Parenting stress in parents of children with refractory epilepsy before and after vagus nerve stimulation implantation.

OBJECTIVES: The purpose of this study was to evaluate parenting stress in parents of children with refractory epilepsy before and after their children received vagus nerve stimulation (VNS) implantation. METHODS: Parents of children with refractory epilepsy completed the Parenting Stress Index (PSI) under a psychologist's assessment before and at least 12 months after their children received VNS implantation. The PSI questionnaire measures parenting stress in two domains; a parent domain with seven subscales, and a child domain with six. Age, gender, epilepsy comorbidity, VNS implantation date, seizure frequency, and anticonvulsant history before and after VNS implantation were obtained from reviews of medical charts. RESULTS: In total, 30 parents completed the first and follow-up PSI questionnaires. Seventeen of their children (56.7%) were boys. The children aged from 1 to 12 years (7.43 ± 3.59 years, mean ± SD). After VNS implantation, the mean total parenting stress scores decreased from 282.1 ± 38.0 to 272.4 ± 42.9. A significant decrease was found on the spouse subscale of the parent domain. For the parents of boys, the mean total parenting stress scores decreased significantly. The mean total parenting stress scores also decreased significantly for parents of epileptic children without autism and who did not taper off the number of different anticonvulsants used after VNS. CONCLUSIONS: VNS is an advisable choice to treat refractory epilepsy. Our study showed that 12 months or more after VNS implantation, seizure frequency and parenting stress typically decreased. However, in some special cases the parenting stress may increase, and external help may be required to support these patients and their parents.

Protective effect against focal cerebral ischemia injury in acute phase of a novel invasive device for regional hypothermia.

BACKGROUND: Systemic hypothermia is considered beneficial to stroke patients. However, many complications ensue. The aim of this study was to evaluate the effect of a new invasive regional cooling device in cerebral ischemic injury in a rat model. METHODS: After a pilot study confirming the efficiency of the cooling device, 15 adult male Sprague-Dawley rats, weighing 300-400 g, were randomly assigned into three groups: cooling device applied at 14°C and at 26°C, and a sham group. Focal cerebral ischemic injury was achieved by electrocauterization of the left middle cerebral artery through craniectomy and temporal occlusion of both common carotid arteries for 3 hours. Within 30 minutes after the end of ischemic injury, the cooling device was inserted into the rat brain through a stereotactic frame to provide regional hypothermia for 2 hours. The rats were sacrificed immediately after the 2-hour regional hypothermia. RESULTS: Although triphenyltetrazolium chloride staining showed smaller ischemic lesions in both the 26°C and 14°C groups compared to the control group, Fluoro Jade C staining showed no neuroprotective effects in the rostrum cerebral cortex in both groups. However, both triphenyltetrazolium chloride and Fluoro Jade C staining indicated significant beneficial effects in the caudal cerebral cortex in rats with cooling device applied at 26°C compared to the 14°C and control groups. CONCLUSION: Our findings indicated that the device can effectively achieve regional hypothermia and could be beneficial for patients with cerebral ischemia during the acute phase.

Antipruritic effect of cold stimulation at the Quchi acupoint (LI11) in mice.

BACKGROUND: Acupuncture and moxibustion are used to treat pruritus and atopic dermatitis. However, whether cold stimulation (defined as that the temperature conducted under skin temperature) of acupoints affects itching in experimental murine models remains unclear. METHODS: The present study was designed to determine the therapeutic effects of different thermal stimulations at the Quchi acupoint (LI11) in a murine model in which scratching behaviour was elicited by subcutaneous injection with a pruritogenic agent (compound 48/80). Male ICR mice were divided into several groups as follows: control (saline), those receiving compound 48/80 and compound 48/80 with various thermal stimulations (5°C-45°C) at LI11 (n = 6 per group). The scratch response of each animal to these stimulations was recorded for 30 min. The antipruritic effect of the acupoint was further evaluated in LI11 and sham (non-acupoint) groups (n = 6 per group). RESULTS: Treatment with lower temperature (20°C) at the LI11 acupoint significantly attenuated compound 48/80-induced scratching; however, this antipruritic effect was not observed with stimulation at the sham point. The expression of c-fos in the neuron of the cervical spine induced by compound 48/80 was suppressed by cold stimulation at LI11. The antipruritic effect of cold stimulation was blocked by ruthium red (RR), a non-selective transient receptor potential (TRP) channel blocker, suggesting that TRP channels may play an important role in the antipruritic effect of cold stimulation at LI11 in mice. CONCLUSIONS: This study demonstrated that cold stimulation at LI11 attenuated compound 48/80-induced scratching behaviour in mice, possibly by a TRP-related pathway.

