Paediatric gastrointestinal endoscopy in the Asian-Pacific region:Recent advances in diagnostic and therapeutic techniques

There has been a rapid expansion in the knowledge of paediatric gastroenterology over the recent decade,with a fast-growing repertoire of diagnostic techniques and management strategies for a wide spectrum of childhood gastrointestinal(GI)diseases.Paediatric GI endoscopy is a core competency every paediatric gastroenterologist should possess,and represents one of the most common procedures performed in children for both diagnostic and therapeutic purposes.Yet there remains a dearth of literature on the utility and outcomes of paediatric GI endoscopy in the Asia-Pacific region.Data on the diagnostic value of paediatric GI endoscopy would be an important aspect of discussion,with the emergence of inflammatory bowel disease(IBD)and eosinophilic GI disease as increasingly common endoscopic diagnoses.Time-based trends in paediatric GI endoscopy do point towards more IBD and gastroesophageal reflux disease-related complications being diagnosed,with a declining incidence of GI bleeding.However,the real-world diagnostic value of endoscopy in Asia must be contextualised to the region-specific prevalence of paediatric GI diseases.Helicobacter pylori infection,particularly that of multidrug-resistant strains,remains a highly prevalent problem in specific regions.Paediatric functional GI disorders still account for the majority of childhood GI complaints in most centres,hence the diagnostic yield of endoscopy should be critically evaluated in the absence of alarm symptoms.GI therapeutic endoscopy is also occasionally required for children with ingested foreign bodies,intestinal polyposis or oesophageal strictures requiring dilation.Endoscopic haemostasis is a potentially life-saving skill in cases of massive GI bleeding typically from varices or peptic ulcers.Advanced endoscopic techniques such as capsule endoscopy and balloon-assisted enteroscopy have found traction,particularly in East Asian centres,as invaluable diagnostic and therapeutic tools in the management of IBD,obscure GI bleeding and intestinal polyposis.State of the art endoscopic diagnostics and therapeutics,including the use of artificial intelligence-aided endoscopy algorithms,real-time confocal laser endomicroscopy and peroral endoscopic myotomy,are expected to gain more utility in paediatrics.As paediatric gastroenterology matures as a subspecialty in Asia,it is essential current paediatric endoscopists and future trainees adhere to minimum practice standards,and keep abreast of the evolving trends in the diagnostic and therapeutic value of endoscopy.This review discusses the available published literature on the utility of paediatric GI endoscopy in Asia Pacific,with the relevant clinical outcomes.

Examining the life-cycle of the Coblator II device:Increases in paediatric post-tonsillectomy haemorrhage after six years of use

All paediatric tonsillectomies were examined from 2012–2019 at a single tertiaryreferral institution,and all were performed by one of two paediatric otolaryngologists.One exclusively used the diathermy,the other exclusively used the Coblator II.Two Coblator units were purchased simultaneously in 2012 and not replaced.There was no significant difference in number of tonsillectomies performed(1298 via diathermy,1221 via Coblator),nor in postoperative day of bleed,patient age,indication for procedure,and no patient had an underlying coagulopathy.The most common indication for tonsillectomy in both groups was sleep-disordered breathing.There was no significant difference in postoperative haemorrhage rates between groups for the first six years of the study(0%-1.4%/year).Years 7 and 8 saw the Coblator group haemorrhage rate significantly increase(0%-0.6%diathermy group vs 2%-3%Coblator group),though still fell within accepted rate of postoperative haemorrhage.The devices were then replaced,and the differences in haemorrhage disappeared.There appears to be a significant increase in paediatric post-tonsillectomy haemorrhage when using a Coblator device greater than six years old.This may suggest a useful lifespan for the Coblator II device.

