Reliability of renal point-of-care ultrasound (POCUS) performed by pediatric postgraduates to diagnose hydronephrosis in infants

Purpose

Point-of-care ultrasound (POCUS) has gained prominence in a variety of medical specialties due to advances in ultrasound technology. POCUS has not been fully integrated into pediatric residency training programs despite its widespread use and proven benefits. At our institution, renal POCUS is performed by pediatric residents for the evaluation of hydronephrosis, which is the main pathology for which ultrasound is used in the clinical practice of pediatric nephrology. This study was conducted to evaluate the quality of renal POCUS performed by pediatric residents in infants.

Methods

Four pediatric residents, comprising two first-year and two second-year residents at Konyang University Hospital, participated in the study conducted from May 2021 to May 2022. All participants had completed our Point-of-Care Ultrasound (POCUS) training program. The study focused on infants admitted to the pediatric inpatient unit, identified by attending physicians as requiring renal ultrasound. All infants underwent their initial kidney ultrasound examination. Temporal alignment between renal Point-of-Care Ultrasound (POCUS) performed by pediatric residents and conventional ultrasound (USG) conducted by radiologists was asynchronous. Pediatric residents conducted POCUS sessions during scheduled radiologist appointments throughout the day, occurring either before or after the radiologist's examination. There was no mutual awareness of each other's results. Inter-observer agreement between radiologists and pediatric residents was compared for the presence or absence of hydronephrosis and its grade, which are primary considerations in pediatric renal ultrasound.

Results

Our study found that 53 infants (68.8%) were diagnosed with hydronephrosis using point-of-care ultrasound (POCUS), compared to 48 infants (62.3%) diagnosed with conventional ultrasound (USG). Among the POCUS examinations conducted by pediatric residents, hydronephrosis of SFU grades 1, 2, 3, and 4 were observed in 56.6%, 35.8%, 7.5%, and 0%, respectively. Inter-observer reliability between POCUS and conventional USG showed good agreement, with Cohen's kappa coefficients exceeding 0.8 for sensitivity and 0.6 for grading.

Conclusions

Renal POCUS performed well in diagnosing and grading hydronephrosis in infants when performed by pediatric residents who had completed a two-phase training program.

Structural and functional characterization of USP47 reveals a hot spot for inhibitor design

USP47 is widely involved in tumor development, metastasis, and other processes while performing a more regulatory role in inflammatory responses, myocardial infarction, and neuronal development. In this study, we investigate the functional and biochemical properties of USP47, whereby depleting USP47 inhibited cancer cell growth in a p53-dependent manner-a phenomenon that enhances during the simultaneous knockdown of USP7. Full-length USP47 shows higher deubiquitinase activity than the catalytic domain. The crystal structures of the catalytic domain, in its free and ubiquitin-bound states, reveal that the misaligned catalytic triads, ultimately, become aligned upon ubiquitin-binding, similar to USP7, thereby becoming ready for catalysis. Yet, the composition and lengths of BL1, BL2, and BL3 of USP47 differ from those for USP7, and they contribute to the observed selectivity. Our study provides molecular details of USP47 regulation, substrate recognition, and the hotspots for drug discovery by targeting USP47.

State-level nursing home in-service dementia training requirements and inappropriate psychotropic medication use

BACKGROUND

Although non-pharmacological interventions, which are staff intensive, are recommended for behavioral symptoms of dementia, psychotropics are often prescribed in nursing homes (NHs), with insufficient nurse staffing levels and dementia care training. Since 2017, deficiency citations can be assigned for inappropriate psychotropics use (F-758 tag). Some states require in-service dementia training above federal minimums, but it is unknown whether extra dementia training requirements were related to fewer F-758 citations for residents with dementia and whether nurse staffing influenced the relationship between receiving F-758 citations and having additional state-level dementia training requirements.

PURPOSE

To relate F-758 citation occurrence to extra in-service dementia training regulations and to explore how the relationships are affected by nurse staffing levels.

METHOD

Generalized linear mixed models were used to examine F-758 citation occurrence in relation to state-level in-service dementia training regulations. Stratification was also conducted to compare the effects in NHs with low versus high nurse staffing.

FINDINGS

Requiring in-service dementia training with extra hours was inversely related to receiving F-758 tags. That relationship was also noted in NHs with lower registered nurse and certified nurse assistant staffing.

DISCUSSION

In-service dementia training may be helpful in reducing inappropriate psychotropics use, particularly in facilities with lower nurse staffing.

DEFICIENCY CITATIONS ON INAPPROPRIATE PSYCHOTROPIC MEDICATION USE WHEN CARING FOR BEHAVIORAL SYMPTOMS OF DEMENTIA

The National Partnership to Improve Dementia Care in Nursing Homes in 2012, initiated by the Centers for Medicare and Medicaid (CMS), helped decrease antipsychotics use. However, inappropriate psychotropics use to control behavioral symptoms associated with dementia remains. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to explore the nature of inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia using a mixed-methods study design. During the first quarter of 2018 (January–March), 444 NHs received F-758 tags related to care of residents with dementia. Information on deficiencies were obtained from 2018 Certification and Survey Provider Enhanced Reporting (CASPER) data. Deficiency reports were obtained from CMS Nursing Home Compare and ProPublica. Quantitative analysis was done to examine the frequency of involved psychotropic medications, scope and severity of F-758 tags, and reasons for the citations. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports. Antipsychotics were the most involved drug category for F-758 tag citations. The three most common reasons for F-758 citations included failure to: identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on PRN psychotropic orders (121 NHs). This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality dementia care workforce and improving cooperation within healthcare professionals are recommended to ensure proper non-pharmacological and pharmacological interventions.

Nurse staffing and deficiency of care for inappropriate psychotropic medication use in nursing home residents with dementia

PURPOSE

Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms.

DESIGN

This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018.

METHODS

Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid.

RESULTS

There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44-0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77-0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04-0.26).

CONCLUSION

Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use.

CLINICAL RELEVANCE

Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

A decision tree model for predicting intravenous immunoglobulin resistance and coronary artery involvement in Kawasaki disease

Objectives

This study aims to develop a new algorithm for predicting intravenous immunoglobulin (IVIG) resistance and coronary artery involvement in Kawasaki disease (KD) through decision tree models.

Methods

Medical records of children hospitalized for KD were analysed retrospectively. We compared the clinical characteristics, and the laboratory data in the groups with IVIG resistance and coronary artery dilatations (CADs) in KD patients. The decision tree models were developed to predict IVIG resistance and CADs.

