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Survival in pediatric Ewing sarcoma (ES) lags in low- and middle-income countries (LMICs). This study analyzed factors contributing to a lower outcome in an LMIC center. A retrospective case review of children with localized ES treated from January 2011 till December 2017 was performed. Neoadjuvant chemotherapy with alternating cycles of vincristine, doxorubicin, cyclophosphamide; and ifosfamide, etoposide was administered 3-weekly for 48 weeks. Reassessment was planned for week 12, followed by local therapy (surgery/radiotherapy or both) tailed by adjuvant chemotherapy. Forty-eight patients with mean age 8 years (range: 0.7-14) were evaluated. Extremity and central axis tumors were seen in 25 (52%) and 23 (48%) patients. Three patients died of neutropenic sepsis and five abandoned therapy. Local therapy included primary surgery, radiotherapy and a combination of surgery and radiotherapy in 7 (16%), 20 (45%) and 17 (39%) patients. The 3-year event-free survival (EFS) and disease-free survival (DFS) for the cohort were 47.7 ± 11% and 57.6 ± 11.2%. Time to local therapy16 weeks was associated with inferior DFS

Carboplatin is being advocated more frequently for treatment of childhood germ cell tumors (GCT), due to less long-term toxicity, and demonstrable equivalence in outcome as compared to cisplatin. This analysis presents the survival of GCT in a low middle-income country and compares two different chemotherapeutic regimens. A retrospective analysis of patient case records was carried out over 10-years (January 2007-December 2016). Chemotherapy regimen used was bleomycin, etoposide, and cisplatin (PEb) for initial 6-½ years and carboplatin, etoposide, and bleomycin (CEb) subsequently. Ninety patients with GCT were treated over 10-years. Malignant GCT was diagnosed in 69 (77%) patients, with 21(23%) having teratoma. The chemotherapy protocol was PEb in 38 (42%), CEb in 28 (31%) patients, while 24 patients were treated with surgery only. Stage 4 tumor was observed in 19 (21%) patients. Relapse or disease progression was seen in 11(12%). Overall and event-free survival at 5-years for the entire cohort was 77% and 73%, being similar with PEb (OS:77%; EFS:72.5%) vs. CEb (OS:69%; EFS: 69%). Significantly better overall survival was noted for patients with gonadal GCT) and non-stage 4 disease, while event-free survival was significantly better in patients with non-stage 4 disease. The chemotherapeutic regimen (PEb vs. CEb), very high AFP (value ≥10,000 IU/L), and risk stratification (low, intermediate, or high-risk disease) did not affect survival significantly. Carboplatin-based strategy was equivalent in our cohort to cisplatin-based strategy, and could be used safely in the LMIC set-up. The overall survival is suboptimal, with delayed presentation, abandonment, and relapse being barriers to survival.

High temperature as a part of the climate change scenario is imposing a severe threat to rice production and productivity worldwide. Field experiment was conducted in ICAR-IIRR during rabi 2016–17 to screen 60 diverse rice genotypes comprising of 2 germplasm lines, 11 green super rice lines, 2 introgression lines, 8 landraces, 2 tropical japonicas and 35 released varieties including 2 checks for identification of high temperature tolerant genotypes. They were tested for their nature of thermotolerance using cell membrane thermostability, PSII activity (Fv/Fm) and paraquat tolerance test as screening criteria. There was a reduction in all the above measured traits in all the genotypes however, among the genotypes the extent of reduction varied. Among the genotypes screened, Rasi, Akshayadhan, HKR47, IR64, Assanchidiya had recorded a higher grain yield under high temperature conditions and hence could be categorized as heat tolerant whereas ADT43, Vandana, NDR359 MTU1001 and IR36 had lower yields and hence were categorized as heat susceptible. The screening traits were correlated with grain yield recorded under high temperature. Positive and significant association was noted between cell membrane thermostability, Fv/Fm measured under high temperature stress with the grain yield. The tolerant genotypes also had a higher cell membrane thermostability and higher Fv/Fm under high temperature conditions. Among the analysed traits, it can be concluded that CMS and Fv/Fm can be used efficiently to screen the germplasm for thermotolerance.

