Comparison of 16S rRNA gene sequencing microbiota among children with serological IgE-mediated food hypersensitivity.

BACKGROUND: We hypothesized that specific food hypersensitivity (FH) in children is linked to specific gut microbiota. The aim of our study was to quantify and evaluate differences in gut microbial composition among children with different IgE-mediated FH. METHODS: Children (n = 81) aged 18 to 36 months were enrolled, fecal samples of 57 children with FH and 24 healthy children were evaluated using next-generation sequencing. Individual microbial diversity and composition were analyzed via targeting the 16 S rRNA gene hypervariable V3-V5 regions. RESULTS: Children with IgE-mediated FH (in milk, egg white, soy) had significantly lower gut microbiota diversity and richness than healthy children. Children with IgE-mediated FH exhibited relatively high abundances of Firmicutes and relative underrepresentation of the phylum Bacteroidetes. We observed significant increases in relative abundances of Ruminococcaceae, Clostridiaceae, and Erysipelotrichaceae (p < 0.01, compared to control) in children with milk hypersensitivity and of Clostridiaceae and Erysipelotrichaceae (p < 0.01) in children with peanut hypersensitivity. We also found significant increases in the numbers of Clostridiaceae, Lachnospiraceae and Pasteurellaceae (p < 0.01) in children with egg white hypersensitivity. CONCLUSIONS: These findings identify early evidence of different gut microbiota development/ differentiation in children with food hypersensitivity. Specific food hypersensitivities may be associated with compositional changes in intestinal microbiota. IMPACT: These findings identify early evidence of different gut microbiota development/differentiation in children with food hypersensitivity. We built a gut microbial profile that could identify toddlers at risk for food hypersensitivity. Children with enriched Firmicutes (phylum) with partial different families may be associated with food hypersensitivity. Enriched family Clostridiaceae, Ruminococcaceae, Lachnospiraceae, or Erysipelotrichaceae in gut microbiota may be associated with specific food hypersensitivities (such as milk, egg white, peanut) in children.

Magnet ingestion by children: A retrospective study in a medical center in Taiwan.

BACKGROUND: The ingestion of multiple magnets may lead to severe complications including bowel obstruction, perforation, fistula, peritonitis, short bowel syndrome, life-threatening injuries, and even death. The annual case number of high-powered neodymium magnets ingestion has been increasing in the western world and the dearth of available data demonstrates that this issue has been neglected in Taiwan. METHODS: We searched the electronic medical records of our institution for patients younger than 18 years old who were diagnosed with, who had ever visited our emergency department, or been hospitalized for magnetic foreign body ingestion between January 2009 and March 2018. Demographic data including the number, shape, and size of magnets ingested, the clinical presentation, type of intervention, and complications were reviewed. RESULTS: Thirteen patients who met the enrollment criteria were analyzed. One patient was documented between 2009 and 2013, and twelve were documented between January 2014 and March 2018. Five of the cases documented between 2014 and 2018 had ingested Buckyballs. The median age of the patients was 5 years. All of the patients with clinical symptoms had ingested more than one magnet and required endoscopic or surgical intervention. Bowel perforation or deep ulcer with impending perforation was found in three patients during surgery. CONCLUSION: The number of children who visited our emergency department or were hospitalized due to the ingestion of magnets has increased recently. The presence of high power of neodymium magnets in many products increases the risk of ingesting multiple magnets resulting in serious complications. Therefore, stricter policies are needed to prevent children from obtaining products that contain magnets.

Probiotic Lactobacillus casei: Effective for Managing Childhood Diarrhea by Altering Gut Microbiota and Attenuating Fecal Inflammatory Markers.

