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ImportanceDistraction using virtual reality (VR) has been found to provide a clinically significant reduction in the experience of pain during various painful procedures. Commercially available VR systems usually require the user to wear a head-mounted display helmet, which can be challenging for young children, and whether VR can reduce pain during intravenous (IV) placement in young children is currently unknown.ObjectiveTo determine whether a VR environment using a novel domed ceiling screen reduces distress among children over the course of IV placement compared with standard care in a pediatric emergency department.Design, Setting, and ParticipantsThis randomized clinical trial was conducted from June 3, 2020, to February 8, 2021, at an urban tertiary academic children’s hospital. Included were children aged 6 months to 4 years undergoing IV placement in the pediatric emergency department.InterventionChildren in the intervention group lay on a bed to experience a VR animation using a domed ceiling screen during the IV placement procedure, which was performed as usual. Children in the control group also lay on a bed during the procedure but did not view a VR animation.Main Outcomes and MeasuresThe primary outcome was pain scores measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at 4 time points during IV placement: immediately after the child lay down on the bed (T1), the moment the tourniquet was applied (T2), the moment a sterile alcohol swab was applied (T3), and the moment the needle penetrated the skin (T4).ResultsOf the 88 children included in the final analysis, 44 received VR distraction (median [IQR] age, 24.0 [14.5-44.0] months; 27 boys [61.4%]), and 44 received standard care (median [IQR] age, 23.0 [15.0-40.0] months; 26 boys [59.1%]). The median [IQR] FLACC scores at T4 were 6.0 (1.8-7.5) in the intervention group and 7.0 (5.5-7.8) in the control group. The ordinal logistic regression model showed that children in the VR intervention group vs the control group had a lower probability of higher FLACC scores (odds ratio, 0.53; 95% CI, 0.28-0.99; P = .046).Conclusions and RelevanceThe findings of this trial indicate that displaying VR using a domed ceiling screen may be an effective distraction method that reduces distress in young children undergoing IV placement.Trial Registrationisrctn.org Identifier: KCT0005122

We aimed to find the ideal chest compression point undergoing cardiopulmonary resuscitation (CPR) in patients with a single ventricle with dextrocardia corrected by Fontan surgery. The most recent saved chest computed tomography images of all patients 8 years or older with a single ventricle who underwent Fontan surgery were retrospectively analysed. We defined the ideal chest compression point as the largest part of the compressed single ventricle. To find the ideal chest compression point, we measured the distance from the midline of the sternum to the point of the maximum sagittal area of the single ventricle as a deviation and calculated the area fraction of the compressed structures. Fifty-eight patients (male 67.2%) were analysed. The mean right deviation from the midline of the sternum as the ideal compression point was almost like the mean sternum width (32.85 ± 15.61 vs. 31.05 ± 6.75 mm). When chest compression was performed at the ideal point, the area fraction of the single ventricle statistically significant increased by 7%, wider than conventional compression (0.15 ± 0.10 vs. 0.22 ± 0.11, p < 0.05). When performing CPR on a patient with Fontan circulation with dextrocardia, right-sided chest compression is better than the conventional location.

Purpose: Genital injury is a common pediatric injury. Given the lack of nationwide data, the authors aimed to show age group-related epidemiologic features of genital injury in Korea.Methods:We reviewed the data from 2011-2016 Emergency Department-based Injury In-depth Surveillance registry, which involves 23 emergency departments in Korea. From the dataset, we included children (< 18 years) with the International Classification of Diseases, 10th Revision codes related to genital injury as the final diagnosis with excluding those with other codes or combined injuries. Age groups were defined as follows; infants (< 1 year), toddlers (1-3), preschoolers (4-6), schoolers (7-12), and adolescents (13-17). The clinical features and outcomes were analyzed.Results: A total of 3,030 children were included with the median age of 6 years (interquartile range, 4-10) and the proportion of girls of 53.0%. Only 144 children (4.8%) were transported by the emergency medical service providers. The most common mechanism and place were blunt injury (1,826 [60.3%]) and home (1,535 [50.7%]), respectively. Of the codes, “Contusion of external genital organs (S30.2)” was most common (1,574 [51.9%]). As for outcomes, 2,770 children (91.4%) were discharged, 252 (8.3%) were hospitalized (intensive care units, 1 child [0.03%]), and 108 (3.6%) underwent surgery. Severe injury occurred in 111 children (3.7%) without a mortality. With increasing age in the age groups, non-accidental injury, school and sports-related injuries, hospitalization, and surgery (All Ps < 0.001).Conclusion: Genital injury may occur at evening, in spring and summer, at home, and in the form of accidental or blunt injury. Most children are discharged. Contrary to these general features, older children tend to undergo more frequently non-accidental injury, school and sports-related injuries, hospitalization, and surgery. Thus, we need age-specific strategies for injury prevention.