Background: The WHO Multimodal Hand Hygiene Improvement Strategy (MHHIS) has been proposed to improve the Hand Hygiene (HH) compliance of the WHO recommendations on HH.Therefore, the current study was planned in our neonatal unit with the objective of evaluating the effectiveness of a Hand Hygiene Promotional Program (HHPP) based on the WHO MHHIS, in terms of compliance and decontamination efficacy among the health-care workers (HCWs) in the unit. Objective: The objective of the study was to evaluate the effectiveness of the WHO MHHIS on HH compliance and decontamination efficacy. Methods: The HHPP was carried out in our neonatal surgical intensive care unit from July to August 2013. A pre-intervention phase consisted of assessment of ward infrastructure, HH knowledge and perception, determination of HH compliance and collection of hand rinse samples from the HCWs before and after handwashing. Intervention phase consisted of changing traditional to elbow-operated taps, display of posters and reminders, placement of soaps in water draining trays, autoclaved single-use paper towels for hand drying, availability of hand rubs and training sessions for health-care providers. In the post-intervention phase, all the assessments and observations of pre-intervention phase were repeated. Results: HHPP resulted in a significant increase in overall HH compliance from 26.6% (95% confidence interval [CI] 23.9–29.3) to 65.3% (95% CI 62.4–68.2) (P < 0.001) and reduction in load of microorganisms (P = 0.013). There was a significant improvement in HH knowledge (P < 0.001), and perception surveys revealed high appreciation of each strategy component by the participants. Conclusion: To the best of our knowledge, this is the first study about the effect of implementation of the WHO MHHIS from an Indian hospital. HHPP was found to be effective in terms of HH compliance and decontamination efficacy. Its implementation is highly recommended to promote HH in a developing country like India.

Aims To investigate the role of glycopyrrolate in decreasing oral secretions in patients of esophageal atresia (EA) with anastomotic leak and evaluate its effect on healing of anastomotic dehiscence. Methods The study comprised consecutive neonates of esophageal atresia, who had undergone primary surgery and developed anastomotic leak. The patients were randomized into two groups with the observer blinded to the group. The patients in the treatment group were administered glycopyrrolate in the dose of 8 μg/kg 8 hourly, whereas placebo group patients were injected normal saline only. Neonates, in both the groups, were managed conservatively based on the clinical and radiological parameters. The end points of the study were either resolution or progression of the leak. The study was approved by the institute ethics committee. Results There were 21 patients each in two groups with comparable preoperative characteristics. All the cases had anastomotic leaks clinically detectable in the chest tube. Saliva alone constituted the leak material in 18 cases in the treatment group and 10 in the placebo group. Cumulative total of mean chest tube output per patient for all patients in the treatment group was 124.15ml as compared to 370.27ml in the placebo group ( p =0.001). Anastomotic leak stopped in 16 cases (76%) in the treatment group, as compared to 6 cases (29%) in the placebo group ( p =0.004). The postoperative ventilation was required in 8 cases (8/21, 38%) in the treatment group and 17 cases (17/21, 81%) in the placebo group ( p =0.010). In the treatment group, the diversion procedures were carried out in 2 out of 21 cases (10%), whereas in the placebo group, 52% of the patients (11/21) required such an intervention ( p =0.003). At the time of discharge, the oral feeds could be started in 15 cases (15/21, 71%) in the treatment group, as compared to 3 (3/21, 14%) in the placebo group ( p =0.0004). Conclusions Administration of glycopyrrolate in patients of anastomotic leak after primary repair of esophageal atresia resulted in reduced oral secretions, which helped in healing of the anastomotic dehiscence in a significant number of patients.