Results

A total 896 patients (511 males and 385 females; 1 month-12 years) were eligible. IVIG resistance was identified in 111 (12.3%) patients, and CADs were found in 156 (17.4%). Total bilirubin and nitrogen terminal- pro-brain natriuretic peptide (NT-proBNP) were significantly higher in IVIG resistant group than in IVIG responsive group (0.62 ± 0.8 mg/dL vs 1.38 ± 1.4 mg/dL and 1231 ± 2136 pg/mL vs 2425 ± 4459 mL, respectively, P < 0.01). Also, CADs were more developed in the resistant group (39/111; 14.9% vs. 117/785; 35.1%, P < 0.01). The decision tree for predicting IVIG resistance was classified based on total bilirubin (0.7 mg/mL, 1.46 mg/dL) and NT-proBNP (1561 pg/mL), consisting of two layers and four nodes, with 86.2% training accuracy and 90.5% evaluation accuracy. The Receiver Operating Characteristic (ROC) evaluated the predictive ability of the decision tree, and the area under the curve (AUC) (0.834; 95% confidence interval, 0.675–0.973; P < 0.05) showed relatively higher accuracy. The group with CADs had significantly higher total bilirubin and NT-proBNP levels than the control group (0.64 ± 0.82 mg/dL vs 1.04 ± 1.14 mg/dL and 1192 ± 2049 pg/mL vs 2268 ± 4136 pg/mL, respectively, P < 0.01). The decision trees for predicting CADs were classified into two nodes based on NT-proBNP (789 pg/mL) alone, with 83.5% training accuracy and 90.3% evaluation accuracy.

Conclusion

A new algorithm decision tree model presents for predicting IVIG resistance and CADs in KD, confirming the usefulness of NT-proBNP as a predictor of KD.

Saccharomyces boulardii and Lactulose for Childhood Functional Constipation: A Multicenter Randomized Controlled Trial

Background/Aims

The effects of probiotics in children vary based on diseases and probiotic strains. We aim to investigate the effectiveness of Saccharomyces boulardii and lactulose for treating childhood functional constipation.

Methods

This open-label randomized controlled trial was conducted at 10 university hospitals in Korea. Children who were diagnosed with functional constipation were allocated to 3 groups (lactulose monotherapy, combination therapy, and S. boulardii monotherapy). The primary outcome was treatment success rate that was accordingly defined as ≥ 3 bowel movements without incontinence at week 12. The cumulative successful maintenance and drug maintenance rates without drug changes were calculated throughout the study period. We compared stool frequency, incontinence, consistency, and painful defecation at week 2 among the 3 groups.

Results

Overall, 187 children were assigned to the lactulose monotherapy (n = 69), combination therapy (n = 68), or S. boulardii monotherapy (n = 50) groups. The primary outcome was significantly higher in the lactulose monotherapy group (26.1%) or combination therapy group (41.2%) than in the S. boulardii monotherapy group (8.0%). The S. boulardii monotherapy group showed a significantly lower cumulative successful maintenance and drug maintenance rate than the other 2 groups. There were no significant intergroup differences in the frequency of defecation, incontinence, painful defecation, or stool consistency during the follow-up at week 2.

Conclusion

S. boulardii monotherapy was not superior to lactulose monotherapy or combination therapy and showed a higher drug change rate, supporting the current recommendation of probiotics in the treatment of childhood functional constipation.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia

OBJECTIVES

The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.

DESIGN

A mixed-methods study was performed.

SETTING AND PARTICIPANTS

During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.

METHODS

Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ² tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports.

RESULTS

Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on PRN psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001).

CONCLUSIONS AND IMPLICATIONS

This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Correlation between Transient Elastography (Fibroscan®) and Ultrasonographic and Computed Tomographic Grading in Pediatric Nonalcoholic Steatohepatitis

PURPOSE

This study aimed to examine the advantages and usefulness of transient elastography (Fibroscan^®) in diagnosing non-alcoholic steatohepatitis in children and adolescents compared to those of abdominal computed tomography and liver ultrasonography.

METHODS

Forty-six children and adolescent participants aged between 6 and 16 years who underwent transient elastography (Fibroscan^®) as well as liver ultrasonography or abdominal computed tomography were included. Thirty-nine participants underwent liver ultrasonography and 11 underwent computed tomography. The physical measurements, blood test results, presence of metabolic syndrome, and the degree of liver steatosis and liver fibrosis were analyzed, and their correlations with transient elastography (Fibroscan^®), abdominal computed tomography, and liver ultrasonography, as well as the correlations between examinations, were analyzed.

RESULTS

Thirty-six participants (78.3%) were boys, and the mean age was 12.29±2.57 years, with a mean body mass index of 27.88±4.28. In the 46 participants, the mean values for aspartate aminotransferase, alanine aminotransferase, and total bilirubin were 89.87±118.69 IU/L, 138.54±141.79 IU/L, and 0.77±0.61 mg/dL, respectively. Although transient elastography (Fibroscan^®) and abdominal computed tomography grading had a statistically significant positive correlation with aspartate aminotransferase and alanine aminotransferase values, the correlations between the results of grading performed by transient elastography (Fibroscan^®), abdominal computed tomography, and liver ultrasonography were not statistically.

CONCLUSION

We confirmed that each examination was correlated with the results of some blood tests, suggesting the usefulness and possibility of diagnosis and treatment of steatohepatitis mediated by transient elastography (Fibroscan^®) in the department of pediatrics.

Hybrid Method Incorporating a Rule-Based Approach and Deep Learning for Prescription Error Prediction

INTRODUCTION

Recently, automated detection has been a new approach to address the risks posed by prescribing errors. This study focused on prescription errors and utilized real medical data to supplement the Drug Utilization Review (DUR)-based rules, the current prescription error detection method. We developed a new hybrid method through artificial intelligence for prescription error prediction by utilizing actual detection accuracy improvement to reduce 'warning fatigue' for doctors and improve medical care quality.

OBJECT

This study was conducted in the Department of Pediatrics, targeting children sensitive to drugs to develop a prescription error detection system. Based on the DUR prescription history, 15,281 patient-level observations of children from Konyang University Hospital (KYUH)'s common data model (CDM) and DUR were collected and analyzed retrospectively.

METHOD

Among the CDM data, inspection information was interlocked with DUR and reflected as standard information for model development; this included outpatient prescriptions from January 1 to December 31, 2018. Through consultation with pediatric clinicians, rule definitions and model development were conducted for 35 drugs, with 137,802 normal and 1609 prescription errors.

RESULTS

We developed a novel hybrid method of error detection in the form of an advanced rule-based deep neural network (ARDNN), which showed the expected performance (precision: 72.86, recall: 81.01, F1 score: 76.72) and reduced alarm pop-up alert fatigue to below 10%. We also created an ARDNN-based comprehensive dashboard that allows doctors to monitor prescription errors with alarm pop-ups when prescribing medications.

CONCLUSION

These results can advance the existing rule-based model by developing a prescription error detection model using deep learning. This method can improve overall medical efficiency and service quality by reducing doctors' fatigue.

