The effect of restricted fluid intakes in the first week of life on the risk of bronchopulmonary dysplasia and patent ductus arteriosus in very low birth weight infants / 소아과

PURPOSE: We investigated the effects of restricted fluid in the first 7 days of life on the risk of bronchopulmonary dysplasia (BPD) or patent ductus arteriosus (PDA) in very low birth weight (VLBW) infants. METHODS: Eighty three VLBW infants who lived more than 28 days were selected. The amount of daily maintenance fluid was determined by calculation of insensible water loss (IWL) and urine output (UO). Seventy to 80 percent of calculated amount was given to the ventilated infants. Subjects were grouped into low (75th%) fluid groups for the first 24 hours, 3 days and 7 days. Chi square tests analyzed proportions of subjects with or without morbidities across fluid groups. Multivariate logistic regression was used to analyze the effect of fluid intake on BPD or PDA, controlling for factors that are significantly associated with BPD or PDA by univariate analysis. RESULTS: Rates of BPD and PDA were not significantly associated with fluid groups on each time period. The result was the same after controlling for factors that are significantly associated with BPD or PDA by univariate analysis. For the first 3 and 7 days, fluid intakes were positively related with maximal weight loss, urine output and mechanical ventilation duration. CONCLUSION: In VLBW infants, when given based on needs reflected from IWL and UO versus intake, relatively low fluid intakes in the first week of life do not decrease the risk of BPD or PDA, and vice versa. We suggest that calculation of daily fluid based on IWL and UO is appropriate for VLBW infants.

Effects of Antenatal Steroid on Postnatal Fluid Balance in Very Low Birth Weight (VLBW) Infants during the First Week of Life

PURPOSE: Antenatal steroid (AS) may result in lower insensible water loss (IWL), and higher urine output (UO) in early life. We examined if the postnatal fluid balance differed between infants exposed to AS or not (control) in VLBW infants. METHODS: Fifty-four VLBW infants were grouped into AS (n=24) or control (n=30). Fluid intake, UO, IWL and maximal % of weight loss on day 1, day 2, day 3 and day 7 after birth were analyzed. Daily maintenance fluid was determined in each infants by calculation of insensible water loss (IWL=[intake-output]-Delta wt) and UO. RESULTS: Fluid intake (AS vs control; 117.2+/-33.9 vs 126.0+/-29.6 mL/kg/d, P=0.315), IWL (28.1+/-23.7 vs 21.1+/-20.5 P=0.248), UO and maximal % of weight loss on day 7 were not different between groups: similar findings were observed on day 1, day 2, and day 3 after birth. Neonatal morbidities and clinical relevant factors were not different between groups. The duration of assisted ventilation was shorter in the AS than in the control (10.8+/-9.2 vs 27.6+/-26.2, P=0.002). However, the difference disappeared after adjustment for RDS severity and oxygenation index. CONCLUSION: VLBW infants exposed to AS did not have an alteration in postnatal fluid balance during the first week of life, when given fluid based on needs reflected by IWL and UO. The decreased need for assisted ventilation in the AS group may be related to the effects of steroid on fetal lung fluid absorption or maturity, but not on postnatal fluid balance.

Vesicoureteral Reflux and Renal Scar

PURPOSE: Vesicoureteral reflux(VUR) is the major risk factor of urinary tract infection(UTI) in children and may result in serious complications such as renal scarring and chronic renal failure. The purpose of this study was to evaluate the relationship between VUR and renal scar formation, the usefulness and correlation of various imaging studies in reflux nephropathy, and the spontaneous resolution of VUR. METHODS: We retrospectively reviewed 106 patients with VUR with no accompanying urogenital anomalies in the Department of Pediatrics, Bundang CHA Hospital during the period from Jan. 1996 to Mar. 2005. Ultrasonography and 99mTc-dimercaptosuccinic acid(DMSA) scan were performed in the acute period of UTI. Voiding cystourethrography(VCUG) was performed 1 to 3 weeks after treatment with UTI. Follow-up DMSA scan was performed 4 to 6 months after treatment and a follow-up VCUG was performed every 12 months. RESULTS: The mean age at detection of VUR was 13.8+/-22.2 months and the male to female ratio was 2:1. The incidence of renal scarring showed a tendency of direct correlation between severity of VUR(P<0.001) and abnormal findings of renal ultrasonography(P<0.01). 63.2%(24 of 38 renal units) of renal parenchymal defects present in the first DMSA scan disappeared on follow-up DMSA scans. Follow-up DMSA scans detected renal scars in 7(14%) of 50 renal units with ultrasonographically normal kidneys. Meanwhile, ultrasonography did not show parenchymal defects in 7(36.8%) of 19 renal units where renal scarring was demonstrated on a follow-up DMSA scan. The spontaneous resolution rate of VUR was higher(75%) in cases with low grade(I to III) VUR(P<0.01). CONCLUSIONS: The presence and severity of VUR and abnormal findings of renal ultrasonography significantly correlated with renal scar formation. DMSA scan was useful in the diagnosis of renal defects. Meanwhile renal ultrasonography was an inadequate method for evaluating renal parenchymal damage. Therefore, follow-up DMSA scans should be performed to detect renal scars even in children with low-grade VUR and normal renal ultrasonography.

