonary embolism occurred five months after PFO closure in one patient, but the cause of pulmonary embolism was not identified. However, it is believed that the pulmonary embolism occurred without stroke recurrence because occlusion of the PFO was performed when the patient had a stroke event. CONCLUSION: It can be concluded that according to the intermediate and long-term follow-up results, transcatheter PFO closure is an effective and safe therapeutic modality in the prevention of thromboembolic events, especially in the patients with cryptogenic stroke/TIA, and PFO closure is helpful in the treatment of migraine. However, this study involved a small number of patients and also the follow-up period was not long enough. Hence, randomized, controlled trials are necessary to determine if this approach is preferable to medical therapy for the prevention of recurrent stroke or as primary treatment for patients with migraine headache.

Clinical Review of the of Seizures among Children

PURPOSE: The purpose of this study was to evaluate childhood seizures to provide appropriate medical services. METHODS: We retrospectively reviewed the medical records of 221 chidren under 18 years of age with seizures (excluding febrile convulsion), who were admitted to the pediatric department of Sacred Heart Hospital, Hallym University from 2007 to 2009. RESULTS: The male to female was 1.3:1 and the peak age was 6 years or less, accounting for 63%. The most common causes of seizures according to age were listed as follows; hypocalcemia (41%) and hypoxic ischemic encephalopathies (41%) in the neonatal period, benign convulsion with mild gastroenteritis (BCwMG, 47%) in preschool children (1month and 5 years), and unprovoked seizure (80%) more than 6 years. Electroencephalogram and neuroimaging abnormalities were found in the ratio from 20% and 14% respectively. CONCLUSION: Seizure is the most common neurologic disease in the childhood. The above results reveal that the causes of childhood seizures in the different age group are different. Therefore, the exact diagnosis of disease according to age is needed. We hope that further clinical studies on this topic will be performed.

Microbiological spectrum and antibiotic susceptibility pattern in more than 24-month-old children with urinary tract infection: A6-year retrospective, single center experience / 소아과

PURPOSE: To characterize the pathogens and their antibiotic susceptibilities in more than 24-month-old children with urinary tract infection (UTI) and to study the Escherichia coli antimicrobial susceptibility trend. METHODS: We retrospectively reviewed the record of more than 24-month-old children with UTI between January 2003 and December 2008. Positive results for 1 bacterial species with a colony count of > or =10(5) CFU/mL was considered statistically significant. We analyzed uropathogens and their antibiotic susceptibilities. To investigate E. coli antibiotic susceptibility trend, we compared 2 study periods (group A: 2003-2005 versus group B: 2006-2008) using the chi-square test for trend. RESULTS: In all, 63 bacterial isolates were identified in children with febrile UTI. The most common pathogen was E. coli (77.8%). There was no difference in the resistance patterns of uropathogens during the 2 study periods (P>0.05). Antibiotic susceptibility of the E. coli isolates to aztreonam, cefotetan, cefotaxime, ceftriaxone, cefepime, amikacin, and imipenem was >90% to trimethoprim/sulfamethoxazol, 49% and to ampicillin and ampicillin/sulbactam, 20-25%. Over the 2 study period, the E. coli susceptibilities to most antibiotics did not change: the susceptibility to cefuroxime increased from 74.1% to 95.5% (P=0.046) and that to ciprofloxacin increased from 59.3% to 86.4% (P=0.039). CONCLUSION: Empirical treatment with trimethoprim/sulfamethoxazole, ampicillin, and ampicillin/sulbactam alone appeared to be insufficient in childhood UTI because of the high resistance of E. coli and other gram-negative uropathogens. Antibiotics for empirical therapy should be selected based on the sensitivity and resistance pattern of uropathogens found in a particular region.

A Case of Infantile Alexander Disease

Alexander disease(AD) is a rare fatal demyelinating disorder, caused by the mutation of glial fibrillary acidic protein(GFAP) gene. It is characterized by progressive demyelination of central nervous system, and the accumulation of Rosenthal fibers within astrocytes. It is divided into three group: infantile, juvenile, and adult. The infantile type is most common, has onset during the first 2 years of life. It shows macrocephaly and psychomotor delay, spastic paraparesis, seizure, and feeding problems, and usually dies within the first decade. The severity of the pathological changes depend on the age of onset. Radiological study revealed white matter loss, usually with frontal predominance. It is diagnosed by DNA analysis. We present case of a 10-month-old male patient with AD. He had focal seizures, demyelination in the frontal lobe in MRI, and the presence of a K86E mutaion in the GFAP gene, involving the replacement of adenosine with guanine.

