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Background: The global impact of COVID-19 has prompted profound shifts in public health policies. The epidemiology of respiratory infectious disease may change in the post-covid era. This study investigates the repercussions of these policies on respiratory infectious diseases, specifically the resurgence of severe influenza and enterovirus infections in the post-COVID-19 era. Methods: Examining the period from January 2020 to December 2023, our nationwide study analyzes data from the Taiwan Centers for Disease Control and Our World in Data. Two distinct phases, containing (Week 1, 2020, to Week 43, 2022) and coexisting (Week 44, 2022, to Week 50, 2023), are scrutinized, emphasizing policy changes and their potential impact on epidemiology. Results: Epidemiological trends reveal a decline in COVID-19 and all-cause pneumonia during the co-existing period but a notable rise in severe influenza and enterovirus infections. Interrupted time series analysis confirms the surge in severe influenza and enterovirus cases post-restriction ease. Conclusion: The post-COVID-19 era introduces challenges with the resurgence of traditional respiratory diseases, necessitating continuous surveillance, timely non-pharmaceutical interventions, and vaccination as crucial strategies. Vigilance and targeted measures by policymakers and healthcare providers are imperative to navigate the evolving landscape of respiratory infectious diseases in the aftermath of the pandemic.

Background and purpose: Urinary tract infections (UTIs) are the most common bacterial infection in young children. This study aimed to formulate nomogram plots for clinicians to predict UTIs in children aged

Purpose: This study examined the efficacy of prescribing antibiotics, specifically a single dose of vancomycin, in reducing the incidence of culture-positive and culture-negative sepsis prior to the removal of peripherally inserted central catheters (PICCs). Materials and methods: We retrospectively reviewed charts of infants who had PICCs in a tertiary level hospital during the period from 2010 to 2019. The incidence of post-catheter removal clinical sepsis between the groups with or without antibiotics was compared. The antibiotic group was defined by receiving a single dose of vancomycin or any other antibiotic prior to line removal. Results: We enrolled 585 PICC removal episodes in 546 infants for analysis. Antibiotics were given prior to removal in 257 cases (43.9%) and not given prior to removal in 328 cases (56.1%). There were 13 episodes of post-catheter removal clinical sepsis detected within 72 h (2.2%), 2 of which were culture-positive (0.3%). A 9.3-fold decrease in the odds for clinical sepsis was observed in the antibiotic group (p = 0.01). The incidence of post-catheter removal sepsis was decreased by a single prophylactic dose of vancomycin (p = 0.02), whereas the use of other antibiotics showed no effect (p = 0.35). Logistic regression analysis demonstrated that comorbidities with gastrointestinal diseases (p = 0.01), PICC insertion sites in the scalp and neck (p = 0.04), and no vancomycin administration prior to line removal (p = 0.02) were independent risk factors for subsequent clinical sepsis. Conclusion: A single prophylactic dose of vancomycin prior to PICC line removal might reduce clinical sepsis events in infants.

Purpose: This study aimed to describe the etiology, clinical features, hospital course, and outcomes of hospitalized children with skin and soft tissue infections (SSTIs) and to test if clinical and laboratory variables at admission could differentiate between community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and community-acquired methicillin-sensitive S. aureus (CA-MSSA). Methods: We reviewed the clinical, laboratory, treatment, and outcome data for children hospitalized with SSTIs, aged 0–18 years at MacKay Children's Hospital between 2010 and 2019. Multivariable logistic regression was used to identify independent predictors of CA-MRSA and CA-MSSA SSTIs. Results: A total of 1631 patients were enrolled. Erysipelas/cellulitis (73.8%) was the most common pediatric SSTI type, followed by acute lymphadenitis (13.6%) and abscess/furuncle/carbuncle (8.6%). Among the 639 culture-positive isolates (purulent SSTIs), 142 (22.2%) were CA-MSSA and 363 (56.8%) were CA-MRSA. The age group 0–1 month (OR, 6.52; 95% CI 1.09–38.92; P = 0.04) and local lymph node reaction (OR, 2.47; 95% CI 1.004–6.08; P = 0.049) were independent factors for differentiating children with CA-MSSA from those with CA-MRSA SSTIs. MRSA isolates in our cohort were highly susceptible to glycopeptides (100%), linezolid (100%), daptomycin (100%), and sulfamethoxazole/trimethoprim (98.6%) but were significantly less susceptible to clindamycin compared with MSSA (34.2% vs. 78.2%, P

Background: Mycoplasma pneumoniae is a common pathogen of respiratory tract infections in pediatric patients. Serological studies are traditional methods for the diagnosis. However, early diagnosis of M. pneumoniae infections remains problematic. We investigate the value of early serum immunoglobulin A (IgA), in addition to immunoglobulin G (IgG), and immunoglobulin M (IgM) levels, in children infected with M. pneumoniae. Methods: From August 2016 to February 2017, we enrolled pediatric patients based on both clinical symptoms and chest x-ray, and confirmed by positive throat culture for M. pneumoniae. Serum titers of M. pneumoniae IgM, IgG, and IgA during the acute phase were checked. All respiratory samples were further analyzed by polymerase chain reaction (PCR). Diagnostic values of different tests were evaluated. Results: Fifty-six patients fulfilled the diagnostic criteria, with a median age of 4.84 years. Most of them (89.3%) were enrolled within 7 days of disease onset. PCR was positive in 71.4% of the study population. Early IgG samples were of limited value in diagnosing M. pneumoniae infection, of which 89.3% showed a negative result. Positive rates of early serum IgA and IgM were 48.2% and 46.4%, respectively. In combination with IgA and/or IgM, the sensitivity increased to 71.4% during their early clinical course. Conclusions: In the pediatric population, combined serological tests of M. pneumoniae IgA and IgM, offer an accurate method of early diagnosis comparable to that of PCR, and can be an alternative choice for prompt detection of mycoplasma infections when PCR and culture are not available. Keywords: Mycoplasma pneumoniae, Children, Diagnosis, Culture, Serology