Use of endolumenal functional lumen imaging probe in investigating paediatric gastrointestinal motility disorders

Investigating gastrointestinal(GI)motility disorders relies on diagnostic tools to assess muscular contractions,peristalsis propagation and the integrity and coordination of various sphincters.Manometries are the gold standard to study the GI motor function but it is increasingly acknowledged that manometries do not provide a complete picture in relation to sphincters competencies and muscle fibrosis.Endolumenal functional lumen imaging probe(EndoFLIP)an emerging technology,uses impedance planimetry to measure hollow organs cross sectional area,distensibility and compliance.It has been successfully used as a complementary tool in the assessment of the upper and lower oesophageal sphincters,oesophageal body,the pylorus and the anal canal.In this article,we aim to review the uses of EndoFLIP as a tool to investigate GI motility disorders with a special focus on paediatric practice.The majority of EndoFLIP studies were conducted in adult patients but the uptake of the technology in paediatrics is increasing.EndoFLIP can provide a useful complementary data to the existing GI motility investigation in both children and adults.

Evaluation of Entrance Skin Dose from Paediatric Diagnostic X-Ray Examination

As children are prone to be more radiosensitive than adults, it is imperative to assess the Entrance Skin Doses (ESDs) for patients being examined by X-rays, in order to ensure the optimization of dose while considering a number of other fickles. The ESD received by 50 paediatrics (aged 1-13 years) undergoing 8 types of X-ray examinations were measured at Federal Teaching Hospital, Ido-Ekiti, Ekiti, Nigeria, within a period of February 2019 to March 2020 using thermoluminescent dosimeters. The mean ± SD of ESDs were 0.85 ± 0.32, 2.04 ± 0.75, 0.60 ± 0.07, 0.62 ± 0.22, 0.57 ± 0.24, 1.75 ± 0.76, 0.93 ± 0.31 and 0.63 ± 0.06 mGy for Chest, Skull, Hand, Forearm, Knee, Abdomen, Leg and Feet, respectively. The mean ESDs were found to be within the recommended reference dose in all examinations, except for the Chest examination which was higher. The data obtained in this study will serve as existing data in Nigeria for future research works, as it would assist in optimizing dose to patients, especially the paediatrics.

Epidemiology and incidence of paediatric orthopaedic trauma workload during the COVID-19 pandemic:A multicenter cohort study of 3171 patients

BACKGROUND Coronavirus disease 2019(COVID-19)has a major influence on all parts of society.AIM To examine the consequences of the national lockdown and political initiatives during the first surge of the COVID-19 pandemic expressed by changes in incidences of musculoskeletal paediatric injuries.METHODS Study design was a retrospective multicenter cohort study.A‘pandemic’cohort was established from 16 March 2020 to 21 April 2020,where all institutions including day care and schools were closed.A‘pre-pandemic’cohort was established from the same period in 2019 for comparison.Included were all patients admitted at the emergency departments with paediatric musculoskeletal injuries(aged 0-15 years)identified by a relevant musculoskeletal ICD-10 diagnosis(DSxxx),concussions(DZ033D),or burns(DT2xx).RESULTS The‘pre-pandemic’cohort consisted of 2101 patients,and the‘pandemic’cohort consisted of 1070 patients,indicating a decrease of paediatric musculoskeletal injuries of 51%.The incidence of paediatric injury in the‘pre-pandemic’cohort was 10460/100000/year.In the‘pandemic’cohort,the incidence was 5344/100000/year.CONCLUSION A resource re-allocation to help serve the COVID-19 patients might be possible without reducing the level of care for injury-related paediatric patients.

Paediatric retinal detachment:a review

Paediatric retinal detachment（PRD）is an uncommon and challenging disease;it differs from adult detachments in etiology,anatomical characteristics,management and prognosis.PRDs can be particularly challenging,even for the most expert paediatric surgeons due to the higher prevalence of total retinal detachments,late diagnosis and bilateral involvement with respect to those which occur in adulthood.Moreover,the anatomical success,when achieved,is frequently not related to a functional recover.Postsurgical adverse events,refractive errors and amblyopia may additionally undermine the final outcome.Up to date there are few reviews regarding the approach of retinal detachment in children,mainly dealing with rhegmatogenous retinal detachment.In this review,rhegmatogenous,retinopathy of prematurityrelated and Coats’-related PRDs were considered.The available literature from the last decades were reviewed and summarized.Epidemiology,etiology and clinical presentation,together with therapeutic approaches and outcomes have been reviewed and discussed.