Risk of subsequent attention deficit-hyperactivity disorder in children with febrile seizures.

OBJECTIVE: In this study, we obtained relevant data from a nationwide cohort database to investigate the risk of attention deficit-hyperactivity disorder (ADHD) in children with a history of febrile seizures (FS). METHODS: We identified 1081 children with FS as the case cohort, and the date of diagnosis was used as an index date. Four controls were matched randomly with each case based on age, sex, urbanisation level, parents' occupation, and index date. We applied Cox's proportional hazards regression to estimate the HR and CI of FS-associated ADHD. RESULTS: After 11 years of follow-up, the incidence of ADHD for the FS and control cohorts is 7.83 and 4.72 per 1000 person-years, respectively. The FS cohort was 1.66 times more at risk of ADHD occurrence (95% CI 1.27 to 2.18) than the control cohort. The risk of developing ADHD increased in conjunction with the frequency of FS-related visits. CONCLUSIONS: FS may increase the risk of subsequent ADHD occurrence in children. Children who visited physicians for FS more than twice had a significantly higher cumulative incidence of ADHD.

The changes of cerebral morphology related to aging in Taiwanese population.

A cross-sectional study with the 3-dimensional (3D) MRI reconstruction technique was conducted to investigate cerebral complexity changes related to age differences in native Taiwanese population. In our sample of 85 participants aged between 25 and 81, age was associated with gradual ventricular expansion. A nonlinear quadratic relationship between white matter volume and age was found overall in the brain. Widespread age-related reduction in white matter was detected from late adulthood onwards. However, no significant age-related changes in the cortex and whole brain volume were determined throughout adulthood. These findings provided information in describing brain structural complexity, which might in the future serve as an objective diagnostic index or as a predictive parameter for neurological diseases. Our method then may be used for cross-cultural longitudinal studies to evaluate the effect of disease, environment and aging on the brain.

Three-dimensional brain images in preterm children with periventricular leukomalacia.

BACKGROUND: To investigate the use of three-dimensional (3D) brain magnetic resonance imaging (MRI) to evaluate in preterm children with periventricular leukomalacia. MATERIALS AND METHODS: Semiautomated 3D classification of the gray and white tissues was used to reconstruct brain images of patients with confirmed periventricular leukomalacia from 2D MRI. RESULTS: We studied 14 preterm patients. The gestational age ranged from 25-37 weeks. The corrected age ranged from 5-49 months. We reconstructed the gray matter, white matter, and ventricles in order to analyze the brain volume. CONCLUSION: Three-dimensional MRI is a good tool that can be used to demonstrate brain lesions in stereo and differentiate the gray matter, white matter, and ventricles. Brain volume can also be accurately evaluated.

Utility of laboratory tests for children in the emergency department with a first seizure.

OBJECTIVE: The objective of the study was to evaluate the factors associated with abnormal laboratory findings in patients visiting the emergency department (ED) after having their first seizure. METHODS: We included ED patients with first seizures and divided them into groups based on normal and abnormal laboratory results for serum levels of sodium, potassium, calcium, and glucose. We evaluated the differences in age, sex, the presence of fever, the presence of gastrointestinal symptoms, the duration and pattern of the seizure, and whether the seizure was still present at the ED. RESULTS: We evaluated 240 patients. Among them, abnormalities were found in 83 (34.8%) of 238 for serum sodium, 16 (6.7%) of 238 for potassium, 11 (6.2%) of 177 for calcium, and 121 (52.3%) of 231 for glucose. In the serum sodium and calcium group, no differences in associated factors between patients with and without abnormal laboratory results were found. However, results revealed differences in seizure duration between patients with and without abnormal laboratory glucose results (P = 0.005) and in age between patients with normal and abnormal potassium results (P = 0.002). CONCLUSIONS: There was no significant association among the factors of sex, fever, gastrointestinal symptoms, seizure duration, and seizures in patients who came to the ED with electrolyte abnormalities after a first seizure. However, glucose level abnormalities may have an association with increased seizure duration. We still do not have any suggestions as to which associated factors should be considered when doing common blood examinations in these patients.

