The Barriers to Recognizing and Reporting Child Physical Abuse by Emergency Physicians and Associated Factors.

BACKGROUND: Although the reporting rate of child abuse is increasing every year, the child abuse detection rate is 3.81% as of 2019 in Korea, which is significantly lower than that of developed countries for child rights. OBJECTIVE: We investigated the associated factors with barriers that emergency physicians face in recognizing and reporting cases of child abuse. METHODS: From May to July 2022, 240 emergency physicians working in the 15 emergency department were asked to participate in the survey via email. The questionnaire included the respondent's basic information, treatment experience for child abuse, reasons for reporting or not reporting, and opinions on measures to increase the reporting rate. We conducted a logistic regression analysis to discern the factors contributing to underreporting. RESULTS: Seventy-one individuals were included in the analysis, after excluding those who had never encountered suspected cases of child abuse. A multivariable logistic regression was performed with the above variables, and although it was not statistically significant, there was a tendency for workers to report well when working at a pediatric emergency department (odds ratio [95% confidence interval], 3.97 [0.98-16.09]). The primary reason for reporting suspected abuse was the pattern of damage suspected of abuse. The first reason for not reporting suspected abuse was because they were not sure it was child abuse. Respondents answered that to report better, a quick and appropriate response from the police and confidentiality of the reporter were needed. CONCLUSIONS: Physicians in pediatric emergency departments demonstrated a tendency for more proactive reporting suspected cases of child abuse.

Ideal chest compression site for cardiopulmonary resuscitation in fontan circulation patients with dextrocardia.

BACKGROUND: We aimed to identify the ideal chest compression site for cardiopulmonary resuscitation (CPR) in patients with a single ventricle with dextrocardia corrected by Fontan surgery. METHODS: The most recent stored chest computed tomography images of all patients with a single ventricle who underwent Fontan surgery were retrospectively analysed. We reported that the ideal chest compression site is the largest part of the compressed single ventricle. To identify the ideal chest compression site, we measured the distance from the midline of the sternum to the point of the maximum sagittal area of the single ventricle as a deviation and calculated the area fraction of the compressed structures. RESULTS: 58 patients (67.2% male) were analysed. The mean right deviation from the midline of the sternum to the ideal compression site was similar to the mean sternum width (32.85 ± 15.61 vs. 31.05 ± 6.75 mm). When chest compression was performed at the ideal site, the area fraction of the single ventricle significantly increased by 7%, which was greater than that of conventional compression (0.15 ± 0.10 vs. 0.22 ± 0.11, P < 0.05). CONCLUSIONS: When performing CPR on a patient with Fontan circulation with dextrocardia, right-sided chest compression may be better than the conventional location.

Comparison of age-adjusted shock indices as predictors of injury severity in paediatric trauma patients immediately after emergency department triage: A report from the Korean multicentre registry.

