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Rajasegaran S, Ahmad NA, Tan SK, Lechmiannandan A, Mohamed OM, Cheng JQ, Hassan J, Sanmugam A, Singaravel S, Mohd Khalid H, Abdullah MY, Nah SA. Anorectal malformation and Hirschsprung's disease: a cross-sectional multicentre comparison of quality of life and bowel function to a healthy population. Arch Dis Child 2024:archdischild-2023-326724. [PMID: 38649254 DOI: 10.1136/archdischild-2023-326724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Children with anorectal malformation (ARM) and Hirschsprung's disease (HD) often experience bowel symptoms into adulthood, despite definitive surgery. This study evaluates the quality of life (QOL) and bowel functional outcome of children treated for ARM and HD in comparison to healthy controls. METHODS Between December 2020 and February 2023, we recruited patients with ARM and HD aged 3-17 years at four tertiary referral centres, who had primary corrective surgery done >12 months prior. Healthy controls were age-matched and sex-matched. All participants completed the Pediatric Quality of Life Inventory Generic Core Scales 4.0, General Well-Being (GWB) Scale 3.0 and Family Impact (FI) Module 2.0 Questionnaires. Bowel Function Score (BFS) Questionnaires were also administered. We also performed subgroup analysis according to age categories. Appropriate statistical analysis was performed with p<0.05 significance. Ethical approval was obtained. RESULTS There were 306 participants: 101 ARM, 87 HD, 118 controls. Patients with ARM and HD had significantly worse Core and FI Scores compared with controls overall and in all age categories. In the GWB Scale, only ARM and HD adolescents (13-17 years) had worse scores than controls. ARM and HD had significantly worse BFSs compared with controls overall and in all age categories. There was significant positive correlation between BFS and Core Scores, GWB Scores and FI Scores. CONCLUSION Patients with ARM and HD had worse QOL than controls. Lower GWB Scores in adolescents suggests targeted interventions are necessary. Bowel function influences QOL, indicating the need for continuous support into adulthood.
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Affiliation(s)
- Suganthi Rajasegaran
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Nur Aini Ahmad
- Department of Paediatric Surgery, Sabah Women and Children's Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Shung Ken Tan
- Paediatric Surgery Unit, Department of Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah Darul Aman, Malaysia
| | - Abhirrami Lechmiannandan
- Department of Paediatric Surgery, Women's and Children's Hospital Kuala Lumpur, Hospital Tunku Azizah, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Omar Mazali Mohamed
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Joo Qing Cheng
- Paediatric Surgery Unit, Department of Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah Darul Aman, Malaysia
| | - Junaidah Hassan
- Paediatric Surgery Unit, Department of Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah Darul Aman, Malaysia
| | - Anand Sanmugam
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Hazlina Mohd Khalid
- Department of Paediatric Surgery, Sabah Women and Children's Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Mohd Yusof Abdullah
- Department of Paediatric Surgery, Women's and Children's Hospital Kuala Lumpur, Hospital Tunku Azizah, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Department of Surgery, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
- Department of Surgery, University Malaya Medical Center, Kuala Lumpur, Kuala Lumpur, Malaysia
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Shaari MK, Tan YW, Abdullah MY, Sharudin MF, Osman M, Teoh THQ, Lim CJ, Nah SA. Comparing Consistency and Usability of Common Bowel Function Scoring Systems in Anorectal Malformation Patients. J Pediatr Surg 2024; 59:571-576. [PMID: 38160189 DOI: 10.1016/j.jpedsurg.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Assessment of postoperative bowel function in anorectal malformation (ARM) patients is crucial for benchmarking outcomes. We compared existing bowel function scoring systems in various aspects in patients with ARM. METHODS With ethical approval, this was a cross-sectional study involving 5 paediatric surgery referral centres in Malaysia, comparing the Kelly, Japanese Study Group of Anorectal Anomalies (JSGA), Holschneider and Krickenbeck bowel function questionnaires. We recruited patients aged 4-17 years, who had completed definitive surgery & stoma closure (where relevant) > 12 months prior to participation. We standardised outcomes of each scoring system into categories ('good', 'fair', 'poor' and 'very poor') to facilitate comparison. Parents & patients were surveyed and asked to rate the ease of understanding of each questionnaire. The difference in protocol scores rated between parents and patients were compared. Association of each bowel function scoring protocol with type of anomaly was assessed. Statistical significance was p < 0.05. RESULTS Thirty-nine parents (21 mothers, 18 fathers) and 23 patients were included in this study. Fair agreement was found between Kelly and Krickenbeck protocols (κ = 0.343; p < 0.001), between JSGA constipation and Holschneider protocols (κ = 0.276; p = 0.002); JSGA constipation and Krickenbeck protocols (κ = 0.256; p = 0.004); and between Holschneider and Krickenbeck protocols (κ = 0.273; p = 0.003). Only the Kelly protocol showed significant correlation between parents and patients' answers (ρ = 0.459, p = 0.028). Krickenbeck demonstrated the best negative correlation of patients' scores with ARM types (ρ = -0.401, p = 0.001). The Kelly protocol ranked highest when comparing ease of understanding. CONCLUSION All the questionnaires appeared comparable in assessing postoperative faecal continence in ARM patients. The Kelly questionnaire performed best in 3 key areas of assessment. LEVEL OF EVIDENCE Level III Cross-Sectional Study.
