Role of Long-Chain Cyanoacrylate as an Adjunct Interposition Layer in Repair of Hypospadias and Urethrocutaneous Fistula in Children: A Novel Technique.

Purpose Hypospadias is an anomaly wherein the urethral opening is ectopically located on the ventral aspect of the penis. The most common complications after hypospadias repair are urethrocutaneous fistula (UCF) and meatal stenosis. Long Chain Cyanoacrylate (LCCA) tissue adhesive promises safety, feasibility, and durability due to its tensile strength and bacteriostatic and hemostatic properties. We conducted this study to ascertain whether LCCA tissue adhesive can prove a more effective adjunct to traditional suturing techniques. Methods Patients were divided into two groups. Group A underwent surgery with conventional reconstruction of the neourethral tube along with the buttressing layer using Buck's fascia or Tunica Vaginalis. In addition to the traditional procedure of Group A, Group B patients were administered a layer of LCCA tissue adhesive as an adjunct between the neourethral suture line and the buttressing layer. Patients were followed up for six months and were evaluated for complications like UCF, meatal stenosis, hematoma, skin infection, glans dehiscence, and flap necrosis. Results Thirty-eight children in the age group 1-6 years were studied, of which 20 were in Group A and 18 in Group B. Among patients of Group A seven (35%) developed complications. In contrast, only four (22.2%) patients developed complications in Group B. The statistical significance in the complication rates between the two groups could not be achieved due to the modest sample size. However, the numerical and proportional reduction in the number of complications was noted. Conclusion LCCA adhesive as an adjunct numerically reduces the number of complications compared to traditional suturing alone in patients undergoing surgery for hypospadias and UCF.

Transcutaneous Hitching Sutures in Paediatric Minimally Invasive Surgery: A Novel Technique of "Assistant Without Port".

BACKGROUND: Transcutaneous hitching sutures in paediatric minimally invasive surgery (MIS) is a unique and rare technique. This technique has been used previously in adult patients undergoing gastric resections and laparoscopic cholecystectomy; however, its use in paediatric population has never been reported in the world literature. The primary objective of this study was to bring out the advantages and feasibility of this technique in minimally invasive gastrointestinal, hepatobiliary, urological and thoracoscopic surgeries on paediatric patients. MATERIALS AND METHODS: This retrospective observational study was conducted on 167 paediatric patients who underwent MIS surgery for different indications between April 2016 and March 2020 at two paediatric surgery tertiary care centres. RESULTS: A total of 167 patients, including 91 boys and 76 girl patients between the age group of new-born period to 12 years were operated. The mean hospital stay was 4 days. Five out of 167 cases (3%) had post-operative surgical emphysema, which resolved spontaneously. At 6-month follow-up, parental satisfaction was 100%, and in 99% of patients, scars were imperceptible. CONCLUSION: This versatile technique is of exemplary utility, especially in paediatric patients where there is a paucity of working space at low intra-abdominal pressure, and eases the dissection even in narrow and closed spaces with a better functional and cosmetic outcome.

Ten Years Analysis of Parental Counselling-in-Continuum in Paediatric Surgery: Psychosocial and Medico-legal Outcome.

BACKGROUND: Parents are anxious and apprehensive about the health of their children. A standardised, reproducible and meticulous parental counselling is helpful to both the parents and the treating doctors, as well as markedly reduces instances of scrimmage and medico-legal litigations. The aim of this study is to assess the psychosocial and medico-legal outcomes of parental counselling-in-continuum (PCiC) in paediatric surgery. MATERIALS AND METHODS: The study was conducted at two government-run Tertiary Healthcare Centres in North India. The study design involves prospective feedback-based study. It included all the admitted paediatric surgery patients. Periodic multisession PCiC was done for each patient by three paediatric surgery teams from 2011 to 2021. At the time of discharge, feedback was taken to assess the psychosocial outcome of PCiC, and the medico-legal outcome was calculated based on the number of litigations. RESULTS: A total of 22,353 admissions were done in paediatric wards at these institutes. 1574 cases were managed conservatively and 20,779 patients who underwent surgeries were included in the study. 4758 (22.89%) were emergency procedures and 16,021 (77.11%) were elective procedures. Parents rated the counselling efforts excellent in 18,285 (81.80%), good in 3162 (14.14%), satisfactory in 876 (3.91%) and poor in 30 (0.13%) cases with zero medico-legal litigations and 12 incidents of scrimmage. CONCLUSIONS: PCiC, being a novel concept, should form a centerpiece of paediatric surgical management as it maximally enhances the patient satisfaction level and protects the treating paediatric surgical team from scrimmage and medico-legal litigations.

