A case report and literature review of sigmoid volvulus in children.

RATIONALE: Sigmoid volvulus (SV) is an exceptionally rare but potentially life-threatening condition in children. CHIEF COMPLAINT: Abdominal distention for 1 week. DIAGNOSES: Sigmoid volvulus. PATIENT CONCERNS: We present a case of a 12-year-old boy with mechanical ileus who was finally confirmed to have SV with the combination of abdominal plain film, sonography, and computed tomography (CT) with the finding of mesenteric artery rotation. INTERVENTIONS: Because bowel obstruction was suspected, abdominal plain film, sonography, and CT were performed. The abdominal CT demonstrated whirlpool sign with torsion of the sigmoid vessels. In addition, lower gastrointestinal filling study showed that the contrast medium could only reach the upper descending colon. Therefore, he received laparotomy with mesosigmoidoplasty for detorsion of the sigmoid. OUTCOMES: The postoperative recovery was smooth under empirical antibiotic treatment with cefazolin. A follow-up lower gastrointestinal series on the seventh day of admission showed no obstruction compared with the previous series. He was finally discharged in a stable condition 8 days after admission. LESSONS: SV is a congenital anomaly and an uncommon diagnosis in children. Nevertheless, case series and case reports of SV are becoming more prevalent in the literature. Failure to recognize SV may result in life-threatening complications such as sigmoid gangrene/perforation, peritonitis, sepsis, and death. Thus, if the children have persistent and recurrent abdominal distention, abdominal pain, and vomiting, physicians should consider SV as a "do not miss diagnosis" in the differential diagnosis.

Evaluation of a water-soluble contrast agent for the conservative management of adhesive small bowel obstruction in pediatric patients.

BACKGROUND/PURPOSE: The diagnostic and therapeutic benefits of a commercial water-soluble contrast agent (Gastrografin) in pediatric patients with adhesive small-bowel obstruction (ASBO) are controversial. The aim of this study was to assess the therapeutic value of Gastrografin in the management of ASBO in children after unsuccessful conservative treatment. METHODS: Medical records from patients with uncomplicated ASBO managed at Cathay General Hospital, Taipei, Taiwan between January 1996 and December 2011 were retrospectively reviewed. All children ≤18 years of age with clinical evidence of ASBO were managed conservative treatment, unless there was suspicion of strangulation. Patients who did not improve after 48 hours of conservative treatment were administered Gastrografin. RESULTS: Twenty-four patients with 33 episodes of ASBO were analyzed. Of those, there were 19 episodes of ASBO that failed to respond to the initial conservative management, and 16 (84%) responded well to Gastrografin administration thereby abrogating the need for surgical intervention. There were neither complications nor mortality that could be attributed to the use of Gastrografin. CONCLUSION: This preliminary study suggested that the use of a water-soluble contrast agent in ASBO is safe in children and useful for managing ASBO, particularly in reducing the need for surgery when conservative treatment fails. However, larger prospective studies would be needed to confirm these results.

Hospital-based school for children with chronic illness in Taiwan.

BACKGROUND/PURPOSE: To provide educational support and avoid unwanted damage that may impede learning for children with chronic illness, the learning environment should be friendly and safe. There is a need to establish schools inside hospitals, however, which may be neglected in a highly efficient health care system. A study was conducted to identify hospital-based schools for sick children in Taiwan, and to explore the barriers for implementation. METHODS: The data were collected by structured telephone interview and retrieval of hospital web information. The study targeted social workers and nurses in the pediatric wards of 29 hospitals, plus officials from the Education Bureau in Taiwan. The interviewers inquired about the availability of a formal educational program inside hospitals and the barriers (if any) in providing educational supports. RESULTS: Taiwan has only one hospital-based informal school and eight hospitals with rotating bedside teachers. Education inside hospitals occurs mostly through voluntary teaching in informal education models. Information about special educational resources has not been widely distributed to patients and health care providers. Professional personnel in Taiwan are not well aware of the needs to establish a hospital-based school. CONCLUSION: The educational needs of children with chronic illness can be easily neglected even in an industrialized country. The establishment of policy and the enrichment of professional education on advocacy are necessary to eliminate educational inequities and benefit sick children.

Conservative treatment of adhesive small bowel obstruction in children: a systematic review.

