Health Related Quality of Life (HRQOL) in pediatric population after surgical intervention in traumatic lower limb injuries: A prospective cohort.

Objective: To assess health related quality of life (HRQOL) of children who had undergone surgical intervention after lower limb trauma. Methods: A prospective observational study was conducted at KEMU and UCHS, from September 2021 to June 2022. Fifty children aged 5 to 12 years who had undergone surgical intervention for lower limb trauma were included. Patients whose parents couldn't understand Urdu or English, or with polytrauma, needing amputation and/or comorbidities were excluded. Another fifty-school going, age matched children were enrolled as controls. After informed consent, two responses from participants and parents on PedsQL questionnaires were recorded, first one week after discharge and second after six months, assessing age specific quality of life in four domains (physical, emotional, social, school). Impaired HRQOL was defined as a score that was more than 1SD below the mean of healthy sample. Results: Baseline HRQOL scores were significantly lower in patients and parents reported data taken at one week, overall difference of 39.13 in total HRQOL scores (effect size, d 2.76). Difference of 39.86 was observed between baseline and follow-up data taken from parents with the highest effect size (d=3.34) in physical functioning scores. There was a significant difference of 10.07 between the total HRQOL scores of patients on follow up and controls, and HRQOL patients' scores were higher than controls across all domains. Parent reported scores were less than those reported by children in almost all cases. Conclusion: HRQOL of children at discharge after management of lower limb trauma was lower than age-matched control group. It, however, significantly exceeded controls' scores after six months showing complete recovery.

A rare case report of extrahepatic hepatoblastoma in a child.

Hepatic malignancies account for 1-4% of all childhood solid tumours and Hepatoblastoma is the most common malignant liver tumour in children. Its extrahepatic origin is rare. Here we present the case of a three-year-old boy who came with a large non-tender mass in the right upper abdomen for six months. Ultrasound abdomen revealed a huge heterogenous mass anterior to the right kidney and inferior to the liver with internal vascularity and calcifications, mimicking a neuroblastoma. Tru-cut needle biopsy showed foetal-type hepatoblastoma. After neoadjuvant chemotherapy, the tumour was explored. It was found to be adherent to the inferior surface of the liver with no capsular breech. Hence differentiating it from exophytic growth of hepatoblastoma. The tumour was completely resected. The postoperative course was uneventful and adjuvant chemotherapy was given. So far only a few cases of extrahepatic hepatoblastoma have been reported.

Non-operative treatment versus appendectomy for acute uncomplicated appendicitis: A randomized controlled trial.

OBJECTIVES: To compare the outcome of non-operative treatment (NOT) with antibiotics versus surgical management of uncomplicated appendicitis in children. METHODS: This randomized clinical trial (NCT04030741) was carried out in Pediatric Surgery Department, Mayo Hospital from September 2018 to September 2019. Total sample size was 180, and after informed consent patients were randomly allocated in two groups. All children between 5 and 15 years of age and having pediatric appendicitis score (PAS) >7 were included. Patients with previous abdominal surgery, peritonitis, appendicular mass, or intra-abdominal abscess were excluded. Children in NOT group (Group A) were given intravenous Meropenem and Metronidazole for 48 hours and after starting oral, antibiotics were continued orally for 7 days. In Group B, children underwent appendectomy. Failure of NOT was labeled if there was abscess formation or peri-appendiceal fluid collection on ultrasound, development of peritonitis or recurrence of appendicitis. RESULTS: In Group A, mean age was 9.56±1.8 years and in Group B 10.11±1.8 years. There were 123 male and 57 female patients. Group B had 100% successful outcome. NOT (Group A) had successful outcome in 75 patients (83.3%) and failure was noted in 15 (16.7%). Five needed operation within 48 hours, all had appendicolith, and 10 patients presented within 6 months. Raised total leukocyte count (p value < 0.0001) and C reactive protein (p value < 0.04) levels were noted with failure of NOT. CONCLUSIONS: In this study, success of NOT was 84% so a trial of NOT in cases of uncomplicated appendicitis should be considered in children.

