Protective effect of vitamin C against thiamethoxam-induced toxicity in male rats.

Background: Thiamethoxam (THM) is a neonicotinoid insecticide used to control different insect pests on fruits, vegetables, and field crops. The misuse and continuous exposure to THM cause many harmful effects on health and the reproductive system. Aim: This work aims to investigate the efficiency of vitamin C (vit C) in reducing or eliminating the harmful effects of THM on the testes, liver, and kidney of male rats. Methods: Forty-eight sexually mature male Wister albino rats (weight: 170-190 g; age: 10-11 weeks) were randomly allocated into six groups (8 males/group). The control group was orally given distilled water, vit C group was orally treated with 200 mg/kg b.wt of vit C, group 1/10 of THM LD50 orally treated with 156.3 mg/kg b.wt of THM, group 1/20 of THM LD50 orally treated with 78.15 mg/kg b.wt of THM, group 1/10 of THM LD50 + vit C orally treated with 156.3 mg/kg b.wt of THM + 200 mg/kg b.wt of vit C, and group 1/20 of THM LD50 + vit C orally treated with 78.15 mg/kg b.wt of THM + 200 mg/kg b.wt of vit C. All groups were treated for five days per week for a whole period of 58 days. Blood samples were collected at the end of the experiment, and serum was extracted for liver and kidney functions and antioxidant measurements. Reproductive organs (testis, epididymis, and seminal vesicles) were collected and weighed at the end of the experiment. Results: The results showed that groups exposed to 1/10 and 1/20 of THM LD50 significantly (p < 0.05) decreased the body weight, the reproductive organ weights (testis, epididymis, and seminal vesicles), spermatid count, sperm (count and motility), and testosterone concentration with an increase in abnormalities. In addition, the groups exposed to THM showed a decrease in protein concentration, albumin, and globulin, and caused an increase in glucose concentration. The activities of alkaline phosphatase (ALP), alanine transaminase (ALT), aspartate transaminase (AST), creatinine, urea, and malondialdehyde (MDA) were increased while caused decrease in total antioxidant capacity (TAC) due to exposure to THM. The co-administration of vit C with HM modulated the harmful effects of the insecticide on testicular, liver, and kidney parameters, which confirmed in histopathological examination of testis. Groups orally treated with vit C showed a significant increase in spermatogenesis, spermatid numbers, and the weight of seminal vesicles. Conclusion: This study showed the importance of vit C in reducing toxic effects from exposure to THM. Accordingly, the intake of vit C by individuals who regularly handle this insecticide will be beneficial in reducing the adverse effects that may occur in the liver and kidney.

Medium-Term Outcomes of Antegrade Continent Enema (ACE): Cairo University Specialized Pediatric Hospital (CUSPH) Experience.

AIM OF THE STUDY: To assess the medium-term outcomes of ACE in children with fecal incontinence (FI). METHOD: Eligible children were recruited from the colorectal clinic between December 2016 and January 2020 and were followed prospectively for 2-6 years. A series of questionnaires were used to assess QOL, patients and parent satisfaction, and to assess the outcomes of the ACE. RESULT: 24 children aged 6-12 years (mean age 8.17 ± 1.95), including 18 males (75%) and 6 females (25% were studied. Cases included anorectal malformations (45.83%)., Hirschsprung disease (25%), neural tube defects (16.66%), sacrococcygeal teratoma (4.16%), and intractable pseudoincontinence (8.33%). QOL improved from (3) [3 -3] to (16) [16-16],p < 0.05. Fecal incontinence index showed significant improvement: 20 [20-20] versus 3 [0-4],p < 0.05. Bowel symptoms demonstrated improvement in the ability to decide when to pass stools and a decrease in soiling. Stooling survey showed lower scores representing better outcome. ACE questionnaire showed that the range of irrigation volumes used by parents is wide, and that all families recommend the ACE for children with similar condition. Postoperative complications were stenosis (16.66%), stomal prolapse (12.5%), leakage (4.16%), and false passage (4.16%). Satisfaction questionnaire showed a median score of 9 (range, 5-10). CONCLUSION: ACE is an effective method to keep the child with FI clean, more socially active, and with a better QOL and FII in the medium-term. The reported complications were stenosis, false passage, and leakage. ACE mucosa prolapse is a novel complication picked up on medium-term follow up.

Outcome of Tapering Enteroplasty in Managing Jejunoileal Atresia.