Background: Many strategies have been explored to reduce multiple donor exposures in neonates such as use of restrictive transfusion protocols, limiting iatrogenic blood loss, use of recombinant erythropoietin and single donor programs. Method: In our study we assessed the feasibility of dedicating single donor units with reserving all the components from the same donor for the specified neonates/ infants undergoing surgery and estimating reduction of donor exposure. Fifty neonates undergoing surgery were included in the prospective study group and the transfusion details were compared with 50 retrospective cases with same inclusion criteria. Results: An intra-operative blood loss of >13 ml/Kg was significantly associated with transfusion (P

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.

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.

Aims and Objectives: We studied the short- and long-term outcomes and quality of life (QOL) in patients undergoing a two-staged modified Duhamel's procedure for Hirschsprung's disease. Materials and Methods: Patients who had undergone this modified procedure, with initial Hartmann's procedure based on contrast enema, followed by bowel preparation and low colo-anal anastomosis below the dentate line were included. The patient who underwent this procedure over 10 years with a minimum 2-year follow-up were analysed based on an interview-based questionnaire. Results: Of the 152 patients, 69 responded. Mean age at the time of interview was 7.72 ± 3.04 years with mean follow-up of 4.9 years (2–11 years). Perineal excoriation and soiling was present in 60.9% and 36.2% of patients initially which reduced to 0 and 4.3% by the end of 2 years. In the first 6 months, postoperative period, 15.9% of patients had constipation and 78.2% had altered stool consistency. Good fecal continence score was present in 97.1% of patients in the long term. About 95.4% had good QOL scores. There was no mortality in this series. Conclusions: Although short-term outcomes showed altered bowel function, soiling, and perineal excoriation, this improved significantly in the long term, with good QOL scores in the majority.

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.

Aims: Neonatal tumors (NTs) include a group of diverse neoplasms. In this study, we reviewed our data for clinical presentations, management options, and outcome. Materials and Methods: All patients from 0- to 1-month age presenting with solid tumors, from 2006 to 2018 were studied. The gender, presentation, location, type of tumor, and management were analyzed. The final diagnosis was made with histopathology in all cases. Hemangiomas and lymphangiomas were excluded from the study. Results: A total of 32 neonates were studied. The most common tumor was sacrococcygeal teratoma (SCT,16) followed by teratoma at other sites including two cases of fetus-in-fetu, soft-tissue sarcoma (STS, 4), mesenchymal hamartoma (2), hemangioendothelioma (2), and other rare tumors. Three tumors were diagnosed antenatally; of whom, two were neither visible externally nor palpable. Complete surgical excision was done for all except in a case of ovarian cyst where near-total cystectomy was done. No patient received chemotherapy or radiotherapy. Six patients had postoperative complications, including two who had local recurrence requiring excision. There was one mortality. All the other patients are doing well during follow-up. Conclusion: NTs have varied presentations. SCT and STS were the most common benign and malignant tumor, respectively. Early diagnosis and complete surgical excision are often curative for all, regardless of the pathology with the minimal role of chemotherapy or radiotherapy.

Juvenile xanthogranuloma (JXG) is a histiocytic disorder of childhood that mostly affects the skin although extracutaneous and visceral manifestations are well documented in English literature. The renal involvement is less commonly documented as a manifestation of xanthogranuloma and the reported cases occur in conjunction with cutaneous xanthogranuloma, especially in association with multiple skin lesions. We present a case of isolated renal JXG presenting as a renal mass with perinephric soft tissue and muscle involvement but without any cutaneous manifestation. This is the first case report of renal JXG without cutaneous involvement, to the best of our knowledge.

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.

Background: Congenital pouch colon (CPC) is a rare variant of anorectal malformation. In male patients, CPC communicates distally with the urogenital tract by a large fistula. The CPC cases which do not fulfill the criteria as mentioned in the classical description are reported along with the pertinent literature review. Materials and Methods: This was a retrospective study from January 2004 to December 2017 of male children with Type IV CPC. We evaluated clinical presentation, primary management, anatomical relationship, previous surgical intervention, definitive management, result, and outcome in terms of continence status on Templeton score. Results: Fifty-one children were included in the study among whom 36 children (Group 1) had a colovesical fistula and 15 children (Group 2) had no communication of the pouch with the genitourinary tract. In Group 2 children, the clinical presentations and management were varied: 4 underwent primary pull-through procedure, whereas 11 underwent staged procedure. Group 2 included three children in whom a narrow and thin-walled anal canal or anal canal with lower rectum was present, which was incorporated during the pull-through procedure. On continence assessment, only one child in Group 1 had “good” continence score compared to four children (three having anal canal) in Group 2. Conclusion: CPC Type IV can present without genitourinary tract communication (fistula), contrary to its emblematic description. Awareness about anatomical variations and adaptation of surgical technique accordingly is vital. The identification of the anal canal with or without the lower part of the rectum (even though apparently narrow and thin walled) and incorporation of this in bowel continuity lead to better outcomes in terms of continence.