OBJECTIVE: To assess the effectiveness of conservative treatment for adhesive small bowel obstruction (ASBO) in children. DESIGN: Systematic review of studies involved children with ASBO who received initial conservative/non-operative treatment. SETTING: The search was performed in April 2013 using PubMed (see online supplementary file 1), current contents, and the Cochrane database. PARTICIPANTS: Children with ASBO. INTERVENTIONS: Conservative treatment included nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance. PRIMARY OUTCOME: Treatment success. SECONDARY OUTCOMES: Length of hospital stay and the time to first feeding after hospital admission. RESULTS: 7 studies (six retrospective, one prospective), involving 8-109 patients (age: 1 month to 16 years) treated conservatively, were included in the review. The nature of conservative treatment was generally consistent between studies (nasogastric decompression, parenteral fluids and correction of electrolyte and fluid imbalance), although patients in one study also received Gastrografin. The rate of conservative treatment success ranged from 16% to 75% among the five studies, but one trial showed 0% successful rate. The hospital length of stay ranged from 3 to 6.5 days for conservative treatment (vs 10.2-13 days for operative treatment). The time to first feeding ranged from 31 to 84 h for conservative treatment. CONCLUSIONS: In conclusion, in the majority of cases, conservative treatment is an effective means of managing ASBO in children.

Career satisfaction, commitment, and well-being among Taiwanese pediatricians.

BACKGROUND: Currently, the pediatrician shortage in Taiwan has raised concerns about pediatricians' workloads and wellbeing. This study aimed to understand in-hospital pediatricians' perceptions toward career satisfaction and their wellbeing. METHODS: A questionnaire exploring pediatricians' life management, commitment to work, and work satisfaction was distributed to all the pediatricians (including attending physicians and residents) in 79 certified training institutions in Taiwan. After expert validation and pilot testing, 17 items with a five-point rating scale were developed to reflect the pediatricians' perceptions. There were 287 responses in total, including 180 attending physicians and 107 residents. Factor analysis was used to explore the construct structure underlying the 17 items. RESULTS: None of the 17 items had a "positive" mean score (≥4/5). Using factor analyses, five factors were extracted: commitment to medical career, self-care, benefit, work environment, and job satisfaction, which accounted for 66.97% of the variance. The factor with the lowest scores was self-care, followed by benefit. The mean score of factors ranged from 2.91 ± 0.17 to 1.64 ± 0.1, all considered "negative." Only 33.6% indicated satisfaction with their jobs. Only 60% of the pediatricians liked their medical career and work environment. The reliability alphas of the five factors ranged from 0.85 to 0.60. CONCLUSION: Currently, Taiwanese pediatricians are not satisfied with their jobs, having low commitment, poor self-care, and little wellbeing. This study provides a possible explanation for why young physicians leave the pediatric sector, and it also reveals the consequences of physician shortage in Taiwan.

Power of the policy: how the announcement of high-stakes clinical examination altered OSCE implementation at institutional level.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) has been widely applied as a high-stakes examination for assessing physicians' clinical competency. In 1992, OSCE was first introduced in Taiwan, and the authorities announced that passing the OSCE would be a prerequisite for step-2 medical licensure examination in 2013. This study aimed to investigate the impacts of the announced national OSCE policy on implementation of OSCE at the institutional level. Further, the readiness and the recognition of barriers toward a high-stakes examination were explored. METHODS: In 2007 and 2010, the year before and after the announcement of high-stakes OSCE policy in 2008, respectively, questionnaires on the status of OSCE implementation were distributed to all hospitals with active OSCE programs in Taiwan. Information on OSCE facilities, equipment, station length, number of administrations per year, and the recognition of barriers to the success of implementing an OSCE were collected. The missing data were completed by telephone interviews. The OSCE format, administration, and facilities before and after the announcement of the nationwide OSCE policy were compared. RESULTS: The data were collected from 17 hospitals in 2007 and 21 in 2010. Comparing the OSCE formats between 2007 and 2010, the number of stations increased and the station length decreased. The designated space and the equipment for OSCE were also found to have been improved. As for the awareness of OSCE implementation barriers, the hospital representatives concerned mostly about the availability and quality of standardized patients in 2007, as well as space and facilities in 2010. CONCLUSIONS: The results of this study underscored an overall increase in the number of OSCE hospitals and changes in facilities and formats. While recruitment and training of standardized patients were the major concerns before the official disclosure of the policy, space and facilities became the focus of attention after the announcement. The study results highlighted the influence of government policy on different aspects of OSCE implementation in Taiwanese training institutes that showed high level of support as reflected in the improved hardware and the change in OSCE format to serve the summative purpose.

