Delta Neutrophil Index as a Prognostic Marker in the Pediatric Intensive Care Unit / 대한구급학회지

BACKGROUND: The delta neutrophil index (DNI) is a useful marker for diagnosing and predicting the prognosis of sepsis. The purpose of this study was to investigate the usefulness of DNI as a prognostic marker in patients within the pediatric intensive care unit (PICU), as well as its association with other prognostic factors. METHODS: A total of 516 children admitted to Severance Children's Hospital PICU from December 2009 to February 2015 were analyzed. DNI was measured on the day of PICU admission. Mortality was defined as death within 28 days following PICU admission. RESULTS: The median value of DNI was 1.2% (interquartile range [IQR] 0-4.3%) in the survivor group and 9.5% (IQR 2.3-20.8%) in the non-survivor group, and the difference was statistically significant (p < 0.001). DNI was significantly positively correlated with ICU scores such as Pediatric Index of Mortality 3 and Pediatric Risk of Mortality III, as well as with C-reactive protein and lactate levels. The area under the receiver operating characteristic curve of DNI for mortality was 0.748 (95% CI: 0.687-0.808) and the cut-off value was 4.95%. CONCLUSIONS: The initial DNI level can be considered a useful indicator for predicting prognosis in PICU patients.

Delta Neutrophil Index as a Prognostic Marker in the Pediatric Intensive Care Unit / 대한중환자의학회지

BACKGROUND: The delta neutrophil index (DNI) is a useful marker for diagnosing and predicting the prognosis of sepsis. The purpose of this study was to investigate the usefulness of DNI as a prognostic marker in patients within the pediatric intensive care unit (PICU), as well as its association with other prognostic factors. METHODS: A total of 516 children admitted to Severance Children's Hospital PICU from December 2009 to February 2015 were analyzed. DNI was measured on the day of PICU admission. Mortality was defined as death within 28 days following PICU admission. RESULTS: The median value of DNI was 1.2% (interquartile range [IQR] 0-4.3%) in the survivor group and 9.5% (IQR 2.3-20.8%) in the non-survivor group, and the difference was statistically significant (p < 0.001). DNI was significantly positively correlated with ICU scores such as Pediatric Index of Mortality 3 and Pediatric Risk of Mortality III, as well as with C-reactive protein and lactate levels. The area under the receiver operating characteristic curve of DNI for mortality was 0.748 (95% CI: 0.687-0.808) and the cut-off value was 4.95%. CONCLUSIONS: The initial DNI level can be considered a useful indicator for predicting prognosis in PICU patients.

Diagnostic utility of skin prick test to cooked egg in children with egg allergy

PURPOSE: Reliable predictors of tolerance to cooked egg in an egg allergic population are not established. We investigated the usefulness of the skin prick test to cooked egg in children with egg allergy. METHODS: We studied 36 children with egg allergy. Skin prick tests (SPTs) for the uncooked or cooked form of egg white and egg yolk, whole egg, ovomucoid (OVM), and ovalbumin (OVA) were performed at diagnosis. The reagents of cooked egg for SPT were prepared by baking for 25 minutes in 200 degree oven. We also examined specific IgE levels to whole egg, egg white, egg yolk, OVM, and OVA. RESULTS: Patients with history of allergic reaction to extensively heated egg showed significantly increased wheal size for cooked egg white (median [interquartile range]), 10.5 [7.0-14.6] vs. 4.2 [0.0-5.6], P<0.001) and OVM (9.6 [7.3-13.8] vs. 5.6 [0.0-7.8], P=0.001) than those without the history. The strongest positive correlation was found between wheal size for cooked egg white and OVM (r=0.788, P<0.001). SPT wheal size for cooked egg white were positively correlated with serum OVM-specific IgE levels (r=0.691, P<0.001). Cutoff value was 7.0 mm in SPT wheal size for cooked egg white, the sensitivity was 73.1% and specificity was 99.0%. SPT for cooked egg white showed significantly higher area under curve than serum egg white specific IgE. CONCLUSION: Our results suggest that SPT to cooked egg white may be useful predictor of allergic reaction to cooked egg. Further investigations will be needed.

