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Kawasaki Disease (KD) is the most common acquired pediatric heart disease in the developed world. Rapid infusion of high-dose intravenous immunoglobulin is the standard therapy. Different manufacturing processes of IVIG may influence their efficacy. This study aims to conduct a head to head comparison of two IVIGs, TBSF and Privigen, from a nationwide perspective. The main data source was the National Health Insurance Research Database (NHIRD) of Taiwan. A total of 3368 KD cases involving children under 2 years of age were enrolled from January 2015 to November 2020. The primary endpoint was IVIG resistance, which we defined as the total amount exceeding 26 g in one admission. The secondary endpoints encompassed two distinct criteria: coronary involvement, which was defined as the prolonged use of aspirin or anti-coagulation agents between 180 and 360 days after the index date, and recurrence, which was defined as readmission for IVIG therapy occurring more than 30 days after previous KD index day and continuing until the end of the follow-up period. Privigen demonstrated a lower IVIG resistance rate at 9.4% in comparison to TBSF, which exhibited a rate of 9.7% (odds ratio 0.72, 95% CI 0.52-0.99). Privigen had a lower odds of coronary involvement (odds ratio 0.38, 95% CI 0.18-0.82). There is no difference in recurrence rate (odds ratio 0.60, 95% CI 0.22-1.68). Privigen might have a lower rate of IVIG resistance and reduced coronary artery involvement. The discrepancy may be due to the concentration, the stabilizers, or the source of plasma. Further investigation is needed to compare the effectiveness of different IVIGs in the large randomized controlled clinical trial., (© 2023. The Author(s).)

The healthcare industry has made significant progress in the diagnosis of heart conditions due to the use of intelligent detection systems such as electrocardiograms, cardiac ultrasounds, and abnormal sound diagnostics that use artificial intelligence (AI) technology, such as convolutional neural networks (CNNs). Over the past few decades, methods for automated segmentation and classification of heart sounds have been widely studied. In many cases, both experimental and clinical data require electrocardiography (ECG)-labeled phonocardiograms (PCGs) or several feature extraction techniques from the mel-scale frequency cepstral coefficient (MFCC) spectrum of heart sounds to achieve better identification results with AI methods. Without good feature extraction techniques, the CNN may face challenges in classifying the MFCC spectrum of heart sounds. To overcome these limitations, we propose a capsule neural network (CapsNet), which can utilize iterative dynamic routing methods to obtain good combinations for layers in the translational equivariance of MFCC spectrum features, thereby improving the prediction accuracy of heart murmur classification. The 2016 PhysioNet heart sound database was used for training and validating the prediction performance of CapsNet and other CNNs. Then, we collected our own dataset of clinical auscultation scenarios for fine-tuning hyperparameters and testing results. CapsNet demonstrated its feasibility by achieving validation accuracies of 90.29% and 91.67% on the test dataset.

(1) Background: Attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are common cognitive and behavioral disorders. Antibiotics are widely used in pregnant women and their newborns. The objective of this study was to examine the potential association between prenatal exposure to antibiotics and the risk of ADHD and ASD in childhood from a nationwide perspective. (2) Methods: The Taiwan National Health Insurance Research Database (NHIRD) was used as the primary data source. This nationwide cohort study included only first-time pregnancies. A total of 906,942 infants were enrolled. All infants were followed up for at least 6 years. The Cox regression model was applied for covariate control. (3) Results: Prenatal exposure to antibiotics was found to significantly increase the cumulative incidence of ADHD while having only a borderline effect on the cumulative incidence of ASD. Exposure to antibiotics during any of the three different gestational age ranges significantly increased the cumulative risk. However, only exposure after 34 weeks of gestation had a significant impact on the occurrence of ASD. The study also revealed a dose-dependent effect on the occurrence of ADHD but no effect on the occurrence of ASD. (4) Conclusions: This study suggests that prenatal exposure to antibiotics may increase the risk of developing ADHD and ASD later in life.