Comparison of Urethrocutaneous Fistula Rate After Single Dartos and Double Dartos Tubularized Incised Plate Urethroplasty in Pediatric Hypospadias.

Background and objective Tubularized incised plate (TIP) urethroplasty is an easy and popular technique for repairing hypospadias, however urethrocutaneous fistula (UCF) is a frequently reported complication. Different techniques are used to reduce this complication. We aimed to compare the rate of UCF after single dartos and double dartos TIP urethroplasty in children with distal and mid penile hypospadias. Methods A randomized controlled trial (NCT04699318) was conducted in the Department of Pediatric Surgery, Mayo Hospital, Pakistan from August 2017 to February 2018, after ethical approval. After informed consent, a total of 60 patients with distal and mid penile hypospadias who were uncircumcised, had no chordee, and/or previous surgery, were randomly allocated in two groups using computer generated table numbers. Group A underwent single dartos TIP urethroplasty and Group B underwent double dartos TIP urethroplasty. Catheter was removed on day 10 post-operatively in both groups and primary outcome (UCF) was noted after a week of catheter removal. Rate of UCF was compared using chi square and p-value of <0.05 was taken as significant. Data was stratified to check for effect modifiers. Results Out of 60 children, eight (13.3%) developed UCF. In Group A, seven (23.3%) developed UCF and in Group B, one (3.3%) developed UCF (p-value 0.02). In both groups, no patient (0%) had urethral disruption, penile torsion, skin necrosis or meatal stenosis. Conclusion Additional covering of neo-urethra by a double dartos layer significantly reduces fistula rate after tubularized incised plate urethroplasty in both primary distal and mid penile hypospadias.

Eczema Herpeticum in children with burns.

BACKGROUND & OBJECTIVE: Eczema herpeticum (EH) is a disseminated viral infection occurring in pre-existing skin conditions and burns. The objective of this study was to determine the frequency, treatment, and outcome of EH in pediatric burn patients. METHODS: This retrospective study was conducted in the pediatric surgery department, King Edward Medical University/ Mayo Hospital, Lahore, from October 2015 to July 2018 after ethical approval. All pediatric burn patients diagnosed with EH and not sensitive to Acyclovir or suffering from chemical burns were enrolled in the study. Diagnosis was confirmed by presence of umbilicated lesions in burnt area and a positive Tzanck smear. Intravenous acyclovir and supportive treatment was started. Mortality, development of contractures, length of hospital stay/ time for wound healing, re-activation of EH was calculated. RESULTS: Out of 3958 admitted pediatric burn patients, 94(2.4%) developed EH. Girls were 58(61.7%) and boys were 36(38.3%). Mean age was 5.16 ±2.88 years. Scald burn was in 43(45.7%) patients, flame burn in 48(51.1%) patients, and electric flash burn in 3(3.2%) patients. Mean TBSA was 21.74+10.38%. Vesicular eruptions settled in 92 (97.9%) patients after treatment with acyclovir. Mean duration of treatment was 19.89+ 8.9 days and hospital stay was 29.84+ 16.98 days. Twenty three patients (24.5%) developed contractures and two patients (2.1%) developed disseminated EH and expired. Six (6.4%) patients had re-activation of EH. CONCLUSION: EH occurred in 2.4% of admitted pediatric burn patients. Intravenous acyclovir was successful in 97.9% of the patients, although 2.1% developed disseminated EH and expired. Re-activation occurred in 6.4% of the cases and was associated with prolonged hospital stay.

Association of Serum Vitamin D and Immunoglobulin E Levels With Severity of Allergic Rhinitis.