A Multicentric Cross-Sectional Observational Study to Analyze the Effects of Moderate High Altitude on Ocular Health.

Objectives: Prolonged exposure to hypoxia at high altitudes can affect the eyes through various mechanisms, culminating in reduced vision. Multiple studies on this subject have focused on the ocular effects of high altitude on intraocular pressure (IOP), corneal thickness, and the retina. However, there is a lack of literature on the effects of 'moderate high altitude (2000-3000 m)' on the eyes. Hence, we designed our study to determine the impact of moderate high altitude on the eyes. Methods: We recruited two age and gender-matched groups of 250 research participants, each at moderate high altitude (Group A) and plains (Group B), respectively, to determine the effects of moderate high altitude on ocular health, if any. Results: We found a statistically significant increase in dry eye in Group A. We also found four cases of central serous retinopathy and one case of central retinal vein occlusion in Group A. There was no statistically significant change in visual acuity, IOP, or central corneal thickness. Conclusion: There is a vast lacuna in the literature on this particular altitude range, and further studies are required to confirm our findings. It is also recommended that lubricant eye drops be advised as a standard prophylactic measure for all individuals traveling and staying at moderate high altitude.

Quantification of the Androgen and Estrogen Receptors in the Penile Tissues of Hypospadias in Comparison with Normal Children.

INTRODUCTION: Hypospadias is a common congenital abnormality typified by a proximally placed ectopic urethral meatus along the ventral surface of the penis. Androgen receptor (AR) and estrogen receptor (ER) expression in the hypospadias tissues may be altered in hypospadias. METHODOLOGY: We evaluated by immunohistochemistry the AR and ER expression in 75 tissues from hypospadias repair, and compared this expression to that of tissue from 75 patients undergoing circumcision. We also compared the intensity of AR and ER expression between different severities of hypospadias. RESULTS: AR quantitative grading score decreased with severity of hypospadias, while the ER score increased as the hypospadias worsened, which was statistically significant (p-value <0.05). CONCLUSION: The penile tissue AR expression is decreased and ER expression is increased with increasing severity of hypospadias.

The Role of Otorhinolaryngological Manifestations of Mild Covid-19 Disease in Hilly Terrain: Lessons Learnt at a Secondary Care Hospital.

We conducted the study to find the prevalence of ENT symptoms amongst mild Covid-19 patients from the hilly region of North India and attempted to propose a solution to curb the spread of Covid-19 through early identification, isolation, and treatment. A retrospective, cross-sectional study at a secondary healthcare center in a hilly region of North India covered 423 mildly symptomatic Covid-19 patients from April 2020 to March 2022. These patients were telephonically contacted or called in person at the outpatient department to answer a preset questionnaire with various parameters such as age, gender, ENT symptoms, and time to recover. The data obtained were statistically analyzed. 207 out of 423 mild Covid-19 patients complained of different ENT symptoms. Cough was the most common ENT symptom and was reported by 162 patients. Dizziness was the least common ENT symptom and was reported by 9 patients. Recovery time for tinnitus was maximum (persistent till six months in 5 patients). A high index of suspicion for Covid-19 disease in patients with ENT symptoms must be practiced. As the Covid-19 restrictions are gradually relaxed, widespread community education for strict adherence to Covid-19 appropriate behaviour and sensitization of General Practitioners a well as Otorhinolaryngologists regarding the importance of ENT symptoms in mild Covid19 disease will play a pivotal role in the early identification, isolation, and treatment of mild Covid-19 disease, which eventually may curb the future waves.