ERRATUM: Acknowledgments. Diagnostic utility of skin prick test to cooked egg in children with egg allergy

In this paper, acknowledgments section for grant support was omitted unintentionally.

Fractional Exhaled Nitric Oxide and Impulse Oscillometry in Children With Allergic Rhinitis

PURPOSE: Airway inflammation, bronchial hyper-responsiveness (BHR), and bronchodilator response (BDR) are representative characteristics of asthma. Because allergic rhinitis (AR) is a risk factor for asthma development, we evaluated these 3 characteristics in AR using measurement of fractional exhaled nitric oxide (FeNO), a methacholine challenge test (MCT), and impulse oscillometry (IOS). METHODS: This study included 112 children with asthma (asthma group), 196 children with AR (AR group), and 32 control subjects (control group). We compared pulmonary function parameters and FeNO levels among the 3 groups. The AR group was subdivided into 2 categories: the AR group with BHR and the AR group without, and again pulmonary function and FeNO levels were compared between the 2 subgroups. RESULTS: FeNO levels were more increased in the AR and asthma groups than in the control group; within the AR group, FeNO was higher in the AR group with BHR than in the AR group without. The BDR was more increased in the AR group than in the control group when percent changes in reactance at 5 Hz (Delta X5) and reactance area (Delta AX) were compared. In the AR group, however, there was no difference in Delta X5 and Delta AX between the AR group with BHR and the AR group without. CONCLUSIONS: Reversible airway obstruction on IOS and elevated FeNO levels were observed in children with AR. Because elevated FeNO levels can indicate airway inflammation and because chronic inflammation may lead to BHR, FeNO levels may be associated with BHR in AR. IOS can be a useful tool for detecting lower airway involvement of AR independent of BHR assessed in the MCT.

Increased inflammatory mediator in exhaled breath condensate from asthmatic children

PURPOSE: There has recently been increasing interest in the use of exhaled breath condensate (EBC) as a simple noninvasive means for understanding the physiology of asthma. The aim of this study was to evaluate the levels of leukotriene B4 (LTB4) and eosinophil cationic protein (ECP) in the EBC of asthmatic children. METHODS: We measured LTB4 and ECP levels in EBC from children aged 6-14 years, including healthy children (n=25) and asthmatic children (n=25). We also measured serum LTB4 and serum ECP. Pulmonary function tests and methacholine challenge tests were performed on all subjects. RESULTS: Exhaled LTB4 levels were increased significantly in patients with asthma compared to normal subjects (7.1+/-3.7 pg/mL vs. 2.2+/-1.7 pg/mL, P<0.05). Serum LTB4 levels were not significantly different in patients with asthma compared to normal subjects (674.7+/-484.1 pg/mL vs. 487.1+/-272.0 pg/mL, P=0.156,) and no significant correlations were found between exhaled and serum LTB4 concentrations in children with asthma (r=0.052, P=0.758). Exhaled ECP levels were not significantly different in patients with asthma compared to normal subjects (P=0.419). Serum ECP levels were significantly increased in patients with asthma compared to normal subjects (44.37+/-32.14 microg/L vs. 16.40+/-13.23 microg/L, P=0.001). CONCLUSION: We found significantly elevated LTB4 levels in the EBC of asthmatic children. Our results suggest that EBC may be one of the supportive tools to measure airway inflammation in children with asthma.