Background: Vascular tumors of spleen represent a wide spectrum of lesions, ranging from benign to highly aggressive neoplasms. Among the benign tumors, localized hemangiomas are the most frequently encountered. Splenic hemangiomatosis is seldom seen especially in the pediatric population with anecdotal cases described in the literature. Case report: We present of 6-month-old child presenting with abdominal distention. The resected spleen was totally replaced with a hemangiomatous lesion. There were no other hemangiomatous foci outside the spleen. Conclusions: Hemangiomatosis limited to the spleen can occur in a child, and the present case demonstrates its characteristic histological features.

Sigmoid atresia is one of the rarest cause of neonatal intestinal obstruction. We report an antenatally diagnosed mesenteric cyst in a neonate that was subsequently diagnosed as a meconium pseudocyst with double sigmoid atresia. A localized type 4 atresia or a colonic atresia associated with meconium pseudocyst has not been reported in the literature to date. Keywords: atresia, obstruction, pseudocyst, sigmoid colon

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.

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 7years, 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 28months (5months–6years). 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.

Background: There is a huge need to develop molecular typing methods which are simple to perform, rapid and cost effective to confirm clonality of nosocomial isolates in outbreak situations. Objectives: The aim of the study was to investigate a hospital outbreak of multi-drug resistant (MDR) Klebsiellapneumoniae septicemia in a paediatric surgery intensive care unit (PSICU) using a repetitive extragenic palindromic polymerase chain reaction (REP-PCR). Materials and Methods: MDR Klebsiella pneumoniae isolates from an outbreak of nosocomial sepsis were typed byREP-PCR using consensus primers. Isolates from different intensive care units (ICUs) but with similar antibiogram were also genotyped for comparison. Results and Conclusion: A cluster of twelve MDR K Pneumoniae septicemia cases was identified at the PSICU by genotyping using REP-PCR. Surveillance cultures failed to pick up any source of infection. REP-PCR was found to be a rapid and simple tool for investigation outbreaks in hospitals. Due to early detection we could initiate infection control practices with focus on hand washing and prevent the further transmission of the organism.

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.

The need for successful management of posterior urethral valves always captivates the minds of pediatric surgeons. Its success, however, depends on several factors ranging from prenatal preservation of upper tracts to postoperative pharmacological compliance. Regardless of measures available, some cases do not respond and progress to end stage. The management depends on several issues ranging from age and severity at presentation to long-term follow-up and prevention of secondary renal damage and managing valve bladder syndrome. This article is based on a consensus to the set of questionnaires, prepared by research section of Indian Association of Paediatric Surgeons and discussed by experienced pediatric surgeons based in different institutions in the country. Standard operating procedures for conducting a voiding cystourethrogram and cystoscopy were formulated. Age-wise contrast dosage was calculated for ready reference. Current evidence from literature was also reviewed and included to complete the topic.

Severe neurological complications are associated with falciparum malaria. We describe the case of an eight-year-old male child with severe falciparum malaria with high-level parasitemia and severe thrombocytopenia. There were features of abnormal gait, speech difficulty and altered behavior pattern during the recovery phase. This occurred even after receiving antimalarial therapy. MRI showed bilateral cerebellar atrophy.

Summary 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 H2O. 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. Download : Download high-res image (183KB) Download : Download full-size image Figure . Cystometry curves with and without detrusor hyperactivity.