Preliminary Reference Interval for 5-Alpha Reductase in Normal Male Children and Its Association with Hypospadias.

BACKGROUND: 5-alpha reductase (5-AR) enzyme is responsible for conversion of testosterone to dihydrotestosterone (DHT) in humans, which subserves various functions. The aim of the study was to establish a normal reference interval (RI) for blood levels of the enzyme 5-AR. METHODS: We conducted a prospective study on 150 boys, 75 of whom underwent circumcision for various benign conditions or for religious reasons (Group A/controls) and 75 suffering from hypospadias of variable severity (Group B/cases). The plasma levels of 5-AR were measured by enzyme-linked immunosorbent assay (ELISA) in all 150 boys and correlated with the severity of hypospadias. RESULTS: The 5-AR levels in Group A ranged from 14.6 to 17.3 ng/mL. The enzyme levels decreased in value with increasing severity of hypospadias in Group B (P-value <0.01 - statistically significant). The levels of the enzyme in this group ranged from 0.6 ng/mL (in the most severe variety of hypospadias) to 11.5 ng/mL (mild variety of hypospadias). CONCLUSIONS: There is no record of RI values of 5-AR in the literature. The RI of 5-AR needs to be determined by conducting more studies globally. Its levels falls considerably with clinical severity of hypospadias, reinforcing the importance of the enzyme in the development of male external genitalia.

Profiling Cognitive Impairment in Mild COVID-19 Patients: A Case-Control Study at a Secondary Healthcare Centre in the Hilly Region of North India.

Context: COVID-19 pandemic continues to be a serious threat to humanity even after the last 2.5 years and multiple reported waves. Post-COVID-19 cognitive impairment has a detrimental effect on the quality of life, education, occupation, psychosocial as well as adaptive functioning and independence. Aims and Objective: Profiling the cognitive impairment in the mild COVID-19 recovered patients. Settings and Design: Interview-based case-control study. Materials and Methods: This study was conducted at a secondary healthcare center in a hilly region of north India. Group A included mild COVID-19 recovered patients and Group B included local non-COVID healthy individuals. Both groups of participants were interviewed using Montreal Cognitive Assessment (MoCA) to identify global and domain-wise cognitive impairment. Statistics Used: Descriptive statistics were used to analyze the demographic and clinical variables. The Chi-square test was used to evaluate these results and statistical analysis was done using the Statistical Package for Social Sciences (version 23) program. Results: A total of 284 individuals were enrolled in our study, equally split into Groups A (cases) and B (controls). No global cognitive decline was found in any participant. However, 40 cases scored low on MoCA. The decrease in domain-wise cognitive function was statistically significant for visuospatial skill/executive function and attention. Conclusion: Our results have demonstrated that there is domain-wise cognitive impairment associated with mild COVID-19 disease. We recommend lowering the threshold of the MoCA to identify the early cognitive impairment and the inclusion of detailed cognitive assessment in post-COVID-19 follow-ups to initiate early cognitive rehabilitation among these patients.

Soft Skills and Psychosocial Counselling in COVID-19 Times: the Changing Tactics.

Introduction: As the COVID-19 pandemic is increasingly griping the world, it starts effecting the psychosocial health of the patients, health care workers, frontline workers and their dependents. The entire landscape of existing patient psychological counselling and management needs to be changed to avoid fear and misinformation about COVID-19. Material and methods: In this article, we have tried to summarize the rules, regulations and protocols in accordance with government guidelines along with practical implementation of counselling in management of psychological health condition of patients and frontline workers. Conclusion: If used wisely and as per recommendations, psychosocial counselling is a very useful tool in the present COVID-19 pandemic, to avoid spread of misinformation, fear and grief about the disease which creates mental health issue and anxiety among close contacts as well as health care workers.

