Incidence and Pattern of Aminotransferase Elevation During Anti-Hypertensive Therapy With Angiotensin-II Receptor Blockers

BackgroundAngiotensin type II receptor blockers (ARBs) are the most widely used anti-hypertensive drugs. This study aimed to elucidate the likelihood and pattern of ARB-induced liver injury in a hospital-based cohort.MethodsData of patients receiving fimasartan (n = 5,543), candesartan (n = 6,406), valsartan (n = 6,040), and losartan (n = 9,126) were retrieved from the clinical data warehouse of two tertiary hospitals. Patients with alanine aminotransferase (ALT) levels > 5 times the upper normal limit were assessed according to the Roussel Uclaf Causality Assessment Method (RUCAM).ResultsA total of 27,115 patients were enrolled, including 14,630 (54.0%) men, with a mean age of 64.6 years (standard deviation, 13.6). During 31,717 person-years of ARB therapy, serum ALT levels > 120 IU/L were found in 558 (2.1%) person-years, and levels > 200 IU/L were found in 155 (0.6%) person-years. The incidence of ALT elevation > 120 IU/L per 10⁶ cumulative defined daily doses was 6.6, 3.6, 3.9, and 4.0 in the fimasartan, candesartan, valsartan, and losartan groups, respectively (P = 0.002). An ALT level > 200 IU/L with RUCAM score ≥ 6 was found in 20 patients, suggesting probable drug-induced liver injury for 11 (0.2%) patients receiving fimasartan, five (0.1%) receiving candesartan, four (0.1%) receiving valsartan, and none receiving losartan (P < 0.001).ConclusionApproximately 2% of patients receiving ARB therapy had significant ALT elevation (4.24/10⁶ cumulative defined daily doses [cDDDs]), which was associated with probable ARB-related liver injury in 0.07% of patients (0.15/10⁶ cDDDs). Elevation of ALT was more commonly associated with fimasartan than the other ARBs. Clinicians should be aware of the possibility of ARB-related ALT elevation in patients with unexplained chronic abnormal ALT.     

Characteristics in Pediatric Patients with Coronavirus Disease 2019 in Korea

BackgroundBased on the reports of low prevalence and severity of pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, the Korean government has released new SARS-CoV-2 infection response and treatment guidelines for children under the age of 12 years. The government has further directed school reopening under strict preventive measures. However, there is still considerable concern on the impact of school reopening on community transmission of Coronavirus disease 2019 (COVID-19). In the present study, we aimed to evaluate the appropriateness of these directives and the severity of SARS-CoV-2 infections in children as compared to adults using sufficient national sample data.MethodsIn the present study, we evaluated the severity of SARS-CoV-2 infection in pediatric patients as compared to adults by analyzing the length of hospital stays (LOS), medical expenses, and hospital and intensive care unit (ICU) admission rates. A multivariate linear regression analysis was carried out to examine the effects of COVID-19 patients that the characteristics on the LOS and medical expenses, and multivariate logistic regression analysis were performed to identify COVID-19 characteristics that affect hospital and ICU admission rates and to prove the low SARS-CoV-2 infection severity in pediatric patients.ResultsThe hospitalization period for children aged 0–9 was 37% shorter and that of patients aged 10–19 years was 31% shorter than those of older age groups (P < 0.001). The analysis of the medical expenses by age showed that on average, medical expenses for children were approximately 4,900 USD lower for children than for patients over 80 years of age. The linear regression analysis also showed that patients who were 0–9 years old spent 87% and those aged 10–19 118% less on medical expenses than those aged 70 and over, even after the correction of other variables (P < 0.001). The probability of hospitalization was the lowest at 10–19 years old (odds ratio [OR], 0.05; 95% confidence interval [CI], 0.03–0.09), and their ICU admission rate was also the lowest at 0.14 (OR, 0.14; 95% CI, 0.08–0.24). On the other hand, the likelihood of hospitalization and ICU admission was the highest in children aged 0–9 years, and among patients under the age of 50 years in general.ConclusionThis study demonstrated the low severity of SARS-CoV-2 infection in younger patients (0–19 years) by analyzing the LOS, medical expenses, hospital, and intensive care unit admission rates as outcome variables. As the possibility to develop severe infection of coronavirus at the age of 10–19 was the lowest, a mitigation policy is also required for middle and high school students. In addition, children with underlying diseases need to be protected from high-risk infection environments.     