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Affiliation(s)
- Mohd Khairulanuar Shaari
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yew-Wei Tan
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Division of Paediatric Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mohd Yusof Abdullah
- Department of Paediatric Surgery, Hospital Tunku Azizah, Kuala Lumpur, Malaysia
| | - Mohd Fauzi Sharudin
- Division of Paediatric Surgery, Department of Surgery, Hospital Sultanah Aminah, Johor, Malaysia
| | - Marjmin Osman
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Tammy Han Qi Teoh
- Division of Paediatric Surgery, Department of Surgery, Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Chien Joo Lim
- Department of Orthopaedic Surgery, Woodlands Health, Singapore
| | - Shireen Anne Nah
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Division of Paediatric Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Rajasegaran S, Nooraziz AN, Abdullah A, Sanmugam A, Singaravel S, Gan CS, Nah SA. Parent-Reported Health-Related Quality of Life Outcomes and Impact on Family of Congenital Diaphragmatic Hernia Survivors After Repair: A Cross-Sectional Comparison to Healthy Controls. J Pediatr Surg 2024; 59:577-582. [PMID: 38160184 DOI: 10.1016/j.jpedsurg.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) survivors often experience long-term CDH-associated morbidities, including musculoskeletal, gastrointestinal and respiratory issues. This study evaluates parent-reported health-related quality of life (HRQOL) and family impact of the disease. METHODS Electronic medical records (EMR) were reviewed and phone surveys performed with parents of CDH survivors who underwent repair at our institution from 2010 to 2019. They completed the following Pediatric Quality of Life Inventory™ (PedsQL™) questionnaires: Generic Core Scales 4.0 (parent-proxy report) and Family Impact (FI) Module 2.0. Age-matched and gender-matched healthy controls from an existing database were used for comparison. Subgroup analysis of CDH patients alone was also performed. Appropriate statistical analysis was used with p < 0.05 significance. Data are reported as median (range). Ethical approval was obtained. RESULTS Of 76 CDH survivors, 45 parents (59 %) consented for study participation. Patients and controls were aged 6 (3-12) years; 51 % were male. In Core Scales, there were significant differences between the groups in the overall scores (p = 0.003) and the psychosocial health sub-scores (p = 0.004), but no difference in the physical health domain scores. In the Family Impact Module, there were no significant differences between the groups in overall scores, in parent HRQOL and in family functioning sub-scores. However, CDH patients with learning disabilities had significantly worse Family Impact Module overall scores compared to CDH patients without learning disabilities (p = 0.04). CONCLUSION The overall HRQOL in children with CDH survivors is worse compared to controls, but impact on family appears similar. We highlight the need for long-term follow-up of CDH patients, especially those with learning disabilities. Healthcare providers should formulate tailored care plans to address patient and caregiver needs. TYPE OF STUDY Prospective Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Suganthi Rajasegaran
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ayna Nadia Nooraziz
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ayesyah Abdullah
- Division of Paediatric & Neonatal Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Anand Sanmugam
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Division of Paediatric & Neonatal Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Division of Paediatric & Neonatal Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Chin Seng Gan
- Paediatric Intensive Care Unit, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Division of Paediatric & Neonatal Surgery, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Jalunis MM, Hng SY, Eg KP, Gowdh NFM, Sanmugam A, Nah SA, Nathan AM, de Bruyne JA. Long-Term Respiratory Outcome of Children with Empyema. Indian J Pediatr 2024:10.1007/s12098-024-05021-4. [PMID: 38224429 DOI: 10.1007/s12098-024-05021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/01/2024] [Indexed: 01/16/2024]
Affiliation(s)
- Mohamed Mustakim Jalunis
- Department of Pediatrics, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Shih Ying Hng
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Kah Peng Eg
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | | | - Anand Sanmugam
- Division of Pediatric & Neonatal Surgery, Department of Surgery, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Pediatric & Neonatal Surgery, Department of Surgery, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Anna Marie Nathan
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Jessie Anne de Bruyne
- Pediatric Respiratory Unit, Department of Pediatrics, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Bal PK, Nah SA, Wan Mohamad Noor WMR, Md Nor MT, Singaravel S, Tan WS, Tan YW, Sanmugam A. Suction rectal biopsy (SRB) in Hirschsprung's Disease: Is a single macroscopically adequate sample sufficient? Malays J Pathol 2023; 45:457-462. [PMID: 38155386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Hirschsprung's Disease (HD) is a congenital disorder causing severe constipation in infants and children. Suction rectal biopsy (SRB) is the preferred technique for obtaining tissue samples for histopathological evaluation. In low-resource settings like Malaysia, cost-effective diagnostic approaches are necessary, making single sample SRB valuable. This study evaluates the diagnostic accuracy and sufficiency of a single macroscopically adequate sample in suction rectal biopsies for the histopathological confirmation of HD. We conducted a retrospective study of children who underwent suction rectal biopsies for the diagnosis of HD at Hospital Raja Perempuan Zainab II (HRPZII), Kota Bharu, Kelantan. A total of 68 patients were included in the study. The inadequacy rate for bedside SRB was 14%, comparable to current literature. Our study found no statistically significant association between sample inadequacy and gestational age, gender, birth weight, or weight at biopsy. Complication rates were 0%, consistent with literature reports. Calretinin staining, an additional technique, was performed in 23 biopsy episodes, with a 4.3% inadequacy rate, compared to 20% in specimens not subjected to calretinin staining. The cost of SRB almost doubled with each additional sample taken, significant in low-resource environments. In conclusion, single sample SRBs can be adequately diagnostic and cost-effective in low-resource settings, providing valuable insights for healthcare facilities in Malaysia and other developing countries. The use of adjunctive techniques such as calretinin staining may improve diagnostic accuracy while maintaining cost-effectiveness. Further prospective studies with larger sample sizes are needed to validate these findings.