INTRODUCTION: Shock index paediatric-adjusted (SIPA) was presented for early prediction of mortality and trauma team activation in paediatric trauma patients. However, the derived cut-offs of normal vital signs were based on old references. We established alternative SIPAs based on the other commonly used references and compared their predictive values. METHODS: We performed a retrospective review of all paediatric trauma patients aged 1-15 years in the Emergency Department (ED)-based Injury In-depth Surveillance (EDIIS) database from January 1, 2011 to December 31, 2019. A total of 4 types of SIPA values were obtained based on the references as follows: uSIPA based on the Nelson textbook of paediatrics 21st ed., SIATLS based on the ATLS 10th guideline, SIPALS based on the PALS 2020 guideline, and SIPA. In each SIPA group, the cut-off was established by dividing the group into 4 subgroups: toddler (age 1-3), preschooler (age 4-6), schooler (age 7-12), and teenager (age 13-15). We performed an ROC analysis and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to compare the predicted values of each SIPA in mortality, ICU admission, and emergent surgery or intervention. RESULTS: A total of 332,271 patients were included. The proportion of patients with an elevated shock index was 14.9 % (n = 49,347) in SIPA, 22.8 % (n = 75,850) in uSIPA, 0.3 % (n = 1058) in SIATLS, and 4.3 % (n = 14,168) in SIPALS. For mortality, uSIPA achieved the highest sensitivity (57.0 %; 95 % confidence interval 56.9 %-57.2 %) compared to SIPA (49.4 %, 95 % CI 49.2 %-49.5 %), SIATLS (25.5 %, 95 % CI 25.4 %-25.7 %), and SIPALS (43.8 %, 95 % CI 43.7 %-44.0 %), but there were no significant differences in the negative predictive value (NPV) or area under the curve (AUC). The positive predictive value (PPV) was highest in SIATLS (5.7 %, 95 % CI 5.6 %-5.8 %) compared to SIPA (0.2 %, 95 % CI 0.2 %-0.3 %), uSIPA (0.2 %, 95 % CI 0.2 %-0.2 %), and SIPALS (0.7 %, 95 % CI 0.7 %-0.8 %). The same findings were presented in ICU admission and emergent operation or intervention. CONCLUSION: The ATLS-based shock index achieved the highest PPV and specificity compared to SIPA, uSIPA, and SIPALS for adverse outcomes in paediatric trauma.

Unpowered scooter injuries in children and risk factors for traumatic brain injuries: An 8-year cross-sectional study using a national registry in South Korea.

INTRODUCTION: Head trauma accounts for a large proportion of unpowered scooter injuries in children. Traumatic brain injury (TBI) is the leading cause of considerable mortality and morbidity in children, who are the main users of unpowered scooters. The aim of this study was to explore the characteristics of unpowered scooter injuries in children and to identify predictors of the occurrence of TBI. METHODS: A multicentre observational retrospective study was conducted using the Emergency Department-based Injury In-depth Surveillance (EDIIS) database in South Korea. Children aged 2 to 18 years old with unpowered scooter injuries between 2011 and 2018 were eligible for inclusion in this study, and the primary outcome was TBI defined based on the International Classification of Diseases, 10th Revision (ICD-10) code. RESULTS: The annual rate of unpowered scooter injuries per 1,000 injured patients increased throughout the study period from 1.4 in 2011 to 16.4 in 2018 (P for trend < 0.001). Of the 3,892 children who had unpowered scooter injuries, 353 (9.2 %) had TBI. Children were at a higher risk of unpowered scooter TBI if they were aged between 2 and 5 years (adjusted odds ratio [aOR]: 1.37; 95 % confidence interval (CI): 1.09-1.73), were male (aOR: 1.45; 95 % CI: 1.14-1.86), were injured either on sidewalks (aOR: 1.80; 95 % CI: 1.20-2.70) or on driveways (aOR: 2.31; 95 % CI: 1.41-3.79), and experienced a fall (aOR: 1.98; 95 % CI: 1.15-3.43). Additionally, children injured after a blunt force were at a lower risk of TBI (aOR: 0.28; 95 % CI: 0.15-0.53). CONCLUSION: Unpowered scooter injuries in children are increasing in South Korea. It is essential for younger children riding unpowered scooters to wear helmets and for caregivers to actively supervise their children to prevent TBI.

Factors contributing to uncertainty in paediatric abdominal ultrasound reports in the paediatric emergency department.

