We assessed the pediatric emergency care system of our hospital. A total of about 11,714 children were carried into the emergency room during 1998. Their age was young, 33.6% being less than 4 years old and 54.5% less than 7 years old. About half a number of them (50.8%) were received between 5 p.m. and midnight and 75.3% at night. They came to our hospital from two or three secondary medical care areas, the population of which was estimated at 800,000 including 120,000 children. Twenty-six percent of outpatients and 43% of inpatients were those who had first visited the emergency unit. During the year 110 persons entered into our pediatric ICU, 45 persons underwent mechanical ventilation therapy, and an average of 7.4 patients stayed in hospital per day.We also reviewed the changes of the pediatric emergency care system of our hospital for 20 years. This system has gradually developed. Chronologically, the neonatal intensive care unit was set up in 1983, followed by the opening of the pediatric intensive care unit in 1986, the start of the 24-hour emergency medical care by pediatricians in 1993, the home mechanical ventilation therapy in 1996 and the respite care since 1997. In other words, our system developed from intensive care to primary care and home care—from in-hospital to out-hospital. These changes were the result of our effort to cope with regional features and meet demands : increase of younger children, insufficiency of pediatricians, expansion of medical area in our change and parents’ request for rediatrician’s examination at any time.In summary, an increasing number of patients who need pediatric emergency care tend to concentrate into one central hospital in a large region. Pediatric emergency care developed into general pediatric medicine including primary care and intensive care and home care.
Hospitals ; Emergency Care ; Pediatric ; seconds ; Child

We experienced two cases of rotavirus-related acute encephalopathy.  Each case followed a different clinical course.  The first case is 2-year and 11-month-old girl who had generalized tonic-clonic convulsion at onset. She was severe enough to a require respirator but she recovered without any sequelae.  The second case is 2-year and 2-month-old girl who had a vague symptom of continuous fretfulness. Her EEG showed a slow wave and her brain MRI detected abnormal signals in the cerebellum. Her motor function was recovered but higher brain dysfunction and light cerebellum symptoms remained.   There wene two types of clinical condition on rotavirus-related encephalopathy; Convulsion type and cerebellum lesion type.  Since the latter type is hard to diagnose and to treat, an effective therapeutic strategy should be established.

　　We often experience difficulty supporting the pediatric social work because, under the present social welfare system, support services change as patients grow. Recently, studies aimed at establishing practice models have increased in the pediatric social work region. With a view to establishing practice models, we reviewed our experience in the neonatal and pediatrics departments.　　Our investigation found that almost all support requests in the neonatal cases were from our medical staff. For inpatients, request were mostly concerned with hospital discharge support. Requests in behalf of outpatients were consultation about physical examination. Most of the support processes ended up in liaison and coordination or providing information.　　In the pediatric department, the most common route of requests for inpatients was from our medical staff, but for outpatients, the requests came from public institutions and private facilities concerned. Most requests for inpatients were related to the use of the social welfare system. Meanwhile, requests in behalf of outpatients were centered on support of consultation about physical examination.　　From the above, we concluded that in the pediatric social work region, social workers should approach not only patients and their family members but also medical staff and community institutions. We deemed it necessary to coordinate social-welfare services based on a long-term plan, taking into account the growth of children.

　We report five cases of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. Five women (27-38 years), Who-presented with psychiatric symptoms, neurological complications, and decreased consciousness, were diagnosed with anti-NMDAR encephalitis after testing positive for serum anti-NMDAR antibodies. The mean（±SD）for hospitalization duration was 272.4（±144.8)days. All patients presented with respiratory failure due to central hypoventilation and required mechanical ventilation for 50.2（±13.1）days on average. Four patients showed no abnormal findings upon brain MRI, one showed high intensity lesions in the right temporal cortex and bilaterally in the hippocampus on T2 weighted images. Higher brain function assessment revealed an overall decrease in intelligence, attention, memory, and executive function in all patients. Temporal assessments revealed progressive improvement in these dysfunctions over several years. Four patients presented with deep venous thrombosis, articular contracture, ectopic ossification, and compression paralysis during the first immobility episode. Two had severely impaired communication and ability to perform activities of daily living when admitted for rehabilitation. However, eventually all the patients attained a premorbid state.
　Anti-NMDAR encephalitis possibly results from reversible synaptic dysfunction；therefore, it has a better functional prognosis compared with classical limbic encephalitis and other paraneoplastic neurologic syndromes. Previous studies found abnormalities in the limbic area on MRI in about 25％ of patients, although other findings were non-specific. Prevention of disuse syndrome due to prolonged immobility is important in acute phase rehabilitation. Our study shows that long-term temporal assessments of higher brain function are necessary and useful in the chronic stage.

A 62-year-old man underwent replacement of the ascending aorta for a Stanford type A acute aortic dissection. The proximal stump was reinforced with using internal and external PTFE felt strips, fibrin glue and cellulose fibers. However, hemolytic anemia and hematuria occurred postoperatively. ECG-gated reconstruction CT demonstrated that the hemolytic anemia was induced by collision of red blood cells on the inverted felt strip of the proximal anastomosis. The patient underwent a reparative procedure 1 week subsequent to the initial operation. During reoperation, half of the inner felt strip used for proximal stump fixation was found to be turned up and protruding into the inner lumen. An incision was made in the synthetic graft and the inverting felt material was removed as much as possible, and then a bovine pericardial patch was used as a means of covering the internal felt strip. Here, we report a rare case of hemolytic anemia at the site of an inverted inner PTFE felt strip used for reinforcement of proximal anastomosis. We found that an ECG-gated reconstruction CT is particularly useful in diagnosing this complication around a beating heart.