Child abuse, can we find child abuse?: Role of the pediatrician / 소아과

Child abuse is defined by a recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm; involved a child; and is carried out by a parent or caregiver. This report provides guidance in the clinical approach to the evaluation of suspected physical abuse in children, and role of pediatrician. The medical assessment is outlined with obtaining a medical history, physical examination, and diagnostic testing. A minor form of child abuse which only involves skin injury is most frequently seen by a pediatrician. This kind of child abuse can be followed by more severe forms of child abuse, which have high mortality rates and cause serious physical and mental sequelae to the survivor. Therefore, a pediatrician's role in an early detection and prevention of child abuse is very important.

Child abuse, can we find child abuse?: Role of the pediatrician / 소아과

Child abuse is defined by a recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm; involved a child; and is carried out by a parent or caregiver. This report provides guidance in the clinical approach to the evaluation of suspected physical abuse in children, and role of pediatrician. The medical assessment is outlined with obtaining a medical history, physical examination, and diagnostic testing. A minor form of child abuse which only involves skin injury is most frequently seen by a pediatrician. This kind of child abuse can be followed by more severe forms of child abuse, which have high mortality rates and cause serious physical and mental sequelae to the survivor. Therefore, a pediatrician's role in an early detection and prevention of child abuse is very important.

Clinical features of transient small bowel intussusception in children / 소아과

Purpose: We analyzed the clinical features, management and outcome of small bowel intussusception in children compared with ileocolic intussusception. Methods: We retrospectively reviewed the records of 210 children with documented intussusception, in whom intussusception was initially diagnosed by ultrasonography during the four-year period of 2002 to 2005. Results: A total of 191 children were diagnosed with ileocolic intussusception and 19 were diagnosed with small bowel intussusception. Children with small bowel intussusception were older than children with ileocolic intussusception (P<0.05). In comparison to patients with ileocolic intussusception the characteristic presenting symptoms-such as currant jelly stool and palpable mass-were rarely observed in patients with small bowel intussusception. In ileocolic intussusception, air reduction (92.2%), or surgical reduction (7.3%) was performed; however, in small bowel intussusception, spontaneous reduction (78.9%) was observed and no surgical reduction was required in our study. Conclusion: Conservative management with close observation and follow-up sonographic evaluation rather than an immediate operation is recommended for children with small bowel intussusception.

Two cases of central nervous system complications caused by Mycoplasma pneumoniae infection / 소아과

Mycoplasma pneumoniae (M. pneumoniae) infection causes a wide variety of clinical manifestations in children and young adults, the main one being pneumonia. M. pneumoniae is transmitted from person to person by infected respiratory droplets. Symptoms caused by M. pneumoniae infection can be divided into those involving the respiratory tract, and those caused by extrapulmonary disease. M. pneumoniae infections may cause central nervous system (CNS) complications-with encephalitis being the most frequent-and stroke being a rare complication. The pathogenesis of the CNS disease is unclear; possibilities include direct infection and an immune-mediated reaction. We present two cases of CNS complications subsequent to infection with M. pneumoniae; both cases had convincing evidence of preceding M. pneumoniae respiratory disease with no evidence of viable M. pneumoniae in the cerebrospinal fluid. We report cases of encephalitis and stroke following a recent M. pneumoniae infection.

Serum creatinine, blood urea nitrogen change in low birth weight infants during their first days of life / 대한주산의학회잡지

OBJECTIVE: To study the changes in serum creatinine and correlation between gestational age or birth weight and serum creatinine in low birth weight infants in the immediate postnatal period. METHODS: Medical records of all premature infants, who were admitted to the neonatal intensive care unit of Hallym University Hospital between January 2003 and December 2007, were reviewed. 162 infants met our inclusion criteria. Medical records were reviewed for : birth weight, gestational age, length, gender, APGAR scores, use of medications, blood urea nitrogen (BUN) and serum creatinine (Scr) during the first days of life. Premature infants were separated into three groups according to their birth weight: 500 to 999 g; 1,000 to 1,499 g; and 1,500 to 2,000 g. RESULTS: Scr was found to decrease postnatally, however there was a delay in the decrease of Scr in the subgroup of infants<1,000 g BW, Scr was also found to decrease with increasing birth weight at 1 week after birth (Pearson test, p=0.01). Serum BUN was found to decrease with increasing birth weight at 1 week after birth (Pearson test, p=0.00). CONCLUSION: In low birth weight infants Scr decrease during the first days of life. However, in infants smaller than 1,000 g birth weight there is a delay in the decrease of their Scr that extends beyond the first days of life. Our findings indicate progression of renal function is directly correlated to birth weight.

