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Author(s): Prabudh Goel (corresponding author) [1]; Prativa Choudhury [1]; Vivek Verma [2]; Shivani Phugat [1]; Mani Kalaivani [3]; Teg Rabab Singh [4]; Kanika Sharma [5]; Vishesh Jain [1]; Devendra Kumar [...], Background: A discrepancy between the true and measured value of stretched penile length (SPL) may be a result of errors that can either be systematic or random. Hence, it becomes important to focus on the quality of measurements to prevent any iatrogenic harm to the patients. Objective: The objective of this study was to assess the magnitude of intra- and interobserver variations in the measurement of SPL with the SPLINT technique. Materials and Methods: SPL was measured prospectively in a cohort of 449 boys aged 0-14 years including 68 infants (substratified into Group I: >4 years, Group II: 4-8 years, and Group III: >8 years) with the SPLINT technique by expert (E: E1 and E2) and trainee (T: T1 and T2) surgeons after completing a three-tiered training module. Intra- and interobserver variability was assessed through descriptive statistics, intraclass correlation (ICC), relative technical error of measurement (rTEM), and reliability or R (). Results: Intraobserver variability: the mean difference between the two readings (E1 and E2) is 0.08 cm (95 confidence interval [CI]: 0.073-0.087), ICC was 0.998 (95 CI: 0.997-0.998), and intraobserver variability ≤0.1 cm in 85 of the participants (n = 370 of 433). The rTEM and reliability () were 1.82 and 98.1 (Group I), 1.65 and 98.9 (Group II), and 1.09 and 99.7 (Group III), respectively. The intraobserver variability was observed to be inversely proportional to the age of the participants (correlation coefficient = -0.56). Interobserver variability was calculated separately for expert versus trainee and trainee versus trainee (T-vs-T) measurements. For expert versus expert, ICC, rTEM, and reliability () were 0.984, 2.4, and 96.8 (Group 1), 0.992, 2.07, and 98.3 (Group 2), and 0.997, 1.38, and 99.05 (Group 3), respectively. A similar pattern of variability was observed for T-vs-T measurements. The reliability () of the SPL by experts is consistently more than that of trainees across all age groups; however, the difference ameliorates with the age of participant. Conclusions: The study has validated the SPLINT technique by demonstrating a high level of intra- and interobserver reliability. The adequacy of the training modules for SPL measurements described in this study has also been established. Evidence that the SPL can be used as an objective marker of penile dimensions is herewith furnished. Keywords: Interclass correlation, interobserver variability, intraobserver variability, relative technical error of measurement, reliability, SPLINT technique, stretched penile length

Author(s): Saundarya Priyadarshini [1]; Sandeep Agarwala [1]; Harsh Priya [2]; Vishesh Jain (corresponding author) [1]; Prabudh Goel [1]; Anjan Kumar Dhua [1]; Devendra Kumar Yadav [1]; Sachit Anand [1]; Nishant [...], Background: Virtual reality (VR) refers to a computer-generated simulation or environment that can be experienced and interacted with by a person through special electronic equipment, such as a headset with a screen and motion-tracking sensors. VR has been used as a distraction technique to alleviate pain and discomfort during medical procedures or as an alternative to traditional pain medication. This article explores VR's effectiveness in reducing pain in pediatric patients undergoing painful clinical procedures. Methodology: This systematic review and meta-analysis was performed as per the preferred reporting item for systematic review and meta-analysis guidelines. A systematic literature search was conducted for all articles published till December 2022 in four different databases: PubMed, Scopus, Embase, and LILACS, which yielded 6886 studies. Studies showing the effect of VR on pediatric patients undergoing clinical procedures were included in the study. Risk of bias (ROB) 2.0 was used to assess the ROB. Outcome data were pooled using a random-effects model and reported as standardized mean difference (SMD) with a 95 confidence interval (CI). The meta-analysis was performed on RevMan5.4. Subgroup analysis was done for the different clinical procedures. Results: A total of 2477 participants from 34 studies were included in the meta-analysis. Children in whom VR was used had a significantly lower pain score as compared to the control group with an SMD of 0.87 (CI 95 -1.20, -0.53; (P < 0.00001). Subgroup analysis based on the type of intervention did not reveal any significant difference (P = 0.19). Heterogeneity for overall pain using a random effect model with I[sup.2] was significant (P < 0.00001). Conclusion: This systematic review suggests that the use of VR distraction in children undergoing painful procedures is associated with significantly lower pain scores. Hence, VR can be a promising intervention for reducing pain experienced by pediatric patients during medical procedures. Keywords: Pain, pediatric patient, virtual reality