Objective The aim of this study was to determine the association of serum vitamin D and immunoglobulin E (IgE) levels with the severity of allergic rhinitis (AR). Methods This case-control study was conducted at Mayo Hospital, Lahore, from June to September 2020 after obtaining ethical approval. Patients of AR were included and divided with the help of allergic rhinitis and its impact on asthma (ARIA) classification, into group A (cases), patients presenting with moderate to severe symptoms, and into group B (control), patients with mild symptoms, after treatment of AR. The mean difference between serum IgE and serum Vitamin D levels of both groups were compared by t-test. Association was determined by logistic regression and odds ratio. Results A total of 224 patients were included in the study, 112 patients in group A and 112 patients in group B. There were 106 (47.3%) female and 118 (52.7%) male. The mean age of patients in group A was 26.78± 8.92 years and in group B, it was 25.72±8.12 years. Mean serum vitamin D levels in group A were 16.24±6.7 ng/ml and in group B 26.92±35 ng/ml (p=0.0001). Mean serum IgE levels in group A were 383.69±154.86 IU/ml and in group B, they were 373.03±106.83 IU/ml (p=0.0001). Vitamin D deficient patients were 24 times more likely to develop moderate to severe AR disease. Conclusion This study showed that in moderate-severe AR, IgE levels are raised statistically as compared to mild AR and the deficiency of Vitamin D is associated with increasing severity of allergic rhinitis symptoms.

Comparison of Ferguson and Gross herniotomy with Mitchell Banks' herniotomy in boys older than two years.

BACKGROUND & OBJECTIVE: In children younger than two years, most surgeons perform the inguinal herniotomy superficially through the external ring, a technique known as Mitchell-Banks' Herniotomy (MBH) while in older children, commonly Ferguson and Gross Herniotomy (FGH) is performed which involves opening of inguinal canal. Our aim was to compare the FGH and MBH in terms of recurrence in boys with inguinal hernia. METHODS: Boys with inguinal hernia presenting to Pediatric Surgery, Mayo Hospital Lahore from Dec 2016 to January 2018 were included in the study, if older than two years and younger than 14 years and without palpable deep ring (2 cm or more in width) or strangulation of inguinal hernia or malnutrition. They were randomly allocated in 2 groups after obtaining informed consent from parents, and underwent MBH (Group-A) and FGH (Group-B). Children were called for follow up after 1 week and at 6 months to assess for recurrence. RESULTS: Total 260 patients with inguinal hernia were enrolled (NCT: 03392636). The mean age of boys in Group-A was 5.2±3.0 years and in Group-B was 5.9±3.1 years. Mean operating time in Group-A (26.65±3.22 minutes) was longer than Group-B (15.92±4.22 minutes), and scrotal oedema was noted in 38 (29.2%) cases in Group-A, while 7 (5.4%) cases in Group-B. Testicular atrophy was noted in one patient of Group-B. Recurrence occurred in 1(0.8%) patient in Group-A, and in 8(6.2%) patients in Group-B (p-value 0.018). CONCLUSION: Mitchell-Banks' herniotomy has lower recurrence rate than Ferguson and Gross Herniotomy in boys older than two years.

Root cause analysis of pre-microscopic errors in anatomical pathology using Eindhoven classification.

OBJECTIVE: To evaluate pre-microscopic errors in anatomical pathology. METHODS: The cross-sectional descriptive study was conducted at the Department of Pathology of a tertiary care hospital in Lahore, Pakistan, from September, 2016, to January, 2017, and comprised surgical pathology specimens. Errors were noted across the pre-microscopic process. Defects per million opportunities were calculated to determine sigma metric value in every step, from requisition to slide preparation. Root cause analysis was applied to the process of histology preparation to identify the root cause of each previously identified problem using Eindhoven classification. All errors were recorded on a pre-designed proforma. RESULTS: There were 2420 specimens. While errors were encountered in all phases of the pre-microscopic process, but the (G6: n=1085, 44.83%), followed by requisition (R3: n=893, 36.9%) and cover slipping (C1: n=776, 32.06%). CONCLUSIONS: Development of standard procedures and protocols with staff training is likely to help in controlling the errors.