Objective: Transcatheter closure of atrial septal defect (ASD) has become an alternative treatment to surgical repair. One of the challenges is the prolapse of the left atrial disc during the procedure. Many techniques have been developed to prevent the prolapse but not reduce it. In this study, we present a novel technique, termed push back technique, that help reduce the prolapsed device., Methods: We enrolled 24 patients (8 males, 16 females) between May 2008 and January 2023 who underwent the push back technique during transcatheter closure of ASD in Taichung Veterans General Hospital. We recorded the hemodynamic data, success rate and complications including device embolization/migration, valvular regurgitation, pericardial effusion, and residual shunt., Results: The median age was 6.3 years (1.2-70.5 years) and the median weight was 19.1 kg (7.8-90 kg). Fifteen (62.5%) patients had mild pulmonary hypertension. The median Qp/Qs was 2.54 (1.5-8.8). The median ASD stretched size was 21.2 mm (7.7-35.3 mm). The median device size was 22 mm (8-40 mm). The median fluoroscopy time was 14 min (5-23 min) and median procedure time was 47 min (25-78 min). The push back technique successfully reduced the prolapsed device in 21 (87.5%) patients. There was no complication in all patients., Conclusion: We present a novel push back technique that can successfully reduce the prolapsed device in 87.5% (21/24) patients without complications. It is feasible, safe and effective., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Liao, Jan, Lin, Lee and Fu.)

Introduction: Inguinal hernia repair is one of the most common surgeries worldwide. However, there is limited information on its underlying genetic mechanism. Studies on the genetic factors related to inguinal hernia in Han Chinese are lacking. Therefore, we aimed to conduct a hospital-based study to assess the genetic factors and comorbidities underlying inguinal hernia in Taiwan. Materials and Methods: This was a retrospective case-control study. Utilizing data from the Taiwan Precision Medicine Initiative, we identified 1000 patients with inguinal hernia and 10,021 matched controls without inguinal hernia between June 2019 and June 2020. Four susceptibility loci (rs2009262, rs13091322, rs6991952, and rs3809060) associated with inguinal hernia were genotyped by the Taiwan Biobank version 2 (TWBv2) array. Inguinal hernia, surgery types, and comorbidities were obtained from the electronic health records of Taichung Veterans General Hospital. Results: Adult-onset inguinal hernia was associated with WT1 rs3809060 GT/TT genotype in males and EFEMP1 rs2009262 TC/CC genotype in females. In addition, we identified sex-specific risk factors associated with inguinal hernia; benign prostatic hyperplasia in males (OR: 3.19, 95% CI: 2.73 - 3.73, p < 0.001), chronic obstructive pulmonary disease in females (OR: 2.34, 95% CI: 1.33 - 4.11, p = 0.003) and overweight, defined by body mass index ≧24 kg/m 2 (OR: 0.75, 95% CI: 0.65 - 0.86, p <0.001 in males, and OR: 0.60, 95% CI:0.37 - 0.98, p = 0.042 in females), were inversely associated with inguinal hernia. After stratifying BMI, overweight males with EFEMP1 rs2009262 TC/CC genotype exhibited a higher risk of inguinal hernia (OR: 1.31, 95% CI: 1.07 - 1.61, p = 0.01). Additionally, rs3809060 was specifically associated with male patients with direct-type inguinal hernia (OR: 1.62, 95% CI: 1.19 - 2.22, p = 0.002). Conclusion: Genetic susceptibility appears to participate in the pathogenesis of inguinal hernia in the Taiwanese population in a sex-specific manner. Future studies are needed to illuminate the complex interplay between heredity and comorbidities., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Objectives: To study the association between antenatal corticosteroids treatment and childhood mental disorders in infants born at different gestational ages, and to investigate the effect of different administration timing., Study Design: This population-based cohort study used data from the Taiwan National Health Insurance Research Database. All singleton live births born between 2004 and 2010 were enrolled and followed up for at least 6 years. The primary outcome was any childhood mental disorder. Secondary outcomes included 7 specific subgroups of mental disorders., Results: A total of 1 163 443 singleton infants were included in the analysis, and 16 847 (1.45%) infants were exposed to antenatal corticosteroid treatment. Children exposed to antenatal corticosteroids were found to have a higher risk of developing childhood mental disorders in the entire cohort (hazard ratio [HR], 1.13; 95% CI, 1.08-1.18), the term group (HR, 1.11; 95% CI, 1.05-1.16), and the late-preterm group (HR, 1.15; 95% CI, 1.06-1.25). The administration of corticosteroids in the early stage of pregnancy (<28 weeks of gestation) significantly increased the risk of childhood mental disorders (HR, 1.22; 95% CI, 1.14-1.31)., Conclusions: Exposure to antenatal corticosteroid treatment increases the cumulative risk of childhood mental disorders and attention deficit hyperactivity disorders, both in term and late preterm infants. The administration of corticosteroids in the early stage of pregnancy tends to increase the risk of mental disorders., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Electromyographic (EMG) endotracheal tubes with surface electrodes are used during neck surgery to prevent recurrent laryngeal nerve (RLN) injury. Proper positioning of the EMG tube is of paramount importance. In this study, we aimed to compare the use of video laryngoscopy with other methods for achieving the optimal depth of the EMG tube., Methods: We retrospectively enrolled 489 adult patients (with 675 nerves at risk [NAR]) undergoing surgery using the EMG endotracheal tube. Patients were categorized into three groups with: rigid laryngoscope (n = 140, NAR = 187), conventional laryngoscope (n = 262, NAR = 370), and video laryngoscope (n = 87, NAR = 118). A formula for predicting optimal depths of the EMG tube was obtained from data of the standard group with rigid laryngoscope. Depths of the EMG endotracheal tube were measured and postoperative RLN injuries were analyzed., Results: Based on linear regression, the formula was derived for predicting the optimal depth of EMG endotracheal tube (cm) = 11.028 + 0.635 * gender (female = 0; male = 1) + 0.069 * height (cm). Compared to conventional laryngoscope, intubation of EMG tube with video laryngoscope resulted in less discrepancy between its actual value and optimal value, and the tube depth was more correct (OR = 2.888, 95% CI = 1.753-4.757, p < 0.001). All five postoperative permanent RLN injuries were found in the group with conventional laryngoscope., Conclusion: EMG endotracheal tube insertion with video laryngoscopy is superior to conventional laryngoscopy, as well as an alternative to rigid laryngoscopy. The video laryngoscopy is a novel approach to get optimal depth of EMG endotracheal tube during neck surgery., Competing Interests: Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article., (Copyright © 2022, the Chinese Medical Association.)