BACKGROUND: Acute diarrhea is a major cause of childhood morbidity and an economic burden for families. The aim of this study is to explore the effect of probiotics on clinical symptoms, intestinal microbiota, and inflammatory markers during childhood diarrhea. METHODS: Children (n = 81) aged six months to six years (mean age 2.31 years) hospitalized for acute diarrhea were randomized to receive probiotics (Lactobacillus casei variety rhamnosus; n = 42) or no probiotics (n = 39) orally twice daily for seven days. Feces samples were also collected to evaluate microbial content using a traditional agar plate and next-generation sequencing. Immunoglobulin A (IgA), lactoferrin, and calprotectin were determined by enzyme-linked immunosorbent assay (ELISA) and compared in different groups. Other clinical symptoms or signs, including fever, vomiting, diarrhea, abdominal pain, bloated abdomen, daily intake, appetite, and body weight were also assessed. RESULTS: Data were collected from 81 individuals across three different time points. Total fecal IgA levels in fecal extracts of the probiotics group were higher than those in the control group, reaching statistical significance (p < 0.05). Concentrations of fecal lactoferrin and calprotectin were significantly downregulated in patients with probiotic Lactobacillus casei variety rhamnosus (Lc) consumption compared to those of the control (p < 0.05). Probiotic Lc administration may be beneficial for gut-microbiota modulation, as shown by the data collected at one week after enrollment. Counts of Bifidobacteria and Lactobacillus species were elevated in stool culture of the probiotic group. Appetite and oral intake, body-weight gain, abdominal pain, bloating, as well as bowel habits (diarrhea) were much better in children receiving probiotics compared with those in the control group. CONCLUSION: Fecal IgA increased during acute diarrhea under Lc treatment; in contrast, fecal lactoferrin and calprotectin were downregulated during acute diarrhea under Lc treatment. Probiotic Lc may be a useful supplement for application in children during acute diarrhea to reduce clinical severity and intestinal inflammatory reaction.

Clinical and nutritional outcome of pediatric esophageal stenosis with endoscopic balloon dilatation.

AIM: The present study evaluates the long-term clinical and nutritional effect to endoscopic balloon dilatation (EBD) in pediatric esophageal stricture. METHODS: This was a 15-year retrospective study involving pediatric patients with esophageal stricture treated with EBD. Outcome parameters included the number of dilatations, procedural success rates, nutritional status, and complications. EBD was performed in patients with a dysphagia score greater than 2. The nutritional status was assessed by weight-for-age z-score. Clinical success was defined as no requirement for EBD for at least 1 year and/or increasing interval between dilatation and the numbers of EBD was fewer than 4 times per year. RESULTS: A total of 50 cases (mean age, 4.41 ± 4.9 years) were enrolled. During a mean follow-up of 3.2 ± 1.9 years, a total of 268 EBD sessions were performed, with an average of 5.36 sessions per patient (range, 1-33). Patients who had short segment stricture (<2 cm) were prone to achieve clinical success after EBD (p = 0.0094). Procedural perforation rate is 2.6% (7/268); subsequent tracheoesophageal fistula occurred in two patients. The clinical success rate of EBD therapy was 72% (36/50). All had increments of weight-for-age z-score after EBD therapy, and the increment was significantly greater in those patients with short segment stricture or stricture in the middle esophagus at 12 months (p = 0.01 and 0.008, respectively). CONCLUSIONS: EBD has good long-term clinical success and nutritional promotion in pediatric patients with esophageal stricture, especially in short segment stricture or stricture in the middle esophagus.

Long-term impact of suboptimal rotavirus vaccines on acute gastroenteritis in hospitalized children in Northern Taiwan.

BACKGROUND/PURPOSE: Rotavirus vaccines were launched in Taiwan since early 2006. Our study was aimed to figure out long-term extended molecular epidemiology in acute gastroenteritis (AGE) in hospitalized young children after rotavirus vaccination in Taiwan. METHODS: During the 10-year period from January 2007 to December 2016, fecal samples from children under 5 years old with AGE hospitalized in Chang Gung Children's Hospital (CGCH) were examined for enteric pathogens and they were divided into two time intervals: early post-vaccine (Jan. 2007 to Dec. 2011; EPV) and late post-vaccine (Jan. 2012 to Dec. 2016; LPV). RESULTS: In total, 837 patients with AGE were enrolled with complete study. In the EPV period, 106 (26.7%) rotavirus and 65 (16.4%) norovirus infections were identified as major pathogens. In the LPV period, 79 (17.9%) rotavirus and 98 (22.2%) norovirus infections were diagnosed. Statistical analyses showed a significantly decreased prevalence of rotavirus infection (P = 0.002) and a significantly increased prevalence of norovirus (P = 0.034) and enteric bacterial infections (P < 0.001). A substantial decrease of rotavirus G1 (P = 0.079) in the LPV period and norovirus GII.4 prevailed through the decade. CONCLUSION: In Taiwan, under a suboptimal rotavirus vaccination policy, there was a marked decrease in the rate of rotavirus AGE of hospitalized young children. Significantly increased norovirus infection has replaced rotavirus as the leading cause. Expansion of rotavirus vaccine coverage, development of a norovirus prevention strategy, and sustained bacterial infection control are important for AGE containment in children in Taiwan.