The Paediatric Observation Priority Score: A System to Aid Detection of Serious Illness and Assist in Safe Discharge

The Paediatric Observation Priority Score (POPS) is a bespoke assessment tool for use in Paediatric Emergency Departments incorporating traditional physiological parameters alongside more subjective observational criteria. Initial performance characteristics of POPS were analysed in a convenience sample of 936 presentations to ED. Triage on the basis of gut instinct parameters identified an additional 261 patients deemed of lowest acuity compared to analysis by physiology scores. Resource consumption increased with increasing acuity on presentation. POPS shows promise in assisting in the assessment process of children presenting to Emergency Departments. Inclusion of subjective triage criteria helps contextualise the physiological parameter scoring by using the experience of staff conducting triage. Initial interpretation of presenting physiology gives a more informed assessment of initial acuity, and thus is better able to identify a child who can be safely managed in the community. The system also allows for rapid detection of those most unwell.

Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review

The incidence of paediatric inflammatory bowel disease(PIBD) has dramatically increased in the last 20 years. Although first reported in mid 1970s',diagnostic laparoscopy has started to be routinely adopted in paediatric surgical practice since late 1990s'. Minimally invasive surgery was first limited to diagnostic purposes. After 2002 it was also applied to the radical treatment of PIBD,either Crohn's disease(CD) or Ulcerative colitis. During the last decade minimally invasive approaches to PIBD have gained popularity and have recently became the "gold standard" for the treatment of such invalidating and troublesome chronic diseases. The authors describe and track the historical evolution of minimally invasive surgery for PIBD and address all available opportunities,including most recent advancements such as robotic surgery,single port approaches and minimally invasive treatment of perianal fistulising CD. A systematic review of all series of PIBD treated with minimally invasive approaches published so far is provided in order to determine the incidence and type of patients' complications reported up to present days. The authors also describe their experience with minimally invasive surgery for PIBD and will report the results of 104 laparoscopic procedures performed in a series of 61 patients between January 2006 and December 2014.

Gliosarcoma:A rare variant of glioblastoma multiforme in paediatric patient:Case report and review of literature

Gliosarcoma is rare central nervous system tumour and a variant of glioblastoma multiforme with bimorphic histological pattern of glial and sarcomatous differentiation. It occurs in elderly between 5^(th) and 6^(th) decades of life and extremely rare in children. It is highly aggressive tumour and managed like glioblastoma multiforme. A 12-year-old female child presented with complaints of headache and vomiting from 15d and blurring of vision from 3d. Magnetic resonance imaging of brain shows heterogeneous mass in right parieto-occipital cortex. A right parieto-occipito-temporal craniotomy with complete excision of mass revealed a primary glioblastoma on histopathological investigation. Treatment consists of maximum surgical excision followed by adjuvant radiotherapy. The etiopathogenesis, treatment modalities and prognosis is discussed. The available literature is also reviewed.

Hepatocellular adenoma in the paediatric population:Molecular classification and clinical associations

Hepatocellular adenomas(HCAs)represent rare,benign liver tumours occurring predominantly in females taking oral contraceptives.In children,HCAs comprise less than 5%of hepatic tumours and demonstrate association with various conditions.The contemporary classification of HCAs,based on their distinctive genotypes and clinical phenotypes,includes hepatocyte nuclear factor 1 homeobox alpha-inactivated HCAs,beta-catenin-mutated HCAs,inflammatory HCAs,combined beta-catenin-mutated and inflammatory HCAs,sonic hedgehogactivated HCAs,and unclassified HCAs.In children,there is a lack of literature on the characteristics and distribution of HCA subtypes.In this review,we summarized different HCA subtypes and the clinicopathologic spectrum of HCAs in the paediatric population.

