Comparison on the profiles of a modified Borg scale and the pediatric dyspnea scale during an induced bronchoconstriction in children with clinical asthma

PURPOSE: Dyspnea is the cardinal symptom of asthma, but it is difficult to quantify clinically. Although modified Borg (mBorg) scale has been successfully used in adult, but there has been some difficulties to apply in children. Recently, Pediatric Dyspnea Scale (PDS) was adequately designed and has been widely used. The aim of this study is to compare 2 evaluating scales of dyspnea provoked by induced-bronchoconstriction in childhood asthma. METHODS: Seventy-three clinically suspected children with asthma were enrolled in this study. Each ‘fractional exhaled nitric oxide (FeNO)’ was documented. Forced expiratory volume in 1 second (FEV₁), mBorg score and PDS score were recorded during methacholine provocation test. RESULTS: Mapping using canonical plot demonstrated global similarity between 2 scales with some distinctive features. Whereas mBorg score showed more diverse categories in low level of dyspnea, PDS score did in medium level of it. A distribution of dyspnea perception score at a 20% decrease in FEV₁ relative to baseline (PS₂₀), a perception score of dyspnea at 20% fall in FEV1 of 2 scales represented similar wide, biphasic feature. Statistical relevance was verified with spearman correlation (R(s)=0.903, P<0.001) and Bland-Altman analysis. PS₂₀ of both scores and FeNO had no statistical relationship. While relationship between PS20 by mBorg score and the concentration of methacholine at 20% fall in FEV₁ (PC₂₀) was not significant (R(s)=0.224, P=0.154), that between PS₂₀ by PDS and PC₂₀ was weak positive (R(s)=0.29, P=0.063). CONCLUSION: PDS had similar pattern to assess the dyspnea with the mBorg scale suggesting adequacy of PDS in evaluating pediatric clinical asthma. We expect these scales to help clinical practice in complementary ways.

Neurosyphilis Presenting with Multiple Cranial Neuropathy

Neurosyphilis can present with various clinical symptoms. We report a patient with multiple cranial neuropathy that, mimicked tuberculosis, but was finally diagnosed as neurosyphilis. A 38-year-old man was admitted due to subacutely progressive hearing loss. Brain MRI revealed multiple dural enhanced masses on contrast-enhanced T1 weighted images. Brain biopsy of the dural enhanced lesion revealed chronic granulomatous inflammation with coagulation necrosis, compatible with syphilitic gumma. Serum venereal disease research laboratory and fluorescent treponemal antibody absorption test results were positive. Treatment with penicillin resolved the patient's symptom.

A case of fat embolism syndrome in juvenile rheumatoid arthritis patient

Fat embolism syndrome is a serious complication that can occur after trauma or operation of the limbs. Clinical criteria are used for the diagnosis of fat embolism syndrome and sometimes radiologic findings are helpful. Fat embolism syndrome is known to occur less frequently in children than in adults, but there is an increased risk in children with connective tissue disease. However, there are only a few reported cases of fat embolism syndrome in juvenile rheumatoid arthritis which is the most common connective tissue disease in children. We report a case of fat embolism syndrome diagnosed in a 13-year-old boy with juvenile rheumatoid arthritis, which was treated with corticosteroid.

A Case of Pulmonary Hemosiderosis that was Dissolved by an Oral Prednisolone and the Milk Avoidance / 소아알레르기및호흡기학회지

A 29-month-old boy presented with fever, dyspnea, and paleness. He was initially diagnosed with pneumonia and severe sepsis. Although he was treated with intravenous antibiotics and high dose methylprednisolone, dyspnea and paleness recurred two times. Under suspicion of pulmonary hemosiderosis, we performed video-assisted thoracoscopic lung biopsy and bronchoalveolar lavage on him and found hemosiderin-laden macrophages in both specimens. Despite thorough history and laboratory examination, we could not find any pathologic or serologic evidence for primary and secondary causes of pulmonary hemosiderosis except for one that indicating Heiner's syndrome. After taking oral prednisolone he showed improvement of anemia and dyspnea, which was maintained by milk avoidance. Based on the history and the existence of immunoglobulin G antibodies against milk components, we are considering it as the case of Heiner's syndrome.