Short-Stay Admissions Associated With Large COVID-19 Outbreaks in Maryland Nursing Homes

At the beginning of the COVID-19 pandemic, some nursing homes (NHs) in Maryland suffered larger outbreaks than others. This study examined how facility characteristics influenced outbreak size. We conducted a retrospective analysis of secondary data from Maryland NHs to identify characteristics associated with large outbreaks, defined as when total resident cases exceeded 10% of licensed beds, from January 1, 2020, through July 1, 2020. Our dataset was unique in its inclusion of short-stay residents as a measure of resident type and family satisfaction as a measure of quality. Facility characteristics were collected prior to 2020. Like other studies, we found that large outbreaks were more likely to occur in counties with high cumulative incidence of COVID-19, and in NHs with more licensed beds or fewer daily certified nursing assistant (CNA) hours. We also found that NHs with a greater proportion of short-stay residents were more likely to have large outbreaks, even after adjustment for other facility characteristics. Lower family satisfaction was not significantly associated with large outbreaks after adjusting for CNA hours. Understanding the characteristics of NHs with large COVID-19 outbreaks can guide facility re-structuring to prevent the spread of respiratory infections in future pandemics.

Nurse Staffing and Nursing Home Deficiency of Care for Inappropriate Psychotropics Use in Residents With Dementia

Psychotropics use to manage behavioral and psychological symptoms of dementia (BPSD) in nursing homes (NHs) has been the focus of policy attention due to their adverse effects. We hypothesized that NHs with lower nursing staffing would have greater reliance on psychotropics use to control BPSD. A NH deficiency of care can be cited for inappropriate psychotropics use (F-tag 758). The association between the occurrence of F-758 tags and nurse staffing in residents with dementia was examined using the 2017-18 Certification and Survey Provider Enhanced Reporting data (n=14,548 NHs). Staffing measures included nursing hours per resident day (HPRD) and registered nurse (RN) skill-mix. Generalized linear mixed models that included covariates (NH location, bed size, ownership, proportion of residents with dementia/depression/psychiatric disorders and with Medicare/Medicaid) estimated the magnitude of the associations. There were 1,872 NHs with F-758 tags indicating inappropriate psychotropics use for NH residents with dementia. NHs with greater RN and certified nurse assistant (CNA) HPRD had significantly lower odds of F-758 tags (OR=0.59 54, 95% CI=0.47 44-0.73 66; OR=0.87, 95% CI=0.77-0.99, respectively) and similar findings were found in NHs with greater RN skill-mix (OR=0.14 10, 95% CI=0.05 04-0.37 25). There were no significant associations between the occurrence of F-758 tags and licensed practice nurse and unlicensed nurse aide HPRD. This study found that RN and CNA staffing had inverse associations with inappropriate psychotropic use citations among residents with dementia. NHs with higher RN staffing ratios may be better able to implement alternatives to pharmacological approaches for BPSD. It is suggested that NHs be equipped with adequate nurse staffing levels to reduce unnecessary psychotropics use.

Dementia Care Training Regulations and Deficiencies of Care for Inappropriate Psychotropics Use in Nursing Homes

Psychotropics are often used to manage behavioral and psychological symptoms of dementia (BPSD) in nursing homes (NHs), despite their adverse effects and lack of efficacy. NHs can be flagged for inappropriate psychotropics use as a deficiency of care (F-tag 758). To improve dementia care, 15 states require dementia-specific in-service training for NH nursing staff with specific training content and hours. The study aimed to relate the occurrence of F-758 citations to the presence of dementia-specific in-service training regulations, stratified by nurse staffing levels (<75th vs ≥75th percentile of nurse hours per resident day, HPRD). Certification and Survey Provider Enhanced Reporting data (n=14,548 NHs) from 2017-18 were used, containing 1,872 NHs with F-758 tags related to care of residents with dementia. NHs in states specifying training content and hours had significantly lower odds of receiving F-758 tags (OR=0.75, 95% CI=0.60-0.94). Among NHs with lower registered nurse HPRD, those in states regulating training content and hours had significantly lower odds of receiving F-758 tags (OR=0.66, 95% CI=0.49-0.89), with similar findings among NHs with lower certified nurse assistant HPRD (OR=0.69, 95% CI=0.51 52-0.91 92). This study found that required dementia-specific in-service training may be helpful in facilities with lower staffing. It is recommended that states develop more comprehensive, robust dementia care training regulations for NH nursing staff.

Mortality Rate and Major Causes of Death by Gestational Age in Korean Children under 5 Years of Age

BACKGROUND

Preterm birth is associated with increased infant mortality. However, it is not clear whether prematurity is associated with mortality after 1 year of age. There is a lack of research on mortality rate and causes of death after infancy in preterm babies in Korea. We aimed to analyze the mortality rates and causes of deaths up to 5 years of age in Korea.

METHODS

Using the Microdata Integrated Service of Statistics Korea database, this retrospective cohort study screened infants born between 2010 and 2012. After applying the exclusion criteria, 1,422,913 live births were classified into the following groups by gestational age: those born at < 32 weeks' gestation (n = 10,411), those born between 32 and 36 weeks' gestation (n = 75,657), and those born at ≥ 37 weeks' gestation (n = 1,336,845). The association of gestational age with mortality in infancy (< 1 year of age) and childhood (1-5 years of age) was analyzed, with and without covariates. The major causes of death in infancy and childhood were analyzed by gestational age.

RESULTS

Overall, 4,930 (0.3%) children died between birth and 5 years of age, with 19.1% of these deaths occurring after infancy. Adjusted hazard ratios (HRs) for infant death were 78.79 (95% confidence interval [CI], 71.33-87.04) and 4.62 (95% CI, 4.07-5.24) for the < 32 and 32-36 weeks groups, respectively, compared to the full-term group; the adjusted HRs for deaths occurring at ages 1-5 years were 9.25 (95% CI, 6.85-12.50) and 2.42 (95% CI, 1.95-3.01), respectively. In infancy, conditions originating in the perinatal period were the most common cause of deaths in the < 32 and 32-36 weeks groups (88.7% and 41.9%, respectively). Contrarily, in the ≥ 37 weeks group, conditions originating in the perinatal period explained 22.7% of infant deaths, with congenital malformations primarily accounting for 29.6% of these deaths. The most common cause of death in children (after infancy) in the < 32 weeks group was perinatal causes (25.0%); in the 32-36 weeks group, congenital malformation and nervous system disease were the common causes (21.7% and 19.1%, respectively). In the ≥ 37 weeks group, injury, poisoning, and other consequences of external causes explained 26.6% of childhood deaths, followed by neoplasms and nervous system disease (15.7% and 14.7%, respectively).

