Color Doppler Ultrasound Indices as Predictors of Propranolol Response in Infantile Hemangioma: A Prospective Study.

OBJECTIVE: To evaluate the utility of color Doppler ultrasonography in assessing infantile hemangioma response to treatment with oral propranolol. METHODS: A prospective study was conducted between January, 2016 and December, 2022, wherein children with symptomatic (ulceration, bleeding, pain and scarring) infantile hemangioma were given oral propranol (2 mg/kg per day in three divided doses) as outpatient therapy. The clinical response was assessed three months post-initiation of treatment (intermediate clinical response) and three months post-completion of treatment (final clinical response, FCR). The primary outcome measurement was a clinical and radiological response (resistivity index (RI), pulsatility index (PI) and peak systolic velocity) to treatment. The secondary outcomes assessed were the complications related to treatment. RESULTS: Out of 601 patients who were started on propranolol, 99 developed severe adverse effects and were excluded from analysis. At FCR assessment, out of 502 participants, 64.3% (n = 323) showed excellent response, 17.7% (n = 89) showed partial, and 17.9% (n = 90) were non-responders. A significant increase in RI and PI values was noted in all children following propranolol treatment for six months. An increase > 7.5% in RI could identify responders with 92% sensitivity, 91% specificity and area under the curve (AUC) of 0.963. An increase of > 11.5% in PI could identify responders with 86% sensitivity, 91% specificity and AUC of 0.896. Patients initially showing no response but later becoming excellent responders had significantly higher RI and PI values. CONCLUSIONS: Color Doppler ultrasonography is a valuable tool in predicting the treatment outcome of infantile hemangioma using propranolol.

Distal duodenal web with malrotation: An unusual finding.

The most common site of the congenital duodenal web is the second part. Web distal to the second part of the duodenum is rare. It mimics the windsock deformity. Diagnosis may be missed if accompanying malrotation is present. We hereby report two cases of distal duodenal webs associated with malrotation and challenges in their diagnosis and management.

Kite String (Manjha) Injuries Among Children: Single Center Experience Over Four Years.

We reviewed hospital records for kite-string injuries among children over four years (2017-2022). Of 42 affected children, mortality was 9.5%. The mean (SD) Pediatric Trauma Score (PTS) was 8.02 (2.66), with passively involved children facing greater severity [mean (SD) PTS, 5.58 (2.23)]. Kite-string injuries, alarmingly, endanger even bystanders, urging stricter preventive strategies.

Fetus-in-Fetu: A Tale of the Trapped Triplets.

A 7-day-old male child presented with abdominal distention and jaundice. Radiological investigations revealed an encapsulated sac encasing three fetus-in-fetu (FIF) in the retroperitoneum. Laparotomy revealed a sac occupying almost the whole of the abdomen. The sac was stretching the duodenum and barely visible common bile duct, which were carefully separated. The rest of the bowel was displaced to the left. The sac containing three FIFs was excised intact. One of the fetuses was highly differentiated and had thoracic meningomyelocele, which has never been reported in FIF.

An economic and sustainable approach to transform aluminosilicate-rich solid waste to functionally graded composite foam for high-temperature applications.

The present study proposes an economical and effective approach for recycling coal overburden and similar solid wastes to fabricate lightweight and high-strength composite foam with industrial applications. Reaction-generated thermo-foaming technique has been used to develop functionally graded mullite-embedded silicate composite foam in a single step. The developed foams with gradient pores exhibit superior thermo-mechanical properties. In situ-growth of mullite phase within the silicate phase results in better mechanical strength of the foam. They possess bulk density, compressive strength and thermal conductivity in the range of 0.31-1.34 g/cm3, 2.97-15.06 MPa and 0.0843-0.2871 W/(m∙K), respectively. Thermal treatment irreversibly transforms the heavy metals present in the solid waste into stable mineral phases, further inhibiting the leaching of heavy metals from the developed foam. The developed foam with tuneable and gradient microstructure is seen as a potential material for thermal insulation and other applications such as refractories, molten metal and hot flue gas filters.

Rapunzel Syndrome: A Concealed Tale of the Misleading Tail.

The diagnosis of Rapunzel syndrome can sometimes be challenging. The silent features such as poor appetite, constipation, anemia, hypoalbuminemia, and hypoproteinemia were all overlooked in our patient initially. The Rapunzel tail leads to multiple intussusceptions and an unexpected perforation sealed by intussusceptions. Perforation sealed by intussusceptions in a clinically stable patient of Rapunzel syndrome has never been reported.