Risk factors for poor outcomes of children with acute acalculous cholecystitis.

BACKGROUND: Acute acalculous cholecystitis (AAC) is generally considered to be a mild disease in children; however, if left untreated or treated without caution, AAC can lead to severe outcomes, such as death. The objectives of this study were to present the clinical features and identify the predictors of mortality in pediatric AAC. METHODS: Patients diagnosed with AAC between 2005 and 2012 were enrolled. AAC was defined by the presence of fever and an echo-proven thickened gallbladder wall exceeding 4 mm. A poor health outcome was defined as death. Further information related to the demographics, clinical manifestations, laboratory results, ultrasound findings, and pathogens present in the AAC patients was also collected. Predictors of mortality were identified by association analyses and confirmed by multivariate logistic regression. RESULTS: A total of 147 pediatric AAC patients (male/female = 1.01, mean age = 5.2 years) were included in this retrospective study. The most common clinical presentation was an elevated C-reactive protein level (84%) followed by hepatomegaly (80%) and anorexia (78%). AAC in children was associated with various diseases, including infectious diseases (70%), systemic diseases (13%), and malignancy (11%). Fourteen of the 147 (9.25%) patients died during the study period. The presences of thrombocytopenia, anemia, gallbladder sludge, hepatitis, and/or sepsis plus hepatitis were found to be the important predictors of AAC mortality. CONCLUSIONS: The factors associated with AAC mortality were anemia, thrombocytopenia, gallbladder sludge, hepatitis, and sepsis plus hepatitis. These predictors are likely to help clinicians identify patients who are at a high risk of poor prognoses and make appropriate clinical decisions.

Risk Factors for Prolonged Hospitalization in Pediatric Appendicitis Patients with Medical Treatment.

BACKGROUND: With effective antibiotics against enteric flora and computed tomography-guided drainage for abscesses, the initial use of nonoperative therapy for children with appendicitis has increased both in recent reports and at our hospital. However, it has been reported that these patients have a relatively longer hospital stay and that their treatment is more expensive than those who undergo aggressive surgical intervention. METHODS: This was a retrospective cohort study based in a single medical center. A systemic chart review was conducted to identify risk factors for prolonged hospitalization in pediatric appendicitis patients not initially undergoing surgical treatment. Patient demographics, clinical symptoms, duration of symptoms, laboratory findings, imaging findings, complications, and length of hospital stay were analyzed. Logistic regression analysis was used to identify significant predictors of prolonged hospitalization (≥15 days) and readmission. RESULTS: One hundred and twenty-five patients were recruited in this study, of whom 53 (42.4%) had prolonged hospitalization. The values of serum C-reactive protein (CRP) were significantly higher in patients with prolonged hospitalization compared with those without prolonged hospitalization (203 ± 108.6 mg/L vs. 140 ± 93.0 mg/L, p = 0.001). Risk factors of prolonged hospitalization were serum CRP >150 mg/L (35/53 vs. 28/72, p = 0.001), abscess formation (38/53 vs. 35/72, p = 0.008), and multiple abscesses (10/53 vs. 1/72, p = 0.001). Under multivariate analysis, CRP >150 mg/L (odds ratio=1.004, p = 0.0334) and multiple abscesses (odds ratio = 8.788, p = 0.044) were two independent predictors for prolonged hospitalization. CONCLUSION: Marked elevation of serum CRP (>150 mg/L) and multiple abscesses are two independent risk factors for prolonged hospitalization in children with appendicitis who are initially treated nonoperatively.