Clinical manifestations in children with ruptured appendicitis.

OBJECTIVES: Appendicitis is the most common abdominal condition leading to urgent surgery in children. With the goal of identifying signs and symptoms that will allow prompt diagnosis of rupture of the appendix and thus decrease associated morbidities, our aim was to determine factors associated with ruptured appendicitis in children diagnosed with appendicitis. METHODS: The medical records of children aged 17 years or younger with a postoperative diagnosis of acute appendicitis treated at Cathay General Hospital, Taipei, Taiwan, from January 2002 and May 2009, were retrospectively reviewed. The patients were divided into with and without ruptured appendicitis. RESULTS: Of the 228 patients, 140 had a postoperative pathological diagnosis of a nonperforated appendix, and 88 had a diagnosis of perforated appendix, resulting in a perforation rate of 38.6%. Younger age, longer duration of abdominal pain, fever, muscle guarding, and elevated C-reactive protein level were significantly associated with a perforated appendix. CONCLUSIONS: Younger age, longer duration of abdominal pain, fever, muscle guarding, and elevated C-reactive protein level are significantly associated with a perforated appendix; these factors should be closely considered in the evaluation of individuals with suspected appendicitis.

Predicting the demand of physician workforce: an international model based on "crowd behaviors".

BACKGROUND: Appropriateness of physician workforce greatly influences the quality of healthcare. When facing the crisis of physician shortages, the correction of manpower always takes an extended time period, and both the public and health personnel suffer. To calculate an appropriate number of Physician Density (PD) for a specific country, this study was designed to create a PD prediction model, based on health-related data from many countries. METHODS: Twelve factors that could possibly impact physicians' demand were chosen, and data of these factors from 130 countries (by reviewing 195) were extracted. Multiple stepwise-linear regression was used to derive the PD prediction model, and a split-sample cross-validation procedure was performed to evaluate the generalizability of the results. RESULTS: Using data from 130 countries, with the consideration of the correlation between variables, and preventing multi-collinearity, seven out of the 12 predictor variables were selected for entry into the stepwise regression procedure. The final model was: PD = (5.014 - 0.128 × proportion under age 15 years + 0.034 × life expectancy)2, with R2 of 80.4%. Using the prediction equation, 70 countries had PDs with "negative discrepancy", while 58 had PDs with "positive discrepancy". CONCLUSION: This study provided a regression-based PD model to calculate a "norm" number of PD for a specific country. A large PD discrepancy in a country indicates the needs to examine physician's workloads and their well-being, the effectiveness/efficiency of medical care, the promotion of population health and the team resource management.

Choledochal cysts in infants and children: experiences over a 20-year period at a single institution.

This analysis was undertaken to compare the clinicopathological features of infants with choledochal cysts to those of older children with these entities and to evaluate the surgical outcomes for both subject groups. The medical records of all children admitted to the Cathay General Hospital with choledochal cysts over a 20-year period were retrospectively reviewed. Twenty-five subjects were included and divided into the infant (<1 year at presentation; 8 subjects) and classical pediatric (1-18 years at presentation; 17 subjects) groups. Anatomical subtypes were: IA (16), IC (6), and IVA (3). The median biliary amylase value was markedly elevated for the pediatric group but not for the infant group. Most (82.4%) patients in the pediatric group, but none in the infant group, presented with abdominal pain. Jaundice and clay-colored stool were present in all patients in the infant group but only 35% of those in the pediatric group. All patients underwent choledochocystectomy and Roux-en-Y hepaticojejunostomy with good outcomes. Neonates/infants with choledochal cysts present differently from older children with these entities. Amylase measurements may serve to distinguish biliary atresia with cystic dilatation from choledochal cyst in neonates/infants. Prognosis following radical cyst excision and reconstruction with Roux-en-Y hepaticojejunostomy is excellent.