Allergic Fungal rhino-sinusitis frequency in chronic rhino-sinusitis patients and accuracy of fungal culture in its diagnosis.

OBJECTIVE: To determine the frequency of Allergic Fungal Rhino-sinusitis (AFRS) in Chronic Rhino-sinusitis (CRS) patients and the accuracy of fungal culture in diagnosing AFRS. METHODS: Immunocompetent patients with CRS and without invasive fungal rhino-sinusitis presenting over a period of 3 years in ENT department of Mayo Hospital, from April 2014 to September 2017 were included in the study. AFRS was diagnosed clinically and on Bent and Kuhn diagnostic criteria. All patients underwent endoscopic sinus surgery. Removed tissue histopathology and fungal culture was done. Diagnostic accuracy of fungal culture in AFRS patients was determined. RESULTS: Out of 216 patients of CRS, 45 (20.8%) had AFRS. Mean age of patients diagnosed with AFRS was 29.49±9.16. Out of 45 patients, 26 were male and 19 were female. Nasal polyps were present in 45 (100%) patients, fungal stain was positive in 39(86.7%). CT scan showed sinus expansion in 28(62.2%) patients, heterogeneous opacity in 45(100%) patients and bone destruction in 13(28.9%). Presence of Allergic Mucin was seen in 45(100%) patients, high IgE levels in 36(80.0%), eosinophilia in 21(46.7%), presence of Charcot Leyden crystals in 27(60.0%). Asymmetrical involvement of sinuses was seen in 30 (66.7%) and co-existent asthma was seen in 18(40.0%). Fungal culture positive patients were 25(55.6%). Diagnostic accuracy of fungal culture was 91.6%. CONCLUSION: Fungal culture has a key role in confirming diagnosis of AFRS. We also noted that frequency of AFRS is increasing in CRS patients.

Motor cycle spoke wheel injuries in children: A preventable accident.

BACKGROUND: The incidence of motorcycle-induced spoke wheel injury is on the rise in our set up. These injuries range from minor soft tissue laceration to extensive crush injuries. This study aimed to evaluate the mechanism, characteristics, incidence and management of wheel spoke injuries. METHODS: Data of all children admitted to Pediatric Surgery Emergency from January 2014 to December 2017, presenting with wheel spoke injuries were analyzed. Incidence, mechanism and characteristics of injury, along with management plan, were noted. The outcomes were assessed by evaluating patients in follow up. RESULTS: Total study patients were 120, with an incidence of 21.7%. Mean age was 8.03±2.28 years. There were 101male patients and nine female patients. All patients were passengers and were sitting astride. Most of the patients were wearing shoes, and hindfoot area of the right foot was mainly involved. Grade 2 injury was seen in 55 (45.8%) and Grade 3 in 55 (45.8%) patients. Flap was needed in 27(22.5%) patients. All patients were mobile at the time of the follow-up. CONCLUSION: We noted the rising incidence of entrapment injuries; however, we had a satisfactory outcome in our patients using different management techniques. We recommend the implementation of safety protocols to avoid such catastrophic injuries.

Do parents have knowledge of first aid management of burns in their children? A hospital based survey.

