The diagnosis of Kawasaki disease in a 10-year-old girl presenting with cervical lymphadenopathy and fever suggesting retropharyngeal abscess

Given that Kawasaki disease (KD) can cause cardiac complications, it is crucial to diagnose and treat the disease in the emergency department. We report a case of a 10-year-old girl who presented to the emergency department with cervical lymphadenopathy and fever. The initial diagnosis was retropharyngeal abscess based on computed tomography findings, but antibiotic therapy failed and she was subsequently diagnosed with KD. After 3 doses of intravenous immunoglobulin along with methylprednisolone and methotrexate, she was discharged on hospital day 21. The cervical lymphadenopathy suggesting retropharyngeal abscess might be an early sign of incomplete or intravenous immunoglobulin-resistant KD

A rare presentation of Rapunzel syndrome with multiple small bowel intussusceptions

Rapunzel syndrome is caused by gastric trichobezoar with extended tail and small bowel obstruction. Patients with gastric trichobezoar can be asymptomatic until the bezoar increases in size. We report a case of a girl who visited the emergency department with abdominal pain. She was finally diagnosed with Rapunzel syndrome that causes multiple small bowel intussusceptions associated with trichophagia. Surgery was needed to reduce the multiple intussusceptions, and to remove the large trichobezoar. This case highlights to consider the possibility of Rapunzel syndrome when diagnosing the main cause of intussusceptions

Clinical features of adolescents with suicide attempt and the factors associated with their outcomes: poisoning versus non-poisoning

Purpose Methods for suicide attempt are largely divided into poisoning and non-poisoning, which differ in clinical features and severity. We aimed to investigate the clinical features of adolescents with suicide attempt and factors associated with poor outcomes from the 2 methods. Methods A retrospective study was conducted on adolescents (10-18 years) who visited the emergency department after suicide attempt from 2011 through 2018. The adolescents were divided into the poisoning and non-poisoning groups. We analyzed the differences of clinical features and outcomes between the 2 groups. Poor outcomes were defined as hospitalization to the intensive care unit or death. Factors associated with poor outcomes were investigated using multivariable logistic regression. Results Of 4,335 adolescents in total, 2,134 (49.2%) were categorized as the poisoning group. In this group, the adolescents with poor outcomes used acetaminophen most frequently (26.5%), followed by sedative or antipsychotics (22.3%). In the non-poisoning group, those with the outcomes used fall from height (73.2%) most commonly, followed by hanging (21.0%). The factors associated with the outcomes were age (for increment of 1 year; odds ratio, 1.11; 95% confidence interval, 1.02-1.22) in the poisoning group, and being boys (1.34; 1.03-1.73) and non-use of alcohols (2.87; 1.73-4.74) in the non-poisoning group. Conclusion In adolescents who used poisoning for suicide attempt, increasing age is associated with poor outcomes. The outcomes are associated with being boys and non-use of alcohols in those who used non-poisoning methods

Risk factors of delayed diagnosis of acute appendicitis in children: for early detection of acute appendicitis

PurposeThis study examined the risk factors of a delayed diagnosis of acute appendicitis in children undergoing an appendectomy.MethodsThis retrospective study involved children aged below 18 years, who underwent an appendectomy. After dividing them into a delayed diagnosis group and nondelayed diagnosis group according to the time interval between the initial hospital visit and final diagnosis, the risk factors of delayed diagnosis were identified using logistic regression analysis.ResultsAmong 712 patients, 105 patients (14.7%) were classified in the delayed diagnosis group; 92 patients (12.9%) were diagnosed using ultrasonography (US), and both US and computed tomography were performed in 38 patients (5.3%). More patients in the delayed diagnosis group underwent US (P=0.03). Spring season and prior local clinic visit were significantly associated with a delayed diagnosis. Fever and diarrhea were more common in the delayed diagnosis group (fever: odds ratio [OR], 1.37; 95% confidence interval [CI], 1.05–1.81; diarrhea: OR, 1.94; 95% CI, 1.08–3.46; P<0.05). These patients showed symptoms for a longer duration (OR, 2.59; 95% CI, 1.78–3.78; P<0.05), and the admission course (OR, 1.26; 95% CI, 1.11–1.44; P<0.05) and C-reactive protein (CRP) levels (OR, 1.47; 95% CI, 1.19–1.82; P<0.05) were associated with the delayed diagnosis.ConclusionTo decrease the rate of delayed diagnoses of acute appendicitis, symptoms such as fever and diarrhea, seasonal variations, admission course, and CRP levels should be considered and children with a longer duration of symptoms should be closely monitored

The origin of proinflammatory cytokines in patients with idiopathic dilated cardiomyopathy.