Background: Children with tracheostomy are at increased risk for respiratory tract infections, yet the risk involved in tracheostomy related infections is unclear. Methods: We conducted a retrospective review of the medical records of children who underwent tracheostomy between January 2002 and December 2016 at a teaching hospital in Taipei. Demographics, underlying disease, indication for tracheostomy, laboratory data and management, and long-term outcome data were collected. Infection episodes were grouped into definite, possible, non-bacterial pneumonia, and local infection groups. Results: Ninety patients were enrolled. Forty-two (46.7%) patients had infections that required hospitalization. Definite bacterial pneumonia accounted for 12 (8.5%) episodes, 113 episodes (80.1%) were possible bacterial pneumonia, 12 (8.5%) were non-bacterial pneumonia, and 4 (2.8%) were local infections. Patients with definite and possible bacterial pneumonia were found to have a longer hospital duration than patients with non-bacterial pneumonia (p=0.024), with mean hospitalization stays of 8.83±5.59 days and 5.67±2.55 days, respectively. The median duration from tracheostomy to bacterial pneumonia was 1.78 years (range, 0.04- 11.38) whereas for the non-bacterial pneumonia group it was 0.57 years (range, 0.04-6.61). Cerebral palsy (CP) (adjusted odds ratio [AOR] 3.65; 95% confidence interval [CI]: 1.11-11.99; p=0.033) and gastroesophageal reflux disease (GERD) (AOR 2.84; 95% CI: 1.09-7.38; p=0.033) were independently associated with respiratory tract infections in these children. Conclusion: In this study, CP and GERD were associated with infections in children with tracheostomy. Bacterial and non-bacterial pneumonia are difficult to differentiate clinically which may lead to unnecessary antibiotics use. Keywords: Children, Respiratory tract infections, Tracheostomy

Background: Most cases of complicated pneumonia in children are caused by pneumococcal infections. Thomsen-Friedenreich antigen (TA) is present on erythrocytes, platelets and glomeruli, and it can be activated during pneumococcal infection. The aim of this study was to investigate the predictive value of TA activation for pneumococcal infection and association with the severity of complicated pneumonia. Materials and methods: Patients with lobar pneumonia were routinely tested for TA at the Department of Pediatrics, Mackay Memorial Hospital from January 2010 to December 2015. We retrospectively reviewed and analyzed their charts and data including age, sex, etiology of infection, chest tube insertion or video-assisted thoracoscopic surgery, length of hospital stay, TA activation, white blood cell count and level of C reactive protein. Results: A total of 142 children with lobar pneumonia were enrolled, including 35 with empyema, 31 with effusion, 11 with necrotizing pneumonia and four with lung abscess. Streptococcus pneumoniae was the most commonly identified pathogen. Twenty-two patients (15.4%) had activated TA, all of whom were infected with S. pneumoniae. TA activation had 100% specificity and 100% positive predictive value for pneumococcal infection. In the multivariate analysis in lobar pneumonia, TA activation (OR, 15.8; 95% CI, 3.0–83.5; p = 0.001), duration of fever before admission (OR, 1.2; 95% CI, 1.1–1.5; p = 0.013) and initial CRP level (OR, 1.1; 95% CI, 1.0–1.1; p = 0.004) were independent predictors of empyema. Conclusions: TA activation is a specific marker for pneumococcal pneumonia and might indicate higher risk for complicated pneumonia. Keywords: Empyema, Parapneumonic effusion, Pediatric, Streptococcus pneumoniae, Thomsen-Friedenreich antigen

Background: Campylobacter and Non-typhoidal Salmonella (NTS) are the two most common bacterial pathogens associated with acute gastroenteritis in children. This study aims to elucidate the epidemiology of Campylobacter and NTS gastroenteritis and develop a scoring system to differentiate them. Materials and methods: This retrospective study enrolled 886 children ≤18 years of age, hospitalized due to acute gastroenteritis with stool culture-proven Campylobacter or NTS infection from July 2012 to December 2015. Pearson's chi-square test and multivariate logistic regression were used to compare clinical manifestations and laboratory data. Receiver operating characteristic curves were plotted to evaluate the scoring system. Results: Seasonality was found in NTS gastroenteritis from May to September, but no seasonality in Campylobacter gastroenteritis. Campylobacter jejuni and Salmonella serogroup B were the most common pathogens. The median ages were 68.2 and 18.5 months and the incidence rates of bacteremia were 0.6% and 7.1% in the Campylobacter and NTS groups, respectively. Salmonella serogroup C2 infection had the highest risk of bacteremia (OR: 5.9, 95% CI: 2.8–12.7, p

Background: Concerns about non-typeable Haemophilus influenzae (NTHi) in otitis media (OM) have grown after the introduction of pneumococcal conjugate vaccine (PCV). We aim to better understand the clinical role of NTHi in pediatric OM. Methods: Middle ear fluid samples from children

Background/Purpose: The aim of this study is to determine the best dosing strategy for vancomycin by studying the associated factors and examining correlations between the area under the plasma concentration-time curve (AUC) values and trough concentrations in children. Methods: Children aged 3 months to 18 years were included if they received vancomycin for more than three doses between January 1, 2010 and December 31, 2012 and had one or more serum vancomycin trough concentrations. Vancomycin clearance (CL) was calculated using the following model: CL = 0.248*Wt0.75*(0.48/serum creatinine)0.361*[ln (age)/7.8]0.995. The AUC (mg-h/L) was calculated by 24-hour dose (mg/kg/d)/CL(L/h). The value of AUC divided by the minimum inhibitory concentration (MIC) of vancomycin was AUC/MIC. Results: A total of 218 children were included. The mean age was 6.0 ± 5.1 years and the mean body weight was 20 ± 11.7 kg. Vancomycin trough concentrations were moderately correlated with AUC values (r2 = 0.232, p

Background/Purpose: Respiratory infections caused by human adenoviruses (HAdV) are worldwide, and have significantly increased recently in Taiwan. This study aimed to clarify the molecular epidemiology and risk factors of HAdV severe infections and pneumonia among Taiwanese children. Methods: Patients with HAdV infections and hospitalized in a medical center between 2009 and 2013 were divided into severe or nonsevere HAdV infections based on whether or not they received intensive care. HAdV pneumonia was identified for comparison. The HAdV genotype was determined by sequencing the partial hexon and fiber genes. The nucleotide sequences were compared by phylogenetic analysis. Results: The 176 patients (97 boys, 79 girls) had a median age of 3.7 years. The HAdV infections circulated year-round. HAdV B3 (54.5%) was the most common genotype, followed by HAdV C2 (21%), HAdV E4 (8%), and HAdV B7 (6.8%). Thirty-two patients needed intensive care. In multivariate analysis, the risk factors for severe HAdV infections were underlying neurologic diseases [odds ratio (OR): 164.9; p