OBJECTIVE: To ascertain knowledge of first aid among parents of children suffering from burns. METHODS: The cross-sectional study was conducted at Mayo Hospital, Lahore, Pakistan, from July 2017 to January 2018, and comprised parents of patients in the paediatric burns unit. Questionnaires were filled by the duty doctor after interviewing parents, and data was collected regarding first aid, application of traditional remedies and demographic details. Optimal knowledge was defined as parent's knowledge of application of tap water on burns as first aid. SPSS 20 was used for data analysis . RESULTS: There were parents of 310 patients who had a mean total body surface area of burns of 25.11}13.80%. All (100%) accidents had occurred at home. All (100%) parents had removed their children from heat and electric source immediately after the accident, while 282(91%) stripped their children of their clothes. Only 41(13.2%) parents irrigated the burn area with tap water and 93(30%) applied traditional remedies. Further, 21(6.8%) parents had covered the burnt area with sterile dressing, while 25(8.1%) had covered the child to avoid hypothermia. One (0.3 2%) parent had attended a first aid course, while 13(4.2%) had knowledge of first aid because of previous history of a child having suffered from burns. Optimal knowledge wasstatistically associated with previous knowledge of first aid (p=0.0001), level of education of the parent (p=0.003) and monthly income (p=0.01). CONCLUSIONS: The knowledge of first aid among parents was found to be inadequate and there was an urgent need to introduce campaigns focussing on prevention and first aid to manage burns, especially among illiterate and poor classes.

Cutaneous manifestations in chronic myeloid leukemia in chronic phase treated with imatinib.

OBJECTIVE: The aim of this study was to see the patterns of skin changes in chronic myeloid leukemia (CML) in chronic phase treated with different doses of imatinib. METHODS: This cross-sectional study was conducted in the Oncology Department of Jinnah Hospital, Lahore, over a period of 6 months. Patients aged 7-70 years diagnosed either by fluorescence in situ hybridization (FISH) for BCR-ABL or cytogenetics for Philadelphia (Ph) chromosomes and consuming different doses of imatinib for the treatment of CML were randomly selected. Skin manifestations were analyzed and recorded on a predesigned proforma by a dermatologist. RESULTS: A total of 132 patients were enrolled; 65 male (49.24%) and 67 female (50.75%). Periorbital edema was found in 48.5% of cases, and hyperpigmentaion and melasma were found in 76.5% of cases. Pruritus was diagnosed in 6.8% of cases, alopecia in 5.3% of cases, and photosensitivity in 43.9% of cases. CONCLUSIONS: It was concluded that imatinib is associated with many adverse cutaneous side effects which should be overcome or reduced by either decreasing the duration of treatment with imatinib or switching to other treatment options.

Educational environment for residents in Obstetrics and Gynaecology working in teaching hospitals of Lahore, Pakistan: A cross-sectional study.

The objective of this study was to determine the educational environment of residents in the specialty of Obstetrics and Gynaecology (OBG) working in the hospitals of Lahore, Pakistan. This cross-sectional study was conducted at OBG Department, King Edward Medical University. All the Post-graduate Residents (PGR's) of OBG working in Lahore, Pakistan were included in this study. Educational environment was assessed using Postgraduate Hospital Educational Environment Measure (PHEEM).A total of 368 PGR's from 11 institutions were included in this study. The mean PHEEM score was 63.68 ± 29.60. Most of the participants labeled the environment as 'plenty of problems' as per global scale of PHEEM. PHEEM score was significantly higher for those working in Government hospitals. Gender, year of residency and marital status showed no difference in PHEEM score. We conclude that educational environment in our OBG departments is not adequate and up to the mark.

Variability of presentation and surgical approach in Congenital Cystic Lesions of Lung: A retrospective study in children presenting in Mayo Hospital.

The objective was to study the clinical presentation and surgical outcome in children with congenital cystic lesions of the lung. The medical records of 11 patients operated in the department of paediatric surgery, from January 2014 to December 2017, were evaluated retrospectively. Median age was 18 months (1-108).Respiratory distress was seen in 5 (45.4%) patients, recurrent chest infections in 4 (36.4%) patients and only 2 (18.2%) presented after birth. One patient of congenital lobar emphysema was misdiagnosed as pneumothorax and four patients of recurrent chest infection had been misdiagnosed as pulmonary tuberculosis. All patients underwent lateral thoracotomy. There was no mortality, median length of hospital stay was 4 days (4-5) and only one patient needed postoperative ventilation. On follow up, 10 (90.9%) patients had attained normal level of physical activities. We conclude that increasing awareness of these lesions can prevent misdiagnosis and unnecessary tube thoracostomy and anti-tubercular therapy in children.