Introduction The delta neutrophil index (DNI) is a reported marker that can be used to predict the diagnosis, prognosis, and disease severity of bacteremia and sepsis. We determined whether the DNI is useful in differentiating bacterial infection without bacteremia from viral infections in pediatric febrile patients in the emergency department (ED). Method This study involved a retrospective analysis of patient medical records from the pediatric ED of the teaching hospital. After extracting the list of patients with complete blood count (CBC) and DNI data,patients with bacterial infection (BI) without bacteremia and those with viral infection (VI) were identified. The primary outcome was the diagnostic performance of DNI in differentiating BI without bacteremia from VI. The secondary outcome was a comparison of the diagnostic performances of DNI, CRP, WBC, and neutrophil count between the two groups. Results After excluding 756 patients, a total of 574 patients were included in the study. A total of 151 (26.3%) patients were in the BI group, and 423 (73.7%) were in the VI group. There was no significant difference in DNI between the two groups (3.07 (2.52~3.63) vs. 3.51 (2.40~4.62), mean (95% CI), BI vs. VI). There was no difference in WBC count, neutrophil levels, or RDW between the two groups, but CRP levels were significantly higher in the BI group than in the VI group (1.39 (1.19~1.60) vs. 4.56 (3.66~5.45), mean (95% CI), VI vs. BI, p < 0.05). The AUROCs achieved in analyses of DNI, WBC count, neutrophil levels, RDW, and CRP levels were 0.5016, 0.5531, 0.5631, 0.5131, and 0.7389, respectively, and only CRP levels were helpful in differentiating BI from VI. Conclusion In the absence of bacteremia, DNI wound not be helpful in differentiating BI from VI in pediatric febrile patients.

Urethral catheterization (CATH) and suprapubic aspiration (SA) are reliable methods of collecting urine for the diagnosis of urinary tract infections (UTIs), but both are invasive and difficult. Therefore, urine collection through a sterile urine bag (SUB) is commonly used for UTI screening. However, when pyuria is found in SUB specimens, it is difficult to interpret whether this result is true or false.We aimed to determine the diagnostic performance of the urinary NAG/Cr ratio in detecting true pyuria in SUB specimens for children with suspected UTIs.This retrospective study included children 2-24 months of age presenting to the pediatric emergency department (PED) and in whom urinary NAG and creatinine levels were measured and a urine culture was performed between January 1, 2018, and December 31, 2019. Children with the presence of pyuria in SUB specimens were categorized into true or false pyuria groups depending on whether pyuria was present in CATH specimens. The diagnostic performance of the urinary NAG/Cr ratio in detecting true pyuria was identified using receiver operating characteristic (ROC) curve analysis. The optimal cutoff was calculated based on ROC curve analysis. Sensitivity, specificity, and positive and negative likelihood ratios were assessed for optimal cutoff values.Among 606 children with measured urinary NAG levels, 144 children with pyuria in SUB specimens were included in the analyses. Pyuria was consistently present in the CATH specimens of 67 (46.5%) children and absent in those of 77 (44.5%) children. The urinary NAG/Cr ratio was significantly higher in the true pyuria group than in the false pyuria group (21.5 IU/g; 95% confidence interval [CI]: 12.3-35.6; vs 9.6 IU/g; 95% CI: 6.7-16.1, P 0.001). The area under the ROC curve (AUC) for the urinary NAG/Cr ratio was 0.776 (95% CI: 0.700-0.851). The optimal cutoff of 18.85 IU/g corresponded to the best combination of sensitivity (58.2, 95% CI: 46.4-70.0) and specificity (83.3, 95% CI: 74.7-91.6), with positive and negative likelihood ratios of 3.49 (95% CI: 2.04-5.97) and 0.50 (95% CI: 0.37-0.68), respectively.The urinary NAG/Cr ratio may be a potential indicator discriminating true pyuria from false pyuria in SUB specimens in the PED. However, large prospective studies are required to implement the NAG/Cr ratio in clinical practice.