Alterations in the gut microbiotas of children with food sensitization in early life.

BACKGROUND: We hypothesized that food sensitization (FS) in children could be linked to specific gut microbiota. The aim of our study is to quantify and evaluate differences in gut microbiota composition between children with FS and healthy controls. METHODS: A case-control study of 23 children with FS and 22 healthy children was performed. Individual microbial diversity and composition were analyzed via parallel barcoded 454 pyrosequencing targeting the 16S rRNA gene hypervariable V3-V5 regions. RESULTS: The children with FS exhibited lower diversity of both the total microbiota (p = 0.01) and the bacterial phylum Bacteroidetes (p = 0.02). In these children, the number of Bacteroidetes bacteria was significantly decreased and that of Firmicutes were significantly increased compared with the healthy children. At the genus level, we observed significant increases in the numbers of Sphingomonas, Sutterella, Bifidobacterium, Collinsella, Clostridium sensu stricto, Clostridium IV, Enterococcus, Lactobacillus, Roseburia, Faecalibacterium, Ruminococcus, Subdoligranulum, and Akkermansia in the FS group. We also found significant decreases in the numbers of Bacteroides, Parabacteroides, Prevotella, Alistipes, Streptococcus, and Veillonella in this group. Furthermore, linear discriminant analysis (LDA) coupled with effect size measurements revealed the most differentially abundant taxa (increased abundances of Clostridium IV and Subdoligranulum and decreased abundances of Bacteroides and Veillonella), which could be used to identify FS. CONCLUSIONS: Our results showed that FS is associated with compositional changes in the gut microbiota. These findings could be useful for developing strategies to control the development of FS or atopy by modifying the gut microbiota.

Infantile hepatitis B in immunized children: risk for fulminant hepatitis and long-term outcomes.

BACKGROUND: Infantile hepatitis B after neonatal immunoprophylaxis is a rare yet distinct disease. This study aimed to analyze the long-term outcomes and risk factors in immunized infants with hepatitis B. METHODS: The clinical parameters and outcomes of 41 infants born after universal immunization, and admitted for HBV-positive hepatitis were studied. All patients were followed for at least 6 months (median  = 4.4 years, range 0.6-18.1 years). Patient survival, changes of HBsAg and HBeAg status, and complications were analyzed. RESULTS: Among the 41 cases (32 males, 9 females), 21 presented with fulminant hepatitis (FH), and 20 with non-fulminant hepatitis (NFH). Ninety-five percent (36/38) of the mothers were positive for hepatitis B surface antigen (HBsAg). Multivariate analyses revealed younger age of onset (age <7 months) and negative maternal hepatitis B e antigen (HBeAg) were associated with FH (p = 0.03 and p = 0.01, respectively). An infantile fulminant hepatitis B risk score using maternal/infant HBeAg positivity and onset age was proposed. Among the FH cases, the rate of mortality, HBsAg clearance, and chronic HBV infection were 47.6%, 38.1%, and 14.3%, respectively. Among the NFH cases, 35% developed chronic infection. Of the 9 chronically infected children received long-term follow-up, 8 had HBeAg seroconversion before 4 years of age. One case of FH developed hepatocellular carcinoma 14 years later. CONCLUSIONS: Maternal HBsAg + /HBeAg- and early onset age were risk factors for FH in immunized infants. A significant portion of patients with FH or NFH evolve to chronic HBV infection, with HBeAg seroconversion in young childhood. Close surveillance for hepatocellular carcinoma is warranted in patients surviving infantile hepatitis B.

Diverse presentations in pediatric Meckel's diverticulum: a review of 100 cases.