Locating the Acupoint Baihui (GV20) Beneath the Cerebral Cortex with MRI Reconstructed 3D Neuroimages.

Baihui (GV20) is one of the most important acupoints of the Du meridian (the government vessel) and is commonly used in neurology and psychiatry and as a distal point of anorectal disorders by general practitioners. The anatomical relationship between the scalp region of the acupoint and the underlying corresponding cortex remains obscure. In this study, we first prepared the indicator for MRI scanning on a GE 1.5 T excite machine in a mode suitable for 3D reconstruction. The 3D Avizo software system (version 6.0, Mercury Computer Systems, Inc., Germany) was then used for image processing and the resulting data subsequently analyzed using descriptive statistics and analysis of variance (ANOVA). The mean distance from the Baihui anterior to the central sulcus in the adult group was greater than that in the child group (22.7 ± 2.2 and 19.7 ± 2.2 mm, resp., P = .042), whereas in the child group the distance between the Baihui anterior and the precentral sulcus was greater than in the adult group (6.8 ± 0.8 and 3.8 ± 0.8 mm, resp., P < .001). This MRI presentation demonstrates that the location of Baihui (GV20) can be identified using the distance from the central or precentral sulcus.

The cerebellar development in chinese children-a study by voxel-based volume measurement of reconstructed 3D MRI scan.

Cerebellar disorder was frequently reported to have relation with structural brain volume alteration and/or morphology change. In dealing with such clinical situations, we need a convenient and noninvasive imaging tool to provide clinicians with a means of tracing developmental changes in the cerebellum. Herein, we present a new daily practice method for cerebellum imaging that uses a work station and a software program to process reconstructed 3D neuroimages after MRI scanning. In a 3-y period, 3D neuroimages reconstructed from MRI scans of 50 children aged 0.2-12.7 y were taken. The resulting images were then statistically analyzed against a growth curve. We observed a remarkable increase in the size of the cerebellum in the first 2 y of life. Furthermore, the unmyelinated cerebellum grew mainly between birth and 2 y of age in the postnatal stage. In contrast, the postnatal development of the brain mainly depended on the growth of myelinated cerebellum from birth through adolescence. This study presents basic data from a study of ethnic Chinese children's cerebellums using reconstructed 3D brain images. Based on the technique we introduce here, clinicians can evaluate the growth of the brain.

Study of brain growth in children--a new approach to volume measurements using MRI-reconstructed 3D neuroimaging.

OBJECTIVE: The three-dimensional (3D) reconstructed neuroimages are currently available to analyze brain structure. It provides a new tool for clinical evaluation and academic research on brain. However, there are several methods for processing 3D images. In this article, we present a technique that utilizes a work station and a software program to process reconstructed 3D neuroimages after magnetic resonance imaging (MRI) scanning. METHODS: The brain volumes of 50 normal children aged between 3 months and 12 years and 11 months were measured by 3D neuroimages reconstructed from regular MRI scans. These results were then analyzed statistically against the growth curve. RESULTS: The regression curve of cortical growth was y = 39.317Ln(x) + 631.31, R (2) = 0.1318. The regression curve of white matter growth was y = 81.754Ln(x) + 186.07, R(2) = 0.5675. The regression curve of whole brain growth was y = 121.07Ln(x) + 817.738, R (2) = 0.4077. Current studies show that at the postnatal stage, the cortex grows mainly between birth and 4 years of age. At the same time, the postnatal development of the brain depends mainly on the growth of white matter from birth through adolescence. CONCLUSIONS: This study presents the basic data from a study of children's brains using reconstructed 3D brain images. A 3D reconstructed neuroimage provides a new tool for neurological and psychological in vivo research of the brain. Based on the techniques we introduce here, the clinician may evaluate the growth of the brain in a more efficient and precise manner.

Observation of sympathomimetic effect of ear acupuncture stimulation for body weight reduction.