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Affiliation(s)
- P K Bal
- Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - S A Nah
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric And Neonatal Surgery, Kuala Lumpur, Malaysia
| | - W M R Wan Mohamad Noor
- Hospital Raja Permaisuri Zainab II, Department of Surgery, Kota Bharu, Kelantan, Malaysia
| | - M T Md Nor
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric And Neonatal Surgery, Kuala Lumpur, Malaysia
| | - S Singaravel
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric And Neonatal Surgery, Kuala Lumpur, Malaysia
| | - W S Tan
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric And Neonatal Surgery, Kuala Lumpur, Malaysia
| | - Y W Tan
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric And Neonatal Surgery, Kuala Lumpur, Malaysia
| | - A Sanmugam
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric And Neonatal Surgery, Kuala Lumpur, Malaysia.
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Zubaidi SA, Ezrien DE, Chen Y, Nah SA. Laparoscopic versus Open Incarcerated Inguinal Hernia Repair in Children: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg 2023; 33:414-421. [PMID: 36220132 DOI: 10.1055/a-1958-7830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Laparoscopic hernia repair (LH) is reported to have superior outcomes in pediatric inguinal hernia repair, but its advantages in incarcerated inguinal hernia (IIH) are not defined. We compare the outcomes of LH versus open hernia repair (OH) for pediatric IIH. METHODS We performed a systematic review on all published analyses of LH versus OH for IIH. We identified studies published in 2000 to 2018 from Medline, PubMed, Embase, Google Scholar, and Cochrane databases. We included only studies that compared both surgical techniques on children aged 18 years or younger. Search terms were variations of "incarcerated inguinal hernia," "hernia repair," "laparoscopy," and "child." We categorized complications as major (testicular atrophy, ascending testis, recurrence, iatrogenic visceral injury) and minor (wound infection). Heterogeneity was assessed using I2; meta-analyses were performed using random- or fixed-effects models as appropriate. Weighted mean differences (WMDs) or odds ratios (ORs), with their corresponding 95% confidence intervals (CIs), were used for analysis of continuous and dichotomous variables, respectively. Significance level was at p-value less than 0.05. RESULTS Our initial search yielded 549 unique citations. Eight retrospective cohort (RC) studies (584 patients) were included in the final analysis (339 LH, 245 OH). Overall, major complications (eight RC; n = 584; OR = 0.38; 95% CI: 0.17-0.88; p = 0.02) were more common in OH. When each complication was assessed individually, there were no differences between groups. The length of hospital stay in the LH group was shorter than in the OH group (five RC; n = 418; WMD = - 1.39; 95% CI, -2.56 to -0.22; p = 0.02). CONCLUSION Laparoscopic repair for IIH is associated with less major complications and shorter hospital stay, but data are limited due to the absence of randomized controlled trials.
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Affiliation(s)
- Syukri Ahmad Zubaidi
- Division of Paediatric Surgery, Department of General Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Don Evana Ezrien
- Division of Paediatric Surgery, Department of General Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Shireen Anne Nah
- Faculty of Medicine, Department of Surgery, University of Malaya, Kuala Lumpur, Malaysia