Usefulness of Nested PCR for Diagnosis of Scrub Typhus in Clinical Practice: Prospective study / 감염과화학요법

BACKGROUND: Laboratory studies as diagnostic tools of scrub typhus have shown PCR to be sensitive and specific, but there have been few clinical studies. The aims of this study were to determine the diagnostic accuracy and clinical usefulness of the nested PCR through a prospective comparison of the nested PCR and indirect immunofluorescence assay (IFA). MATERIALS AND METHODS: We conducted a multicenter prospective study of patients with possible scrub typhus. Adult patients who have had fever together with eschar or a maculopapular skin rash and more or equal to two of the following symptoms: headache, malaise, myalgia, coughing, nausea, and abdominal discomfort were enrolled. Each patient was admitted between September, 2004 and December, 2004 to Chosun University Hospital and one of its three community branch hospitals (Haenam General Hospital, Jangheung Hospital, Muan Hospital), which are all located in the southwest of Korea. Whole blood samples were collected for PCR testing and sera were obtained for serology evaluation using the IFA and passive hemagglutination assay (PHA). RESULTS: We enrolled 135 possible scrub typhus patients, and 118 scrub typhus patients were confirmed on the basis of either a single indirect immunofluorescent specific IgM titer against O. tsutsugamushi of > or =1:10 or 4-fold or greater rise in IFA follow up titer. One hundred eighteen patients were confirmed as scrub typhus, 7 patients were undetermined and 10 patients were confirmed as the other diseases. The result of nested PCR assay demonstrated a sensitivity of 82.2% (95% confidence interval 0.74-0.88), a specificity of 100% (95% confidence interval 0.66-1), positive predictive value of 1 (95% confidence interval 0.95-1) and negative predictive value of 0.32 (95% confidence interval 0.17-0.51). 96 patients out of 118 patients were positive for IgM on the admission day. Of 22 patients with negative for IgM antibody at admission, 19 had positive results for nested PCR using buffy coat. CONCLUSION: The nested PCR assay of buffy coat is useful for rapid and reliable test for confirmation of the diagnosis of scrub typhus.

Usefulness of Nested PCR for Diagnosis of Scrub Typhus in Clinical Practice: Prospective study / 감염과화학요법

BACKGROUND: Laboratory studies as diagnostic tools of scrub typhus have shown PCR to be sensitive and specific, but there have been few clinical studies. The aims of this study were to determine the diagnostic accuracy and clinical usefulness of the nested PCR through a prospective comparison of the nested PCR and indirect immunofluorescence assay (IFA). MATERIALS AND METHODS: We conducted a multicenter prospective study of patients with possible scrub typhus. Adult patients who have had fever together with eschar or a maculopapular skin rash and more or equal to two of the following symptoms: headache, malaise, myalgia, coughing, nausea, and abdominal discomfort were enrolled. Each patient was admitted between September, 2004 and December, 2004 to Chosun University Hospital and one of its three community branch hospitals (Haenam General Hospital, Jangheung Hospital, Muan Hospital), which are all located in the southwest of Korea. Whole blood samples were collected for PCR testing and sera were obtained for serology evaluation using the IFA and passive hemagglutination assay (PHA). RESULTS: We enrolled 135 possible scrub typhus patients, and 118 scrub typhus patients were confirmed on the basis of either a single indirect immunofluorescent specific IgM titer against O. tsutsugamushi of > or =1:10 or 4-fold or greater rise in IFA follow up titer. One hundred eighteen patients were confirmed as scrub typhus, 7 patients were undetermined and 10 patients were confirmed as the other diseases. The result of nested PCR assay demonstrated a sensitivity of 82.2% (95% confidence interval 0.74-0.88), a specificity of 100% (95% confidence interval 0.66-1), positive predictive value of 1 (95% confidence interval 0.95-1) and negative predictive value of 0.32 (95% confidence interval 0.17-0.51). 96 patients out of 118 patients were positive for IgM on the admission day. Of 22 patients with negative for IgM antibody at admission, 19 had positive results for nested PCR using buffy coat. CONCLUSION: The nested PCR assay of buffy coat is useful for rapid and reliable test for confirmation of the diagnosis of scrub typhus.