Ischemic colitis following cardiac surgery is a rare but critical complication. We report two cases of ischemic colitis following cardiac surgery successfully treated with stenting of the stenotic celiac trunk. Case 1 was a 65-year-old man who developed perioperative myocardial infarction during off-pump coronary artery bypass grafting. He experienced abdominal pain and bloody stool on postoperative day 19. Severe ischemic changes in the sigmoid colon and descending colon were seen on colonoscopy, and CT scan revealed significant stenosis of the celiac trunk and occlusion of the inferior mesenteric artery and bilateral internal iliac arteries. Revascularization of the celiac trunk via stenting resulted in dramatic improvement in colonic ischemic changes. Case 2 was a 60-year-old woman who underwent a restoration procedure for a left ventricular aneurysm. She experienced gradual onset of postprandial pain beginning 9 days after surgery and massive bloody stool on postoperative day 33. Imaging revealed severe ischemic changes in the descending colon on colonoscopy and stenoses of the celiac trunk, superior mesenteric artery, inferior mesenteric artery, and bilateral common iliac arteries on CT angiogram. Stenting was performed to the celiac trunk on postoperative day 52. Her abdominal pain and bloody stool were completely resolved after treatment. Prior to the introduction of endovascular treatment of mesenteric ischemia in 1980, the standard treatment had been open surgical repair. Since then, endovascular repair has become widely accepted. In our experience, endovascular treatment of the mesenteric vessels may be an effective and less invasive approach to treating mesenteric ischemia in unstable patients after cardiac surgery.

A 12-year-old girl had relative graft stenosis following the reconstruction of type A interrupted aortic arch. At 25 days after birth she underwent ascending aorta-descending aorta bypass with a 7mm knitted Dacron graft, ligation of the patent ductus arteriosus and pulmonary artery banding. She had patch closure of a ventricular septal defect (VSD) as well at 20 months of age. At age 12 catheterization was carried out, because she had headache and dizziness on exertion. The pressure of the ascending aorta was 163/79mmHg and the pressure gradient between the ascending and the descending aorta was 65mmHg. Aortography revealed severe stenosis of the graft, which might have occurred according to her growth. An extra-anatomic bypass was placed between the right axillary and the right common iliac artery through the intrapleural and preperitoneal route with a 10mm Dacron graft. Six months later, the blood pressure was 108/63mmHg in the upper extremities, the pressure gradient between the upper and lower extremities was reduced to 18mmHg, and headache and dizziness had disappeared.

Fever is a major symptom of Kawasaki disease, occurring in 99.5% of patients. We report a case of coronary artery aneurysms without fever in an 8-month-old male infant, who was referred to our department on the 8th day of illness for evaluation of red eyes and erythema at the BCG vaccination site. On the 16th day of illness, he was referred again to our department with membranous debris on his fingers. Cardiac ultrasonography revealed coronary artery aneurysms (#1, 3.9mm [Z=6.68]; #5, 3.3mm [Z=4.96]), and we diagnosed incomplete Kawasaki disease. Coronary angiography performed at the age of 1 year (3 months after disease onset) showed regression of coronary artery aneurysms #1 and #5 to 2.1mm (Z=2.12) and 2.1mm (Z=1.33), respectively; therefore, administration of anticoagulants and antiplatelet agents was discontinued. Considering the possibility of incomplete Kawasaki disease, comprehensive evaluation of coronary artery lesions is warranted even in afebrile patients who present with red eyes and erythema at the site of the BCG inoculation.

Background/Aims: Many Japanese institutions use electromagnetic extracorporeal shock wave lithotripsy (ESWL) systems for treating pancreatic duct stones. However, there are no reports on direct comparisons between recent electromagnetic lithotripters. This study aimed to verify whether the new electromagnetic lithotripter can improve the efficiency of pancreatic stone fragmentation, and to clarify the role of combined endoscopic treatment on the clearance of pancreatic duct stones. Methods: We retrospectively identified 208 patients with pancreatolithiasis who underwent endoscopic adjunctive treatment after pancreatic ESWL at a single Japanese center over a 17-year period. We evaluated the outcome data of this procedure performed with SLX-F2 (last 2 years; group A) and Lithostar/Lithoskop (first 15 years; group B), as well as additional endoscopic treatments for pancreatolithiasis. We also performed logistic regression analysis to detect various factors associated with the procedure. Results: For pancreatic head stones, ESWL disintegration was achieved in 93.7% of group A patients and 69.0% of group B patients (p=0.004), and adjunctive endoscopic treatment removed stones in 96.8% of group A patients and 73.0% of group B patients (p=0.003). Multivariate analysis revealed that lithotripter type (odds ratio, 6.99; 95% confidence interval, 1.56 to 31.33; p<0.01) and main pancreatic duct stricture (odds ratio, 2.87; 95% confidence interval, 1.27 to 6.45; p<0.01) were significant factors for ESWL fragmentation. Conclusions The SLX F2 showed high performance in fragmenting the pancreatic duct stones.In addition, endoscopic adjunctive treatment improved the overall success rate of the procedure. The improved ESWL lithotripter has many advantages for patients undergoing pancreatic lithotripsy treatment.