CONCLUSION

Low gestational age is associated with not only infant mortality but also child mortality. The major causes of death differed by gestational age in infancy and childhood. For the care of preterm infants, especially those born at < 32 weeks' gestation, particular attention and continuous monitoring are needed in consideration of the major causes of deaths until 5 years of age.

Juvenile Polyp associated with Hypovolemic Shock Due to Massive Lower Gastrointestinal Bleeding

Juvenile polyps are the most common types of polyps in children, and patients usually present with lower gastrointestinal (GI) bleeding as the predominant symptom. These lesions, which are referred to as hamartomas, usually measure approximately 2 cm in size and are benign tumors located mainly in the rectum and sigmoid colon. The most common symptom of a juvenile polyp is mild intermittent rectal bleeding. It is rare for anemic patients because the amount of blood loss is small and often not diagnosed immediately. We present the case of a 6-year-old girl with a juvenile polyp in the distal transverse colon, who developed hypovolemic shock due to massive lower GI bleeding. Pediatricians must perform colonoscopy for thorough evaluation of polyps, because their location and size can vary and they can cause massive bleeding.

Delta-neutrophil index: a potential predictor of coronary artery involvement in Kawasaki disease by retrospective analysis

DNI is the immature granulocyte fraction provided by a blood cell analyzer, which is determined by subtracting the fraction of mature polymorphonuclear leukocytes from the sum of myeloperoxidase-reactive cells. We aimed to evaluate the role of Delta-neutrophil index (DNI) in cardiac prognosis prediction in children with Kawasaki disease (KD). Medical records of 193 patients were retrospectively reviewed. The values of DNI, white blood cells, erythrocyte sedimentation rate, the percent of polymorphonuclear leucocytes, C-reactive protein, aspartate transaminase, alanine aminotransferase, total bilirubin data of children with KD were analyzed. Also, sex and age of children were compared. The value of DNI was higher in children with cardiac complications [median 0.8 (0-0.26) vs 5.3 (3.55-8.95); P < 0.001]. The ROC curves showed that DNI was a better predictor of cardiac complications than other parameters. The best cutoff value for DNI to predict cardiac complications was 5.55% with sensitivity of 80% and specificity of 82% (AUC 0.883, 95% confidence interval [CI] 0.807-0.959, P < 0.05). DNI could serve as a facile and useful marker to predict cardiac complications in children with KD, as it is included in a routine complete blood count.

Usefulness of Transient Elastography for Non-Invasive Diagnosis of Liver Fibrosis in Pediatric Non-Alcoholic Steatohepatitis

BACKGROUND

Transient elastography (FibroScan®) is a non-invasive and rapid method for assessing liver fibrosis. While the feasibility and usefulness of FibroScan® have been proven in adults, few studies have focused on pediatric populations. We aimed to determine the feasibility and usefulness of FibroScan® in Korean children.

METHODS

FibroScan® examinations were performed in 106 children (age, 5-15 years) who visited the Konyang University Hospital between June and September 2018. Liver steatosis was measured in terms of the controlled attenuation parameter (CAP), while hepatic fibrosis was evaluated in terms of the liver stiffness measurement (LSM). Children were stratified into obese and non-obese controls, according to body mass index (≥ or < 95th percentile, respectively).

RESULTS

The obese group was characterized by significantly higher levels of aspartate aminotransferase (AST, 57.00 ± 48.47 vs. 26.40 ± 11.80 IU/L; P < 0.001) and alanine aminotransferase (ALT, 91.27 ± 97.67 vs. 16.28 ± 9.78 IU/L; P < 0.001), frequency of hypertension and abdominal obesity (abdominal circumference > 95% percentile) (P < 0.001), CAP (244.4-340.98 dB/m), and LSM (3.85-7.77 kPa) (P < 0.001). On FibroScan®, 30 of 59 obese children had fibrosis (LSM > 5.5 kPa), whereas the remaining 29 did not (LSM < 5.5 kPa). Obese children with fibrosis had higher levels of AST (73.57 ± 56.00 vs. 39.86 ± 31.93 IU/L; P = 0.009), ALT (132.47 ± 113.88 vs. 48.66 ± 51.29 IU/L; P = 0.001), and gamma-glutamyl transferase (106.67 ± 69.31 vs. 28.80 ± 24.26 IU/L; P = 0.042) compared to obese children without fibrosis. LSM had high and significant correlation (P < 0.05) with AST, ALT, homeostasis model assessment for insulin resistance, and AST-to-platelet ratio index.

CONCLUSION

FibroScan® is clinically feasible and facilitates non-invasive, rapid, reproducible, and reliable detection of hepatic steatosis and liver fibrosis in the Korean pediatric population.

The improvement of right ventricular function after adenotonsillectomy in children with obstructive sleep apnea

Purpose

Adenotonsillar hypertrophy (ATH) that causes upper airway obstruction might lead to chronic hypoxemic pulmonary vasoconstriction and right ventricular (RV) dysfunction. We aimed to evaluate whether adenotonsillectomy (T&A) in children suffering from obstructive sleep apnea (OSA) due to severe ATH could improve RV function.

Methods

Thirty-seven children (boy:girl=21:16; mean age, 9.52±2.20 years), who underwent T&A forsleep apnea due to ATH, were included. We analyzedthe mean pulmonary artery pressure (mPAP), the presence and the maximal velocity of tricuspid regurgitation (TR), the tricuspid annular plane systolic excursion (TAPSE), and the right ventricular myocardial performance index (RVMPI) with tissue Doppler echocardiography (TDE) by transthoracic echocardiography pre- and post-T&A. The follow-up period was 1.78±0.27 years.

Results

Only the RVMPI using TDE improved after T&A (42.18±2.03 vs. 40±1.86, P=0.001). The absolute value of TAPSE increased (21.45±0.90 mm vs. 22.30±1.10 mm, P=0.001) but there was no change in the z score of TAPSE pre- and post-T&A (1.19±0.34 vs. 1.24±0.30, P=0.194). The mPAP was within normal range in children with ATH, and there was no significant difference between pre- and post-T&A (19.6±3.40 vs. 18.7±2.68, P=0.052). There was no difference in the presence and the maximal velocity of TR (P=0.058).

Conclusion

RVMPI using TDE could be an early parameter of RV function in children with OSA due to ATH.

Clinical manifestation of Campylobacter enteritis in children

Purpose

Timely antibiotic therapy in selected cases of diarrhea associated with bacterial infections can reduce the duration and severity of illness and prevent complications. The availability of a predictive index before identification of causative bacteria would aid in the choice of a therapeutic agent.

Methods

The study included patients admitted to the pediatrics unit at Konyang University Hospital for acute inflammatory diarrhea from August 1, 2015 to July 31, 2016 who underwent multiplex polymerase chain reaction testing. Of 248 patients, 83 had positive results. The clinical symptoms and blood test results were examined in 61 patients with Campylobacter spp. (25 patients), Salmonella spp. (18 patients), and Clostridium perfringens (18 patients) infections. The mean age of the 61 patients (male:femal=31:30) was 84.0±54.8 months, and the mean hospital stay was 4.6±1.7 days.

