A Cause Analysis of Missed Fractures in an Emergency Medical Center

PURPOSE: A missed fracture is a very common occurrence in the Emergency Department (ED) and can have serious results because of delays in treatment, resulting in long-term disability. It is also one of the most common causes leading to medical legal issues. We analyzed the causes of missed fractures by using a bone scan which is known to be an effective tool for diagnosing bony lesions. METHODS: We reviewed the medical records of trauma patients who underwent a bone scan after being discharged the ED from September 2006 to March 2008. Cases of missed fractures were identified by using electronic medical records to review each diagnosis. Definition of missed fracture was read after bone scan by radiologist. We decided that there was no fracture if we read 'trauma-related lesion' or 'cannot rule out fracture' on a bone scan read by a radiologist. Enrolled patients were analyzed by age, sex, time until bone scan and Injury Severity Score (ISS). Patients were divided into two groups, alert mentality and not-alert mentality, so there were split between a diagnosis group and a missed fracture group. ISS was also used in determining the severity of the patient's injury upon discharge from the ED. RESULTS: A total of 532 patients were enrolled in this study. Of those, 487 patients were in the diagnosis group, and 45 patients (8.4%) were discovered to have had a fracture. Of the 45 missed fracture patients, 34 patients (6.4%) had one-site fractures, 8 patients (1.5%) had two-site fractures, and 3 patients (0.6%) had threesite fractures. The most commonly missed fracture was multiple rib fractures (18 patients, 30.5%), followed by lumbosacral (LS) spine fractures (10 patients, 16.9%), thoracic spine fractures (8 patients, 13.6%), and clavicle fractures (6 patients, 10.2%). Mean age was 50.12+/-18.54 years in the diagnosis group and 57.38+/-16.88 years in the missed fracture group. For the diagnosis group, the mean ISS was 9.03+/-8.26, but in the missed fracture group it was 17.53+/-9.69. Missed fractures were much more frequent in the not-alert mentality (p or =16) group (p<0.01). CONCLUSION: Missed fractures occur most frequent in patients of old age, not-alert mentality, and high ISS. Multiple rib and spine fractures were found to be the most frequent missed fractures, regardless of trauma severity. This study also shows a high possibility of clavicle and scapula fractures in patients with severe trauma.

An Emergency Ultrasound (EUS)-Enhanced Scoring System for Diagnosing Acute Appendicitis in Patients with Right Lower Quadrant (RLQ) Pain; Constant or Aggravated Pain, Male Sex, and Ultrasound (CAMUS) Scores

PURPOSE: We hypothesized that a new scoring system that included emergency ultrasound (EUS) and clinical or laboratory predictors for diagnosing acute appendicitis (AA) in patients with right lower quadrant (RLQ) pain could decrease the false negative rate when EUS is performed alone. METHODS: During a 10 month period, patients with RLQ pain were evaluated with EUS just after history taking and physical examination. We also checked the 17 well-known predictors of AA. Univariate analyses for each predictor including EUS findings identified 11 predictors. We then tested those predictors with logistic regression analysis. RESULTS: A total 397 patients (mean age=31.13+/-18.25 years: 196 males, 201 females) were enrolled in this study. Among the 397, 247 underwent an operation, but 14 turned out to have normal appendices. Among 233 patients with appendicitis, 75 had a perforated appendix. Four independent correlates of AA (constant pain, aggravated pain, male sex, and positive EUS findings) were identified with logistic regression analysis. We developed a novel scoring system using regression coefficients as follows: 6 points for a positive EUS, 3 points for aggravated pain, 2 points for constant pain, and 2 points for being male. We named the new scoring system "CAMUS" for "Constant or Aggravated pain, Male sex, and UltraSound score". The area under the receiver-operating characteristic curve (ROC) for the CAMUS score for AA was 0.93(95% confidence interval: 0.871 to 0.959). CONCLUSION: Our new CAMUS scoring system can help emergency physicians diagnose AA accurately and rapidly.