Changes in the Indices of Bronchial Reversibility Assessed by the Office Spirometry and Their Relationship to Asthma Symptoms after Discontinuing Controller Medication in Children with Controlled Asthma: Pilot Study / 소아알레르기및호흡기학회지

PURPOSE: It is important to assess the level of control in asthmatic children who were well-controlled and thus discontinued controller medications. Office spirometry has been regarded to provide objective measures. We aimed to see time changes in lung function indices measured by the office spirometry and their relationship to clues for asthma exacerbation after discontinuation of controller medications. METHODS: As a pilot study, a total of 20 well-controlled children with persistent asthma were included. After discontinuing controller medications, each made follow-up visits at the 2nd, 6th, and 12th week. At each visit, spirometric values before and after bronchodilators were evaluated by the office-based spirometer. Time changes and their relationship to clues for asthma exacerbation were assessed. RESULTS: Among 20 children, 13 (65%) were successfully followed-up for 12 weeks with asthma kept stable. They presented similar spirometric values (forced expiratory volume in 1 second [FEV1], peak expiratory flow rate [PEFR], bronchodilator responses [BDRs] based on the FEV1 and PEFR) across all time-points. No differences in spirometric values were found between those who were stable and those who exhibited clues for asthma exacerbation. BDRs calculated from FEV1 values (BDRFEV1) correlated well with those calculated from PEFR values (BDRPEFR). CONCLUSION: When controller medications were discontinued in children with well-controlled asthma, many of them were able to maintain the stable condition. Since the spirometric measures including BDR failed to differentiate clues for asthma exacerbation, the usefulness of office spirometry needs to be reevaluated by the larger population of children with controlled asthma after discontinuing medications.

Relationship between Bronchial Hyperresponsiveness and Development of Asthma in Preschool Children with Cough Variant Asthma / 소아알레르기및호흡기학회지

PURPOSE: A significant proportion of patients with cough variant asthma (CVA) eventually develops asthma. The aim of this study was to investigate the relationship between bronchial hyperresponsiveness (BHR) and development of asthma in preschool children with CVA. METHODS: We reviewed the medical records of children aged 5 to 7 years who presented with chronic cough and had regular check-up by the school age. All children had methacholine bronchial challenge test (MBCT) at preschool age with a modified auscultation method. The end-point was defined as the appearance of wheezing and/or oxygen desaturation. Positive BHR was defined as end-point concentration (EPC)< or =8 mg/mL. MBCT was performed at the school age with spirometric method. Positive BHR was defined as PC20< or =8 mg/mL. We collected information on the development of wheezing or dyspnoea from the medical records. RESULTS: Thirty-six children with CVA were analyzed. During follow-up (2.1+/-0.9 years), 9/36 children developed wheezing or dyspnoea (group A), and 27/36 children did not (group B). EPC (geometric mean, 95% confidence interval) was significantly lower in group A than group B (1.59 mg/mL, 0.93 to 2.70 mg/mL vs. 3.43 mg/mL, 2.34 to 5.03 mg/mL; P=0.02, respectively). The prevalence of positive BHR at school age was significantly higher in group A than group B (77.8% vs. 22.2%, P<0.01). CONCLUSION: These results suggest that the increase and the persistence of BHR may have an important role in the development of asthma during the course of CVA in preschool children.