Results

There were no statistical differences in sex, age, clinical symptoms, or signs. Patients with Campylobacter infection were significantly older (P=0.00). C-reactive protein (CRP) levels in patients with Campylobacter infection were higher than those in the other 2 groups, at 9.6±6.1 mg/dL. The results of receiver-operating characteristic curve analysis showed that the cutoff age was ≥103.5 months (sensitivity, 72%; specificity, 86%) and the CRP cutoff level was ≥4.55 mg/dL (sensitivity, 80%; specificity, 69%).

Conclusion

Age (≥103.5 months) and higher CRP level (≥4.55 mg/dL) were good predictors of Campylobacter enterocolitis. If neither criterion was met, Campylobacter enterocolitis was unlikely (negative predictive value 97.2%). When both criteria were met, Campylobacter enterocolitis was highly likely.

Trends in Fetal and Perinatal Mortality in Korea (2009-2014): Comparison with Japan and the United States

Fetal death is an important indicator of national health care. In Korea, the fetal mortality rate is likely to increase due to advanced maternal age and multiple births, but there is limited research in this field. The authors investigated the characteristics of fetal deaths, the annual changes in the fetal mortality rate and the perinatal mortality rate in Korea, and compared them with those in Japan and the United States. Fetal deaths were restricted to those that occurred at 20 weeks of gestation or more. From 2009 to 2014, the overall mean fetal mortality rate was 8.5 per 1,000 live births and fetal deaths in Korea, 7.1 in Japan and 6.0 in the United States. While the birth rate in Korea declined by 2.1% between 2009 and 2014, the decrease in the number of fetal deaths was 34.5%. The fetal mortality rate in Korea declined by 32.9%, from 11.0 in 2009 to 7.4 in 2014, the largest decline among the 3 countries. In addition, rates for receiving prenatal care increased from 53.9% in 2009 to 75.0% in 2014. Perinatal mortality rate I and II were the lowest in Japan, followed by Korea and the United States, and Korea showed the greatest decrease in rate of perinatal mortality rate II. In this study, we identified that the indices of fetal deaths in Korea are improving rapidly. In order to maintain this trend, improvement of perinatal care level and stronger national medical support policies should be maintained continuously.

Pathologic Impact of Insulin Resistance and Sensitivity on the Severity of Liver Histopathology in Pediatric Non-Alcoholic Steatohepatitis

PURPOSE

Insulin resistance (IR) has an important role in the development of non-alcoholic steatohepatitis (NASH). We aimed to analyze the association between liver histopathology and IR in pediatric patients with NASH.

MATERIALS AND METHODS

In 24 children with non-alcoholic fatty liver disease (NAFLD), we investigated whether the hepatic pathologic characteristics have relations with following three biochemical indices; IR index including homeostasis model assessment of IR (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), and insulin sensitivity indices-free fatty acid (ISI-FFA).

RESULTS

Among 24 patients, 16 (66.6%) had a high NAFLD activity score (NAS), which is diagnostic of NASH. Higher serum triglyceride level was significantly correlated with a high NAS. Higher steatosis grades were significantly associated with low insulin sensitivity (p=0.023). In addition, severe lobular inflammation was associated with higher IR: HOMA-IR (p=0.014) and QUICKI (p=0.023). Severe fibrosis correlated with low insulin sensitivity and high IR indexes: ISI-FFA (p=0.049), HOMA-IR (p=0.028), and QUICKI (p=0.007).

CONCLUSION

Patients with high IR had more severe lobular inflammation and hepatic fibrosis. Analyses of biochemical and endocrine parameters can be applied to determine the severity of the hepatic pathologic status in patients with NASH, especially in children who cannot undergo a liver biopsy.

The Relationships between Respiratory Virus Infection and Aminotransferase in Children

PURPOSE

We sought to examine the relationship between the clinical manifestations of nonspecific reactive hepatitis and respiratory virus infection in pediatric patients.

METHODS

Patients admitted to the pediatric unit of Konyang University Hospital for lower respiratory tract disease between January 1, 2014 and December 31, 2014 and who underwent reverse transcriptase polymerase chain reaction tests were examined. The patients were divided into those with increased levels of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) and those with normal ALT or AST levels. Further, patients with increased ALT and AST levels were individually compared with patients in the normal group, and the blood test results were compared according to the type of respiratory virus.

RESULTS

Patients with increased ALT or AST levels had one more day of hospital stay, on average, compared with patients in the normal group (5.3±3.1 days vs. 4.4±3.0 days, p=0.019). Patients in the increased ALT level group were younger and had a longer mean hospital stay, compared with patients in the normal group (p=0.022 and 0.003, respectively). The incidences of increased ALT or AST were the highest in adenovirus infections (6/24, 25.0%), followed by enterovirus (2/11, 18.2%) and respiratory syncytial virus A (21/131, 16.0%) infections.

CONCLUSION

Nonspecific reactive hepatitis is more common among patients with adenovirus, enterovirus and respiratory syncytial virus infection, as well as among those infected at a younger age. Compared with AST levels, ALT levels are better indicators of the severity of nonspecific reactive hepatitis.

Granular cell tumor of the esophagus in an adolescent

Esophageal granular cell tumor (GCT) is a rare neoplasm originating from the Schwann cells of the submucosal neuronal plexus. Histology is the gold standard for its diagnosis. Endoscopic resection or surgical excision should be considered, depending on the potential for malignancy. Here, we report a case of an esophageal GCT in an adolescent. A 12-year-old boy presented with a 1-year history of dysphagia and vomiting. Upper gastrointestinal endoscopic examination and esophagography showed narrowing of the midesophagus, and computed tomography angiography of the thoracic aorta revealed an esophageal or periesophageal mass posterior to the paratracheal segment of the esophagus. The tumor was surgically excised, and based on the pathological findings, esophageal GCT was diagnosed.

Interstitial deletion of 5q33.3q35.1 in a boy with severe mental retardation

Constitutional interstitial deletions of the long arm of chromosome 5 (5q) are quite rare, and the corresponding phenotype is not yet clearly delineated. Severe mental retardation has been described in most patients who present 5q deletions. Specifically, the interstitial deletion of chromosome 5q33.3q35.1, an extremely rare chromosomal aberration, is characterized by mental retardation, developmental delay, and facial dysmorphism. Although the severity of mental retardation varies across cases, it is the most common feature described in patients who present the 5q33.3q35.1 deletion. Here, we report a case of a de novo deletion of 5q33.3q35.1, 46,XY,del(5)(q33.3q35.1) in an 11-year-old boy with mental retardation; to the best of our knowledge this is the first case in Korea to be reported. He was diagnosed with severe mental retardation, developmental delay, facial dysmorphisms, dental anomalies, and epilepsy. Chromosomal microarray analysis using the comparative genomic hybridization array method revealed a 16-Mb-long deletion of 5q33. 3q35.1(156,409,412-172,584,708)x1. Understanding this deletion may help draw a rough phenotypic map of 5q and correlate the phenotypes with specific chromosomal regions. The 5q33.3q35.1 deletion is a rare condition; however, accurate diagnosis of the associated mental retardation is important to ensure proper genetic counseling and to guide patients as part of long-term management.