Differential Diagnosis of Acute Dyspnea: The Usefulness of Tissue Doppler Echocardiography in Emergency Department by Emergnecy Physician

PURPOSE: In managing acutely dyspneic patients, differentiating the underlying disease rapidly is important but not easy. Although B-type natriuretic peptide (BNP) is generally accepted as a useful marker, inconclusive results require an emergency physician (EP) to have something more confirmative. We evaluate whether Tissue Doppler Echocardiography (TDE) performed by an EP can better discriminate between heart disease and lung disease than can BNP in the emergency department (ED). METHODS: For enrolled ED patients with acute dyspnea and unclear pathology, initial BNP level and TDE performed by EP were checked prospectively. The ratios of peak early diastolic transmitral blood flow velocity (E) versus the peak early diastolic tissue velocity over mitral annulus (Ea) on TDE were recorded. The sensitivity and specificity of tissue Doppler parameters and BNP levels for diagnosing acute heart failure were calculated and we compared the discriminatory ability of the two tools. RESULTS:49 patients (39 heart failure, 10 respiratory disease) were enrolled. The area under the ROC curves for BNP and E/Ea were 0.946 and 0.888 (p<0.001) respectively. Cutoff values were 350 pg/ml for BNP (sensitivity and specificity of 82.1% and 100%) and 9.0 for E/Ea (89.2% and 100%). Especially in the group with low BNP (<350), BNP was a poor discriminator of the underlying disease, whereas E/Ea was still effective (AUC: 0.943, p=0.021). CONCLUSION: TDE by EP is a useful tool for diagnosing acute heart failure in ED and could easily and rapidly discriminate the underlying disease of acutely dyspneic patients, especially in patients with inconclusive BNP levels.

Emergency Abdominal Ultrasonography for Differential Diagnosis of Acute Abdominal Pain : COUCH (Complaint-oriented Ultrasonography with CHecklist) approach

PURPOSE: The purpose of this study was to verify objectively whether abdominal ultrasonography performed by emergency physicians (EP) in emergency departments (ED) immediately after history taking and physical examination could give effective diagnostic information and to check the feasibility and usefulness of the COUCH method. METHODS: From May 1, 2005 to September 30, 2005 we recruited 368 patients who complained of abdominal pain in the ED. Senior level emergency physicians (EP) conducted history taking and physical examinations, following which they were asked for their suspected diagnosis and their level of confidence (from maximum 5 to minimum 1) regarding each diagnosis. The same EP then performed abdominal ultrasonography (US), using the COUCH method and were again asked for their suspected diagnosis and level of confidence. We compared the suspected diagnoses and levels of confidence before and after abdominal US by using the t-test. RESULTS: A total of 106 patients (55 male, 51 female, average age 35.46+/-18.11 years) were enrolled. The number of patients with a suspected diagnosis of after history taking and physical examination only (2.43+/-0.5) was significantly greater than after abdominal US (1.34+/-0.5) (p<0.01). The level of confidences of suspected diagnosis of after history taking and physical examination only (3.43+/-1.14), by contrast, was less than after abdominal US (4.40+/-1.22) (p<0.01). Each year of postgraduate residents could have the same results after US. CONCLUSION: We found that abdominal ultrasonography could give EP more informations for pronouncing a correct diagnosis for patients with abdominal pain in the ED, and the COUCH method could lead the EP to get better training for ultrasonography and to diagnose more rapidly and accurately.

Correlation between Serum Albumin Level and IgG Level in Minimal Change Nephrotic Syndrome

PURPOSE: Hypogammaglobulinemia has been observed in nephrotic syndrome, but its pathophysiology remains unknown. We evaluated the relationship between the serum IgG and albumin levels for children with minimal change nephrotic syndrome(MCNS). METHODS: The levels of immunoglobulin G(IgG), albumin and total cholesterol of a total of 46 children with MCNS(proteinuria >40 mg/m2/h, and serum albumin level <2.5 g/dL) were analyzed. RESULTS: The mean values of albumin, IgG and total cholesterol in MCNS children were 1.7+/-0.3 g/dL, 368+/-143 mg/dL and 431+/-78 mg/dL, respectively. There was an inverse correlation between the albumin values and the total cholesterol values(r=0.68, P=0.0001), whereas there was a direct-proportional correlation between albumin values and the IgG values(r=0.4, P=0.01). CONCLUSION: The IgG level is associated with albumin level, and it may reflect the severity of urinary protein loss in MCNS. Further studies are needed to evaluate this phenomenon.