Prognostic Usefulness of Eosinopenia in the Pediatric Intensive Care Unit

Eosinopenia, a biomarker for infection, has recently been shown to be a predictor of adult mortality in the intensive care unit (ICU). Our study assessed the usefulness of eosinopenia as a mortality and an infection biomarker in the pediatric ICU (PICU). We compared the PICU mortality scores, eosinophil count and percentage at ICU admission between children who survived and those who did not survive and between children with infection and those without infection. A total of 150 patients were evaluated. The initial eosinophil count and percentage were significantly lower in the group that did not survive when compared to those that did survive (P < 0.001; P < 0.001). However, there was no significant difference in the eosinophil count and percentage seen in patients with and without infection. Eosinopenia, defined as an eosinophil count < 15 cells/microL and an eosinophil percentage < 0.25%, (hazard ratio [HR]: 2.96; P = 0.008) along with a Pediatric Index of Mortality (PIM) 2 (HR: 1.03; P = 0.004) were both determined to be independent predictors of mortality in the PICU. The presence of eosinopenia at the ICU admission can be a useful biomarker for mortality in children, but is not useful as a biomarker for infection.

The safety of influenza vaccination in children with egg allergy

PURPOSE: Although influenza vaccine contains some residual egg protein (ovalbumin), recent studies have been reported that the influenza vaccine is even safe for patients with egg allergy. The object of this study was to assess the safety of influenza vaccination and estimate the risk factors of allergic reactions to influenza vaccination in children with egg allergy. METHODS: The medical records of 108 children were reviewed retrospectively, those were diagnosed as egg allergy at Department of Pediatrics in Severance Children's Hospital between January 2006 and December 2011. All of them were vaccinated with very low ovalbumin concentration (< or =0.12 microg/mL). Patients were vaccinated in graded doses by the international guideline. Subjects without allergic reactions to influenza vaccine among egg allergy patients were recruited as control subjects. RESULTS: Only 12 subjects of patients had adverse reactions to influenza vaccination. There were no significant relationships between adverse reactions to influenza vaccine and their own history of other allergy, history of breast feeding or graded vaccination. The egg allergy symptoms or egg-specific IgE levels were not associated with adverse reactions to influenza vaccination. CONCLUSION: These results show that patients with egg allergy may have adverse reactions with influenza vaccine, but severe adverse reactions are rare as general population. Therefore, the patients with egg allergy can be safe vaccinated with influenza vaccine, regardless of severity of allergic reaction after egg ingestion or methods of vaccination.

Forced expiratory flow between 25% and 75% of vital capacity as a predictor for bronchial hyperresponsiveness in children with allergic rhinitis

PURPOSE: Allergic rhinitis (AR) is regarded as a risk factor for asthma and bronchial hyperresponsiveness (BHR) is frequently observed in patients with AR. The purpose of this study is to analyze the characteristics of AR patients with BHR and identify factors that contribute to the incidence of BHR. METHODS: The medical records of a total of 176 children with AR were analyzed retrospectively. All patients were evaluated by performing spirometry and a methacholine challenge test. RESULTS: One hundred and fifty-five patients (88%) were classified as the BHR-negative group and 21 patients (12%) were classified as the BHR-positive group. Forced expiratory flow between 25% and 75% of vital capacity (FEF25-75 %predicted) was reduced, and total eosinphil counts, total immunoglobulin E (IgE) level, and serum specific IgE levels of Dermatophagoides pteronyssinus and Dermatophagoides farinae were higher in the BHR-positive group compared to the BHR-negative group. However, FEF25-75 was the only statistically significant predictor for the presence of BHR on multivariate logistic regression analysis. The cutoff value to distinguish BHR-positive subjects obtained from a receiver operating characteristics curve of FEF25-75 was 88.4%. A higher frequency of BHR was found in the group with a FEF25-75 less than 88.4%, and the sensitivity, specificity, positive predictive value and negative predictive value were 57.1%, 80.6%, 28.6%, and 93.3%, respectively. CONCLUSION: Reduced FEF25-75 values in children with AR can be helpful in predicting BHR. Children with low FEF25-75 in spirometric tests should be followed closely for apparent onset of clinical symptoms of asthma.