Innovative color jet 3D printing of levetiracetam personalized paediatric preparations

3D printing is a promising technology used in the fabrication of complex oral dosage delivery pharmaceuticals.This study first reports an innovative color jet 3D printing(CJ-3DP)technology to produce colorful cartoon levetiracetam pediatric preparations with high accuracy and reproducibility.For this study,the ideal printing ink consisted of 40%(v/v)isopropanol aqueous solution containing 0.05%(w/w)polyvinylpyrrolidone and 4%(w/w)glycerin,which was satisfied with scale-up of the production.The external and internal spatial structures of the tablets were designed to control the appearance and release,and cartoon tablets with admirable appearances and immediate release characteristics were printed.The dosage model showed a good linear relationship between the model volume and the tablet strength(r>0.999),which proved the potential of personalized administration.The surface roughness indicated that the appearance of the CJ-3DP tablets was significantly better than the first listed 3D printed drug(Spritam R).Moreover,the scanning electron microscopy and porosity results further showed that the tablets have a structure of loose interior and tight exterior,which could ensure good mechanical properties and rapid dispersion characteristics simultaneously.In conclusion,the innovative CJ-3DP technology can be used to fabricate personalized pediatric preparations for improved compliance.Due to the stable formulation and fabrication process,this technology has the potential in scale-up production.

Developments in diagnosis and treatment of paediatric septic arthritis

Acute septic arthritis in children is an orthopaedic emergency.A delay in diagnosis and inappropriate treatment can result in devastating damage to the joint with lifelong disability as a consequence.The clinical presentation can be a diagnostic challenge,especially in young children.A recent systematic review showed that joint tenderness and fever are important signals of septic arthritis.Ultrasound is helpful in detecting the presence of a joint effusion.Plain radiographs may show bone changes but magnetic resonance imaging is the most reliable imaging study for detecting concomitant osteomyelitis.The diagnosis of acute septic arthritis is highly suggestive when pus is aspirated from the joint,in case of a positive culture or a positive gram stain of the joint fluid,or if there is a white blood-cell count in the joint fluid of more than 50000/mm3.Staphylococcus aureus is the most commonly cultured organism.Recent systematic reviews have identified the most effective drainage techniques,including needle aspiration,arthroscopy and arthrotomy,depending on the affected joint.After the drainage procedure it is important to monitor the clinical and laboratory outcomes.Additional drainage procedures may be necessary in select cases.

Use of ketamine sedation for the management of displaced paediatric forearm fractures

AIM To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department. METHODS Following an agreed interdepartmental protocol, fractures of the radius and ulna(moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and postmanipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken.RESULTS During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate(3), fractures of both radius and ulna(6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of ￡1470, the overall study saving being ￡14700. CONCLUSION Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.

Surgical strategies in paediatric inflammatory bowel disease

Inflammatory bowel disease(IBD) comprises two distinct but related chronic relapsing inflammatory conditions affecting different parts of the gastrointestinal tract. Crohn's disease is characterised by a patchy transmural inflammation affecting both small and large bowel segments with several distinct phenotypic presentations. Ulcerative colitis classically presents as mucosal inflammation of the rectosigmoid(distal colitis), variably extending in a contiguous manner more proximally through the colon but not beyond the caecum(pancolitis). This article highlights aspects of the presentation, diagnosis, and management of IBD that have relevance for paediatric practice with particular emphasis on surgical considerations. Since 25% of IBD cases present in childhood or teenage years, the unique considerations and challenges of paediatric management should be widely appreciated. Conversely, we argue that the organizational separation of the paediatric and adult healthcare worlds has often resulted in late adoption of new approaches particularly in paediatric surgical practice.