Age-adjusted plasma N-terminal pro-brain natriuretic peptide level in Kawasaki disease

Purpose

Recent reports showed that plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) could be a useful biomarker of intravenous immunoglobulin (IVIG) unresponsiveness and coronary artery lesion (CAL) development in Kawasaki disease (KD). The levels of these peptides are critically influenced by age; hence, the normal range and upper limits for infants and children are different. We performed an age-adjusted analysis of plasma NT-proBNP level to validate its clinical use in the diagnosis of KD.

Methods

The data of 131 patients with KD were retrospectively analyzed. The patients were divided into 2 groups—group I (high NT-proBNP group) and group II (normal NT-proBNP group)—comprising patients with NT-proBNP concentrations higher and lower than the 95th percentile of the reference value, respectively. We compared the laboratory data, responsiveness to IVIG, and the risk of CAL in both groups.

Results

Group I showed significantly higher white blood cell count, absolute neutrophil count, C-reactive protein level, aspartate aminotransferase level, and troponin-I level than group II (P<0.05). The risk of CAL was also significantly higher in group I (odds ratio, 5.78; P=0.012). IVIG unresponsiveness in group I was three times that in group II (odds ratio, 3.35; P= 0.005).

Conclusion

Age-adjusted analysis of plasma NT-proBNP level could be helpful in predicting IVIG unresponsiveness and risk of CAL development in patients with KD.

The Association between Helicobacter pylori Infection and Body Weight among Children

PURPOSE

We performed to reveal the association between the Helicobacter pylori infection and body weight among children.

METHODS

Out retrospective study included patients who underwent the H. pylori immunoglobulin G testing at Konyang University Hospital between March 2011 and June 2014. These patients were classified as seropositive (28 boys, 27 girls; mean age: 9.89±3.28 years) or seronegative (55 boys, 54 girls; mean age: 9.84±3.02 years). Next, we compared various characteristics between the seropositive and negative groups, as well as between obese children (body weight ≥90th percentile) and non-obese children (body weight <90th percentile). Furthermore, we compared the change in body weight after 2 months of treatment with amoxicillin, clarithromycin and omeprazole among the 55 seropositive children (14 treated children and 41 non-treated children).

RESULTS

There were no differences in the weights and laboratory data for the 55 seropositive children and 109 seronegative children (weight; 40.96±18.11 kg vs. 36.85±13.72 kg, respectively; p=0.14). And, there was no difference in the prevalence of H. pylori infection among the 29 obese and 135 non-obese children (p=0.581). However, after 2 months of eradication, the 14 treated patients exhibited a significant weight gain (+0.91±0.52 kg), compared to the 41 non-treated patients (-0.29±1.16 kg, p=0.025).

CONCLUSION

Our findings present that obesity was not associated with the H. pylori infection, although H. pylori eradication led to significant increase in body weight.

A pediatric case of Bickerstaff's brainstem encephalitis

Bickerstaff's brainstem encephalitis is characterized by ophthalmoplegia, ataxia, and disturbance of consciousness. It is similar to Miller Fisher syndrome, a variant of Guillain-Barre syndrome, in that they share features such as ophthalmoplegia and ataxia. The difference is that patients with Bickerstaff's brainstem encephalitis have impaired consciousness, whereas patients with Miller Fisher syndrome have alert consciousness and areflexia. Here, we report the case of a 3-year-old child who was diagnosed with Bickerstaff's brainstem encephalitis presenting typical clinical features and interesting radiological findings. The patient showed ophthalmoplegia, ataxia, and subsequent stuporous mentality. Brain magnetic resonance imaging revealed high signal intensity in the pons and cerebellum around the 4th ventricle on a T2-weighted image. He was successfully treated with intravenous immunoglobulin. Differentiation of Bickerstaff's brainstem encephalitis and Miller Fisher syndrome is often difficult because they possess many overlapping features. Brain magnetic resonance imaging may be helpful in diagnosing Bickerstaff's brainstem encephalitis, especially when lesions are definitely found.

Prognosis of Glioblastoma With Oligodendroglioma Component is Associated With the IDH1 Mutation and MGMT Methylation Status

Glioblastoma (GBM) with oligodendroglioma component (GBMO) is a newly described GBM subtype in the 2007 World Health Organization classification. However, its biological and genetic characteristics are largely unknown. We investigated the clinicopathological and molecular features of 34 GBMOs and compared the survival rate of these patients with those of patients with astrocytoma, oligodendroglioma, anaplastic oligoastrocytoma (AOA), and conventional GBMs in our hospital. GBMO could be divided into two groups based on the presence of an IDH1 mutation. The IDH1 mutation was more frequently found in secondary GBMO, which had lower frequencies of EGFR amplification but higher MGMT methylation than the wild type IDH1 group, and patients with mutant IDH1 GBMO were on average younger than those with wild-type IDH1. Therefore, GBMO is a clinically and molecularly heterogeneous subtype, largely belonging to a proneural and classical subtype of GBM. The survival rate of GBMO patients itself was worse than that of AOA patients but not significantly better than that of conventional GBM patients. GBMO survival was independent of the dominant histopathological subtype i.e., astrocyte-dominant or oligodendroglioma -dominant, but it was significantly associated with the IDH1 mutation and MGMT methylation status. Therefore, GBMO should be regarded as a separate entity from AOA and must be classified as a subtype of GBM. However, further study is needed to determine whether it is a pathologic variant or a pattern of GBM because GBMO has a similar prognosis to conventional GBMs.

Effect of adenotonsillar hypertrophy on right ventricle function in children

Purpose

Chronic upper airway obstruction causes hypoxemic pulmonary vasoconstriction, which may lead to right ventricle (RV) dysfunction. Adenotonsillar hypertrophy (ATH) is the most common cause of upper airway obstruction in children. Therefore, we aimed to evaluate RV function in children with ATH.

Methods

Twenty-one children (male/female, 15/6; mean age, 92.3¡¾39.0 months; age range, 4-15 years) with ATH and 21 healthy age- and gender-matched controls were included in this study. Tricuspid annular plane systolic excursion and RV myocardial performance index were measured by transthoracic echocardiography. Further, the plasma level of N-terminal of probrain natriuretic peptide (NT-proBNP), an indicator of RV function, was determined.