BACKGROUND: Our objective was to analyze demographics and characteristics of Meckel's diverticulum with different manifestations in pediatric patients. METHODS: This is a retrospective study in children with symptomatic Meckel's diverticulum who underwent resection between September 1998 and October 2010. The diagnosis was confirmed by surgery and pathology. Demographic characteristics, manifestations, Meckel's scan results, surgical and histological findings were analyzed. RESULTS: One hundred symptomatic Meckel's diverticula were identified in 74 boys and 26 girls aged from one day to 18 years old over 13 years. Depending on whether or not obstruction occurred, the patients were classified into two categories. Each category was further subdivided into two diagnostic groups: 17 intussusception and 24 non-intussusception bowel obstruction in the obstructive category and 44 gastrointestinal bleeding and 15 diverticulitis and/or perforation in the non-obstructive category. The sex discrepancy was higher in the non-obstructive category than in the obstructive category (male-to-female, 4.36 vs. 1.73, p < 0.05). Forty-one of 44 patients with gastrointestinal bleeding underwent a Meckel's scan with a high positive rate (92.7%). The ectopic tissues were identified in 73 patients and included 61 gastric type, two pancreatic type and 10 mixed type. Ectopic tissues were more prevalent in non-obstructive category (p < 0.05) with ectopic gastric tissue even more pronounced (p < 0.01). Ectopic pancreatic tissue was significantly more prevalent in intussusception (p < 0.01). Laparoscopic surgery was performed more frequently in Meckel's diverticulum with non-obstructive symptoms (p < 0.001). CONCLUSION: Diverse presentations in pediatric Meckel's diverticulum are affected by different ectopic tissue types and male sex. Laparoscopic surgery is widely used for children with non-obstructive symptoms.

Fecal calprotectin as a correlative marker in clinical severity of infectious diarrhea and usefulness in evaluating bacterial or viral pathogens in children.

BACKGROUND: Calprotectin is a marker associated with intestinal inflammation. The aim of this study is to explore the diagnostic value of fecal calprotectin in predicting bacterial/viral diarrhea and the application of fecal calprotectin in the clinical course of infectious diarrhea. METHODS: Patients ages from 3 months to 10 years with infectious diarrhea were enrolled, and from each patient, 2 to 3 stool samples were collected. Fecal calprotectin levels were determined by enzyme-linked immunosorbent assay and compared by pathogen and disease activity. A univariate linear regression was used to determine the correlation between fecal calprotectin and the clinical parameters, and generalized estimating equations (GEEs) were used for the time course analyses. RESULTS: The data include 451 evaluations for 153 individuals across 3 different time points. The fecal calprotectin level was higher in patients with Salmonella infection (median with range 765 [252-1246] µg/g) or Campylobacter infection (689 [307-1046] µg/g) compared with patients with rotavirus infection (89 [11-426] µg/g), norovirus infection (93 [25-405] µg/g), or adenovirus infection (95 [65-224] µg/g). Fecal calprotectin concentrations were elevated in patients with severe (843 [284-1246] µg/g) or moderate (402 [71-995] µg/g) disease activity compared with those with mild (87 [11-438] µg/g) disease activity (P < 0.05). GEE analysis suggests that fecal calprotectin is correlated with clinical severity (e.g., Vesikari score) and may provide information for disease management. CONCLUSIONS: Fecal calprotectin levels increased during bacterial infection and as disease severity increased, and its levels on the initial evaluation and follow-up visit are correlated with clinical severity. Fecal calprotectin may be a useful marker for application in children during infectious diarrhea.

Oral inoculation of probiotics Lactobacillus acidophilus NCFM suppresses tumour growth both in segmental orthotopic colon cancer and extra-intestinal tissue.

Modulation of the cellular response by the administration of probiotic bacteria may be an effective strategy for preventing or inhibiting tumour growth. We orally pre-inoculated mice with probiotics Lactobacillus acidophilus NCFM (La) for 14 d. Subcutaneous dorsal-flank tumours and segmental orthotopic colon cancers were implanted into mice using CT-26 murine colon adenocarcinoma cells. On day 28 after tumour initiation, the lamina propria of the colon, mesenteric lymph nodes (MLN) and spleen were harvested and purified for flow cytometry and mRNA analyses. We demonstrated that La pre-inoculation reduced tumour volume growth by 50·3 %, compared with untreated mice at 28 d after tumour implants (2465·5 (SEM 1290·4) v. 4950·9 (SEM 1689·3) mm³, P<0·001). Inoculation with La reduced the severity of colonic carcinogenesis caused by CT-26 cells, such as level of colonic involvement and structural abnormality of epithelial/crypt damage. Moreover, La enhanced apoptosis of CT-26 cells both in dorsal-flank tumour and segmental orthotopic colon cancer, and the mean counts of apoptotic body were higher in mice pre-inoculated with La (P<0·05) compared with untreated mice. La pre-inoculation down-regulated the CXCR4 mRNA expressions in the colon, MLN and extra-intestinal tissue, compared with untreated mice (P<0·05). In addition, La pre-inoculation reduced the mean fluorescence index of MHC class I (H-2Dd, -Kd and -Ld) in flow cytometry analysis. Taken together, these findings suggest that probiotics La may play a role in attenuating tumour growth during CT-26 cell carcinogenesis. The down-regulated expression of CXCR4 mRNA and MHC class I, as well as increasing apoptosis in tumour tissue, indicated that La may be associated with modulating the cellular response triggered by colon carcinogenesis.

