Endoscopic injection for primary vesicoureteric reflux: Predictors of resolution and long term efficacy.

AIM: We investigated the efficacy of endoscopic-Deflux-injection in treating primary-vesicoureteric-reflux (VUR) and identified factors to predict resolution. MATERIALS AND METHODS: Records of children treated with Deflux for primary-VUR from 1995 to 2016 were reviewed, and outcomes were investigated. RESULTS: Eighty-eight ureters (35 bilateral, 18 unilateral) in 53 children underwent 124 injections. Thirty-five (66%) patients had single injection (13 unilateral, 22 bilateral). Fifteen (28%), two (37%), and one (2%) patients had two, three, and four injections, respectively. Overall success rate by ureters was 57% after single injection. Complete resolution occurred in 65% of ureters with VUR below grade III, 63% of grade III, 40% of grade IV, and 70% of grade V VUR. Four patients had reimplantation. The median follow up duration was 60months (range 20-216months). Univariate analysis showed that lower VUR grade (p=0.03) and absent renal scars (p=0.04) were statistically significant predictors of resolution. In multivariate analysis, absent renal scars were statistically significant (p=0.01). CONCLUSION: We demonstrated efficacy of endoscopic-Deflux-injection as the first line treatment for primary-VUR. Absent renal scar and lower VUR grade were statistically significant predictors of resolution after single injection. TYPE OF STUDY: Case-Control / Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Pneumovesical ureteric reimplantation using T-fastener: A modification for bladder wall anchorage.

INTRODUCTION: Bladder anchoring during pneumovesical ureteric reimplantation (PUR) can be difficult. Here we describe our new technique using a T-fastener (Kimberly Clark, Irving, TX, USA) to tackle this problem. METHODS: A T-fastener has been applied to all patients who underwent PUR in our center since 2011. RESULTS: Seventeen consecutive cases were performed between 2011 and 2015. No bladder dislodgement or air leak was observed in any of the operations. No morbidity or mortality has been associated with the use of T-fasteners. CONCLUSION: In our experience, this technique is simple to learn and transferrable. It decreases intraoperative complications and helps to climb the learning curve.

Pneumovesical Ureteric Reimplantation in Pediatric Patients: An Intermediate Term Result.

INTRODUCTION: Pneumovesical ureteric reimplantation has gained increasing popularity for the treatment of vesicoureteric reflux (VUR) and vesicoureteric junction obstruction (VUJO) in pediatric patients. In this study we reviewed our experience at an intermediate term basis. METHODS: A retrospective review of all patients with pneumovesical ureteric reimplantation performed in a tertiary referral center between 2005 and 2015 was carried out. Patients' demographics, operative measures, and postoperative outcomes were recorded. RESULTS: Thirty-one patients were identified during the study period. Twenty-three patients had VUR and 8 patients had VUJO. A total of 42 ureteric reimplantation procedures were carried out. The mean age at operation was 6.1 years old. The mean operative time was 221 minutes. On average the length of hospital stay was 7.4 days. Four patients required conversion to open approach. Four patients had low-grade residual VUR after the operation and all of them were treated conservatively. There was no major complication or mortality. CONCLUSION: Pneumovesical ureteric reimplantation is safe and effective for pediatric patients. Intermediate term result confirmed its reliability and low recurrence rate. It has good potential to become the preferred approach of choice in the future.

Outcomes of Re-Intervention for Laparoscopic Transperitoneal Pyeloplasty in Children.

BACKGROUND: There is no consensus for the management of failed laparoscopic pyeloplasty in pediatric surgical patients, and only limited publications are available. We evaluated here the clinical outcomes of re-intervention for failed laparoscopic transperitoneal pyeloplasty in infants and children. MATERIALS AND METHODS: Retrospective review of all children who had undergone laparoscopic transperitoneal dismembered Anderson-Hynes pyeloplasty for ureteropelvic junction obstruction from 2002 to 2013 was performed. Patients' demographics, indications, operative details, and outcomes for primary operation as well as re-intervention were studied. RESULTS: There were 42 patients with a median age of 20 months (range, 3-192 months) and a median body weight of 12 kg (range, 6-56 kg) who underwent a total of 46 laparoscopic transperitoneal pyeloplasties during the study period. The median operative time and blood loss were 193 minutes (range, 115-480 minutes) and trace amount (range, trace amount to 400 mL), respectively. No conversion was reported. Ten cases (22%) required re-intervention. No statistically significant risk factor for failed pyeloplasty was identified. Indications for re-intervention included deterioration of differential renal function (n = 6), progressive hydronephrosis (n = 1), urinary ascites (n = 2), and urosepsis (n = 1). Median time of re-intervention was 6.5 ± 38 months postpyeloplasty. Re-intervention was categorized into the redo pyeloplasty group (n = 6) and the urinary diversion group (n = 4) (insertion of double-J ureteral stent or endopyelotomy) with success rates of 50% and 25%, respectively. Among the redo pyeloplasty group, 3 patients underwent redo laparoscopic pyeloplasty, and all of them had drainage restored with a median improvement in differential renal function of 11%. The mean follow-up duration was 77 ± 38 months. CONCLUSIONS: Laparoscopic transperitoneal pyeloplasty is safe and feasible in children. Redo pyeloplasty is a more favorable re-intervention compared with urinary diversion in our series. Redo laparoscopic pyeloplasty has been shown to improve differential renal function.