Predictors of Mortality and Complication in Pediatric Patients Who Require Continuous Renal Replacement Therapy in Pediatric Intensive Care Unit / 대한구급학회지

BACKGROUND: The objective of this study is to analyze the factors associated with mortality and complication in children requiring continuous renal replacement therapy (CRRT) in a pediatric intensive care unit. METHODS: We retrospectively analyzed 96 patients who required CRRT at a pediatric intensive care unit in Seoul National University Hospital between April 2005 and April 2011. We evaluated the clinical features, diagnosis, mortality risk factors and complications related to CRRT. RESULTS: Univariate and multivariate analyses were performed to analyze the mortality risk factors of patients requiring CRRT. The overall mortality was 56.3%, the median age was 8 years, and the ages ranged from 4 days to 22 years. The median weight of the patients was 7.9 kg, and the weights ranged from 3.6-72.9 kg. 16 patients were diagnosed with primary renal disease, and the remainder with other underlying diseases. Mortality was higher in children who received stem cell transplantation and in children with a diagnosis of imunologic disease and neurologic disease. The Pediatric Risk of Mortality (PRISM) III score at initiating CRRT was 17.8 +/- 8.9 and the degree of fluid overload at CRRT (FO%) was 12.9 +/- 16.0. The PRISM III score at the start of CRRT and low uric acid level were the factors associated with an increased risk of mortality. Of the 96 children, 13 (13.53%) presented problems of venous catheterization. Hypotension during connection to CRRT was detected in 28 patients (29.2%). Clinically significant hemorrhage occurred in 10 patients (10.4%). CONCLUSIONS: Children who require CRRT have a high mortality rate. The higher score of PRISM III at the starting time of CRRT and the lower uric acid level are the factors associated with a higher mortality. The most frequent complication of CRRT was hypotension on connection to CRRT.

Atelectasis and the Risk Factors in the Patients Admitted to Pediatric Intensive Care Unit / 대한구급학회지

BACKGROUND: Atelectasis is a state of a collapsed and non-aerated region of the lung parenchyma, which is otherwise normal. This condition is usually associated with pulmonary disorders. The purpose of this study is to analyze the incidence and risk factors of atelectasis in patients admitted to the pediatric intensive care unit (PICU). METHODS: We retrospectively analyzed the clinical characteristics and chest radiography of 280 PICU patients under 18 years old. We analyzed the incidence and pattern of atelectasis and compared the incidence according to the phase and mode of mechanical ventilation. We compared the incidence of ventilator care need and respiratory disease in 93 atelectasis patients. RESULTS: Atelectasis incidence was 33.2%. The age (4.9 +/- 4.4 years) was younger and the admission-duration (17.8 +/- 25.1 days) was significantly longer in atelectasis patients (p < 0.01). Ventilator care need and respiratory disease in atelectasis patients (86.0%, 66.7% respectively) was significantly higher than in non-atelectasis patients (62.6%, 43.3% respectively) (p < 0.01). Atelectasis incidence in ventilator-required patients and respiratory-diagnosed patients (40.6%, 43.4% respectively) was significantly higher than that in non ventilator-required patients and non respiratory-diagnosed patients (15.7%, 22.6% respectively) (p < 0.01). Atelectasis was more common in the right upper lobe (55.6%) and during or after ventilator care (62.6%) (p < 0.05). Atelectasis incidence in ventilator care did not differ between the assist-control and intermittent mandatory ventilation modes. CONCLUSIONS: In the PICU, atelectasis incidence was higher in patients with ventilator care and respiratory disease. Atelectasis was more common in the right upper lobe and in the phase after ventilator initiation. Atelectasis incidence in ventilator care did not differ between ventilation modes.

Atopy as a Risk Factor for an Elevated Bronchodilator Response in Children with Asthma / 소아알레르기및호흡기학회지