A Clinical Study of Child Abuse / 소아과

PURPOSE: To promote awareness and efforts by pediatricians to identity and prevent child abuse by investigation of characteristics of victim and types of injury caused by abuse. METHODS: A retrospective study was performed with 20 patients who had been diagnosed or suspected as child abuse at Hallym University Hospital from January 1999 to December 2005. The medical records, radiologic documents, and social worker's notes were reviewed to investigate age, sex, visiting time, form of abuse, perpetrator, risk factor, and type of injury. RESULTS: The mean age of the subjects was 2.8 years. Fourteen patients were between 0-1 years old, 2 patients between 1-6 years old, 3 patients between 7-12 years old, and 1 case over 13 years old. The ratio of male to female was 1:1. The majority of these patients (70%) visited via emergency department. Eight five percent of these patients reported with physical abuse, 5% psychological abuse, 5% sexual abuse, and 5% neglect respectively. The suspected perpetrator was the biological father in six cases, the biological mother in three cases, the stepmother in two cases, caregiver in one case, relatives in one case and "unknown" in six cases. Bruise and hematoma (80%) were the most common physical findings. Skull fractures were diagnosed in six cases, long bone fractures in two cases, hemoperitoneum in two cases, subdural hemorrhage in 10 cases, epidural hemorrhages in two cases, subarachnoidal hemorrhages in two cases, and retinal hemorrhages in five cases respectively. Seventeen cases required hospitalization and surgical operations performed were in nine cases. Four patients died and three patients had sequalae such as developmental delay and quadriplegia. CONCLUSION: Child abuse results in high mortality and morbidity in victims. Therefore early recognition and prevention is very important. Pediatricians should always suspect the possibilities of abuse in cases of fracture, intracranial hemorrhage, abdominal injury, or even any injury to the body. We recommend that the clinical investigation of suspicious children should include a full multidisciplinary social assessment, a skeletal survey and CT or MRI.

Percutaneous Nephrostomy Combined with Antifungal Agent Therapy for Both Hydronephrosis and Obstructive Uropathy in VLBW Infant

With increasing survival of smaller, more immunocompromised preterm infants, the incidence of invasive fungal infection is increasing among NICU patients, with highly associated morbidity and mortality. The most common site of end organ dissemination in premature infants with fungemia is the renal system. Renal fungal infection is followed by acute pyelonephritis and renal cortical abscess, and leads to obstructive nephropathy and renal failure. We recently experienced a case of VLBW infant who was dignosed as both hydronephrosis and obstructive uropathy due to Candida albicans that was treated intravenous amphotericin B combined with direct daily irrigation into the renal pelvis via percutaneous nephrostomy catheter.

A survey of infant sleep positions associated with sudden infant death syndrome / 소아과

PURPOSE: As the prone position is thought to be an important factor in sudden infant death syndrome(SIDS), this study was conducted to contribute to reducing SIDS by analyzing sleeping positions of infants. METHODS: A face-to-face questionnaire was carried out with a total of 170 parents with a baby aged less than 6 months. RESULTS: A total of 170 infants included 95 males(55.9 percent) and 75 females(44.1 percent); their average age was 2.8 months. 45.3 percent slept in a supine position; 34.7 percent in a side or supine position; 7.1 percent in a side position; 4.7 percent in a prone position; 4.1 percent in a non-specific position. Among those in a side position, 59.7 percent were in a supine position in the morning; 19.5 percent were in the side position; 13.4 percent were in a non-specific position; and 4.1 percent were in a prone position. To the question why they slept in a specific position, 34.9 percent answered their baby slept comfortably, and particularly, 42.9 percent in the prone position group answered so. In the supine position group, 21.6 percent answered they had no reason. Both in the prone position and side position groups, 21 percent each answered they were worried about the shape of their baby's head. In the side position group, 22 percent answered that they had a fear of choking due to vomiting. In all sleeping position groups, 8.2 percent and 7.4 percent answered it was because they had a fear of suffocation and they wanted to avoid SIDS, respectively. CONCLUSION: Many of the parents preferred unstable positions, e.g. the side position and the prone position, which could cause SIDS. Their decision on their baby's sleeping position was not based on exact medical knowledge, but on convenience in taking care of their baby. As it was found that only 6 percent of the subjects were advised from their pediatrist about their baby's sleeping position, moreover, it is necessary to carry out more studies and activities for preventing SIDS caused by improper sleeping positions and educating patents about recommended sleeping positions for their baby.