Ear acupuncture stimulation has been used for body weight reduction as early as the 1970s. Several hypotheses have been proposed in literature regarding its mechanism of action, among which are the effects of the stimulation of the hypothalamic satiety center on decreased neuropeptide Y production. Here, we present another possible mechanism to account for the temporary and short-term effects of ear acupuncture stimulation in the treatment of obesity, the sympathetic effects of the autonomic nervous system. 14 female volunteers underwent a randomized clinical trial of the ear acupuncture stimulation. A prospective, sham-point control, crossover study was performed with two sequential four-week stimulation periods separated by a two-week washout interval. The clinical features of and effects on the autonomic nervous system were recorded and analyzed. Decreased body weight was observed in both the experimental and the control groups in the first 4 weeks of stimulation. Sympathomimetic effects were also noted in both groups. Whereas the sympathomimetic effects and body weight reduction were sustained in the experimental group in the second 4 weeks of stimulation, such effects were not observed in the control group. Some sympathomimetic effects were noted in both the experimental and the control groups initially. This effect remained apparent in the experimental group in sequential stimulation but was lost in the control group. Consequently, we believe that sympathomimetic effects may account for the reduction in body weight by temporarily increasing basal metabolic rate and decreasing appetite, but the body may regain weight after the termination of such effects. Accordingly, the combination of an optimal exercise and diet program with repeated acupoint therapy may be necessary to maintain a healthy body weight.

Short-term sulpiride treatment of children and adolescents with Tourette syndrome or chronic tic disorder.

BACKGROUND/PURPOSE: Tourette syndrome (TS) is characterized by motor and vocal tics, and its diagnosis is based on clinical criteria. Dopamine-blocking neuroleptics are regarded as the most effective drugs for the treatment of TS. Sulpiride is a selective dopamine D2 antagonist. However, only one study with a large number of patients has reported the effect of treatment of TS with sulpiride. The purpose of this study was to evaluate prospectively the effect of sulpiride treatment of children and adolescents with TS or chronic tic disorder. METHODS: The inclusion criteria were patients who fulfilled the diagnosis of TS or chronic tic disorder, and who had not received previous treatment. The severity of TS was assessed by the Yale Global Tic Severity Score (YGTSS) every 2 weeks for a total of 6 weeks. The patients started treatment with low-dose sulpiride according to their age on the first visit. The adverse effects of sulpiride were evaluated by subjective complaints from the patients themselves or their parents. The change in scores between each assessment point was analyzed by repeated measures one-way analysis of variance, with SPSS version 12.0 software. RESULTS: One hundred and eighty-nine patients were enrolled. Their average age was 8.0 +/- 2.5 years (range, 3-15 years). Most patients were male (n = 165, 87.3%). Six weeks' treatment significantly improved motor tics (p < 0.05), vocal tics (p < 0.05) and total YGTSS (p < 0.05). The most commonly encountered adverse effect was sedation (n = 31, 16.4%). CONCLUSION: Sulpiride is effective for short-term treatment of children and adolescents with TS or chronic tic disorder, and has few adverse effects.

Steroid use in sepsis-induced conjugated hyperbilirubinemia: report of one case.

We report a girl with acute lymphoblastic leukemia who developed severe conjugated hyperbilirubinemia (total bilirubin 34.32 mg/dl, direct bilirubin 26.94 mg/dl) following gram-negative (Escherichia coli ) sepsis. Despite broad-spectrum antibiotics, her hyperbilirubinemia progressed. Her mental status deteriorated and steroid therapy (hydrocortisone 8 mg/kg/d) was initiated. Her condition then recovered rapidly. Based on our findings, we suggest that steroid may help to treat progressive conjugated hyperbilirubinemia due to gram-negative sepsis.

The efficacy of frequency-specific acupuncture stimulation on extracellular dopamine concentration in striatum--a rat model study.

Acupuncture is a practice that has existed in Chinese society for thousands of years. Today, it is gaining greater acceptance and integration into medical practices of the western world. Its mechanism, however, remains elusive. Our study shows that only specific stimulation frequencies at specific acupoints will induce dopamine release in the corpus striatum, as demonstrated by in vivo microdialysis performed on Sprague-Dawley rats. In the first trial, electroacupuncture (EA) stimulation at 15 Hz and 15 mA was conducted at six different points on the upper limbs of the experimental rats. These points mimic acupoints along six different meridians in the human body. Only Point 2 (corresponding to Pericardium 7) induced a response. In the second trial, EA stimulation at varying frequencies of 3, 6, 9, 12, 15, 18, 21, 24, 27 and 30 Hz, and 15 mA were conducted through Point 2. Stimulation at 6 and 15 Hz induced an immediate response; 21 Hz induced a response only after the ceasing of stimulation. All other frequencies failed to induce a response. The data point to the importance of frequency-specific stimulation at specific acupoints for the release of neurotransmitters in the brain. We speculate that each meridian entails a stimulus of a specific frequency and intensity, which induces the release of its associated neurotransmitters or cytokines. This is a concept with far-reaching clinical implications for acupuncture therapy, including the treatment of dopamine-related disorders.

