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Background: The use of trans anastomotic feeding tube (TAFT) during the repair of Esophageal atresia/Tracheo-esophageal fistula (EA/TEF) aims to enhance outcomes by enabling early feeding, reducing the requirement for parenteral nutrition, and reducing complications such as anastomotic leak by stenting the anastomosis. However, TAFT's benefits and drawbacks are debated due to conflicting reports. Thus, we conducted a prospective pilot randomized control trial to elucidate the impact of TAFT on postoperative outcomes and the potential benefits of avoidance of TAFT., Methods: We performed a single-center randomized controlled trial in 53 neonates diagnosed with Type C EA/TEF who were operated on from January 2022 to June 2023. The patients were randomized into TAFT (n = 30) and non-TAFT (n = 23) groups. The patients were followed up for a minimum of 6 months following discharge. The primary objective of the study was to compare the rate of anastomotic leaks following primary repair of EA/TEF in both groups. Secondary objectives included early postoperative outcomes such as the occurrence of anastomotic stricture, time taken to initiate feeding, the time required to reach full feeding, the incidence of brief resolved unexplained events (BRUE) or acute life-threatening events (ALTE), the incidence of gastroesophageal reflux (GER), somatic growth, and all-cause mortality within 30 days post-surgery., Result: The study demonstrated that TAFT placement was associated with a higher incidence of anastomotic leaks (20 % vs 0, p = 0.03). However, there was no difference in the 30-day mortality between both groups. Although the rate of anastomotic strictures and GER was higher in the TAFT group (54.5 % vs 27.8 %, p = 0.08 and 25 % vs 57.1 %, p = 0.076), it did not reach statistical significance. Avoiding TAFT resulted in earlier initiation of enteral feeding (18 vs 22 days, p = 0.002), shorter time to achieve full feeds (15 vs 21 days, p = 0.03), reduced duration of TPN (3 vs 10 days; p = 0.001), improved weight gain at the 2-week follow-up (27.5 vs. 24.4 g/kg/day, p-value = 0.037) and lesser incidence of ALTE/BRUE (11.1 % vs 48 %, p = 0.01) at 6 months., Conclusion: While previous research has covered TAFT's impact on complications such as anastomotic leak, stricture, use of TPN and enteral feed, prospective randomized studies remain limited, and the impact on GER, somatic growth, and occurrence of ALTE/BRUE is still unexplored. This study evaluated the short-term outcomes of EA/TEF in a resource-challenged setting, shedding light on the potential benefits of repair without TAFT such as reduction in the rate of anastomotic leak, earlier feeding, reduced GER, better somatic growth and reduced incidence of ALTE/BRUE., Level of Evidence: Level II (Treatment study/Randomized controlled trial)., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Emerging in vivo evidence suggests that repeated muscle contraction, or exercise, impacts peripheral nerves. However, the difficulty of isolating the muscle-specific impact on motor neurons in vivo, as well as the inability to decouple the biochemical and mechanical impacts of muscle contraction in this setting, motivates investigating this phenomenon in vitro. This study demonstrates that tuning the mechanical properties of fibrin enables longitudinal culture of highly contractile skeletal muscle monolayers, enabling functional characterization of and long-term secretome harvesting from exercised tissues. Motor neurons stimulated with exercised muscle-secreted factors significantly upregulate neurite outgrowth and migration, with an effect size dependent on muscle contraction intensity. Actuating magnetic microparticles embedded within fibrin hydrogels enable dynamically stretching motor neurons and non-invasively mimicking the mechanical effects of muscle contraction. Interestingly, axonogenesis is similarly upregulated in both mechanically and biochemically stimulated motor neurons, but RNA sequencing reveals different transcriptomic signatures between groups, with biochemical stimulation having a greater impact on cell signaling related to axonogenesis and synapse maturation. This study leverages actuating extracellular matrices to robustly validate a previously hypothesized role for muscle contraction in regulating motor neuron growth and maturation from the bottom-up through both mechanical and biochemical signaling., (© 2024 The Author(s). Advanced Healthcare Materials published by Wiley‐VCH GmbH.)

Innovations in control mechanisms for muscle-powered robots are advancing the sophistication of biohybrid machines.

Background: Intraoperative fluid therapy maintains normovolemia, normal tissue perfusion, normal metabolic function, normal electrolytes, and acid-base status. Plethysmographic variability index has been shown to predict fluid responsiveness but its role in guiding intraoperative fluid therapy is still elusive., Aims: The aim of the present study was to compare intraoperative goal-directed fluid therapy based on plethysmographic variability index with liberal fluid therapy in term neonates undergoing abdominal surgeries., Methods: A prospective randomized controlled study was conducted in a tertiary care centre, over a period of 18 months. A total of 30 neonates completed the study out of 132 neonates screened. Neonates with tracheoesophageal fistula, congenital diaphragmatic hernia, congenital heart disease, respiratory disorders, creatinine clearance <90 mL/min and who were hemodynamically unstable were excluded. Neonates were randomized to goal-directed fluid therapy group where the plethysmographic variability index was targeted at <18 or liberal fluid therapy group. Primary outcome was comparison of total amount of fluid infused intraoperatively in both the groups. Secondary outcomes included intraoperative and postoperative arterial blood gas parameters, biochemical parameters, use of vasopressors, number of fluid boluses, complications and duration of hospital stay., Results: There was no significant difference in total intraoperative fluid infused [90 (84-117.5 mL) in goal-directed fluid therapy and 105 (85.5-144.5 mL) in liberal fluid therapy group (p = .406)], median difference (95% CI) -15 (-49.1 to 19.1). There was a decrease in serum lactate levels in both groups from preoperative to postoperative 24 h. The amount of fluid infused before dopamine administration was significantly higher in liberal fluid therapy group (58 [50.25-65 mL]) compared to goal-directed fluid therapy group (36 [22-44 mL], p = .008), median difference (95% CI) -22 (-46 to 2). In postoperative period, the total amount of fluid intake over 24 h was comparable in two groups (222 [204-253 mL] in goal-directed fluid therapy group and 224 [179.5-289.5 mL] in liberal fluid therapy group, p = .917) median difference (95% CI) cutoff -2 (-65.3 to 61.2)., Conclusion: Intraoperative plethysmographic variability index-guided goal-directed fluid therapy was comparable to liberal fluid therapy in terms of total volume of fluid infused in neonates during perioperative period. More randomized controlled trials with higher sample size are required., Trial Registration: Central Trial Registry of India (CTRI/2020/02/023561)., (© 2024 John Wiley & Sons Ltd.)

Biliary atresia (BA) is a fibro-obliterative cholestatic disease of infancy. The presence of cartilage in the resected tissue is an uncommon finding. We documented the presence of both mature and immature hyaline cartilage in the portal plate and the wall of the gallbladder in a 2-month-old girl infant with BA who had undergone Kasai portoenterostomy. The presence of cartilage could be part of a heterotopia or an uncommon connective tissue metaplasia. The presence of immature cartilage with the merging of the perichondrium with the soft tissue highlights a metaplastic etiology in the index case., Competing Interests: Conflict of interest: None., (Copyright © 2024 The Authors.)