Clinical Consideration of Premature Twins Conceived by in Vitro Fertilization and those of Naturally Conceived / 대한주산의학회잡지

OBJECTIVE: The aim of this study was to evaluate and compare neonatal outcome of premature twins conceived by in vitro fertilization (IVF) to those of naturally conceived. METHODS: We retrospectively analyzed neonatal outcome of sixty pairs of premature twins conceived by IVF (IVF twin group) and 34 pairs that naturally conceived (natural twin group). Maternal and obstetric characteristics were also compared. All were born before 35 weeks of gestation between January 2000 and December 2004 at Pochon-Cha Hospital and admitted to neonatal intensive care unit. Student t-test and chi-square test were used for statistical analysis. RESULTS: For obstetrical characteristics, maternal age and rates of nulliparous were sibnificanty twin group. But, other parameters (preterm labor, premature rupture of membranes, pregnancy-induced hypertension, gestational diabetes mellitus) were similar between two groups. For neonatal outcome, gestational age, duration of hospital stay, Apgar score, neonatal mortality and morbidity were reviewed. All parameters were no significant differences in IVF twin group compare to natural twin group CONCLUSIONS: In our study, IVF twin group had no significant differences in obstetric characteristics (except for maternal age and parity) and neonatal outcome compare to natural twin group.

Comparisons of Physical and Biological Activities between Newfactan(R), Surfacten(R) and Exosurf(R)

PURPOSE: Neonatal respiratory distress syndrome (RDS) is caused by the deficiency of pulmonary surfactants in the newborn. We aim to determine and compare the physical and biological activities of the three surfactants currently on the market, namely Newfactan(R), Surfacten(R) and Exosurf(R). METHODS: For physical activities, we performed the stable microbubble test (SMR) and Pulsating Bubble Surfactometer (PBS). The minimum and maximum surface tensions measured at 1 and 5 minutes allowed us to create the surface-tension diagrams, from which the compressibility at a surface tension of 10 mN/m was calculated for all three products. The biological activities were compared using the pressure-volume curves measured from premature rabbit fetuses. RESULTS: For all three products, the concentration of surfactant and the number of stable microbubbles exhibited a proportional increase in relationship. For both Newfactan(R) and Surfacten(R), the minimal surface tensions were lower than 10 mN/m at 1 and 5 minutes. Hysteresis was evident at 1 and 5 minutes for both Newfactan(R) and Surfacten(R), and their surface tensions were reduced below 10 mN/m at 20% surface compression. As for Exosurf(R), all the hysteresis measurements were below expectations, and the reduction in surface tension during compression was also minimal. The compressibilities at a surface tension of 10 mN/m and measured at 1 and 5 minutes for Newfactan(R) and Surfacten(R), were less than 0.020 cm/dyne at almost concentrations. The pulmonary surface areas of the fetal rabbits were, after aeration by a maximum of 30 cmH2O, adequately maintained after decompression to 5 cmH2O in the groups treated with Newfactan(R) and Surfacten(R). However, the lung volume was not maintained upon decompression to 5 cmH2O in the groups treated with Exosurf(R). CONCLUSIONS: Newfactan(R) and Surfacten(R) were effective agents in prevention of pulmonary collapse in premature lungs.

A Case of Multiple Giant Coronary Aneurysms with Large Mural Thrombus due to Kawasaki Disease in a Young Infant / 소아과

Kawasaki disease is an acute systemic vasculitis of unknown origin. Giant coronary aneurysm is one of the most serious complications, although peripheral artery vasculitis can produce life-threatening events. Myocardial ischemia and infarction can be caused by coronary artery stenosis, aneurysm, and stagnation of blood flow in coronary arteries which triggers thromboembolism. Atypical presentation in young infants often interferes with prompt diagnosis and timely treatment, resulting in poor outcomes. We describe a 3-month-old infant with multiple giant coronary aneurysms with flow stagnation, stenosis and large mural thrombus due to Kawasaki disease. He presented with a prolonged course of severe coronary involvement in spite of all measures to reduce coronary complications. Finally, surgical intervention was tried because of the worsening coronary artery abnormalities. The patient died of acute cardiorespiratory failure shortly after weaning from cardiopulmonary bypass.