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Adisa A, Bahrami-Hessari M, Bhangu A, George C, Ghosh D, Glasbey J, Haque P, Ingabire JCA, Kamarajah SK, Kudrna L, Ledda V, Li E, Lillywhite R, Mittal R, Nepogodiev D, Ntirenganya F, Picciochi M, Simões JFF, Booth L, Elliot R, Kennerton AS, Pettigrove KL, Pinney L, Richard H, Tottman R, Wheatstone P, Wolfenden JWD, Smith A, Sayed AE, Goswami AG, Malik A, Mclean AL, Hassan A, Nazimi AJ, Aladna A, Abdelgawad A, Saed A, Abdelmageed A, Ghannam A, Mahmoud A, Alvi A, Ismail A, Adesunkanmi A, Ebrahim A, Al-Mallah A, Alqallaf A, Durrani A, Gabr A, Kirfi AM, Altaf A, Almutairi A, Sabbagh AJ, Ajiya A, Haddud A, Alnsour AAM, Singh A, Mittal A, Semple A, Adeniran A, Negussie A, Oladimeji A, Muhammad AB, Yassin A, Gungor A, Tarsitano A, Soibiharry A, Dyas A, Frankel A, Peckham-Cooper A, Truss A, Issaka A, Ads AM, Aderogba AA, Adeyeye A, Ademuyiwa A, Sleem A, Papa A, Cordova A, Appiah-Kubi A, Meead A, Nacion AJD, Michael A, Forneris AA, Duro A, Gonzalez AR, Altouny A, Ghazal A, Khalifa A, Ozair A, Quzli A, Haddad A, Othman AF, Yahaya AS, Elsherbiny A, Nazer A, Tarek A, Abu-Zaid A, Al-Nusairi A, Azab A, Elagili A, Elkazaz A, Kedwany A, Nuhu AM, Sakr A, Shehta A, Shirazi A, Mohamed AMI, Sherif AE, Awad AK, Abbas AM, Abdelrahman AS, Ammar AS, Azzam AY, Ciftci AB, Dural AC, Sanli AN, Rahy-Martín AC, Tantri AR, Khan A, Al-Touny A, Tariq A, Gmati A, Costas-Chavarri A, Auerkari A, Landaluce-Olavarria A, Puri A, Radhakrishnan A, Ubom AE, Pradhan A, Turna A, Adepiti A, Kuriyama A, Kassam AF, Hassouneh A, El-Hussuna A, Habeebullah A, Ads AM, Mousli A, Biloslavo A, Hoang A, Kirk A, Santini A, Melero AV, Calvache AJN, Baduell A, Chan A, Abrate A, Balduzzi A, Sánchez AC, Navarrete-Peón A, Porcu A, Brolese A, Barranquero AG, Saibene AM, Adam AA, Vagge A, Maquilón AJ, Leon-Andrino A, Sekulić A, Trifunovski A, Mako A, Bedada AG, Broglia A, Coppola A, Giani A, Grandi A, Iacomino A, Moro A, D’amico A, Malagnino A, Tang A, Doyle A, Alfieri A, Haynes A, Wilkins A, Baldwin A, Heriot A, Laird A, Lazarides A, O'connor A, Trulson A, Rokohl AC, Caziuc A, Triantafyllou A, Anesi A, Nikova A, Andrianakis A, Charalabopoulos A, Tsolakidis A, Chirca A, Arnaud AP, Narvaez-Rojas AR, Kavalakat A, Spina A, Recordare A, Annicchiarico A, Conti A, Mohammed AD, Kocataş A, Almhimid A, Arnaout A, Fahmy A, Mangi A, Modabber A, Ulas AB, Mohamedahmed AYY, Frontali A, Moynihan A, Yunus A, Ahmad A, Kent AJ, Khamees A, Ugwu AO, Turan A, Mohammed AAK, Navarro-Barrios A, Yebes A, De Sousa ÁFL, Moreno A, Sethi A, Dawson AC, Othman AAA, Kaur A, Wolde A, Antonelli A, Scifo A, Alhamad A, Davis A, Alderazi A, Harky A, Mohammed-Durosinlorun A, Seguya A, Okhakhu A, Chamakhi A, Sebai A, Souadka A, Asla A, Agrawal A, Persad A, Gupta A, Elgazar A, Kulkarni A, Coates A, Bellés AC, Hadzibegovic AD, Jotic A, Kowark A, Martins A, Pineda AM, Peral A, Gollarte AS, Senent-Boza A, Camarena AIA, Castaño-Leon AM, Bravo AMM, Moro AMG, Musina AM, Tapia-Herrero AM, Kothari A, Gupta A, Raja A, Aljaiuossi A, Taha A, Majbar AM, Prodromidou A, Kanatas A, Gupte A, Zakaria AD, Balla A, Barberis A, Bondurri A, Bottari A, Costantino A, Figus A, Lauretta A, Mingoli A, Romanzi A, Sagnotta A, Scacchi A, Picchetto A, Valadez AEC, Luzzi AP, Älgå A, Fontalis A, Hecker A, Demetriades AK, Serban AM, Văcărașu AB, Cokan A, Isaza-Restrepo A, Beamish A, Schache A, Stevenson A, Yiu A, Cockbain AJ, Litvin A, Abad-Motos A, Becerra A, Ramos ÁC, Chiaradia A, Dell A, Romano A, Pascale A, Marra AA, Dimas A, Kolias A, Cerovac A, Koneru A, Tidjane A, Agbeko AE, Bajaj A, Gosain A, Allan A, Carreras-Castañer A, D'amore A, Dare A, Maffioli A, Palepa A, Paspala A, Konney A, Gatta AND, Ezanno AC, Yiallourou A, Kinnair A, Rayner A, Scafa AK, Bowan AB, Veglia A, Russo A, Maniaci A, Castaldi A, Gil-Moreno A, Maffuz-Aziz A, Meola A, Nenna A, Ferrer AP, Bonilla AR, Ramos-De La Medina A, Infante AR, Santoro A, Laganà AS, Bateman A, Michael ALR, Abozid A, Seidu AS, Lowery A, Tantraworasin A, Rasheed A, Picciariello A, Isik A, Saif A, Anjum A, Ioannidis A, Abeldaño A, Hussain A, Nathan A, Bedzhanyan A, Perfecto A, De Virgilio A, Galvan A, Sablotzki A, Böttcher A, Pellacani A, Gatti A, Ibrahimli A, Menon A, Sahni A, Mwenda AS, Choudhry A, Jayawardane A, Gupta A, Ramasamy A, Mitul AR, Bawa A, Nugur A, Rammohan A, Sachdeva A, Mehraj