Correlations between the CagA Antigen and Serum Levels of Anti-Helicobacter pylori IgG and IgA in Children

We tested correlations between anti-Helicobacter pylori IgG and IgA levels and the urease test, anti-CagA protein antibody, degree of gastritis, and age. In total, 509 children (0–15 years) were enrolled. Subjects were stratified as 0–4 years (n = 132), 5–9 years (n = 274), and 10–15 years (n = 103) and subjected to the urease test, histopathology, ELISA, and western blot using whole-cell lysates of H. pylori strain 51. The positivity rate in the urease test (P = 0.003), the degree of chronic gastritis (P = 0.021), and H. pylori infiltration (P < 0.001) increased with age. The median titer for anti-H. pylori IgG was 732.5 IU/mL at 0–4 years, 689.0 IU/mL at 5–9 years, and 966.0 IU/mL at 10–15 years (P < 0.001); the median titer for anti-H. pylori IgA was 61.0 IU/mL at 0–4 years, 63.5 IU/mL at 5–9 years, and 75.0 IU/mL at 10–15 years (P < 0.001). The CagA-positivity rate was 26.5% at 0–4 years, 36.5% at 5–9 years, and 46.6% at 10–15 years for IgG (P = 0.036), and 11.3% at 0–4 years, 18.6% at 5–9 years, and 23.3% at 10–15 years for IgA (P < 0.001). Anti-H. pylori IgG and IgA titers increased with the urease test grade, chronic gastritis degree, active gastritis, and H. pylori infiltration. Presence of CagA-positivity is well correlated with a high urease test grade and high anti-H. pylori IgG/IgA levels.     

Clinical Characteristics of Primary Epstein Barr Virus Hepatitis with Elevation of Alkaline Phosphatase and γ-Glutamyltransferase in Children

Purpose

The aim of the present study was to evaluate the clinical characteristics of the primary Epstein-Barr virus (EBV) hepatitis with elevation of both serum alkaline phosphatase (ALP) and γ-glutamyltransferase (γ-GT) levels in children.

Materials and Methods

A retrospective study was performed by reviewing of the medical records of 36 patients who were diagnosed with primary EBV hepatitis. The patients were divided into 2 groups: patients with elevated serum ALP and γ-GT levels (group 1) and patients without (group 2).

Results

The classic features of infectious mononucleosis (fever, pharyngitis and/or tonsillitis, and cervical lymphadenitis) were seen in 20 (57.1%) of group 1 patients and 18 (50.0%) of group 2 patients. Hepatitis with elevated serum ALP and γ-GT levels were present in 14 (38.9%) of the all patients. Of these patients, Jaundice occurred in only 2 (5.6%). The mean levels of aspartate aminotransferase and alanine aminotransferase (ALT) as well as the number of patients with ALT greater than 400 IU/L were significantly different between the groups (177 IU/L vs. 94 IU/L, 418 IU/L vs. 115 IU/L, and 50.0% vs. 13.6%; p=0.001, p=0.001, p=0.026, respectively). The mean duration of elevated serum ALT levels was 17.5 days in group 1 and 9.0 days in group 2 (p=0.013). All patients recovered fully without any chronic or serious complications.

Conclusion

Primary EBV hepatitis with predominant biochemical abnormalities of the elevation of ALP and γ-GT is frequent and mostly anicteric. This may represent a benign disease, but a delay in recovery of liver function as well.     

Factors associated with gastro-duodenal ulcer in compensated type 2 diabetic patients: a Romanian single-center study