Background: Jejunoileal atresia (JIA) represents a common cause of neonatal bowel obstruction. There is a discrepancy between the diameters of the proximal and the distal bowel loops and this is managed with excision or tapering of the dilated proximal bowel loop. We aim primarily to evaluate the outcome of tapering enteroplasty (TE) in managing JIA and secondarily to compare the outcome of TE to non-TE. Materials and Methods: A retrospective analysis of records of all neonatal admissions with JIA from January 2017 to December 2018 at a tertiary university children's hospital. Type and location of atresia, time to full enteral feeds, length of stay (LOS), complications, and outcome were assessed in TE and non-TE groups. Results: Forty-one patients were included in the study; 29 (70.7%) cases had jejunal atresia and 12 (29.3%) had ileal atresia. Seventeen (41.4%) patients had TE. The median days to full feeds was 19; 28 in the TE group versus 16 in the non-TE group (P = 0.022). Four (9.7%) cases needed a re-exploration because of failure to start feeds; all in the non-TE group. The median LOS was 33 days for TE versus 22 days for non-TE (P = 0.101). Twenty-one cases (51.2%) developed a wound infection and showed a significantly longer median LOS of 29.5 versus 19 days (P = 0.019). Mortality was 7 (17.1%). Conclusions: TE did not show a superior outcome when compared to resection of the dilated bowel. It was associated with longer time to reach full enteral nutrition and longer LOS.

Optimism for the Single-stage Transanal Swenson in Neonates.

BACKGROUND: Hirschsprung's disease (HD) has been traditionally treated from infancy onward and different techniques have been used including Swenson, Soave, and Duhamel procedures. The purpose of this study was to evaluate the transanal Swenson's procedure for classical rectosigmoid HD in neonates. PATIENT AND METHODS: This was a prospective study in which neonates diagnosed with HD were recruited from January 2017 to December 2018. Cases with a transition zone proximal to the midsigmoid were excluded. All patients underwent a transanal Swenson's procedure in the neonatal period using a unified protocol. Intraoperative course and postoperative outcomes such as leak, pelvic abscess, soiling, perianal excoriation, stricture, enterocolitis, and constipation were evaluated and all patients were followed for at least 6 months. RESULTS: Twenty-three patients (17 males and 6 females) underwent transanal Swenson's procedure. The mean age was 22 ± 5.7 days. Follow-up ranged from 6 to 30 months. No anastomotic leak, retraction, or prolapse was reported. Mild perianal excoriations occurred early in 9 (39%) cases and all responded to medical treatment and disappeared before 2 months postoperatively. Stricture occurred in 2 (8%) patients, enterocolitis in 3 (13%), and constipation in 3 (13%). CONCLUSION: Transanal Swenson's procedure is feasible and can be performed safely in neonates with rectosigmoid HD with good short-term outcomes. Proper patient selection and standard protocol following fine procedural hall-marks and details are keys for optimal results and patient satisfaction.

Outcome of thoracoscopic repair of type-C esophageal atresia: a single-center experience from North Africa.

Thoracoscopic repair of esophageal atresia is gaining popularity worldwide attributable to availability and advances in minimally invasive instruments. In this report, we presented our experience with thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair in our tertiary care institute. A prospective study on short-gap type-C EA/TEF was conducted at Cairo University Specialized Pediatric Hospital between April 2016 and 2018. Excluded were cases with birth weight < 1500 gm, inability to stabilize physiologic parameters, or major cardiac anomalies. The technique was standardized in all cases and was carried out by operating team concerned with minimally invasive surgery at our facility. Primary outcome evaluated was successful primary anastomosis. Secondary outcomes included operative time, conversion rate, anastomotic leakage, recurrent fistula, postoperative stricture, and time till discharge. Over the inclusion period of this study, 136 cases of EA/TEF were admitted at our surgical NICU. Thoracoscopic repair was attempted in 76 cases. In total, 30 cases were pure atresia/long gap type-C atresia and were excluded from the study. Remaining 46 cases met the inclusion criteria and were enrolled in the study. Mean age at operation was 8.7 days (range 2-32), and mean weight was 2.6 Kg (range 1.8-3.6). Apart from five cases (10.8%) converted to thoracotomy, the mean operative time was 108.3 minutes (range 80-122 minute). A tension-free primary anastomosis was possible in all thoracoscopically managed cases (n = 41) cases. Survival rate was 85.4% (n = 35). Anastomotic leakage occurred in seven patients (17%). Conservative management was successful in two cases, while esophagostomy and gastrostomy were judged necessary in the other for five. Anastomotic stricture developed in five cases (16.6%) of the 30 surviving patients who kept their native esophagus. Despite the fact that good mid-term presented results may be due to patient selection bias, thoracoscopic approach proved to be feasible for management of short-gap EA/TEF. Authors of this report believe that thoracoscopy should gain wider acceptance and pediatric surgeons should strive to adopt this procedure.

Establishment of an antimicrobial stewardship strategy on the surgical NICU at Cairo University specialized pediatric hospital.