Urine Concentration and the Adaptation of Renal Medullary Cells to Hypertonicity

Hypertonicity(hypernatremia) of extracellular fluid causes water movement out of cells, while hypotonicity(hyponatremia) causes water movement into cells, resulting in cellular shrinkage or cellular swelling, respectively. In most part of the body, the osmolality of extracellular fluid is maintained within narrow range(285-295 mOsm/kgH2O) and some deviations from this range are not problematic in most tissue of the body except brain. On the other hand, the osmolality in the human renal medulla fluctuates between 50 and 1,200 mOsm/kgH2O in the process of urine dilution and concentration. The adaptation of renal medullary cells to the wide fluctuations in extracellular tonicity is crucial for the cell survival. This review will summarize the mechanisms of urine concentration and the adaptation of renal medullary cells to the hypertonicity, which is mediated by TonEBP transcription factor and its target gene products(UT- A1 urea transporter etc.).

Comparison of Blood and Urine Renal Indices Between Hypercalciuric and Non-hypercalciuric Hematuria Patients

PURPOSE: The purpose of this study was to investigate whether hypercalciuria patients with hematuria show different renal indices compared to non-hypercalciuria patients with hematuria. METHODS: We retrospectively reviewed the medical records of patients with gross or microscopic hematuria whose blood chemistry and 24 hour urine chemistry were examined. After excluding the patients with more than 4 mg/m2/day proteinuria or the patients with urinary calcium excretion between 3 and 4 mg/kg/day, we divided the patients into two groups: a hypercalciuria group whose calcium excretion was more than 4 mg/kg/day(n=30) and a non- hypercalciuria group whose calcium excretion was less than 3 mg/kg/day(n=41). The urinary excretion, clearance, and fractional excretion(FE) of Na, K, Cl, Ca, P, urea, and creatinine were calculated and compared between the two groups. RESULTS: The hypercalciuria group had more calcium excretion(6.1+/-2.9 vs 1.5+/-0.9 mg/kg/day), more urea excretion(341+/-102 vs 233+/-123 mg/kg/day), greater glomerular filtration rate(GFR) (93.7+/-31.1 vs 79.5+/-32.0 mL/min) but lower FENa(1.0+/-0.4% vs 1.3+/-0.6%) than the nonhypercalciuria group, although the urinary sodium excretion was similar between the two groups. CONCLUSION: The greater urea excretion and GFR in hypercalciuric patients suggest that they might be on a higher protein diet than the non-hypercalciuria group. The increased glomerular filtration of sodium and calcium induced by the higher GFR in hypercalciuria would have increased their delivery to the distal tubule, where sodium is effectively reabsorbed but calcium is not, which is suggested by the lower FENa but higher FECa in hyercalciuria. It is recommended that the diet of hematuria patients be reviewed in detail at initial presentation and during treatment.

Pathophysiology and management of disorders in water metabolism / 소아과

Even though we drink and excrete water without recognition, the amount and the composition of body fluid remain constant everyday. Maintenance of a normal osmolality is under the control of water balance which is regulated by vasopressin despite sodium concentration is the dominant determinant of plasma osmolality. The increased plasma osmolality (hypernatremia) can be normalized by the concentration of urine, which is the other way of gaining free water than drinking water, while the low plasma osmolality (hyponatremia) can be normalized by the dilution of urine which is the only regulated way of free water excretion. On the other hand, volume status depends on the control of sodium balance which is regulated mainly by renin-angiotensin-aldosterone system, through which volume depletion can be restored by enhancing sodium retention and concomitant water reabsorption. This review focuses on the urine concentration and dilution mechanism mediated by vasopressin and the associated disorders; diabetes insipidus and syndrome of inappropriate antidiuretic hormone secretion.

The Utility of Emergency Ultrasound for Diagnosing Wrist and Ankle Injuries

PURPOSE: Ultrasound is of proven accuracy in abdominal and thoracic trauma and may be useful for diagnosing extremity injury in situations where radiography is not available, such as disasters and military and space applications. However, the diagnosis of fractures is suggested by history and physical examination and is typically confirmed with radiography. As a alternative to radiography, we prospectively evaluated the utility of extremity ultrasound performed by trained residents of emergency medicine (EM) one patient with wrist and ankle extremity injuries. METHODS: Initially, residents of EM performed physical examinations for fractures. The emergency ultrasound (EM US) was performed by trained residents, who used a portable ultrasound device with a 10- to 5-MHz linear transducer, on suspected patients before radiography examination. The results of emergency ultrasound and radiography and the final diagnosis were recorded, and correlations among them were determined by using Kappa`s test. RESULTS: Thirty-nine patients were enrolled in our study. The average age was 36.6+/-19.3 years. There were radius Fx. (n=21), radius-ulna Fx. (n=1), ulna Fx. (n=1), and contusion (n=2) injuries among the wrist injury and lat.-med. malleolar Fx. (n=13), lat. malleolar Fx. (n=6), and med. malleolar Fx. (n=3) injuries among the ankle injury. Comparing EM US with radiography, we found the sensitivity, specificity, positive predictive value, and negative predictive value of EM US for Fx. diagnosis to be 100%, 66.7%, 97.3%, 100% and those of radiography to be 97.2%, 100%, 100%, and 75%, respectively. Kappa`s test for a correlation between the Fx. diagnosis of EM US and the final diagnosis of Fx was performed, and Kappa`s value was 0.787 (P = 0.004). CONCLUSION: EM US for Fx. can be performed quickly and accurately by EM residents with excellent accuracy in remote locations such as disaster areas and in military and aerospace applications. EM US was as useful as radiography in our study and had a high correlation to the final diagnosis of Fx. Therefore, ultrasound should performed on patients with extremity injury to determine whether extremity evaluation should be added to the FAST (focused abdominal sonography trauma) examination.