Use of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in a paediatric patient: problem encountered.

This report is of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in a 12-year-old patient with detrusor underactivity and hereditary sensory neuropathy. The whole operation was performed in 555 minutes with no open conversion. The patient experienced one episode of stomal stenosis, which required dilatation. At 3-year follow-up, the patient had both stomal and urinary continence. This is a safe and effective procedure to create a means of urinary catheterisation with avoidance of a large unsightly scar and comparable clinical outcome to an open procedure.

Childhood intussusception: 17-year experience at a tertiary referral centre in Hong Kong.

OBJECTIVES: To review all paediatric patients with intussusception over the last 17 years. DESIGN: Retrospective case series. SETTING: A tertiary centre in Hong Kong. PATIENTS: Children who presented with intussusception from January 1997 to December 2014 were reviewed. MAIN OUTCOME MEASURES: The duration of symptoms, successful treatment modalities, complication rate, and length of hospital stay were studied. RESULTS: A total of 173 children (108 male, 65 female) presented to our hospital with intussusception during the study period. Their median age at presentation was 12.5 months (range, 2 months to 16 years) and the mean duration of symptoms was 2.3 (standard deviation, 1.8) days. Vomiting was the most common symptom (76.3%) followed by abdominal pain (46.2%), per rectal bleeding or red currant jelly stool (40.5%), and a palpable abdominal mass (39.3%). Overall, 160 patients proceeded to pneumatic or hydrostatic reduction, among whom 127 (79.4%) were successful. Three (1.9%) patients had bowel perforation during the procedure. Early recurrence of intussusception occurred in four (3.1%) patients with non-operative reduction. No recurrence was reported in the operative group. The presence of a palpable abdominal mass was a risk factor for operative treatment (relative risk=2.0; 95% confidence interval, 1.8-2.2). Analysis of our results suggested that duration of symptoms did not affect the success rate of non-operative reduction. CONCLUSIONS: Non-operative reduction has a high success rate and low complication rate, but the presence of a palpable abdominal mass is a risk factor for failure. Operative intervention should not be delayed in those patients who encounter difficult or doubtful non-operative reduction.

A light bulb moment: an unusual cause of foreign body aspiration in children.

A 15-month-old girl developed persistent cough with no associated history of foreign body aspiration. Chest X-ray showed a U-shaped radiopaque foreign body, which was initially thought to be a hairpin, in the right main bronchus. Rigid bronchoscopy was performed and the foreign body turned out to be a light-emitting diode (LED) bulb. In this article, we report our experience of LED bulb aspiration in children, with the view to raise the awareness of clinicians about this potentially life-threatening emergency.

A two-stage mining framework to explore key risk conditions on one-vehicle crash severity.

This paper proposes a two-stage mining framework to explore the key risk conditions that may have contributed to the one-vehicle crash severity in Taiwan's freeways. In the first stage, a genetic mining rule (GMR) model is developed, using a novel stepwise rule-mining algorithm, to identify the potential risk conditions that best elucidate the one-vehicle crash severity. In the second stage, a mixed logit model is estimated, using the antecedent part of the mined-rules as explanatory variables, to test the significance of the risk conditions. A total of 5563 one-vehicle crash cases (226 fatalities, 1593 injuries and 3744 property losses) occurred in Taiwan's freeways over 2003-2007 are analyzed. The GMR model has mined 29 rules for use. By incorporating these 29 mined-rules into a mixed logit model, we further identify one key safe condition and four key risk conditions leading to serious crashes (i.e., fatalities and injuries). Each key risk condition is discussed and compared with its adjacent rules. Based on the findings, some countermeasures to rectify the freeway's serious one-vehicle crashes are proposed.

Peanut aspiration: an avoidable life-threatening condition.