PURPOSE: Antimicrobial resistance is a major concern that we are facing nowadays. This is due to antibiotic misuse and bacteria developing resistance to the commonly used antibiotics. This may lead to increased mortality and consumption of country resources. Implementation of an antimicrobial stewardship program [ASP] can limit the use of unnecessary antibiotics and subsequently decrease the infection rates with better patient outcome. We aimed to control antibiotic misuse, reduce infection rate, decrease drug costs, and reduce length of hospital stay in the ICU. METHODS: We conducted a prospective study on the surgical neonatal ICU [SNICU] over a period of 6 months divided into pre-implementation phase, followed by an ASP phase, in which we applied the antibiotic guidelines approved by the ASP committee. Data were collected in the two phases and analyzed for demographics, compliance with guidelines, prescribed antibiotics, lab investigations, surgical site infection [SSI], length of stay and patient outcome. RESULTS: Compliance to the guidelines was encountered in 86% and SSI rate decreased to 20%. Days of Therapy (DOT) per 1000 patient days showed a significant decrease in Ampicillin Sulbactam by 296 (p = 0.024), Imipenem by 220.34 (p = 0.024) and Vancomycin by 287.34 (p = 0.048). Drug cost showed a 1185.97 EGP decrease in the ASP period compared to the pre-implementation period (p = 0.714). Average LOS decreased in the ASP period by a mean difference of 2.5 (p = 0.027). CONCLUSION: ASP implementation can control antibiotic misuse, decrease the medical care expenses and improve patient outcome. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: Level one.

Quality of life in children with pseudoincontinence after implementing a bowel management program in Egypt.

AIM OF THE STUDY: The aim of this study was to evaluate the impact of implementing a Bowel Management Program (BMP) on the quality of life (QOL) in children with pseudoincontinence. METHOD: Children aged 2.5-13 years with pseudoincontinence were included. Evaluations were performed before and after BMP implementation. Perceptions from parents about QOL were assessed by a QOL questionnaire, and the severity of fecal incontinence (FI) was assessed using the fecal incontinence index (FII) of the Wexner scale. RESULTS: 115 children (mean age of 7.54 ±â€¯2.48) were studied over a 3-12 month period (mean duration 4.36 months). QOL improved from 2.45 ±â€¯1.57 to 14.36 ±â€¯1.37, P˂0.05. There was a significant improvement of the FII: 18.65 ±â€¯1.25 versus 0.13 ±â€¯0.39, P˂ 0.05. There was a significant inverse correlation between the final scores of QOL (14.36 ±â€¯1.37) and FII (0.13 ±â€¯0.39) after implementation of the BMP (r = -0.53; P ˂ 0.05). CONCLUSION: This is the largest case series examining QOL in pseudoincontinent children. It demonstrates that BMP significantly improves the QOL of these children in the short and midterm. In addition, it is feasible to apply the FII in assessing incontinence in children. To our knowledge, this is the first study of its kind in our region. LEVEL OF EVIDENCE: Level IV.

Outcome of declined neonatal surgical referrals at Cairo University Specialized Pediatric Hospital.

BACKGROUND: The combination of a high birth rate and limited resources leads to a strain on health services with dire consequences to the patient. This study aimed to track the outcome of declined referrals at the tertiary center in the Cairo University Specialized Pediatric hospital. METHODS: Data were collected prospectively on all declined surgical neonates at the tertiary center. The families were later contacted to document outcomes. Verbal consent was taken. FINDINGS: Over a 12 month period from January 2017 to December 2017, 668 neonatal surgical referrals were received. Of these 278, (41·6%) were declined for lack of available places. The majority were cases of esophageal atresia with tracheoesophageal fistula (35%), followed by bowel obstruction (21%). Thirty-six cases were lost to follow up. Of the remaining 242 cases, 103 (42·5%) died, 63 (26%) were referred to public hospitals, 69 (28·5%) to private hospitals and seven (2·8%) were managed conservatively. CONCLUSIONS: Nearly half of neonatal surgical cases die while waiting for surgical intervention. Cases were shared equally between the public and private sector. The collected data are crucial in planning service provision for neonates requiring surgical treatment. To the best of our knowledge, this is the first study from Egypt and the region to report the number and outcome of surgical neonates who do not get access to expert surgical services. The study outlines the burden of disease faced by a single pediatric surgery unit and documents the various congenital anomalies encountered as well as their outcome when treated elsewhere. STUDY TYPE: Prognosis study. LEVEL OF EVIDENCE: IV.

Assessment of gastroschisis risk factors in Egypt.