Paediatric and adult colonic manometry: A tool to help unravel the pathophysiology of constipation

Colonic motility subserves large bowel functions, including absorption, storage, propulsion and defaecation. Co-lonic motor dysfunction remains the leading hypothesis to explain symptom generation in chronic constipation, a heterogeneous condition which is extremely prevalent in the general population, and has huge socioeconomic impact and individual suffering. Physiological testing plays a crucial role in patient management, as it is now accepted that symptom-based assessment, although im-portant, is unsatisfactory as the sole means of directing therapy. Colonic manometry provides a direct method for studying motor activities of the large bowel, and this review provides a contemporary understanding of how this technique has enhanced our knowledge of normalcolonic motor physiology, as well as helping to elucidate pathophysiological mechanisms underlying constipation. Methodological approaches, including available catheter types, placement technique and recording protocols, are covered, along with a detailed description of re-corded colonic motor activities. This review also criti-cally examines the role of colonic manometry in current clinical practice, and how manometric assessment may aid diagnosis, classification and guide therapeutic inter-vention in the constipated individual. Most importantly, this review considers both adult and paediatric patients. Limitations of the procedure and a look to the future are also addressed.

Growth and bone health in paediatric patients with Crohn's disease receiving subcutaneous tumor necrosis factor antibody

AIM:To study whether adalimumab(ADA) was associated with improvement in growth,bone mineraldensity(BMD) and bone metabolism.METHODS:In children with Crohn's disease(CD) there is a high prevalence of growth failure and reduced BMD.Treatment with infliximab is associated with an improvement in growth.Anthropometry,paediatric CD activity index(PCDAI),bone markers and BMD was measured in 18 patients(72% females) one year before and after start of ADA with a median age of 14.4 years(range:5-19 years) at treatment start.Outcomes were indicators of growth with treatment as well as interval growth.RESULTS:Eleven(61%) children experienced catchup growth after ADA.PCDAI significantly decreased from 52.1 ± 16 to 30.4 ± 23(P ≤ 0.001).Post ADA,body mass index(BMI) standard deviation score(SDS) 0.1[range:2.7-(-0.8)] vs-1 [range:0.1-(-3.6)],P = 0.04 and △BMI SDS in children 0.3 [range:0.7-(-0.2)] vs-1.1 [range:1.2-(-2.3)],P = 0.01 in remission were significantly higher compared to those with moderate to severe inflammation.The main predictors for growth were 25-hydroxycholecalciferol and for bone mineralisation weight and height SDS.ADA had no significant influence on bone markers and BMD.CONCLUSION:Next to improvement of PCDAI,half of the children achieved a positive catch-up growth.A better nutritional status with improvement in BMI and weight is positive predictor for improved growth and bone mineralisation.

Paediatric computed tomography radiation dose: A review of the global dilemma

Computed tomography(CT)has earned a well-deserved role in diagnostic radiology,producing crosssectional and three-dimensional images which permit enhanced diagnosis of many pathogenic processes.The speed,versatility,accuracy,and non-invasiveness of this procedure have resulted in a rapid increase in its use.CT imaging,however,delivers a substantially higher radiation dose than alternative imaging methodologies,particularly in children due to their smaller body dimensions.In addition,CT use in children produces an increased lifetime risk of cancer,as children’s developing organs and tissues are inherently more vulnerable to cellular damage than those of adults.Though individual risks are small,the increasing use of CT scans in children make this an important public health problem.Various organizations have recommended measures to minimize unnecessary exposures to radiation through CT scanning.These include elimination of multiple or medically unnecessary scans,development of patientspecific dosing guidelines,and use of alternative radiographic methodology wherever possible.Another important factor in excessive CT exposures,however,is a documented lack of awareness among medical practitioners of the doses involved in CT usage as well as itssignificant potential dangers.This review examines the effects of paediatric CT radiation,discusses the level of medical practitioner awareness of these effects,and offers recommendations on alternative diagnostic methods and practitioner education.