IntroductionHelicobacter pylori infection is accepted as the leading cause of chronic gastritis, ulcer disease and gastric cancer, with an important impact on health care burden, especially in countries with a high prevalence of infection. The aim of the study was to investigate the influence of H. pylori infection, medication, associated medical conditions or social habits on endoscopic ulcer occurrence in the compensated type 2 diabetic population.Material and methodsTwo hundred and sixty type 2 diabetic patients investigated on endoscopy (57 patients with peptic ulcer and 203 controls) with a complete set of biopsies, demographic and medical data were enrolled.ResultsOn univariate regression analysis, H. pylori infection (42.1% vs. 35.5%, p = 0.359) or a history of peptic ulcer (61.4% vs. 61.6%, p = 0.981) was not a predictor for ulcer on endoscopy in the diabetic population, and heartburn was more frequent in diabetics without ulcer (21.2% vs. 8.8%, p = 0.033). Anemia was the best predictor for ulcer on endoscopy in both diabetics with (p < 0.001, OR = 4.77, 95% CI: 2.02–11.28) and without (p = 0.027, OR = 2.76, 95% CI: 1.10–6.91) chronic proton pump inhibitor (PPI) therapy. In diabetic patients on PPI more than 1 month anticoagulants – acenocoumarol or low-weight molecular heparin (p = 0.038, OR = 2.37, 95% CI: 1.04–5.40), low-dose aspirin 75–125 mg/day (p = 0.029, OR = 2.61, 95% CI: 1.08–6.28) and alcohol consumption (p = 0.015, OR = 2.70, 95% CI: 1.19–6.13) were predictors for ulcer on endoscopy.ConclusionsIn diabetic patients, anemia is the most important predictor for ulcer on endoscopy, but not H. pylori or digestive symptoms, while low-dose aspirin or anticoagulant therapy and alcohol consumption are the most important predictors for ulcer in diabetics on chronic proton pump inhibitor therapy.     

Comparison of Initial Presentation of Pediatric Diabetes Before and During the Coronavirus Disease 2019 Pandemic Era

BackgroundHospital visitation has become challenging during the coronavirus disease 2019 pandemic because of quarantine measures and fear of infection. Consequently, newly diagnosed patients may present with more severe diseases during the pandemic. The present study analyzed the differences in the initial clinical presentations of newly diagnosed patients with type 1 diabetes (T1D) and type 2 diabetes (T2D), comparing pre-pandemic and pandemic periods.MethodsNewly diagnosed patients with T1D or T2D and aged < 18 years during 2018–2020 were included in the study. Data were collected retrospectively from four academic centers in Gyeonggi-do, South Korea. Initial clinical data were compared between the pre-pandemic (2018–2019) and pandemic (2020) periods.ResultsIn the pre-pandemic and pandemic periods, 99 patients (41 T1D and 58 T2D patients) and 84 patients (51 T1D and 33 T2D patients) were identified, respectively. During the pandemic, the proportion of diabetic ketoacidosis (DKA) cases increased compared to the pre-pandemic period (21.2% during 2018–2019 vs. 38.1% in 2020; P = 0.012). In the pre-pandemic and pandemic periods, initial pH was 7.32 ± 0.14 and 7.27 ± 0.15, respectively (P = 0.040), and HbA1c values were 11.18 ± 2.46% and 12.42 ± 2.87%, respectively (P = 0.002). During the pandemic, there was an increased risk of DKA in patients with T1D (odds ratio, 2.42; 95% confidence interval, 1.04–5.62; P = 0.040).ConclusionDuring the pandemic, the proportion of DKA in newly diagnosed patients with T1D increased and clinical parameters showed a deteriorating pattern. Increased awareness of pediatric diabetes, especially DKA, could facilitate visit to the hospital for an early diagnosis; thus, reducing the number of DKA cases during the pandemic era.     

Late to early velocity index as a predictor of iatrogenic femoral artery pseudoaneurysm recurrence in patients treated with ultrasound-guided thrombin injection

IntroductionUltrasound-guided thrombin injection (UGTI) is the preferred treatment of pseudoaneurysms (psA). The potential risk of complications increases with the number of UGTI treatments needed for complete psA obliteration. Identification of risk factors for recurrent psA is needed.Material and methodsIn total, 508 patients with femoral artery psA underwent UGTI, followed by ultrasound examination repeated twice, at 1-week intervals, to assess UGTI effectiveness. In cases of psA recurrence, the procedure was repeated. Clinical and ultrasound data were prospectively collected.ResultsThe psA recurrence occurred in 76 (15%) patients. UGTI was repeated twice in 49 (64%), three times in 15 (20%) and more than three times in 12 (16%) patients. The median thrombin dose was 150 IU (80–250 IU), and was lower in initial procedures than repeated UGTI (p = 0.025). The median psA volume was 2.26 ml (0.86–5.47 ml). The median length of the communicating channel was 4 mm (0–12 mm). A time interval between vessel catheterization and UGTI greater than 7 days (p < 0.001), a late to early velocity index (LEVI) of < 0.2 identified during the outflow phase (p < 0.001), a psA volume > 5 ml (p = 0.032), and a short communicating channel between the psA and the artery (p = 0.037) predicted psA recurrence. Antiplatelet and anticoagulant agents did not increase the risk.ConclusionsThe LEVI and time interval between artery cannulation and UGTI treatment are strong parameters identifying patients at risk of psA recurrence. The psA volume and communicating channel length are less substantial risks, but still significant. Concomitant antiplatelet and anticoagulant therapy do not affect the success rate of UGTI.     