A Case of Neonatal Hydrometrocolpos Accompanying Urinary Tract Obstruction / 소아과

Neonatal hydrometrocolpos is the cystic dilatation of the vagina and uterus, which is caused by the combination of vaginal obstruction such as imperforate hymen, transverse vaginal septum, or vaginal atresia, and glandular secretion by maternal estrogenic stimulation. Although hydrometrocolpos is a rare congenital abnormality unlike pubertal hematocolpos, it is one of the relatively common abdominal masses in neonates. In typical cases the diagnosis may be determined easily by the combination of a pelvic mass, upper urinary tract dilatation and a bulging membrane in the vaginal introitus. The presense of a lower abdominal mass in a female infant should always arouse suspicion of hydrometrocolpos and lead to careful examination of the vagina. We report a case of neonatal hydrometrocolpos due to imperforate hymen which was initially presented as a large abdominal mass and a bulging membrane in the vaginal introitus. For 72 hrs, the abdominal mass increased rapidly, accompanied by urinary tract obstruction. It was relieved by a simple incision of the imperforate hymen and drainage of 300 cc of whitish mucoid vaginal fluid, and by Foley catheter drainage of 750 cc urine. No other anomaly was observed.

A Clinical Study of Sepsis with Thrombocytopenia in Premature Infants / 소아과

PURPOSE: This study was performed to characterize sepsis with thrombocytopenia in premature infants to determine if thrombocytopenia is a prognostic factor in sepsis in premature infants. METHODS: We retrospectively analyzed the medical records of sepsis in premature infants admitted to the neonatal intensive care unit(N=41) at the Hallym University Sacred Heart Hospital from January 1999 to December 2002. The incidence, risk factors, symptoms, hematologic and bacteriologic findings were analyzed during episodes of sepsis. RESULTS: Of the 41 cases, 29(72%) were associated with thrombocytopenia. The ratio of male to female was 1.2 : 1. The vast majority(98%) were late-onset sepsis. The risk factors of the thrombocytopenic group were low birth weight and low gestational age. Major symptoms were poor activity (72%), apnea/tachypnea(52%), but were not significantly different between two groups. In the thrombocytopenic group(N=29), low total WBC count and high CRP level were discovered(P=0.03, P<0.01). The mean platelet count was 70.17(x103/mm3) at diagnosis of sepsis, and a mean platelet nadir was 43.10(x103/mm3). The severe thrombocytopenia(below 50x103/mm3) in the thrombocytopenic group was discovered in 69% and the duration of thrombocytopenia was about eight days. The majority of pathogens were gram-negative bacteria and candida. The thrombocytopenic group showed a pro longed length of stay and a high mortality rate. According to comparisons between the survived and expired groups, low birth weight, low gestational age, neutropenia and thrombocytopenia were significantly correlated with mortality(P<0.05). CONCLUSION: The sepsis with thrombocytopenia in premature infants showed late-onset sepsis and high morbidity and mortality, although differences were not significant statistically. Especially, low birth weight and low gestational aged infants should be cautiously treated and monitored.

A Case of Krabbe Disease Confirmed by Identification of Mutations in the Galactocerbroside beta-galactosidase Gene (GALC)

Krabbe disease is an autosomal recessive disorder involving white matter caused by deficient activity of the lysosomal galactocerebrosidase (GALC). A typical infantile-onset patient shows developmental regression, spasticity, and seizure before 6 months of age, and dies within 2 years. Previously, one case was confirmed by an enzyme test in Korea. We herein report a 2 year-old girl who showed the characteristic clinical course and neuroimaging features of infantile-onset Krabbe disease. Genetic testing identified the compound heterozygote mutations in the GALC gene; NLWE212_215TP/302A.

A Clinical Study and Sonographic Findings of Neonatal Adrenal Hemorrhage / 소아과

PURPOSE: This study was performed to present out experience of neonatal adrenal hemorrhage (NAH) and to help diagnosis and management of NAH. METHODS: We conducted a retrospective study on 14 neonates diagnosed as NAH from January 1993 to August 2002 at Hallym Medical Center. Their clinical manifestations, risk factors, sonographic findings and progression of NAH were evaluated using medical records. RESULTS: There were 12 male cases and two female cases. All cases were full-term babies. In terms of method of delivery, there were 13 cases of vaginal delivery and one case of cesarean section. The most common symptom was jaundice(10 cases). Poor feeding, vomiting, anemia, scrotal swelling with bluish discoloration, abdominal distension and cyanosis were also noted. The risk factors included perinatal asphyxia(five cases), large baby(three cases), sepsis(one case) and birth trauma(one case). Twelve cases(85.7%) involved the right adrenal gland, one case(7.1%) the left side and one case(7.1%) bilateral. In abdominal sonography, hemorrhage was seen as an isoechoic mass with central anechoic portion(35.7%), a central hypoechoic mass with peripheral hyperechoic portion(28.6%), an anechoic cystic mass(28.6%) and a heterogeneous hyperechoic mass(7.1%). Only a conservative treatment was sufficient in all cases. In the 12 cases(85.7%) followed up, size of hemorrhage was reduced in repetitive sonography without any complications. CONCLUSION: The review of these patients emphasizes the subtle and diverse clinical presentation of adrenal hemorrhage in neonates and stresses the importance of repetitive abdominal sonography in establishing the diagnosis.