Introduction Pre-operative testosterone use in hypospadias surgery is known to increase penile dimensions and vascularity, which should facilitate tension-less formation of the urethral tube and tissue healing. However, androgens can have a negative effect on wound healing. There are very few randomized studies on postoperative results after androgen use, and this study attempted to understand the utility of pre-operative testosterone in distal hypospadias. Objective To study the effect of parenteral testosterone in children undergoing single stage urethroplasty for distal hypospadias, especially the occurrence of urethrocutaneous fistula and wound dehiscence. Design Patients were prospectively enrolled and randomized into two groups: Group 1 (control group) and Group 2 (receiving three injections of pre-operative intramuscular testosterone enanthate (2 mg/kg) at 1 monthly intervals; they were further subdivided into those operated 1 month (Group 2A) or 3 months (Group 2B) later. Patients with micropenis, previous testosterone use or any surgical intervention were excluded. Preputial skin was studied with hematoxylin and eosin (H&E) staining and CD31 immunohistochemistry. Patients were followed up for at least 18 months. Results Ninety four patients underwent urethroplasty over a 3.5-year period. Penile dimensions increased significantly after testosterone use (Summary table). On H&E staining, proliferating blood vessels and increased lymphocytic infiltrates were significantly increased in Group 2B. Group 2 patients tended to have more postoperative edema and inflammation. Although urethrocutaneous fistula rates were similar in Group 1 (n = 7) and Group 2 (n = 5) (P = 0.438), wound dehiscence occurred only in Group 2 (P = 0.01). Discussion The total number of patients in this study was small and this was a drawback. Although, several factors played a role in wound healing, the overall higher complication rate, especially wound dehiscence in Group 2, pointed to a higher incidence of inflammatory reaction and healing complication rates with testosterone use. Conclusion Testosterone should be used judiciously in distal hypospadias. While tissue availability significantly increased, there was an increase in inflammatory reaction and edema, which increased the risk of wound dehiscence in cases of precocious surgery. Summary table. Morphological changes after testosterone use in Group 2. Morphological parameter Measurements at different time periods Mean (cm) Standard deviation Standard error (mean) P-value Length Baseline 3.588 0.672 0.106

AIMS Histopathologic spectrum and expression of β-catenin were analyzed in patients with hepatoblastoma, diagnosed over a period of 14 years. These were correlated with the survival outcome. The morphologic features subsequent to chemotherapy were also analyzed. METHODS AND RESULTS Histomorphologic features were studied on paraffin-embedded sections. There were 24 cases with 15 fetal, 4 embryonal, 4 macrotrabecular, and 1 of small cell subtype. Follow-up was available in 20 cases (mean = 16.8 mo). β-catenin immunostaining performed by indirect immunoperoxidase method revealed 14 cases with nuclear and 10 cases with cytoplasmic positivity. Statistical analysis revealed no significant correlation between morphologic subtype and survival. Significant difference in survival was noted with respect to tumor stage, mitotic index, and β-catenin staining pattern. Cases with nuclear expression had a mean survival of 71.54 ± 8.1 months in comparison with 14.71 ± 6.5 months in cases with cytoplasmic expression. Besides osteoid and cartilage formation, interesting postchemotherapy findings were the presence of tumoral maturation, hepatocellular carcinoma-like areas, peliotic-like foci, and "glomeruloid clusters." CONCLUSIONS Nuclear β-catenin expression is not a poor prognostic factor and this might be indicative of different genetic alterations in hepatoblastoma in the Indian subcontinent. There was no significant correlation between histologic subtype and osteoid differentiation with survival. The histopathologic changes observed were peliotic-like areas, tumoral maturation, hepatocellular carcinoma-like changes, and glomeruloid clusters besides the well-established features of osteoid differentiation after chemotherapy.