Usefulness of fecal lactoferrin in predicting and monitoring the clinical severity of infectious diarrhea.

AIM: To explore the value of fecal lactoferrin in predicting and monitoring the clinical severity of infectious diarrhea. METHODS: Patients with acute infectious diarrhea ranging from 3 mo to 10 years in age were enrolled, and one to three stool samples from each subject were collected. Certain parameters, including white blood cells /differential count, C-reactive protein, fecal mucus, fecal pus cells, duration of fever, vomiting, diarrhea and severity (indicated by Clark and Vesikari scores), were recorded and analyzed. Fecal lactoferrin was determined by enzyme-linked immunosorbent assay and compared in different pathogen and disease activity. Generalized estimating equations (GEE) were also used for analysis. RESULTS: Data included 226 evaluations for 117 individuals across three different time points. Fecal lactoferrin was higher in patients with Salmonella (11.17 µg/g ± 2.73 µg/g) or Campylobacter (10.32 µg/g ± 2.94 µg/g) infections and lower in patients with rotavirus (2.82 µg/g ± 1.27 µg/g) or norovirus (3.16 µg/g ± 1.18 µg/g) infections. Concentrations of fecal lactoferrin were significantly elevated in patients with severe (11.32 µg/g ± 3.29 µg/g) or moderate (3.77 µg/g ± 2.08 µg/g) disease activity compared with subjects with mild (1.51 µg/g ± 1.36 µg/g) disease activity (P < 0.05). GEE analysis suggests that this marker could be used to monitor the severity and course of gastrointestinal infections and may provide information for disease management. CONCLUSION: Fecal lactoferrin increased during bacterial infection and with greater disease severity and may be a good marker for predicting and monitoring intestinal inflammation in children with infectious diarrhea.

Risk factors for intestinal gangrene in children with small-bowel volvulus.

OBJECTIVES: Pediatric small-bowel volvulus (SBV) is a surgical emergency, and early diagnosis is difficult. We analyzed the clinical manifestations, imaging findings, and laboratory parameters in children with SBV and attempted to determine the risk factors for bowel gangrene. PATIENTS AND METHODS: Forty-nine children (35 boys and 14 girls) with SBV who were admitted to the hospital for a period of 13 years were enrolled. Clinical and laboratory parameters and evaluation measures included fever, abdominal pain, vomiting, bloody stool, peritoneal signs, severe dehydration, disease duration, white blood cell counts, sugar, C-reactive protein (CRP), sodium, potassium, metabolic acidosis, blood urea nitrogen, and creatinine. These parameters were statistically compared between patients with and without bowel gangrene. RESULTS: Thirty-six patients (73.5%) were 5 years old or younger, and nearly half were younger than 1 year old. Abdominal pain and vomiting were 2 major symptoms. Malrotation was the most common cause of SBV. In univariate analysis, nonbilious vomiting, peritoneal signs, severe dehydration, leukocytosis (WBC count >18,000 cells/mm3), elevated CRP (>50 mg/dL), and hyponatremia (<130 mmol/L) were significantly associated with bowel gangrene (P < 0.05). In multivariate analysis, nonbilious vomiting, leukocytosis, and elevated CRP were significantly (P < 0.05) associated with bowel gangrene. The resection rate for bowel gangrene was 44.9%, and no mortality was found. Seven (14.3%) patients had postoperative complications, including short-bowel syndrome (n = 2), adhesion ileus (n = 3), and intraabdominal abscess (n = 3). Seven experienced failure to thrive in later follow-up. CONCLUSIONS: Specific clinical manifestations and laboratory parameters are helpful in the identification of bowel gangrene in children with SBV.