Background: Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder. Treatments for ADHD include pharmacological and nonpharmacological therapy. However, pharmacological treatments have side effects such as poor appetite, sleep disturbance, and headache. Moreover, nonpharmacological treatments are not effective in ameliorating core symptoms and are time-consuming. Hence, developing an alternative and effective treatment without (or with fewer) side effects is crucial. Music therapy has long been used to treat numerous neurological diseases. Although listening to music is beneficial for mood and cognitive functions in patients with ADHD, research on the effects of music and movement therapy in children with ADHD is lacking. Methods: The present study investigated the effects of an 8-week music and movement intervention in 13 children with ADHD. The Pediatric Quality of Life Inventory (PedsQL) was used to evaluate changes in participants' quality of life. Conners’ Kiddie Continuous Performance Test (K-CPT 2) and the Swanson, Nolan, and Pelham rating scale (SNAP-IV) were used to assess core symptoms. Electroencephalogram (EEG) recordings were analyzed to determine neurophysiological changes. Results: The results revealed that the participants' quality of life increased significantly after the 8-week intervention. Furthermore, the participants' hit reaction times in the block 1 and block 2 tests of K-CPT 2 decreased significantly after the intervention. EEG analysis demonstrated an increase in alpha power and Higuchi's fractal dimension and a decrease in delta power in certain EEG channels. Conclusion: Our music and movement intervention is a potential alternative and effective tool for ADHD treatment and it can significantly improve patients’ quality of life and attention.

Objective: To present the ultrasound imaging and genetic diagnosis of a fetus with prenatal lethal form of Gaucher disease. Case report: A 37-year-old primiparous woman was pregnant at her 23 weeks of gestation and the prenatal fetal ultrasound revealed hydrops fetalis, cerebellum hypoplasia, and fetal immobility. The pregnancy was terminated due to major fetal anomaly, and whole exome sequencing (WES) analysis of fetal tissue and parental blood unveiled a pathogenic variant in exon 10 of the GBA gene (NM_001005741.3: c.1265T > G: p.L422R) originating from the mother. Additionally, a novel CNV (chr1: 155204785–155205635 deletion, 0.85 kb) spanning exon 10–12 in the GBA gene was identified from the father. This compound heterozygosity confirmed the diagnosis of prenatal lethal form of Gaucher disease and was informative for genetic counseling. Conclusion: WES is a powerful tool to detect pathogenic variants among fetuses with nonimmune hydrops fetalis and complex abnormality from prenatal ultrasound. Compound heterozygosity consisted of single nucleotide variants (SNV) and copy number variations (CNVs) may lead rare inherited metabolic disorders including prenatal lethal form of Gaucher disease.

Background: The SARS-CoV-2 virus has been a global public health threat since December 2019. This study aims to investigate the neurological characteristics and risk factors of coronavirus disease 2019 (COVID-19) in Taiwanese children, using data from a collaborative registry. Methods: A retrospective, cross-sectional, multi-center study was done using an online network of pediatric neurological COVID-19 cohort collaborative registry. Results: A total of 11160 COVID-19-associated emergency department (ED) visits and 1079 hospitalizations were analyzed. Seizures were the most common specific neurological symptom, while encephalitis and acute disseminated encephalomyelitis (ADEM) was the most prevalent severe involvement.In ED patients with neurological manifestations, severe neurological diagnosis was associated with visual hallucination, seizure with/without fever, behavior change, decreased GCS, myoclonic jerk, decreased activity/fatigue, and lethargy. In hospitalized patients with neurological manifestations, severe neurological diagnosis was associated with behavior change, visual hallucination, decreased GCS, seizure with/without fever, myoclonic jerk, fatigue, and hypoglycemia at admission. Encephalitis/ADEM was the only risk factor for poor neurological outcomes at discharge in hospitalized patients. Conclusion: Neurological complications are common in pediatric COVID-19. Visual hallucination, seizure, behavior change, myoclonic jerk, decreased GCS, and hypoglycemia at admission are the most important warning signs of severe neurological involvement such as encephalitis/ADEM.

Relatively few studies have addressed the use of vacuum arc evaporation (VAE) in conjunction with high-power impulse magnetron sputtering (HiPIMS), due to differences in the respective pressure requirements. This paper describes the use of HiPIMS-enhanced VAE (HEVAE) technology for the deposition of TiN coatings on tungsten carbide and silicon wafers. We determined that HiPIMS could reduce the formation of macro-particle (MP) defects, while enhancing hardness and adhesion strength. Electron microscopy results revealed that both the quantity and size of MPs decreased inversely with HiPIMS power. Under the highest HiPMS power (4 kW), we observed a notable decrease in the size of columnar crystals and a significant increase in the number of nanocrystalline structures. The formation of nanocrystals enhanced hardness by reducing the probability of dislocations. Overall, HiPIMS power of 4 kW proved optimal in terms of MP formation, hardness (32.1 GPa), and adhesion strength (137 N).