BACKGROUND: Abdominal pain, which is a common cause of children presenting to the paediatric emergency department (PED), is often evaluated by ultrasonography (US). However, uncertainty in US reports may necessitate additional imaging. OBJECTIVE: In this study, we evaluated factors contributing to uncertainty in paediatric abdominal US reports in the PED. MATERIALS AND METHODS: This retrospective cohort study included children younger than 18 years of age who underwent abdominal US in the PED of the study hospital between January 2017 and December 2019. After exclusion, the researchers manually reviewed and classified all US reports as 'certain' or 'uncertain'. Univariate and multivariate logistic regression analyses were performed to identify the factors contributing to uncertain reports. RESULTS: In total, 1006 patients were included in the final analysis., 796 patients were tagged as having certain reports, and 210 as having uncertain reports. Children with uncertain reports had a significantly higher rate of undergoing an additional computed tomography (CT) scan (31.0% vs. 2.5%, p < 0.001) and a longer PED median length of stay (321.0 (Interquartile range (IQR); 211.3-441.5) minutes vs. 284.5 (IQR; 191.8-439.5) minutes, p = 0.042). After logistic regression, US performed by a radiology resident (odds ratio, 5.01; 95% confidence interval, 3.63-7.15) was the most significant factor contributing to uncertainty in paediatric abdominal US reports followed by obesity and age. CONCLUSION: Several factors contribute to uncertainty in paediatric abdominal US reports. Uncertain radiological reports increase the likelihood of additional CT scans. Measures to improve the clarity of radiological reports must be considered to improve the quality of care for children visiting the PED.

Brain natriuretic peptide as a clinical screening tool for the diagnosis of Kawasaki disease.

N-terminal pro-brain natriuretic peptide (NT-proBNP) has been studied as a diagnostic screening tool for Kawasaki disease (KD). However, brain natriuretic peptide (BNP) has been less studied while has less variability among age groups. We aimed to find out if BNP can be used as a diagnostic screening tool for KD in Korea. This was a retrospective cohort study performed in a single pediatric emergency department. Patients younger than 19 years of age who presented with fever and underwent BNP examination for suspected KD was included. The primary outcome was the diagnostic performance of BNP for KD, and the secondary outcome was the diagnostic performance of BNP for coronary artery aneurysm (CAA). We also derived a scoring system for predicting KD and CAA. Of the 778 patients who were finally included, 400 were not diagnosed with KD and 378 were diagnosed with KD. The odds ratio of BNP at the cutoff of 30 pg/mL for KD was 7.80 (95% CI, 5.67-10.73) in the univariate analysis and 3.62 (95% CI, 2.33-5.88) in the multivariable analysis. The odds ratio of BNP at the cutoff of 270 pg/mL for CAA was 3.67 (95% CI, 2.18-6.19) in the univariate analysis and 2.37 (95% CI, 1.16-8.74) in the multivariable analysis. The AUC of KD and CAA were 0.884 and 0.726, respectively, which was the highest AUCs among all variables. Additionally, we proposed a scoring system for KD and CAA. It is important to clinically suspect KD and CAA in children with high BNP levels.

Delta Neutrophil Index Does Not Differentiate Bacterial Infection without Bacteremia from Viral Infection in Pediatric Febrile Patients.

Introduction: We sought to determine whether the delta neutrophil index (DNI), a marker that is reported to be used to predict the diagnosis, prognosis, and disease severity of bacteremia and sepsis, is useful in differentiating bacterial infection without bacteremia (BIWB) from viral infections (VI) in pediatric febrile patients in the emergency department (ED). Method: We conducted a retrospective analysis of febrile patients' medical records from the pediatric ED of the teaching hospital. The patients with BIWB and those with VI were identified with a review of medical records. The primary outcome was the diagnostic performance of DNI in differentiating BIWB from VI. The secondary outcome was a comparison of the diagnostic performances of DNI, CRP, WBC, and neutrophil count between the two groups. Results: A total of 151 (26.3%) patients were in the BIWB group, and 423 (73.7%) were in the VI group. There was no significant difference in DNI between the two groups (3.51 ± 6.90 vs. 3.07 ± 5.82, mean ± SD, BIWB vs. VI). However, CRP levels were significantly higher in the BIWB group than in the VI group (4.56 ± 5.45 vs. 1.39 ± 2.12, mean ± SD, BIWB vs. VI, p < 0.05). The AUROCs of DNI, WBC count, neutrophil levels, RDW, and CRP levels were 0.5016, 0.5531, 0.5631, 0.5131, and 0.7389, respectively, and only CRP levels were helpful in differentiating BIWB from VI. Conclusion: In the absence of bacteremia, DNI would not be helpful in differentiating BIWB from VI in pediatric febrile patients.