Acute pancreatitis in children.

AIM: To identify clinical, laboratory, and imaging characteristics associated with severe acute pancreatitis in children. METHODS: This was a retrospective study of children under 18 years of age with acute pancreatitis between September 1993 and August 2008. Severity of pancreatitis was graded according to established criteria. Clinical, laboratory and radiological data for mild and severe pancreatitis were collected for analysis. RESULTS: There were 180 cases of pancreatitis; 51 (28.3%) met criteria for severe disease. Severe pancreatitis was most commonly associated with systemic disease (22 of 51; 43.1%) and trauma (13 of 51; 25.4%). Patients with severe pancreatitis had significantly higher body weight, higher frequency of dyspnoea and pleural effusion, and lower serum calcium and albumin levels. Ten patients with systemic disease died; four of them had systemic lupus erythematosus (SLE). Computed tomography (CT) was more accurate than ultrasound in evaluation of the severity of pancreatitis. CONCLUSIONS: Acute pancreatitis in children is associated with significant morbidity and mortality. The severity of paediatric pancreatitis may be influenced by aetiology. CT is recommended for evaluation of severity of pancreatitis.

Balloon-assisted enteroscopy with prophylactic polypectomy for Peutz-Jeghers syndrome: experience in Taiwan.

BACKGROUND: Peutz-Jeghers syndrome (PJS) is a very rare disease that often causes severe complications such as bowel obstruction or gastrointestinal tract bleeding. In the past, it was usually treated by using surgical intervention despite the associated complications. Balloon-assisted enteroscopy (BAE) has been documented as an effective and safe method for the diagnosis and treatment of small bowel lesions. Hence, we conducted this study to verify whether BAE is useful for patients with PJS. AIM: To evaluate the safety and efficacy of BAE with prophylactic polypectomy in patients with PJS. METHODS AND PATIENTS: From August 2005 to February 2010, 6 consecutive patients were diagnosed with PJS after pathological and clinical examination, and underwent BAE examination and polypectomy at Chang Gung Memorial Hospital, an academic tertiary referral center. RESULTS: Six consecutive patients (4 men and 2 women) diagnosed with PJS underwent BAE with polypectomy. BAE was performed 17 times for complete examination of the entire small bowel. The range of the diameter of the removed polyps was 1-6 cm. No immediate complications such as hemorrhage or hollow organ perforation were noted during the procedure, and no patient developed intussusception during the follow-up period (32 ± 17.5 months). CONCLUSION: BAE with polypectomy is useful for patients with PJS in order to reduce the complications of the condition.

Misdiagnosed acute appendicitis in children in the emergency department.

BACKGROUND: To identify clinical features that distinguish children with appendicitis who visited the emergency department twice or more from those diagnosed on the first visit to the emergency department. METHODS: A retrospective review of all children with appendicitis diagnosed in the emergency department between January and December 2004 was conducted. Records were reviewed for all patients on their initial presentation to the emergency department. Clinical features were compared between those children who were misdiagnosed and those who were diagnosed correctly. RESULTS: One hundred seventy-three cases were included (mean age, 10.4 years). Twenty-six (15%) were seen twice or more in the emergency department before appendicitis was diagnosed. Misdiagnosed patients had a relatively shorter duration of symptoms at their initial visit, and most presented late at night. Eighteen misdiagnosed patients (69.2%) initially visited the emergency department within 24 hours of onset of symptoms. Compared with patients diagnosed correctly on initial presentation, misdiagnosed patients had a significantly shorter hospital stay, fewer laboratory tests, and fewer physical findings of right lower quadrant tenderness, muscle guarding, rebound tenderness, fever, and migrating pain. Patients diagnosed late at night had a significantly shorter hospital stay and fewer abdominal ultrasound evaluations. On final presentation, initially misdiagnosed patients had a higher rate of appendiceal perforation than did correctly diagnosed patients. CONCLUSION: Misdiagnosed appendicitis is a problem in the emergency department. A shorter stay in the emergency department, fewer laboratory tests, less diagnostic imaging, and fewer physical findings may be responsible for misdiagnosed appendicitis late at night in the emergency department.