Background: Cryptogenic strokes related to a patent foramen ovale (PFO) in young patients have been reported. Percutaneous transcatheter occlusion is considered a safe and effective method for achieving PFO closure. Here, we present our experience of PFO closure in a series of young patients diagnosed with cryptogenic stroke., Methods: This was a retrospective study of 62 patients who were younger than 60 years of age and previously diagnosed with cryptogenic stroke. They underwent cardiac catheterization for the diagnosis of PFO and/or device closure. Bubble and echocardiography studies, the patients' characteristics, complications, and recurrence of stroke were recorded. The Risk of Paradoxical Embolism (RoPE) score index was also calculated., Results: Patients with a bubble study grade greater than grade I were likely to have PFO (odds ratio: 22.2 [95% confidence interval: 1.2-412.3]). The mean RoPE score in the PFO closure group was 7.18. Two patients (3.9%) developed atrial fibrillation during the procedure. Ischemic stroke recurred in two patients (3.3%)., Conclusions: Combining a bubble study with transcranial Doppler ultrasound or transthoracic echocardiography may increase the validity of PFO diagnosis. Because of the low recurrence rate of stroke and low complication rate, it is important to identify PFO patients with a bubble study grade greater than grade I. Closure of PFO may be a good strategy for preventing recurrent stroke among such patients.

Kawasaki disease (KD) is the most common form of acquired pediatric cardiac disease in the developed world. However, its etiology is still unclear. Epidemiological studies have shown that air pollution is a plausible risk factor in stimulating oxidative stress, inducing inflammation and causing autoimmune diseases. This study aims to assess the connections between prenatal and early life air pollution exposure to the incidence of KD. The main data source of this nationwide longitudinal study was the National Health Insurance Research Database (NHIRD) of Taiwan. NHIRD was linked with Taiwan Maternal and Child Health Database to establish the link between mothers and children. In total, 4192 KD cases involving children under 6 years of age were identified between January 2004 and December 2010. Children in the control group were randomly selected at a 1:4 ratio and matched using their age and index year. Integrated data for the air pollutants were obtained from 71 Environmental Protection Agency monitoring stations across Taiwan. Patients who had main admission diagnosis of KD and subsequently received intravenous immunoglobulin treatment were defined as incidence cases. Ambient exposure, including pollutant standards index (PSI), carbon monoxide (CO), nitric oxide (NO), nitric dioxide (NO 2 ), and nitrogen oxide (NOx) during pregnancy were all positively associated with KD incidence. Conversely, ozone (O 3 ) exposure had a negative correlation. Exposure to CO, NO, NO 2, and NOx after childbirth remained consistent with regards to having a positive association with KD incidence. Exposure to PSI and O 3 after delivery displayed no significant association with KD. Both prenatal and postnatal cumulative CO, NO, NO 2 , and NOx exposure had a dose dependent effect towards increasing KD incidence. Certain prenatal and early life air pollutant exposure may increase the incidence of KD., (© 2022. The Author(s).)