Professional Status of Infectious Disease Specialists in Korea: A Nationwide Survey

BackgroundInfectious disease (ID) specialists are skilled facilitators of medical consultation who promote better outcomes in patient survival, antibiotic stewardship as well as healthcare safety in pandemic response. This study aimed to assess the working status of ID specialists and identify problems faced by ID professionals in Korea.MethodsThis was a nationwide cross-sectional study in Korea. An online-based survey was conducted over 11 days (from December 17–27, 2020), targeting all active adult (n = 281) and pediatric (n = 71) ID specialists in Korea (N = 352). Questions regarding the practice areas of the specialists were divided into five categories: 1) clinical practices of outpatient care, inpatient care, and consultations; 2) infection control; 3) antibiotic stewardship; 4) research; and 5) education and training. We investigated the weekly time-use patterns for these areas of practice.ResultsOf the 352 ID specialists, 195 (55.4%; 51.2% [144/281] adult and 71.8% [51/71] pediatric ID specialists) responded in the survey. Moreover, 144 (73.8%) of the total respondents were involved in all practice categories investigated. The most common practice area was outpatient service (93.8%), followed by consultation (91.3%) and inpatient service (87.7%). Specialists worked a median of 61 (interquartile range: 54–71) hours weekly: patient care, 29 (14–37) hours; research 11 (5–19) hours; infection control 4 (2–10) hours; antibiotic stewardship, 3 (1–5) hours; and education/training, 2 (2–6) hours.ConclusionID specialists in Korea simultaneously undertake multiple tasks and work long hours, highlighting the need for training and employing more ID specialists.     

The Global Spread of Severe Obesity in Toddlers,Children, and Adolescents: A Systematic Review and Meta-Analysis

IntroductionSevere obesity among children and adolescents has emerged as a public health concern in multiple places around the world.MethodsWe searched the Medline database for articles on severe obesity rates in children published between January 1960 and January 2020. For studies with available prevalence rates for an early and a more recent time period, the relative increase in prevalence was imputed.ResultsIn total, 874 publications were identified, of which 38 contained relevant epidemiological data. Rates of severe obesity varied significantly according to age, gender, geographic area, and the definition of severe obesity. The highest rates of class II and III obesity in the USA according to the Centers of Disease Control cut-off were 9.5% and 4.5%, respectively. Seventeen studies reported prevalence rates in at least two time periods. Data for 9,190,718 individuals showed a 1.71 (95% CI, 1.53–1.90) greater odds for severe obesity in 2006–2017 (N = 5,029,584) versus 1967–2007 (N = 4,161,134). In an analysis limited to studies from 1980s with a minimum follow-up of 20 years, a 9.16 (95% CI, 7.76–10.80) greater odds for severe obesity in recent versus earlier time was found. An analysis limited to studies from 2000, with a follow-up of 5–15 years, a 1.09 (95% CI, 0.99–1.20) greater odds was noted when comparing (2011–2017; N = 4,991,831) versus (2000–2011; N = 4,134,340).ConclusionSevere pediatric obesity is escalating with a marked increase from the 1980s and a slower rate from 2000.     