A, Yildirim A, Alqaseer A, Radwan A, Sallam A, Syllaios A, Tampakis A, Alwael A, Samara A, Eroglu A, Rahman A, Ulkucu A, Zaránd A, Dulskas A, Tawiah A, Zani A, Vas A, Lukosiute-Urboniene A, Adamu A, Aujayeb A, Malik AA, İplikçi A, Mahmud A, Cil AP, Makanjuola A, Akwaisah A, Galandarova A, Saracoglu A, Regan A, Barlas AM, Alhassan BAB, Mostafa B, Hamida BB, Torun BC, Abdullah B, Balagobi B, Banky B, Singh B, Alegbeleye B, Yigit B, Hajjaj BN, Burgos-Blasco B, Seeliger B, Alayande B, Alhazmi B, Enodien B, Torre B, Pérez BG, Tamayo BV, De Andrés-Asenjo B, Quintana-Villamandos B, Girgin B, Barmayehvar B, Beisenov B, Creavin B, Dunne B, Marson B, Waterson B, Martin B, Zucker B, Wong BNX, Ozmen BB, Hammond B, Mbwele B, Núñez B, Dhondt B, Gafsi B, Mcleish B, Lieske B, Tailor B, La Pira B, Picardi B, Zampogna B, Casagranda B, Festa BM, Panda B, Kirmani B, Sulaiman B, Gurung B, Zacharia B, Bette B, Ayana B, Nikolovska B, Vilaró BC, De Vega Sánchez B, Hameed BZ, Diaconescu B, Kovacevic B, Bumber B, Sakakushev B, Tadic B, Malek B, Alrayes B, Thomas B, Gális B, Gallagher B, Knowles B, Cunningham B, Daley B, Mishra B, Ashford B, Pirozzi BM, Berselli B, Martinez-Leo B, Sensi B, Nardo B, Celik B, Giray B, Abud B, Almiqlash B, Pramesh CS, Taskiran C, De Campos Prado CA, Cipolla C, Kumar C, English C, Riccetti C, Vanni C, Brasset C, Downey C, Duffy C, Chwat C, Cutmore C, Sars C, Ratto C, Pacilio CA, De La Infiesta García C, Moreno CG, Magalhães C, Prada C, Zapata CS, Senni C, Flumignan CDQ, Martinez-Perez C, Duarte CL, Garcia CSR, Anderson C, Hing C, Cullinane C, Cina C, Zabkiewicz C, Sohrabi C, Guldogan CE, Ciubotaru C, Desai C, Raut C, Demetriou C, Handford C, Okpani C, Paranjape C, Koh C, Khatri C, Parmar C, Mok CW, Caricato C, Marafante C, Echieh CP, Tan CY, Ong CS, Conso C, Jardinez C, Konrads C, Warner C, Makwe CC, Henein C, Fleming C, Roland CL, Maurus C, Nitschke C, Mittermair C, Mallmann C, Andro C, Harmston C, Kuppler C, Lotz C, Nahm C, Rowe C, Ryalino C, Wallis C, Millward CP, Anthoulakis C, Apostolou C, Chouliaras C, Kalfountzos C, Kaselas C, Vosinakis C, Okereke C, Chean CS, Barlow C, Tatar C, Clancy C, Forde C, Sharpin C, Mccarthy C, Nestor C, Warden C, Ávila CC, Massaguer C, Fang CEH, Martins CP, Guerci C, Mauriello C, Holzmeister C, Miller C, Weber C, Wiesinger CG, Kenington C, Noel C, Sue-Chue-Lam C, Adumah C, Neary C, Sen C, Fitzgerald C, Ezeme C, Nastos C, Mesina C, Bombardini C, Torregrosa C, Valdespino CP, Don CP, Wickramasinghe D, Milanesi D, Armijos D, Asiimwe D, Beswick D, Clerc D, Cox D, Doherty D, Martínez DF, Lechuga DG, Gero D, Gil-Sala D, Lindegger D, Reim D, Shaerf D, Shmukler D, Branzan D, Filipescu D, Rega D, Bernardi D, Bissacco D, Fusario D, Morezzi D, Sabella D, Zimak DM, Vinci D, Sale D, Khan DZ, Thereska D, Andreotti D, Tartaglia D, Abdulai DR, Mukherjee D, Verdi D, Idowu D, John D, Johnson D, Moro-Valdezate D, Naumann D, Omar D, Proud D, Roberts D, Guzmán DS, Watson D, Bergkvist DJ, Lumenta DB, Ferrari D, Rizzo D, Degarege D, Castillo DFC, Douglas D, Wright D, Nanjiani D, Bratus D, Altun D, Sievers D, Vaysburg D, Katechia D, Ghosh D, Azize DA, Rodrigues D, Pachajoa DAP, Hayne D, Mutter D, Raimondo D, Eskinazi D, Sasia D, Corallino D, Muduly D, Grewal D, Hadzhiev D, Peristeri D, Pournaras D, Raptis DA, Angelou D, Haidopoulos D, Magouliotis D, Moris D, Schizas D, Symeonidis D, Tsironis D, Korkolis D, Tatsis D, Thekkinkattil D, Bulian DR, Pandey D, Vatansever D, Parker D, Wiedemann D, Borselle D, Pedini D, Schweitzer D, Venskutonis D, Otokwala J, Adamu KM, Pk P, Garod M, Ellafi AAD, Zivkovic D, Jelovac D, Wijeysundera D, Mcpherson D, Ryan É, Ugwu E, Baidoo EI, Shaddad E, Memişoğlu E, Naranjo EPL, Brodkin E, Segalini E, Viglietta E, Hendriks E, Bonci EA, Sá-Marta E, Ortega EN, Gomez EGL, Joviliano EE, Clune E, Horwell E, Mains E, Vasarhelyi E, Caruana EJ, Nevins EJ, Yenli EMTA, Baili E, Lostoridis E, Morgan E, Shiban E, Latif E, Tampaki EC, Ezenwa E, Irune E, Borg E, Eisa E, Gialamas E, Parvez