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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.124, No.9, September 2020
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Review
Title
Achievement of Wild Poliovirus-free Status in Africa toward Eradication
Author
Yuho Horikoshi1) Atsuna Tokumoto1) Masamitsu Takamatsu1)2) Mai Okitsu1) and Kyoko Sudo1)3)
1)Nigeria Country Office, World Health Organization
2)Health and Global Policy Institute
3)National Center for Global Health and Medicine, National College of Nursing
Abstract
Poliovirus infection causes acute flaccid paralysis, which is a public health concern. Both inactivated and live oral poliovirus vaccines are effective to prevent transmission. In 1988, 350,000 individuals developed poliovirus-related paralysis worldwide, mostly in developing countries without a poliovirus vaccine program. The global poliovirus eradication initiative approved at the World Health Assembly subsequently succeeded in achieving poliovirus-free status through immunization programs in many countries. The main strategy comprises routine immunization, supplementary immunization activity, mop-up immunization, and surveillance. Although most African countries also achieved wild poliovirus-free status in the late 1990s, re-emergence of wild poliovirus strains was observed in African countries caused by transmission from remaining endemic countries, specifically Nigeria, after 2000. In the early 2000s, "reaching every district" was a new policy for global immunization strategy to eradicate the poliovirus. Eventually, the last endemic country in Africa, Nigeria, was declared poliovirus-free in 2015. However, as Nigeria faced major domestic conflict that resulted in halting necessary public health services including immunization, wild poliovirus was detected again in 2016 and the declaration of poliovirus-free status was revoked. With many public health efforts, the African region again achieved wild poliovirus-free status in 2019. The remaining issue in Africa is circulating vaccine-derived poliovirus type 2. This emphasizes that continuation of an effective immunization program and surveillance is critical for poliovirus eradication.
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Original Article
Title
Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit
Author
Maho Fujino Taito Kitano Hirosato Aoki Ikuyo Arai Hajime Yasuhara Reiko Ebisu Ayako Ohgitani and Hideki Minowa
Department of Neonatal Intensive Care Unit, Nara Prefecture General Medical Center
Abstract
Introduction: The aim of an antimicrobial stewardship program (ASP) is to optimize the treatment of infection and minimize adverse events by choosing appropriate antimicrobials. We introduced an ASP in the NICU of a Japanese community hospital where there is no pediatric infection disease specialist.
Methods: We created a protocol for the ASP and implemented it starting in September 2017. The protocol includes: 1) criteria on when we should start antimicrobials and continue antimicrobial treatments over a 48-hour period, 2) weekend report of blood culture results from the Microbiology Department, and 3) prohibition on ordering antimicrobials for the next day. We compared days of therapy (DOT) before (Pre-ASP) and after (Post-ASP) the implementation of the ASP by interrupted time series analysis.
Results: We analyzed 913 and 405 patients in Pre-ASP and Post-ASP, respectively. The average gestational age was 36.1±3.2 weeks Pre-ASP and 36.4±2.9 weeks Post-ASP, and the average birth weight was 2,347±702 g and 2,417±663 g, respectively. We found no significant change in DOT/1,000 patient-days during the Pre-ASP period or Post-ASP period but 116.67 DOT/1,000 patient-days was reduced by the implementation of ASP (p=0.002). The mortality rate was 0.8% vs 0.7% (p=0.63) and treatment failure rate was 3.0% vs 3.7% (p=0.476) Pre-ASP and Post-ASP, respectively.
Conclusions: We were able to reduce DOT safely and significantly by implementing the ASP without the presence of a pediatric infection disease specialist.
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Original Article
Title
The Status of Short Stature in Children Five Years after the Initial Visit to Our Hospital
Author
Yuichi Mushimoto Shuichi Suzuki Atsuko Kawano and Kenichi Miyako
Department of Endocrinology and Metabolism, Fukuoka Children's Hospital
Abstract
We investigated the status and diagnosis of short stature of 548 children with short stature (263 boys and 285 girls) 5 years after they had presented to our hospital during the 3-year period from October 2008 through September 2011. The mean (±SD) age at the time of initial presentation was 7.1±4.3 years in boys and 5.1±4.0 years in girls, and the mean height standard deviation score (±SD) was −2.32±0.60 in boys and −2.41±0.69 in girls. A total of 417 children had short stature with a standard deviation score of −2.0 or less. The status of 548 children 5 years after presentation was as follows: 126 had received a diagnosis, 204 had discontinued follow-up because of no request or need for a detailed examination, 34 continued to be followed up, 54 had switched to different hospitals, and 130 had discontinued follow-up without notice. The diagnosis of the 126 children was growth hormone deficiency in 26, small-for-gestational age short stature in 13, hypothyroidism in 6, Turner syndrome in 6, Prader-Willi syndrome in 1, other chromosomal abnormalities or specific syndromes in 13, and idiopathic short stature in 61. Growth hormone therapy was suggested for 46 children (8.4% of 548), and endocrine hormone therapy was suggested for 52 children (9.5% of 548).
