Is It Mandatory To Ligate Sac In Emergency Herniotomy In Paediatric Age Group? A Prospective Cohort.

BACKGROUND: Herniotomy is standard treatment for inguinal hernia in children. Paediatric surgeons remain divided on whether ligation of sac is mandatory. In our study, we left the sac open to see early recurrence. METHODS: This quasi=experimental study, done in emergency cases, was sequel to our previous study done in elective cases. It was carried out at surgical unit C of Ayub Hospital Complex, Abbottabad, from Jan 2016 to June 2020. Children from birth to 12 years of age were randomly divided into two groups. In group I (experimental), sacs were cut high up and left open during herniotomy while in group II (control), high ligation of hernia sac was done. Follow up was scheduled for day 10 and 1, 3 and 6 months. Patients were assessed for early recurrence and other complications. RESULTS: A total of 151 emergency inguinal herniotomies were done including 147 males (97.4%) and 4 females (2.6%). 136 sacs (90.1%) were ligated with vicryl 3/0 or 4/0 while 15 sacs (9.9%) were left open. We did not find early recurrence, but found 1 case of scrotal hematoma (n=1/15) (6.7%) and 1 case of scrotal oedema (n=1/15) (6.7%) in the experimental group. In control group, complications were similar with 7 cases of hematoma (n=7/136) (5.1%) and 9 cases of scrotal oedema (n=9/136) (6.6%). CONCLUSIONS: Complications are comparable in herniotomy with or without ligation of sac but ligation adds an extra step. Herniotomy without sac ligation in children is safe and preferable in emergency setup.

Drug-induced duodenal perforation in the paediatric patient with thalassemia major, an unreported side effect of iron- chelating agent: A case report.

Duodenal ulcer disease is uncommon in paediatric age group. Its perforation is even rarer. However, it should be kept in mind when examining children with acute abdomen especially if there are signs of shock or possibility of upper gastrointestinal bleed. We report a case of a 6 years old female child, a known case of thalassemia major and taking oral Deferasirox since two years of age. She had atypical presentation as there was no previous history of peptic ulcer disease and she only suffered epigastric pain and vomiting for a week but due to lack of proper diagnosis at a local clinic developed duodenal ulcer perforation, which was ultimately diagnosed at a tertiary care hospital and managed with Graham Patch Closure.

Bilateral multifocal choroiditis with disc edema in a 15-year-old girl following COVID-19 vaccination.

A few cases of posterior uveitis following COVID-19 vaccination have been reported but none in the pediatric age group. A 15-year-old girl presented with history of headache and bilateral blurred vision of five days duration. The symptoms developed five days after vaccination with the first dose of Covaxin (inactivated SARS-CoV-2 vaccine). Her anterior segment was normal in both eyes (BE), whereas the posterior segment showed mild vitritis with disc edema and multiple yellowish lesions at the level of choroid clustered at the macula and associated with multiple serous detachments. BE uveitis resolved, and the vision was completely recovered three weeks after treatment with steroids. Hence, ophthalmologists should be aware of uveitis following vaccination-a condition that is usually benign, transient, and results in excellent outcomes with timely diagnosis and early treatment with steroids.

Relationship Between Atopic Dermatitis and Food Allergy in Children.

Atopic dermatitis (AD) is a chronic inflammatory skin condition characterized by a compromised skin barrier due to a variety of reasons, such as hereditary predisposition, immunological overactivity, and skin microbiome disruption. There is strong evidence linking food allergies (FA) with AD in some children, and many children with AD develop asymptomatic food sensitivity. FA and AD are two frequent childhood illnesses that are closely related. Food allergies affect 30% of kids suffering from moderate and severe eczema and can cause a variety of symptoms, including dry, cracked skin, rash, itchiness, oozing, and crusted skin. While preteens and teens with AD are commonly sensitive to environmental allergens including house dust mites, mold, pollen, or dander of animals, younger kids with AD typically exhibit sensitivity to food items like peanuts, milk, or eggs. A food challenge test (FC) should be used to confirm allergies before recommending a stringent diet that could be hazardous to the patient. While elimination diets continue to be the cornerstone of the management of FA, they should only be carried out under the guidance of a specialist. Topical treatments are crucial for all individuals with AD. Early skin care with emollients, topical steroid treatment, and early introduction of highly allergenic foods are promising methods of alleviating symptoms of AD.

Management outcomes of mesenteric cysts in paediatric age group.