Serious bacterial infection (SBI) is a major cause of morbidity and mortality in children. Distinguishing SBI from self-limiting viral infections is a very important task in the emergency department (ED), especially in the children with fever without source (FWS). The aim of this study was to analyze whether parents’ statements about clinical manifestations, which were categorized according to grades, are related to the actual diagnosis of SBI in children with FWS. Retrospective analysis was conducted using prospectively acquired cohort data for all febrile children in the pediatric ED of Seoul National University Hospital from August 2016 to August 2017. The association of clinical manifestations and SBI was the main outcome of this study. The SBIs included diagnoses such as bacteremia, bacterial meningitis, urinary tract infection, and pneumonia. Clinical manifestations including activity, urination, and feeding were categorized into 3 or 4 grades according to the parents’ statements. The linear-by-linear association test was used to examine linear associations between the severity of clinical manifestations and SBI. Receiver operating characteristic curves for clinical manifestations were constructed for patients with SBI. Area under the curve (AUC) statistics and 95% confidence intervals (CIs) were obtained to evaluate the predictive performance of clinical manifestations. There was no linear association between SBI and non-SBI when compared by severity of the clinical manifestations, such as duration of fever (P = .299), activity (P = .781), feeding (P = .161), and urination (P = .834). The AUC was 0.54 (95% CI 0.41–0.67) for duration of fever, 0.52 for activity (95% CI 0.40–0.64), 0.42 for feeding (95% CI 0.32–0.53), and 0.51 for urination (95% CI 0.39–0.62). There was no evidence that the test performance of the clinical manifestations is valid for predicting SBIs, even considering the severity of manifestations. For optimal evaluation of the children with FWS, more comprehensive approach including laboratory tests, are needed.

According to lymphoma guidelines, gastric diffuse large B cell lymphoma (DLBCL) patients should undergo regular computed tomography (CT) and/or positron emission tomography (PET) examinations to assess treatment response. Endoscopic examinations are not indicated in the guidelines. The aim of this study was to investigate the utility of endoscopic examinations during and after treatment for DLBCL.We reviewed the patients diagnosed with gastric DLBCL at Seoul St. Mary's Hospital. All patients underwent endoscopy and radiologic examinations at every follow-up appointment. Radiologic response was defined according to World Health Organization criteria and endoscopic response was determined based on the Groupe d'Etude des Lymphomes de l'Adult grading system that is widely used in post-treatment evaluation of gastric MALT lymphoma.Forty-five patients were analyzed. Within a median follow-up period of 34 months, 35 patients achieved both radiologic and endoscopic complete remission (CR). The median times to endoscopic and radiologic CR were not significantly different (21 versus 16 weeks, p = 0.118). However, in 25 patients with stage I disease, endoscopic CR [median (range), 20 (11-36)] was achieved later than radiologic CR [median (range), 13 (8-36)] (p = 0.027). Among 40 patients who achieved radiologic CR, 35 patients who also achieved endoscopic CR maintained remission during the follow-up. Two of the five patients who achieved radiologic CR without endoscopic CR experienced recurrence.In gastric DLBCL patients, endoscopic response does not always correlate with radiologic response and might predict disease recurrence. We suggest that follow-up endoscopic examination with biopsy should be performed in addition to radiologic examination.