Results

The snoring-tiredness during daytime-observed apnea-high blood pressure (STOP) questionnaire was completed by the patients' parents, and loud snoring was noted in the ATH group. The plasma NT-proBNP level was significantly higher in the ATH group than that in the controls (66.44±37.63 pg/mL vs. 27.85±8.89 pg/mL, P=0.001). The echocardiographic parameters were not significantly different between the groups.

Conclusion

We were unable to confirm the significance of echocardiographic evidence of RV dysfunction in the management of children with ATH. However, the plasma NT-proBNP level was significantly higher in the ATH group than that in the control, suggesting that chronic airway obstruction in children may carry a risk for cardiac dysfunction. Therefore, more patients should be examined using transthoracic echocardiography. In addition, pediatricians and otolaryngologists should consider cardiologic aspects during the management of children with severe ATH.

Fabrication of nanocrystalline surface composite layer on Cu plate under ball collisions

It was demonstrated that the severe plastic deformation of a surface induced by repeated ball collisions can be effectively used for fabrication of the nanocrystalline surface composite layers. The Cu disk was fixed at the top of a vibration chamber and ball treated. Al, Zr, Ni, Co and Fe were introduced into a Cu plate as contaminants from the grinding media one after the other by 15-min ball treatment. The composite structure was formed as a result of mechanical intermixing of the components. The particle size in as-fabricated layer ranged from 2 nm to 20 nm, with average values of about 7 nm. As-fabricated layer contained non-equilibrium multicomponent solid solution based on FCC Cu crystal structure, Zr-based phase, nanosized steel debris and amorphous phase. The hardness of the as-fabricated composite was almost ten times that of the initial Cu plate.

Fecal calprotectin concentration in neonatal necrotizing enterocolitis

PURPOSE

Among the many factors associated with acute intestinal mucosal infection, numerous studies have proposed the usefulness of fecal calprotectin. The aim of this study was to evaluate the usefulness of fecal calprotectin in the diagnosis of necrotizing enterocolitis (NEC).

METHODS

We collected 154 stool samples from 16 very low birth weight and premature newborns at the Konyang University Hospital neonatal intensive care unit or neonatal nursery. The stool samples were collected using the Calprest device, and the fecal calprotectin level was measured with the BÜHLMANN Calprotectin enzyme-linked immunosorbent assay kit.

RESULTS

Fecal calprotectin levels were significantly higher in the NEC group than in the non-NEC group (P=0.02). There was a significant positive linear relationship between the fecal calprotectin level and number of days after birth (P=0.00) in the gestational age <26 weeks group. There was a significant negative linear relationship between the calprotectin level and number of days after birth (P=0.03) in the gestational age ≥26 weeks and <30 weeks group. There was no difference in the calprotectin levels according to the type and method of feeding between the NEC and non-NEC groups.

CONCLUSION

Fecal calprotectin levels were significantly increased in premature infants with NEC. The fecal calprotectin test is a noninvasive, easy, and useful tool for the diagnosis of NEC.

Dyslipidemia in children and adolescents: when and how to diagnose and treat?

Recently, the incidence and prevalence of obesity and dyslipidemia are increasing. Dyslipidemia is associated with significant comorbidities and complications, and with cardiovascular risk factors (obesity, diabetes mellitus, hypertension and smoking). The main objectives of this article are that describe the prevalence of dyslipidemia in Korean children and adolescents and review the diagnosis and management of dyslipidemia in children and adolescents.

Increase in Aminotransferase Levels during Urinary Tract Infections in Children

PURPOSE

The aim of this study was to evaluate the prevalence of increased aminotransferase levels and to identify associated factors in children admitted to hospital with urinary tract infections (UTIs).

METHODS

The study included children with a diagnosis of UTI who were admitted to the Konyang University Hospital from January 2007 to May 2011. The total number of patients was 249 and the mean age was 15.88±28.21 months. UTI was defined as a positive urine culture (>10(5)/colony forming unit [CFU]) with pyrexia. Patients were treated by intravenous antibiotics, such as ampicillin/sulbactam, aminoglycoside, cephalosporins or vancomycin. Patients with neonatal jaundice or other liver disease were excluded. We investigated the relationship of aminotransferase levels with the type of antibiotic, degree of vesicoureteral reflux (VUR), and causative organisms.

RESULTS

Children with increased aminotransferase levels were younger than those with normal levels (p=0.001), but white blood cell count, platelet count, causative organisms, type of antibiotics and presence of VUR were not associated with aminotransferase levels. Aminotransferase levels became normal within 1 month after discharge without special measures, except in 1 case.

CONCLUSION

We found that many children with UTI have abnormal aminotransferase levels. In most cases, this change is mild and self-limiting. We conclude that increased aminotransferase level increase during UTI do not require unnecessary tests and excessive treatment.

Effect of early postnatal neutropenia in very low birth weight infants born to mothers with pregnancy-induced hypertension

Purpose

In this study, we aimed to investigate the perinatal clinical conditions of very low birth weight (VLBW) infants born to mothers with pregnancy-induced hypertension (PIH) focusing on the effects of early postnatal neutropenia.

Methods

We reviewed the medical records of 191 VLBW infants who were born at Konyang University Hospital, between March 2003 and May 2011. We retrospectively analyzed the clinical characteristics of the infants and their mothers and compared the incidence of perinatal diseases and mortality of the infants according to the presence or absence of maternal PIH and neutropenia on the first postnatal day.

Results

Infants born to mothers with PIH showed an increased incidence of neutropenia on the first postnatal day (47.4%), cesarean delivery, and intrauterine growth restriction. When the infants born to mothers with PIH showed neutropenia on the first postnatal day, their incidence of respiratory distress syndrome (RDS) was increased (P=0.031); however, the difference was not found to be significant through logistic regression analysis. In all the VLBW infants, neutropenia on the first postnatal day was correlated with the development of RDS. The incidence of the other perinatal diseases involving sepsis and mortality did not significantly differ according to the presence or absence of neutropenia in infants born to mothers with PIH.

Conclusion

In VLBW infants born to mothers with PIH, the incidence of neutropenia on the first postnatal day was increased and it was not significantly correlated with the development of perinatal diseases involving RDS, sepsis, and mortality.