Objective: Simpson–Golabi–Behmel syndrome type 1 (SGBS1) is a rare X-linked recessive disorder characterized by overgrowth and multiple anomalies. Most clinical diagnoses of SGBS1 are made postnatally. We present the case of a pregnant woman in whom the fetus presented with a thick nuchal fold 5.6 mm at 15 weeks of gestation, leading to the prenatal diagnosis of SGBS1 with Xq26.2 (133408101–134221889) deletion. Case report: We report the case of a 34-year-old pregnant woman with the initial presentation of fetal thick nuchal fold 5.6 mm at 15 weeks of gestation. Amniocentesis of the fetal karyotype revealed a normal 46, XY, and single nucleotide polymorphism array showed Xq26.2 (133408101–134221889) deletion. Prenatal ultrasound at 21 weeks of gestation revealed a thick nuchal fold, hepatomegaly, nephromegaly, congenital diaphragmatic hernia, hypospadias, and polyhydramnios. Fetal magnetic resonance imaging revealed hepatomegaly, nephromegaly, congenital diaphragmatic hernia, and right lung hypoplasia. The woman had her pregnancy terminated at 24 weeks of gestation. The proband had a general appearance of low-set ears, hypertelorism, a large tongue, and hypospadias and some unique findings on autopsy, including hepatomegaly, right hiatal hernia, liver extensive extramedullary hematopoiesis, kidney marked congestion, and focal hemorrhage. Discussion: The main prenatal ultrasound findings that alert clinical doctors about the possible diagnosis of SGBS1 included macrosomia, polyhydramnios, organomegaly, renal malformations, congenital diaphragmatic hernia, and cardiac anomalies. Our case underscores the importance of fetal karyotyping combined with single nucleotide polymorphism array when a thick nuchal fold is found. Genetic counseling is essential in SGBS1, and prenatal testing or preimplantation testing for subsequent pregnancies is necessary to identify possible pathogenic variants.

Background: Attention-deficit/hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder in schoolchildren. ADHD diagnoses are generally made based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The diagnosis is made clinically based on observation and information provided by parents and teachers, which is highly subjective and can lead to disparate results. Considering that hyperactivity is one of the main symptoms of ADHD, the inaccuracy of ADHD diagnosis based on subjective criteria necessitates the identification of a method to objectively diagnose ADHD. Methods: In this study, a medical chair containing a piezoelectric material was applied to objectively analyze movements of patients with ADHD, which were compared with those of patients without ADHD. This study enrolled 62 patients—31 patients with ADHD and 31 patients without ADHD. During the clinical evaluation, participants’ movements were recorded by the piezoelectric material for analysis. The variance, zero-crossing rate, and high energy rate of movements were subsequently analyzed. Results: The results revealed that the variance, zero-crossing rate, and high energy rate were significantly higher in patients with ADHD than in those without ADHD. Classification performance was excellent in both groups, with the area under the curve as high as 98.00%. Conclusion: Our findings suggest that the use of a smart chair equipped with piezoelectric material is an objective and potentially useful method for supporting the diagnosis of ADHD.

Objective: One multiparity women had recurrent pregnancies of skeletal dysplasia. The karyotype and array-comparative genomic hybridization were unremarkable. Thus, trio whole exome sequencings were suggested. Case report: The ALPL gene mutations were identified. Maternal heterozygous deletion on Chr1: 21880592 (GRCh37) TA->T, paternal heterozygous insertion on Chr1 21894597, 21894598 (GRCh37) G->GC, T->TAA, and the compound heterozygous mutation were noted on her third pregnancy. The prenatal ultrasound findings and ALPL variants were compatible with the diagnosis of hypophosphatasia. Sanger sequencings were performed and found their normal phenotype daughter carried the same heterozygous mutation with her mother. The mother was then incidentally found her fourth pregnancy; unfortunately, the fetus was prenatally diagnosed of hypophosphatasia with the compound heterozygous mutations. Conclusion: The whole exome sequencing could assist to find the disease-causing variants, which may not be identified through routine prenatal diagnosis. With the precise diagnosis, we could provide the counseling for prenatal or pre-implantation diagnosis.

Background: The decision to continue or discontinue antiepileptic drug (AED) treatment in patients who are seizure free for a prolonged time is critical. Studies have used certain risk factors or electroencephalogram (EEG) findings to predict seizure recurrence after the withdrawal of AEDs. However, applicable biomarkers to guide the withdrawal of AEDs are lacking. Methods: In this study, we used EEG analysis based on multiscale deep neural networks (MSDNN) to establish a method for predicting seizure recurrence after the withdrawal of AEDs. A total of 60 patients with epilepsy were divided into two groups (30 in the recurrence group and 30 in the non-recurrence group). All patients were seizure free for at least 2 years. Before AED withdrawal, an EEG was performed for each patient, which showed no epileptiform discharges. These EEG recordings were classified using MSDNN. Results: We found that the performance indices of classification between recurrence and non-recurrence groups had a mean sensitivity, mean specificity, mean accuracy, and mean area under the receiver operating characteristic curve of 74.23%, 75.83%, 74.66%, and 82.66%, respectively. Conclusion: Our proposed method is a promising tool to help physicians to predict seizure recurrence after AED withdrawal among seizure-free patients.

The Coronavirus Disease-2019 (COVID-19) pandemic has brought catastrophic impact on the world since the beginning of December 2019. Extra precautionary measures against COVID-19 during and after delivery are pivotal to ensure the safety of the baby and health care workers. Based on current literature, it is recommended that delivery decisions be discussed between obstetricians and neonatologists prior to delivery, and designated negative pressure delivery rooms should be arranged for COVID person under investigation (PUI). During delivery, a minimal number of experienced staff attending delivery should don personal protective equipment (PPE) and follow the neonatal resuscitation program (NRP). Positive pressure ventilation is best used in a negative pressure room if available. At-risk babies should be transported in an isolette, and tested for COVID-19 in a negative pressure room soon after bathing. Skin-to-skin contact and breast milk feed should continue under certain circumstances. Although newborns with COVID-19 infections often present with symptoms that mimic sepsis and one third of affected patients may demand some form of respiratory support, short-term prognoses are favorable and most recover within two weeks of symptoms onset. In this article, we will further elaborate on topics covering timing and mode of delivery, antenatal steroid, vertical transmission, delivery room management, airway management, transport, testing and isolation after birth, skin-to-skin contact, breast milk feeding, clinical features, outcomes, and discharge plans. In addition, we also share our experiences of encountering neonates born of suspected COVID-19 positive mothers.