Bleomycin-triamcinolone sclerotherapy in the management of propranolol resistant infantile hemangioma of the maxillofacial region: A single arm prospective evaluation of clinical outcome and Doppler ultrasound parameters.

INTRODUCTION: Propranolol has emerged as a first line agent in the management of hemangiomas. With increased use of propranolol, studies have also focused on relapses following propranolol therapy. Our current study evaluates the role of bleomycin triamcinolone sclerotherapy for the management of propranolol resistant Infantile Hemangioma (IH). We also evaluated the role color Doppler USG for response assessment of sclerotherapy. METHODS: Patients with Propranolol resistant (Non- responders/ Partial responders) IHs were included in the study. Patients received intralesional bleomycin at a dose of 0.5 IU/kg followed by intralesional injection of triamcinolone at a dose of 2mg/kg body weight. Clinically patients were grouped into excellent, partial and non responders. Doppler parameters; Resistivity index (RI), Pulsatility index(PI) and Peak systolic velocity (PSV) were used to evaluate the response to sclerotherapy. These parameters were evaluated prior to sclerotherapy and 3 months following completion of therapy. The clinical responses of the patients were compared with the change in Doppler parameters before and after treatment. RESULTS: A total of 115 participants were considered for analysis; 60.86% had excellent response, 32.17% had partial response and 6.95% had poor response. There was a significant change in terms of RI, PI and PSV in patients who were either excellent or partial responders. Poor responders did not have a significant change in Doppler parameters. CONCLUSION: Combined bleomycin- triamcinolone sclerotherapy is an effective therapy for the management of propranolol resistant IHs. Doppler parameters RI, PI and PSV are reliable indicators of response in the management of IH.

Congenital Segmental Dilatation of Ascending Colon with Distal Microcolon: A Diagnostic Dilemma.

A 5-day-old male presented with bilious vomiting, a grossly distended abdomen, and passage of a small amount of stool. The anal opening was at a normal position. X-ray abdomen showed a large bowel loop with a single air-fluid level occupying more than half of the abdominal width. On laparotomy, the ascending colon was dilated to form a pouch-like structure, and the ileum and appendix were opening into it. Colon distal to pouch was present as microcolon. Histopathology of the dilated segment was suggestive of congenital segmental dilatation (CSD). In CSD, the distal bowel is of normal caliber. This is a rare case of CSD of ascending colon with distal microcolon.

Adenomatous Hyperplasia of Palatal Minor Salivary Gland and Angiolipoma of the Floor of Mouth: The First Documented Case Report in a Neonate.

Adenomatous hyperplasia of the salivary glands usually affects the parotid gland. Within the oral cavity, palate is the most common site. However, this lesion occurs in adults and till date no case has been documented in neonates. Angiolipomas are a variant of congenital lipomas which undergoes vascular proliferation. Angiolipomas of the oral cavity have not been documented till date among neonates. We herein report the first case of combined angiolipoma of the floor of the mouth with adenomatous proliferation of the minor salivary glands in a neonate. The case was managed through surgical excision, and the follow-up was uneventful. Histopathology confirmed the diagnosis.

Does Early Treatment of Paediatric Orbital Fracture Offer Any Advantage in Terms of Post-Operative Clinical Outcomes.

Background: Trapdoor fractures commonly occur in children below 6 years of age. The high resiliency of bone, pneumatisation of sinuses and other factors lead to entrapment of muscle and/or soft tissue which undergoes ischaemic changes leading to residual diplopia. The timing of intervention in children ranges from 24 h to greater than 2 weeks. Early surgical intervention is particularly indicated in cases of Oculocardiac reflex. Methods: A Prisma guided systematic review of literature was conducted with no filters on language till September 2020. Studies on paediatric orbital fractures with data on timing of intervention and clinical outcomes were considered eligible for the review. The Oxford Level Of Evidence was used to assess the strength of individual studies. Results: A total of 19 studies (18 English, 1 French) were selected; except for one study all were retrospective series. The timing of intervention ranged from 24 h to more than 1 month. Most of the studies agreed that orbital fractures in children should receive early intervention preferably within 2 weeks. In case of white-eyed blowout fracture, oculocardiac reflex and trapdoor fractures with muscle entrapment surgical intervention should be carried out within 24-48 h. Discussion: Children presenting with facial injuries should be thoroughly examined for signs of muscle entrapment, diplopia, nausea, vomiting and bradycardia. If present these should receive early intervention. In cases with no signs of oculocardiac reflex and muscle entrapment a treatment within 2 weeks is recommended. If diplopia is mild or resolving with minimal hypoglobus and enophthalmos a wait and watch policy should be carried out.

