Tsuen-Chiuan Tsai

Screening Young Children with a First Febrile Urinary Tract Infection for High-grade Vesicoureteral Reflux with Renal Ultrasound Scanning and Technetium-99m-labeled Dimercaptosuccinic Acid Scanning

OBJECTIVE To evaluate the predictive value of renal ultrasound scanning and 99m-Technetium-dimercaptosuccinic acid (DMSA) scintigraphy for high-grade vesicoureteral reflux (VUR) in young children with a first urinary tract infection (UTI). STUDY DESIGN The medical records of children who had been examined with renal ultrasound scanning, DMSA scanning, and voiding cystourethrography (VCUG) were reviewed. The findings of renal ultrasound scanning, DMSA scanning, and their predictive values were evaluated. RESULTS Of 699 children, high-grade VUR (grades III-V) was diagnosed in 119 (17.0%). Signs of renal hypodysplasia (OR, 16.15), cyclic dilatation of pelvicaliceal system (OR, 11.73), hydroureter (OR, 4.00) with renal ultrasound scanning, and renal hypodysplasia (OR, 8.78), acute pyelonephritis (OR, 2.76) with DMSA scanning were associated with high-grade VUR. The sensitivities for high-grade VUR of ultrasound scanning alone (67.2%) or DMSA scanning alone (65.5%) were not as good as that of a both-test strategy, which had a sensitivity rate of 83.2%. The negative predictive value of the both-test strategy was 91.5%. CONCLUSION Renal ultrasound scanning and DMSA scanning both should be routinely performed in children with a first febrile UTI. VCUG is only indicated when abnormalities are apparent on either ultrasound scanning or DMSA scanning or both.

Asymptomatic vesicoureteral reflux detected by neonatal ultrasonographic screening

Abstract. Renal ultrasonography was performed in 2,384 healthy and asymptomatic neonates. The definition and grading of hydronephrosis was according to the system of the Society for Fetal Urology. Voiding cystourethrography was performed in the cases with moderate to severe hydronephrosis or persistent mild hydronephrosis. In cases with vesicoureteral reflux (VUR), a dimercaptosuccinic acid (DMSA) renal scan was arranged immediately to evaluate the renal parenchyma. VUR was diagnosed in 30 infants with a prevalence of 1.26%; 7 had bilateral VUR. The male/female ratio was 4:1 and the right/left ratio was 1.85:1. Comparing with the abnormal ultrasonographic findings, VUR appeared ipsilaterally in 23 ureters and contralaterally in 14 ureters. Using ultrasonography for diagnosing VUR, the sensitivity, specificity, positive predictive value, and negative predictive value were 62.2%, 36.1%, 11.0%, and 88.2%, respectively. DMSA renal scan was perfomed in 31 refluxing kidneys, and congenital renal scarring was found in 9 (29.0%) kidneys. Six neonates underwent reimplantation surgery. We conclude that although ultrasonography is not a reliable tool for diagnosing VUR, it can detect many cases of VUR during the newborn stage using our screening program, which thus makes early treatment from the neonatal period possible. Whether our screening program can improve the outcome of VUR will require further follow-up.

Current Trends in Developing Medical Students' Critical Thinking Abilities

Health care is fallible and prone to diagnostic and management errors. The major categories of diagnostic errors include: (1) no‐fault errors—the disease is present but not detected; (2) system errors—a diagnosis is delayed or missed because of the imperfection in the health care system; and (3) cognitive errors—a misdiagnosis from faulty data collection or interpretation, flawed reasoning, or incomplete knowledge. Approximately one third of patient problems are mismanaged because of diagnostic errors. Part of the solution lies in improving the diagnostic skills and critical thinking abilities of physicians as they progress through medical school and residency training. However, this task is challenging since both medical problem‐solving and the learning environments are complex and not easily understood. There are many interacting variables including the motivation of the medical student (e.g. deep versus surface learning), the acquisition and evolution of declarative and conditional knowledge (e.g. reduced, dispersed, elaborated, scheme, and scripted), problem‐solving strategies (e.g. procedural knowledge—guessing, hypothetical deductive, scheme inductive, and pattern recognition), curricular models (e.g. apprenticeship, discipline‐based, body system‐based, case‐based, clinical presentation‐based), teaching strategies (e.g. teaching general to specific or specific to general), the presented learning opportunities (PBL versus scheme inductive PBL), and the nature of the learning environment (e.g. modeling critical thinking and expert problem‐solving). This paper elaborates on how novices differ from experts and how novices can be educated in a manner that enhances their level of expertise and diagnostic abilities as they progress through several years of medical training.

Intermittent hydronephrosis secondary to ureteropelvic junction obstruction: clinical and imaging features.