Background: The location of the accessory pathway (AP) can be precisely identified on surface electrocardiography (ECG) in adults with Wolff-Parkinson-White (WPW) syndrome. However, current algorithms to locate the AP in pediatric patients with WPW syndrome are limited., Objective: To propose an optimal algorithm that localizes the AP in pediatric patients with WPW syndrome., Methods: From 1992 to 2016, 180 consecutive patients aged below 18 years with symptomatic WPW syndrome were included. After the exclusion of patients with non-descriptive electrocardiography (ECG), multiple APs, congenital heart diseases, non-inducible tachycardia, and those who received a second ablation, 104 patients were analyzed retrospectively. Surface ECG was obtained before ablation and evaluated by using previously documented algorithms, from which a new pediatric algorithm was developed., Results: Previous algorithms were not highly accurate when used in pediatric patients with WPW syndrome. In the new algorithm, the R/S ratio of V1 and the polarity of the delta wave in lead I could distinguish right from the left side AP with 100% accuracy. The polarity of the delta wave of lead V1 could distinguish free wall AP from septal AP with an accuracy of 100% in left-side AP, compared to 88.6% in leads III and V1 for right-side AP. The overall accuracy was 92.3%., Conclusions: This simple, novel algorithm could differentiate left from right AP and septal from free wall AP in pediatric patients with WPW syndrome.

Background: For infants with very low birth weights (VLBW), their neurodevelopmental outcomes are thought to be associated with extra-uterine growth retardation (EUGR). In this study, based on a single institute, we analyzed the association between different levels or severity of EUGR of VLBW infants and their neurodevelopmental outcomes later at a corrected age of 24 months., Methods: This is a hospital-based retrospective cohort study. The severity of EUGR was classified into three categories according to the z-score of discharge weight: z < -2.0, <-2.5, and <-3.0. The outcomes were assessed using the Bayley Scales of Infant Development-II (BSID-II) at a corrected age of 24 months. We then estimated the association of EUGR with low mental developmental index (MDI) or low psychomotor developmental index (PDI). Multiple logistic regression and stratified analyses were used to adjust for the possible confounding factors., Results: In total, 224 VLBW infants were enrolled in this study from 1997 to 2006. In the univariate analysis, EUGR for weight at discharge from hospital was associated with MDI <85 at the corrected age of 24 months, and this association was related to the severity of EUGR (z < -2.5, OR: 1.92 (1.04-3.53); z < -3.0, OR: 2.83 (1.26-6.36)). In addition, the relationship was not confounded by gender nor small for gestational age. The stratified analysis against hemodynamic significant patent ductus arteriosus also revealed that EUGR was an independent predictor for neurodevelopmental outcomes., Conclusion: In VLBW preterm infants, EUGR was significantly associated with low MDI scores assessed at a corrected age of 24 months. Early evaluation and recognition of EUGR should be emphasized when caring for preterm infants., (Copyright © 2017. Published by Elsevier B.V.)

Background: The traditional treatment of subarterial ventricular septal defect (VSD) is open heart surgery. This study aimed to evaluate the feasibility, safety and outcome of transcatheter closure with the Amplatzer duct occluder (ADO)., Methods: Between March 2012 and June 2015, a total of 16 patients (8 male and 8 female) with subarterial VSD who underwent transcatheter closure with the ADO were enrolled retrospectively. Their age ranged from 3.0 to 65.6 years, with the median of 35.6 years; their body weights ranged from 14 to 92 kg with the median of 60 kg. All patients had prolapse of the right coronary cusp without subaortic rim. Mild aortic regurgitation was noted in 11 (69%) patients., Results: Left ventriculogram showed VSD size ranged from 1.3 to 9.3 mm with the median of 3.5 mm. The device was successfully implanted in 88% (14/16) of the patients. Although one patient had mild skin allergy to contrast medium, no other complication was noted. Complete closure rate was 64%, 86%, 86% and 86% at 1-day, 1-month, 6-month and 12-month follow-up, respectively. Two patients developed new or worsening aortic regurgitation during follow-up., Conclusion: Transcatheter closure of subarterial VSD with ADO is technically feasible and safe in patients older than 7 years of age. However, development or worsening of aortic regurgitation requires long-term follow-up., (Copyright © 2017. Published by Elsevier Taiwan LLC.)