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Case Report
Title
Surgical Repair of Coronary Artery Stenosis after Kawasaki Disease
Author
Junko Arakawa1) Shiro Baba1) Kentaro Akagi1) Koichi Matsuda1) Daisuke Yoshinaga1) Takuya Hirata1) Kazuhiro Yamazaki2) and Junko Takita1)
1)Department of Pediatrics, Kyoto University Hospital
2)Department of Cardiovascular Surgery, Kyoto University Hospital
Abstract
Large coronary aneurysm, a complication of Kawasaki disease (KD), occurs in approximately 0.2% of patients. Blood flow disorder in the aneurysm often causes coronary stenosis accompanied by thrombosis and calcification, and increases the risk of acute coronary occlusion. Acute coronary occlusion is treated by medical therapies, catheter interventions, and surgical treatment. Among these, surgical treatments are most suitable for re-establishing stable and long-term coronary blood flow. Here, we describe an effective surgical treatment of a case of unstable angina with coronary artery stenosis after KD. A 34-year-old male patient with a right coronary artery aneurysm and stenosis after KD was treated with antiplatelet therapy. Cardiac catheterization at 16 years after KD diagnosis revealed progressive coronary stenosis. Thus, he received additional anticoagulant therapy. Exercise electrocardiography (ECG) at 24 years post-onset of KD revealed ST segment depression in the II, III, aVf, and V5-6 leads. A few days after the ECG examination, he suffered severe chest pain and was given a diagnosis of unstable angina with 95% right coronary stenosis. Coronary artery bypass operation was performed using a greater saphenous vein graft. The post-operative course is favorable and the patient is receiving only antiplatelet therapy. Thus, surgical intervention is a valuable therapy for coronary artery stenosis after KD.
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Case Report
Title
Two Cases of Nonconvulsive Status Epilepticus (NCSE) Due to Posterior Reversible Encephalopathy Syndrome (PRES) during Anticancer Therapy
Author
Kaoru Yamamoto1) Atsuro Daida1) Daisuke Hasegawa1) Shunsuke Kimura1) Yuri Yoshimoto1) Shinsuke Hirabayashi1)3) Yosuke Hosoya1) Taiki Nozaki2) Mina Yokoyama1) Atsushi Manabe1)3) and Masaaki Ogihara1)
1)Department of Pediatrics, St. Luke's International Hospital
2)Department of Radiology, St. Luke's International Hospital
3)Department of Pediatrics, Hokkaido University Graduate School of Medicine
Abstract
We encountered two cases of NCSE due to PRES during anticancer therapy. Patient 1: A 4-year-old girl with acute lymphoblastic leukemia presented with loss of consciousness and eye deviation during induction remission therapy. Her disturbed consciousness prolonged and EEG revealed NCSE 3 days after the onset. MRI showed T2 hyperintense signal abnormality in subcortical and deep white matter in the parieto-occipital lobes, which extended to the bilateral frontal lobes including the cerebral cortex afterwards. Her NCSE was refractory to medication. Finally, she developed epilepsy. Patient 2: A 7-year-old girl with refractory metastatic rhabdomyosarcoma presented with focal seizure of the left arm during palliative therapy with pazopanib. Based on MRI, a diagnosis of PRES was made. She showed a decreased level of consciousness for two days and the EEG revealed NCSE. Antiseizure medication was effective and the patient became alert. Discussion: Recent literatures suggest that PRES is not uniformly reversible. NCSE can be associated with PRES and may affect the neurological outcome. We recommend EEG monitoring as early as possible when disturbed consciousness prolongs, in order to facilitate prompt diagnosis of NCSE.
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Case Report
Title
Five Pediatric Cases of Malignancy with Bowel Obstruction as the Initial Symptom
Author
Nobuhiro Kanie1) Toshimasa Obonai1) Motohiro Matsui2) Yuya Saito2) and Yuki Yuza2)
1)Department of Pediatrics, Tokyo Metropolitan Health and Medical Treatment Corporation Tama-Hokubu Medical Center
2)Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center
Abstract
Pediatric bowel obstruction often arises from an underlying primary disease. Here, we report five pediatric cases of bowel obstruction due to a malignancy, including three cases of Burkitt's lymphoma and two cases of colon cancer. Four cases occurred in school-aged children. In each case, the clinical course had a subacute pattern, and the duration from the onset of abdominal pain and vomiting to diagnosis ranged from several weeks to several months. It is important to suspect pediatric malignancies based on adolescent and subacute patterns in cases of pediatric bowel obstruction.