E, Theophilidou E, Toma EA, Arnaoutoglou E, Samadov E, Kantor E, Ulman EA, Colak E, Cassinotti E, Bannone E, Sarjanoja E, Yates E, Vincent E, Lun EWY, Cerovac E, Dif ES, Alkhalifa E, Daketsey E, Fayad EA, Sheikh E, Pontecorvi E, Cammarata E, La Corte E, Rausa E, Odai ED, Guasch E, Cano-Trigueros E, Uldry E, Ros EP, Matthews E, Donmez EE, Giorgakis E, Kapetanakis E, Stamatakis E, Bua E, Schneck E, Nachelleh EA, Ofori EO, Akin E, Gönüllü E, Kirkan EF, Çelik E, Wong E, Capozzi E, Pinotti E, Colás-Ruiz E, González E, Fekaj E, Ohazurike E, Kebede E, Erginöz E, Duran EES, Scott E, Aytac E, Albanese E, Castro EJ, Albayadi E, Kriem E, Siddig E, Otify E, El Tayeb EEABH, Hong EH, Saguil E, Belzile E, Tuyishime E, Panieri E, Martínez EG, Myriokefalitaki E, Wong EG, Samara E, Agbeno EK, Drozdov E, Tokidis E, Shah FA, Barra F, Carbone F, Ferreli F, Marino F, Martinelli F, D'acapito F, Masciello F, Bàmbina F, Issa F, Salameh FT, Kethy F, Mahmood F, Gareb F, Idrees F, Karimian F, Ashraf F, Haji F, Inayat F, Begum F, Nabil F, Rosa F, Haider F, Parray F, Calculli F, Ferracci F, Saraceno F, Coppola F, Coccolini F, Fusini F, Migliorelli F, Pecoraro F, Alconchel F, Coimbra FJF, Trivik-Barrientos F, Naegele F, Almarshad F, Agresta F, Fleming F, Mendoza-Moreno F, Brzeszczyński F, Carannante F, Wu F, Aljanadi F, Hayati F, Campo F, Sorbi F, Milana F, Takeda FR, Shekleton F, Gessler F, Recker F, Grama F, Cherbanyk F, Faponle F, Angelis F, Calabretto F, Gaino F, Toia F, Bianco F, Bussu F, Cammarata F, Castagnini F, Colombo F, Ferrara F, Fleres F, Guerrera F, Litta F, Mongelli F, Pata F, Roscio F, Mulita F, Ardura F, Tejero-Pintor FJ, Calvo FJR, Escobedo FJB, Camacho FJB, Odicino F, Schmitt F, Bloemers F, Hölzle F, Gyamfi FE, Messner F, Koh F, Cáceres F, Smolle-Juettner FM, Herman F, Ayeni F, Djedovic G, De Oliveira GP, Rodrigues G, Wagner G, Bellio G, Giarratano G, Capolupo GT, Budd G, Marom G, Poillucci G, Thiruchandran G, Nicholson G, Groot G, Hoey G, Bass GA, Sachdev G, Agarwal G, Aggarwal G, Cormio G, Mazzarella G, Perrone G, Osterhoff G, Singer G, Dejeu G, Fowler G, Garas G, Gradinariu G, Theodoropoulos G, Tzimas G, Babis G, Wong GKC, Cross GWV, Micha G, Chrysovitsiotis G, Koukoulis G, Peros G, Tsoulfas G, Kapetanios G, Karagiannidis G, Verras GI, Ekwen G, Perrotta G, Petruzzi G, Bertelli G, Calini G, Fiacchini G, Pirola GM, Dolci G, Mendiola G, Baiocchi GL, Palini GM, Prucher GM, D'andrea G, Maggiore G, Cassese G, Franceschini G, Pellino G, Saponaro G, Pattacini GC, Pantuso G, Iannella G, Bonsaana GB, Lever G, Brachini G, Giraudo G, Lisi G, Russo GI, Aprea G, Pascale G, Tomasicchio G, Sandri GBL, Armatura G, Turri G, Zaccaria G, Barugola G, Lantone G, Gasparini G, Iacob G, Sozzi G, Zancana G, Mercante G, Bianco G, Brisinda G, Consorti G, Currò G, Giannaccare G, Palomba G, Pascarella G, Rotunno G, Spriano G, Vizzielli G, Cucinella G, Sica G, Campisi G, Baiocchi G, Guerra GR, Pacheco GMF, Atis G, Augustin G, Šantak G, Chauhan GS, Branagan G, Harris G, Stewart GD, Padmore G, Kocher GJ, Di Franco G, De Jesus Labrador Hernandez G, Christodoulidis G, Neal-Smith G, Yim G, Piozzi GN, Claret G, Yanowsky-Reyes G, Dhaity GD, Cakmak GK, Mohamed G, Kucuk GO, Ancans G, Banipal GS, De Bacco Marangon G, Laporte G, Martinez-Mier G, Recinos G, V GMM, Benshetrit G, Vijgen G, Pickett G, Rodriguez HA, Shiwani H, Derilo H, Awad H, El Assaad H, Raji HO, Hardgrave H, Karakullukcu HK, Abdussalam HO, Mustafa H, Parwaiz H, Khan H, Arbab H, Naga H, Salem H, Ulgur HS, Perez-Chrzanowska H, Greenlee H, Javanmard-Emamghissi H, Lederhuber H, Osman H, Adamou H, Majid HJ, Van Goor H, Spiers HVM, Manesh HF, Mushtaq H, Aljaaly H, Hasan HB, Ahmed HTA, Martinez-Said H, Aguado HJ, Consani H, Chaplin H, Mohan H, Van Vliet H, Lohse HAS, Shah H, Claireaux H, Lule H, Juara H, Abozied H, Bayo HL, Alibrahim H, Kroon HM, Ulman H, Khan H, Yonekura H, Abou-Taleb H, Wong HYF, Carpenter H, Majd HS, Zenha H, Mayer HF, Elghadban H, Abdou H, Elfeki H, Yusefi H, Gomez-Fernandez