Sandwich therapy in the management of propranolol resistant infantile hemangioma of the lip.

RATIONALE: Propranolol has evolved as a first line management of infantile haemangiomas. Nevertheless, the resistance to propranolol has warranted alternative treatment modalities. We hypothesize that combination of medical and surgical therapy (sandwich therapy) to be beneficial in the management. METHODS: Patients were divided into three groups (total=31), Group A (bleomycin sclerotherapy), Group B (surgical group), Group C (sandwich therapy). A p value <0.05 was taken as significant. RESULTS: In Group A 54.5% of patients had excellent response, 27.3% partial response and 18.2% had no response. Comparing cosmetic outcome, 25% of patients in Group B and 16.7% of patients in Group C had excellent upshot. On the contrary 18.2% of patients in bleomycin had unsatisfactory and 18.2% had poor cosmetic outcome. Sandwich therapy was cosmetically more acceptable than Bleomycin sclerotherapy (p- value = 0.049). In terms of recurrence, sandwich therapy differed significantly from surgical therapy with fewer recurrences (p-value= 0.049). CONCLUSION: Sandwich therapy is superior to bleomycin sclerotherapy in terms of cosmetic outcome and has fewer recurrences compared to surgical group and requires single stage resection. However, further studies with the help of Doppler ultrasound are required in this regard.

Modified Laparoscopic Excision of Choledochal Cyst: Technique and Early Results.

BACKGROUND: Choledochal cyst is a common congenital anomaly requiring surgical treatment. Nowadays, laparoscopic excision is the preferred approach. We studied a modification in the classical laparoscopic approach to facilitate the dissection of a cyst. MATERIALS AND METHODS: A prospective comparative study was done on 42 Type I choledochal cyst children. One group was operated by classical laparoscopic technique, while the other group was operated by modification of classical technique by deliberately opening the cyst wall and dividing the cyst into two hemi-cups, followed by dissection and excision. The intraoperative and postoperative parameters were assessed in both the groups. RESULTS: The age, gender ratio, clinical presentation, and cyst diameter were comparable in both the groups. There was a significantly higher success rate (95.7% vs. 73.7%, P = 0.042) and lesser time for cyst excision (96.43 ± 12.15 vs. 120.91 ± 17.38 min P < 0.001) in the modified technique when compared to the classical technique. Further in three patients, it was possible to convert the classical procedure to a modified technique and complete the cyst excision. The postoperative outcomes were similar in both the groups. CONCLUSION: The modified laparoscopic excision shortens the operative time with higher success rate and comparable short-term morbidity vis-a-vis classical laparoscopic technique.

Adverse Drug Reactions Following Propranolol in Infantile Hemangioma.

OBJECTIVES: To assess the adverse effects of propranolol therapy in infantile hemangioma. METHODS: An ambispective study was conducted from August 2011 to December 2019. In retrospective arm all children managed for infantile hemangioma with propranolol were included and case records were assessed for adverse reactions. In prospective arm the adverse reactions were identified on the basis of predefined criteria. RESULTS: A total of 514 patients (358 retrospective records) were included. A majority, 378 (73.5%) patients had an excellent response, 75 (14.5%) had partial response and 61 (11.8 %) had no response. A total of 82 (15.9%) patients experienced at least one adverse effect. Diarrhea with weight loss (27, 32.9%) and irritability with decreased sleep (21, 25.6%) were the most common adverse effects. The adverse effects in 22 (4.2%) cases lead to the discontinuation of propranolol. Younger age, low body weight and early onset were risk factors for development of severe adverse reactions. CONCLUSIONS: Young children with low body weight were at higher risk for adverse effects of propranolol.

A Clinicopathological Study to Assess the Role of Intralesional Sclerotherapy Following Propranolol Treatment in Infantile Hemangioma.