Amyand's hernia in an eighteen month old boy: A case report.

Amyand's hernia is a rare type of hernia in which vermiform appendix is found in the hernial sac. We describe the case of an 18 month old boy in which a non-inflamed appendix was found incidentally in the hernial sac of right sided inguinal hernia while doing herniotomy by Mitchell- Banks' technique. We also discuss the different types of Amyand's hernia and how they can be managed by reviewing the literature.

Role of needle aspiration and surgical excision in management of suppurative Bacillus Calmette Guerin lymphadenitis.

The aim was to determine the role of needle aspiration and surgical excision in the management of suppurative Bacillus Calmette Guerin (BCG) lymphadenitis. This prospective study was done in Rafha Central Hospital, over 1.5 years. Thirty two patients were enrolled after informed consent. Needle aspiration was done if size of lymphadenitis was up to 3cm. Surgical excision was done primarily for size more than 3cm or in cases of failed aspiration. Eighteen were males and 14 were females. Median age was 3.75 months (IQR 2-7). All were full term with normal birth weight and vaccinated in first 2 days of life. Predominantly single region of lymphadenitis was involved in 75% cases; with left axilla being mainly affected (56.3% cases). Needle aspiration was done in 18 cases and surgical excision was carried out in 14 cases. Resolution of lymphadenopathy was 7 days in cases of surgical excision, while within 60 days in cases of aspiration. Failure of aspiration was noted in cases of multiple, matted suppurative lymph nodes.

Hybrid Lesion: Extralobar Sequestration with Cystic Adenomatoid Malformation - Misdiagnosed as Pulmonary Tuberculosis.

We report a rare case of bronchopulmonary extralobar sequestration in a 9-year girl mimicking pulmonary tuberculosis. Patient had recurrent chest infections and two episodes of massive hemoptysis. Preoperative x-ray chest showed an opacity in left lower lobe and computed tomography-aortogram showed that the lesion had systemic arterial supply from celiac trunk. Diagnosis of pulmonary sequestration was made and left lateral muscle sparing thoracotomy was planned. Intraoperatively, extralobar sequestration was found with dual systemic blood supply. Histopathology confirmed it to be a hybrid lesion.

Sealed Duodenal Perforation by nail ingestion in a Child.

Unintentional foreign body ingestion is common among children. Normally, these ingested foreign bodies pass spontaneously and the rest can be removed endoscopically; only few ingested foreign bodies lead to complications and need surgical intervention. We are reporting a case of accidental nail ingestion in a 10-year-old child which led to a sealed perforation of duodenum. Operative management included primary duodenal repair after removal of nail. Post operative recovery was smooth and oral was started on day 5. We recommend that all ingested sharp and large foreign bodies should be removed endoscopically, if not passed spontaneously.

An evaluation of management of transferred paediatric burn patients.

The aim of study was to evaluate whether adequate initial management and safe transfer of paediatric burn patients was carried out in our setup. Patients transferred from other hospitals/ cities to Paediatric Surgery Department, Mayo Hospital were evaluated in this prospective study. Data was entered in a proforma. Around 90.4% patients on presentation had discrepancy in their burn percentage calculation. No intravenous fluids were administered to 75.4% patients and 71.1% patients did not have any intravenous access. Foley's catheter was inserted in 2 patients only though 72.8% needed it. No fasciotomy was performed in 10.5% patients needing it. Two patients needed endotracheal intubation but it was not passed, 49.1% patients were transferred by ambulance and 28.9% patients presented with sepsis. The mortality rate was 38.2%. Initial fluid resuscitation was compared with survival and found significant (p=0.000). This shows that initial burn management, transfer system and referral system is full of errors.