Background: Foetal thoracic lesions are uncommon, with the incidence of 1 in 15,000 live births. Antenatal monitoring of these lesions is required to prognosticate the parents about the postnatal outcome of the lesions and about the well-being of the baby. Foetal ultrasound and magnetic resonance imaging (MRI) are the modalities to detect these lesions and follow-up during pregnancy and postnatally. Congenital pulmonary adenomatoid malformations (CPAM), congenital diaphragmatic hernia (CDH) and bronchopulmonary sequestrations (BPS) are the commonly detected foetal thoracic lesions. Parameters such as congenital cystic adenomatoid malformation (CCAM) volume ratio (CVR) and lung-to-head ratio (LHR) determine the prognosis of these lesions. With this background, we planned to study the prognosis and outcome of antenatally detected thoracic lesions., Materials and Methods: This was a prospective study carried out for 2 years (January 2017 to December 2018). Pregnant females with foetuses diagnosed to have thoracic lesions on the second- and third-trimester ultrasound and foetal MRI were enrolled for the study. CVR and LHR were noted. Outcomes were analysed in terms of the need of termination of pregnancy, foetal or neonatal demise and need of surgery or conservative management., Results: Of a total of 521 pregnancies, thoracic lesions were detected in 22 (4.22%) cases. Individually, the incidence of each lesion was: CPAM-10 (45.45%), BPS-5 (22.73%), CDH-5 (22.73%) and congenital higher airway obstruction-2 (9.1%). Chromosomal screening was normal in 100% of cases. Follow-up was done for 2 years. Termination of pregnancy was required in 3 (13.64%) cases, postnatal death occurred in 4 (18.2%) cases, surgery was required in three cases of CDH soon after birth and two cases of extralobar BPS at 2 years of age. 10 (45.45%) cases were managed conservatively, who are doing well at 2-year follow-up., Conclusion: CPAMs, BPSs and CDH are the commonly detected antenatal thoracic lesions. Ultrasonography and MRI help detect and prognosticate the parents about the outcomes of these lesions. CVR and LHR with associated congenital malformations are important prognostic markers for these lesions. There is a need of long-term prospective studies to delineate the natural history of these lesions., (Copyright © 2023 Copyright: © 2023 African Journal of Paediatric Surgery.)

Introduction: Diabetes mellitus is a multisystem disorder, which is one of the most prevalent and important non-infectious causes of morbidity and mortality worldwide. While diabetic retinopathy (DR) and diabetic cataracts are well-known complications, dry eye syndrome (DES), also referred to as keratoconjunctivitis sicca, is also common in the diabetic population. If left untreated, severe dry eye may lead to eye inflammation, abrasion of the corneal surface, corneal ulcers, and vision loss. So, it is very important to diagnose it earlier as these devastating complications can be prevented., Materials and Methods: A total of 200 adult patients diagnosed with type II diabetes of either sex with an age more than 40 years were selected. Complete ophthalmological examination was done. Dry eye was diagnosed on the basis of various objective tests, and proportion of dry eye and its relation with glycemic control were studied., Conclusion: Patients with uncontrolled type II diabetes had a higher proportion of dry eye disease. A significant co-relation was found among the FBS levels, the HbA1c levels, age, duration of disease, and dry eye in patients with diabetes. No significant co-relation was found between the sex of the patient and dry eye in patients with diabetes. Hence, our study recommends that primary care physicians should advise their patients to get clinical evaluation for dry eye done along with diabetic retinopathy in uncontrolled diabetes., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Family Medicine and Primary Care.)

Objective: Our objectives were to investigate the recent frequency of cerebrospinal fluid (CSF) HIV RNA escape and other CSF viral nucleic acid detection in people with HIV with neurological symptoms and to assess associated clinical factors., Method: This was a retrospective cohort analysis of people with HIV who underwent CSF examination for clinical indications between 2017 and 2022. Individuals were identified from pathology records, and clinical data were recorded. CSF HIV RNA escape was defined as CSF HIV RNA concentrations greater than in plasma. CSF viral screen included herpes simplex virus types 1 (HSV-1) and 2 (HSV-2), varicella zoster virus (VZV), Epstein Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus 6 (HHV-6) and JC virus. When cases were detected in five or more people with HIV, associated clinical factors were assessed using linear regression modelling., Results: CSF HIV RNA escape was observed in 19 of 114 individuals (17%) and was associated with the presence of HIV drug resistance mutations and non-integrase strand transfer inhibitor-based antiretroviral therapy (p < 0.05 for all) when compared to people with HIV without escape. Positive viral nucleic acid testing included EBV (n = 10), VZV (3), CMV (2), HHV-6 (2) and JC virus (4). Detectable CSF EBV was not considered related to neurological symptoms and was associated with concomitant CSF infections in eight of ten individuals and with CSF pleocytosis, previous AIDS, lower nadir and current CD4 T-cell count (p < 0.05 for all)., Conclusion: In people with HIV with neurological symptoms, the frequency of CSF HIV RNA escape remains similar to that in historical reports. Detectable EBV viral nucleic acid in the CSF was observed frequently and, in the absence of clinical manifestations, may be a consequence of CSF pleocytosis., (© 2023 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Ageing leads to a sharp decline in immune function, precipitating the development of inflammatory conditions. The combined impact of these processes renders older individuals at greater risk of inflammatory and immune-related diseases, such as cancer and infections. This is compounded by reduced efficacy in interventions aiming to limit disease impact, for instance vaccines being less effective in elderly populations. This state of diminished cellular function is driven by cellular senescence, a process where cells undergo stable growth arrest following exposure to stressful stimuli, and the associated pro-inflammatory secretory phenotype. Removing harmful senescent cells (SnCs) using senolytic therapies is an emerging field holding promise for patient benefit. Current senolytics have been developed either to specifically target SnCs, or repurposed from cancer therapies or vaccination protocols. Herein, we discuss recent developments in senolytic therapies, focusing on how senolytics could be used to combat the age-associated diminution of the immune system. In particular, exploring how these drugs may be used to promote immunity in the elderly, and highlighting recent trials of senolytics in idiopathic pulmonary fibrosis and diabetic kidney disease. Novel immunotherapeutic approaches including chimeric antigen receptor T-cells or monoclonal antibodies targeting SnCs are being investigated to combat the shortcomings of current senolytics and their adverse effects. The flexible nature of senolytic treatment modalities and their efficacy in safely removing harmful SnCs could have great potential to promote healthy immune function in ageing populations., Competing Interests: The authors declare no conflict of interest., (© The Author(s) 2023. Published by Oxford University Press.)