Background: Transcatheter device closure of postmyocardial infarction ventricular septal defect (PMIVSD) is less invasive than surgical repair. However, its feasibility, timing, outcome, and prognostic factors remain unclear., Methods: This was a multicenter, retrospective cohort study. Between February 2012 and July 2015, a total of 10 (8 male and 2 female) patients with PMIVSD undergoing attempted device closure were enrolled retrospectively. The procedures were performed under general anesthesia with fluoroscopic and transesophageal echocardiographic guidance., Results: The patients enrolled in the study were in the age range 50-85 years (median age of 76.5 years). The interval from infarction to device closure ranged from 6-147 days, with the median of 12 days. A total of 13 devices were implanted in 10 patients. There were five Amplatzer muscular ventricular septal defect occluders, four Amplatzer septal occluders, three Amplatzer PMIVSD occluders and one Amplatzer vascular plug II. Complications included transient ventricular tachycardia in three patients, device embolization in one patient, and tracheal bleeding in one patient. No procedure-related death, stroke, or cardiac tamponade was noted. During follow-up, two patients died of heart failure and two patients died of sepsis. Overall, subjects with age ≥ 80 years, systolic blood pressure ≤ 90 mmHg, and procedure time ≥180 minutes were significant predictor factors for mortality. All patients with the interval of infarction to device closure >12 days survived., Conclusion: Our findings indicate that transcatheter device closure of PMIVSD is technically feasible, safe, and effective to reduce the shunt. The crucial prognostic factors were ascertained to be age ≥ 80 years, systolic blood pressure ≤ 90 mmHg, and procedure time ≥180 minutes., (Copyright © 2016. Published by Elsevier Taiwan LLC.)

Background: Kawasaki disease is the leading cause of pediatric acquired cardiac disease in many industrialized countries. The aim of this study was to estimate the incidence of Kawasaki disease in acute stages in Taiwan, by linking the diagnosis code to medication and comparing the differences in epidemiological features with those of previous reports that used the diagnosis code alone., Methods: We searched the National Health Insurance Research Database from 1997 to 2010. For the International Classification of Diseases, Ninth Revision (ICD-9) set, all inpatients with a main diagnosis of Kawasaki disease (ICD-9, 446.1) were retrieved. For the ICD-9 + intravenous immunoglobulin (IVIG) set, Kawasaki disease in acute stages was defined as the disease stages requiring IVIG. The epidemiologic features were calculated and compared by both methods., Results: The incidence rates for children under 5 years ranged from 21.5 to 68.5 per 100,000 person-years (average 49.1) for the ICD-9 + IVIG set and from 48.5 to 82.8 per 100,000 person-years (average 74.9) for the ICD-9 set. Significant discrepancy in peak season estimation occurred in summer. The 5-year recurrence rate was 1.1% for the ICD-9 + IVIG set and 4.5% for the ICD-9 set. The coronary complication rates were around 7.24% (ICD-9 + IVIG) and 6.48% (ICD-9)., Conclusion: Discrepancies occurred when different case definitions were used in claims data analysis. Previous reports might have overestimated the incidence, recurrence rate, and complication rate in older children. The new method might slightly underestimate them. The true incidence might lie in between., (Copyright © 2014. Published by Elsevier Taiwan.)

The growth of uniform gallium nitride (GaN) thin films was reported on (100) Si substrate by remote plasma atomic layer deposition (RP-ALD) using triethylgallium (TEG) and NH3 as the precursors. The self-limiting growth of GaN was manifested by the saturation of the deposition rate with the doses of TEG and NH3. The increase in the growth temperature leads to the rise of nitrogen content and improved crystallinity of GaN thin films, from amorphous at a low deposition temperature of 200 °C to polycrystalline hexagonal structures at a high growth temperature of 500 °C. No melting-back etching was observed at the GaN/Si interface. The excellent uniformity and almost atomic flat surface of the GaN thin films also infer the surface control mode of the GaN thin films grown by the RP-ALD technique. The GaN thin films grown by RP-ALD will be further applied in the light-emitting diodes and high electron mobility transistors on (100) Si substrate.