Author(s): Gaurav Prasad [1]; Anjan Kumar Dhua (corresponding author) [1]; Prabudh Goel [1]; Devendra Kumar Yadav [1]; Sandeep Agarwala [1]; Shivam Pandey [2] INTRODUCTION Hypospadias is the most common congenital [...], Aims: Antenatal androgen exposure has been suggested as a contributing factor in hypospadias etiology. This study aimed to investigate the correlation between anogenital distance (AGD), index finger-to-ring finger ratio (2D:4D ratio), and hypospadias severity in prepubertal boys, with the goal of exploring these parameters as potential markers of genital anomalies in utero. Materials and Methods: A cross-sectional observational study was conducted on boys under 8 years old presenting to our outpatient department (April 2020-December 2022). Those with hypospadias were included in the study group, whereas those without hypospadias formed the comparator group. Confounding factors (age, weight, and height) were accounted for using multivariate linear regression analysis. AGD, 2D:4D ratio, and hypospadias severity were measured during clinical visits, with still images taken for precise measurements. Statistical analysis was performed using the Mann-Whitney U and student's t-tests (software: STATA Version 14). Results: Data were collected for 100 cases of hypospadias (26 proximal and 74 distal) and 50 controls. There was no significant difference in mean age between groups (P = 0.90). AGD was slightly lower in cases (3.44 ± 1.13 cm) compared to controls (3.70 ± 1.43) (P = 0.88). 2D:4D ratios were marginally higher in cases compared to controls (P = 0.12 for both hands). Conclusions: Although our study did not find significant associations between AGD and 2D:4D ratios with hypospadias severity, it offers insights into the role of prenatal androgen in genital development. The lack of significance underscores the need for region-specific research, suggesting AGD and 2D:4D ratio may not universally apply as hypospadias markers. Keywords: 2D:4D ratio, anogenital distance, hypospadias, Indian population

Author(s): Prabudh Goel (corresponding author) [1]; Prativa Choudhury [1]; Komal Kaur Saroya [1]; Vishesh Jain [1]; Anjan Kumar Dhua [1]; Devendra Kumar Yadav [1]; Sachit Anand [1]; Sandeep Agarwala [1]; [...], Purpose: The purpose of this study was to synthesize evidence and propose a technique for estimation of stretched penile length (SPL) applicable to children. Materials and Methods: This review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. PubMed, Embase, and Scopus databases were queried on penile length (PL) measurement techniques in humans published from 1990 onward. The devices and the techniques used for PL measurement, state of the penis, the habitus of the participants, proximal and distal landmarks for measurement, handling the foreskin and pubic pad of fat, optimal stretching of the penis, and other factors (including the environment) which should be accounted for in the technique were identified from the study cohort (90895 participants across 145 included studies). Results: PL has been represented through flaccid (33.79), stretched (81.3), and erect (12.41) PLs as well as the greatest corporeal length (1.4). Following devices have been used to measure the PL in the study cohort: rulers [54.68], calipers [9.7], measuring tapes [14.5], coloured measuring strips [2.06], spatulas/tongue depressors [11.03], FitKit, syringe [1.4], cotton swab (and ruler), titan cylinders, slide gauge and ultrasonography [1.37]. The factors relevant to SPL measurement have been incorporated into the proposed SPL INdicator Technique (SPLINT) which is essentially a holistic extension of the 'Conventional PL Measurement' technique. Conclusions: There is a wide range of heterogeneity in the technique for estimation of PL across the study cohort; the underlying factors have been identified along with the respective variables, and the SPLINT for SPL has been described. Keywords: Erect penile length, measurement, penile length, Stretched Penile Length INdicator Technique, stretched penile length