Usefulness of Thrombocytopenia and Changes in Platelet Counts as Prognostic Markers in Pediatric Intensive Care Units / 대한구급학회지

BACKGROUND: Thrombocytopenia has been shown to be a useful predictor of mortality in adult intensive care units (ICUs). The aim of this study is to assess whether the level of platelet count at ICU admission and the changes in platelet counts can predict mortality in the pediatric ICU (PICU). METHODS: Platelet counts were checked daily for at least 4 days in a total of 303 children who were admitted to the ICU. We compared the initial platelet counts and changes in platelet counts between survivors and non-survivors. A multivariable logistic regression model, a receiver operating characteristic curve and a linear mixed model were used. RESULTS: The initial platelet count was significantly lower in non-survivors when compared to survivors. Multivariate analysis demonstrated that platelet count <120 x 10(9)/L (Odds ratio, 4.913; 95% confidence interval 2.451-9.851; p < 0.0001) was an independent predictor of mortality. In the case of children with thrombocytopenia (<120 x 10(9)/L) at admission to the ICU, the platelet counts increased serially in survivors, whereas non-survivors maintained their decreased platelet counts. In the case of children without thrombocytopenia, the platelet counts decreased most on day 3 in non-survivors. CONCLUSIONS: At admission to the ICU, thrombocytopenia defined as a platelet count <120 x 10(9)/L can be a useful predictor of mortality in children. In children who had initial thrombocytopenia, the serial increase of platelet counts can be related to increased survival, whereas in children who did not have initial thrombocytopenia, more than a 10% decrease of platelet counts on day 3 can be related to mortality.

Clinical Course of Eosinophilic Bronchitis in Children / 소아알레르기및호흡기학회지

PURPOSE: It has been identified that eosinophilic bronchitis (EB) in adults can progress to asthma or fixed airway obstruction. In the present study, we evaluated the clinical course and prognosis of EB in children and their relationship with accompanying rhinosinusitis. METHODS: A total of 55 children with EB followed up for over than a year after the diagnosis were enrolled for the present study. We classified the subjects into two groups according to the prognosis and the presence of rhinosinusitis, respectively, and compared them with respect to clinical characteristics, eosinophil percentage in induced sputum, fractional exhaled nitric oxide (FeNO) and pulmonary function test. The poor prognostic group was defined as the children with asthma or asthma-like symptoms, or persistent or recurrent chronic cough in the long-term follow-up. RESULTS: The poor prognosis was achieved in 12 children (22%), and 3 children (5%) amongst them were diagnosed with asthma. There were no significant differences in clinical characteristics, eosinophil percentages in induced sputum, FeNO, spirometry and IOS according to the prognosis and the presence of rhinosinusitis. Additionally, the children with rhinosinusitis did not show any poorer outcome than those without rhinosinusitis. CONCLUSION: There were some limitations of this study for which the relationship between EB and rhinosinusitis in children was evaluated. However, in case of either poor short-term response to inhaled corticosteroids or elevated eosinophilic inflammation in airways or abnormal airway reversibility in impulse oscillometry, the long-term prognosis of EB in children needs to be considered, regardless of the presence of rhinosinusitis.

Usefulness of DeltaFEV0.75 and DeltaFEV0.5 for Airway Reversibility in Preschoolers with Asthma / 소아알레르기및호흡기학회지