Congenital pyloric atresia - nine new cases: Single-center experience of the long-term follow-up and the lessons learnt over a decade.

BACKGROUND: Congenital pyloric atresia (CPA) is a rare anomaly with an incidence of 1 in 100,000 live births. Depending on the type of anomaly patients can either present in the neonatal period or later in life with subtle nonspecific signs and symptoms. We present our institute's experience in handling these cases over the last decade and highlight lessons learnt. MATERIALS AND METHODS: We retrospectively reviewed records of patients diagnosed with CPA and managed at our centre between Jan 2006 to June 2016. We looked into the period of gestation, birth weight, gender, age at onset of symptoms, age at presentation to the hospital, symptoms, investigations, associated anomalies, management and outcomes and follow up periods. RESULTS: Nine patients were operated during the ten year period of study (6 males and 3 females). The median age at onset of symptoms was 06 months (01 day-36 months) and the median age of reporting to the hospital was 07 months (01 day-44 months) with a mean delay of 5 months between onset of symptoms and reporting to hospital. Six patients (67%) had associated anomalies including one with posterior urethral valve which has been reported for the first time in literature. Four out of five (80%) late presenters underwent an upper gastrointestinal endoscopy for diagnostic confirmation. All patients were operated upon and Type 1 CPA was seen in five patients (56%), Type 2 in two patients (33%) and Type 3 in one patient (11%). The overall survival was 89% as one patient with associated Epidermolysis Bullosa expired after 4 months due to fulminant sepsis. Three patients were lost to follow up and amongst the remaining five; the median follow up period is 36 months. CONCLUSION: CPA is a rare entity that may present late with subtle signs like failure to thrive and nonbilious vomit. A high index of suspicion is mandated in these cases and an Upper Gastrointestinal Endoscopy will help in early diagnosis and avoid further unnecessary investigations. A feeding jejunostomy may benefit malnourished sick children before definitive surgery. LEVEL OF EVIDENCE: Level 3, Type of study: Retrospective study.

Annular pancreas, type I choledochal cyst and malrotation in a low-birth weight newborn: A case report.

We present a low-birth weight newborn who presented with bilious vomit and had a "double bubble" sign on plain abdominal X-ray. Intraoperatively, we found annular pancreas with malrotation and type I choledochal cyst. To the best of our knowledge, this is the first reported case with a combination of these anomalies.

Malrotation and volvulus associated with heterotaxy syndrome.

A 2-year-old boy with heterotaxy syndrome with associated polysplenia, ventricular septal defect, and malrotation of gut with volvulus is presented. There was delay in diagnosis due to the unusual plain abdominal radiography findings. At laparotomy, the midgut was also found to be enclosed in a thin transparent cocoon.

Small bowel hemangiomas: Diagnostic role of capsule endoscopy.

Vascular anomalies involving the small bowel are an uncommon cause of gastrointestinal bleeding in childhood. We present here an 11-year-old boy who presented with severe anemia and malena. The routine investigations did not reveal any pathology. A capsule endoscopy study was performed, which clinched the diagnosis and identified two intestinal hemangiomas. The hemangiomas were resected and the child recovered.

Lumbocostovertebral syndrome with associated VACTERL anomaly.

Lumbocostovertebral syndrome is a rare clinical association syndrome rarely accompanied by associated VACTERL anomalies. Only one similar case has been reported previously. We describe the second case, where a male neonate born at 38 weeks of gestation had an unusually high number of congenital anomalies including thoracic hemivertebrae with kyphoscoliosis, a high anorectal malformation, dextrocardia with an atrial septal defect, renal pelvic pyelectasis, hypospadias, and congenital talipes equinovarus.

Bilateral ovarian cysts in a neonate with salt-wasting congenital adrenal hyperplasia.

Congenital adrenal hyperplasia is by far the most common cause of ambiguous genitalia. The occurrence of ovarian cysts has not been previously described in the classical salt-wasting form of 21-hydroxylase-deficient congenital adrenal hyperplasia. We report a very rare case of bilateral ovarian cysts in one such neonate.