Antinucleosome antibodies correlate with the disease severity in children with systemic lupus erythematosus.

We compared the serum levels of antinucleosome antibodies (anti-NCS Abs) in thirty pediatric systemic lupus erythematosus (SLE) patients by using enzyme-linked immunosorbent assay (ELISA) to 29 adult SLE patients, 30 healthy controls, 21 juvenile idiopathic arthritis (JIA) and 23 Henoch-Schonlein purpura (HSP) patients as autoimmune disease controls. The mean anti-NCS Ab titer in the pediatric SLE patients was 1552.7+/-1842.2 U/ml, higher than those of adult SLE patients (194.3+/-402.7 U/ml), normal controls (9.5+/-5.7 U/ml) and disease controls (JIA: 7.7+/-4.0 U/ml, HSP: 5.7+/-4.4 U/ml) (p<0.05). The prevalence of both anti-NCS Ab (90%) and anti-ds DNA Ab (76.7%) in pediatric SLE patients were higher (p<0.05) than that of adult SLE patients (58.6% and 48.3%). A positive correlation was demonstrated between anti-NCS Ab and anti-dsDNA Ab as well as the SLEDAI scores in pediatric and adult patients (p<0.05). The inverse correlation of anti-NCS Ab levels with C3 was observed in both pediatric and adult SLE patients (pediatrics, r=-0.61, p=0.0003; adult, r=-0.44, p=0.02). Our data suggested that in pediatric SLE patients, anti-NCS Ab could be as good a marker for SLE diagnosis and disease activity assessment as in adult SLE patients.

Maternal acupuncture effects on surfactant and antioxidant enzymes in preterm rat lungs.

The objectives of this study are to evaluate the effects of maternal acupuncture treatment on lung maturation in preterm rats. Two stainless-steel needles were inserted into the Tsu-San-Li locus in the right hind leg of timed pregnant Sprague-Dawley rats for 30 min. One-day acupuncture-group mothers received electroacupuncture on day 18 of gestation. Two-day acupuncture-group mothers received electroacupuncture on days 17 and 18 of gestation. Control-group mothers received acupuncture at a site not contained in the Atlas of Human Acupuncture Points on day 18 of pregnancy. On day 19 of gestation, pups in all dams were delivered by cesarean section. Maternal 2-day acupuncture treatment significantly increased total phospholipids in fetal lung tissue when compared with control and 1-day acupuncture-treated groups. Two-day acupuncture-treated fetuses had higher saturated phosphatidylcholine level in lung tissue although the difference did not reach statistical significance. Two-day acupuncture-treated fetuses had significantly lower superoxide dismutase, catalase, and glutathione peroxidase activities than did the control and 1-day acupuncture-treated fetuses. We conclude that maternal acupuncture treatment affects surfactant and antioxidant enzyme development in contrasting ways and may have both beneficial and potentially harmful effects on different aspects of lung development.

Serial sonographic findings of lenticulostriate vasculopathy.

The vessels supplying basal ganglia and thalami are not usually detectable on the neurosonogram in the neonates. In recent studies, bright linear echogenesitis in these regions have been well decribed and were defined as lentriculostriate vasculopathy (LSV). These lesions suggested as a marker of a previous insult to the fetal or neonatal brain and the hemodynamics in the immature brain play an important role in its pathogenesis. In a period of 2 year and 5 months, we collected 39 cases of neonates and prematurities with LSV. These include 16 cases of premature babies, 16 cases of normal full-term neonates and 7 cases with perinatal insults. LSV was detected incidentally in most cases, distinctly different from the previous reports that LSV are linked with congenital anomaly, chromosomal anomaly, prematurity, perinatal insult or congenital infection, etc. There are early onset (< or = 7 days) LSV in 23 cases (59%) and late onset (>7 days) in 16 cases (41%). 16 cases (41%) had total remission, 7 cases (18%) had partial remission, and 16 cases (41%) remained persistantly. Rare reports remined of the long term effect of LSV including tics, attention deficit hyperactive disorder and developmental delay. An isolated LSV generally has a good long term prognosis and a grave neurologic deficit may be mainly due to its associated brain damage.