Background: There is a paucity of research focusing on the stress levels in parents of newborns undergoing surgery. Resource challenged systems have to deal with overcrowding, a shortage of workforce along with demographic and socioeconomic issues like delayed presentations and out of pocket expenses. The primary objective of this study was to understand the factors associated with stress in the parents of these congenitally malformed neonates., Methodology: This was a prospective cohort study, which was conducted in a neonatal surgical ICU of a tertiary care teaching hospital. Factors affecting stress levels in parents of surgical neonates were studied in 100 participants. A multi-dimensional questionnaire - The PSS: NICU score was utilized in the study. The parents were interviewed on Day 3-5 after surgery., Result: 59% of the respondents were fathers. The majority of the parents were in the age bracket of 24 to 35 years. The mean scores for the subscales sights and sounds, looks and behavior and alteration in the parental role were 3.24±0.8, 3.52±0.63, 3.55±0.8 and 2.8 ± 0.9 respectively. The highest level of stress was found in the domains of alteration of parental role and infant appearance and behavior. Comparisons showed significantly higher maternal scores in all the domains. Overall stress scores were highest for abdominal wall defects., Conclusion: Parents of neonates undergoing surgery suffer from significant stress levels and appropriate counseling targeted towards specific stressors is required to allay this important parental issue., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Currently, 21−30% supplemental oxygen is recommended during resuscitation of preterm neonates. Recent studies have shown that 58% of infants < 32 week gestation age are born with a heart rate (HR) < 100 bpm. Prolonged bradycardia with the inability to achieve a preductal saturation (SpO2) of 80% by 5 min is associated with mortality and morbidity in preterm infants. The optimal oxygen concentration that enables the achievement of a HR ≥ 100 bpm and SpO2 of ≥80% by 5 min in preterm lambs is not known. Methods: Preterm ovine model (125−127 d, gestation equivalent to human neonates < 28 weeks) was instrumented, and asphyxia was induced by umbilical cord occlusion until bradycardia. Ventilation was initiated with 30% (OX30), 60% (OX60), and 100% (OX100) for the first 2 min and titrated proportionately to the difference from the recommended preductal SpO2. Our primary outcome was the incidence of the composite of HR ≥ 100 bpm and SpO2 ≥ 80%, by 5 min. Secondary outcomes were to evaluate the time taken to achieve the primary outcome, gas exchange, pulmonary/systemic hemodynamics, and the oxidative injury. Results: Eighteen lambs (OX30-6, OX60-5. OX100-7) had an average HR < 91 bpm with a pH of <6.92 before resuscitation. Sixty seven percent achieved the primary outcome in OX100, 40% in OX60, and none in OX30. The time taken to achieve the primary outcome was significantly shorter with OX100 (6 ± 2 min) than with OX30 (10 ± 3 min) (* p = 0.04). The preductal SpO2 was highest with OX100, while the peak pulmonary blood flow was lowest with OX30, with no difference in O2 delivery to the brain or oxidative injury by 10 min. Conclusions: The use of 30%, 60%, and 100% supplemental O2 in a bradycardic preterm ovine model did not demonstrate a significant difference in the composite primary outcome. The current recommendation to use 30% oxygen did not achieve a preductal SpO2 of 80% by 5 min in any preterm lambs. Clinical studies to optimize supplemental O2 in depressed preterm neonates not requiring chest compressions are warranted.

Background: Neonatal Resuscitation Program does not recommend placental transfusion in depressed preterm neonates., Methods: Our objectives were to study the effect of delayed cord clamping (DCC) with ventilation for 5 min (DCCV, n-5), umbilical cord milking (UCM) without ventilation (n-6), UCM with ventilation (UCMV, n-6), early cord clamping followed by ventilation (ECCV, n-6) on red cell volume (RCV), and hemodynamic changes in asphyxiated preterm lambs. Twenty-three preterm lambs at 127-128 days gestation were randomized to DCCV, UCM, UCMV, and ECCV. We defined asphyxia as heart rate &lt;100/min., Results: The UCMV had the highest neonatal RCV as a percentage of fetoplacental volume compared to the other groups (UCMV 85.5 ± 10%, UCM 72 ± 10%, ECCV 65 ± 14%, DCCV 61 ± 10%, p &lt; 0.01). The DCCV led to better ventilation (66 ± 1 mmHg) and higher pulmonary blood flow (75 ± 24 ml/kg/min). The carotid flow was significantly higher in UCM without ventilation. The fluctuations in carotid flow with milking were 25 ± 6% higher from baseline during UCM, compared to 6 ± 3% in UCMV (p &lt; 0.01)., Conclusions: Cord milking with ventilation led to higher RCV than other interventions. Ventilation during cord milking reduced fluctuation in carotid flow compared to UCM alone. DCCV led to better ventilation and pulmonary blood flow but did not increase RCV., Impact: The best practice of placental transfusion in a depressed preterm neonate remains unknown. Ventilation with an intact cord improves gas exchange and hemodynamics in an asphyxiated preterm model. Cord milking without ventilation led to lower red cell volume but higher carotid blood flow fluctuations compared to milking with ventilation. Our data can be translated to bedside and could impact preterm resuscitation., (© 2022. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Effective positive-pressure ventilation is a critical factor in newborn resuscitation. Neonatal endotracheal intubation (ETT) needs considerable training and experience, which poses a human factor challenge. Laryngeal mask airway (LMA) ventilation can be a secure and viable alternative during the initial stages of newborn resuscitation. However, there is limited evidence for its use during chest compression (CC)., Methods: Seventeen lambs were randomized into LMA or ETT ventilation post cord occlusion induced cardiac arrest. After 5 min of cardiac arrest, resuscitation was initiated as per NRP recommendations. Ventilation, oxygenation, systemic and pulmonary hemodynamic parameters were recorded till the return of spontaneous circulation (ROSC) or 20 min., Results: Baseline characteristics were similar between the groups. The incidence of ROSC was 75% (6/8) in the LMA group and 56% (5/9) in the ETT group (p = 0.74). The median (IQR) time to achieve ROSC was 6.85 min (6 min-9.1 min) in the LMA group and 7.50 min (5.33 min-18 min) in the ETT group (p = 0.65)., Conclusion: LMA ventilation during CC is feasible and non-inferior to ETT in this model., Impact: Laryngeal mask airway (LMA) ventilation with chest compression is feasible and non-inferior to endotracheal tube ventilation in this experimental near-term lamb model of asphyxial cardiac arrest. First translational study to evaluate the use of LMA as an airway device with chest compression. Evidence primer for clinical studies to evaluate and confirm the feasibility and efficacy of LMA ventilation with chest compression are necessary before randomized clinical trials in neonates. LMA use in neonatal cardiopulmonary resusciation (CPR) could have the potential to optimize advanced resuscitation, especially in resource-limited healthcare settings., (© 2021. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Outcome of Isolated ventriculomegaly diagnosed antenatally depends on size of ventricles and associated malformations. There is scarcity of literature on the guidelines for prognostication based on outcomes as per the ventricle size., Aim: The aim of this work was to study outcome of antenatally detected isolated ventriculomegaly in terms of medical termination, postnatal neuro-developmental milestones, and mortality; and also to propose a new prognostication classification., Methods: Prospective and retrospective observational study on antenatal mothers with isolated ventriculomegaly diagnosed in fetus. Outcomes in terms of termination of pregnancy, postnatal mortality, need of surgery, and morbidity were recorded. Patients were categorized into four groups: Group 1--ventricle size <10 mm, II--11-15 mm, III--16-20 mm, and IV > 20 mm and neuro-developmental milestones were co-related. Association with chromosomal anomalies, congenital heart disease, and maternal infection were also analyzed., Results: 521 antenatal females were referred with fetal anomalies with 163 having CNS malformations. Isolated ventriculomegaly was seen in only 44. Patients of groups 1 and 2 had 100% normal neuro-developmental milestones without any intervention. Group 3 patients had normal neurodevelopmental milestones in 60% only while shunt surgery was required in 40% of patients. All patients of group 4 had poor outcome with only 50% survival. No association with chromosomal anomalies and heart disease was found., Conclusions: Prognosis of isolated ventriculomegaly depends upon size of ventricles and its progressive increase on serial ultrasounds. New proposed classification is simple and would be useful for the treating surgeons to explain the prognosis to parents so as to relieve them of anxiety., Competing Interests: None

Objective: To estimate the impact of delayed presentation of anorectal malformation (ARM) in neonates and to compare the presenting characteristics and outcomes of early versus delayed presentation., Methods: This is a prospective observational study of all neonates (age < 28 d) with ARM over 2 y. Delayed presentation was defined as presentation beyond 48 h of birth. Various presenting features and their early postoperative outcomes were compared., Results: Nearly half (26, 48%) of the 54 neonates with ARM had delayed presentation. Early and late presenters did not differ in terms of gender, gestational age, birth weight, place of delivery, and type of ARM (p > 0.05 for all). Delayed group had lower weight at presentation (p = 0.008), higher incidence of severe abdominal distension (p = 0.05), and sepsis (p = 0.171) and required longer time for resuscitation (p = 0.007) and more inotropes (p = 0.015), preoperatively. Early postoperative outcomes including time for stoma to function, initiate feeds and time to reach full feeds were significantly delayed in late presenters. They also had more wound infections, longer hospital stay and higher mortality., Conclusions: Delayed diagnosis of ARM is associated with significantly higher morbidity and mortality. Adequate awareness and training of health workers for early identification of ARM by careful perineal examination of all newborns at birth is the need of the hour., (© 2021. Dr. K C Chaudhuri Foundation.)