Background: The primary aim of the study was to investigate the changes in composition of breast milk from mothers with preterm infants (gestation age < 35 weeks) during the first 4-6 weeks of lactation., Methods: Breast milk from 17 mothers who had delivered preterm infants was collected longitudinally for 4-6 weeks. Breast milk from 15 mothers of full-term infants was also collected at the 1(st) week and 4(th) week. Fat, protein, lactose, energy, minerals (calcium and phosphate), and immune components [secretory immunoglobulin A (IgA), leptin, lysozyme, and lactoferrin] content were measured weekly in each participant. A mid-infrared human milk analyzer was used to measure the protein, fat, and lactose contents. Calcium and phosphate components were checked via spectrophotometry. The concentrations of major immune components (secretory IgA, lactoferrin, lysozyme, and leptin) were quantified using enzyme-linked immunosorbent assay kits., Results: Eighty samples from 17 preterm mothers were collected. The mean gestational age was 29.88 ± 2.39 weeks. There were significant changes in nutrient components during these periods, with increases in lactose (p < 0.001), lipid (p = 0.001), calorie (p = 0.012), and phosphate (p = 0.022) concentration and decreases in protein (p < 0.001) and secretory IgA (p < 0.001) concentration. There were no differences in calcium (p = 0.919), lactoferrin (p = 0.841), leptin (p = 0.092), and lysozyme (p = 0.561) levels. Furthermore, there were no significant differences in most components of breast milk between full-term and preterm mothers., Conclusion: The longitudinal study revealed significant changes in macronutrient contents and secretory IgA concentration in preterm milk over the 4-6 week period, which is compatible with the results of previous studies. The quantification of phosphate in preterm breast milk was lower than the normal range, suggesting that close monitoring of body bone mass may be indicated. More studies are warranted to evaluate the clinical significance of alterations of major milk components during the postnatal stage., (Copyright © 2014. Published by Elsevier B.V.)

Background: The clinical significance of influenza B is frequently overlooked, and reports on influenza B pneumonia in children are limited. Therefore, the clinical features of associated complications have rarely been reported. The aim of this study is to evaluate the clinical characteristics in pediatric patients with influenza B virus-associated pneumonia., Methods: From January 2009 to February 2012, 389 consecutive patients under 18 years old with influenza B virus infection were enrolled into the study. Thirty-four patients were defined as the pneumonia group by clinical symptoms and chest X-ray (CXR) findings, and 90 patients who had laboratory data and normal CXR findings were recruited to form the nonpneumonia group., Results: The age of the patients in the pneumonia group was significantly younger (median of 5.3 vs. 6.6 years). The white blood cell count (median of 7.5 vs. 5.7 × 10(9) cells/L) and C-reactive protein level (median of 21.1 vs. 5.7 mg/L) were higher, but the hemoglobin level was lower (median of 12.6 vs. 13.2 g/dL) in the pneumonia group. The CXR findings revealed that 29.4% of patients had alveolar consolidation, 32.4% had interstitial infiltration, and 38.2% had ground glass opacity. Two of four patients with pleural effusion had a positive bacteria culture, and both of them died., Conclusion: Pneumonia should be considered in pediatric patients with influenza B virus infection presenting with younger age, higher white blood cell count, lower hemoglobin, and higher C-reactive protein level. The CXR findings were varied. Patients with pleural effusion and positive bacterial culture may have more severity of clinical outcome., (Copyright © 2013. Published by Elsevier B.V.)

Purpose: This study aimed to evaluate the impact of previous antibiotic exposure and the influence of time interval since exposure on the evolution of antibiotic-resistant infections., Methods: We retrospectively analyzed 167 mechanically ventilated patients with nosocomial infections over a 3-year period, with focus on infections in the bloodstream, urinary tract, lower respiratory tract, and surgical sites., Results: Of 167 patients, 62% were confirmed as antibiotic resistant. The most common isolated pathogen was extended-spectrum β-lactamase Enterobacteriaceae (43.9%), followed by methicillin-resistant Staphylococcus aureus (22.8%), and carbapenem-resistant Acinetobacter baumannii (17.5%). Multivariate analysis revealed that the association between resistance and the time interval increased within 10 days (odds ratio [OR], 2.45; P=.133) and peaked at 11 to 20 days (OR, 7.17; P=.012). The data were categorized into 2 groups: when the time interval was more than 20 days, there was a 23.9% reduction in resistance rate compared with when the time interval was 20 days or less (OR, 0.36; P=.002)., Conclusions: Although antibiotic exposure increased resistance rate in nosocomial infections, this association decreased as time interval increased. Antibiotic stewardship should consider the significance of time interval while investigating the evolution of subsequent antibiotic-resistant infections., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background/purpose: Acute otitis media (AOM) is a common complication of upper respiratory tract infection (URTI) among children. The purpose of this study was to evaluate the epidemiology of AOM among young children in Taiwan, including the age incidence and seasonality by combining multiple databases., Methods: Two country-based questionnaire survey studies had been conducted to evaluate the experience of otitis media (OM) among young children: one in 2007 and the other between 2005 and 2010. The number of OM cases (5% of population younger than 7 years) in 2005 and annual visiting rates for URTI from 2005 to 2010 obtained from the National Health Insurance Research Database of Taiwan were collected and comprised the third database. The fourth database comprised ambulatory visits of children with OM to a medical center in central Taiwan between 2005 and 2010., Results: Data from a total of 1099 questionnaires were entered into Database I in 2007, and data from 9705 questionnaires between 2005 and 2010 comprised Database II. There were 86,702 children (younger than 7 years, representing 5% of the whole population for this age group) retrieved from Database III in 2007, and 5,904 cases of OM in children between 2005 and 2010 in a hospital. In Database I, 7.46% children experienced at least one episode of AOM compared with 9.21% in Database II for children aged 5 years and younger. In Database III, 13.2% children younger than 7 years had AOM in 2005. The peak season of AOM among children was from March to May (Databases III and IV)., Conclusion: AOM was thought to be a very common disease among children; however, this comparative analysis showed that the overall prevalence of AOM among children younger than 5 years was only 20%, much lower than in other countries. AOM was more prevalent during the spring season, and still was similarly common after age 2 years., (Copyright © 2012. Published by Elsevier B.V.)