PURPOSE: Preschoolers complete forced expiration in a short time, sometimes more quickly than in 1 second, and therefore the importance of forced expiatory volume in 0.75 seconds (FEV0.75) or forced expiatory volume in 0.5 seconds (FEV0.5) has been raised. The purpose of this study is to evaluate the clinical usefulness of DeltaFEV0.75 and DeltaFEV0.5. METHODS: We analyzed 401 subjects of an asthma group, and 150 subjects of a control group under 7 years of age. RESULTS: DeltaFEV1, DeltaFEV0.75 and DeltaFEV0.5 values of the asthma group were significantly higher than those of the control group, respectively (P or =12%. Cutoff values for asthma were 8.6% in DeltaFEV1, 7.9% in DeltaFEV0.75 and 14.2% in DeltaFEV0.5. DeltaFEV0.75 (0.91; 0.88 to 0.94) showed significantly higher area under curve (AUC) than DeltaFEV0.5 (0.77; 0.73 to 0.82) when stratified by 12%, in predicting airway reversibility defined as DeltaFEV1> or =12%. Cutoff values were 12.3% in DeltaFEV0.75, and 13.4% in DeltaFEV0.5. When airway reversibility is defined as DeltaFEV1> or =8.6%, DeltaFEV0.75 (0.90; 0.87 to 0.92) also showed significantly higher AUC than DeltaFEV0.5 (0.79; 0.75 to 0.82), and Cutoff values were 8.4% in DeltaFEV0.75, and 11.3% in DeltaFEV0.5. CONCLUSION: DeltaFEV0.75 or DeltaFEV0.5 can be a means to replace DeltaFEV1 for diagnosis of asthma and assessment of airway reversibility in preschool children.

A Case of Mediastinal and Pulmonary Cryptococcosis in a 3-Year-Old Immunocompetent Girl / 소아알레르기및호흡기학회지

Cryptococcosis is an infrequently recognized infection in children, particularly those who are immunocompetent. The disease is mainly caused by Cryptococcus neoformans, a fungal pathogen that primarily affects the central nervous system (CNS) and lungs. Most reports of children with cryptococcosis are of the CNS or disseminated infections among immunocompromised patients. This report is a case of a 3-year-old immunocompetent girl who presented with intermittent fever and cough; a large mass was found in the right infrahilar area on chest X-ray. Chest computed tomography revealed large conglomerated mediastinal lymph nodes caused by C. neoformans, which was confirmed by the polymerase chain reaction as well as a histological evaluation. The patient improved after a prolonged period of antifungal therapy. This is the only known report of mediastinal and pulmonary cryptococcosis in an immunocompetent child.

Exhaled Nitric Oxide is Associated with Allergic Inflammation in Children

Exhaled nitric oxide (eNO) has been proposed as a noninvasive marker of airway inflammation in asthma. In asthmatic patients, exhaled NO levels have been shown to relate with other markers of eosinophilic recruitment, which are detected in blood, sputum, bronchoalveolar lavage fluid and bronchial biopsy samples. The purpose of this study was to assess the possible relationship between eNO and allergic inflammation or sensitization in childhood asthma and allergic rhinitis. Subjects consisted of 118 asthmatic children, 79 patients with allergic rhinitis, and 74 controls. Their age ranged from 6 to 15 yr old. eNO level, peripheral blood eosinophil count, eosinophil cationic protein (ECP), serum total IgE level and specific IgE levels were measured. Methacholine challenge test and allergic skin prick test for common allergens were performed in all subjects. Atopic group (n = 206, 44.48 +/- 30.45 ppb) had higher eNO values than non-atopic group (n = 65, 20.54 +/- 16.57 ppb, P < 0.001). eNO level was significantly higher in patients with asthma (42.84 +/- 31.92 ppb) and in those with allergic rhinitis (43.59 +/- 29.84 ppb) than in healthy controls (27.01 +/- 21.34 ppb, P < 0.001) but there was no difference between asthma and allergic rhinitis group. eNO also had significant positive correlations with Dermatophagoides pteronyssinus IgE level (r = 0.348, P < 0.001), Dermatophagoides farinae IgE level (r = 0.376, P < 0.001), and the number of positive allergens in skin prick test (r = 0.329, P = 0.001). eNO had significant positive correlations with peripheral blood eosinophil count (r = 0.356, P < 0.001), serum total IgE level (r = 0.221, P < 0.001), and ECP (r = 0.436, P < 0.001). This study reveals that eNO level is associated with allergic inflammation and the degree of allergic sensitization.