Background: Buprenorphine-naloxone (BUP-NX) is a first-line treatment for opioid use disorder and has a superior safety profile compared to other forms of opioid agonist therapy. In Canada, restrictions on BUP-NX prescribing were relaxed in 2016, which may have had an effect on rates of diversion and non-prescribed use. We sought to longitudinally examine the reported availability and use of non-prescribed BUP-NX among people who use drugs (PWUD) in an urban Canadian setting., Methods: We collected data from two linked prospective cohorts of PWUD in Vancouver, Canada, and examined self-reported availability and use of non-prescribed BUP-NX over time. We used a multivariable generalized estimating equations model to identify trends and factors associated with the immediate availability (i.e., within 10 min) of non-prescribed BUP-NX., Results: Among 1617 participants between 2014 and 2020, the immediate availability of non-prescribed BUP-NX increased from 16% to 63% (p<0.001). In the multivariable analysis, factors independently associated with immediate BUP-NX availability included calendar year (adjusted odds ratio = 1.19, 95% confidence interval: 1.15-1.23), along with a number of other variables suggestive of more severe substance use disorders. Only 17 participants ever reported use of non-prescribed BUP-NX., Conclusions: We observed that BUP-NX has become increasingly available in the unregulated drug supply in recent years but its use has remained infrequent in this setting. These results suggest that relaxed restrictions on BUP-NX prescribing have not been a major driver of increased non-prescribed use in this population., Competing Interests: Declarations of Interest The authors report no conflicts of interest., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives: The purpose of this study was to evaluate the accuracy and reliability of Mobile Application-Based Software for chair side cephalometric analysis., Materials and Method: Pretreatment lateral cephalograms of 20 patients (10 males and 10 females) were selected randomly and were traced manually and also using Application-based software (One Ceph). 20 angular and three linear parameters were measured both manually and with the software in all the patients. Inter and intra-operator reliability of one ceph was evaluated and the measured parameters were statistically compared with the manual method (Gold Standard)., Result: The accuracy of angular and linear values was compared for all 23 parameters and our results showed no significant difference in the two methods used for most of the measurements. Three of the measurements [Angle of convexity (N-A; A-Pog); ANB angle; Upper Incisor to NA (Angular)] did show a statistically significant difference though these were clinically irrelevant., Conclusion: Application-based cephalometric analysis can be an effective clinical diagnostic tool for chair-side cephalometric evaluation of orthodontic patient., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Orthodontic Science.)

Purpose: To evaluate role of 3-T magnetic resonance portovenography (MRPV) in children with extra hepatic portal venous obstruction (EHPVO) and compare unenhanced and contrast-enhanced sequences., Methods: 20 Children with EHPVO underwent MRPV using unenhanced [T2, T1 pre-contrast, Balanced turbo field echo (BTFE)] and contrast-enhanced (CE) modified DIXON (mDIXON) sequences. The images were evaluated for the patency of abdominal veins, hepatic and splenic parenchyma by two radiologists for interobserver agreement., Results: BTFE and post-contrast mDIXON sequences performed best for evaluation of abdominal veins. Concordance between the BTFE and CE sequences was good to very good for both the radiologists for splenic vein (SV) evaluation. The concordance between the two sequences for evaluation of superior mesenteric vein and its confluence with the SV was less remarkable and varied from fair to good, while the interobserver agreement was very good to perfect. The interobserver agreement between the BTFE and CE sequence for the evaluation of left renal vein was very good, while that for IVC was perfect. The agreement between BTFE and CE sequence was perfect for the evaluation of right and middle hepatic veins, while the interobserver agreement was good to perfect. The interobserver agreement was poor for evaluation of hepatic parenchyma on BTFE sequence as compared to CE sequence, and moderate for splenic parenchyma., Conclusion: BTFE sequence is the single best unenhanced MR pulse sequence to detect all the vascular structures in children with EHPVO. CE-MRI is not superior to BTFE sequence and should be used at the discretion of the radiologist., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction:  Minimal access surgical approach to choledochal cyst (CC) is becoming a standard of care in pediatric age group. Robotic-assisted excision of CC is increasingly being practiced at centers which have access to the system. We present our experience and technique of hepaticoduodenostomy (HD). Over all initial experience, short-term outcomes and complications are also presented and discussed., Materials and Methods:  Patients with CC and undergoing robotic excision were retrospectively studied. Patients with active cholangitis, liver dysfunction, and perforated CC were excluded for robotic procedures. All included patients were preoperatively evaluated as per the defined protocol. They underwent excision of CC with HD. The duodenal anastomosis was done after limited mobilization and emphasis was laid on anastomosing the distal D2 part to the common hepatic duct. This prevents bile reflux into stomach. The follow-up evaluation was done for these patients. Hepatobiliary iminodiacetic acid (HIDA) scan for duodenogastric reflux (DGR) was done only if patients reported symptoms related to it., Results:  A total of 19 patients (10 females) were studied. The mean age was 84 months. Type 1b was present in 12 patients and the rest were type IVb. Complete cyst excision with HD was done in all patients except conversion to open in one patient. The mean surgical time was 170 ± 40 minutes with console time of 140 ± 20 minutes. Median follow-up duration is 2.5 years (range: 3.5-0.5 years). HIDA scan was done in five patients who had reported epigastric pain. Of these five, one patient had a positive DGR. He is on conservative management., Conclusion:  Robot-assisted CC excision with HD is feasible as proven by the outcome of 19 patients presented in this series. HD is to be done away from pylorus in distal part of down curving D2. This particular step prevents DGR and is the most important point of technique in doing HD. The presented series is the first report of robotic excision of CC with HD. The robot is a facilitator for complex and difficult operations as CC excision and HD., Competing Interests: None declared., (Thieme. All rights reserved.)

(1) Background: Optimal initial oxygen (O 2 ) concentration in preterm neonates is controversial. Our objectives were to compare the effect of delayed cord clamping with ventilation (DCCV) to early cord clamping followed by ventilation (ECCV) on O 2 exposure, gas exchange, and hemodynamics in an asphyxiated preterm ovine model. (2) Methods: Asphyxiated preterm lambs (127-128 d) with heart rate <90 bpm were randomly assigned to DCCV or ECCV. In DCCV, positive pressure ventilation (PPV) was initiated with 30-60% O 2 and titrated based on preductal saturations (SpO 2 ) with an intact cord for 5 min, followed by clamping. In ECCV, the cord was clamped, and PPV was initiated. (3) Results: Fifteen asphyxiated preterm lambs were randomized to DCCV (N = 7) or ECCV (N = 8). The inspired O 2 (40 ± 20% vs. 60 ± 20%, p < 0.05) and oxygen load (520 (IQR 414-530) vs. 775 (IQR 623-868), p-0.03) in the DCCV group were significantly lower than ECCV. Arterial oxygenation and carbon dioxide (PaCO 2 ) levels were significantly lower and peak pulmonary blood flow was higher with DCCV. (4) Conclusion: In asphyxiated preterm lambs, resuscitation with an intact cord decreased O 2 exposure load improved ventilation with an increase in peak pulmonary blood flow in the first 5 min.

