Impact of COVID-19 on pediatric surgical practice in Taiwan: a comprehensive analysis.

Background: The COVID-19 pandemic has profoundly impacted global healthcare systems, causing significant disruptions in various medical practices. This study focuses on the specific effects of the pandemic on pediatric surgical practice in Taiwan, a region known for its effective public health measures and proximity to the initial outbreak. Methods: The study analyzes data from January 2020 to August 2022, comparing it with historical records from January 2017 to August 2019. It examines changes in surgical case volumes, patient demographics, surgical indications, and trends in preoperative evaluations, surgical procedures, and postoperative care. Results: The study reveals a decrease in total surgical cases from 2,255 to 1,931 during the pandemic. Notable findings include a slight increase in the average age of patients (4.81 to 5.10 years, p = 0.064), a significant shift in gender distribution towards male patients (68.9% to 73.5%, p = 0.0009), and changes in the types of surgical procedures performed, with head and neck and gastrointestinal surgeries seeing an increase. The average hospital stay lengthened, and certain specific surgical diseases, like hypospadias and liver tumors, showed an increase. However, the age distribution of pediatric surgical patients remained stable, and emergency surgical care was resiliently maintained. Discussion: The findings demonstrate the adaptability of Taiwan's healthcare system in maintaining pediatric surgical care during the pandemic. The study highlights a significant gender disparity in surgical interventions and a shift towards more urgent and emergent care, reflecting the reorganization of healthcare services during this period. The study's limitations include its retrospective nature and focus on a single institution. Conclusion: This research contributes valuable insights into the impact of the COVID-19 pandemic on pediatric surgical practice in Taiwan. It underscores the importance of adaptable healthcare strategies in ensuring continuity and quality of care during public health emergencies. Future research should focus on multi-institutional data and prospective studies to further understand these dynamics.

Investigating the Association of Polygenic Risk Scores With Thyroid Cancer Susceptibility in a Han Chinese Population.

Background: Thyroid cancer, the leading endocrine tumor with a rising global incidence, especially in women, is influenced by both genetic and environmental factors. This study examines the relationship between polygenic risk scores (PRS) and thyroid cancer susceptibility in the Han Chinese population, as well as the impact of genetic variants on clinical outcomes. Methods: Analyzing data from 57 257 participants in the Taiwan Precision Medicine Initiative, the study employed the Affymetrix Genome-Wide TWB 2.0 SNP Array for genotyping. PRS were calculated using single nucleotide polymorphisms (SNPs) from prior genome-wide association studies, specifically PGS000087 and PGS000797, and correlated with clinical parameters like age, sex, comorbidities, and treatment methods. Results: Among 4063 participants with thyroid tumors (839 malignant, 3224 benign), higher PRS quartiles correlated significantly with increased thyroid cancer incidence. The highest quartile showed a 1.15-fold (PGS000797) and 1.14-fold (PGS000087) greater risk than the lowest quartile. Key findings included an association between higher PRS quartiles and younger onset age, along with a notable link to chronic kidney disease and thyroid hormone levels in specific SNPs. Conclusion: The study demonstrates PRS's utility in predicting thyroid cancer risk in the Han Chinese population, with higher PRS associated with increased risk and distinct clinical features. While this study focuses on the Han Chinese population, we recognize the importance of comparing PRS performance across different ancestries to fully understand ethnic genetic diversity in cancer risk assessment. Future studies should aim to include such comparative analysis.

Congenital bronchogenic cyst: From prenatal diagnosis to postnatal management.

OBJECTIVE: Bronchogenic cysts are rare congenital abnormalities, and usually asymptomatic until adulthood. We present a fetus prenatally diagnosed with a bronchogenic cyst, experiencing compression symptoms immediately after birth and underwent thoracoscopic surgery at 14 days old. CASE REPORT: A 33-year-old primigravida had a suspicion of fetal tracheal cyst. Prenatal ultrasound scan revealed a cyst near the trachea at 23 weeks' gestation. Fetal MRI defined a cystic lesion in the upper mediastinum, displacing surrounding vessels. A 3,940 g girl was delivered vaginally at 38 weeks' gestation. Shortly after birth, she developed respiratory distress, and imaging revealed a mediastinal cyst compressing the trachea and esophagus. The cyst was successfully removed through video-assisted thoracoscopic surgery at 14 days old, and pathology confirmed it as a bronchogenic cyst. Follow-up images demonstrated well-aerated lungs. At present, this 1-year-old girl develops normally without respiratory symptoms. CONCLUSION: Early detection in utero, accurate diagnosis, and timely management are crucial for bronchogenic cysts in neonates.