Incidence of Postnatal CMV Infection among Breastfed Preterm Infants: a Systematic Review and Meta-analysis

BackgroundWe performed a systematic review and meta-analysis to evaluate the incidence of breast milk-acquired cytomegalovirus (CMV) infection in preterm infants born to CMV-seropositive mothers.MethodsPubMed, Embase, and Cochrane Library databases were searched using the terms: (“breast feeding” or “breast milk” or “human milk” or “breast”) and (“HCMV” or “cytomegalovirus”) and (“infant, extremely premature” or “premature birth” or “newborn” or “neonate” or “low birth weight” or “very low birth weight” or “premature” or “preterm infant”). Studies that had information on CMV status and breast feeding were included in the meta-analysis.ResultsA total of 2,502 newborns from 19 studies were included in this meta-analysis. The rate of postnatally acquired CMV infection among breastfed infants with CMV-seropositive mothers was 16.5% (95% confidence interval [CI], 0.10–0.26; P < 0.001). The infection rate was 26% with fresh breast milk, 8% with a combined diet of fresh and freeze–thawed breast milk, and 11% with freeze–thawed breast milk. Among cases where the CMV status of breast milk was determined, CMV shedding into breast milk occurred in 80.5% (95% CI, 0.71–0.87; P < 0.001) of CMV seropositive mothers. The breast milk-acquired CMV infection rate among infants fed CMV-positive breast milk was 20.7% (95% CI, 0.14–0.30; P < 0.001).ConclusionThis meta-analysis examined the rate of breast milk-acquired CMV infections in preterm infants with CMV-seropositive mothers; the CMV infection rate was higher in preterm infants fed fresh breast milk. Until further data are available, we cautiously suggest the use of freeze–thawed breast milk, rather than fresh breast milk, for preterm infants or very low birth weight infants.     

Epidemiology and Clinical Features of Myocarditis/Pericarditis before the Introduction of mRNA COVID-19 Vaccine in Korean Children: a Multicenter Study

BackgroundKorean health authority plans to vaccinate adolescents against coronavirus disease 2019 (COVID-19) starting high school seniors during the summer vacation of 2021. However, the myocarditis/pericarditis following COVID-19 vaccine has been reported recently in adolescents and young adults. This study was performed to answer the urgent questions about the basic epidemiology and clinical course of myocarditis/pericarditis in hospitalized patients prior to the introduction of COVID-19 vaccines in pediatric population.MethodsA retrospective medical record analysis including frequency, clinical characteristics, etiology and outcome of myocarditis/pericarditis was conducted in 17 years and younger patients who were hospitalized in two referral hospitals in Korea between 2010 and 2019.ResultsTotal 142 patients with myocarditis (n = 119) and/or pericarditis (n = 23) were identified. Median age was 5.4 years (interquartile range, 0.6–12.9 years; range, 11 days–17.8 years), and male was 61%. In adolescents aged 12–17 years, the male to female ratio was 3.2. Myocarditis/pericarditis occurred 0.70 per 1,000 in-patients during the study period: 0.96 (< 1 year), 0.50 (1–5 years), 0.67 (6–11 years) and 1.22 (12–17 years) per 1,000 in-patients, respectively. There was an increasing tendency for the annual frequency from 0.34 in 2010 to 1.25 per 1,000 in-patients in 2019 (P = 0.021). Among the 56 (40%) proven pathogens at admission, Mycoplasma pneumoniae (n = 11, 8%) and enterovirus (n = 10, 7%) were most common. Of the 142 patients, 99 (70%) required pediatric intensive care unit care and 10 (7%) received heart transplantation. In addition, 61 patients (61/131, 47%) without heart medication at admission needed heart medication when they were discharged. Eleven (7.7%) patients died, of which five patients were previously healthy. The median age of deceased patients was lower than the survival group (0.8 vs. 6.3 years, P = 0.014).ConclusionThe frequency of myocarditis/pericarditis was highest among male adolescent in-patients; however, the outcome was favorable in this group without any mortality.     

Reappraisal of sepsis-3 and CLIF-SOFA as predictors of mortality in patients with cirrhosis and infection presenting to the emergency department: A multicenter study