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Case Report
Title
Two Cases of Human Parvovirus B19 Infection with Prolonging Fever and Purpura
Author
Hiroki Tsukada1) Hiroko Sakuma1) Naoko Suzuki1) Fumi Mashiyama1) Kazuo Kato1) Masatoki Sato2) and Mitsuaki Hosoya2)
1)Department of Pediatrics, Hoshi General Hospital
2)Department of Pediatrics, Fukushima Medical University
Abstract
We report two cases of human parvovirus B19 (PVB19) infection with purpura and reduced serum complement levels during the febrile period. Case 1 was an 11-year-old boy who was admitted to our hospital with fever and purpura that persisted for 7 days. Blood analysis revealed decrease in the leukocyte, platelet, reticulocyte counts, and serum complement levels. PVB19 DNA was detected in the blood, serum, pharynx, and anal wipes at the time of hospitalization. The purpura disappeared with the alleviation of fever. Case 2 was an 8-year-old boy who was admitted to our hospital with fever and purpura that persisted for 4 days. Blood analysis revealed decrease in the leukocyte, reticulocyte counts, and serum complement levels. PVB19 DNA was detected in blood, serum, and pharynx samples and anal wipes at the time of hospitalization. Purpura appeared during fever with DNAemia, and a decrease in the serum complement level was observed in both cases. Purpura caused by PVB19 infection is considered to occur owing to vascular endothelial cytotoxicity and vasculitis via the immune complex. Typical childhood diseases with purpura include idiopathic thrombocytopenic purpura and IgA vasculitis; in the former, platelet counts in the peripheral blood decreases, whereas in the latter, serum complement levels do not decrease. Moreover, purpura caused by PVB19 infection can be distinguished from other purpura. PVB19 infection should also be considered in a febrile patient who presents with purpura accompanied with decreased serum complement levels, reticulocytopenia, and insignificant thrombocytopenia.
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Case Report
Title
A Case of Herbst's Triad: A 3-year-old Boy with Reflux Esophagitis Associated with Hiatal Hernia
Author
Shun Takahashi1) Yasuko Kobari3) Yoshiko Igarashi1) Takashi Ishige1) Takuya Nishizawa1) Maiko Tatsuki1) Makoto Suzuki2) Sayako Kudo4) Takumi Takizawa1) and Hirokazu Arakawa1)
1)Department of Pediatrics, Gunma University Graduate School of Medicine
2)Department of General Surgical Science, Gunma University Graduate School of Medicine
3)Department of Pediatrics, Isesaki Municipal Hospital
4)Department of Oral and Maxillofacial Surgery, Hidaka Hospital
Abstract
A 3-year-old-boy developed a fever with cough and was referred to a local hospital. At the first visit, massive erosion of all his teeth and clubbing finger were evident. Blood tests revealed iron deficiency anemia and hypoalbuminemia. Since vomiting, a typical symptom of gastroesophageal reflux disease (GERD), was not evident, and since he was on a severely unbalanced diet, he was fed adequate meals, which did not result in any improvements; therefore, protein-losing gastroenteropathy was suspected. Esophagogastroduodenoscopy revealed severe erosion of the middle to lower parts of the esophagus, and he was given a diagnosis of reflux esophagitis due to hiatus hernia. Nissen fundoplication was performed, and his albumin and hemoglobin levels improved.
GERD results in several extraesophageal symptoms. Severe phenotypes are known as Herbst's triad, which includes anemia, protein-losing gastroenteropathy, and clubbing finger. A literature search revealed an additional eight cases of pediatric-onset GERD with Herbst's triad. Typical symptoms such as heartburn and emesis are not always evident even in such severe cases.
To the best of our knowledge, this is the first reported case of Herbst's triad in Japan. It can be suggested that treatment, bearing in mind the possibility of Herbst's triad, was important for making an appropriate diagnosis, referring to reflux esophagitis as a differential disease.
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Case Report
Title
Two Pediatric Cases of Acute Cutaneous Nerve Entrapment Syndrome for Which Ultrasound Findings Are Useful for Diagnosis
Author
Ayako Tanimoto1) Takaki Asano1) Ayaka Ono1) Yoshiko Kitamura1) Ryoji Futagami1) Tomoki Sato1) Shuji Yoshino1) Yuji Fujii1) Hiroyuki Shimozono1) Keita Matsubara1) Takeshi Asai2) and Rika Okano1)
1)Department of Pediatrics, Hiroshima City Funairi Citizens Hospital
2)Department of Pediatric Surgery, National Hospital Organization Shikoku Medical Center for Children and Adults
Abstract
Acute cutaneous nerve entrapment syndrome (ACNES) has recently become well-known among European countries as a causal disease of abdominal wall pain although it remains relatively unknown in Japan. We report two pediatric patients with ACNES. Case 1: A 14-year-old boy presenting with repeated right abdominal pain for over 8 months showed tenderness in the right lower abdominal region and was initially suspected to have acute appendicitis. There were no abnormalities in his examination findings. Although it took time to diagnose, we suspected and diagnosed ACNES because of the positive Carnett's sign and reduction of pain by trigger point injection (TPI). However, some pain still persisted and neurectomy was performed. Case 2: An 11-year-old boy presenting with repeated right abdominal pain for over 6 months was initially suspected to have acute appendicitis. There were no abnormalities in his examination findings. Positive Carnett's sign and TPI delivering him from the pain led to the diagnosis of ACNES. In both cases, we found a high echoic area at the tenderness point. In the current pediatric field, ACNES appears to be largely undiagnosed and we believe that these findings may help in the diagnosis. ACNES is treatable, and early diagnosis can contribute to patients' prognoses. Therefore, awareness of ACNES as a cause of abdominal pain among pediatricians is important.
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