Proinflammatory cytokines and their receptors are increased in the peripheral blood of patients with heart failure. We measured cytokines and their receptors in systemic artery (SA), coronary sinus (CS) and infra-renal inferior vena cava (IVC), in order to investigate their origin and influential factors. Thirty patients with idiopathic dilated cardiomyopathy were performed echocardiography at admission, and right heart catheterization after stabilization. Blood was drawn from 3 sites for measurement of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and soluble tumor necrosis factor-alpha receptor (sTNFR) I, II. TNF-alpha at CS (3.25 +/- 0.34 pg/mL) was higher than those of SA (1.81 +/- 0.39 pg/mL) and IVC (1.88 +/- 0.38 pg/mL, p<0.05). IL-6 at CS (18.3 +/- 3.8 pg/mL) was higher than that of SA (5.8 +/- 1.2 pg/mL, p<0.01). The levels of sTNFR I, II showed increasing tendency in sequence of SA, IVC and CS. TNF-alpha and sTNFR I, II from all sites were proportional to worsening of functional classes at admission (p<0.05). E/Ea by Doppler study at admission, which reflects left ventricular end-diastolic pressure (LVEDP) was positively correlated with TNF-alpha from SA (R=0.71, p<0.01), CS (R=0.52, p<0.05) and IVC (R=0.46, p<0.05). Thus, elevated LVEDP during decompensation might cause cytokine release from myocardium in patients with idiopathic dilated cardiomyopathy

Impact of Body Mass Index on the relationship of epicardial adipose tissue to metabolic syndrome and coronary artery disease in an Asian population

<p>Abstract</p> <p>Background</p> <p>In a previous study, we demonstrated that the thickness of epicardial adipose tissue (EAT), measured by echocardiography, was increased in patients with metabolic syndrome (MS) and coronary artery disease (CAD). Several studies on obese patients, however, failed to demonstrate any relationship between EAT and CAD. We hypothesized that body mass index (BMI) affected the link between EAT and MS and CAD.</p> <p>Methods</p> <p>We consecutively enrolled 643 patients (302 males, 341 females; 59 ± 11 years), who underwent echocardiography and coronary angiography. The EAT thickness was measured on the free wall of the right ventricle at the end of diastole. All patients were divided into two groups: high BMI group, ≥27 kg/m²(n = 165), and non-high BMI group, < 27 kg/m²(n = 478).</p> <p>Results</p> <p>The median and mean EAT thickness of 643 patients were 3.0 mm and 3.1 ± 2.4 mm, respectively. In the non-high BMI group, the median EAT thickness was significantly increased in patients with MS compared to those without MS (3.5 vs. 1.9 mm, p < 0.001). In the high BMI group, however, there was no significant difference in the median EAT thickness between patients with and without MS (3.0 vs. 2.5 mm, p = 0.813). A receiver operating characteristic (ROC) curve analysis predicting MS revealed that the area under the curve (AUC) of the non-high BMI group was significantly larger than that of the high BMI group (0.659 vs. 0.506, p = 0.007). When compared to patients without CAD, patients with CAD in both the non-high and high BMI groups had a significantly higher median EAT thickness (3.5 vs. 1.5 mm, p < 0.001 and 4.0 vs. 2.5 mm, p = 0.001, respectively). However, an ROC curve analysis predicting CAD revealed that the AUC of the non-high BMI group tended to be larger than that of the high BMI group (0.735 vs. 0.657, p = 0.055).</p> <p>Conclusions</p> <p>While EAT thickness was significantly increased in patients with MS and CAD, the power of EAT thickness to predict MS and CAD was stronger in patients with BMI < 27 kg/m². These findings showed that the measurement of EAT thickness by echocardiography might be especially useful in an Asian population with a non-high BMI, less than 27 kg/m².</p

Age group characteristics of children who visited a regional trauma center and analysis of factors affecting the severe trauma

