Ictal sinus pause and myoclonic seizure in a child

Ictal tachycardia and bradycardia are common arrhythmias; however, ictal sinus pause and asystole are rare. Ictal arrhythmia is mostly reported in adults with temporal lobe epilepsy. Recently, ictal arrhythmia was recognized as a major warning sign of sudden unexpected death in epilepsy. We present an interesting case of a child with ictal sinus pause and asystole. A 27-month-old girl was hospitalized due to 5 episodes of convulsions during the past 2 days. Results of routine electroencephalography (EEG) were normal, but she experienced brief generalized tonic seizure for 3 days. During video-monitored EEG and echocardiography (ECG), she showed multiple myoclonic seizures simultaneously or independently, as well as frequent sinus pauses. After treatment with valproic acid, myoclonus and generalized tonic seizures were well controlled and only 2 sinus pauses were seen on 24-hour Holter ECG monitoring. Sinus dysfunction should be recognized on EEG, and it can sometimes be treated successfully with only antiepileptic medication

Epilepsy in children with a history of febrile seizures

PurposeFebrile seizure, the most common type of pediatric convulsive disorder, is a benign seizure syndrome distinct from epilepsy. However, as epilepsy is also common during childhood, we aimed to identify the prognostic factors that can predict epilepsy in children with febrile seizuresMethodsThe study comprised 249 children at the Korea University Ansan Hospital who presented with febrile seizures. The relationship between the subsequent occurrence of epilepsy and clinical factors including seizure and fever-related variables were analyzed by multivariate analysis.ResultsTwenty-five patients (10.0%) had additional afebrile seizures later and were diagnosed with epilepsy. The subsequent occurrence of epilepsy in patients with a history of febrile seizures was associated with a seizure frequency of more than 10 times during the first 2 years after seizure onset (P<0.001). Factors that were associated with subsequent occurrence of epilepsy were developmental delay (P<0.001), preterm birth (P=0.001), multiple seizures during a febrile seizure attack (P=0.005), and epileptiform discharges on electroencephalography (EEG) (P=0.008). Other factors such as the age at onset of first seizure, seizure duration, and family history of epilepsy were not associated with subsequent occurrence of epilepsy in this study.ConclusionFebrile seizures are common and mostly benign. However, careful observation is needed, particularly for prediction of subsequent epileptic episodes in patients with frequent febrile seizures with known risk factors, such as developmental delay, history of preterm birth, several attacks during a febrile episode, and epileptiform discharges on EEG

Pediatricians and Emergency Physicians’ Recognition and Training Regarding Child Abuse

Purpose To explore the recognition levels and educational experiences of child abuse among physicians. Methods We conducted an electronic questionnaire survey of pediatricians and emergency physicians. Results Of the 245 total respondents, 63% remarked that child abuse occurred “frequently” in Korea. One hundred twenty-seven (51.8%) respondents experienced an abused child during their practice, and only 55.9% reported the event. Regarding the knowledge for obligation of report as a medical specialist, 45.7% knew where they should report the case, and 39.2% of the respondents knew the phone number of the “Child Protection Agency”. Most respondents (70.2%) answered that they had never received an education about child abuse. Some respondents answered that they had not reported a suspected abused case because they were not certain that the case was abuse and thereby felt discomfort in making the report. To enhance child abuse reports, respondents thought that an immediate intervention is necessary for the reported case. Also, they answered that their confidentialities have to be assured and that the education about child abuse is needed. Conclusion The survey results show that pediatricians and emergency physicians often do not report suspected abuse despite their suspicion of the seriousness and frequent occurrence of child abuse. Such behaviors are affected by the recognition and knowledge levels about child abuse, the experience of training for child abuse, and discomfort of the reporting process. For medical specialists’ attention and reporting of abuse, repetitive education, appropriate public relations and improvement of the reporting process are needed

Analysis of clinical information and reverse transcriptase-polymerase chain reaction for early diagnosis of enteroviral meningitis

PurposeMeningitis is among the most common infections affecting the central nervous system. It can be difficult to determine the exact pathogen responsible for the infection and patients are often treated with empiric antibiotics. This study was conducted to identify the most common clinical characteristics of enteroviral meningitis in children and evaluate the diagnostic efficacy of reverse transcriptase-polymerase chain reaction (RT-PCR) for early detection of an enterovirus.MethodsWe analyzed the medical records of children admitted to Korea University Medical Center and diagnosed with meningitis on the basis of cerebrospinal fluid (CSF) analysis and RT-PCR from CSF and other samples from January 2010 to August 2013.ResultsA total of 333 patients were enrolled and classified into four groups based on diagnosis: enteroviral meningitis (n=110), bacterial meningitis (n=23), other viral meningitis (n=36), and unknown etiology (n=164). Patients with bacterial meningitis were younger than those in the other groups (P<0.001). Pleocytosis in CSF was similar across all groups. Of patients in the enteroviral meningitis group, 92.7% were diagnosed based on RT-PCR findings. Mean length of hospital stay for patients with enteroviral meningitis was 6.08 days, which was significantly shorter than that for patients with meningitis of bacterial etiology (19.73 days, P<0.001).ConclusionDiagnosis of enteroviral meningitis before viral culture results are available is possible using RT-PCR. Accurate diagnosis reduces the length of hospital stay and helps to avoid unnecessary empiric antibiotic treatment