Clinical Aspects of Necrotizing Pneumonitis Resulting from Mycoplasma pneumoniae Infection in Children / 소아알레르기및호흡기학회지

PURPOSE: Necrotizing pneumonitis is a complication of severe invasive lobar pneumonia characterized by necrotic foci in consolidated areas and its development may be due to excessive host cell-mediated immune response. Necrotizing pneumonitis caused by Mycoplasma pneumoniae (M. pneumoniae) in children and its successful treatment have been reported. We reviewed 5 cases to determine the disease course and outcome in pediatric patients with necrotizing pneumonitis resulting from M. pneumoniae infection. METHODS: Five patients with necrotizing pneumonitis caused by M. pneumoniae who were diagnosed and treated in the Department of Pediatrics, Uijeongbu St. Mary`s Hospital from January 2003 to December 2006 were reviewed in this study. Sex, age, clinical manifestations, laboratory and radiologic findings, treatments, and long-term follow-up outcomes of these patients were analysed retrospectively. RESULTS: One patient was a boy and others were girls. All were less than 5 years of age and had no immunocompromised conditions. Lower pH and glucose, higher protein and LDH were observed in pleural fluid. On the radiologic examinations, all had multilobar pneumonic involvements, especially in the right lobes and lower lobes. Necrotizing pneumonitis was diagnosed on chest CTs taken between two and 20 days following admission. The necrotic foci were identified as multiple low-attenuation changes within the contrast-enhanced consolidation areas mainly in the lower lobes of the affected side of lung. Cavitary necrosis was shown in 3 patients and persisted as pneumatoceles, which disappeared on the follow-up chest radiographs nearly up to 7 months following admission. Macrolide and broad-spectrum antibiotics were administered in all patients and chest tube drainage was performed in 2 patients. Systemic steroid therapy was added in 4 patients. Of those four, 2 patients, both under 2 years of age, improved more rapidly than others in clinical status and radiographic findings. In spite of steroid therapy, one patient died of acute respiratory distress syndrome. Consequently 4 patients were improved and discharged. Two patients who were under 2 ears were normalized and 2 patients who were 4 years of age showed remaining cavitation or fibrosis in the last follow-up chest radiographs. CONCLUSION: Our results may suggest though they are not yet proven nor have they been discussed extensively that younger patients show better prognoses than older children. Further well-designed and large scale studies may be warranted.

Initial Unmeasured Anions on Emergency Department in Critically ill Patients: Can they Predict the Morbidity?

PURPOSE: To determine whether initial corrected anion gap (C(o)AG), base excess caused by unmeasured anions (BEua), and strong ion gap (SIG) can predict the morbidity of critically ill patients admitted to emergency department (ED). METHODS: 138 patients who visited the critical section of the ED and were admitted to intensive care unit (ICU) were enrolled. We calculated the C(o)AG, BEua, and SIG from the initial blood samples of the patients and initial logistic organ dysfunction score (LODS) also. Then we measured the LODS at the last day of ICU stay again. Comparing with the initial LODS, we divided the patients into two groups based on the changes of the values: favorable group and poor group. RESULTS: There was a significant difference in the mean AGcorr (p=0.007), BEua (p=0.008), SIG (p=0.037) between favorable and poor group. The area under the receiver operating characteristic (AUROC) curves for morbidity prediction were relatively small: 0.66 (95% CI, 0.56-0.77) for C(o)AG, 0.65 (95% CI, 0.54-0.76) for BEua, and 0.59 (95% CI, 0.49-0.70) for SIG. CONCLUSION: We found the initial unmeasured anions at the ED of the patients who eventually showed improved LODS during ICU period are significantly different to those of the other patients. But they failed to show enough capability of discriminating the morbidities between two groups.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.