Background: Benzo[a]pyrene (BaP), a toxic carcinogen, is associated with various adverse effects but is rarely discussed in muscle-related disorders. This study investigated in vitro and in vivo effects triggered by BaP exposure in muscles and hypothesized that exposure might induce conditions similar to sarcopenia due to the shared mechanism of oxidative stress. In vitro experiments used C2C12 mouse myoblasts to examine effects induced by BaP exposure in control (untreated) and BaP-treated (10 µM/ml) muscle cells. An established TNF-α-treated sarcopenia model was utilized to verify our results. In vivo experiments compared immunohistochemical staining of sarcopenia-related markers in rats exposed to clean air and polluted air. Results: In C2C12 cells, after 2–72 h of BaP exposure, elevated mRNA and protein expressions were observed in aryl hydrocarbon receptor (AhR) and cytochrome P450 1A1, subsequently in ROS (NOX2 and NOX4) production, inflammatory cytokines (IL-6, TNF-α, and NF-kB), and proteins mediating apoptotic cell death (caspase-3 and PARP). Two myokines also altered mRNA and protein expressions akin to changes in sarcopenia, namely decreased irisin levels and increased myostatin levels. In addition, N-acetylcysteine, a well-known antioxidant, led to decrease in oxidative markers induced by BaP. The validation by TNF-α-treated sarcopenia model revealed comparable biological responses in either TNF-α or BaP treated C2C12 cells. In vivo experiments with rats exposed to air pollution showed increased expression of BaP, AhR, 8-hydroxydeoxyguanosine, and myostatin and decreased irisin expression in immunohistochemical staining. Conclusions: Our results suggest that BaP exerts deleterious effects on the muscle, leading to conditions indicative of sarcopenia. Antioxidant supplementation may be a treatment option for BaP-induced sarcopenia, but further validation studies are needed.

Objective: To evaluate the association between intrauterine growth restriction (IUGR) and the incidence of fetuses with patent ductus arteriosus (PDA) and Hemodynamically significant PDA (Hs-PDA) in dichorionic twins (DC) with selective IUGR. Materials and methods: This is an observational cohort study and retrospective case assessment, involved twins born at Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan between 2013 and 2018. DC twins with selective IUGR (sIUGR) were defined as the presence of a birth weight discordance of >25% and a smaller twin with a birth weight below the tenth percentile. PDA was diagnosed using echocardiography between postnatal day 3 and 7. Hs-PDA was defined as PDA plus increased pulmonary circulation, poor systemic perfusion, cardiomegaly, pulmonary edema, or hypotension requiring pharmacotherapeutic intervention. Result: A total of 1187 twins were delivered during the study period, and 53 DC twins with selective IUGR were included in this study. DC twins with PDA have higher rate of preterm birth, lower gestational age of delivery, and lower mean birth weight of both twins compared with DC twins without PDA. In a comparison of the sIUGR twin with the appropriate for gestational age co-twin, both the incidences of PDA (28.30% vs. 7.55%, respectively; P = 0.003) and Hs-PDA (24.53% vs. 5.66%, respectively; P = 0.002) were higher in sIUGR fetuses than in the appropriate for gestational age co-twins. Small gestational age of delivery was the only variable to predict PDA and Hs-PDA [p = 0.002, Odds ratio = 0.57 (0.39–0.82), p = 0.009, Odds ratio = 0.71 (0.55–0.92), respectively]. Conclusion: An analysis of dichorionic twins with sIUGR indicated that IUGR increased the risk of PDA and hemodynamically significant PDA.

Objective: A monochorionic dizygotic (MCDZ) twin is rare, especially when complicated with twin–twin transfusion syndrome (TTTS) and treated by laser therapy. Case report: A pregnancy achieved from oocyte donation and intracytoplasmic sperm injection resulted in two embryos transferred. A monochorionic diamniotic twin pregnancy was diagnosed by an early ultrasound; however, at 16 weeks of gestation, instead of the same sex, the ultrasound suspected there was sex discrepancy between the twins. TTTS with severe polyhydramnios occurred at 22 weeks, leading to a laser therapy, which was followed with a smooth post-operation course. Then the Cesarean section was performed at the gestational age of 29 weeks due to severe preeclampsia, giving birth to two live newborns: one female and one male baby both without neurological sequelae at the time of discharge. Blood chromosomes obtained at delivery and 65 days after delivery all revealed an XX and XY chimera from both babies. Conclusion: Laser therapy is also effective in MCDZ twin complicated with TTTS. Determination of chorionicity in early pregnancy could timely prompt us to watch out for complications unique to monochorionic twin pregnancy.

Objective: To examine the factors affecting pregnant women's decisions to accept or decline the prenatal pertussis (Tdap) vaccination in Taiwan. Materials and methods: We conducted a cross-sectional survey, recruiting pregnant women who had received prenatal care from eight maternity hospitals between January and December 2018. We examined the participants’ demographic characteristics, perceptions of pertussis disease risk and vaccination effectiveness, beliefs regarding vaccine information, physician recommendation, and other potential factors affecting decision-making regarding prenatal vaccination. Results: The complete survey response rate among eligible women was 78%. Among the participants, 74% accepted and 26% declined prenatal Tdap vaccination. Most women accepted Tdap during pregnancy because of perceived severity of pertussis in their infants, perceived effectiveness of the prenatal Tdap in preventing neonatal pertussis, and perceived safety of the prenatal Tdap vaccine for the fetus, as well as a provider's recommendation, which was the factor strongly associated with actual Tdap reception. Most of the participants who accepted Tdap vaccination during pregnancy and who believed that the Tdap vaccine could protect their infants from pertussis reported the receiving sufficient information to make an informed decision and trust in the information. By contrast, a large proportion of the participants who declined Tdap and who did not want to experience possible fetal side effects of Tdap reported not getting sufficient information to make an informed decision and a lack of trust in the information. Conclusion: Developing a comprehensive strategy involving government policy, the health care system, public media, health professionals, and pregnant women to launch a successful campaign may improve the nationwide acceptance of the prenatal pertussis vaccination. Keywords: Pertussis, Vaccine, Prenatal