Survival analysis of spinal muscular atrophy type I / 소아과

PURPOSE: The life expectancy of patients with spinal muscular atrophy (SMA) type I is generally considered to be less than 2 years. Recently, with the introduction of proactive treatments, a longer survival and an improved survival rate have been reported. In this study, we analyzed the natural courses and survival statistics of SMA type I patients and compared the clinical characteristics of the patients based on their survival periods. METHODS: We reviewed the medical records of 14 pediatric patients diagnosed with SMA type I during a 9-year period. We examined the demographic and clinical characteristics of these patients, calculated their survival probabilities, and plotted survival curves as on the censoring date, January 1, 2010. We also compared the characteristics of the patients who died before the age of 24 months (early-death, ED group) and those who survived for 24 months or longer (long-survival, LS group). RESULTS: The mean survival time was 22.8+/-2.0 months. The survival probabilities at 6 months, 12 months, 18 months, 24 months, and 30 months were 92.9%, 92.9%, 76.0%, 76.0%, and 65.1%, respectively. Birth weight was the only factor that showed a statistically significant difference between the ED and LS groups (P=0.048). CONCLUSION: In this study, the survival probabilities at 2 years were far greater than expected. Because of the limited number of patients and information in this study, the contribution of improved supportive care on longer survival could not be clarified; this may be elucidated in larger cohort studies.

A Case of Gluten Allergy in a 4-Year-Old Boy With Recurrent Urticaria / 소아알레르기및호흡기학회지

Wheat is the most widely cultivated grain and an important source of food and dietary protein. Wheat proteins are classified based on extraction in different solvents, which are albumin, globulin, prolamin (gliadin) and glutenin. The term 'gluten' contains approximately equal amounts of gliadin and glutenin and is the major determinant of the properties of wheat flour conferring cohesiveness and viscoelasticity that allows its dough to be processed into many kinds of food. Gluten is known to be responsible for triggering celiac disease and wheat allergy. Wheat allergy is primarily an IgE-mediated response. Clinical manifestations of wheat allergy are similar to those of other food allergies, with symptoms on the skin, gut and respiratory tract. Recent studies have shown that IgE to gliadin can be an indicator for risk of severe immediate reaction-like anaphylaxis and wheat-dependent, exercise-induced anaphylaxis (WDEIA). However, current in vitro test reagents for the diagnosis of wheat allergy mainly contain water-soluble wheat protein and a small amount of gluten, so there are some limitations to diagnose gluten allergy. Furthermore, there is no acceptable method to measure gluten in food products for preparing effective gluten-free diet. To overcome these limitations and to improve quality of life of wheat allergy sufferers, more work is needed. We report a case of a 4-year-old boy with gluten allergy who presented with urticaria after ingestion kneaded wheat flour with a brief review of the literature.

The Relationship between Stress and Eating Habits of University Students

BACKGROUND: Recently, many studies have reported that university students have been suffering from stress because of their the uncertainty of their future and employment. Eating habits have often been considered as one of health-related behaviors that may be affected by life stress. The purpose of this study was to examine the association between stress and eating habits in university students. METHODS: A cross-sectional study was designed. The subjects were 282 university students which assessed their eating habits and stresses. The total numbs of students in the study 263. Eating habits were scored using a questionnaire consisting of three categories-regularity, balance, and preference. The stress was assessed by modified Korean version of BEPSI. RESULTS: The stress score was 2.4 and the total score of eating habits was 44.2. The regularity among the domains of eating habits was 14.1, the balance score was 16.1, and the preference was 14.0. In multiple regression after adjustment with confounding variables, stress had a negative relationship with eating habits. CONCLUSION: The relationship between stress and eating habits was statistically significant, especially in regularity and balance. It is important to know not only the health status, but also the factors associated with health such as stresses and eating habits in order to improve the health status of the university students. Further research needs to uncover causality and make a generalization.