Ellen Ai-Rhan Kim

Transcatheter Arterial Embolization of Pulmonary Sequestration in Neonates: Long-term Follow-up Results

The purposes of this study are to describe experience with the safety and long-term efficacy of transcatheter arterial embolization (TAE) of pulmonary sequestration in neonates and to introduce a new technique of embolization by an umbilical-artery route. TAE was performed in five neonates, via the femoral artery in one and the umbilical artery in four. Complete regression was achieved in four cases and partial regression (>90%) was obtained in one. TAE is a safe and effective alternative therapeutic modality for the treatment of pulmonary sequestration. The umbilical artery represents a preferable route for performing embolization in neonates.

Clinical Outcomes in Methicillin-Resistant Staphylococcus aureus-Colonized Neonates in the Neonatal Intensive Care Unit

Background: Methicillin-resistent Staphylococcus aureus (MRSA) colonization can persist for prolonged periods, and patient-related factors are associated with persistent carriage in adults. However, such knowledge is lacking among neonates. Objectives: To better understand the outcome of MRSA-colonized neonates in the neonatal intensive care unit (NICU), we prospectively followed all colonized neonates until decolonization over 39 months and determined the incidence, duration of colonization, clinical outcomes and risk factors associated with prolonged carriage of MRSA. Methods: Nasal and inguinal cultures were obtained from all newly admitted neonates following an outbreak of MRSA. Weekly and 1–2 monthly cultures were obtained from all hospitalized and discharged neonates colonized with MRSA, respectively, until 2 consecutive cultures were negative. Results: 152 of 1,456 (10.4%) neonates became colonized. The mean time to acquire MRSA colonization was 17.1 ± 40.7 (range 1–471) days. The median time to decolonization was 36 days. About 20% of decolonized patients had been colonized for a prolonged period of ≧160 days. 47.5% of colonized patients were sent home colonized, and none with prolonged carriage developed MRSA-related infections in the following 6 months in contrast to 6 infants (3.9%) who developed MRSA sepsis during hospitalization. The only risk factor associated with prolonged carriage was the concurrent colonization of both the inguinal and nasal areas on admission. Conclusion:Nearly all neonates with acquired colonization became decolonized either prior to or after discharge from NICU. A significant percentage failed to decolonize prior to hospital discharge, but almost all decolonized by 30 months in the community without evidence of systemic or local infections.

Embolization versus surgical resection of pulmonary sequestration: clinical experiences with a thoracoscopic approach.

PURPOSE The goal of this study was to compare the safety and efficacy of treatment for pulmonary sequestration (PS) by transcatheter arterial embolization (TAE) versus surgical resection and to consider the role of a thoracoscopic approach. METHODS A retrospective review involving 73 children (≤ 15 years of age) with PS between 2002 and 2011 was performed. RESULTS Forty-two patients were managed with TAE, and 31 underwent surgery alone. Their presenting symptoms were pneumonia (n=11), pneumothorax (n=2), pneumomediastinum (n=1) and respiratory distress (n=6).Fifty-three (72.6%) were asymptomatic. The average age at treatment was 17.0 ± 44.4 and 31.3 ± 41.7 months for the TAE and surgery groups, respectively. In the TAE group, complete regression was observed in only 3 patients, 4 showed no regression, and 35 (83.3%) had residual lesions. Four patients developed sepsis or other blood vessel complications after TAE. The results of resection via thoracotomy versus a thoracoscopic approach were evaluated in 34 patients, including 3 who underwent the operation after TAE. Twenty-seven patients underwent thoracotomy, and 7 underwent thoracoscopic resection. There were no significant differences between the groups except time to chest tube removal, which was shorter in the thoracoscopic group (p=0.046). Complications included a wound infection in 1 patient after thoracotomy. CONCLUSIONS We believe that even in asymptomatic patients, all PSs should be resected because of the risk of infection, the low rate of natural regression, complications after TAE, and to exclude other pathology. Our experience also shows that thoracoscopic resection of PS is feasible, efficacious, and safe in newborns and infants.