Effect of prothymosin α on neuroplasticity following cerebral ischemia­reperfusion injury.

Prothymosin α (ProT), a highly acidic nuclear protein with multiple cellular functions, has shown potential neuroprotective properties attributed to its anti­necrotic and anti­apoptotic activities. The present study aimed to investigate the beneficial effect of ProT on neuroplasticity after ischemia­reperfusion injury and elucidate its underlying mechanism of action. Primary cortical neurons were either treated with ProT or overexpressing ProT by gene transfection and exposed to oxygen­glucose deprivation for 2 h in vitro. Immunofluorescence staining for ProT and MAP­2 was performed to quantify ProT protein expression and assess neuronal arborization. Mice treated with vehicle or ProT (100 µg/kg) and ProT overexpression in transgenic mice received middle cerebral artery occlusion for 50 min to evaluate the effect of ProT on neuroplasticity­associated protein following ischemia­reperfusion injury. The results demonstrated that in cultured neurons ProT significantly increased neurite lengths and the number of branches, accompanied by an upregulation mRNA level of brain­derived neurotrophic factor. Furthermore, ProT administration improved the protein expressions of synaptosomal­associated protein, 25 kDa and postsynaptic density protein 95 after ischemic­reperfusion injury in vivo. These findings suggested that ProT can potentially induce neuroplasticity effects following ischemia­reperfusion injury.

Secondary Carnitine Deficiency in Neonates and Infants Requiring Surgery for Intestinal Obstructions-An Underestimated and Undermanaged Problem.

This study aims to elucidate the relationship between intestinal obstruction and carnitine deficiency in neonates and infants. We retrospectively reviewed medical records of 330 neonates and infants, younger than six months, who underwent surgery for intestinal obstruction at our institute from January 2009 to April 2022. The analysis focused on clinical symptoms, related signs, complications, and etiology of the intestinal obstruction. Tandem mass spectrometry (MS/MS) or urine organic acid analysis was conducted for 47 patients, revealing carnitine deficiency in 16 patients. The incidence of carnitine deficiency was 34.0% in the suspicious group and 4.8% overall, significantly higher than in the general population in Taiwan. Notably, patients with carnitine deficiency experienced prolonged ileus, with a mean fasting duration of 41.7 days (range 7.8-65.5 days), compared to 10.8 days (range 8.2-13.4 days) in patients without carnitine deficiency. Carnitine replacement therapy was administered to twelve patients at dosages ranging from 32 to 90 mg/kg/day. One patient exhibited a drug allergy with skin rashes. Our findings suggest that carnitine deficiency should be considered in cases of neonatal and infant intestinal obstruction. Replacement therapy is straightforward and can be prognostically beneficial for some patients. Therefore, we recommend generalizing MS/MS and urine organic acid analysis, particularly for patients with prolonged ileus.

Polygenic Risk Score in Predicting Esophageal, Oropharyngeal, and Hypopharynx Cancer Risk among Taiwanese Population.

Esophageal cancer shares strong associations with oropharyngeal and hypopharyngeal cancers, primarily due to shared risk factors like excessive tobacco and alcohol use. This retrospective study at Taichung Veterans General Hospital involved 54,692 participants, including 385 with squamous cell carcinoma (SCC) of the esophagus, oropharynx, or hypopharynx. Using a polygenic risk score (PRS) derived from 8353 single-nucleotide polymorphisms, researchers aimed to assess its correlation with cancer incidence and prognosis. The study found a 1.83-fold higher risk of esophageal, oropharyngeal, and hypopharyngeal SCCs in participants with a high PRS (Q4) compared to the low-PRS group (Q1). Esophageal cancer risk demonstrated a significant positive association with the PRS, as did hypopharyngeal cancer. Clinical parameters and staging showed limited associations with PRS quartiles, and the PRS did not significantly impact recurrence or mortality rates. The research highlighted that a higher PRS is linked to increased susceptibility to esophageal and hypopharyngeal cancer. Notably, a specific polygenic risk score, PGS001087, exhibited a discernible association with SCC risk, particularly in specific subtypes and advanced disease stages. However, it was not significantly linked to clinical cancer staging, emphasizing the multifactorial nature of cancer development. This hospital study reveals that a higher PRS correlates with increased susceptibility to esophageal and hypopharyngeal cancers. Notably, PGS001087 shows a discernible association with SCC risk in specific subtypes and advanced stages, although not significantly linked to clinical cancer staging. These findings enhance our understanding of genetic factors in upper aerodigestive tract cancers, particularly esophageal SCC, guiding future research and risk assessment strategies.