H, Horsfall HL, Meleiro H, Sungurtekin H, Junior HFL, Moloo H, Bayhan H, Şevi̇k H, Embarek H, Hamid HKS, Pradeep IHDS, Donkin I, Ateca IV, Jafarov I, Salisu I, Abdalaal I, Garzali IU, Sall I, Adebara I, Aghadi I, Ugwu I, Zapardiel I, Reis I, Nwafor I, Fakhradiyev I, Surya IU, Robo I, Njokanma I, Iannone I, Khan I, Correia I, Königsrainer I, Seiwerth I, Linero IB, Kadiri I, Florian IA, Tzima I, Akrida I, Baloyiannis I, Gerogiannis I, Katsaros I, Tsakiridis I, Valioulis I, Negoi I, Yadev I, De Haro Jorge I, Vázquez IO, Dajti I, Russo IS, Afzal I, Wasserman I, Chukwu I, Gracia I, Oliver IM, Hughes I, Mondi I, Ncogoza I, Bsisu I, Rashid I, Balasubramanian I, Omar I, Dominguez-Rosado I, Smati I, Vokshi I, Al-Badawi IA, Saleh IA, Pilkington I, Kirac I, Trostchansky I, Gawron IM, Trebol J, Martellucci J, Andreuccetti J, Abou-Khalil J, Shah J, Manickavasagam J, De Alarcón JR, Mihanovic J, O'riordan J, Archer J, Ashcroft J, Blair J, Hamill J, Munthali J, Park J, Parry J, Ryan J, Tomlinson J, Wheeler J, Wilkins J, Balogun JA, Hodgetts JM, Vatish J, Žatecký J, Dziakova J, Martin J, Beatty JW, Stijns J, Faiz J, Ripollés-Melchor J, Mata J, Vásquez JAG, Mitra JK, Tuech JJ, Mvukiyehe JP, Fallah JM, Díaz JT, Vishnoi JR, Van Den Eynde J, Rickard J, Rolinger J, Kaplowitz J, Meyer J, Reid J, Rossaak J, Smelt J, Thomas JJ, Reyes JAS, Davies J, Luc J, Alonso JAM, Hajiioannou J, Querney J, Van Acker J, Pu JJ, Cama J, Simoes J, Cozens J, Barbosa-Breda J, Ribeiro J, De Haro J, Nigh J, Bowen J, Pollok JM, Strotmann JJ, Doerner J, Edwards J, Green J, Massoud J, Mcgrath J, Squiers J, Street J, Windsor J, Santoshi JA, Meara JG, Abebrese JT, Reilly JJ, Zabaleta J, Phillips J, Herron J, Horsnell J, Dawson J, Sheen J, Kauppila JH, Konsten J, Raurich-Leandro J, Romera JS, Nuñez J, Gass JM, Blanco J, Calvache JA, Iturralde JLF, D’addino JL, Hermosa JMG, Guillen JRO, Beristain-Hernandez JL, Sole-Sedeno JM, Vives JMM, Attwood J, Furey J, Hadaya J, Mckay J, Meilak J, Natale J, Shalhoub J, Jung J, Arthur J, Kealey J, Wright J, Moreau J, Miskovic J, Juloski J, Bauset JCC, Segura-Sampedro JJ, Cisneros JRT, Gomez-Rosado JC, Arneja J, Heider J, Fernández JD, Plata-Bello J, Villanueva J, Olaogun J, Hing JX, Košir JA, Daruwalla J, Yeung J, Wormald J, Seyi-Olajide J, Rani J, Wong KY, Hristova K, Kajal K, Algarni K, Theivendran K, Futaba K, Elsayem K, Kapur K, Bailey K, El-Boghdadly K, Ataya K, Lacorbiniere K, Shah K, Tellez KSM, Szyluk K, Rangasamy K, Iyengar K, Szabómihályová K, Atkinson K, Camargo-Parra K, Galliard K, Dickson K, Singh K, Qader K, Hasan K, Spellar K, Feeney K, Ajenifuja K, Oh KE, Okunade K, Adanu K, Bateman K, Saracoglu K, Ho KW, Enwerem K, Mishra K, Verhoeff K, Bensoltane K, Larabi K, Hamdan KH, Nadi K, Fozo K, Abdelwahab K, Al-Sayaghi K, Dajani K, Algahtany K, Abdel-Galil K, Ahmed K, Bajunaid K, Bhatti K, Sofi K, Abdulsalam K, Tamoos K, Dzhumabaev K, Samo KA, Purich K, Madhvani K, Qin KR, Underwood K, Senanayake KJ, Augestad KM, Sigamoney K, Apostolou K, Bouchagier K, Bouliaris K, Bramis K, Gousias K, Lasithiotakis K, Paraskevopoulos K, Perivoliotis K, Roditis K, Stamatis K, Stroumpoulis K, Paraskevas KI, Govindarajan KK, Šimko K, Olson KA, Khobragade K, Seah KM, Kishore K, Ayad K, Papavasiliou K, Angelou K, Paniagua LC, Czako L, Ching LVK, Rai L, Gupta L, Ismail L, Mbodi L, Dasanayake L, Schröder L, Baiyewu LA, Fortuna L, Fernandez LG, Vivancos LG, Jack L, Keçi L, Lavalle L, Leonard L, Shelmerdine L, Vaassen L, Hasan L, Lazarou L, Tzelves L, Matos L, Siragusa L, Licari L, Lima LS, Solaini L, Lichman L, Moral LT, Cabeza L, Kaplan L, Valeanu L, Kaman L, Karout L, Pieteris L, Chan L, Grüßer L, Zamora L, Catarzi L, Rampersad L, Anyanwu LJ, Cheung LK, Rodríguez LV, Andreani L, Cobianchi L, Petagna L, Howse L, Gonzalez LE, Bains L, Vohra L, Ansaloni L, Bertolaccini L, Ferrario L, Orecchia L, Tirloni L, Zanin L, Morelli L, Scaravilli L, Locatello LG, García LD, Vida L, Carbone L, Heindl LM, Bonavina L, Conti L, Marano L, Verre