AIM: Mortality in infants born with gastroschisis (GS) in low-to-middle-income countries (LMICs) is high. This study aimed to assess factors which might affect outcome in Egypt in order to improve survival. METHODS: A prospective study over a 15-month duration was completed. Variables assessed covered patient, maternal, antenatal, treatment, and complications. The Gastroschisis Prognostic Score (GPS) was used to predict outcome. A validated questionnaire was used to assess socioeconomic status. The main outcome was mortality. RESULTS: Twenty-four cases were studied. Median gestational age was 37 (26-40) weeks, and 9 (38%) were preterm. Mortality occurred in 15 (62%) infants. Median transfer time was 8 (1.5-35) hours, and 64% survived if transferred before 8 h. Median maternal age was 20 (16-27) years. All families were of a low or very-low socioeconomic level. Only 25% had antenatal scans. Most cases were simple GS, and only 3 (12.5%) were complex GS. Median length of stay was 14 (1-52) days, TPN duration was 12 (0-49) days, and days to full feeds was 5 (3-11) days. The GPS score ranged from 0 to 6 in the studied cases and negatively correlated with outcome (rS = -0.98; p = 0.03). CONCLUSION: The mortality of GS in Egypt is very high, mainly due to sepsis and prematurity. Young maternal age and poor socioeconomic status are linked to GS. The GPS is a good indicator of morbidity and mortality in a LMIC setting. Survival improved with better resuscitation and strict management protocols. More effort is needed to improve antenatal detection, and transfer time should be ideally below 8 h. LEVEL OF EVIDENCE: Level IV.

Planimetry of the porta hepatis in biliary atresia.

AIMS: Orientation and digital analysis of the biliary remnants in the resected porta hepatis in infants with biliary atresia. METHODS AND RESULTS: Samples were orientated intra-operatively then stained with haematoxylin and eosin and immunostained for cytokeratin 7 (CK7). Sections were then digitized and analysed. Most proximal transected surface area was defined as the porta hepatis area (PHA) and the biliary epithelial area was defined as 'BEA'. Data are quoted as median (range). Non-parametric statistical comparisons were made as appropriate. P < 0.05 was regarded as significant. Thirty-eight infants underwent surgery [median age 53 (16-120) days]. Eight specimens were excluded from the study due to technical reasons, leaving 30 specimens as the study cohort. Median PHA was 70 (30-133) mm2 , median BEA 0.57 (0.07-5.5) mm2 (r = 0.51; P < 0.002). The median BEA/PHA ratio was 9.6 × 10-3 (1.9-104 × 10-3 ). There was a marked correlation of PHA with plasma γ-glutamyl transpeptidase (r = -0.51; P = 0.001). Both total BEA and the BEA/PHA ratio correlated with alkaline phosphatase (r = -0.35; P = 0.03 and r = -0.47; P = 0.005, respectively). Age at surgery correlated inversely with BEA (r = -0.44; P = 0.01) but not PHA (P = 0.1). CONCLUSIONS: Precise quantification of biliary remnants is possible and correlates with biochemical variables. Values for BEA were associated with and declined demonstrably with increasing age at surgery.

Portal venous pressure in biliary atresia.

UNLABELLED: Biliary atresia (BA) is characterized by a variable degree of fibrosis within the liver, causing portal hypertension sometimes evident at the time of presentation. AIM: The aims of this study are to measure portal venous pressure (PVP) at time of Kasai portoenterostomy (KP) and to investigate the value of surrogate indices. METHODS: At the time of KP and before any liver manipulation, an attempt was made to recanalize the umbilical vein, allowing a catheter to be sited. Preoperative noninvasive variables included maximum splenic diameter (on ultrasound); platelet count, aspartate aminotransferase, and bilirubin; and the aspartate aminotransferase/platelet index ratio (APRi). Clearance of jaundice was defined as achieving a bilirubin of less than 20 µmol/L. Data are quoted as median (range). Nonparametric statistical tests were used, and P < .05 was regarded as significant. RESULTS: Portal venous pressure measurements were available in 61 infants, who underwent a KP during the period February 2007 to October 2010. Median age at KP was 52 (19-151) days. Median PVP was 9 (3-26) mm Hg and was significantly lower in those with isolated (n = 47) BA vs cytomegalovirus-associated BA (n = 6) (8 vs 17 mm Hg; P = .02). Overall, PVP correlated with spleen size (r(s) = 0.38; P < .0001), APRi (r(s) = 0.5; P < .0001), bilirubin (r(s) = 0.38; P = .001), and age at KP (r(s) = 0.33; P = .0004). Thirty-three infants (56%) cleared their jaundice (to <20 µmol/L). There was no significant difference in median PVP (7 vs 9.5 mm Hg; P = .1) between these groups. To date, 6 children have undergone endoscopy, with 2 requiring intervention for significant varices. Neither infant at time of KP had elevated PVP (3 and 9 mm Hg). CONCLUSIONS: Portal venous pressure is a key variable in the assessment of the BA liver, and differences can be shown depending on underlying cause (eg, cytomegalovirus status). Furthermore, it has modest correlation with noninvasive indices (eg, spleen size and APRi) but appears of limited use when used as prognostic index of outcome and indeed in the later development of varices.