Isolated prolongation of activated partial thromboplastin time following wasp sting.

Reactions after bee or wasp sting are similar to anaphylaxis. Symptoms such as weakness, fatigue, vomiting, diarrhea, urticaria, and hypotension may occur. Serious toxic reactions usually occur after numerous stings. Massive bee envenomations can result in immediate onset of shock, hemolysis, rhabdomyolysis, disseminated intravascular coagulation (DIC), coma, and renal failure. In milder cases, patients may only have isolated prolonged activated partial thromboplastin time (aPTT) and normal prothrombin time (PT), clinically without a tendency to bleed. As a rule, they recover spontaneously without any complication. We report three cases of wasp stings; they all manifested prolongation of aPTT and finally recovered completely. Isolated prolongation of aPTT in cases of wasp stings may be related to an extract from the venom inhibiting the coagulation pathway.

Isolation and characterization of neurogenic mesenchymal stem cells in human scalp tissue.

Recent studies have shown that adult tissues contain stem/ progenitor cells capable of not only generating mature cells of their tissue of origin but also transdifferentiating themselves into other tissue cells. Murine skin-derived precursor cells, for example, have been described as unique, nonmesenchymal-like stem cells capable of mesodermal and ectodermal neurogenic differentiation. Human-derived skin precursors are less well characterized. In this study, the isolation and characterization of adherent, mesenchymal stem cell-like cells from human scalp tissue (hSCPs) are described. hSCPs initially isolated by both medium-selection (ms-hSCPs) and single-cell (c-hSCPs) methods were cultured in medium containing epidermal growth factor and fibroblast growth factor-beta. Cultured ms-hSCPs and c-hSCPs demonstrated a consistent growth rate, continuously replicated in cell culture, and displayed a stable phenotype indistinguishable from each other. Both hSCPs expressed surface antigen profile (CDw90, SH2, SH4, CD105, CD166, CD44, CD49d-e, and HLA class I) similar to that of bone marrow mesenchymal stem cells (BM-MSCs). The growth kinetics, surface epitopes, and differentiation potential of c-hSCP cells were characterized and compared with BM-MSCs. In addition to differentiation along the osteogenic, chondrogenic, and adipogenic lineages, hSCPs can effectively differentiate into neuronal precursors evident by neurogenic gene expression of glial fibrillary acid protein, NCAM, neuron filament-M, and microtubule-associated protein 2 transcripts. Therefore, hSCPs may potentially be a better alternative of BM-MSCs for neural repairing, in addition to their other mesenchymal regenerative capacity. Our study suggests that hSCPs may provide an alternative adult stem cell resource that may be useful for regenerative tissue repair and autotransplantations.

Effect of topiramate on intractable seizures in Taiwanese children.

We performed a prospective study to evaluate the effect of topiramate as an adjunctive therapy in Taiwanese children with intractable partial epilepsy and generalized epilepsy. Thirty children aged from 2 to 16 years (8.5 +/- 3.8 years) were enrolled in this study. Eighteen children (60.0%) had partial epilepsy, and 12 children (40.0%) had generalized epilepsy. These children were experiencing more than one seizure per month even under a stable antiepileptic regimen treatment. Topiramate was begun at 1 mg/kg x day, and the dosage was raised by 1 mg/kg x day each week. Titration continued for 4 weeks or more. The maximal dosage was 10 mg/kg x day. In children with partial epilepsy, six children (33.3%) achieved > or = 50% frequency reduction, while eight children (44.4%) achieved a seizure-free state. In children with generalized epilepsy, including infantile spasms, four children (33.3%) achieved > or = 50% frequency reduction, while five children (41.7%) achieved a seizure-free state. The most common adverse effect was poor appetite (10.0%). No idiosyncratic reactions to topiramate were found. Only one patient discontinued topiramate because of central hyperventilation. Topiramate can be used as an adjunctive antiepileptic drug for intractable epileptic children in Taiwan.