Effect of a Virtual Reality Environment Using a Domed Ceiling Screen on Procedural Pain During Intravenous Placement in Young Children: A Randomized Clinical Trial.

Importance: Distraction using virtual reality (VR) has been found to provide a clinically significant reduction in the experience of pain during various painful procedures. Commercially available VR systems usually require the user to wear a head-mounted display helmet, which can be challenging for young children, and whether VR can reduce pain during intravenous (IV) placement in young children is currently unknown. Objective: To determine whether a VR environment using a novel domed ceiling screen reduces distress among children over the course of IV placement compared with standard care in a pediatric emergency department. Design, Setting, and Participants: This randomized clinical trial was conducted from June 3, 2020, to February 8, 2021, at an urban tertiary academic children's hospital. Included were children aged 6 months to 4 years undergoing IV placement in the pediatric emergency department. Intervention: Children in the intervention group lay on a bed to experience a VR animation using a domed ceiling screen during the IV placement procedure, which was performed as usual. Children in the control group also lay on a bed during the procedure but did not view a VR animation. Main Outcomes and Measures: The primary outcome was pain scores measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at 4 time points during IV placement: immediately after the child lay down on the bed (T1), the moment the tourniquet was applied (T2), the moment a sterile alcohol swab was applied (T3), and the moment the needle penetrated the skin (T4). Results: Of the 88 children included in the final analysis, 44 received VR distraction (median [IQR] age, 24.0 [14.5-44.0] months; 27 boys [61.4%]), and 44 received standard care (median [IQR] age, 23.0 [15.0-40.0] months; 26 boys [59.1%]). The median [IQR] FLACC scores at T4 were 6.0 (1.8-7.5) in the intervention group and 7.0 (5.5-7.8) in the control group. The ordinal logistic regression model showed that children in the VR intervention group vs the control group had a lower probability of higher FLACC scores (odds ratio, 0.53; 95% CI, 0.28-0.99; P = .046). Conclusions and Relevance: The findings of this trial indicate that displaying VR using a domed ceiling screen may be an effective distraction method that reduces distress in young children undergoing IV placement. Trial Registration: isrctn.org Identifier: KCT0005122.

Tablet personal computer distraction during intravenous placement for young children in the pediatric emergency department: A pilot study.

BACKGROUND: Intravenous (IV) placement is a common procedure experienced by children visiting the pediatric emergency department (PED). However, uncontrolled anxiety and pain cause children to interfere with the procedure. In this pilot study, we sought to evaluate the effectiveness of tablet personal computers as a distraction method during IV placement. METHODS: This is a single-center pilot study conducted at a tertiary teaching hospital. Children visiting the PED were eligible if they were aged 3-5 years and required IV placement during the PED visit. After written consent was obtained from the guardian, the child was randomly assigned to a control group or an intervention group. For the intervention group, an animated video was played via tablet PC during IV placement. For both groups, children's anxiety, heart rate, and pain scale scores (the Face, Legs, Activity, Cry, Consolability and Evaluation Enfant Douleur) and guardian satisfaction were recorded. RESULTS: 22 children were eligible for the final analysis. There was no significant difference in the pain scale scores between the two groups, with the exception of the degree of pain relief after the procedure measured using Evaluation Enfant Douleur (intervention group: 6.0, interquartile range (IQR): 4.2-6.8, and control group; 3.0, IQR: 2.0-3.8, P = 0.011) and Face, Legs, Activity, Cry, Consolability (intervention group: 4.0, IQR: 4.0-4.2 and control group; 3.0, IQR: 1.5-3.5, P = 0.043). CONCLUSION: In this pilot study, distraction using tablet personal computers may have reduced children's distress during the recovery phase after venipuncture. Further study with a larger sample size and different methods of distraction is essential.