Early Prediction of Bronchopulmonary Dysplasia in Very Low Birth Weight Infants with Mechanical Ventilation in the First Week of Life

PURPOSE: Multifactorial in pathogenesis, bronchopulmonary dysplasia is difficult to predict based on any single factor, especially early in life. We evaluated clinical and ventilatory parameters in the first week of life, and their combinations were tested for early prediction of BPD. METHODS: Eighty-one very low birth weight (VLBW) infants born at gestational ages or =4.5 on day 7 (OR 3.982, 95% CI 1.046-15.162) and maximum FiO2> or =0.3 on day 7 (OR 7.626, 95% CI 1.570-37.054). The combination of these factors for prediction of BPD had a 79% positive predictive value with an 85% sensitivity. CONCLUSION: A number of clinical and ventilatory parameters in combination (gestation, maximum MAP and FiO2 on day 7) can predict BPD in VLBW infants early in life with a relatively high sensitivity and positive predictiveness. With early identification of infants prone to BPD, the clinicians may resort to more active measures to minimize lung injury and to prevent BPD.

A Clinical Study of Infective Endocarditis in Childhood / 소아과

PURPOSE: Advances in the treatment of congenital heart disease and a decline in the incidence of rheumatic fever has led to changes in the causative organisms and the clinical outcome of infective endocarditis(IE). We sought to analyze the clinical outcome, prognostic factors, causative organisms and corresponding antibiotic sensitivity in IE. METHODS: Retrospective analysis of medical records of 104 children diagnosed and treated with IE at Severance Hospital, Yonsei University College of Medicine from January 1986 to June 2003 was undertaken. According to the Duke criteria, 55 patients were classified into the definite group(DG) and possible group(PG). RESULTS: Thirty one cases(56.4%) fulfilled the criteria for the definite group in the Duke criteria, whereas 24 cases(43.6%) fulfilled the criteria for the possible group. The most common chief complaint on admission was fever(93%). The most common infecting organism was Staphylococcus aureus, which was found in 14 cases(48.3%). Three cases(21.4%) of this organism were methicillin- resistant S. aureus(MRSA). Other causative organisms were alpha-streptococcus(seven cases, 24.1%), Staphylococcus epidermidis(three cases, 10.3%), Citrobacter freundii(one case, 3.8%), Enterococcus faecium(one case, 3.4%) and Candida albicans(three cases, 10.3%). Penicillin-resistant organisms were found in 90.5%(19/21) of total cases and the most sensitive antibiotics were vancomycin(13/13, 100 %) and teicoplanin(12/12, 100%). One case of IE due to MRSA unresponsive to vancomycin was treated with Arbekacin. CONCLUSION: The incidence of IE caused by S. aureus, especially MRSA, is increasing. Multi-drug resistant organisms are also emerging as a frequent cause of IE. Thus, in patients strongly suspected of having IE in patients with underlying heart disease, glycopeptides such as vancomycin combined with aminoglycosides should be considered, and if fever and positive blood cultures continue despite treatment with glycopeptides, a consideration of the use of new antibiotics may improve the treatment results.

A Clinicopathological Study on the Prognosis of IgA Nephropathy in Children

PURPOSE: This study was performed to determine the natural history of histologically confirmed IgA nephropathy in pediatric patients who presented with hematuria and proteinuria. PATIENTS AND METHODS: We reviewed the clinical course of 57 patients diagnosed with IgA nephropathy at the age of 15 years or younger from 1981 to 2000. All patients presented with hematuria or minimal proteinuria( or =40 mg/m2/day), hypertension, and chronic renal failure. RESULTS: The mean age at presentation was 9.5+/-2.8 years(4 to 15 years) and 42(74%) were male. Isolated gross hematuria was observed in 20 patients(35%), microscopic hematuria in 3(5%), minimal proteinuria in 4(7%), both gross hematuria and minimal proteinuria in 15(26 %), and both microscopic hematuria and minimal proteinuria in 15(26%). During a median follow-up of 7.0+/-3.5 years, 38(67%) had complete resolution of hematuria and proteinuria, 12(21%) had persistently abnormal urinalysis without development of adverse events. Only 7(12%) developed adverse events:4(7%) developed severe proteinuria, 1(2%) became hypertensive, and 2(3%) developed impaired renal function. By univariate analysis using the chi-square test, the age at presentation(>10 years)(P<0.01) and poor histological classes of the Lee or Haas classification at onset(P<0.05) were significantly correlated with adverse events, whereas sex and clinical signs at onset were less concordant. CONCLUSION: We can conclude that the prognosis of IgA nephropathy diagnosed in early childhood is better and a good correlation exists between the clinical manifestations of this disease and the histological classes.