Back to the basics-risk factor identification of pediatric malignant lymphadenopathy proven by pathological studies.

PURPOSE: Lymphadenopathy (LAP) is a common problem in the pediatric patient. History, physical examinations (PE), ultrasounds, and blood tests were often obtained while studying such lesions. Malignancy should be highly suspected in certain conditions. This study evaluates the relationship between malignant LAP and risk factors for pediatric patients. MATERIALS AND METHODS: Medical records of matched patients are reviewed, and data are retrospectively collected. History, PE findings, laboratory data, ultrasound findings, and pathological findings were recorded and analyzed. The median values (interquartile range, IQR) were expressed for continuous variables, and the number of patients (percentage) for categorical variables. Comparisons between groups were performed using the Mann-Whitney U test and the chi-squared test. The significance was set as p value < 0.05. RESULTS: A total of 142 pediatric patients underwent a biopsy in our department for LAP from July 2004 to August 2021. Among them, 108 (76.1 %) patients had benign lesions, and 34 (23.9 %) had malignancies. Weight loss, fixed LAP, firm consistency, and serum lactate dehydrogenase (LDH) exceeding 240 U/L were more related to malignant LAP than other risk factors. Multiple regression analysis revealed two independent risk factors. The receiver operating characteristic curve regarding LDH level predicting malignancy revealed a sensitivity of 79.31 % and specificity of 36.51 % by applying the criterion as 230 U/L. CONCLUSIONS: For pediatric LAP, history-taking and physical examinations remained the most important approaches. Ultrasounds, serum LDH, and other laboratory studies may only provide clues. The cutoff level of LDH revealed low sensitivity and specificity for malignant LAP. With firm LAP, which is fixed, a biopsy for tissue proof should be performed.

Nicotinamide Deteriorates Post-Stroke Immunodepression Following Cerebral Ischemia-Reperfusion Injury in Mice.

(1) Background: Inducing experimental stroke leads to biphasic immune responses, where the early activation of immune functions is followed by severe immunosuppression accompanied by spleen and thymus atrophy. Nicotinamide, a water-soluble B-group vitamin, is a known neuroprotectant against brain ischemia in animal models. We examined the effect of nicotinamide on the central and peripheral immune response in experimental stroke models. (2) Methods: Nicotinamide (500 mg/kg) or saline was intravenously administered to C57BL/6 mice during reperfusion after transiently occluding the middle cerebral artery or after LPS injection. On day 3, the animals were examined for behavioral performance and were then sacrificed to assess brain infarction, blood-brain barrier (BBB) integrity, and the composition of immune cells in the brain, thymus, spleen, and blood using flow cytometry. (3) Results: Nicotinamide reduced brain infarction and microglia/macrophage activation following MCAo (p < 0.05). Similarly, in LPS-injected mice, microglia/macrophage activation was decreased upon treatment with nicotinamide (p < 0.05), suggesting a direct inhibitory effect of nicotinamide on microglia/macrophage activation. Nicotinamide decreased the infiltration of neutrophils into the brain parenchyma and ameliorated Evans blue leakage (p < 0.05), suggesting that a decreased infiltration of neutrophils could, at least partially, be the result of a more integrated BBB structure following nicotinamide treatment. Our studies also revealed that administering nicotinamide led to retarded B-cell maturation in the spleen and subsequently decreased circulating B cells in the thymus and bloodstream (p < 0.05). (4) Conclusions: Cumulatively, nicotinamide decreased brain inflammation caused by ischemia-reperfusion injury, which was mediated by a direct anti-inflammatory effect of nicotinamide and an indirect protective effect on BBB integrity. Administering nicotinamide following brain ischemia resulted in a decrease in circulating B cells. This warrants attention with respect to future clinical applications.

Successful rescue pneumovesicoscopic surgery for post-Deflux® vesicoureteral junction obstruction.