Introduction Urinary tract infection (UTI) is the most common and severe bacterial infection in children. Renal scarring and associated deterioration in the differential renal function is a frequent finding. Scarring may occur even in asymptomatic patients without vesicoureteric reflux. Materials and methods Fifty-three children (43 M:10 F, mean age:5.3 years; range 2-10 years) with evidence of recurrent UTI were enrolled in the study. Patients with duplex or crossed fused ectopic kidneys and with acute or chronic renal failure were excluded from the study protocol. Each patient underwent 99mTc-DMSA and 99mTc-EC renal scintigraphy within a period of 2 weeks. Results Analysis of results was performed by comparing the diagnostic accuracy of the summed 99mTc-EC and 99mTc-DMSA images for the detection of renal cortical scars and correlation (linear regression analysis) between the two renal scintigraphic procedures for the estimation of differential renal function. 99mTc-DMSA imaging demonstrated scarring in 41 kidneys whereas 99mTc-EC scintigraphy revealed scarring in 29/41 kidneys only. The percentage function of both kidneys with 99mTc-EC and 99mTc-DMSA showed good correlation. The r2 for left kidney was 0.95 and for right kidney was 0.94. Conclusion 99mTc-EC scintigraphy has low sensitivity (70%) for the detection of cortical scarring as compared to 99mTc-DMSA (100%) renal imaging. On the hand, 99mTc-DMSA static imaging gives good estimate for the DRF and the values are in good agreement with the corresponding values derived from dynamic 99mTc-EC scanning. How to cite this article Raja S, Pareek V, Singh B, Sharma S, Rao KLN, Mittal BR. Comparison of 99mTc-Ethylene Dicysteine and 99mTc-Dimercaptosuccinic Acid Scintigraphy for the Evaluation of Cortical Scarring and Differential Renal Function in Children with Recurrent Urinary Tract Infection. J Postgrad Med Edu Res 2012;46(4):183-186.

Aim To perform a qualitative assessment of research publications coming from two premier medical institutes in India. Materials and methods Research publications from AIIMS and PGIMER published during 2004 to 2008 were analyzed. The publications were categorized into five types. A year-wise analysis was done for both the institutes. Data was obtained from Scopus. The collected data included the number of papers published in a category, total citations received by a type of publication in a year, number of publications which have no citations, number of publications with only one citation, h-index, number of zero and only one citation were added to get publications with negligible citations. Results A total number of 4,828 and 2,882 research publications were analyzed from AIIMS and PGIMER respectively. The original articles attracted highest no of citations that is 64 and 66% of the total citations in a year for AIIMS and PGIMER respectively. Approximately 37 to 42% of the original articles get negligible citations. The h-index for various categories of article was higher for the original articles (18/13), whereas it was very low for other category of research publications. Conclusion The original articles fetch more citations in long run. Close to 40% of the original research done in the studied institutes get negligible citations pointing toward their outcome utility and quality. More than 60% of the minor category publications remain uncited. This sort of data if periodically obtained should serve as a benchmark for quality analysis of scientific research. How to cite this article Kanojia RP, Rathod KK, Rao KLN. Qualitative Assessment of Research done at Two Premier Medical Institutes in India: Some Data for Introspection. J Postgrad Med Edu Res 2012;46(1):24-33.

The appropriate pain management in neonates and children is lacking. Factors that prevent the execution of proper pain relief vary from center to center. We studied the factors responsible for it in a surgical unit. We conducted a survey at a tertiary-level institute among the resident doctors and nursing staff by means of an informal questionnaire analyzing their basic knowledge. The questions pertained mainly to pain assessment, analgesic usage, role of opioids, and formal training, and the responses so obtained were analyzed under these four headings. Seventy-three percent (22/30) of the residents and 74% (26/35) of the nursing staff knew about pain assessment scoring system in pediatric patients. However, assessment of pain in emergency cases was always done by only 6.6% of the residents. Effect of analgesia on severity of pain was never recorded by 33% (10/30) of the residents. Eighty-six percent (26/30) of the residents and 91% (32/35) of the nursing staff had adequate knowledge about analgesic dosage and interval for routine use. Ten of the 30 (33%) residents believed that analgesic administration in an acute abdomen, before definitive diagnosis, will always mask the symptoms. During a minor procedure, 56% (17/30) of the residents always used analgesia. Only 3.3% (1/30) of residents and 2.8% (1/35) of the nursing staff had received a structured training for pain management. Although, 93% (28/30) of the residents claimed to know about the safety of use of opioids, only 46% (14/30) used them routinely as analgesics. Pain management in surgical neonates and children is often ignored. Lack of formal training, inadequate knowledge, and standard protocols are the barriers in our setup, which may in turn be due to overwhelming attention given to the surgical condition.