Probiotic Bio-Three induces Th1 and anti-inflammatory effects in PBMC and dendritic cells.

AIM: To investigate the immune response of peripheral blood mononuclear cells (PBMCs) and dendritic cells (DCs) that were stimulated by probiotic preparations. METHODS: PBMCs were isolated, cultured, and stimulated with Bio-Three (a mixture of Bacillus mesentericus, Clostridium butyricum and Enterococcus faecalis; 10(5), 10(6) and 10(7) CFU/mL for 24 h). Cytokine production of (1) circulating PBMCs; (2) PBMCs stimulated by probiotic preparation; (3) monocyte-derived DCs; and (4) DC and T cell co-culture was determined by enzyme-linked immunosorbent assay. Phenotypic analysis of circulating PBMCs was also investigated by flow cytometry. Blood was obtained from individuals who consumed Bio-Three (10(9) CFU/d B. mesentericus, C. butyricum and E. faecalis) for 2 wk, or those who did not take probiotics orally. RESULTS: In culture supernatants, interferon-gamma (IFN-gamma) and interleukin (IL)-10 production increased, but IL-4 and tumor necrosis factor-alpha (TNF-alpha) production by PBMCs decreased after 1 and 2 wk of probiotic treatment. Flow cytometry was also performed on day 14 and detected enhanced expression of CD11b, HLA-DR, CD4, CD45RA, CD25, CD44 and CD69 in response to Bio-Three. Furthermore, IL-10 and IL-12 were upregulated in supernatants of monocyte-derived DCs, and IFN-gamma and IL-10 were enhanced in supernatants of CD4(+) T cells co-cultured with DCs. CONCLUSION: Bio-Three appeared to stimulate the Th1 immune response, downregulate pro-inflammatory cytokines (TNF-alpha) and upregulate anti-inflammatory cytokine (IL-10). Probiotics could be effective in activation of PBMCs and DCs.

Clinical and nutritional outcomes in children with idiopathic superior mesenteric artery syndrome.

OBJECTIVE: There are no available data for outcomes in children's idiopathic superior mesenteric artery syndrome (SMAS) strictly treated conservatively. The aim of the study was to evaluate clinical and nutritional outcome in children with idiopathic SMAS. PATIENTS AND METHODS: A 1-year prospective observation study of effects of treatment and outcome was performed in 27 children (8 boys, 19 girls) with idiopathic SMAS who underwent an upper gastrointestinal (UGI) series, ultrasound measurement of the aortomesenteric angle, treatment, clinical assessment, growth evaluation, and regular clinical visits for more than 12 months. RESULTS: Mean age of the patients was 11.77 +/- 2.15 years. The major clinical complaints were postprandial pain or fullness (88.9%), vomiting (55.6%), and early satiety (51.9%). Eight patients (29.6%) had weight loss. The UGI series revealed typical features of SMAS. The aortomesenteric angle on ultrasound was 10 degrees to 19 degrees. The height of most patients (92.6%) was above the 10th percentile, whereas 15 (55.6%) patients weighed below the 10th percentile. Six patients underwent surgical intervention (3 for obstruction and 3 for persistent anorexia with weight loss), and their clinical symptoms and weight status improved steadily during the follow-up months. Among the 21 patients not subject to surgical intervention, 11 (52.4%) experienced a reduction of symptoms >50% after 3 months of treatment, and weight-for-age percentile increased significantly after 6 months of treatment. Overall, a significant increase in the weight-for-age status was seen in the patients with surgical treatment or with medication only after 6 and 12 months of treatment. CONCLUSIONS: An aortomesenteric angle <20 degrees is a constant phenomenon in children with idiopathic SMAS. A duodenojejunostomy can effectively relieve the obstructive symptoms, such as anorexia, and improve nutritional status, whereas long-term medical treatment may aid in relieving the clinical symptoms, promoting appetite, and improving nutritional status in pediatric patients with idiopathic SMAS.