Virtual reality environment using a dome screen for procedural pain in young children during intravenous placement: A pilot randomized controlled trial.

We assessed the feasibility and potential efficacy of a virtual reality (VR) environment using a dome screen as a distraction method in young children during intravenous (IV) placement in the pediatric emergency department. This randomized controlled pilot study enrolled children aged 2 to 6 years who underwent IV placement into either the intervention group or the control group. Children in the intervention group experienced VR using a dome screen during IV placement. The child's pain intensity was measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at four time points of IV placement: immediately after arrival to the blood collection room (base); immediately after the child laid down on the bed (preparation); when the tourniquet was applied (tourniquet); and the moment at which the needle penetrated the skin (venipuncture). The guardian's satisfaction and rating of the child's distress were assessed using a 5-point Likert-type questionnaire. We recruited 19 children (9 in the intervention group and 10 in the control group). Five children in the control group were excluded from the analysis because of missing video recordings (n = 3), failed first attempt at IV placement (n = 1), and the child's refusal to lie on the bed during the procedure (n = 1). No side effects of VR were reported during the study period. Although the average FLACC scale score at each time point (preparation, tourniquet, venipuncture) was lower in the intervention group than the control group, the difference was not statistically significant (2.3, interquartile range [IQR]: 2.0-3.0; vs. 3.3, IQR: 2.7-6.7, P = 0.255). There were no statistically significant differences between the groups in the guardian's satisfaction and anxiety or his/her rating of the child's pain and anxiety. The guardians and emergency medical technicians reported satisfaction with the use of VR with a dome screen and considered it a useful distraction during the procedure. VR using a dome screen is a feasible distraction method for young children during IV placement. A larger clinical trial with further development of the VR environment and study process is required to adequately evaluate the efficacy of VR using a dome screen.

Role of the urinary N-acetyl-beta-D-glucosaminidase/creatinine (NAG/Cr) ratio in discriminating between true and false pyuria in sterile urine bag specimens.

INTRODUCTION: Urethral catheterization (CATH) and suprapubic aspiration (SA) are reliable methods of collecting urine for the diagnosis of urinary tract infections (UTIs), but both are invasive and difficult. Therefore, urine collection through a sterile urine bag (SUB) is commonly used for UTI screening. However, when pyuria is found in SUB specimens, it is difficult to interpret whether this result is true or false. OBJECTIVE: We aimed to determine the diagnostic performance of the urinary NAG/Cr ratio in detecting true pyuria in SUB specimens for children with suspected UTIs. STUDY DESIGN: This retrospective study included children 2-24 months of age presenting to the pediatric emergency department (PED) and in whom urinary NAG and creatinine levels were measured and a urine culture was performed between January 1, 2018, and December 31, 2019. Children with the presence of pyuria in SUB specimens were categorized into true or false pyuria groups depending on whether pyuria was present in CATH specimens. The diagnostic performance of the urinary NAG/Cr ratio in detecting true pyuria was identified using receiver operating characteristic (ROC) curve analysis. The optimal cutoff was calculated based on ROC curve analysis. Sensitivity, specificity, and positive and negative likelihood ratios were assessed for optimal cutoff values. RESULTS: Among 606 children with measured urinary NAG levels, 144 children with pyuria in SUB specimens were included in the analyses. Pyuria was consistently present in the CATH specimens of 67 (46.5%) children and absent in those of 77 (44.5%) children. The urinary NAG/Cr ratio was significantly higher in the true pyuria group than in the false pyuria group (21.5 IU/g; 95% confidence interval [CI]: 12.3-35.6; vs 9.6 IU/g; 95% CI: 6.7-16.1, P < 0.001). The area under the ROC curve (AUC) for the urinary NAG/Cr ratio was 0.776 (95% CI: 0.700-0.851). The optimal cutoff of 18.85 IU/g corresponded to the best combination of sensitivity (58.2, 95% CI: 46.4-70.0) and specificity (83.3, 95% CI: 74.7-91.6), with positive and negative likelihood ratios of 3.49 (95% CI: 2.04-5.97) and 0.50 (95% CI: 0.37-0.68), respectively. CONCLUSION: The urinary NAG/Cr ratio may be a potential indicator discriminating true pyuria from false pyuria in SUB specimens in the PED. However, large prospective studies are required to implement the NAG/Cr ratio in clinical practice.