Purpose The aim of this study was to analyze the age group characteristics and factors associated with the severe trauma in children who visited a regional trauma center. Methods We reviewed children aged 18 years or younger who visited a regional trauma center, equivalent to level 1 trauma centers in the United States, in Incheon, Korea from July 2014 through December 2019. They were classified by the age groups: preschoolers (0-6 years), schoolers (7-12 years), and adolescents (13-18 years). Across the 3 age groups, event profiles, severity, and outcomes of injury were compared. Multivariable logistic regressions were used to identify factors associated with the severe trauma, defined as the Injury Severity Score of 16 or higher. Results Among the total of 367 children, 74 (20.2%) were preschoolers, 73 (19.9%) were schoolers, and 220 (59.9%) were adolescents. The most common injury mechanisms in the preschoolers, schoolers, and adolescents were fall (40.5%), pedestrian collision (32.9%), and motorcycle accident (38.6%), respectively. The adolescents had the highest median Injury Severity Score (13 [interquartile range, 6-23]; P < 0.001). In the multivariable analyses, the Glasgow Coma Scale of 3-8 (odds ratio [OR], 14.60; 95% confidence interval, 5.40-39.42) had the highest OR for severe trauma, followed by injury in the abdomen or pelvic contents (OR, 11.61; 95% confidence interval, 4.66-28.89). Conclusion In pediatric trauma, the mechanism and severity of injury may differ according to age groups, with the severe trauma associated with injuries to the head and torso. It is advisable to have age group-specific approaches and strategies for injury prevention

Age group characteristics of children who visited the emergency department with acute poisoning by ingestion

Purpose To investigate the age group characteristics of children who visited the emergency department with acute poisoning by ingestion. Methods We reviewed children under 19 years who visited the emergency department for acute poisoning by ingestion from 2012 to 2017. The children were divided into 3 age groups; infants (0-1 years), preschoolers (2-5 years), and schoolers (6-18 years). Clinical characteristics, intentional ingestion, involved substances (drugs, household products, artificial substances, and pesticides), decontamination and antidote therapy, and outcomes of the 3 age groups were compared. We also performed multivariable logistic regression analysis to identify factors associated with hospitalization. Results A total of 622 children with acute poisoning by ingestion were analyzed. Their annual proportions to overall pediatric emergency patients ranged from 0.3% to 0.4%. Age distribution showed bimodal peaks at 0-2 years and 15-17 years. The infants showed lower frequency of girls, intentional ingestion, ingestion of drugs, performance of decontamination and antidote therapy, and hospitalization than 2 older groups (P < 0.001). Most decontamination, antidote therapy, and hospitalization occurred in the schoolers (P < 0.001). The most frequently reported substances were household cleaning substances in the infants (18.2%), antihistamines in the preschoolers (15.8%), and analgesics in the schoolers (37.5%). The factors associated with hospitalization were intentional ingestion (adjusted odds ratio [aOR], 7.08; 95% confidence interval [CI], 2.85-17.61; P = 0.001) and schoolers (aOR, 2.33; 95% CI, 1.10-7.53; P = 0.031; compared with infants). Only 1 in-hospital mortality was found in a boy aged 2 years who ingested methomyl. Conclusion Infants may experience non-intentional ingestion, ingestion of non-pharmacologic substances (especially household cleaning substances), discharge without decontamination and antidote therapy more frequently than older children. Thus, we need age group-specific, preventive and therapeutic plans for children with acute poisoning

The effect of introducing Pediatric Emergency Care Applied Research Network rule on reducing brain computed tomography use for children with minor head injury

Purpose Computed tomography (CT) scan is an effective modality for detecting fatal traumatic brain injury. However, radiation exposure from CT can increase the risk of cancer, and children are more vulnerable to radiation than adults. We aimed to investigate the effect of introducing the Pediatric Emergency Care Applied Research Network (PECARN) rule to the emergency department (ED). Methods Medical records of children younger than 2 years with minor head injury who visited ED from January 2013 to June 2015 were reviewed. We started the education of radiation hazard and the PECARN rule in January 2014. The children were divided into pre- and post- education groups. The baseline characteristics, CT rate, and clinical outcomes were analyzed. The safety and efficacy of CT were defined as patients who received head CT scan per those experiencing clinically important traumatic brain injury (ciTBI) and patients without CT scan per those without ciTBI, respectively. Results Of 911 patients, 360 (39.5%) visited during the post-education period. Median age was 16.0 months (interquartile range, 11.0-20.0 months), and boys accounted for 58.5%. CT rate was reduced from 40.5% to 12.8% (P < 0.001). There was no difference in ciTBI rates between the two groups (1.3% vs. 1.7%, P = 0.622). The safety was 100% in both periods and the efficacy increased from 52.9% to 88.7%. Conclusion We have seen a significant decrease in CT rate through the education of the PECARN rule. After its introduction, CT use was reduced, and the efficacy was improved without decrease in the safety