Purpose: Association of spinal or vertebral anomalies and the iatrogenic denervation during surgical correction of anorectal malformation patients especially in boys can lead to neurogenic bladder inthese subset of patients. The paucity of literature with regard to urodynamic studies focusing exclusively in male children with high-anorectal malformations (HARM) lead us to analyze the urodynamic changes. The objective was to study urodynamic profile in male patients who have undergone surgery for anorectal malformation., Methods: Male high-anorectal malformation patients who had completed all the stages of repair were prospective studied. Following the basic work up, all patients based on the urodynamics were categorized into 2 groups as safe or unsafe bladders. Unsafe bladder was defined as detrusor pressure > 40 cm (high detrusor pressure) or pressure variability of 15 cm of water (detrusor overactivity) or significant post-void residue. MRI was limited to patients with only abnormal urodynamics to rule out spinal causes of neurogenic bladder and due to financial constraints, it could not be offered to all patients., Results: 41 HARM meet the exclusion criteria. All patients were asymptomatic with none having history of urinary tract infections. Ultrasound showed bladder wall thickening in 31.7% patients. UDS revealed reduction in bladder capacity and compliance was noted in 31.7% and 30% patients, respectively. Elevated detrusor pressures (> 40 cm of water) were noted in 10% (4/41), detrusor overactivity with concomitant elevated detrusor pressures in 19.5% (8/41) and normal UDS in 70% (29/41). 13 patients (31.7%) had abnormal cystometric parameters with 12(30%) having unsafe bladders. MRI confirmed sacral agenesis in 1 patient with unsafe bladder., Conclusion: Urodynamics can demonstrate occult neurovesical dysfunction in patients with HARM. This would help in early renal protective therapy and prevent the burden of long-term sequelae of neurovesical dysfunction in HARM patients.

Introduction: Neurogenic bladder (NB) post-meningomyelocele (MMC) repair is a major challenge and needs lifelong follow-up. Many cytokines have been implicated in the pathogenesis of NB. To avoid repeated urodynamic studies (UDS) and renal scans, we studied urinary tissue inhibitors of metalloproteinases-2 (TIMP-2) levels and correlated with urodynamic profiles to establish their efficacy., Materials and Methods: Prospective case-control study on children between 6 months to 12 years of age, who were at least 6 months post-MMC repair and had NB on UDS. Patients were evaluated under 4 cohorts of 20 patients each: Group A (NB on treatment), Group B (NB not on treatment), Group C (no NB), and Group D (Controls). All groups underwent radiofrequency thermocoagulation, urine culture, ultrasonography. Urine samples were stored at -800°C and analyzed using a validated Human ELISA kit for TIMP-2., Results: Eighty patients with a mean age of 3.54 ± 2.1 years were studied. A common ultrasound finding was a thickened urinary bladder (33.3%). All UDS parameters showed a statistically significant differences between groups with NB (Groups A and B) and a group without NB (Group C). Analysis of TIMP-2 levels between individual groups was statistically significant. The area under the receiver operating characteristic curve between urinary TIMP-2 and cystometric parameters indicated that urinary TIMP-2 levels are highly diagnostic of NB. TIMP-2 value of 358.5 pg/ml was found to be the least value with 93.5 sensitivity and 86.2% specificity., Conclusion: This study highlights the potential of urinary marker TIMP-2 as noninvasive and cost-effective test to initially diagnose and predict the progression of disease in NBs with reasonable sensitivity and specificity., (© 2020 Wiley Periodicals LLC.)

Purpose: This study is carried out to characterize the prognosis and outcome of antenatally diagnosed cystic hygroma in a series of registered pregnancies., Methods: This is a prospective cohort study, carried out over a period of 4 years (Jan 2016-Sept 2019). All the pregnancies referred from the department of obstetrics with antenatally detected cystic hygroma or increased nuchal thickness on level II ultrasonography suggestive of lymphangiomas were registered in the Pediatric Surgery outpatient department. Amniocentesis, fetal ECHO and fetal MRI (if indicated)were done. Prognosis was explained to the family and mode of delivery was planned as per the obstetric indications. Postnatal evaluation included general physical examination along with ultra sound (USG)doppler of the lesion. The neonates were admitted in neonatal surgical ICU for the administration of intralesional bleomycin in a dose of 0.3 IU/kg under strict observation. All the babies were followed up at 3, 6 and 12 months. Results were segregated as excellent, good and still in follow up cohort as per the final outcome. The fetal neck masses detected antenatally and the age at first dose of bleomycin were compared with the number of sclerotherapy doses required to achieve good response., Results: Only nine patients out of 626 registered pregnancies (1.4%) were diagnosed with cystic hygroma. One antenatal mother opted for termination of pregnancy at 19 weeks of gestation and another patient was lost to follow up after receiving two doses of bleomycin in postnatal period. Maternal hypothyroidism was noted in two pregnancies. Antenatal USG shows increased nuchal thickness in 2 cases (first trimester) and 6 cases in level II scan. Amniocentesis shows normal fetal karyotyping in all these pregnancies. Fetal ECHO suggests normal biventricular function in 100% cases while fetal MRI done in one case completely ruled out any aerodigestive compromise. Mode of delivery is found to be planned elective LSCS in 57% of cases while normal vaginal delivery attained in 43% of cases as per the obstetric guidelines. Six cases achieved good response with >50% reduction in size out of which 4 cases received the dose at the first 10 days of life. Complete disappearance of lesion at the end of 6 months of follow up were seen in two babies., Conclusions: Antenatal screening for early detection of fetal cystic hygroma with possible associated congenital aneuploidies helps in prognostication and planning the mode of delivery. A multimodality approach during intra and postpartum increases safety margin. Even huge neck masses without associated anomalies carry fair prognosis. Intralesional bleomycin is safe and prevents surgical morbidity., (Copyright © 2020. Published by Elsevier B.V.)

Aim: Vesicoscopic Cohen's reimplantation closely replicates the open procedure and is reported to have equally good results. Robotic assisted vesicoscopic reimplantation (RAVR) is a new procedure, and the information on technique of RAVR is sparse. We present our technique, experience, and early outcome with RAVR and review of literature. Patients and Methods: We retrospectively evaluated patients with vesicoureteric reflux grade II and above. These patients were subjected to RAVR. Selection criteria for this procedure were age >4 years, preserved renal function, and bladder capacity >250 mL. Patients with previous bladder surgery or urethral issues were excluded. Patients were operated by DaVinci Si system, and the technique is described in detail. Three ports were placed by use of bougie. The ureters were adequately mobilized before placing in submucosal tunnel. Results: Total of 5 ureters were reimplanted in 4 patients (2 females and 1 bilateral). Ureteral tapering was done in 1 patient. Mean port placement time was 25 minutes with 12 minutes of docking time. Mean console time was 70 minutes for unilateral cases and 100 minutes for the bilateral case. There was resolution of reflux in all patients. The mean follow-up duration is 9 months. Conclusions: Robotic assisted vesicoscopic reimplantation is a feasible and safe method of replicating Cohen's reimplantation. There is a learning curve with the procedure, and nuances related to the technique need to be learned by the surgeon. This is the third report on RAVR and provides the necessary technical details required by a robotic surgeon to replicate this procedure.