Collateral Ventilation to Congenital Hyperlucent Lung Lesions Assessed on Xenon-Enhanced Dynamic Dual-Energy CT: an Initial Experience

Objective We wanted to evaluate the resistance to collateral ventilation in congenital hyperlucent lung lesions and to correlate that with the anatomic findings on xenon-enhanced dynamic dual-energy CT. Materials and Methods Xenon-enhanced dynamic dual-energy CT was successfully and safely performed in eight children (median age: 5.5 years, 4 boys and 4 girls) with congenital hyperlucent lung lesions. Functional assessment of the lung lesions on the xenon map was done, including performing a time-xenon value curve analysis and assessing the amplitude of xenon enhancement (A) value, the rate of xenon enhancement (K) value and the time of arrival value. Based on the A value, the lung lesions were categorized into high or low (A value > 10 Hounsfield unit [HU]) resistance to collateral ventilation. In addition, the morphologic CT findings of the lung lesions, including cyst, mucocele and an accessory or incomplete fissure, were assessed on the weighted-average CT images. The xenon-enhanced CT radiation dose was estimated. Results Five of the eight lung lesions were categorized into the high resistance group and three lesions were categorized into the low resistance group. The A and K values in the normal lung were higher than those in the low resistance group. The time of arrival values were delayed in the low resistance group. Cysts were identified in five lesions, mucocele in four, accessory fissure in three and incomplete fissure in two. Either cyst or an accessory fissure was seen in four of the five lesions showing high resistance to collateral ventilation. The xenon-enhanced CT radiation dose was 2.3 ± 0.6 mSv. Conclusion Xenon-enhanced dynamic dual-energy CT can help visualize and quantitate various degrees of collateral ventilation to congenital hyperlucent lung lesions in addition to assessing the anatomic details of the lung.

Neonatal pulmonary sequestration: clinical experience with transumbilical arterial embolization.

Pulmonary sequestration (PS) is a rare congenital malformation of the lower respiratory tract. The exact natural course of PS is not well understood and there are no well‐established treatment guidelines for antenatally diagnosed PS. The aim of this study was to describe clinical outcomes in neonates with PS and to evaluate the efficacy of transumbilical arterial embolization (TUE). From 1998 to 2006, total 30 neonatal cases were included. Serial antenatal ultrasound in 26 cases found 6 (23%) regressed lesions, all of which were demonstrated on postnatal chest CT. Six (20%) cases were classified as mixed‐type (combined cystic) lesions. Surgery was performed early (during initial hospitalization) in two cases and lately (after the neonatal period) in four cases. TUE was performed for 17 (57%) cases of intrapulmonary PS. Follow‐up images obtained a median of 19 months (range, 4–51) after TUE demonstrated complete (9, 53%), partial (5, 29%), and no (3, 18%) regression. The regression rate was significantly higher in solid‐type lesions (13/13, 100%) than in mixed‐type (1/4, 25%) (P = 0.006). Complications included transient hypertension (two cases, 12%), post‐embolization fever (two cases, 12%) and migration of a microcoil (one case, 6%), without long‐term morbidities. Natural courses could be observed in 10 cases of extralobar PS and regression was observed in 2 cases (20%) during a median follow‐up of 12 months (range, 6–45). A well‐designed comparative study is warranted to evaluate the long‐term efficacy and safety of TUE. Pediatr Pulmonol. 2008; 43:404–413.

Effect of Furosemide on Ductal Closure and Renal Function in Indomethacin-Treated Preterm Infants during the Early Neonatal Period

Background: Furosemide is known to increase renal prostaglandin synthesis. However, its influence on ductal closure and renal toxicities of indomethacin in preterm infants has not been conclusive, especially during the early neonatal period. Objectives: To identify the effects of furosemide after indomethacin administration on the rate of patent ductus arteriosus (PDA) closure and renal function in preterm infants. Methods: 68 infants (gestational age <34 weeks and birth weight <2,000 g) receiving indomethacin therapy (one course: 0.2–0.1–0.1 mg/kg q 12 h, mostly started <48 h after birth) were randomly assigned to the furosemide (n = 35) or control (n = 33) group. Each indomethacin dose was followed by furosemide (1.0 mg/kg) or placebo. The primary (PDA closure) and secondary (acute renal failure (ARF) and others) outcomes were assessed. Renal parameters before and 0–12 and 24–36 h after the first course of indomethacin were also investigated. Results: In an intention-to-treat analysis, there were no differences in the PDA closure rate between the furosemide (29/34) and the control (27/29) group (p = 0.437). The incidence of ARF (serum creatinine >1.6 mg/dl) was greater in the furosemide group (20/34) than in the control group (3/29) (p < 0.001). Compared with the control group, serum creatinine and cystatin C levels and fractional excretion of sodium were significantly increased in the furosemide group for 24–36 h after indomethacin therapy (p < 0.01). There were no between-group differences in mortality and other neonatal morbidity rates. Conclusions: Use of furosemide in combination with indomethacin increased the incidence of ARF but did not affect the PDA closure rate in preterm infants.