Budd-Chiari syndrome is a rare, heterogenous and potentially lethal condition due to hepatic venous outflow obstruction. Classic triads include hepatomegaly, ascites and abdominal pain. Most cases are caused by abnormal coagulopathy, infection, inflammation or tumor invasion. Status post liver transplantation was rarely mentioned in the pediatric group. Here we report a case of 4-year-old girl with biliary atresia status post living donor liver transplantation. Marked ascites developed 2 months later and Budd-Chiari syndrome was diagnosed. Cardiac catheterization showed significant stenoses of the hepatic vein and inferior vena cava. Initial balloon angioplasty of inferior vena cava only resulted in mild improvement. After successful balloon angioplasty of the hepatic vein stenosis, the stenosis of the inferior vena cava improved significantly. The ascites resolved soon, and no more happened up to 8 months' follow-up.

Atrial septal defect (ASD) and patent ductus arteriosus (PDA) are common congenital heart defects and usually isolate. The combination of these two defects is infrequent. Nowadays, both defects are amenable to transcatheter closure, without surgery. However, both defects by transcather closure was rarely reported. Here we report that two children with ASD and PDA benefited from combined interventional therapy using the Amplatzer septal occluder for the ASD and Gianturco coils for the PDA. Based on our limited experience, closing the PDA before the ASD may be a better option.

Purpose: To compare the right atrial pressure to the central venous pressures measured at different points in spontaneously breathing children and try to find a formula to estimate right atrial pressure by central venous pressure measurement., Methods: Fifty-one children, aged 5 +/- 4.7 years, who underwent right heart catheterization were studied. All patients were sedated and breathed naturally. The mean pressure was the electronic mean of nine heart beats calculated by Philips BC4000 digital angiographic system. Mean pressure of the right atrium was compared to those measured at the high superior vena cava (SVC), low SVC, high inferior vena cava (IVC) (T10-11), middle IVC (L1-2), low IVC (L3-4), and iliac vein (L5-S1)., Results: Mean pressures of central veins were significantly higher than that of the right atrium (all p<0.01). Adjusted central venous pressures of SVC-0.5, high IVC-1.5, middle IVC-2, low IVC-2.5, and iliac vein-3 (mmHg) had a good agreement with the right atrial pressure., Conclusions: Central venous pressures are significantly higher than the right atrial pressure in spontaneously breathing children. Adjusted pressures of SVC-0.5, high IVC-1.5, middle IVC-2, low IVC-2.5, and iliac vein-3 (mmHg) can accurately reflect the right atrial pressure.