Background: We wish to describe a novel technique of transdiaphragmatic excision of hepatic hydatid in patients with synchronous ipsilateral lung hydatid. Patients and Methods: Two patients, aged 11 and 6 years, presented with large synchronous hydatid cyst in right lung and liver. Second patient had two large cysts in right lobe of liver in posterior-superior segment of VII and VIII. The patients underwent thoracoscopic excision of lung cyst, and in same sitting the liver hydatid was seen bulging through the diaphragm. The diaphragm was incised to expose the cyst beneath, with excision of hydatid. Port-in-cyst technique was used to excise the membranes. Results: Both lung and liver cyst were successfully removed through thoracoscopic approach and a laparotomy was altogether avoided. Both patients did well in follow-up (3 years and 6 months). There are no respiratory issues in these patients. Conclusions: This is a novel approach for multiple synchronous hepatic and pulmonary hydatid. This can be applied in specific scenario as described. It gives a significant advantage of avoiding a laparotomy and thoracotomy in patients and thus reducing morbidity.

Aim: The aim is to prospectively study 125 trauma patients admitted in the pediatric surgery ward in our institute., Materials and Methods: Pediatric patients admitted in the ward after initial resuscitation in the triage room were included. Isolated neurosurgical and orthopedic injuries were excluded. X-ray cervical spine, hip, and chest and a focused assessment with sonography in trauma ultrasound were done for all patients. Computed tomography of the abdomen or chest was done where relevant. Injury profile and surgical intervention when needed were analyzed., Results: Road traffic accidents and fall from height caused 73.6% of the injuries. School-going children were most commonly affected (60.8%). Distinctive injuries were noted such as abdominal wall hernias and delayed bladder perforation. All solid organ injury irrespective of grade treated conservatively. Forty percent of the children required surgical intervention. Five patients after laparotomy were found to have surgical conditions unrelated to trauma, whereas another 14 required delayed surgery. Five patients had injuries secondary to sexual abuse. All except two patients were discharged in a satisfactory condition and are doing well in the follow-up., Conclusion: In spite of extensive injuries and the need for multiple surgeries, children with trauma have a good prognosis. Close observation during admission and also in follow-up are essential, as many patients may require delayed surgery ≥1 week from injury., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Indian Association of Pediatric Surgeons.)

Context: Anterior sagittal anorectoplasty (ASARP) is accepted as one of the techniques for the repair of vestibular fistula (VF) and low-type anomalies, but some may have reservations., Aims: The aim of the study is to describe the technique, important features, and functional and cosmetic outcomes of ASARP for the treatment of anorectal malformation (ARM) in females., Settings and Design: A prospective study was performed from 1992 to 2017., Materials and Methods: The study included 157 pediatric patients (aged 1-15 years) with diagnosis of ARMs with VF, perineal fistula (perineal ectopic anus), and rectovaginal fistula managed by ASARP., Results: Most cases (36.94%) were 1-6 months' age group; 92.99% of patients (146) were having VF, 5.09% (8) perineal fistula, and 1.91% (3) rectovaginal fistula. Associated anomalies (37) were present in 19.75% (31) of patients. Primary ASARP was performed in 85.35% (134) of cases. The mean operative time was 105 (±15) min. Intraoperative complications were seen in 3.82% (6) of patients. Early postoperative complications were seen in 5.09% (8) of patients - wound infection (4), wound dehiscence (3), and retraction of the rectum (1). Late complications were seen in 12.73% (20) of cases. Overall, five patients developed anal stenosis, two responded to dilatation therapy, and three required anoplasty. The external appearance of the perineum after the 3 rd month (postoperatively) was satisfactory in 95.54% (150); overall, 4.46% (7) of patients required the second procedure. Stooling pattern could be assessed in 80.25% (126) of patients at 3 years' age group. Only one had poor outcome with severe soiling (incontinence) and perineal excoriation that also had myelomeningocele., Conclusions: ASARP is an excellent procedure for VF as it results in optimal correction with minimal sphincteric damage, without additional complexity or difficulties. Primary ASARP is a quick and effective technique and does not require colostomy if performed after due preoperative gut preparation and by an experienced pediatric surgeon., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Indian Association of Pediatric Surgeons.)

The house crickets, Acheta domesticus, are sustainable and nutritious future sources of food, due to their nutritional benefits, particular high protein content and potential in solving global malnutrition. Different diets, particularly protein content, can influence the growth and nutritional value of crickets. The aim of this present study was to evaluate the effects of commercial diets and other formulated diets on the nutritional composition and growth parameters of the house crickets, being a major challenge to cricket's farmers in Thailand. Feed conversion ratio were 1.50, 1.50, and 1.51 for fed crickets on a blend of 22% protein and dry pulp pumpkin powder, fed 22% protein plus fresh pumpkin pulp, and fed 22% protein alone, indicated that these groups are high feed convertors and represented the quality of these diets compared to 1.73 and 1.81 for fed crickets on a blend of 22% and 16% protein, and those fed on 16% protein alone. Fed crickets on 22% protein had the highest amount of protein (76%), the lowest (48%) in those fed on 22% protein and fresh pumpkin pulp inclusion. The group on 22% protein diet also had the highest amount of phosphorus, potassium, calcium, and sodium. Fed 22% protein and either dry pulp pumpkin powder or fresh pumpkin pulp condition have shown improvement in vitamin B content. Crickets can effectively be produced on 22% protein diet to improve yield output and several minerals such as phosphorus, potassium, calcium, and sodium. In contrast, the supplementation of 22% protein diet with pumpkin (Cucurbita maxima) will improve vitamin B content., (© The Author(s) 2020. Published by Oxford University Press on behalf of Entomological Society of America.)

A novel route was created to facilitate the degradation of diethyl phthalate (DEP) upon micellar polyoxometalate (POM) catalysts and H 2 O 2 . The best catalytic activity was obtained using [C 16 H 33 N(CH 3 ) 3 ]H 4 PMo 10 V 2 O 40 (N-hexadecyl-N,N,N-trimethylammonium tetrahydrogen decamolybdo-divanadophosphate, abbreviated as (CTA)H 4 PMoV) with 90.2% degradation efficiency within 30 min, while the chemical oxygen demand (COD) and total organic carbon (TOC) removal efficiency were about 77.7% and 74.3% within 40 min. The highest efficiency was attributed to the concentration of DEP by amphiphilic POM catalyst, coupling with its strong Brønsted acidity and higher redox potential to catalyze esterolysis and oxidation of DEP. This allowed the phthalate acid esters (PAEs) with long carbon chains in super low concentration of 0.03 μM to be efficiently decomposed. The above synergistic effects explored DEP being degraded into ethanol, lactic acid and CO 2 , which were non-toxic to the water surroundings. And the reaction activation energy (Ea) of 12.49 kJ/mol was obtained upon the degradation of DEP with (CTA)H 4 PMoV followed first-order kinetics. Meanwhile, (CTA)H 4 PMoV acted as a heterogeneous catalyst, which showed long duration and higher stability with only 3.7% loss amount during ten recycles., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Placement of ventriculoperitoneal shunt is a standard treatment for hydrocephalus. The risk of shunt malfunction in the first year is 25%-40% making endoscopic third ventriculostomy (ETV) a feasible option in those patients with shunt failure., Aim: The aim of this study was to evaluate ETV as a viable option in patients with shunt malfunction and to correlate the clinical outcome following successful ETV with functional and radiological outcomes., Materials and Methods: All patients who underwent ETV as a diversion procedure for hydrocephalus following shunt failure or malfunction over 1 year were studied. Functional outcome was evaluated by Wee function independence measure score carried out preoperatively, postoperatively, and at 6-month follow-up. Similar comparison was carried out for radiological parameters such as effacement of gyri, periventricular lucency, frontal horn diameter (maximum), Evans' index, and third ventricular diameter., Results: Of 15 patients, 61.5% were shunt free after ETV. All the failures were noted in the first month following the procedure. The factors, which showed statistically significant correlation with the outcome of ETV, included age ( P = 0.030), preoperative functional score ( P = 0.006), and all the three components of the functional scoring, namely self-care score ( P = 0.087), motor control score ( P = 0.035), and neurocognitive score ( P = 0.003). Parameters such as Evans' index, maximum frontal horn diameter, and third ventricular diameter showed no significant difference between preoperative and postoperative scans. In follow-up imaging, only the frontal horn diameter showed a significant improvement ( P = 0.047)., Conclusion: ETV leads to significant neurocognitive improvement and postoperative functional status making it a viable option in patients who present with shunt malfunction., Competing Interests: There are no conflicts of interest.

