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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.121, No.1, January 2017
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Original Article
Title
The Usefulness and Safety of the Immobilizer Not Using the Sedative in the Examination of Brain MRI before the NICU Discharge
Author
Ryuichi Tanaka Syunsuke Ogaya Jun Nakayama Takahiro Kanzawa Toshihiko Okumura Sayako Hamazaki Takashi Tachibana Ayako Yasuda Makoto Oshiro and Osamu Kito
Department of Pediatrics, Japanese Red Cross Nagoya Daiichi Hospital
Abstract
When the conventional examination of MRI scan conventionally, it is necessary to use various sedatives because of motion artifacts. However, sedation has many side effects. We conducted a retrospective and comparable study of infants who were hospitalized in our NICU from January, 2013 to June, 2015. We obtained data on 137 patients who received triclofos sodium and 118 patients who used the immobilizer without sedation for brain MRI. There were no significant difference in the perinatal factors, success rate (sedative group 97.1% vs immobilizer group 100%), acceptable quality of the image (sedative group 75.6% vs immobilizer group 83.9%). However, sedated infants had more side effects like suckling disorder, drowsiness, desaturation, apnea and restlessness. The 15% immobilizer group increased the body temperature more than 0.5°C degrees after MRI. Contrary the 16% sedative group decreased the body temperature less than 0.5°C degrees. Although it might have changed the examination period, the immobilizer group could be more acceptable about the points of the same success rate, image quality and less side effects with the sedation. At the examination of brain MRI, the method using an immobilizer without sedation was useful to compare with the method using the triclofos sodium.
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Original Article
Title
Intensive Care for Transition to Home Care in Severe Chronic Lung Disease Complicated with Pulmonary Hypertension
Author
Takafumi Honda1) Yuri Shirato2) Hiromichi Hamada2) Tsutomu Kondo3) and Masaru Terai1)2)
1)Department of Pediatric Critical Care, Tokyo Women's Medical University, Yachiyo Medical Center
2)Department of Pediatrics, Tokyo Women's Medical University, Yachiyo Medical Center
3)Department of Neonatology, Tokyo Women's Medical University, Yachiyo Medical Center
Abstract
Due to advances in medical treatment, it has become possible for even a child of less than 24 weeks gestation to survive. However, some of these premature babies developed pulmonary hypertension caused by severe chronic lung disease. The outcome of these patients have not been improved, because they often need long-term management of mechanical ventilation in intensive care units. We had three patients born between 23-27 weeks gestation, who developed chronic lung disease complicated with severe pulmonary hypertension from January 2007 through December 2012. Tracheomalacia occured in all three patients. We performed high end-expiratory pressure during mechanical ventilation. Additionally, we treated them with epoprostenol or sildenafil for pulmonary hypertension. These treatments dramatically improved pulmonary hypertension and normalized hemodynamics in all three cases. All three cases were discharged thereafter, and are healthy at home with the help of their family and aid agencies.
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Original Article
Title
Factors Associated with Severity of Human Metapneumovirus Infections Diagnosed by Rapid Antigen Test
Author
Yukari (Tsushima)Atsumi1) Mihoko Isogai2) Kenta Ito2) Toshiro Terakawa1) and Yuho Horikoshi2)
1)Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center
2)Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center
Abstract
Human metapneumovirus (hMPV) is relatively new virus identified in 2001. Although hMPV causes common respiratory infections in childhood, factors associated with severe diseases are not well understood yet in Japan. We reviewed factors associated with severe hMPV infections diagnosed by antigen rapid test at Tokyo Metropolitan Children's Medical Center from July 2014 to May 2015. The rapid antigen test for hMPV were performed for 469 cases. Positive results were obtained in 73 cases (16%). Severe hMPV diseases were defined as patients admitted to pediatric intensive care units. Among them, 15 cases (21%) were categorized in severe diseases. There were 42 boys (58%) and the median age was 1.7 year old (range: 1 month old-15 year old, interquartile range (IQR): 0.7-3.9 year old). Symptoms were fever (93%), cough (77%), rhinorrhea (53%), emesis (25%) and convulsion (22%). Median febrile period was 6 days (range: 0-33 days, IQR 3-7 days). Median hospitalization was 4 days (range: 1-16 days, IQR: 3-5 days). Multivariate logistic regression model was fitted to assess the factors associated with severe hMPV infections. We estimated that having underlying respiratory disease, underlying cardiac diseases and congenital malformation syndrome were associated with increased odds of 11 (95% confidence interval [CI]: 2.5-46, p<0.001), 13 (95% CI: 2.9-56, p<0.001) and 4.6 (95% CI: 1.1-19, p=0.013). Patients with these underlying diseases should be treateed with caution in case of developing severe hMPV infections.