Background/AimsSepsis-3 criteria and quick Sequential Organ Failure Assessment (qSOFA) have been advocated to be used in defining sepsis in the general population. We aimed to compare the Sepsis-3 criteria and Chronic Liver Failure-SOFA (CLIF-SOFA) scores as predictors of in-hospital mortality in cirrhotic patients admitted to the emergency department (ED) for infections.MethodsA total of 1,622 cirrhosis patients admitted at the ED for infections were assessed retrospectively. We analyzed their demographic, laboratory, and microbiological data upon diagnosis of the infection. The primary endpoint was inhospital mortality rate. The predictive performances of baseline CLIF-SOFA, Sepsis-3, and qSOFA scores for in-hospital mortality were evaluated.ResultsThe CLIF-SOFA score proved to be significantly better in predicting in-hospital mortality (area under the receiver operating characteristic curve [AUROC], 0.80; 95% confidence interval [CI], 0.78–0.82) than the Sepsis-3 (AUROC, 0.75; 95% CI, 0.72–0.77, P<0.001) and qSOFA (AUROC, 0.67; 95% CI, 0.64–0.70; P<0.001) score. The CLIF-SOFA, CLIF-C-AD scores, Sepsis-3 criteria, septic shock, and qSOFA positivity were significantly associated with in-hospital mortality (adjusted hazard ratio [aHR], 1.24; 95% CI, 1.19–1.28; aHR, 1.13; 95% CI, 1.09–1.17; aHR, 1.19; 95% CI, 1.15–1.24; aHR, 1.88; 95% CI, 1.42–2.48; aHR, 2.06; 95% CI, 1.55–2.72; respectively; all P<0.001). For CLIF-SOFA scores ≥6, in-hospital mortality was >10%; this is the cutoff point for the definition of sepsis.ConclusionsAmong cirrhosis patients presenting with infections at the ED, CLIF-SOFA scores showed a better predictive performance for mortality than both Sepsis-3 criteria and qSOFA scores, and can be a useful tool of risk stratification in cirrhotic patients requiring timely intervention for infection.     

Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea

PurposeRapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications.Materials and MethodsThis multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted.ResultsA total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p<0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p<0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p<0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120–1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093–4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257–11.626).ConclusionRSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.     

Severe Disease Activity Based on the Paris Classification Is Associated with the Development of Extraintestinal Manifestations in Korean Children and Adolescents with Ulcerative Colitis

BackgroundThere are limited data regarding the extraintestinal manifestations (EIMs) associated with pediatric inflammatory bowel disease (IBD) in Korea. We aimed to investigate the clinical features and factors associated with the development of EIMs in Korean children and adolescents with IBD.MethodsThis multicenter, retrospective study was conducted from 2010 to 2017. Baseline clinicodemographic, laboratory findings, disease activity, disease phenotypes, and EIMs were investigated.ResultsA total of 172 patients were included. One-hundred thirty-seven (79.7%) had Crohn''s disease (CD), and 35 (20.3%) had ulcerative colitis (UC). EIMs occurred in 42 patients (24.4%). EIMs developed in 34/137 diagnosed with CD (24.8%), and in 8/35 diagnosed with UC (22.9%), during a median follow-up duration of 3.2 (interquartile range, 1.9–5.4) years for CD and 3.0 (1.0–4.0) years for UC, respectively. Arthritis/arthralgia was most commonly observed (n = 15, 35.7%), followed by stomatitis/oral ulcer (n = 10, 23.8%), hepatitis (n = 5, 11.9%), nephritis (n = 4, 9.5%), pancreatitis (n = 2, 4.8%), erythema nodosum (n = 2, 4.8%), pyoderma gangrenosum (n = 1, 2.4%), primary sclerosing cholangitis (n = 1, 2.4%), uveitis (n = 1, 2.4%), and ankylosing spondylitis (n = 1, 2.4%). A significant difference in disease severity based on the Paris classification (P = 0.011) and ESR at diagnosis (P = 0.043) was observed between the EIM positive and negative group in patients with UC. According to logistic regression analyses, S1 disease severity based on the Paris classification was the only factor that was significantly associated with the development of EIMs (odds ratio, 16.57; 95% confidence interval, 2.18–287.39; P = 0.017).ConclusionSevere disease activity based on the Paris classification in pediatric patients with UC was significantly associated with EIM development. As disease severity in the Paris classification is a dynamic parameter, treatment should be focused on disease control to minimize the occurrence of EIMs in Korean children and adolescents with UC.     