Background Hirschsprung’s disease (HD) is an anomaly characterized by the absence of myenteric and submucosal ganglion cells (GC) in the distal alimentary tract. Diagnosis of HD is made by the absence of GC and missing out on even a single ganglion cell can be very devastating. Acetylcholinesterase (AChE) histochemistry, done on frozen sections is said to be a very useful ancillary technique in the diagnosis and in aiding the operative procedures of HD. Methods To assess this, 73 samples from 42 suspected/known cases of HD were subjected to frozen section analysis with rapid haematoxylin and eosin, toluidin blue stain along with AChE histochemistry. The remnant sample was paraffin embedded for routine haematoxylin and eosin staining. Results On frozen section analysis, 33 samples showed absence of ganglion cells, AChE histochemistry showed a positive staining pattern in 17 samples and paraffin embedded routine, H&E stained sections showed absence of ganglion cells in 19 samples. Sensitivity and specificity of both tests ie frozen section rapid H&E/AChE histochemistry in the diagnosis of HD, were calculated taking paraffin embedded H&E stained sections as the gold standard. Sensitivity of frozen section rapid H&E in the diagnosis of HD is 57.57 % and specificity is 79.10 %. The p-value is

Background: A significant number of esophageal atresia and tracheoesophageal fistula patients have long gaps and a high propensity to leak. Anastomotic leak in esophageal atresia is associated with a significant morbidity and mortality. Aim : In a prospective randomized trial, we analyzed the risk factors leading to anastomotic dehiscence and studied the effect of pleural wrap as an additional vascular cover around the esophageal anastomosis. Materials and Methods: Forty patients were divided into two groups A and B randomly. In 20 patients of group A, pleural wrap was utilized for covering the anastomosis and in 20 patients of group B, no such wrap was utilized. Results: Both the groups were comparable regarding age, sex, weight, gap length, tension at anastomosis and the hospital stay. The overall leak rate was 25% (10/40) in both the groups. The leak rate was not significantly different in two groups whenever a gap length was less than 2 cm or more than 3 cm. However, for a gap length of 2-3 cm, the leak rate in group A was 18% (2/11) and in group B was 50% (4/8) (P = 0.05). Thirty percent (3/10) of patients, whose anastomosis was under tension, leaked in group A as compared to 75% (6/8) in group B patients (P = 0.001). Conclusions: Use of pleural wrap was associated with less anastomotic dehiscence in patients with moderate gap esophageal atresia (2-3 cm) especially when the anastomosis was under tension.

Neonatal paraesophageal hernia with intrathoracic gastric volvulus is very rare in the newborn period. We report a case of a 2-day-old term neonate who presented with an antenatal diagnosis of paraesophageal hernia. We discuss the diagnosis and management with classical radiological features including an antenatal diagnosis of this extremely rare surgical cause of neonatal nonbilious emesis.

Congenital nevi and fibrolipomatous hamartoma are benign tumors of childhood, the latter being very uncommon. Fibrous hamartoma of infancy typically occurs in