Author(s): Prabudh Goel (corresponding author) [1]; Mahima Sharma [1]; Himani Kaushik [2]; Sourabh Kumar [1]; Harpreet Singh [3]; Vishesh Jain [1]; Anjan Kumar Dhua [1]; Devendra Kumar Yadav [1]; Neeta [...], Objective: To identify the genetic markers of spina bifida through a systematic survey of the exome in an Indian cohort. Materials and Methods: Three consecutive patients (P1: 1 year, male; P2: 2.8 years, male; and P3: 10 years, female) with spina bifida (lumbosacral meningomyelocele) underwent whole-exome sequencing (libraries: SureSelect Human All Exon V8; sequencing: 2 150 bp paired-end run, 100x) with NovaSeq 6000. Data analysis was performed using SMART-One™ (secondary analysis) and SMARTer™ (tertiary analysis) for automated quality check, alignment (GRCh38/hg38), variant calling, annotation (ClinVar, OMIM, avsnp150, 1000 Genomes v5b, ExAC v0.3, gnomAD v4.0, and esp6500vi2all v0.0.25), v0.0.25), interpretation. The pathogenic and likely pathogenic (ClinVar/ InterVar), non-synonymous, exonic markers (read depth ≥ 5) were matched with the Familial Neural Tube Defects (Version 1.10) panel (FNTD panel). Results: Pathogenic variants overlapping with the FNTD panel were MTRR, CC2D2A, and ZIC2 in P1 and P2, TGIF1 in P1 only, and none in P3. Novel pathogenic/likely pathogenic variants common to all three patients were PRUNE1, PKD1, PDZD2, and DAB2 in the homozygous state as well as in the heterozygous state, PLK1 and NLGN2. The possible role of such markers in etiopathogenesis was explored through a literatur search. Conclusions: The genetic landscape of the spina bifida in an Indian cohort is diverse compared to that reported from other parts of the world. A comprehensive catalog of single-nucleotide variants in the etiopathogenesis of the spina bifida on a background of the Familial Neural Tube Defects Panel has been generated. Keywords: Gene panel, genetic markers, neural tube defects, spina bifida, whole-exome sequencing

Author(s): Tanvi Luthra [1]; Sachit Anand [1]; Anjan Kumar Dhua (corresponding author) [1]; Devendra Yadav [1]; Vishesh Jain [1]; Prabudh Goel [1]; Devasenathipathy Kandasamy [2]; Sandeep Agarwala [1]; Rohan Malik [...], Diffuse esophageal leiomyomatosis (DEL) is a rare condition characterized by the growth of multiple benign smooth muscle tumors (leiomyomas) in the esophagus. These tumors can cause obstruction and functional impairment of the esophagus, leading to symptoms such as difficulty swallowing, chest pain, and weight loss. The disease can present with leiomyomas or glomerular nephropathy in other body parts, hearing defects, astigmatism, or myopia (Alport's syndrome). However, isolated cases are also reported in the literature. Surgical management of DEL presents several challenges due to the location and extent of the tumors. Herein, we describe a girl afflicted with DEL and required multiple surgeries for management, highlighting the unique challenges faced by the surgical team in restoring esophageal function and improving the patient's quality of life. Keywords: Colonic interposition, esophageal leiomyomatosis, esophageal replacement, gastric pull-up