Long-Term Regulation of Renal Urea Transporters during Antidiuresis

To produce a concentrated urine, the renal medulla needs hypertonicity for the reabsorption of free water from collecting duct. The single effect that increases interstitial tonicity in the outer medulla is the active NaCl reabsorption in the thick ascending limb, while the single effect in the inner medulla is the passive efflux of NaCl through the thin ascending limb. The passive mechanism in the inner medulla requires high interstitial urea concentration. Two main groups of urea transporters (UT-A, UT-B) are present in the kidney, which maintains the high concentration of urea in the deepest portion of the inner medulla by intra-renal urea recycling. Recent studies suggest that UT-A1 in the terminal inner medullary collecting duct is up-regulated when urine or inner medullary interstitial urea is depleted in order to enhance the reabsorption of urea, while UT-A2 in the descending thin limb of loops of Henle and UT-B in the descending vasa recta are increased when outer medullary interstitial urea concentration is high, in order to prevent the loss of urea from the medulla to the systemic circulation, thereby increasing intra-renal urea recycling. This review will summarize the functions of the renal urea transporters in urine concentration mechanism and the recent knowledge about their long-term regulation.

The effects of high-dose intravenous immunoglobulin on plasma protein and lipid levels in the patients with Kawasaki disease / 소아과

PURPOSE: The reticuloendothelial system is composed of sinusoidal capillaries, through which even large protein molecules are freely movable between plasma and interstitial space, including the lymphatic system. Therefore, high-dose intravenous immunoglobulin (IVIG) would cause a redistribution of proteins between two compartments. To investigate this hypothesis, we measured plasma protein and lipid levels in patients with Kawasaki disease before and after high-dose IVIG treatment. METHODS: Thirty four children with Kawasaki disease who had complete responses to high-dose IVIG treatment (1 g/kg/day for two consecutive days), were analyzed. Before and after the administration of IVIG, serum analyses were performed for such parameters as total protein, albumin, gamma-globulins (IgG, IgM, IgA), alpha1-, alpha2-, and beta-globulin fractions, and lipid profiles (total cholesterol, HDL-cholesterol, LDL-cholesterol and triglyceride). RESULTS: The levels of gamma-globulins including IgG, IgM, IgA were significantly increased, and IgG was increased by 1,779+/-304 mg/dL after two-dose of IVIG infusion. The levels of albumin, alpha1-, alpha2-, and beta-globulin fractions were significantly decreased by 18 percent, 24 percent, 19 percent and 12 percent, respectively. HDL-cholesterol level was significantly decreased by 20 percent, while LDL-cholesterol and triglyceride levels were significantly increased by 21 percent and 50 percent, respectively. The total cholesterol level was not changed. CONCLUSION: High-dose IVIG treatment decreased the levels of a variety of proteins except immunoglobulins, and the increase of IgG after IVIG treatment was lower than expected. Our results suggest that a part of infused IVIG and plasma proteins, including etiologic proteins for Kawasaki disease, may be distributed to the extravascular compartments. The rapid improvement of symptoms induced by IVIG in Kawasaki disease might be explained by this mode of action of IVIG.

Hypernatremia and hyponatremia / 소아과

Sodium is the major cation of the extracellular fluid and the primary determinant of extracellular osmolality. Therefore, hypernatremia causes water movement out of cells, while hyponatremia causes water movement into cells, resulting in cellular shrinkage and cellular swelling, respectively. Serious central nervous system symptoms may complicate both conditions. Since hypernatremia and hyponatremia are accompanied by abnormalities in water balance, it is essential to understand the mechanisms regulating extracellular osmolality and volume as well as the pathophysiology of hypernatremia and hyponatremia, in order to manage both conditions with swiftness and safety.

Intravenous and Oral Fluid Therapy in Dehydrated Children

The administration of adequate fluid to the severely dehydrated patients takes precedence over all other treatment regardless of the underlying disease. Although the understanding of pathogenesis and the appropriate management of water, electrolytes, and acid-base disturbance are emphasized in medical education, many physicians are not very confident in treating the patients with those disturbances. The first thing that should be remembered in fluid therapy is how much of water and sodium is required to the patients-in other words, how much water with what concentration of sodium should be given to the patients. Water deficit can be estimated by assessing the severity of dehydration, while the sodium deficit from the types of dehydration, that is, the plasma sodium concentration of the patients. This review will summarize the principles of how to choose and give the adequate fluid according to the severity and the types of dehydration.