The immune modulation of Clara cell-10 in human peripheral monocytes and dendritic cells

Although Clara cell secretory protein (CC-10, CC-16 or uteroglobin, secretoglobin 1A1) has been ascribed anti-inflammatory, immunomodulatory and anti-cancer activity roles in lung diseases including lung cancer, its precise function remains unclear. The objective of the present study was to evaluate the role of CC-10 in the immunomodulation of human monocytes and dendritic cells (DCs). The human lung adenocarcinoma cell line A549, was used to examine PGE2 production after cyclooxygenase (COX) inhibition and adenovirus encoding human CC-10 cDNA (Ad-CC-10) transfection. Type I and II cytokines were measured from peripheral blood mononuclear cells (PBMCs) and DCs which were cultured with tumor supernatant (TSN) or Ad-CC-10 transfected TSN. When PBMCs were cultured with supernatant A549 (tumor supernatant, TSN), the levels of T-cell helper type 1 (Th1) and 2 (Th2) cytokines increased. However, CC-10 inhibited the induction of Th2 cytokines of PBMCs stimulated with TSN. In DCs, TSN inhibited Th1 type cytokines but induced Th2 type. In contrast, TSN treated with either CC-10 or NS398 (COX-2 inhibitor) stimulated Th1 type and inhibited Th2 type without any phenotypic changes. The supernatants generated in the presence of NS-398 or CC-10 prevented tumor-induced inhibition of allogeneic T-cell stimulation. While the level of interleukin (IL)-10 secretion from DC-Ad-CC-10 was decreased, the level of IL-12 secretion was increased by CC-10. Collectively our data suggest that a supernatant of NSCLC causes an imbalance in the immune response of PBMCs and DCs, which is reversed by CC-10. This suggests that CC-10 is a candidate for the development of a new immunotherapy for lung cancer.

Clinical and histological features of nonalcoholic fatty liver disease in children

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is becoming more frequently diagnosed as the prevalence of obesity in children increases rapidly.

AIM

The aim of this study was to investigate the correlation of clinical findings with histopathologic features in children with NAFLD.

METHODS

We reviewed the clinical data and liver histology results of children with biopsy-proven NAFLD at Seoul National University Hospital. NAFLD was classified as simple steatosis, type 1 nonalcoholic steatohepatitis (NASH), characterized by ballooning degeneration and perisinusoidal fibrosis, or type 2 NASH, characterized by portal inflammation and portal fibrosis.

RESULTS

Among 80 total patients, 84% were male. All patients were obese or overweight. Insulin resistance was present in 96% of children. Perisinusoidal fibrosis was noted in 45% of children and portal fibrosis was noted in 77%. Simple steatosis was present in 22% of children, type 1 NASH in 34%, and type 2 NASH in 44%. No differences were found among NAFLD subtypes or NAFLD activity score with regard to sex, blood pressure, or levels of aminotransferase, fasting lipid, or insulin. Children with NASH were older and had higher body mass index than those with simple steatosis. Patients with type 2 NASH had higher body mass index and advanced fibrosis compared with patients with type 1 NASH.

CONCLUSIONS

Obesity and older age are associated with development of NASH. Type 2 NASH is the most common form and associated with a greater severity of obesity and advanced fibrosis.

Identification of farnesyl pyrophosphate and N-arachidonylglycine as endogenous ligands for GPR92

A series of small compounds acting at the orphan G protein-coupled receptor GPR92 were screened using a signaling pathway-specific reporter assay system. Lipid-derived molecules including farnesyl pyrophosphate (FPP), N-arachidonylglycine (NAG), and lysophosphatidic acid were found to activate GPR92. FPP and lysophosphatidic acid were able to activate both G(q/11)- and G(s)-mediated signaling pathways, whereas NAG activated only the G(q/11)-mediated signaling pathway. Computer-simulated modeling combined with site-directed mutagenesis of GPR92 indicated that Thr(97), Gly(98), Phe(101), and Arg(267) of GPR92 are responsible for the interaction of GPR92 with FPP and NAG. Reverse transcription-PCR analysis revealed that GPR92 mRNA is highly expressed in the dorsal root ganglia (DRG) but faint in other brain regions. Peripheral tissues including, spleen, stomach, small intestine, and kidney also expressed GPR92 mRNA. Immunohistochemical analysis revealed that GPR92 is largely co-localized with TRPV1, a nonspecific cation channel that responds to noxious heat, in mouse and human DRG. FPP and NAG increased intracellular Ca(2+) levels in cultured DRG neurons. These results suggest that FPP and NAG play a role in the sensory nervous system through activation of GPR92.

Inhibition of the catalytic activity of hypoxia-inducible factor-1alpha-prolyl-hydroxylase 2 by a MYND-type zinc finger

Hypoxia-induced gene expression is initiated when the hypoxia-inducible factor-1 (HIF-1) alpha subunit is stabilized in response to a lack of oxygen. An HIF-1alpha-specific prolyl-hydroxylase (PHD) catalyzes hydroxylation of the proline-564 and/or -402 residues of HIF-1alpha by an oxygen molecule. The hydroxyproline then interacts with the ubiquitin E3 ligase von Hippel Lindau protein and is degraded by an ubiquitin-dependent proteasome. PHD2 is the most active of three PHD isoforms in hydroxylating HIF-1alpha. Structural analysis showed that the N-terminal region of PHD2 contains a Myeloid translocation protein 8, Nervy, and DEAF1 (MYND)-type zinc finger domain, whereas the catalytic domain is located in its C-terminal region. We found that deletion of the MYND domain increased the activity of both recombinant PHD2 protein and in vitro-translated PHD2. The zinc chelator N,N,N',N'-tetrakis(2-pyridylmethyl)ethylenediamine augmented the activity of wild-type PHD2-F but not that of PHD2 lacking the MYND domain, confirming that the zinc finger domain is inhibitory. Overexpression of PHD2 lacking the MYND domain caused a greater reduction in the stability and function of HIF-1alpha than did overexpression of wild-type PHD2, indicating that the MYND domain also inhibits the catalytic activity of PHD2 in vivo.

Adenovirus-uteroglobin suppresses COX-2 expression via inhibition of NF-κB activity in lung cancer cells

Uteroglobin (UG, Clara cell secretory protein) is a steroid inducible, multifunctional protein that is secreted by the mucosal epithelia. UG has anti-proliferative and anti-metastatic effects in cancer cells. COX-2, which catalyzes the first step in the synthesis of prostanoids, has been shown to be overexpressed in tumors. This study investigated the effect of UG on the inhibition of COX-2 expression in lung cancer cells. The level of the COX-2 protein and its mRNA were decreased by UG, as demonstrated by Western blot and the RT-PCR, respectively. The EIA shows that UG suppressed PGE2 synthesis. Western blot showed that the NF-kappaB nuclear translocation was inhibited by the transduction of UG. In addition, an EMSA demonstrated the inhibition of the NF-kappaB-DNA binding by UG. The luciferase assay showed that UG also inhibited the NF-kappaB-mediated transcription activity. Furthermore, transfection of the lung cancer cell lines with the COX-2 reporter gene constructs demonstrated that the transcription of COX-2 gene was suppressed by UG. These results show that the inhibition of COX-2 expression by UG transduction correlated with the suppression of NF-kappaB activity in the lung cancer cells. This suggests that UG have the possibility for the treatment of lung cancer.