BACKGROUND: Mesenteric cysts are rare intra-abdominal masses and high index of suspicion is required to clinically suspect this pathology and make a definitive diagnosis. They are most commonly located in the ileal mesentery but can be located anywhere along the gastrointestinal tract mesentery and may extend into the retroperitoneum. The rarity of these anomalies and diversity of clinical picture pose challenges in the diagnosis and operative management. The objective of this study is to determine the demographic pattern, clinicopathological diagnosis and management outcome of mesenteric cysts in our hospital. MATERIALS AND METHODS: This retrospective study was conducted on children operated for mesenteric cysts from October 2013 to September 2020. Statistical analysis was performed using Open Epi Version 3.01. RESULTS: Out of 32 children with a diagnosis of mesenteric cyst, 78% were below 5 years of age. Small intestine was affected in 26 cases and large bowel mesentery was the site of origin in six cases. Complete excision of mesenteric cyst was possible in all cases. Bowel resection was required in ten cases (31%) to enable complete excision. Bowel resection was required more often in children operated on emergency than those with elective surgery, and is statistically significant (P = 0.04; confidence interval: 0.05-0.96, odds ratio: 0.23). An uncommon co-existence with ileal atresia and detection of rare chylolymphatic cyst in another infant were also remarkable findings. Histopathology proved the diagnosis in all cases. There was no mortality or recurrence during hospitalisation and follow-up, which ranged from 3 months to 3 years. CONCLUSIONS: Mesenteric cysts present with diverse clinical features and children below 5 years of age are most commonly affected. Complete surgical excision is the optimal treatment and may require bowel resection in significant number of cases, especially those operated during emergency. Histopathology is the gold standard for diagnosis.

Cushing's Disease in Children: A Review.

Cushing's disease is rare in the paediatric age group. The disease manifestations are similar to that seen in adults. Most of the management protocols have, therefore, been adopted from experience in adults and the therapeutic strategies employed in the latter group. Management of paediatric Cushing's disease poses significant challenges with regard to achieving an optimal growth, a proper body composition, an adequate bone health and reproductive capability as well as a good quality of life. This article reviews the special clinical, biochemical, radiological, surgical, and adjunctive therapeutic considerations in paediatric Cushing's disease.

[Antibiotic strategy in pleural empyema in children: Consensus by the DELPHI method]. / Stratégie antibiotique dans les pleurésies en pédiatrie : consensus par méthode DELPHI.

INTRODUCTION: The evolution of the microbial epidemiology of pleuropulmonary infections complicating community-acquired pneumonia has resulted in a change in empirical or targeted antibiotic therapy in children in the post Prevenar 13 era. The three main pathogens involved in pleural empyema in children are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus. METHODS: A questionnaire according to the DELPHI method was sent to experts in the field (paediatric pulmonologists and infectious disease specialists) in France with the purpose of reaching a consensus on the conservative antibiotic treatment of pleural empyema in children. Two rounds were completed as part of this DELPHI process. RESULTS: Our work has shown that in the absence of clinical signs of severity, the prescription of an intravenous monotherapy is consensual but there is no agreement on the choice of drug to use. A consensus was also reached on treatment adjustment based on the results of blood cultures, the non-systematic use of a combination therapy, the need for continued oral therapy and the lack of impact of pleural drainage on infection control. On the other hand, after the second round of DELPHI, there was no consensus on the duration of intravenous antibiotic therapy and on the treatment of severe pleural empyema, especially when caused by Staphylococci. CONCLUSIONS: The result of this work highlights the needed for new French recommendations based on the evolution of microbial epidemiology in the post PCV13 era.

Thymic lesions of the paediatric age group: a comprehensive review of non-neoplastic and neoplastic etiologies.

Thymus is an important part of the immune system of the paediatric age group. Thymic lesions are rare causes of anterior mediastinal pathology. Their occurrence in children is rarer, nevertheless, knowledge about their pathologies help in clinching the correct diagnosis. All lesions both non-neoplastic as well as neoplastic are found in children, however, they differ from adults not only in the clinical presentation but also in the pathogenesis and natural history of the disease. Thymic hyperplasia may not actually be true if age is taken into consideration. Similarly, a type B thymoma may be mistakenly diagnosed as a lymphoblastic lymphoma especially on small biopsies. This review has been carried out after extensive search of literature using the Google and Pubmed search engines. An attempt has been made to comprehensively cover all aspects of thymic pathology of the paediatric age group having historical significance as well as the recent updates.

Non-union fracture neck femur in a toddler: Reconstructed by valgus osteotomy - A minimally invasive approach.