BACKGROUND: Vesicoureteral junction (VUJ) obstruction after Deflux® subureteral injection for vesicoureteral reflux (VUR) is rare and minimally invasive management has not been reported. This work investigated the patients who underwent Deflux® injection for VUR and identified those with subsequent VUJ obstruction. METHODS: Medical records of matched patients from October 2003 to March 2022 were reviewed, and parameters were retrospectively studied. All patients underwent Deflux® injection. The injection was performed under general anesthesia using the same manner. For patients complicated with VUJ obstruction, the symptoms, signs, management, images, renal ultrasounds, Tc-99m dimercaptosuccinic acid renal scintigraphy, histology of VUJ region, and outcomes were documented and reported. VUJ stenosis was diagnosed by performing renal ultrasound and magnetic resonance imaging. RESULTS: Totally 407 patients (554 ureterorenal units) received Dx/HA injections for VUR. VUJ obstruction was found in three patients (four ureterorenal units). Originally, three were grade V VUR, and one was grade IV. The repeated injection was not a risk factor for VUJ obstruction. The overall incidence of VUJ obstruction post-Dx/HA injection was 0.7% by ureter. The incidences were 0%, 0.75%, and 2.25% for grade I-III, IV, and V VUR, respectively. After the initial conversion case of pneumovesicoscopic ureteral reimplantation, the procedure was performed smoothly and successfully in the two following cases. CONCLUSIONS: Pneumovesicoscopic ureteral reimplantation offers an alternative for VUJ obstruction following Dx/HA injection for VUR. Fibrosis and foreign-body reaction may influence the feasibility. High-grade VUR and young age of injection were related to VUJ obstruction.

Porous silicon decorated with Au/TiO2 nanocomposites for efficient photoinduced enhanced Raman spectroscopy.

In this study, we investigated the potential of porous silicon (PSi) modified with Au/TiO2 nanocomposites (NCPs) as a substrate for photoinduced enhanced Raman spectroscopy (PIERS). One-step pulsed laser-induced photolysis (PLIP) was used to embed Au/TiO2 NCPs in the surface of PSi. Scanning electron microscopy revealed that adding TiO2 nanoparticles (NPs) during PLIP led to the formation of predominantly spherical Au NPs with a diameter of approximately 20 nm. Furthermore, modifying the PSi substrate with Au/TiO2 NCPs considerably enhanced the Raman signal of rhodamine 6G (R6G) after 4 h of ultraviolet (UV) irradiation. Real-time monitoring of the Raman signals of R6G at different concentrations under UV irradiation revealed that the amplitude of the signals increased with the irradiation time for R6G concentrations ranging from 10-3 M to 10-5 M. PSi substrates decorated with Au/TiO2 NCPs may be used to develop materials for PIERS applications.

The Optimal Primary Treatment for Pediatric Perianal Abscess and Anal Fistula: A Systemic Review and Meta-Analysis.

BACKGROUND: Perianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients. METHODS: Using PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis. RESULTS: Thirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615-2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109-0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761-10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information. CONCLUSION: Strong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence. LEVEL OF EVIDENCE: Type of study: Systemic review; Evidence level: Level II.

Video-Assisted Rigid Endoscopic Laser Ablation for Endobronchial Mucoepidermoid Carcinoma in Pediatrics Without Pulmonary Resections.

INTRODUCTION: Mucoepidermoid carcinoma (MEC) is a rare malignancy of primary endobronchial lesions in children. Early diagnosis is crucial for the disease, but it is often misdiagnosed as asthma or lung infection. Chest computed tomography and bronchoscopy are the most important diagnostic tools. Surgical resection is the current treatment of choice for low-grade MEC. In the past, lobectomy, sleeve lobectomy, or segmental resections were the most standard surgeries. Endoscopic treatment was used for lung preservation and effectual removal of the lesions. METHODS: A retrospective study of pediatric patients with primary endobronchial lesions who underwent rigid bronchoscopic laser ablation since 2010 was conducted. Pre-operative images, endoscopic pictures, post-operative images, histological analyses, and patients' clinical conditions were recorded and illustrated. RESULTS: Four patients were enrolled. Three patients presented initially with cough or hemoptysis. The lesion sites were the bronchus of the left upper lobe, left lower lobe, left main bronchus, and trachea. All patients underwent bronchoscopic laser ablation for tumor excision without anatomical resection. No major surgical complications were encountered. All patients survived without recurrence after a mean postoperative follow-up of 4.5 years (3-6 years). CONCLUSION: Video-assisted rigid endoscopic laser ablation for pediatric low-grade endobronchial MEC is a feasible, effective, and safe method. Close follow-up is essential for lung preservation management. EVIDENCE LEVEL: Level IV. TYPE OF STUDY: Case series with no comparison group.