Aim: Report of 125 pediatric patients of empyema thoracis treated by open decortication, highlighting the presentation, delay in referral, operative findings, the response to surgical intervention and follow-up. Materials and Methods: All the children who underwent open decortication for stage III empyema thoracis during the study period were included. Preoperative workup included hemogram, serum protein, chest radiographs and contrast-enhanced computed tomographic (CECT) scan of the chest. Results: One hundred and twenty-five patients (81 males, 44 females) (age 3 months-12 years, mean 4.9 years) were operated during a 4.5-year period. Among them, two children underwent bilateral thoracotomies. Also, 81.6% patients were referred 3 weeks after the onset of disease (mean duration 9 weeks). Intercostal chest drainage (ICD) had been inserted in (119) 95% cases. Thickened pleura, multiloculated pus and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in 10 patients and empyema necessitatis in 2. Decortication, removal of necrotic tissue and closure of air leaks was performed in all the patients. Necrotizing pneumonia was seen in (35) 27.5% cases. Mean duration of postoperative ICD was 7 days. Follow-up ranged from 3 months to 4 years (mean 12 months). There was no mortality. Six patients had proven tuberculosis. Conclusions: The duration of the disease had a direct relationship with the thickness of the pleura and injury to the underlying lung. Delayed referral causes irreversible changes in the lung prolonging recovery. Only 18% presented within the early period of the disease. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.

BACKGROUND Intrathecal (IT) neostigmine produces dose-dependent analgesia in adults. However, the dose of spinal neostigmine has not been investigated in infants. The purpose of this study was to assess spinal anesthesia (SA) duration provided by four doses of spinal neostigmine added to bupivacaine for lower abdominal and urogenital procedures in infants. METHODS Seventy-five infants were randomized into five groups. The control group B received IT plain 0.5% hyperbaric bupivacaine. Groups BN.25, BN.50, BN.75, and BN1.0 received bupivacaine with 0.25, 0.5, 0.75, and 1 microg/kg of neostigmine, respectively. The primary variable was the duration of anesthesia assessed by recovery of hip flexion. Postoperative pain with facial expression, leg activity, arm activity, crying and consolability scale score, and rescue analgesic requirements were the secondary variables measured, and the side effects were noted. RESULTS Seventy-three infants completed the study. There was a significant linear increase in SA duration with IT neostigmine to 65.2 (4.3) min with 0.5 microg/kg (P

Empyema thoracis can produce significant morbidity in children if inadequately treated. Correct evaluation of the stage of the disease, the clinical condition of the child and proper assessment of the response to conservative treatment is crucial in deciding the mode of further surgical intervention. This ranges from intercostal chest tube drainage and video-assisted thoracoscopic surgery to open decortication. Surgical decortication becomes mandatory in neglected cases; it gives very gratifying results ameliorating the disease rapidly and is well tolerated by young patients. This article reviews the current literature and discusses the important considerations while managing these patients. Indications for surgery are highlighted, based on our large experience at a tertiary care center.

The most common surgery on the esophagus by pediatric surgeons the world over is performed in the newborn period in babies with congenital esophageal atresia with tracheo-esophageal fistula. Post-operative complications like recurrent fistula, anastomotic stricture and some patients with gastroesophageal reflux would also require surgical intervention. Apart from esophageal dilatation, gastrostomy and feeding jejunostomy, children with strictures secondary to caustic ingestion, reflux or previous esophageal anastomosis may require esophageal substitution. This operation may also be required in babies with pure esophageal atresia as well as those with a long gap esophageal atresia with fistula. The entire stomach, stomach tubes, colon or jejunum are often used but techniques preserving as much of the original esophagus as possible are preferable and more physiological. Surgery is also required in children with congenital esophageal stenosis and duplication cyst.

Wandering spleen is a rare clinical entity characterized by splenic hypermobility resulting from laxity or maldevelopment of supporting splenic ligaments. Its major complication is splenic torsion, which is a potentially fatal surgical emergency. We present a rare case of wandering spleen with torsion and splenic infarction in a patient with marfanoid hypermobility syndrome and vertebral abnormalities.

Nutritional support is different in pediatric patients more so in neonatal surgical patients. Stress during and following surgery does not increase the metabolic requirements as significantly as in the case of children and adults. Postoperative enteral nutrition is gaining more and more importance as knowledge regarding the intestinal motility and hormonal secretion following surgery accumulate. Continuous versus intermittent bolus enteral feeds is still an area of investigation. Parenteral nutrition plays an important role especially in certain abdominal surgical conditions. Asepsis and maintenance of intravenous lines are vital issues in providing parenteral nutrition.