The Amplatzer Septal Occluder (ASO) is the first and only device to receive full approval for clinical use in patients with secundum atrial septal defect (ASD) from the United States Food and Drug Administration. This study reports the device's initial results in Taichung Veterans General Hospital, a tertiary medical center in central Taiwan. Between October 2001 and December 2004, 39 consecutive patients (31 females, 8 males) with secundum ASD underwent attempt at transcatheter closure using the ASO under general anesthesia and transesophageal echocardiographic guidance. Six patients were excluded due to deficient rims (2 patients), multiple ASDs (1 patient), too large a defect (1 patient), too small a defect (1 patient) and 1 patient with associated atrial flutter. A total of 33 patients (26 females, 7 males) underwent the device closure procedure. The median age was 10.6 years (range 3.1-57.5 years) and median weight was 42 kg (range 13.5-73 kg). The median Qp/Qs ratio was 2.12 (range 1.02-5.52). The median balloon stretched diameter of the defect by sizing plate was 16 mm (range 5-37 mm). A total of 33 devices (median size 17 mm, range 7-38 mm) were implanted in 33 patients. The median fluoroscopy time was 10.1 minutes (range 5.9-29 minutes) and the median procedure time was 55 minutes (range 30-105 minutes). Complications included asymptomatic device embolization to the right ventricle in 1 patient (surgical removal) and transient complete atrioventricular block in 1 patient. Follow-up echocardiography at 10 minutes, 24 hours, 1 month, 6 months, 1 year and 2 years after the procedure showed complete closure rates of 76% (25/33), 91% (30/33), 100% (32/32), 100% (22/22), 100% (22/22), and 100% (9/9), respectively. In conclusion, transcatheter closure of secundum ASD using the Amplatzer Septal Occluder is safe and effective, with a very low complication rate.

Critical aortic valve stenosis (AS) is a difficult clinical condition. Besides supportive medical care, relief of the stenosis is most important to the patients' survival. We present two cases using transcatheter balloon valvuloplasty in managing critical AS in young infants. Case 1 was a 2 month-old female infant. She presented with cardiopulmonary failure. Aortic annulus was 8 mm and the aortic valve was dilated with a 6 mm and then an 8 mm diameter balloon. The pressure gradient was reduced from 83 to 13 mmHg. Case 2 was a 7 day-old male infant. Aortic annulus was 6.7 mm and the aortic valve was dilated with a 6 mm diameter balloon. The pressure gradient was reduced from 87 to 44 mmHg. Both patients tolerated the procedure well. No major complications developed except that a transient weak femoral pulse was noted in case 1. In our limited experience, balloon valvuloplasty is a safe and effective therapeutic choice for managing critical AS in young infants. The advantages include no need of bypass or general anesthesia, shortened hospital course, reduced exposure to blood product, and no scar.

PHACE syndrome indicates a neurocutaneous syndrome including Posterior fossa malformation, large facial Hemangioma, Arterial malformation, Coarctation of the aorta and/or other Cardiac anomalies, and Eye abnormalities. We here report a female infant who presented a giant facial hemangioma. Dandy-Walker malformations with hydrocephalus was found subsequently. We treated the hemangioma with prednisolone, methylprednisolone, interferon-alpha, and local injections of corticosteroid. Encephalomalacia was found later and it was attributed to carotid artery anomalies. Brain image studies, thorough ophthalmologic and cardiac examinations are strongly recommended in infants with large, plaquelike facial hemangiomas. Carotid angiography should also be considered if carotid artery anomalies are suspected.

Acute renal failure is a frequently reported complication after open heart surgery in children and carries a high mortality. Conservative treatment often makes post-operative care difficult and ambiguous. Peritoneal dialysis (PD) or hemofiltration is another therapeutic choice. Hemofiltration has some limitations in pediatric patients. Many aspects of PD are currently under discussion. We retrospectively reviewed 184 children who underwent open heart surgery with cardiopulmonary bypass. Four patients fulfilled the criteria of acute renal failure. PD was performed after conservative treatment failed. All patients successfully survived through the post-operative period. No electrolyte imbalance, fluid overload or acute hemodynamic changes was observed after the initiation of PD. In our limited experience, PD is a safe and effective method for managing patients with acute renal failure after open heart surgery.

A 22-day-old female infant was referred to our hospital due to unusual urine odor suspecting inborn error of metabolism. Physical examination revealed a stuporous and hypotonic infant with poor reflexes. Intravenous thiamine and high glucose along with appropriate protein were given under the suspicion of maple syrup urine disease (MSUD), which was confirmed by blood and cerebrospinal fluid amino acid assays, and urinary organic acid assay. Progressive neurological deterioration was observed despite the non-invasive treatment. So, we performed pump assisted continuous arteriovenous haemofiltration (CAVHF). Dramatic improvement in neurological function was observed hours after initiation of CAVHF, along with decrease in the level of isoleucine, leucine and valine. In our experience, CAVHF is a well-tolerated procedure for managing the acute phase of neonatal MSUD. Further study on indications, duration of treatment, and preventing complications is needed.