A Clinical and Radiologic Study of Acute Focal Bacterial Nephritis in Children

PURPOSE: To raise awareness of the clinical importance of, and the need for proper management of acute focal bacterial nephritis(AFBN), we analyzed 22 AFBN patients and 22 other upper urinary tract infection patients by use of comparative studies. METHODS: From January 2000 to May 2002, 22 AFBN patients aged from 1 month to 12 months were selected. As a control group, 22 UTI patients with no radiologic abnormalities were selected and matched by age and sex. RESULTS: The incidence of AFBN was more common in boys than in girls. Since both groups had similar symptoms, it was difficult to diagnose AFBN by clinical presentations alone. ESR and CRP were significantly higher in AFBN patients. The most common causative organism was E. coli in both groups. On the sonographic findings, the most lesions were seen on the upper lobe of the kidney; more frequently, on left kidney. The lesions showed globular or wedge-shaped increased echogenecity. 99mTc-DMSA scan showed the complete coincidence of the location, size and shape in all cases compared to the findings of renal sonography. CONCLUSION: The roles of renal sonography and DMSA scan were very important, and ultrasonography was an excellent initial tool in diagnosing AFBN. Since the degree of infection in AFBN is more severe than other urinary tract infections and evollution into a renal abscess is possible, early diagnosis and appropriate antibiotics therapy is essential.

Emergency Treatment of Neurologic Disease

No abstract available.

Five Cases of Shaken Baby Syndrome

Shaken baby syndrome is a serious form of child abuse, mostly involving children younger than 2 years. It results from extreme rotational cranial acceleration induced by violent shaking. The characteristic injuries include subdural hemorrhage, retinal hemorrhage, and fracture of ribs or long bones. If physicians have no recognition of, or suspicion about, shaken baby syndrome, this syndome is difficult to diagnosis because of a lack of obvious external signs and failure of the abuser to admit his or her actions. In addition to the high mortality, 60% of survivors have significant long term neurologic and developmental abnormality. The authors experienced five cases of shaken baby syndrome presented with seizures or vomiting, without external signs of trauma. All of these cases had subdural hemorrhages, and four cases had retinal hemorrahges. In our follow up, two children were found to have sequelae such as quadriplegia, monoplegia, and developmental delay. We emphasize that early recognition and prompt treament are key to overall success of case management. The incidence of shaken baby syndrome can be reduced through public awareness and education of parents not to shake a babies.

A Clinical Study of Non-Accidental Intracranial Hemorrhage in Children

PURPOSE: Non-accidental intracranial hemorrhage in children is not low in incidence and results in high mortality and serious sequelae. So, the authors have researched the distribution of sex and age, causes, symptoms and signs, hemorrhagic types, mortality rate and sequelae of the patients hospitalized with non-accidental intracranial hemorrhage at Hallym University Sacred Heart Hospital. METHODS: The medical records of twenty patients, aged 15 or younger, and excluding neonatal patients, were analyzed retrospectively. The patients in this study were admitted with non-accidental intracranial hemorrhage from January 1999 to June 2002. RESULTS: Of the twenty cases, the ratio of male to female was 1 : 0.8. The patients aged one or less and between 11 and 15 were discovered to be the most frequent cases. Shaken baby syndrome and arteriovenous malformation were found to be the most frequent causes. Seizure was most frequently found to be a symptom and a sign. Hemorrhagic type was classified into subdural hemorrhage eight, intracerebral hemorrhage five. There were three mortal cases. Twelve surviving patients, excluding five not-followed ones, were reclassified into six cases of complete recovery and six of sequalae. CONCLUSION: Non-accidental intracranial hemorrhage in children is not low in incidence, with a high mortality rate and a high incidence of serious sequelae after survival. Consequently, early diagnosis and appropriate treatment are required. In addition, appropriate rehabilitation after treatment is needed because the high survival rate due to advanced medical treatment results in an increasing number of neurologic sequelae.