OBJECTIVE. We sought to assess the clinical and imaging findings in intermittent hydronephrosis secondary to ureteropelvic junction obstruction, with particular emphasis on the characteristic ultrasonographic findings. METHODS. This prospective, longitudinal, observational study included all children who had intermittent ureteropelvic junction obstruction and presented with abdominal pain over 6 years. Renal ultrasound was used as an initial screening tool to detect intermittent hydronephrosis. Renal ultrasonography was repeated every 1 to 2 days to record serial changes from the symptomatic to the asymptomatic stage. Their clinical manifestations and imaging findings were studied. RESULTS. Eighteen patients (14 boys, 4 girls) were studied. Most had sharp pain that began acutely and typically lasted for <2 days. Most of the children (16 of 18) had nausea and vomiting that accompanied the pain. The acute episode generally resolved spontaneously and was followed by a pain-free interval that ranged from days to months. Factors that predisposed to an attack included increased water intake, vigorous exercise, or bladder distention. All patients had clearly demonstrable obstruction of the renal pelvis during an acute attack, a finding that diminished or resolved during the symptom-free intervals. During convalescence, all patients had renal pelvic wall thickening on ultrasonography. This finding appeared on the second or third day after a painful episode subsided, persisted for 6 to 9 days, and then disappeared in the symptom-free stage. Pyeloplasty was performed in 17 patients, none of whom had recurrent pain on follow-up. Extrinsic obstructions were found in 9 patients. CONCLUSIONS. The keys to diagnosis are awareness of the syndrome, a detailed history, and immediate and serial imaging studies during painful crises. A thickened renal pelvic wall during convalescence is an important ultrasonic sign of intermittent hydronephrosis.

Students' perception on medical professionalism: the psychometric perspective

Background: The main purpose of this study was to identify and understand the structure of latent traits underlying the concept of medical professionalism of Taiwanese students. Methods: A 32 item questionnaire assessing medical professionalism derived from the definition by the American Board Internal Medicine (ABIM) was distributed to 133 year seven medical students. A five-point rating scale of importance was used to identify the extent of their values or beliefs in each item. Results: The three items perceived most important were: accountability to patients, respect for patients and their families; and integrity and prudence. The least important component underlying professionalism was ‘enduring unavoidable risks to oneself when a patients welfare is at stake’. Factor analysis resulted in eight factors: ‘commitment to care’ (factor 1); ‘righteous and rule-abiding’ (factor 2); ‘pursuing quality patient care’ (factor 3), ‘habit of professional practice’ (factor 4); ‘interpersonal relationship’ (factor 5); ‘patient-oriented’ issues (factor 6); physicians ‘self-development’ (factor 7); and finally, ‘respect for others’ (factor 8). Most of the variance was contributed by factor 1 (34.9%). The mean score of factors ranged from 3.84 (factor 1: commitment to care) to 4.7 (factor 8: respect of others), and the reliability alphas ranged from 0.86 to 0.66. Conclusions: These results of young physicians’ professional values have implications for medical school curriculum for improvement.

Retroperitoneal fibrosis and juvenile rheumatoid arthritis.

We describe a 13-year-old girl with juvenile rheumatoid arthritis who developed obstructive uropathy and renal failure. Retroperitoneal fibrosis (RPF) was confirmed by surgery. Although the renal failure and hydronephrosis resolved after surgery, the symptoms of vascular occlusion persisted. We consider that early diagnosis and treatment are essential. In cases of autoimmune disease, RPF should be considered when there is acquired obstructive uropathy accompanied by vascular occlusion syndrome.

Resolution of vesicoureteral reflux during medical management in children.

A retrospective study was performed to evaluate the results of medical management of primary vesicoureteral reflux (VUR) in infants and children. The charts of 105 patients (74 boys, 31 girls) with 167 refluxing ureters were reviewed. The age at diagnosis ranged from 3 days to 9.2 years (mean 1.3±1.9 years). The mean duration of follow-up was 2.4±1.5 years. We found that the patients sex did not influence the fate of VUR and its complications. Patients whose reflux improved while being managed medically were younger than those who did not improve, and the younger the patient the sooner the reflux resolved. Improvement and resolution of reflux were also related to grade, and the lower the initial grading the sooner the reflux resolved. Spontaneous resolution rates of reflux were 92.3%, 76.2%, 61.7%, and 32.0% for grades I, II, III, and IV, respectively. No ureters with grade V reflux resolved without complications. The most common complications in our series were renal scarring and secondary obstructive uropathy.

In utero urinary bladder perforation, urinary ascites, and bilateral contained urinomas secondary to posterior urethral valves: clinical and imaging findings

Abstract We report on a rare in utero appearance of urinary bladder perforation, urinary ascites, and bilateral contained urinomas secondary to posterior urethral valves. The findings on prenatal sonography, postnatal voiding cystourethrography, and magnetic resonance imaging are described.

Sonographic findings in familial juvenile nephronophthisis–medullary cystic disease complex

Familial juvenile nephronophthisis–medullary cystic disease complex (JN‐MCD) is an autosomal inherited renal disease with insidious symptoms that ultimately progresses to renal failure. We describe the abnormal sonographic findings in JN‐MCD at various stages of the disease in a Taiwanese family.

Assessing ethical problem solving by reasoning rather than decision making

Context  The assessment of ethical problem solving in medicine has been controversial and challenging. The purposes of this study were: (i) to create a new instrument to measure doctors’ decisions on and reasoning approach towards resolving ethical problems; (ii) to evaluate the scores generated by the new instrument for their reliability and validity, and (iii) to compare doctors’ ethical reasoning abilities between countries and among medical students, residents and experts.