Comparison of Base Deficit and Vital Signs as Criteria for Hemorrhagic Shock Classification in Children with Trauma

PurposeBase deficit (BD) is superior to vital signs in predicting trauma outcomes in adults. The authors aimed to compare BD and vital signs as criteria for the four-tiered hemorrhagic shock classification in children with trauma.Materials and MethodsWe retrospectively reviewed the data of 1046 injured children who visited a Korean academic hospital from 2010 through 2018. These children were classified separately based on BD (class I, BD ≤2.0 mmol/L; II, 2.1–6.0 mmol/L; III, 6.1–10 mmol/L; and IV, ≥10.1 mmol/L) and vital signs (<13 years: age-adjusted hypotension and tachycardia, and Glasgow Coma Scale; 13–17 years: the 2012 Advanced Trauma Life Support classification). The two methods were compared on a class-by-class basis regarding the outcomes: mortality, early transfusion (overall and massive), and early surgical interventions for the torso or major vessels.ResultsIn total, 603 children were enrolled, of whom 6.6% died. With the worsening of BD and vital signs, the outcome rates increased stepwise (most p<0.001; only between surgical interventions and vital signs, p=0.035). Mortality more commonly occurred in BD-based class IV than in vital signs-based class IV (58.8% vs. 32.7%, p=0.008). Early transfusion was more commonly performed in BD-based class III than in vital signs-based class III (overall, 73.8% vs. 53.7%, p=0.007; massive, 37.5% vs. 15.8%, p=0.001). No significant differences were found in the rates of early surgical interventions between the two methods.ConclusionBD can be a better predictor of outcomes than vital signs in children with severe hemorrhagic shock.     

Epidemiology of Injuries in National Collegiate Athletic Association Women's Field Hockey: 2014–2015 Through 2018–2019

ContextThe National Collegiate Athletic Association has sponsored women''s field hockey since 1981, and team membership as well as student-athlete participation has grown over time.BackgroundRoutine examinations of injuries sustained by athletes are important for identifying and understanding patterns that can be used to inform sport safety practices.MethodsExposure and injury data collected in the National Collegiate Athletic Association Injury Surveillance Program from 2014–2015 through 2018–2019 were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios were used to examine differential injury rates.ResultsThe overall injury rate was 6.27 per 1000 athlete-exposures (AEs). Head/face injuries (16.0%) and thigh injuries (12.3%) were the most commonly injured body parts during the 2014–2015 through 2018–2019 academic years. Concussion (8.6%) was the most commonly reported injury, and concussion rates notably decreased between 2017–2018 and 2018–2019.SummaryStudy findings were generally consistent with the existing epidemiologic evidence. Incidence rates and trajectories of commonly observed injuries warrant particular attention in the future.     

Infliximab Therapy for Children with Moderate to Severe Ulcerative Colitis: A Step-Up versus a Top-Down Strategy

PurposeWe aimed to investigate clinical outcomes between top-down (TD) and conventional step-up (SU) therapies in pediatric patients with moderate to severe ulcerative colitis (UC).Materials and MethodsAll patients underwent clinical and endoscopic evaluation at diagnosis and 4 months and 1 year after treatment. Patients who started treatment with corticosteroid were grouped in the SU group, while those that initiated early infliximab (IFX) were grouped in the TD group. Among the SU group, patients who eventually changed to IFX treatment due to steroid resistance or dependency were included in the SU(R) group.ResultsIn total, 44 children with moderate to severe UC were included for analysis. Twenty-one patients were included in the SU group, 23 were included in the TD group, and 10 were enrolled in the SU(R) group. Relapse rates were 47.6% (10/21) in the SU group and 17.4% (4/23) in the TD group (p=0.033). Among relapsed patients, the durations from remission to relapse were 17.3 months (0.9–46.9) in the SU group and 24.3 months (1.8–44.9) in the TD group. There was no statistically significant difference in the sustained durations of remission after IFX administration between the SU(R) and TD groups [3.9 (1.4–6.3) and 2.3 (0.3–5.2) years, respectively (p>0.05)].ConclusionAccording to our study, early use of IFX without corticosteroid treatment for children with moderate to severe UC helps to lower relapse rates. We also found that IFX was a very effective treatment for pediatric UC, with a sustained duration of remission similar between TD and SU(R) groups.     