A study on the menstruation of Korean adolescent girls in Seoul

PurposeWesternized eating habits have been associated with early-age menstruation, which increases the incidence of dysmenorrhea and premenstrual syndrome among adolescent girls. We therefore surveyed changes in menarche timing and the general menstrual characteristics of adolescent girls in Seoul, Korea.MethodsWe surveyed 538 teenage girls who visited our hospital between July and November 2007. Items explored included age at menarche, general menstrual characteristics, occurrence of premenstrual syndrome and treatment thereof, and an association between present dysmenorrhea and a family history of the condition.ResultsAverage age at menarche was 12.6 years, with 29% (n=156) subjects beginning menstruation at age 12 years. The prevalence of dysmenorrhea was 82% (n=435). The main symptoms were abdominal (53.2%) and lower back pain (34.2%), and 15.2% of girls who experienced such symptoms required medication. Present dysmenorrhea, and a family history thereof, were statistically correlated (P<0.05). In addition, 58.8% (n=316) of teenage girls had symptoms of premenstrual syndrome. The most frequent psychological symptoms were fatigue (36.4%) and nervousness (38.7%), whereas the most common physical symptom was menstrual cramps (46.5%). Most subjects (87.6%) tolerated the symptoms of premenstrual syndrome without medication; 11.4% took medicines including painkillers; but only 0.1% of subjects visited a doctor.ConclusionThe average age at menarche in Korean girls was 12.6 years, thus younger than in the past. Most teenage girls experienced dysmenorrhea and premenstrual syndrome, but few consulted a doctor. Organized treatment plans are required to manage menstrual problems in teenage girls

Prognostic perspectives of PD-L1 combined with tumor-infiltrating lymphocytes, Epstein-Barr virus, and microsatellite instability in gastric carcinomas

Background The prognostic potential of PD-L1 is currently unclear in gastric carcinomas, although the immune checkpoint PD-1/PD-L1 inhibitors have produced promising results in clinical trials. Methods We explored the prognostic implications of programmed death ligand 1 (PD-L1) in 514 consecutive surgically-resected gastric carcinomas. Overall survival and recurrence-free survival were evaluated. Immunohistochemistry for PD-L1, CD8, FOXP3, and PD-1, and molecular grouping by in situ hybridization for Epstein-Barr virus (EBV)-encoded small RNAs and multiplex PCR for microsatellite instability (MSI) markers were performed. Additionally, to explore the function inherent to PD-L1, PD-L1-specific siRNA transfection, cell proliferation, invasion, migration and apoptosis assays were conducted in five gastric carcinoma cell lines. Results PD-L1(+) tumor and immune cells were observed in 101 (20%) and 244 patients (47%), respectively. Tumoral PD-L1(+)/immune cell PD-L1(-)/CD8+/low tumor-infiltrating lymphocytes (TILs), and more advanced-stage tumors were associated with unfavorable clinical outcomes in the entire cohort through multivariate analysis. Furthermore, tumoral PD-L1(+)/FOXP3+/low TILs were associated with worse clinical outcomes in EBV-positive and MSI-high carcinomas. Tumoral PD-L1(+) alone was an adverse prognostic factor in EBV-positive carcinomas, but not in MSI-high carcinomas, whereas PD-L1(+) immune cells or FOXP3+/high TILs alone were correlated with a favorable prognosis. PD-L1 knockdown in gastric carcinoma cells suppressed cell proliferation, invasion and migration, and increased apoptosis, which were all statistically significant in two EBV(+) cell lines, but not all in three EBV(−) cell lines. Conclusions The prognostic impact of PD-L1 may depend on the tumor microenvironment, and statuses of EBV and MSI, although PD-L1 innately promotes cancer cell survival in cell-based assays. The combination of tumoral PD-L1/immune cell PD-L1/CD8+ TILs may serve as an independent prognostic factor. Tumoral PD-L1(+)/immune cell PD-L1(−)/CD8+/low TILs showing a worse prognosis may be beneficial for combinatorial therapies of anti-PD-L1/PD-1 and anti-cytotoxic T-lymphocyte associated antigen 4 (CTLA4) that would promote effector T cells, thus attack the tumor.This work was supported by the Basic Science Research Program of the National Research Foundation of Korea, which is funded by the Ministry of Education (2016R1D1A1B01010316)

Surgical excision and hyoid suspension without tracheostomy for large cervical lymphatic malformation

Lymphatic malformation is a rare congenital lesion caused by lymphatic abnormality. Herein is a case of extensive pediatric lymphatic malformation involving almost entire neck from skull base to mouth floor. Surgical excision of the huge mass was performed without tracheostomy. Repeated attempts on post-operative extubation resulted in cyanosis and apnea due to narrow postlingual space. Hyoid suspension was performed to improve postlingual insufficiency and apnea events were eventually resolved.Clinical Trial Registration: None