Context: As propranolol has emerged as first-line therapy for problematic infantile hemangioma, the number of non-responders and partial responders to propranolol therapy is also increasing. Aims: The study was conducted to evaluate the response of intralesional bleomycin, triamcinolone, and a combination of both as second line of treatment for the residual hemangioma following propranolol therapy. Settings and Design: A prospective comparative study was conducted in patients who were either non-responders or partial responders to previous propranolol treatment. Materials and Methods: The patients randomly received injection bleomycin, injection triamcinolone, and combination of both bleomycin and triamcinolone. The response to treatment was recorded clinically by using photographs. The pathological response was assessed by calculating pre-treatment and post-treatment microvessel density in biopsy of lesion from the non-cosmetic sites using immunohistochemistry. Statistical Analysis Used: χ2 test was used to test the association between the variables. The utility of microvessel diameter (MVD) in terms of clinical response to the therapy was predicted by using receiver operating characteristic (ROC) curve. Results: Out of the 134 patients, 42 received bleomycin and 44 received triamcinolone and were treated with a combination of both. The overall clinical response was better in the combination group compared with the bleomycin group (P = 0.018) and triamcinolone group (P = 0.0005), respectively, after 6 months of follow-up. There was no difference in clinical response between the triamcinolone and bleomycin groups. Change in MVD correlated with the clinical response. Conclusion: The combination of bleomycin and triamcinolone is effective and safe for the treatment of residual hemangioma.

Utility of Real-Time Online Teaching During COVID Era Among Surgery Postgraduates.

A cross-sectional study was conducted to assess the utility of online teaching for general surgery postgraduate residents at the end of 1 month of online teaching during the COVID-19 lockdown. A questionnaire related to different aspects of online teaching was developed on a 5-point Likert scale from "strongly agree" to "strongly disagree". Following a pilot study, the questionnaire was shared among surgery residents, and response collection was done. The residents who did not attend at least 90% of scheduled classes were excluded. A total of 55 resident doctors without prior experience of online teaching program were enrolled in the study. All the participants responded to all questions and submitted their responses within stipulated time. On the basis of validity testing, questions 1 and 2 were found invalid and hence deleted. The median value for the total cohort was 4 indicating that majority of residents gave affirmative response. On segregating the result with the year of residency program, similar results were found in the 1st year and 2nd year group; however, the 3rd year group showed a median of 3, thus eliciting that only 50% of 3rd year residents liked online teaching. From the present study, it can be concluded that the online teaching is a feasible alternative to the physical class among surgical postgraduates. The questionnaire utilized in the present study can be used for assessing similar online teaching protocols.

Effect of ultrasonic shot peening duration on microstructure, corrosion behavior and cell response of cp-Ti.

Surface mechanical attrition treatment (SMAT) of metallic biomaterials has gained significant importance due to its ability to develop nano structure in the surface region. In the present study, the microstructural changes and corrosion behavior of the commercially pure titanium (cp-Ti), following different durations of ultrasonic shot peening (USSP) has been investigated. cp-Ti was shot peened for different durations from 0 to 120 s and the treated samples were examined for microstructural changes in the surface region, cell viability and corrosion behavior. Cell viability was considerably increased after USSP for 60-120 s, exhibiting maximum for the 90 s of USSP. The passivation tendency was also improved with peening duration up to 90 s, however, it declined for longer duration of USSP. The beneficial effects of USSP may be attributed to nano structuring in the surface region and development of higher positive potentials at the USSP treated surface. Transmission Electron Microscope (TEM) examination of the USSPed surface revealed dislocation entanglement and substructure. Also, higher surface volta potential was observed over the USSPed sample exhibiting better cell proliferation. The present work is corollary to previous work of the group and mainly discusses the role of USSP duration, as a process parameter, on the cell viability and corrosion resistance of cp-Ti.

Our experience with anesthetic management of conjoined twins' separation surgery.

Conjoined twins are one of the most fascinating human malformations. Here, we report the anesthetic management and challenges faced in performing the successful separation surgery of 4-day-old thoraco-omphalopagus conjoined twins, born at term to a multigravida by elective caesarean section weighing 3.5 kg with APGAR score of more than 7. Computerized tomography scan revealed fused anterior surface of the left lobe of liver with common left portal vein. Confirmation of cross-circulation between the twins was done by giving intravenous midazolam to one of the conjoined twins, but no effect seen in the other one. We highlighted the responsibility of anesthesia team in anesthetizing sequentially the two patients who are joined together, technical difficulty of intubating the twins facing each other, need of careful monitoring, anticipation of complications such as massive blood loss, hemodynamic instability, desaturation, and hypothermia, and preparedness for their management and vigilant postoperative care.