Are parents' statements reliable for diagnosis of serious bacterial infection among children with fever without an apparent source?: A retrospective study.

Serious bacterial infection (SBI) is a major cause of morbidity and mortality in children. Distinguishing SBI from self-limiting viral infections is a very important task in the emergency department (ED), especially in the children with fever without source (FWS). The aim of this study was to analyze whether parents' statements about clinical manifestations, which were categorized according to grades, are related to the actual diagnosis of SBI in children with FWS.Retrospective analysis was conducted using prospectively acquired cohort data for all febrile children in the pediatric ED of Seoul National University Hospital from August 2016 to August 2017. The association of clinical manifestations and SBI was the main outcome of this study. The SBIs included diagnoses such as bacteremia, bacterial meningitis, urinary tract infection, and pneumonia. Clinical manifestations including activity, urination, and feeding were categorized into 3 or 4 grades according to the parents' statements. The linear-by-linear association test was used to examine linear associations between the severity of clinical manifestations and SBI. Receiver operating characteristic curves for clinical manifestations were constructed for patients with SBI. Area under the curve (AUC) statistics and 95% confidence intervals (CIs) were obtained to evaluate the predictive performance of clinical manifestations.There was no linear association between SBI and non-SBI when compared by severity of the clinical manifestations, such as duration of fever (P = .299), activity (P = .781), feeding (P = .161), and urination (P = .834). The AUC was 0.54 (95% CI 0.41-0.67) for duration of fever, 0.52 for activity (95% CI 0.40-0.64), 0.42 for feeding (95% CI 0.32-0.53), and 0.51 for urination (95% CI 0.39-0.62).There was no evidence that the test performance of the clinical manifestations is valid for predicting SBIs, even considering the severity of manifestations. For optimal evaluation of the children with FWS, more comprehensive approach including laboratory tests, are needed.

Role of follow-up endoscopic examination in treatment response assessment for patients with gastric diffuse large B cell lymphoma.

OBJECTIVE: According to lymphoma guidelines, gastric diffuse large B cell lymphoma (DLBCL) patients should undergo regular computed tomography (CT) and/or positron emission tomography (PET) examinations to assess treatment response. Endoscopic examinations are not indicated in the guidelines. The aim of this study was to investigate the utility of endoscopic examinations during and after treatment for DLBCL. METHODS: We reviewed the patients diagnosed with gastric DLBCL at Seoul St. Mary's Hospital. All patients underwent endoscopy and radiologic examinations at every follow-up appointment. Radiologic response was defined according to World Health Organization criteria and endoscopic response was determined based on the Groupe d'Etude des Lymphomes de l'Adult grading system that is widely used in post-treatment evaluation of gastric MALT lymphoma. RESULTS: Forty-five patients were analyzed. Within a median follow-up period of 34 months, 35 patients achieved both radiologic and endoscopic complete remission (CR). The median times to endoscopic and radiologic CR were not significantly different (21 versus 16 weeks, p = 0.118). However, in 25 patients with stage I disease, endoscopic CR [median (range), 20 (11-36)] was achieved later than radiologic CR [median (range), 13 (8-36)] (p = 0.027). Among 40 patients who achieved radiologic CR, 35 patients who also achieved endoscopic CR maintained remission during the follow-up. Two of the five patients who achieved radiologic CR without endoscopic CR experienced recurrence. CONCLUSIONS: In gastric DLBCL patients, endoscopic response does not always correlate with radiologic response and might predict disease recurrence. We suggest that follow-up endoscopic examination with biopsy should be performed in addition to radiologic examination.