Zeaxanthin inhibits PDGF-BB-induced migration in human dermal fibroblasts.

Zeaxanthin is the dihydroxy carotenoid and is distributed in our daily foods. Various natural carotenoids, including zeaxanthin, have been shown to inhibit proliferation of several types of cancer cells, but available data on the effect of zeaxanthin on skin fibroblasts and melanoma cells are limited. Platelet-derived growth factor (PDGF) functions as a chemotactic factor for dermal fibroblasts and plays an important role in the progression of melanoma. In this study, we investigated the effects of zeaxanthin on the migration of skin fibroblasts induced by PDGF-BB and melanoma cells. We demonstrated that zeaxanthin inhibited PDGF-BB-induced skin fibroblast migration on collagen and gelatin by a modified Boyden chamber system. The electric cell-substrate impedance sensing (ECIS) method also showed similar inhibitory effects of zeaxanthin on the migration of fibroblasts. In functional studies, zeaxanthin decreased melanoma-induced fibroblast migration in a non-contact coculture system and also the migration stimulated by melanoma-derived conditioned medium. Further analysis showed that zeaxanthin attenuated PDGF-BB and melanoma-conditioned medium induced phosphorylation of PDGFR-beta and MAP kinase in a concentration-dependent manner in human skin fibroblasts. However, these effects did not result from direct interaction of zeaxanthin with PDGF-BB. Thus, our results provide the first evidence showing that zeaxanthin is an effective inhibitor of migration of stromal fibroblasts induced by PDGF-BB and melanoma cells and this effect may further support its antitumor potential.

Choledochal cysts: differences between pediatric and adult patients.

Choledochal cysts in children and adults are believed to be different, but direct comparison between them is lacking in the literature. This study was aimed to identify the clinicopathological differences between 42 children and 59 adults with choledochal cyst treated by same surgeons at the Cathay General Hospital. The mean follow-up period was 8.9 years. The result showed that the female-to-male ratios were 1.5:1 in pediatric patients and 4.9:1 in adult patients. Compared with adults with choledochal cyst, the pediatric patients presented more abdominal mass (52.4% vs 21.2%, P = 0.002) and less abdominal pain (76.2% vs. 98.0%, P = 0.002), are more frequently associated with anomalous pancreaticobiliary ductal union (85.7% vs. 59.6%, P = 0.005) and sudden severe stenosis of terminal choledochus (76.2% vs. 42.3%, P = 0.001), are less commonly associated with choledocholithiasis, are not associated with malignant transformation (0% vs 21.2%), and have fewer perioperative and long-term complications. Nevertheless, patients who received total excision had fewer surgical complications in both groups. This result shows that choledochal cysts in pediatric and adult patients are different in clinicopathological manifestations, prognosis, and the underlying abnormalities of the pancreaticobiliary system, suggesting that patients with choledochal cyst should be managed according to these differences.

Lycopene inhibits PDGF-BB-induced signaling and migration in human dermal fibroblasts through interaction with PDGF-BB.

In melanoma development and progression, platelet-derived growth factor (PDGF) has been suggested to modulate the microenvironment, especially stromal fibroblasts, to the benefit of melanoma growth, invasion, and metastasis. Lycopene, a natural carotenoid that is abundant in tomato, has been shown to inhibit proliferation of several types of cancer cells. However, little attention has been paid to skin fibroblasts and melanoma cells. In the present study, we determined the effects of lycopene on stromal fibroblasts and their interactions with melanoma cells. We found that lycopene inhibited PDGF-BB-induced human Hs68 skin fibroblast migration on gelatin and collagen. Further analysis showed that lycopene inhibited PDGF-BB-induced signaling in human Hs68 and primary cultured skin fibroblasts. PDGF-BB-induced phosphorylation of PDGF receptor beta (PDGFR-beta), extracellular signal-regulated kinase 1/2 (ERK1/2), p38, and c-Jun N-terminal kinase (JNK) was attenuated by lycopene in a concentration-dependent manner, whereas the total expression of each protein was not affected. Interestingly, dot binding assay revealed that lycopene could directly bind to human PDGF-BB in PBS and human plasma, indicating that lycopene can bind to PDGF-BB in both in vitro and in vivo conditions. In functional studies, lycopene inhibited melanoma-induced fibroblast migration in a noncontact coculture system and attenuated signaling in fibroblasts simulated by melanoma-derived conditioned medium. Our results provide the first evidence showing that lycopene is an effective inhibitor of migration of stromal fibroblasts and this effect may contribute to its antitumor activity.