Sonographic windsock sign of a duodenal web.

Abstract. We report a neonate with a duodenal web demonstrating the windsock appearance on US. In neonates, duodenal web is rare and its windsock appearance is also rarely seen. The windsock sign of duodenal web has been a well-known finding on upper gastrointestinal series. The corresponding windsock appearance may be demonstrated on US. Duodenal web can, therefore, be accurately diagnosed by identifying the sonographic windsock sign even in neonates.

Fetus-in-fetu in the scrotal sac of a newborn infant: imaging, surgical and pathological findings

Abstract. We report a case of fetus-in-fetu located in the scrotal sac of a newborn male infant. Plain radiography (including specimen radiography), ultrasonography and MRI clearly demonstrated vertebral column, ribs, skull, pelvic bones, femurs and a portion of tibiae and humeri. The diagnosis was confirmed by pathological examination.

Impact of fetal echocardiography on trends in disease patterns and outcomes of congenital heart disease in a neonatal intensive care unit.

Background: Congenital heart disease (CHD) is the most common developmental malformation and the leading cause of neonatal mortality and morbidity. The introduction of fetal echocardiography has made prenatal diagnosis of CHD possible. Objective: This study was conducted to investigate the impact of fetal echocardiography on the changing disease patterns and outcomes of CHD. Methods: A retrospective analysis of data from infants with CHD admitted to the neonatal intensive care unit (NICU) of the Asan Medical Center during the time periods was performed. Period I (1994–1996) was considered representative of a period before the introduction of fetal echocardiography, while period II (2004–2006) represented a period of more extensive application of fetal echocardiography. Results: A total of 164 patients were admitted to the NICU during period I and 320 during period II. The number of infants prenatally diagnosed with CHD was 5 of 164 (3.0%) in period I and 219 of 320 (68.4%) in period II (p < 0.05). The overall accuracy of fetal diagnosis was approximately 92%. Of the 3 CHD categories, there was a greater proportion of infants with ‘significant’ heart disease in period II than I (47 vs. 32%; p < 0.05). In contrast, there was a smaller proportion of infants with ‘simple’ heart defects in period II than I (22 vs. 40%; p < 0.05). The proportion of infants with ‘complex’ heart disease was similar in both periods (28% in period I and 31% in period II). The 1-year survival rate of patients with CHD has improved remarkably with time (70.1% in period I to 88.8% in period II). Multivariate analysis showed prenatal diagnosis and planned delivery in a tertiary NICU are factors affecting CHD outcomes, especially when defects are ‘complex’ (p < 0.01). Conclusion: Fetal echocardiography has resulted in an increased frequency of prenatal CHD diagnosis, has altered the disease patterns observed in the NICU, and has resulted in better 1-year outcomes.

Scoring Method for Early Prediction of Neonatal Chronic Lung Disease Using Modified Respiratory Parameters

In our previous study, we have demonstrated that peak inspiratory pressure over birth weight (PIP/kg) and mean airway pressure over birth weight (MAP/kg) were more significant risk factors for the development of neonatal chronic lung disease (CLD) than PIP and MAP. We aimed to develop a scoring method using the modified respiratory variables (SMUMRV) to predict CLD at early postnatal period. From 1997 to 1999, a retrospective review was performed for 197 infants <1,500 g for the development of the SMUMRV based on statistical analysis. From 2000 to 2001, calculated scores on day 4, 7 and 10 of life were obtained prospectively for 107 infants <1,500 g. Predictive values and the area under the receiver operator characteristic curve (AUC) were determined and compared with the result of the previous regression model. Gestational age, birth weight, 5 min Apgar score, PIP/kg at 12 hr of age, fractional inspired oxygen (FiO2), MAP/kg, modified oxygenation index and ventilatory mode were selected as parameters of SMUMRV. No significant differences of AUCs were found between the SMUMRV and the Yoder model. It is likely that our scoring method provides reliable values for predicting the development of CLD in very low birth weight infants.