The Levels of IgG Subclasses and Vaccine-induced Viral Antibodies in Childhood Minimal Change Nephrotic Syndrome

PURPOSE: Hypogammaglobulinemia has been observed in nephrotic syndrome, but its pathophysiology remains unknown. We evaluated serum immunoglobulins, IgG subclasses, and vaccine-induced viral antibodies(anti-hepatitis B surface IgG and anti-measles IgG) in children with minimal change nephrotic syndrome(MCNS). METHODS: Using the stored sera, the levels of immunoglobulin(IgG, IgM, IgA, and IgE) and IgG subclasses(IgG 1, 2, 3, and 4), anti-HBs Ab and anti-measles IgG of 21 children with MCNS were analyzed and compared to those of 25 age-matched healthy children. RESULTS: The mean values of IgG and IgG1 were 390+/-187 mg/dL and 287+/-120 mg/dL in nephrotic children, and 1,025+/-284 mg/dL and 785+/-19 mg/dL in control children, respectively. The values of the total IgG and the 4 IgG subclasses in nephrotic children were all significantly depressed(P<0.001), but the IgM(251+/-183 mg/dL vs. 153+/-55 mg/dL, P=0.02) and IgE values(P=0.01) were elevated, and the IgA values were not changed. The seropositivity of anti-HBs IgG was 42.9%(9 of 21 cases) in the MCNS group and 52%(13/25) in the control group, and that of anti-measles IgG was 76%(16/21) and 92%(23/25), respectively, but there was no statistical difference between the two groups. CONCLUSION: IgG and IgG subclass levels in MCNS children are all depressed without significant seronegativity of the vaccine-induced viral antibodies. Further studies are needed to resolve the cause of hypogammaglobulinemia in MCNS.

A Case of Jejunostomy for Cerebral Palsy with Recurrent Aspiration Pneumonia / 소아알레르기및호흡기학회지

Cerebral palsy (CP) usually arises in the prenatal period, interferes with normal development of the brain and presents as a disorder of motor dysfunction. It is a common cause of severe neurologic disability in children with incidence of 2 per 1000 live births in Canada. Presently, with the persistent increase in premature births and improved care in the perinatal period, the incidence of CP is strikingly augmented. According to neurologically impaired motor ability, they commonly have feeding difficulties, like swallowing, leading to frequent aspiration pneumonia and gastroesophageal reflux. Therefore, improvement of feeding techniques should be an urgent requirement to correct the risk of poor growth. We report a case of CP due to kernicterus who have recurrent pneumonia and growth failure, experience a jejunostomy to overcome the feeding problems.

The Therapeutic Effect of Lactobacillus reuteri in Acute Diarrhea in Infants and Toddlers / 소아과

PURPOSE: Certain strains of lactobacilli are known to accelerate recovery from acute diarrhea. Lactobacillus reuteri is isolated from human breast milk and a commonly occurring Lactobacillus species with therapeutic potential in acute diarrhea. The purpose of the present study was to investigate the therapeutic effect of L. reuteri in acute diarrhea in young children. METHODS: Fifty patients between 6 and 36 months of age hospitalized with acute diarrhea (rotavirus in 40 percent) were randomized into two groups to receive either 10 (8) colony-forming units of L. reuteri or a matching placebo, twice a day for their length of hospitalization, or for up to 5 days. Antidiarrheal drugs were not prescribed to either group. The clinical outcome of diarrhea was evaluated. RESULTS: The mean duration of watery diarrhea after initiation of treatment was 2.3 days for the L. leuteri group (n=25) vs. 2.9 days for the placebo group (n=25) (P=0.072). By the second day of treatment, watery diarrhea persisted in 64 percent of patients receiving L. reuteri, compared to 84 percent of those receiving placebo (P=0.006). On the second day, the mean frequency of watery diarrhea was 1.9 in the L. leuteri group and 3.4 in the placebo (P=0.046). Also, vomiting continued to the second day in 16 percent of patients receiving L. reuteri and 40 percent of those recieving placebo (P= 0.031). CONCLUSION: L. reuteri is effective as a therapeutic agent in acute diarrhea in children.