Background and Objectives: This study was to investigate the association between the previous history of seaweed intake after childbirth and subclinical hypothyroidism (SCH) occurrence in Korean women based on the latest nationally representative epidemiological survey data, the Sixth Korea National Health and Nutrition Examination Survey (KNHANES VI). Materials and Methods: This study used data from KNHANES VI, a cross-sectional, nationally representative survey that comprises a health interview survey, health examination survey, and nutrition survey. Of the initial 22,948 Korean participants enrolled in KNHANES VI, 2,046 women were selected for this analysis. To examine SCH, the thyroid-stimulating hormone (TSH) reference range was defined using a population-based TSH range. Results: Subclinical hypothyroidism was increased in those who consumed seaweed soup after childbirth, but this was not significant (OR 1.3, CI: 0.80-2.13, p=0.293). However, the odd ratio for SCH differed according to the duration of seaweed soup consumption. When seaweed soup was consumed within 1 week after birth, the OR was increased in the crude model (OR 2.61, CI: 1.39-4.89, p=0.002), but this was no longer significant in the adjusted model (OR 1.89, CI: 0.79-4.50). Conclusion: The notable finding from this study is that the previous history of excessive seaweed consumption during post-partum period may not be a risk factor for SCH in Korean women.

Electro-spun silk webs are potentially good candidates as tissue engineering scaffolds owing to their good bio- and cyto-compatibility. However, the low fabrication rate of electro-spun silk mats has been one of the obstacles in the mass production of such nanofibrous silk mats in applications to the biomedical field. In this study, the effects of degumming ratio and silk concentration on the electro-spinning process were investigated by using regenerated silk with different residual sericin contents and different silk concentrations in terms of the morphology and structure of the electro-spun silk web. The rate of production of electro-spun silk mats could be increased by approximately 5 fold at a degumming ratio of 19.5%. The electro-spinning rate of silk was affected by two main factors: (1) dope solution viscosity and (2) degumming ratio of silk. The conductivity of the silk dope solution, however, had little effects on the electro-spinning of regenerated silk. A constant spun fiber morphology was observed within the electro-spinning rate range (0.3-1.4 ml/h). Fourier transform infrared spectroscopy showed that partial β-sheet crystallization occurred during electro-spinning. The molecular conformation was relatively unaffected by the electro-spinning rate of silk.

Bevacizumab (Avastin(Ⓡ)) is a monoclonal antibody against the vascular endothelial growth factor (VEGF) receptor that increases the overall survival rate when added to standard chemotherapy regimens in patients with metastatic colorectal cancer. The known toxicities of bevacizumab are hypertension, proteinuria, wound healing complications, arterial thrombosis, bleeding, and gastrointestinal complications. Especially ischemic colitis can rapidly develop into bowel perforation, so an emergency operation often is needed. Recently, a 65-year-old male patient developed ischemic pancolitis after FOLFOX (85 mg/m(2) Oxaliplatin, d1; 200 mg/m(2) Leucovorin, d1; 400 mg/m(2) 5-FU iv bolus, d1-2; and 600 mg/m(2) 5-FU, d1-2, every two wk) and Bevacizumab combination chemotherapy was administered. However, he recovered after early conservative care without surgery. We report this case with a review of literature.

Although the relationship between malignancy risk with systemic sclerosis (SSc) has been inconclusive, there are some previous studies for a positive correlation. Most patients with SSc have some degree of lung parenchymal involvement in the form of interstitial thickening and fibrosis. Interstitial lung disease is the most common pulmonary manifestation of SSc. Interstitial lung disease following chemotherapy (5-fluorouracil, leucovorin, and oxaliplatin [FOLFOX]) is an uncommon life-threatening complication and it is induced by oxaliplatin. We report a case of multiple cancers in a patient with SSc and aggravated interstitial lung disease by chemotherapy.