PURPOSE: The bronchodilator response (BDR) is frequently measured to assess the severity of asthma and to help facilitate therapeutic decisions, as well as to confirm the diagnosis. Few reports are available on the impact of atopy, one of the most important risk factors for childhood asthma, on the BDR. METHODS: The medical records of 207 asthmatic children (174 with atopic asthma and 33 with non-atopic asthma) were retrospectively reviewed. At the time of asthma diagnosis, the subjects underwent blood tests, bronchial provocation tests, and spirometry before and 15 minutes after inhalation of 4 puffs of salbutamol. We compared the mean BDR levels between the children with atopic and non-atopic asthma, then determined the correlations between the BDR and serum markers of eosinophilic inflammation. RESULTS: While the mean pre-bronchodilator FEV1 was not different between children with atopic and non-atopic asthma, atopic asthmatics had a higher mean BDR than non-atopic asthmatics (9.12+/-5.69% vs. 6.93+/-3.80%, P =0.03). There were weak, but significant correlations between the BDR and the serum markers of eosinophilic inflammation (total immunoglobulin E, r =0.192, P =0.01; total eosinophil count, r =0.192, P =0.01; eosinophil cationic protein, r =0.200, P <0.01). CONCLUSION: Asthmatic children had different mean levels of BDR based on atopic status at the time of asthma diagnosis. When the BDR was assessed to aid therapeutic decisions, the presence of atopy should be taken into consideration in children with asthma.

Bronchodilator Response and Its Relationship to Bronchial Hyperresponsiveness in Children with Allergic Rhinitis/Asthma / 소아알레르기및호흡기학회지

PURPOSE: Bronchial impairment has been observed in patients with allergic rhinitis (AR) as well as asthma. Few reports exist on bronchodilator response (BDR) and its relationship with bronchial hyperresponsiveness (BHR) in children with AR. METHODS: A total of 309 children (170 asthmatic children, 80 children with AR and 59 control subjects) were included. After conducting methacholine bronchial provocation and BDR tests, we compared the mean of BDR between the 3 groups and examined the relationships between BDR, prebronchodilator forced expiratory volume in 1 second (FEV(1)) and provocative concentration causing 20% fall in FEV(1) (PC(20)) in both AR and asthmatic patients. RESULTS: Asthmatic children showed a higher mean BDR than those with AR or control subjects. There were significant relationships between BDR, PC(20) and prebronchodilator FEV1 in asthmatic children. Children with AR also showed a higher BDR than control subjects. Though AR children with elevated BDR had lower prebronchodilator FEV1, they showed no significant relationship between BDR and PC(20). CONCLUSION: Children with AR as well as asthma demonstrated an elevated BDR as compared to control subjects. Though the relationship between BDR and BHR in AR subjects was not so remarkable as in asthmatic children, the elevated BDR was associated with the decreased airway caliber in AR patients. These results may reflect the lower airway impairment in children with AR, which suggests a close link between AR and asthma.

The role of inhaled and/or nasal corticosteroids on the bronchodilator response / 소아과

BACKGROUND: To compare the profiles of the bronchodilator response (BDR) among children with asthma and/or allergic rhinitis (AR) and to determine whether BDR in these children is reduced by treatment with inhaled and/or nasal corticosteroid. METHODS: Sixty-eight children with asthma (mean age, 10.9 years), 45 children with comorbid asthma and AR (mean age, 10.5 years), and 44 children with AR alone (mean age, 10.2 years) were investigated. After a 2-week baseline period, all children were treated with inhaled fluticasone propionate (either 100 or 250 microg b.i.d., tailored to asthma severity) or nasal fluticasone propionate (one spray b.i.d. in each nostril) or both, according to the condition. Before and 2 weeks after starting treatment, all children were evaluated with spirometry and bronchodilator testing. BDR was calculated as a percent change from the forced expiratory volume in 1 second (FEV1) at baseline. RESULTS: The mean BDR was 10.3% [95% confidence interval (CI) 8.3-12.4%] in children with asthma, 9.0% (95% CI 7.3-10.9%) in subjects with asthma and AR, and 5.0% (95% CI 4.1-5.9%) in children with AR alone (P<0.001). After treatment, the mean BDR was reduced to 5.2% (95% CI 4.2-6.3%) (P<0.001) in children with asthma and to 4.5% (95% CI 3.5-5.5%) (P<0.001) in children with asthma and AR. However, children with rhinitis showed no significant change in BDR after treatment, with the mean value being 4.7% (95% CI 3.7-5.8%) (P=0.597). CONCLUSION: The findings of this study imply that an elevated BDR in children with AR cannot be attributed to nasal inflammation alone and highlights the close relationship between the upper and lower airways.