System approach to prevent common bile duct injury and enhance performance of laparoscopic cholecystectomy.

Experience collected from 5200 cases of laparoscopic cholecystectomy (LC) and 29 patients (6 ours, 23 referred) with major common bile duct (CBD) injury during LC in our institute between December 1990 and July 2004 was reported to demonstrate that the system approach we applied in performing LC prevents CBD injury and enhances surgical performance. Each case of CBD injury was meticulously analyzed to identify causative factors. We developed preventive strategies focusing on 4 dimensions: patient, environment, procedure, and operator. Surgical performance was then evaluated to demonstrate improvements. Incidence of CBD injury was calculated for early and latter halves of the series to compare 5 parameters of surgical performance: patient selection, operation time, indwelling drainage tube, surgeon, and conversion rate. Results of accident analysis demonstrated that CBD injury followed definite mechanisms; several warning signs appearing before and during injury were identified and classified. According to these results, we designed strategies to prevent injury, including: setting up patient-selection program, controlling surgical environment, developing error-proof procedures, and constructing training programs. Incidence of CBD injury in the whole series was 0.12% (6/5200), 0.27% in early half (6/2224), and zero (0/2967) in latter half. Attending doctors had significantly shorter operation times in latter period for both elective and emergent LC. Rate of using drainage tubes for elective surgery by attending doctors was significantly decreased in latter period. Operation time for elective surgery by residents was similar in both early and latter periods. However, residents in latter period had longer operation times (around 23 min long, P<0.001) for emergent LC. Steps of our system approach include: (1) detailed accident analysis focusing on patient, environment, procedure, and surgeon; (2) developing 4 strategies directly responding to accident analysis results, including proper patient selection, control of environment, error-proof procedures, and a well-designed training program; and (3) demonstrating improved patient safety and surgical performance. Consistent use of systems approach promises continuing quality improvement. We believe our working model will help perform safer LC and also benefit other medical disciplines.

Hepatic mesenchymal hamartoma combined with infantile hepatic hemangioendothelioma in an infant.

Hepatic mesenchymal hamartoma is a rare benign tumor in children, and infantile hepatic hemangioendothelioma is also a rare liver neoplasm. We report a female newborn with an abdominal mass noted by the regular maternal ultrasound at 32 weeks of gestation. After birth, a liver mass was detected by computed tomography and magnetic resonance cholangiopancreatography. Frequent postprandial vomiting and progressive abdominal distension occurred 4 months later. Three tumor masses were detected this time, and the serum alpha-fetoprotein (AFP) was 6700 ng/mL. Segmental resection was performed initially and complete resection of these tumors and left lobectomy were performed 21 days later. Pathologic examination of these liver masses revealed mesenchymal hamartoma combined with infantile hepatic hemangioendothelioma. After half a year of regular follow-up, the AFP level decreased gradually to 79.5 ng/mL, without evidence of tumor recurrence.

Paediatric Intra-abdominal Inflammatory Myofibroblastic Tumour.

Inflammatory myofibroblastic tumour is a rare solid tumour mimicking malignancy with locally aggressive growth and recurrence even after complete resection. We report the case of a 10-year-old girl with an intra-abdominal inflammatory myofibroblastic tumour. This clinical and pathological entity should be differentiated from other malignant sarcomatous lesions when encountered intraoperatively. It is almost impossible to differentiate inflammatory myofibroblastic tumour from other malignancies preoperatively; the diagnosis is often confirmed by careful microscopic examination or immunohistochemical markers after surgical resection. Total excision of the tumour with life-time follow-up is needed because of the risk of recurrence.

Application of the MANTRELS scoring system in the diagnosis of acute appendicitis in children.