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Original Article
Title
Reference Diameter of the Rectum in Children: Use of Pelvic U Sonography
Author
Kazuhiko Tomimoto
Tomimoto Children's Clinic
Abstract
[Background] Childhood chronic constipation is classified as ultrasonography functional fecal retention, slow transit constipation, and obstructed defecation. Slow transit constipation does not exhibit dilated rectum, and therefore, can be differentiated from others based on rectal diameter. We tried to determine the reference range of rectal diameter in Japanese children with normal bowel habits, and thereby make it feasible to diagnose dilated rectum.
[Subjects and methods] Among 999 children who visited our clinic for vaccination, we estimated the diameter of the rectal ampulla using pelvic ultrasonography in 733 who had no underlying diseases and normal bowel habit. The relationship of rectal diameter was compared with gender, age, post-defecation period and vertical/horizontal axis ratio of the urinary bladder.
[Results] Rectal diameter was associated with post-defecation period and age. There was no need for stratification in the children with post-defecation period for more than 3 hrs. On the contrary, stratification over 1 and less than 2 was required because the standard deviation ratio was 0.486. We calculated the reference range of rectal diameter by Box-Cox power transformation in keeping normality. The score was more than 27.9 mm for age 1 > and 38.2 mm for under 1 age 1. Specifically, it is noteworthy to recognize it as a diagnostic value for dilated rectum and not as cutoff value for chronic constipation.
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Original Article
Title
Prospective Observational Study on Procedural Sedation and Analgesia in the Pediatric Emergency Department
Author
Yusuke Hagiwara and Nobuaki Inoue
Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center
Abstract
Purpose: Procedural sedation and analgesia in pediatric patients have come to be important, however, there are no scientific data accumulation in Japan. Therefore, we aimed to summarize descriptive statistics for pediatric cases that required sedation during painful procedures in a pediatric emergency department (ED).
Method: We prospectively collected data on all pediatric patients undergoing procedural sedation in our ED from April 2014 to March 2016. Variables included the patient background, indication, drugs, used, complications, and satisfaction of the physician and the nurse. We present data as proportions with 95% confidence intervals.
Result: We recorded 286 cases. The median age was 6, boys were 188 cases (65.7%), and all of the cases were ASA-PS 2 or less. The most common indications were reduction of a fracture and dislocation (157 cases, 54.9%). The most using drug was ketamine (281 cases, 98.3%). Overall, 47 cases had complications (16.4%, 95% CI: 12.6%-21.2%), 18 cases decreased SpO2 of less than 90 percent (6.3%, 95% CI: 4.0%-9.7%). Treatment completion rate was 100 percent, the median of nurse and physician satisfaction were both 5 (IQR, 4-5).
Conclusion: We summarized the procedural sedation and analgesia in the pediatric ED. Complications rate was seen in about 16%, but there were no serious outcome cases owing to the appropriate care.
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Original Article
Title
Education Program of Clinical Research for Senior Residents: A Pilot Questionnaire Research
Author
Yoshihiko Moirkawa1) Masaru Miura1)2) Emi (Kawaguchi)Morikawa1) Masako Tomotsune1) Kenji Ishikura1)3) Takahiro Matsushima4) Toshiro Terakawa4) and Masataka Honda3)
1)Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center
2)Department of Cardiology, Tokyo Metropolitan Children's Medical Center
3)Department of Nephrology, Tokyo Metropolitan Children's Medical Center
4)Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center
Abstract
Background: In 2011, a program was begun at Tokyo Metropolitan Children's Medical Center in Tokyo, Japan for new senior residents in each academic year to carry out the planning, execution, analysis, and presentation of their findings in a 3-year clinical research practicum. This program is one of a few, though much needed, senior research training programs in Japan.
Objective: The aim of this report was to assess the efficacy of a senior resident clinical research training practicum with a view to promoting the development of this much needed form of education throughout Japan.