Foreign body aspiration is a potentially fatal condition. Yet, an accurate diagnosis may not be easy. Management is also challenging and requires a high level of expertise with proper instruments. In this article, we report our experience in the management of peanut aspiration in two young children by means of a ventilating bronchoscope.

Effects of auricular acupuncture on heart rate, oxygen consumption and blood lactic acid for elite basketball athletes.

This study investigated the effects of auricular acupuncture on athletes' recovery abilities after exercise. Subjects were selected from twenty-four male elite university basketball players, randomly divided into two groups: auricular acupuncture group (AAG), and normal control group (NCG), each group containing twelve subjects. Auricular acupuncture was experimented to each AAG athlete while no auricular acupuncture was conducted to each NCG athlete. Each subject in both groups performed a ride on the stationary bike until exhausted. The data of heart rate (HR(max)), oxygen consumption (VO(2 max)), and blood lactic acid were measured at four points of time: during the rest period after warm-ups and at the 5th, 30th and 60th minutes post-exercise, respectively. One-way ANOVA and repeated Scheffé methods were used to test the differences of the data between these two groups. The results showed that both HR(max) and blood lactic acid in AAG were significantly lower than those in NCG at the 30th and 60th minutes post-exercise. This suggests that auricular acupuncture can enhance athletes' recovery abilities after aggressive exercise.

Episodes of injuries and frequent usage of traditional Chinese medicine for Taiwanese elite wrestling athletes.

Wrestling normally places extreme demands on the body and thus may cause various kinds of injuries. An in-depth understanding of the episodes of injured sites, types, timings, and treatment modalities would help participants be aware of wrestling-related injury occurrences so as to develop effective preventive measures. Therefore, this study aims to investigate the gender-specific injuries among elite wrestling athletes. Subjects were selected from the 2009 Taiwanese National Wrestling Sport Championship. Participants were adolescent wrestling athletes, ages 16-18, who must have received at least one bronze medal at national level tournaments in 2008. A total of 118 respondents, 96 males and 22 females, completed and returned the questionnaire in which demographic data and information about the types, sites, and timings of injuries suffered and treatment modalities adopted were elicited. The data were analyzed with independent t-tests. The questionnaire results revealed a significantly higher injury rate for males than for females. The top three injured sites for males were waist (11.1%), ankle joint (10.1%) and finger (9.6%); while for females were ankle joint (13.6%), knee (12.5%) and waist (11.3%). Contusions were the most frequent type of injury: for males (73.5%) and for females (70.6%); followed by tendon inflammation for males (10.7%) and accumulated injuries for females (15.2%). During training and matching periods, the frequency of injuries for males (69.0%) is lower than that for females (81.8%). Traditional Chinese medicine (TCM) with acupuncture and moxibustion was the most common treatment modalities used for males (51.8%) and for females (68.0%); followed by orthopedics: for males (29.5%) and for females (18.0%). The present study contributed as the first effort to reveal the potency of using TCM with acupuncture and moxibustion in wrestling competitions. To prevent possible brain and body injuries in wrestling, safety education, skills and rules, and scoring systems may require further revision. Increased training of wrestling health professionals and advanced research and development of auxiliary training devices and protective equipment for wrestling athletes are also recommended.

Using hybrid method to evaluate the green performance in uncertainty.

Green performance measure is vital for enterprises in making continuous improvements to maintain sustainable competitive advantages. Evaluation of green performance, however, is a challenging task due to the dependence complexity of the aspects, criteria, and the linguistic vagueness of some qualitative information and quantitative data together. To deal with this issue, this study proposes a novel approach to evaluate the dependence aspects and criteria of firm's green performance. The rationale of the proposed approach, namely green network balanced scorecard, is using balanced scorecard to combine fuzzy set theory with analytical network process (ANP) and importance-performance analysis (IPA) methods, wherein fuzzy set theory accounts for the linguistic vagueness of qualitative criteria and ANP converts the relations among the dependence aspects and criteria into an intelligible structural modeling used IPA. For the empirical case study, four dependence aspects and 34 green performance criteria for PCB firms in Taiwan were evaluated. The managerial implications are discussed.

Deflux injection for the treatment of vesicoureteric reflux in children--a single centre's experience.