A case report; Brown tumor of the maxilla and mandible in association with primary hyperparathyroidism

Comparison of Methacholine and Adenosine 5'-Monophosphate Responsiveness Between Preschool Children with Atopic Asthma and Those with Nonatopic Asthma / 소아알레르기및호흡기학회지

PURPOSE: It is well known that atopy is a major determinant of bronchial hyperresponsiveness (BHR) in both asymptomatic and asthmatic children. However, the relationship between atopy and BHR has not been well studied in preschool children with asthma. The aim of this study was to evaluate and compare BHR to direct and indirect stimuli between young children with atopic asthma and those with nonatopic asthma. METHODS: Methacholine and adenosine 5'-monophosphate (AMP) bronchial challenges were performed on 177 preschool children with asthma (145 atopics and 32 nonatopics) using a modified auscultation method. The endpoint was defined as the appearance of wheezing and/or oxygen desaturation. RESULTS: While the geometric mean of methacholine endpoint concentration was not significantly different between atopics and nonatopics that of the AMP endpoint concentration was significantly lower in atopics than in nonatopics (25.5 vs. 59.4 mg/mL; P=0.032). A positive response to methacholine (an end-point concentration < or =8 mg/mL) was observed in 96.5% (140/145) of patients with atopic asthma and in 84.3% (27/32) with non-atopic asthma. The frequency of a positive response to AMP (an endpoint concentration < or =200 mg/mL) was 86.8% (126/145) in patients with atopic asthma and 75% (24/32) in these with non-atopic asthma. CONCLUSION: Atopics more frequently displayed BHR to AMP and had a higher responsiveness to AMP than nonatopics. These results suggest that atopic and non-atopic asthma in preschool children may be related to the distinctive pathophysiologic pathways.

Relationships of Methacholine and Adenosine 5'-Monophosphate Responsiveness with deltaFVC in Children with Allergic Rhinitis / 소아알레르기및호흡기학회지

PURPOSE: Patients with allergic rhinitis without clinical evidence of asthma often have bronchial hyperresponsiveness (BHR). BHR is commonly assessed by bronchial challenges using direct or indirect stimuli. The percentage decrease in forced vital capacity (FVC) at methacholine PC(20) (deltaFVC) has been proposed as a surrogate marker of the maximal airway response and a useful index of disease severity in asthma. The aim of this study was to compare methacholine and adenosine 5'-monophosphate (AMP) responsiveness with their deltaFVC in children with allergic rhinitis. METHODS: Eighty-two nonasthmatic children with allergic rhinitis underwent methacholine and AMP bronchial challenge tests. A provocative concentration causing a 20% decline in forced expiratory volume in 1 second (PC(20)) was calculated for each challenge, and the deltaFVC on concentration-response curves in methcholine challenge was analyzed retrospectively. RESULTS: A positive response to methacholine (methacholine PC(20)<16 mg/mL) was observed in 42.6% (35/82) of patients and the frequency of a positive response to AMP (PC(20)<200 mg/ mL) was 29.2% (24/82). Of these patients, 23 had a methacholine PC(20) above 100 mg/mL and were excluded from the study. Methacholine PC(20) did not correlate significantly with deltaFVC (r=-0.008, P=0.954). However, there was a significant and strong correlation between AMP PC(20) and deltaFVC (r=-0.325, P=0.012). CONCLUSION: The stronger correlations of deltaFVC for AMP PC(20) than for methacholine PC(20) suggest that the maximal airway response may be better reflected by BHR assessed by AMP than by methacholine in patients with allergic rhinitis.

Electoroglottograph in Normal Adult; Preliminary Study for Electroglottographic Study of Swalloing Disorder

Analysis of Speech Pathologic Evaluation for Children With Ankyloglossia