Introduction: Ventriculoperitoneal (VP) shunt is a commonly performed neurosurgical procedure in pediatric surgical practice. This study is aimed at determining the outcome of congenital hydrocephalus patients who underwent shunt surgery at our center., Materials and Methods: A total of 278 operated cases of congenital hydrocephalus with a minimum follow-up of 6 months were analyzed in terms of complications. Hydrocephalus associated with intracranial hemorrhage, neural tube defects, and ventriculitis were excluded from the study., Results: Complications were observed in 32.0% (89/278) of cases. Shunt block and chamber migration were the most common complications (29.21%). Abdominal wound complications were seen in 4.49% of cases. Shunt exposure due to erosion of overlying skin was noted in 6 patients. Shunt infection was diagnosed in only 9 patients (4.4%). New-onset seizures were seen in 4 cases. Overall, 21% of patients required redo shunt and there were 2 mortalities., Conclusion: VP shunt continues to have high complication rates. Shunt migration and new-onset seizure disorders are important late complications. In spite of inherent problems, shunt surgery is the procedure of choice until a safer effective alternative is available., (© 2019 S. Karger AG, Basel.)

Objective: To report our experience with endoscopic management of vesicoureteral reflux (VUR) by injection of a tissue bulking substance - Dextranomer/ hyaluronic acid co-polymer at vesicoureteric junction., Design: Retrospective analyses of case records., Setting: Pediatric Surgery department in a tertiary care government Institute., Participants: 500 children (767 renal units) consecutively referred to the out-patient department with vesicoureteral reflux noted on micturating cysto-urethrogram (MCU) over a period of 13 years (2004-2016)., Intervention: Preoperative VUR grading and renal scars on radionuclide scans were documented. Dextranomer hyaluronic acid copolymer was injected through a cystoscope at the vesicoureteral junction as a day care procedure under short anesthesia. Patients were followed (average duration 27.3 mo) with clinical assessment, periodic urine cultures and renal scans., Main Outcome Measure: Cessation of VUR and symptomatic relief / clinical success postoperatively at 3 months., Results: Complete symptomatic relief was obtained in 482 (96.4%) patients. In 681 units where MCU was available, 614 (90%) units showed resolution of VUR., Conclusions: Endoscopic injection of tissue bulking substances at vesicoureteric junction to stop VUR seems to be an effective intervention.

The occurrence of multiple neural tube defects in a single patient is rare; the cases reported in the past are mostly of thoracic and lumbosacral region. Double occipital encephaloceles are rare; only four cases have been reported till date. Here we report a case of double encephalocele-one in the vertex and the other in the occiput, and a literature study on similar reports., Competing Interests: There are no conflicts of interest.

Aim: Airway foreign body (FB) is a very common pediatric surgical emergency. On certain difficult occasions, the extraction of FB with optical forceps (OFs) is difficult. These conditions create a life-threatening scenario. We present some of the alternative methods of FB extraction for these situations., Patients and Methods: This is a retrospective case review of patients presenting to pediatric emergency with airway FB. All patients had a chest X-ray done before the procedure. Rigid bronchoscopy was performed in all patients for retrieval., Results: A total of 20 patients (6 females) were successfully scoped. The age ranged from 1.5 years to 12 years (mean 3.5 years). Bronchoscopic removal was aided by dormia basket (DB) in 13, Fogarty's catheter (FC) in 6, and magnet aided removal in 1. Complete removal was achieved in all patients., Conclusions: We recommend that DB, FC, and a magnet should form an indispensable part of bronchoscopy set. The use of these alternative methods is successful and allows ventilation during the removal in contrast to removal by OFs. These should be kept as an option if retrieval is difficult., Competing Interests: There are no conflicts of interest.

Congenital pouch colon (CPC) is frequently associated with vesicoureteric reflux (VUR). These patients require long-term antibiotic prophylaxis and/or an additional surgical intervention for the management of the refluxing system. We propose a single-stage alternative approach in these patients. Two patients diagnosed to have CPC underwent pouch excision and an end colostomy at birth. Further evaluation revealed high-grade reflux in both the patients. At 6 months of age, definitive abdominoperineal pull-through (APPT) surgery along with extravesical detrusorrhaphy was performed. In the follow-up at 1 year, they are thriving well with no urinary complaints. Micturating cystourethrogram revealed complete resolution of VUR. This approach takes the advantage of the anesthesia for APPT and offers a relatively simple and quick solution for the refluxing system, thus, enabling the stoppage of antibiotic prophylaxis and obviating the need for a future endoscopy/surgery., Competing Interests: There are no conflicts of interest.

We report an unusual presentation of annular pancreas with pneumoperitoneum in a newborn with an associated left sided Erb's palsy. The neurological deficit caused considerable confusion in the diagnosis and unexpected complications after surgery. We highlight the importance of clinical examination and the complications that an Erb's palsy can cause. This unusual triad of Erb's palsy, eventration of diaphragm and annular pancreas has hitherto not been described in literature.

Background: Spina bifida is a common cause of pediatric neurogenic bladder. It causes renal failure in almost 100% of patients if the associated detrusor sphincter dyssynergia (DSD) is inadequately managed. Detrusor instability and high detrusor pressures (Figure) have been implicated as the major factors predictive of renal damage in these patients. Urodynamic studies provide early identification of "at risk" kidneys so that appropriate intervention can be made. However, the role in post-operative patients of spina bifida who have no clinical manifestations remains unclear., Objective: To study the bladder dynamics in asymptomatic post-operative patients of spina bifida and to determine whether routine urodynamic study is justifiable., Material and Methods: Urodynamics was performed on 15 operated patients of spina bifida who did not have any neurological deficit and were asymptomatic., Results: The mean age of the patients was 4.97 years. None of the patients had any urological complaints with their ultrasonography being normal. None had scars on nuclear scan. Of the 15 patients, 12 (80%) had abnormal findings on urodynamic assessment. Three patients (20%) had detrusor pressures greater than 40 cm of H 2 O. One patient had significant residual urine and detrusor instability., Discussion: The use of urodynamic studies in asymptomatic patients of spina bifida remains controversial, with one school of thought advocating early invasive urodynamic testing. In contrast, some favor noninvasive sonological monitoring, reserving invasive tests only for patients with renal tract dilatation. In our subset of patients none had renal tract dilatation but three patients (20%) had "at risk" bladders. These patients would benefit from early intervention aimed at renal preservation. The study is limited by a small sample size because of the relative rarity of the patient profile included. A further multicenter study with a case-control design could conclusively indicate the role of urodynamic testing in these patients., Conclusion: Patients of spina bifida, even when asymptomatic, have a high incidence of unsafe bladders. Early identification and appropriate measures can protect kidneys from long-term damage, hence urodynamic profiling is mandatory for identification of potentially high-risk bladders., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Scrotal migration of peritoneal end of ventriculo-peritoneal (VP) shunt into the patent processus vaginalis (PPV) is a rare complication. Its exact incidence is not mentioned in the literature till date. This may be because of the rarity of this complication, and also because all previous articles related to the complication were case reports. We, in our series, had an incidence of 0.9%. This prospective study has been conducted on 437 patients in the age group of 1 month-3 years who underwent VP shunt for hydrocephalus over a period of 5 years from 2007 to 2011. The incidence of a hernia manifesting after shunt insertion has been reported to be around 16.8%. The average age of patients at the time of insertion of the shunt was 27.25 months (3-48 months). All our patients presented with swollen right sided scrotum after an average of 4 months (3-5 months) after shunt insertion. Shunt migration was more common on the right which is consistent with the incidence of hernias in children. The proper management of such cases includes repositioning of the catheter with the proper closure of the PPV. Usually, shunt revision is not required. We discuss the etiology, treatment and preventive measures of this rare entity., Competing Interests: There are no conflicts of interest.