Multiple cancers in a patient with systemic sclerosis and aggravated interstitial lung disease by chemotherapy.

Although the relationship between malignancy risk with systemic sclerosis (SSc) has been inconclusive, there are some previous studies for a positive correlation. Most patients with SSc have some degree of lung parenchymal involvement in the form of interstitial thickening and fibrosis. Interstitial lung disease is the most common pulmonary manifestation of SSc. Interstitial lung disease following chemotherapy (5-fluorouracil, leucovorin, and oxaliplatin [FOLFOX]) is an uncommon life-threatening complication and it is induced by oxaliplatin. We report a case of multiple cancers in a patient with SSc and aggravated interstitial lung disease by chemotherapy.

Effects of degumming conditions on electro-spinning rate of regenerated silk.

Electro-spun silk webs are potentially good candidates as tissue engineering scaffolds owing to their good bio- and cyto-compatibility. However, the low fabrication rate of electro-spun silk mats has been one of the obstacles in the mass production of such nanofibrous silk mats in applications to the biomedical field. In this study, the effects of degumming ratio and silk concentration on the electro-spinning process were investigated by using regenerated silk with different residual sericin contents and different silk concentrations in terms of the morphology and structure of the electro-spun silk web. The rate of production of electro-spun silk mats could be increased by approximately 5 fold at a degumming ratio of 19.5%. The electro-spinning rate of silk was affected by two main factors: (1) dope solution viscosity and (2) degumming ratio of silk. The conductivity of the silk dope solution, however, had little effects on the electro-spinning of regenerated silk. A constant spun fiber morphology was observed within the electro-spinning rate range (0.3-1.4 ml/h). Fourier transform infrared spectroscopy showed that partial ß-sheet crystallization occurred during electro-spinning. The molecular conformation was relatively unaffected by the electro-spinning rate of silk.

[A case of severe bevacizumab-induced ischemic pancolitis, treated with conservative management].

Bevacizumab (Avastin(Ⓡ)) is a monoclonal antibody against the vascular endothelial growth factor (VEGF) receptor that increases the overall survival rate when added to standard chemotherapy regimens in patients with metastatic colorectal cancer. The known toxicities of bevacizumab are hypertension, proteinuria, wound healing complications, arterial thrombosis, bleeding, and gastrointestinal complications. Especially ischemic colitis can rapidly develop into bowel perforation, so an emergency operation often is needed. Recently, a 65-year-old male patient developed ischemic pancolitis after FOLFOX (85 mg/m(2) Oxaliplatin, d1; 200 mg/m(2) Leucovorin, d1; 400 mg/m(2) 5-FU iv bolus, d1-2; and 600 mg/m(2) 5-FU, d1-2, every two wk) and Bevacizumab combination chemotherapy was administered. However, he recovered after early conservative care without surgery. We report this case with a review of literature.

[A case of pseudomembranous colitis in a juvenile rheumatoid arthritis patient taking methotrexate].

Pseudomembranous colitis is mainly caused by antibiotics and Clostridium difficile infection. But conditions such as gastrointestinal surgery, antacid medication, anti-neoplastic agent or immunosuppressive agent which influences the normal flora of colon can induce colitis without the administration of any antibiotics. We experienced a 13 year-old male who was taking low-dose methotrexate for juvenile rheumatoid arthritis complained diarrhea and abdominal pain for 3 weeks. Sigmoidoscopic findings revealed diffuse patch yellowish pseudomembranes on the rectum. Histologic finding was compatible to pseudomembranous colitis. His symptom was improved after stop taking methotrexate and the administration of metronidazole. If a patient treated with immunosuppressive agents or antineoplastic agents complains diarrhea, fever or abdominal pain and has not improved with conservative care, pseudomembranous colitis should be taken into account as a differential diagnosis and prompt treatment is required for better prognosis.