BACKGROUND: Non-union is one of the devastating complications of fracture neck of femur. Though a very rarely encountered entity in a toddler (1-3 years paediatric age group), non-united femoral neck fractures are reported in developing countries because of mismanagement by quacks and delay in referrals. For operative treatment, many different procedures have been described, including close/open reduction and internal fixation using K-wires, cannulated screws, fibula or nails. There is no evidence in the literature that one or other implant influences the rate of postoperative complications, such as avascular femoral head necrosis or coxa vara. But, still the choice of fixation implant is debatable. CASE REPORT: We present a case of 3-year-old child of non-union femoral neck fracture treated with valgus osteotomy. Choice of implant was kept to bare minimum to reduce the cost of implant and magnitude of surgery, which made the surgery minimally invasive, which is not the case in other studies. Two solid cancellous screws and a Kirschner wire (K-wire) were used to acheive fixation. Implant was removed after one year. The patient was followed up for 2 years and was found to be asymptomatic clinically with restoration of neck shaft angle and no signs of AVN. CONCLUSION: Our method of intertrochanteric valgus osteotomy and internal fixation stabilized using K-wire and screws is a technically simple yet effective method of treating difficult fracture neck femur. Although a larger series and multicentric trails are needed, yet we would safely recommend extension of this technique to unstable fractures, to minimize the incidence of complications, cost and magnitude of surgery.

Schwannoma of Upper Lip: Report of a Rare Case in a Rare Age Group.

Schwannoma is a benign, encapsulated perineural tumour originating from the schwann cells of the neural sheath of peripheral motor and sensory nerves. It may develop at any age but is extremely rare in paediatric age group. The tumour is frequently located on the head and neck region, the tongue being the most common site followed by the palate, floor of mouth, buccal mucosa, lips and jaws. Schwannomas rarely occur in the lip area and it is exceedingly rare in the upper lip. The lesion is usually solitary but can be multiple when associated with neurofibromatosis. The diagnosis is usually confirmed after biopsy and anti-S100 protein immuno-histochemical staining is usually used to identify the tumour. In the present study the patient was a 14-year-old young girl with the schwannoma on the upper lip which is probably the third such case in a paediatric age group being reported and was excised without any recurrence at 2 year after excision.

Spontaneous hepatocellular adenoma in paediatric age group - case report.

Hepatocellular adenoma (Hca) is a rare, benign, liver cell tumour. Hca is most frequently seen in women with a history of oral contraceptive use. Hca is also reported in children with glycogen storage disorders, galactosaemia, Hurler's syndrome, severe immune deficiency states, diabetes mellitus, sex hormone disturbances, Fanconis anaemia, in those who are on androgen therapy and also in seizure disorder patients who are on carbamazepine therapy. Usually, Hca arises typically in a clinical setting of hormonal or metabolic abnormalities which stimulate hepatocyte proliferation. Though it is rare, a few cases of spontaneous Hca have been reported in children and also in adults, which were not associated with any of the known risk factors which are associated with Hca. Hca has to be differentiated from focal nodular hyperplasia, hepatocellular carcinoma and hepatoblastoma. The histological features and the assessment of cell proliferation by using immuno histochemistry, help in confirming the diagnosis of Hca. In a few cases of Hca, malignant transformations have been reported. Hence, a careful search for malignant transformations is necessary. In this report, we have documented two cases of spontaneous Hca which occurred in two normal children.

Laryngeal mask airway vs the endotracheal tube in paediatric airway management: A meta-analysis of prospective randomised controlled trials.

A meta-analysis was performed on prospective randomised controlled trials to assess whether the laryngeal mask airway (LMA) offered any advantage over the conventional endotracheal tube in the paediatric age group. Using the Cochrane methodology, a literature search was carried out through peer-reviewed indexed journals in three medical databases to obtain all publications comparing the LMA with the endotracheal tube in the paediatric age group (age less than 12 years), available till December 2010. Data from 16 randomised controlled clinical trials were selected for analysis. A null hypothesis was formed against each of the seven issues tested using the Fisher's method of combining P values. The LMA was seen to have three advantages over the tracheal tube in the form of lower incidence of cough during emergence, lower incidence of postoperative sore throat and lower incidence of postoperative vomiting (P<0.05). It was seen to offer no advantage over the tracheal tube in incidence of bronchospasm or laryngospasm during emergence; also, it did not offer any advantage in increasing the efficacy of the airway seal. The only disadvantage the LMA had over the tracheal tube was its greater incidence of placement failure in the first attempt.