Alimentary tract duplication cysts are rare congenital anomalies, most commonly located in the ileum, but may present anywhere from mouth to anus.Clinically, they may be asymptomatic, incidentally diagnosed or may present with obstruction, volvulus, intussusception or gastrointestinal bleed. Here we report a case of a one year old male child presenting in gasping state and shock. Despite the initial strong suspicion of Meckel's diverticulum and tubercular abdomen, the final diagnosis remained elusive till exploratory laparotomy was performed which revealed a duplication cyst of ileum with perforation into the umbilicus. Duplication cyst should always be kept as a differential diagnosis so that early intervention can help in better management.

Purpose: To analyze quality of life of children operated for congenital hydrocephalus and the concern of parents in taking care of these children., Methods: Thirty patients who underwent ventriculo-peritoneal shunt were randomly selected with minimum gap of 1 year between surgery and study. Canadian validated questionnaire was used. Overall health score (OHS) and parental concern score (PCS) were correlated with gender, family type and number of surgeries., Results: Mean OHS was 159.43 which was summation of physical health (mean 45.76), social-emotional (mean 80.03) and cognitive health scores (mean 33.66). Mean OHS was 151.57 for males and 177.77 for females (p-value 0.233). Nuclear and joint families had mean OHS of 160.36 and 158.89 respectively (p-value 0.944). Those who underwent one surgery had mean OHS of 167.48 and PCS of 23.10 whereas mean OHS was 140.66 and PCS was 27.78 for those with multiple procedures. Mean PCS for males was 26.71 and for females was 19.33 (p-value 0.036 statistically significant). This was not statistically significant between nuclear (24.73) and joint families (24.26)., Conclusions: Quality of life of survivors of hydrocephalus is reasonably good even in developing countries due to keen parental involvement irrespective of gender, family type and number of surgeries., Competing Interests: There are no conflicts of interest.

Background: High and intermediate types of anorectal malformations (ARMs) in male neonates may be managed either by primary neonatal reconstruction without colostomy cover or by traditional policy of staged reconstruction after neonatal colostomy. Posterior sagittal anorectoplasty (PSARP) is the current widely practiced reconstructive technique with varied results., Aim: To assess our functional results of PSARP without colostomy in male neonates with high and intermediate ARMs compared to 3-stage (neonatal colostomy - PSARP - colostomy closure) methodology in a high volume tertiary care institution of a developing country., Patients and Methods: The number of colostomies performed for male high/intermediate anomalies and the number of babies who completed 3-stage reconstruction during a 10-year period is analyzed. The outcome of primary neonatal PSARPs during the same period was analyzed. Eighty primary PSARPs were compared to 81 staged reconstructions for outcome analysis, using Kelly score., Results: A total of 453 colostomies were performed, but only 253 of them completed all stages of reconstruction (52%). Good continence was achieved in 45% of cases of primary PSARP versus 26% in 3-staged surgery., Conclusions: Primary PSARP in neonatal period without colostomy is a good option for high and intermediate ARMs in males if the treating surgeon is reasonably skilled in neonatal surgery and PSARP procedures., Competing Interests: There are no conflicts of interest.

Background: Anticholinergics are well established in the management of neurogenic bladders. However, some patients do have sub-optimal response or severe side effects. This study is designed to assess and compare efficacy of gabapentin with oxybutynin in neurogenic bladders after surgery for spina bifida., Methods: Patients were randomized into three groups after urodynamic studies and started on oxybutynin, gabapentin, and combination of both, respectively. Thorough clinical and urodynamic reassessment was done at 6months and one year after starting treatment., Results: Forty-four patients (3-19years) were studied. Improvement was noted in symptoms as well as urodynamic parameters in all groups. Maximal improvement of symptom score was with combination of drugs at 1year. In urodynamic studies, compliance, pressures, and capacity showed improvement, which was significant between the groups at both six months and 1year for bladder pressures and volume. Improvement in compliance though marked was not statistically significant. Best response was seen in group receiving both drugs. Gabapentin was better tolerated than oxybutynin., Conclusion: Gabapentin is a good alternative to oxybutynin for management of neurogenic bladder, both as monotherapy and as an add-on therapy. It has potential application in patients with inadequate response to anticholinergics., Level of Evidence: prospective competitive treatment study - level II., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aims: To investigate the role of feeding jejunostomy (FJ) in patients of esophageal atresia with anastomotic leak (AL) to decrease the degree of gastroesophageal reflux (GER) and its effect on anastomotic healing., Materials and Methods: Twenty neonates, with major AL and severe GER after primary repair were managed with decompressing gastrostomy and transgastric FJ and analyzed prospectively., Results: Male to female ratio was 1.7:1. Mean birth weight was 2.2 kg. Anastomotic gap ranged from 0 to 4 cm. The amount of leak was more than 20% of nasogastric feeds. Gastrostomy and FJ was done on an average of the 12(th) postoperative day, after observing the general condition, chest tube output, lung expansion, and ventilatory requirement. There was a drastic reduction in chest tube output and lung expanded in all patients. Average hospital stay was 36 days (8-80 days). Sixty percentage patients were discharged successfully on FJ. Esophagogram demonstrated healing and leak free patency after an average of 1.5 months. GER was noted in seven patients, four developed stricture, and one had pseudodiverticulum in follow-up., Conclusion: Decompressing gastrostomy and FJ can be an alternative to managing major ALs. It helps in healing of anastomotic dehiscence and in preserving the native esophagus.

Aims: The treatment of perforating esophageal foreign body impaction (FBI) is complex and unclear. We present the outcome of surgical treatment of esophageal perforations due to FBI in children along with a management algorithm., Methods: During a period of 7 years, 7 cases of esophageal perforations due to foreign body (FB) ingestion were referred to our unit. We analyzed the FB types, lodging duration and location, complications, and the surgical approaches., Results: There were 4 male and 3 female patients. Mean age was 28 months (5 months-6 years). Six patients had metal FBs of variable shapes and 1 had glass marble. Three patients had witnessed history of FB ingestion. Duration of ingestion was variable and unknown in half of the patients. The site of impaction was cervical (1) and thoracic (5) esophagus. One patient had a marble as FB in the superior mediastinum. One patient manifested with features of perforation after removal of the impacted FB and 5 patients presented with perforations. Two patients presented with subcutaneous emphysema. One patient had trachea-esophageal fistula (TEF) after disc battery ingestion. Rigid esophagoscopy failed in 4 out of 6 patients. Five patients underwent thoracotomy, and repair with a pleural patch reinforcement. One patient had lateral esophagotomy in the cervical esophagus for removal of the impacted FB. Mediastinal FB was removed without opening the esophagus. All the patients were discharged uneventfully., Conclusions: Esophageal perforation following FBI is rare and requires prompt treatment. Surgical treatment tailored to the needs of individual patients is associated with a successful outcome and decreased morbidity., (Copyright © 2015 Elsevier Inc. All rights reserved.)