Delayed Influenza Treatment in Children With False-Negative Rapid Antigen Test: A Retrospective Single-Center Study in Korea 2016–2019

BackgroundWe aimed to examine the delay in antiviral initiation in rapid antigen test (RAT) false-negative children with influenza virus infection and to explore the clinical outcomes. We additionally conducted a medical cost-benefit analysis.MethodsThis single-center, retrospective study included children (aged < 10 years) with influenza-like illness (ILI), hospitalized after presenting to the emergency department during three influenza seasons (2016–2019). RAT-false-negativity was defined as RAT-negative and polymerase chain reaction-positive cases. The turnaround time to antiviral treatment (TAT) was from the time when RAT was prescribed to the time when the antiviral was administered. The medical cost analysis by scenarios was also performed.ResultsA total of 1,430 patients were included, 7.5% were RAT-positive (n = 107) and 2.4% were RAT-false-negative (n = 20). The median TAT of RAT-false-negative patients was 52.8 hours, significantly longer than that of 4 hours in RAT-positive patients (19.2–100.1, P < 0.001). In the multivariable analysis, TAT of ≥ 24 hours was associated with a risk of severe influenza infection and the need for mechanical ventilation (odds ratio [OR], 6.8, P = 0.009 and OR, 16.2, P = 0.033, respectively). The medical cost varied from $11.7–187.3/ILI patient.ConclusionAntiviral initiation was delayed in RAT-false-negative patients. Our findings support the guideline that children with influenza, suspected of having severe or progressive infection, should be treated immediately.     

Point-of-care ultrasound assessment of the inferior vena cava distensibility index in mechanically ventilated children in the operating room

Background and aimPoint-of-care ultrasound imaging of the inferior vena cava distensibility index is a potential indicator for determining fluid overload and dehydration in the mechanically ventilated patients. Data on inferior vena cava distensibility index and inferior vena cava distensibility variability are limited in mechanically ventilated pediatric patients. That is why our aim in this study was to measure inferior vena cava distensibility index and to obtain mean values in pediatric patients, ventilated in the operating room before the ambulatory surgical procedure started.Materials and methodsThis crosssectional study was performed between February 2019 and February 2020. Ultrasonographic measurements were performed in a total of 125 children.ResultsIn a period of 13 months, the measurements were performed in a total of 125 children, of which 120 (62.5% male) met the criteria and were included in the study. Overall inferior vena cava distensibility index (%): mean   SD: 6.8   4.0, median (min–max): 5.7 (1.4–19.6), IQR: 3.8–8.7. Overall inferior vena cava distensibility variability (%): mean   SD: 6.5   3.7, median (min–max): 5.5 (1.4–17.8), IQR: 3.7–8.4.ConclusionOur study is the largest series of children in the literature in which inferior vena cava distensibility index measurements were investigated.     

Effects of acetaminophen and ibuprofen monotherapy in febrile children: a meta-analysis of randomized controlled trials

IntroductionWhen a child presents with fever in the clinical encounter, parents are usually concerned about alleviating the fever. However, the indications for selecting an appropriate drug from the most commonly used antipyretic drugs, acetaminophen and ibuprofen, remain unclear. The purpose of this study was to assess the efficacy and safety of acetaminophen and ibuprofen in febrile children through a systematic review with meta-analysis of randomized controlled trials (RCTs).Material and methodsCochrane, Embase, and PubMed databases were searched for the relevant RCTs. Two authors individually extracted information on trial design, demography, rate of fever resolution, body temperature, and overall adverse events. Data were pooled mainly using a random-effects model; however, because of some sparse data, Peto odds ratios (PORs) were used for outcomes of fever resolution and adverse event. 95% confidence intervals (CIs) were also presented.ResultsIn total, 26 RCTs (n = 4137) fulfilled eligibility criteria. Pooled estimates demonstrated that acetaminophen led to significantly lower fever resolution rates than ibuprofen did (POR = 0.91, 95% CI: 0.84–0.98; I ² = 0%) in the subgroup of trials with a mean age of < 2 years. However, the treatment–time interaction model for body temperature demonstrated that the fever resolution effect was mainly from the time factor based on the available data (effect size = –0.20; 95% CI: –0.30 to –0.11; I ² = 6.9%). Acetaminophen demonstrated lower overall adverse event rates than ibuprofen (POR = 0.71; 95% CI: 0.58–0.87; I ² = 0%).ConclusionsThe effects of ibuprofen are similar to acetaminophen even in children with mean age of approximately 5 years. Nevertheless, acetaminophen is safer than ibuprofen, particularly in children approximately 5 years old.