Home Parenteral Nutrition for Children: What Are the Factors Indicating Dependence and Mortality?

Parenteral nutrition (PN) in children with short bowel syndrome is crucial and lifesaving. Taking care of such patients requires interprofessional practice and multiple team resource management. Home PN (HPN) usage allows patients and families to live regular lives outside hospitals. We share our experiences for the last two decades and identify the risk factors for complications and mortality. A retrospective study of HPN patients was conducted between January 2000 and February 2022. Medical records of age, body weight, diagnosis, length of residual intestines, HPN period, central line attempts, complications, weaning, and survival were collected and analyzed. The patients were classified as HPN free, HPN dependent, and mortality groups. A total of 25 patients received HPN at our outpatient clinic, and one was excluded for the adult age of disease onset. There were 13 patients (54.1%) who were successfully weaned from HPN until the record-enroled date. The overall mortality rate was 20.8% (five patients). All mortality cases had prolonged cholestasis, Child Class B or C, and a positive Pediatric End-Stage Liver Disease (PELD) score. For HPN dependence, extended resection and multiple central line placement were two significant independent factors. Cholestasis, Child Class B or C, and positive PELD score were the most important risk factors for mortality. The central line-related complication rate was not different in all patient groups. The overall central line infection rate was 1.58 per 1000 catheter days. Caution should be addressed to prevent cholestasis and intestinal failure-associated liver disease during the HPN period, to prevent mortality. By understanding the risks of HPN dependence and mortality, preventive procedures could be addressed earlier.

The application of artificial intelligence to support biliary atresia screening by ultrasound images: A study based on deep learning models.

PURPOSE: Early confirmation or ruling out biliary atresia (BA) is essential for infants with delayed onset of jaundice. In the current practice, percutaneous liver biopsy and intraoperative cholangiography (IOC) remain the golden standards for diagnosis. In Taiwan, the diagnostic methods are invasive and can only be performed in selective medical centers. However, referrals from primary physicians and local pediatricians are often delayed because of lacking clinical suspicions. Ultrasounds (US) are common screening tools in local hospitals and clinics, but the pediatric hepatobiliary US particularly requires well-trained imaging personnel. The meaningful comprehension of US is highly dependent on individual experience. For screening BA through human observation on US images, the reported sensitivity and specificity were achieved by pediatric radiologists, pediatric hepatobiliary experts, or pediatric surgeons. Therefore, this research developed a tool based on deep learning models for screening BA to assist pediatric US image reading by general physicians and pediatricians. METHODS: De-identified hepatobiliary US images of 180 patients from Taichung Veterans General Hospital were retrospectively collected under the approval of the Institutional Review Board. Herein, the top network models of ImageNet Large Scale Visual Recognition Competition and other network models commonly used for US image recognition were included for further study to classify US images as BA or non-BA. The performance of different network models was expressed by the confusion matrix and receiver operating characteristic curve. There were two methods proposed to solve disagreement by US image classification of a single patient. The first and second methods were the positive-dominance law and threshold law. During the study, the US images of three successive patients suspected to have BA were classified by the trained models. RESULTS: Among all included patients contributing US images, 41 patients were diagnosed with BA by surgical intervention and 139 patients were either healthy controls or had non-BA diagnoses. In this study, a total of 1,976 original US images were enrolled. Among them, 417 and 1,559 raw images were from patients with BA and without BA, respectively. Meanwhile, ShuffleNet achieved the highest accuracy of 90.56% using the same training parameters as compared with other network models. The sensitivity and specificity were 67.83% and 96.76%, respectively. In addition, the undesired false-negative prediction was prevented by applying positive-dominance law to interpret different images of a single patient with an acceptable false-positive rate, which was 13.64%. For the three consecutive patients with delayed obstructive jaundice with IOC confirmed diagnoses, ShuffleNet achieved accurate diagnoses in two patients. CONCLUSION: The current study provides a screening tool for identifying possible BA by hepatobiliary US images. The method was not designed to replace liver biopsy or IOC, but to decrease human error for interpretations of US. By applying the positive-dominance law to ShuffleNet, the false-negative rate and the specificities were 0 and 86.36%, respectively. The trained deep learning models could aid physicians other than pediatric surgeons, pediatric gastroenterologists, or pediatric radiologists, to prevent misreading pediatric hepatobiliary US images. The current artificial intelligence (AI) tool is helpful for screening BA in the real world.