UNLABELLED: Evaluation of abdominal pain in children poses a major challenge for the pediatrician and pediatric surgeon alike. Acute appendicitis is diagnosed in 1%-8% of children who present with acute abdominal pain in pediatric department. However, initial misdiagnosis rate in childhood is still high, so how to make early and adequate diagnosis of acute appendicitis is still a challenge to pediatrician. OBJECTIVE: Application of the MANTRELS scoring system (Alvarado score) was used in the diagnosis of acute appendicitis in children. METHODS: We retrospectively collected a total of 111 cases under 14 years who were proven to have acute appendicitis by operative and pathologic reports and 111 cases who were excluded from having acute appendicitis as control subjects from January 2001 to July 2003. We applied the MANTRELS scores to evaluate these patients. RESULTS: Using statistical analysis, the following four parameters: migration pain, rebounding tenderness, right lower quadrant tenderness, shift WBC count and total MANTRELS scores higher than 6 were shown to have discriminatory values (P<0.01). CONCLUSION: Assessment of the cases in children with suspected acute appendicitis by the MANTRELS scoring system can be an adjuvant method to help us in the early diagnosis of acute appendicitis.

Laparoscopic common bile duct exploration with T-tube choledochotomy for the management of choledocholithiasis.

Although laparoscopic cholecystectomy (LC) has become the gold standard for the management of gallstone disease, the application of laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has been slower. The aim of this study is to determine the feasibility and effectiveness of LCBDE. A retrospective cohort study was conducted to compare LCBDE (n = 82) with conventional common bile duct exploration (CCBDE) (n = 75) and endoscopic sphincterotomy (EST) (n = 80) in the management of choledocholithiasis. All our LCBDEs were performed through choledochotomy with T-tube placement. The mean operative time of the LCBDE group (124 +/- 48 minutes) was not significantly longer then the CCBDE group (118 +/- 35 minutes), while the postoperative hospitalization was shorter in both the LCBDE (8 +/- 5 days) and EST (9 +/- 4 days) groups than in the CCBDE (13 +/- 6 days) group. In the LCBDE group, 14 patients (17.1%) required postoperative choledochoscopy to clear residual stones through the T-tube tract. The only mortality occurred in the CCBDE group. The morbidity rate was 3.7% (3/82) in the LCBDE group, including bile leakage in 1 case and bile peritonitis in 2 cases; 6.7% (5/75) in the CCBDE group, including atlectasis in 2 cases, sepsis in 1, and wound infection in 2. There were 2 cases of postoperative pancreatitis (2.5%; 2/80) in the EST group. The difference in the average number of sessions needed for complete clearance of choledocholithiasis in each group was statistically significant (EST, 1.46 +/- 0.67; LCBDE, 1.23 +/- 0.42; and CCBDE, 1.09 +/- 0.28; P < 0.0001). Our results suggested that EST and LCBDE tended to require more therapeutic sessions then CCBDE, although these sessions were less invasive. The benefits of LCBDE include minimal invasiveness, concurrent treatment of gallbladder stone and CBD stones in a single session, and a shorter postoperative hospital stay. However a longer learning curve is needed. Selection of the most suitable therapeutic option for individual patients by an experienced surgeon gives the most benefits to patients.

Management of bile leakage after laparoscopic cholecystectomy based on etiological classification.

PURPOSE: To analyze and classify bile leakage after laparoscopic cholecystectomy (LC) according to its etiology. This classification will help to determine the most appropriate management strategy, whereby unnecessary intervention can be avoided. METHODS: We examined the medical records of 16 patients in whom bile leakage occurred as a complication of LC. RESULTS: Bile leakage was classified according to its cause into the following groups: insecure closure of the cystic duct stump (n = 3); retention of a common bile duct (CBD) stone (n = 1); CBD injury (n = 10); unsuspected accessory bile ducts (n = 1); and unknown origin (n = 1). The management strategies included observation (n = 3), laparoscopic intervention with drainage (n = 4), laparotomy with drainage (n = 3), and laparotomy with Roux-en-Y choledochojejunostomy for CBD transection (n = 6). All 16 patients recovered uneventfully with similar hospitalization. CONCLUSIONS: Bile leakage is not always caused by bile duct injury, and it would be inappropriate to attribute leakage to bile duct injury if there is a retained CBD stone, an unsuspected accessory duct, or an unsecured cystic duct stump. Thus, the management of each condition should vary accordingly. Reviewing a videotape of the surgery and early cholangiogram can help to establish the etiological diagnosis and select the most appropriate course of action.