Background: A proportion of twin-twin transfusion syndrome (TTTS) patients may have elevated liver enzymes (ELEzs) before fetoscopic laser therapy, but the incidence of ELEzs before laser therapy and the association with the perinatal outcomes after laser therapy remain unclear. Methods: From October 2008 to April 2015, 93 patients with TTTS who received fetoscopic laser therapy at our hospital were included in this study, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were measured within 24 h before therapy. If ELEzs (AST > 34 U/L or ALT > 36 U/L) were observed before therapy, the AST and ALT levels were evaluated within 24 h after therapy. The pre-operative characteristics and post-therapy outcomes were compared between patients with and without ELEzs. Results: Among 93 TTTS patients before laser operation, 18 patients (were found with ELEzs (19.4%) before laser therapy. In 17 (94.4%) of the 18 cases, their liver enzymes values dropped after laser surgery. Maternal body mass index, age, gestational age of laser therapy, hemoglobin level before laser therapy and survival rates after laser therapy were not significantly different between TTTS with and without ELEzs. The maternal hemoglobin dropped significantly from 10.8 [1.6] g/dL before surgery to 9.6 [1.5] g/dL after laser therapy in TTTS with ELEzs (p

Objective: The study was to investigate the prevalence and risk factors of stress urinary incontinence (SUI) and its impact on the quality of life during pregnancy and 12 months after delivery. Materials and methods: 866 women delivering their newborns at a tertiary hospital were recruited. All women were asked to complete several questionnaires including demographic and obstetric data, Short Form 12 health survey (SF-12), Urogenital Distress Inventory Short Form (UDI-6), and Incontinence Impact Questionnaire Short Form (IIQ-7). All women were interviewed via telephone to answer the same questionnaires at 12 months postpartum. Results: There were 446 (51.5%) self-reported SUI women during pregnancy. Out of 560 women delivered vaginally, 70 (12.5%) had SUI at 12 months postpartum; in 306 women undergoing Cesarean delivery, 22 (7.2%) experienced SUI 12 months after delivery. Risk factors of SUI during pregnancy included body weight and body mass index at first visit. At 12 months postpartum, parity stood out as the risk factor of persistent SUI in vaginal delivery group, but no significant risk factor was found in Cesarean group. Women with SUI during pregnancy featured worse mental component summary (MCS) score of SF-12, compared to women without SUI. At 12 months postpartum, women with persistent SUI in vaginal delivery group had higher mean UDI-6 and IIQ-7 scores than those without SUI. Conclusion: Persistent SUI is more prevalent in the vaginal delivery group than Cesarean group. Both SUI during pregnancy and after childbirth have negative impact on the quality of life in women undergoing vaginal delivery.

Objective: To study the maternal and fetal outcomes and assess the risk factors in patients with rupture at the lower-segment or non-lower-segment scarred, or unscarred gravid uterus. Materials and Methods: Gravid patients with uterine rupture were retrospectively collected in Chang-Gung Memorial Hospital from November 2004 to July 2017. The rupture timing and location in association with maternal and fetal outcomes were collected as well as the possible risk factors including surgical history and interval prior to conception were analyzed. Results: Thirty patients were included [mean age (±SEM), 34.4 ± 0.7 years; mean body mass index, 25.0 ± 0.6 kg/m2] with mean onset of rupture at 34.2 ± 0.9 weeks, in which, 12 occurred at term and 18 at preterm (range 20–34 weeks). Four fetal demises, 22 transferals to neonatal intensive care unit, and 17 maternal blood transfusions without maternal mortality were noted. Twenty-two patients presented with acute abdominal pain and/or abnormal fetal heart rate tracing were managed with emergent cesarean delivery. Four ruptures were found in postpartum of vaginal delivery, in which 3 were after trials of labor after cesarean delivery and 1 was unscarred uterus, and two of the four eventually underwent hysterectomy. Unscarred uterus (n = 6) without identifiable risk factor ruptured in significantly later gestation associated with higher fetal birthweights than those of the scarred uterus (n = 24) (both p

Objective: To study the difference of amniotic fluid stem cell potential at different gestational age. Materials and methods: Second trimester amniocentesis was performed during 15 to 22nd week of gestational age in a single medical center from 2015 to 2016. Early second trimester amniotic fluid stem cells (E-AFS) and later one (L-AFS) were defined 15–18th week, and 19–22nd week, respectively. Cell characteristics, surface markers and ability to form induced pluripotent stem cells (iPS) were studied. Results: All the amniotic fluid stem cells samples could be isolated and cultured from second trimester amniocentesis. E-AFS showed more Ckit + cell, shorted doubling time, smaller cell size and higher cell density compared to L-AFS. Both groups had the same stem cell surface markers with highly expression of CD44, CD73, CD90, and CD105, negative for CD45. They can easily be reprogramed into amniotic fluid stem cell derived iPS via standard induction. Conclusion: Human amniotic fluid stem cells could be isolated from early or late second trimester amniocentesis with the similar stem cell surface markers presentation, especially in mesenchymal stem cells markers. However, the cells from early second trimester amniocentesis have more Ckit + number and more potential characteristics compared to late second trimester amniocentesis. Both E-AFS and L-AFS could form the iPS easily which lead to the future disease modeling study.

Objective: Single-nucleotide polymorphism (SNP) microarrays and whole-exome sequencing (WES) are tools to precisely diagnose rare autosomal recessive (AR) diseases. In this study, SNP chip and WES were used to identify a mutated location in WDR34 in a baby born to consanguineous parents. Case report: The baby, born at 36 gestational weeks had a small thoracic cage, symmetric short proximal bones, and polydactyly. Radiography showed short ribs with reduced lung volume and pulmonary opacities, compatible with asphyxiating thoracic dystrophy or short rib-polydactyly syndrome (SRPS). At 4 months of age, she died of pulmonary hypoplasia and sepsis. SNP microarray and evaluation tool confirmed WDR34 as the candidate gene. WES detected an AR mutation at c.554C > T [p.Arg182Trp] in WDR34. Conclusion: This study was the first to identify c.544C > T [p.Arg182Trp] mutation in WDR34 in a patient with SRPS. According to the database, the homozygous mutation of c.544C > T in WDR34 was deleterious and the prevalence of heterozygous mutation was relatively higher in Asian population. More studies of this mutation in patients with SRPS are required.