Author(s): Shivani Phugat [1]; Prativa Choudhury [1]; Vishesh Jain [1]; Anjan Kumar Dhua [1]; Devendra Kumar Yadav [1]; Hemanga Kumar Bhattacharjee [2]; Sachit Anand [1]; Harpreet Singh [3]; Sandeep Agarwala [...], Background: The occupational hazards of glutaraldehyde are well known; the possibility of harm to the patients has been highlighted in the form of isolated reports only. Objective: To synthesize evidence for contact mucosal injury or injury due to intraperitoneal instillation of glutaraldehyde following its use during laparoendoscopy. Materials and Methods: The current review is Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant. PubMed, PubMed Central, and Google Scholar were interrogated for animal and human studies upon the harmful effects of glutaraldehyde during laparoscopy and proctosigmoido-colonoscopy. Results: Thirty-five studies substratified into animal experiments (n = 2), glutaraldehyde-induced colitis (G-iC) postendoscopy (n = 30), and laparoscopy (n = 3) were included. Rats suffered mucosal injury following colonic injection of glutaraldehyde which was time- and concentration-dependent quantum and developed bloody diarrhoea. Omental and renal injury was observed due to glutaraldehyde instillation during simulation of intra-peritoneal insufflation in rats; the serum leucocytes, CRP and creatinine were also elevated. G-iC following colonoscopy was related to contact mucosal injury due to failure (human or machinery) to rinse the chemical off the instrument surface or as a case of mistaken identity (glutaraldehyde was mistaken for saline or another reagent). The incubation period was Conclusions: The use of glutaraldehyde in the patient care facilities should be discontinued; when unavoidable, the standard processes of disinfection and rinsing must be stringently followed. Keywords: Chemical colitis, colonoscopy, contact mucosal injury, glutaraldehyde, laparoscopy, target sign

Author(s): Shreya Shah [1]; Prabudh Goel (corresponding author) [2]; Kanika Sharma [2]; Teg Rabab Singh [2]; Puneet Khanna [1]; Rajeshwari Subramaniam [1]; Vishesh Jain [2]; Anjan Kumar Dhua [2]; Devendra [...], During face mask ventilation, invariably, some air enters the esophagus rather than the airways; this results in gastric insufflation while the esophagus is intact or loss of tidal volume in patients with a cervical esophagostomy (Cx-esophagostomy). Objective: The objective of the study was to report the indigenous use of an electrocardiography (ECG) electrode in successfully occluding the Cx-esophagostomy to prevent inadvertent loss of tidal volume. Materials and Methods: Twenty-nine observations were recorded on 27 patients (mean age: 10.9 months; male:female = 2.6:1). The oral cavity, pharynx, and Cx-esophagostomy were cleared of saliva. Peristomal area was cleaned with dry gauze and dried with alcohol. Latex-free, 50 mm, ECG electrode was pasted symmetrically over the Cx-esophagostomy. The efficacy of the electrode was assessed using a five-point algorithm: (i) collapse of reservoir bag, (ii) chest expansion, (iii) ballooning of electrode, (iv) cotton-wisp test, and (v) change in compliance with manual compression of the electrode. Subgroup analysis was conducted for laterality and health of Cx-esophagostomy. Results: Study cohort: Cx-esophagostomy was located on the left in 58.26 (n = 17/29) patients. The health of Cx-esophagostomies was graded from I to IV (n = 9, 16, 3, and 1, respectively). The collapse of the reservoir bag and chest rise indicated successful ventilation. Ballooning of the electrode with each breath was observed in 79 (23/29) patients. Partial separation of the electrode from the skin (exaggerated with each breath) was observed in 10.3 (3/29) patients (Group I: n = 1, Group III: n = 1, and Group IV: n = 1). This was related to poor local preparation or pooling of saliva (n = 1; Group I: resolved with procedural re-application of a fresh electrode) and underlying skin condition (n = 2; Groups III and IV: resolved only temporarily with re-application). The cotton-wisp test was positive in two additional patients (1 each in Groups II and III) and was related to the pooling of saliva. No change in compliance was observed with manual compression of the electrode. No difference in success was observed between left and right Cx-esophagostomies. Overall success with this technique was 82.8 with a potential for 100 in those with peristomal health graded I-III. Conclusions: The ECG electrode is a technically simple, cost-effective, and widely available device, instrumental in addressing the problem of air leak through Cx-esophagostomy during face mask ventilation before intubation. Keywords: Air leak, cervical esophagostomy, electrocardiography electrode, face mask ventilation, indigenous technique