2-deoxy-2-(^(18)F)fluoro-D-glucose positron emission tomography/computed tomography imaging in paediatric oncology

Positron emission tomography(PET) is a minimally in-vasive technique which has been well validated for the diagnosis, staging, monitoring of response to therapy, and disease surveillance of adult oncology patients. Tra-ditionally the value of PET and PET/computed tomogra-phy(CT) hybrid imaging has been less clearly defined for paediatric oncology. However recent evidence has emerged regarding the diagnostic utility of these mo-dalities, and they are becoming increasingly important tools in the evaluation and monitoring of children with known or suspected malignant disease. Important indi-cations for 2-deoxy-2-(18F)fluoro-D-glucose(FDG) PET in paediatric oncology include lymphoma, brain tumours, sarcoma, neuroblastoma, Langerhans cell histiocytosis, urogenital tumours and neurofibromatosis type Ⅰ. This article aims to review current evidence for the use of FDG PET and PET/CT in these indications. Attention will also be given to technical and logistical issues, the description of common imaging pitfalls, and dosimetric concerns as they relate to paediatric oncology.

Phantom study of the impact of adaptive statistical iterative reconstruction (ASiR^TM) on image quality for paediatric computed tomography

Quantitative analysis of image quality will be helpful for designing ASiRTM-enhanced paediatric CT protocols, balancing image quality and radiation dose. Catphan600 phantom studies were performed on a GE Discovery HD750 64-slice CT scanner. Images were reconstructed with 0% - 100% ASiRTM (tube current 150 mA, variable kVp 80 - 140) in order to determine the optimal ASiRTM-Filtered Back Projection (FBP) blend. Images reconstructed with a 50% ASiRTM-50% FBP blend were compared to FBP images (0% ASiRTM) over a wide range of kVp (80 - 140) and mA (10 - 400) values. Measurements of image noise, CT number accuracy and uniformity, spatial and contrast resolution, and low contrast detectability were performed on axial and reformatted coronal images. Improvements in CNR, low contrast detectability and radial uniformity were observed in ASiRTM images compared to FBP images. 50% ASiRTM was associated with a 26% - 30% reduction in image noise. Changes in noise texture were observed at higher % ASiRTM blends with impact on visualisation of low and high contrast objects. A small decrease in limiting spatial resolution was detected with addition of ASiRTM, more appreciable at very low tube currents. The preferred blend for paediatric body protocols in our study, as determined by the image quality parameters investigated, was 50% ASiRTM when used with tube currents greater than 50 mA.

Paediatric retinal detachment:aetiology,characteristics and outcomes

AIM： To provide contemporary data on the aetiology, clinical features and outcomes of paediatric retinal detachment.METHODS： A retrospective review of all those under 16 y who underwent surgical repair for retinal detachment at a single centre between the years 2008 and 2015 inclusive was performed. In each case the cause of retinal detachment, the type of detachment, the presence or absence of macular involvement, the number and form of reparative surgeries undertaken, and the surgical outcome achieved was recorded.RESULTS： Twenty-eight eyes of 24 patients, 15（62.5%） of whom were male and 9（37.5%） of whom were female, their mean age being 11.6 y and range 2-16y developed retinal detachment over the eight year period studied. Trauma featured in the development of retinal detachment in 14（50.0%） cases. Retinal detachment was associated with other ocular and/or systemic conditions in 11（39.3%） cases. A mean of 3.0 procedures with a range of 1-9 procedures per patient were undertaken in the management of retinal detachment. Complex vitrectomy combined with scleral buckling or complex vitrectomy alone were those most frequently performed. Mean postoperative visual acuity was 1.2 log MAR with range 0.0-3.0 log MAR. In 22 of 26（84.6%） cases which underwent surgical repair the retina was attached at last follow-up.CONCLUSION： Aggressive management of paediatric retinal detachment including re-operation increases the likelihood of anatomical success. In cases where the retinal detachment can be repaired by an external approach alone there is a more favourable visual outcome.