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. Key Words: children, refractory epilepsy, parenting stress, vagus nerve stimulation

Objectives: Pregnancy associated with aplastic anemia (AA) is a rare and heterogeneous disorder. We aimed to identify and evaluate the maternal and pregnant outcomes of pregnancy-associated severe AA treated with supportive care. Materials and methods: A 25-year retrospective study was conducted at in a single center between 1990 and 2014 with pregnancy associated severe AA. In addition, relevant published cases of antenatally diagnosed pregnancy-associated severe AA after 1990 were identified by PubMed. The main goal was to determine the impact of various risk factors on maternal and fetal outcomes. Results: 15 women with 18 pregnancies were enrolled. With addition of the published reports in literature, a total of 36 cases were included for reference review. Univariate analysis showed that low platelet counts (

Objective: To elucidate the etiologies of discordant trisomy 21 in monozygotic twin pregnancy. Case report: A monochorionic diamniotic twin pregnancy with hydrops and cleft lip (twin 1) found in one fetus presented at gestational age of 17 weeks. Amniotic fluid karyotyping showed nonmosaic trisomy 21 in twin 1 (47, XY, +21 [20]) and a normal karyotype in twin 2 (46, XY [20]). Short tandem repeat (STR) polymorphism markers revealed that the two fetuses were monozygotic, and the two chromosomes 21 were maternal isodisomy in the trisomy fetus. The chromosomal constitution of placentas in the territory of trisomy 21 cotwin was 47, XY, +21 [20] and was a mosaic 47, XY+21 [12]/46, XY [8] in the normal karyotyped twin. Conclusion: Our case of monozygotic twin with discordant trisomy 21 might start with a prezygotic maternal meiosis II non-disjunction error-caused trisomy 21 zygote, and after twinning, one remained trisomy 21, and the other twin underwent trisomy rescue and became a mosaic trisomy 21 in morula or early blastocyst stage before the formation of pre-embryo, which subsequently resulted in mosaic trisomy 21 of the placental tissue and normal chromosomal constitution of the fetus.

Objective: Urinary tract infection (UTI) is the main reason of community-acquired infection which causes large losses in social economy. The individual as well as climate factors make changes on the incidence. Acute pyelonephritis (APN) is one of the most serious UTI in female. The object of our study is to analyze whether climate factors will have effect on the incidence of female APN in Taiwan. Materials and methods: This study consisted of 14,568 female patients with APN from 2001 to 2013 in Taiwan and patients with repeated APN were excluded. The monthly climate data was collected from the Central Weather Bureau. The available monthly climate data included highest, lowest, and average level of temperatures, humidity, rainfall, total rain days, and sunshine hours. Results: The total incidence of female APN was 23.44 each 10,000 populations. The incidence of APN was positively correlated with temperature (r = 0.66), sunshine hours (r = 0.45), rainfall (r = 0.42), rain days (r = 0.29), and humidity (r = 0.23) per month. There is the strongest correlation between the average monthly temperature and the incidence of APN (β = 0.54). The correlation with the incidence of APN was also followed by rain days (β = 0.28) and humidity (β = 0.27). Conclusion: There is a significant expression on the incidence of female APN affected by seasonality and climate parameters. The monthly average temperature has the strongest correlation with female APN. The results of this research may facilitate the potential preventive strategies on female APN.

Objective: To assess H1N1 antibody titers between vaccinated and nonvaccinated maternal and cord blood sera after the 2009 pandemic. Materials and Methods: Antibody titers were measured in maternal blood and cord sera from three groups of pregnant women in this prospective study. Group 1 comprised women who received a trivalent seasonal influenza vaccine before conception, Group 2 comprised women who received a single injection of monovalent H1N1 vaccine during pregnancy, and Group 3 comprised women who were nonvaccinated. A seropositive or seroprotective hemagglutination inhibition (HAI) assay was defined as titer ≥ 1:40. Results: In this study, 500 healthy women were enrolled, of which 44 women were in the trivalent seasonal influenza vaccine group, 41 women were in the monovalent vaccine group, and 415 women were in the nonvaccinated group. The seropositive HAI titers in the three groups of mothers were 48%, 78%, and 12%, respectively. The HAI titers in the vaccinated groups were significantly higher than those in the nonvaccinated group. The HAI titers of the cord blood samples of the three groups were comparable to their respective maternal samples. Conclusion: Seroprotection after the 2009 HIN1 pandemic was generally low in pregnant women. Vaccination during pregnancy yielded best seropositivity, whereas receiving a trivalent seasonal influenza vaccine before conception can offer better seroprotection to mothers and newborns than no vaccination.

Objective: Fetuses with intrauterine growth restriction (IUGR) have adaptive hormonal changes including changes in insulin, which may increase their future risks for developing diabetes mellitus. This study compared cord blood insulin concentrations in IUGR and appropriate for gestational age (AGA) fetuses in a monochorionic (MC) twin model. Materials and methods: Ten pairs were classified as selective IUGR (sIUGR) based on having one twin weight below the 10th percentile and with an intertwin birth weight discordance>20%. Fourteen pairs without IUGR were included as a comparison group. Pregnancies with twin–twin transfusion syndrome, congenital structural malformations, and genetic abnormalities were excluded. Insulin and glucose concentrations were measured in cord venous blood at the time of delivery. Results: Cord blood insulin concentrations of sIUGR fetuses were significantly lower than those of AGA counterpart fetuses in MC twins affected by sIUGR (5.1±4.1 mU/L, range: 0.7–9.9 mU/L for sIUGR fetuses and 12.2±7.6 mU/L, range: 3.5–23.7 mU/L for AGA fetuses, p=0.019). No significant difference in insulin concentrations between larger and smaller fetuses in MC twins without IUGR was observed. Insulin concentration was inversely correlated with gestational age of delivery in all fetuses except in those with sIUGR. We did not find any difference in cord blood glucose concentrations between the two fetuses in both groups. Conclusion: Our data show reduced insulin secretion and loss of the physiological decline in concentration over time as gestational age increases in fetuses with sIUGR compared to AGA counterparts.