Method: A team of senior residents in every year from 2011 to 2012 was asked to complete a questionnaire about the program at the end of their respective 3-year training period. The responses were then analyzed to assess the efficacy of the program. Additionally, each group presented their findings in a paper or conference presentation. The questionnaire was distributed to 19 residents, of whom 13 responded (6 participants who began their residency in 2011; response rate, 68.4%).
Results: The results of the survey produced a score of 78.2±15.9 (mean±SD) in response to the question, 'Was the graded training program a good idea?' The responses to the questions, "How difficult was the program to conduct?", "How much do you want to do clinical research again?", and "Do you think the availability of a training program like this one would be a decisive factor in future senior residents' choice of hospital?" produced scores of 78.2±17.7, 72.5±20.0, and 68.9±18.6, respectively.
Conclusion: A graded clinical research training program for pediatric senior residents elicited positive responses, especially regarding on-the-job training aspects, despite some difficulties in implementing parts of this program, suggesting that such a program would be generally well-received by residents. It is to be hoped that the results of this study will help promote this type of training throughout Japan.
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Case Report
Title
Neonatal Alloimmune Thrombocytopenia Prolonged for Two Months
Author
Takuma Ohnishi1)2) Munehiro Furuichi2) Kyoko Takamura3) and Seiji Sato2)
1)Department of Pediatrics, Keio University School of Medicine
2)Department of Pediatrics, Saitama City Hospital
3)Department of Neonatology, Saitama City Hospital
Abstract
We report here a case of neonatal alloimmune thrombocytopenia with detectable anti-human leukocyte antigen antibodies wherein the symptoms prolonged for 2 months. The patient was a 1-day-old female born at 41 weeks and 4 days of gestation. Her weight was 3,580 g at the time of birth. She was admitted for hematemesis and thrombocytopenia. A laboratory analysis conducted on the second day after birth showed that the platelet count was 15,000/μL. Although platelet transfusion was performed and intravenous immunoglobulin administered, the thrombocytopenia resolved approximately 2 months later. The anti-human leukocyte antigen antibodies, which reacted with the platelets isolated from the infant and her father, were detected in the serum of the infant and her mother. Therefore, we diagnosed this case as neonatal alloimmune thrombocytopenia. Neonatal alloimmune thrombocytopenia usually resolves within 1-2 weeks; however, it is necessary to be aware about the potential persistence of thrombocytopenia as in the case reported here.
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Case Report
Title
Unilateral Segmental Lung Lavage and GM-CSF Inhalation in a 4-year-old Child with Autoimmune Pulmonary Alveolar Proteinosis
Author
Kahoru Fukuoka1) Yuichiro Muto1) Takanori Mizobe2) Hiroko Miyatake1) Tomoko Ohira1) Takahiro Nishihara1) Katsuki Hirai1) Nagisa Komatsu1) and Masahiro Migita1)
1)Department of Pediatrics, Japan Red Cross Kumamoto Hospital
2)Department of Respiratory Medicine, Japan Red Cross Kumamoto Hospital
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare disease in which a surfactant from a nonstructured substance in the alveolus accumulates in the terminal respirator tracts, and results in respiratory failure. The patient was a 4-year-old girl, the youngest reported case of autoimmune PAP in Japan. She had no relevant history until she developed chronic cough, hypoxia, and weight loss from 6 months before the consultation. Chest computed tomographic scan indicated PAP, and she underwent bronchoalveolar lavage (BAL) under general anesthesia. The collected BAL was a rice-water-like fluid. Large-sized, small-nucleus foamy macrophages, and nonstructured eosinophilic substance in the cytospin specimens led to the diagnosis of PAP. As the serum was positive for anti-GM-CSF (granulocyte macrophage colony-stimulating factor) antibody, and secondary PAP and congenital PAP were excluded, autoimmune PAP was diagnosed. After conducting unilateral segmental lung lavage four times, both her clinical symptoms and radiologic findings gradually improved. Currently, she receives home oxygen therapy (nasal O2, 0.2 L/min) and GM-CSF inhalation therapy in the outpatient clinic. As childhood-onset PAP, especially autoimmune PAP, is uncommon, the standard treatment has not been established. The present case raises the need for careful observation and modified therapies for adult PAP.
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