BACKGROUND: Vesicoureteric reflux (VUR) is a common condition that may lead to end-staged renal failure. Treatment options include long term prophylactic antibiotics or surgical intervention. Recently, endoscopic treatment by a subureteral injection of Deflux has gained popularity. Our centre has introduced this treatment modality since 2002. METHODS: The medical records of 42 patients (15 male and 27 female) who received Deflux injections for treatment of VUR from 2002 to 2007 were reviewed. All the patients were followed up with voiding cystourethrograms at 3 months after the procedure. RESULTS: The median age at operation was 72.59 months (range, 8 to 216 months). Unilateral involvement was found in 20 patients while 22 patients had bilateral involvement. Of the 64 ureters, VUR were grade II to V in six (9.4%), 31 (48.4%), 20 (31.2%) and seven (10.9%) patients respectively. Resolution of reflux, defined as grade 0 to I, after one injection was seen in six (100%), 20 (64.5%), and 16 (80%) ureters from grade II to IV respectively. Only one patient with grade V reflux achieved complete resolution after a single injection. Of the 21 ureters which had residual reflux, three were lost from follow up and 18 (ten grade III, two grade IV and six grade V) received a second injection and eventually 12 ureters achieved resolution. Thus, the overall success rate was 67.2% after a single injection and 85.9% after two injections. No procedure-related complications was reported. CONCLUSION: Injections of Deflux is an effective treatment for VUR. A significant reduction in disease severity was seen in patients with grade II to IV disease after a single injection. Most patients with grade V disease needed more than one injection before achieving complete resolution. With this high success rate, we recommend the use of endoscopic Deflux injection as the first line treatment for children with vesicoureteric reflux disease.

Thoracoscopic bullectomy for primary spontaneous pneumothorax in pediatric patients.

INTRODUCTION: Primary spontaneous pneumothorax is a condition that carries significant morbidities and mortalities if not managed properly. Thoracotomy with bullectomy has been the treatment of choice for persistent air leak or recurrence after initial chest drain insertion. With the advancement in minimal invasive surgery, the thoracoscopic approach can dramatically reduce the complications of open thoracotomy. We review our experience in managing spontaneous pneumothorax in children using thoracoscopy. MATERIALS AND METHODS: The medical records of all patients who were discharged with the diagnosis of spontaneous pneumothorax from 1997 to 2007 were reviewed. The demographic data and management were noted. For those patients who underwent thoracoscopic surgery, the intra-operative findings, post-operative outcomes and complications were compared. RESULTS: A total of 15 patients with spontaneous pneumothorax were identified. They all received chest drain insertion as the primary treatment modality. Nine patients, with mean age 16.1 +/- 0.9 years, failed the initial management and subsequently received thoracoscopic surgery with a mean interval of 7.6 +/- 2.5 days after initial chest drain insertion. Among these patients, bullae were found in seven patients (two patients had more than one bulla). The bullae were excised with mean operative time being 63.9 +/- 25.2 min. No conversion to thoracotomy was reported. All patients received paracetamol as pain control and there was no associated complication. No recurrence was found at follow-up till now. CONCLUSION: This study confirms that the presence of bulla is commonly seen in patients with spontaneous pneumothorax who fail initial management. Thoracoscopic bullectomy, a safe and effective operation, should be offered to this group of patients.

Effects of acupuncture stimulation on recovery ability of male elite basketball athletes.

Developing effective methods for helping athletes recover from muscle fatigue is deemed essential, particularly on the eves' important competitions. This study aimed to investigate the effects of acupuncture stimulation on athletes' recovery abilities. Subjects were selected from 30 male elite university basketball players who were randomly assigned to 3 groups: acupuncture group, sham group, and normal (control) group, each containing 10 subjects. Acupuncture was carried out on each athlete in acupuncture group at the Neiguan (PC6) and Zusanli (ST36) acupoints, beginning at 15 min prior to exercise and continuing until exhaustion of the subject. Similar acupuncture was also carried out on each athlete in the sham group but the positions were 1 cm away from the PC6 and ST36 acupoints. No acupuncture was conducted on the athletes in the normal group. During the experiments, each subject performed separate runs on the treadmill. The data of heart rate (HR(max)), oxygen consumption (VO(2max)), and blood lactic acid were measured during the rest period and at 3 recovery points of time (5th, 30th and 60th min) post-exercise. The results showed that the acupuncture group (PC6 and ST36) has significantly lower HR(max), VO(2max) and blood lactic acid than both the sham and normal groups at the 30th min post-exercise. Blood lactic acid of the acupuncture group was also significantly lower than that of the other two groups in the 60th min post-exercise. Our findings have shed some light on the development of effective acupuncture schemes to enhance the recovery ability for elite basketball athletes.

Analysis of melamine cyanurate in urine using matrix-assisted laser desorption/ionization mass spectrometry.

Matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) was applied to the direct analysis of melamine cyanurate (MC). The three commonly used MALDI matrixes, namely, alpha-cyano-4-hydroxycinnamic acid (CHCA), sinapinic acid (SA), and 2,5-dihydroxybenzoic acid (DHB), were able to desorb/ionize melamine from MC upon N(2) laser irradiation, with CHCA showing the highest detection sensitivity in the positive mode. Only DHB and SA were able to desorb/ionize cyanuric acid from MC in the negative mode but with remarkably lower sensitivity. The method is able to detect melamine unambiguously from a small amount of MC (down to 12.5 microg) spiked into urine and was successfully applied for the rapid and sensitive detection of melamine in urine stones/residues of the samples collected from patients clinically confirmed of having kidney stones associated with the consumption of melamine-tainted food products. The urine matrix resulted in interfering ion peaks and suppressed the ion intensity of melamine, while a cleanup process consisting of simply washing with water eliminated such interference and enhanced the ion intensity. The merit of the method is simplicity in sample preparation. The analytical time of the method for high-throughput analysis from the time of sample treatment to analysis is less than 7 minutes per sample, with sensitive detection of the presence of melamine in the urine stones/residues of the patient samples.

Abdominal compartment syndrome after open biopsy in a child with bilateral Wilms' tumour.

Although Wilms' tumour is one of the most common solid malignancies in children, bilateral disease is rare. We report a child with bilateral Wilms' tumour who developed abdominal compartment syndrome after an open biopsy.

Impact of prenatal diagnosis on choledochal cysts and the benefits of early excision.

AIM: To evaluate the clinical outcomes of patients with prenatally diagnosed choledochal cysts compared with those diagnosed after birth and the optimal timing of definitive treatment. METHODS: Retrospective review of all patients who underwent primary choledochal cyst excision and Roux-en-Y hepaticojejunostomy from 1996 to 2006 at a single institution. RESULTS: A total of 45 patients were included. Ten (22.2%) of the patients had prior prenatal diagnosis. The mean age at operation for this group was 4.4 months and mean follow up was 55.9 months. There was no operative complication or late morbidity. For the post-natal diagnosis group, the mean age at operation was 5.7 years (P < 0.000) and mean follow up period was 69 months. The most common presentation in this group was abdominal pain (31.4%), followed by pancreatitis (28.6%) and symptoms of cholestasis (25.7%). Early post-operative morbidities occurred in two (5.7%) patients. On long-term follow up, two (5.7%) further patients in the post-natal group developed complications. CONCLUSION: Prenatal diagnosis of choledochal cysts results in earlier definitive surgery. More adverse complications were seen in those who had surgery at an older age. We therefore recommend early excision of choledochal cysts.

Diagnosis and spectrum of melamine-related renal disease: plausible mechanism of stone formation in humans.

BACKGROUND: An epidemic of urinary stones affecting children after consumption of melamine tainted milk is unfolding. We defined clinicopathological features of the disease for diagnosis, monitoring, and treatment of this group of patients. METHODS: A clinicopathological study on exposed children with ultrasonographic evidence of urolithiasis was conducted. Melamine and cyanuric acid levels in the urine were determined by mass spectrometry. RESULTS: Disease severity varied from acute renal failure with hydronephrosis to symptomatic or asymptomatic stones with or without abnormal urinalysis. All cases were aged <3 y with >50% cases having predisposing urinary metabolic risk factors for urolithiasis. Most of the stones were located in the renal pelvis and measured 2.5-18 mm by ultrasonography. We found a strong correlation between renal stone size and urinary melamine concentration. For stones <10 mm, a 10 microg/mmol creatinine increase in urinary melamine concentration is associated with approximately 1 mm increase in the size of the stone. The high degree of correlation strongly suggests that melamine is related to stone formation in humans. Using ROC analysis, we propose that patients who have a persistent melamine level above the optimal cut-off value of 7.1 microg melamine/mmol creatinine in urine might have a significant exposure of melamine-tainted products. Unlike melamine, urinary cyanuric acid is not significantly different between cases and controls. Pathophysiological findings from feeding animals with melamine and cyanuric acid may not be directly applicable to humans. CONCLUSION: Both melamine and urine metabolic lithogenic factors are important for the formation of melamine-related stones. Apart from aiding with case screening and confirmation, the urine melamine level might as well be an indicator of residual melamine load in the body and thus is useful for following-up and monitoring of the confirmed cases. As the stones are small and can be passed out spontaneously, follow-up of these patients with urine melamine will be a convenient tool for monitoring the melamine load of the patients.