Objective: To characterize a prenatally detected chromosomal aberration with molecular cytogenetic approaches and explore its relationship with Beckwith–Wiedemann syndrome (BWS). Case report: A 33-year-old woman, gravida 2, para 0, was referred to our prenatal clinic at 20+ weeks due to an abnormal amniocentesis karyotyping finding, which showed 46,XY,add(11)(q24.2)dn. The mother conceived through in vitro fertilization–intracytoplasmic sperm injection (IVF-ICSI), then embryo transfer. Fetal ultrasound revealed a left-sided congenital diaphragmatic hernia, overgrowth of the fetus, and an enlarged placenta. After genetic counseling and careful deliberation by the family, the pregnancy was subsequently terminated at 22+ weeks of gestation, delivering a fetus weighing 810 g (85th to 90th centile) and a placenta of 325 g (85th to 90th centile). To further delineate the nature of the rearrangement involved in the defective chromosome 11, repeat chromosomal analyses, including array comparative genomic hybridization (aCGH) test and quantitative fluorescence–polymerase chain reaction (QF-PCR) using short tandem repeat (STR) markers, were performed by sampling fetal tissue. The final result confirmed a diagnosis of 46,XY,del(11)(q24.3q25),dup(11)(p14.3p15.5). The abnormal chromosome 11 was inherited from the father and the duplicated segment involved 11p15.5, a critical imprinting region for BWS. Conclusion: We presented a prenatally detected chromosomal aberration characterized by paternal duplication of chromosome 11p15.5, which strongly related to the phenotypic manifestation of BWS.

Neonatal seizures caused by hypocalcemia may be associated with cardiopulmonary dysfunction and may require specific management other than calcium supplementation. Severe dilated cardiomyopathy is an extremely rare complication in neonatal hypocalcemia and often results in high morbidity and mortality. We report here a 14-day-old neonate presenting with a gradually increasing frequency of tonic seizures. After admission, arterial desaturation was found despite supplying oxygen (4 L/min) through nasal prongs and the patient developed life-threatening respiratory distress and heart failure secondary to dilated cardiomyopathy. His critical cardiopulmonary derangements rapidly improved after respiratory support, the administration of diuretic and inotropic drugs, and the correction of his hypocalcemia and hypomagnesemia. The patient responded to treatment and was well during the 1-year follow-up period. We present this unique case history of seizure, respiratory distress, and heart failure induced by transient hypocalcemia to remind clinicians about the importance of this rare, life-threatening, but reversible, disorder.

Summary: Background: Two international Conventions from the International Labor Organization (ILO; C162 Asbestos Convention) and the UN (Basel Convention) offer governments guidelines for achieving a total asbestos ban policy, but the long-term effect of these Conventions on policy implementation, and the role of government effectiveness, remains unknown. We aimed to investigate associations between government ratification of the ILO and UN international Conventions, government effectiveness, and implementation of a national total asbestos ban. Methods: We obtained data for year of a national asbestos ban, year of ratification of one or both international Conventions, and World Bank government effectiveness scores for 108 countries that ever used asbestos. We did a survival analysis for countries with data in the follow-up period (March 22, 1989, to Feb 2, 2018) to assess whether ratification of the international Conventions and greater government effectiveness were associated with time of implementation of a national total asbestos ban. Findings: Of 108 countries with data for asbestos consumption, nine were excluded because they implemented an asbestos ban before 1989. Therefore, 99 countries were included in the survival analysis. 26 countries ratified both international Conventions and 73 ratified either one or no Convention. Countries that ratified both Conventions had a shorter time to adoption of a total asbestos ban (mean 8·9 [SD 6·4] years) than did countries that ratified one or no Conventions (16·9 [6·1] years). After controlling for government effectiveness, countries that ratified both Conventions had a significantly higher conditional probability of banning asbestos than did those ratifying one or no Convention (hazard ratio [HR] 41·8, 95% CI 4·5–383·3; p=0·0010). For every 1 point increment in government effectiveness, the percentage change in HR for persistent asbestos consumption significantly increased by 127% (95% CI 13–354; p=0·021). Interpretation: This study confirms that adoption of both the C162 Asbestos Convention and the Basel Convention facilitates countries in moving towards a total asbestos ban. The effect was reinforced by government effectiveness. Both international programmes and new agreements towards total asbestos bans and government commitments are needed. Funding: China Medical University, and the Ministry of Science and Technology (Taiwan).

Objective: To evaluate the outcome of twin–twin transfusion syndrome (TTTS) treated by fetoscopic laser therapy (FLT) stratified by Quintero staging. Materials and Methods: A total of 100 TTTS cases treated by FLT, from October 2005 to August 2014, were included in this study. Cases were divided into first and second half periods to evaluate the learning effect-related outcomes, and logistic regression was applied to determine the independent factors in predicting the perinatal outcomes. Results: The total fetal survival rate was 68.5%, two fetal survival rate was 55%, and at least one fetal survival rate was 82%. High Quintero stage (Stages III and IV) and small gestational age at delivery were two independent factors predicting lower two fetal survivals. Gestational age at delivery was the only independent factor predicting at least one survival. The odds ratios of high Quintero stage predicting lower two fetal survivals were 11.3 (p

Objective: To investigate the predictors of persistence or resolution of preoperative urgency urinary incontinence (UUI) in women following transvaginal mesh (TVM) repair for advanced pelvic organ prolapse (POP). Material and methods: Patients with advanced POP undergoing TVM repair between 2008 and 2013 in a tertiary hospital were recruited. All patients underwent evaluation including a structured urogynecological questionnaire, voiding diary, pelvic examination using the POP-quantitation system, and urodynamic testing before and after surgery, and intraoperative cystoscopy. Patient demographics, lower urinary tract symptoms, urodynamic findings, and severity of prolapse were analyzed between women with and without preoperative UUI. Results: Of 174 patients who underwent TVM repair, 49 (28.2%) had preoperative UUI; after operation, 23 (13.2%) were found to have postoperative UUI and 13 (7.5%) developed de novo UUI. For those 49 patients with preoperative UUI, 10 (20.4%) had persistent UUI and 19 (38.8%) developed de novo stress urinary incontinence postoperatively. The prevalence of preoperative bladder outlet obstruction, preoperative maximal cystometric capacity (MCC) 60 months were significantly higher in patients with persistent UUI than without it. Logistic regression demonstrated that preoperative MCC 60 months were associated with persistent UUI after prolapse repair. Conclusion: For women with identified preoperative risk factors, including MCC 60 months, preoperative counseling should consist of a discussion about persistent UUI symptoms following TVM repair and the development of de novo stress urinary incontinence.