L, Conte LE, Boccalatte L, Tellez LGS, Loureiro L, Sánchez-Guillén L, Tallon-Aguilar L, Nakano L, Alvarez-Lozada LA, Gonzalez LAS, Flórez LJG, Capitan-Morales LC, Kowalski LP, Widmer LW, Harper L, Render L, Wheldon L, Abdur-Rahman L, Doğan L, Prusty L, Katsiaras L, Gourbault L, Siddiqui MT, Saleh M, Karthigeyan M, Rodriguez M, Chowdhury M, Nagappa M, Sultania M, Bashir M, Alam M, Elshahawy MAM, Elfiky M, Loubani M, Marei M, Mewafy M, Alali M, Nassar MA, Alobied M, Bilfaqirah M, Ahmad M, Rius M, Manangi M, Dornseifer MD, Tripathi M, S M, Sokolov M, Pigeolet M, Alonso MD, Losada M, Carretero MM, Tousidonis M, Cotovio MD, Wijeyaratne M, Boira MA, Franza M, Albdour M, Alkhatieb M, Déserts MDD, Niewiera M, Vallve-Bernal M, Kavanagh MM, Migliore M, Calabrò M, Martino MD, Reicher M, Baia M, Caricato M, Clementi M, De Zuanni M, Fiore M, Giacometti M, Inama M, Maestri M, Materazzo M, Sparavigna M, Pascale MM, Nemeth M, Serra M, Fahim MMF, Soucheiron MC, Papadoliopoulou M, Wittmann M, Sotiropoulou M, García-Conde M, Ranucci MC, Amo MDAD, Boedo MJM, Velázquez MJM, Pissaridou MK, Petersen ML, Sacras ML, Modolo MM, Caubet MM, Di Nuzzo MM, Ntalouka MP, Menna MP, Aguilera-Arevalo ML, Rela M, Capuano M, Hollyman M, Olivos M, Sacdalan MD, Raphael MC, Takkenberg M, Bortul M, Cabrera M, Castaño M, D'oria M, Giuffrida M, Laborde MM, Rodriguez-Lopez M, Trejo-Avila M, Papa MV, Ghobrial M, Kryzauskas M, Anwer M, Cheetham M, Davies M, Higgins M, Siboe M, Tarle M, Velten M, Wurm M, Süleyman M, Bauer M, O’dwyer M, Caretto M, De La Rosa-Estadella M, Fragoso M, Serra ML, Merayo M, Golet MR, Martínez-Sánchez MI, Domingo MMA, Gosselink M, Batstone M, Reichert M, Salö M, Soljic M, Zambon M, Angeles MA, Abdulkhaleq M, Abdelkarim M, Alsefri M, Iwasaki M, Shiota M, Veroux M, Molina-Corbacho M, Frasson M, Serenari M, De Pastena M, Desio M, Risaliti M, Rottoli M, Bence M, Chan M, Watson M, Wiles M, Boisson M, Berselli M, Capobianco M, Di Bartolomeo M, Fehervari M, Pacilli M, Romano M, Zizzo M, Domanin M, Montuori M, Podda M, Zago M, Dzogbefia M, Frountzas M, Thaw MH, Al-Juaifari M, Gharat M, Mohamed M, Hannan MJ, Venketeswaran M, Chisthi M, Dessalegn M, Kaplan M, Çakıcı MÇ, Ulutaş ME, Hassan M, Elsadek M, Mengesha MG, Gómez ME, Elbadawy MA, Pitcher M, Tanal M, Tokocin M, Ergenç M, Çelik MN, Bareka M, Pekcici MR, Cappuccio M, Dasa M, Dewan M, El Boghdady M, Ezeanochie M, Greenhalgh M, Jenkinson M, Kelly M, Spartalis M, Zyskowski M, Racine M, De Cillia M, Chu MJJ, Mallmann MR, Zhu MZL, Klimovskij M, Vailas M, Kisielewski M, Adamina M, Campanelli M, Carvello M, Ammendola M, Manigrasso M, Scopelliti M, White M, Collins ML, Chevallay M, Borges MF, Mayo-Yáñez M, Melo MR, Ruiz-Marín M, Eiras MAF, Cunha MF, Pertea M, Slavchev M, Davidescu M, Prieto M, Agapov M, Gahwagi M, Prats MC, Rudic M, Verbic MS, Kostusiak M, Stoleriu MG, Lucas MA, Barone M, Ahmad M, Alemu MAA, Fatima M, Ida M, Sahu M, Muhaisen M, Salem M, Emara MM, Oludara M, Sotudeh M, Kassab MB, Abdelkhalek M, Alsori M, Anwar M, El-Kassas M, Elbahnasawy M, Eldabaa M, Rabie M, Hassanin MA, Thaha MA, Ali MSM, Alhamid M, Almoshantaf MB, Keramati MR, Bafaquh M, Abuzaid M, Al-Shehari M, Alharthi M, Alkahlan M, Alwash M, Alyousef M, Amir M, Basendowah M, Deputy M, Jibreel M, Alam MS, Alsharif M, Issahalq MD, Omer MEA, Abubakar MK, Draman MR, Elnour MAE, Eltayeb M, Castillo MN, Jawad M, Raut M, Ghalleb M, Katsura M, Lebe M, Abbas M, Abdelrahman M, Shalaby M, Farhan-Alanie M, Farooq M, Musadaq M, Arshad M, Anjum MA, Usman M, Chaudhary MA, Raza MA, Karim MFSA, Chaudhary MH, Janjua MH, Khokhar MI, Malik MIK, Pirzada MT, Younis MU, Elhadi M, Suer MS, Ergenç M, Binnawara M, Emmanuel M, Abbasi M, Naimzada MD, Kulimbet M, Kusunoki M, Eugene M, Chauhan M, Shokor MA, Aljiffry M, Kalın M, Kurawa M, Dincer MB, Tolani MA, Soytas M, Yakubu M, Usman MI, Aremu M, Paranyak M, Talat N, Kausar N, Dudi-Venkata N, Bazzi N, Hasan NB, Van Wyk NN, Shaban N, Almgla N, Kandevani NY, Alzerwi N, Alvarez N, Motas N, Rincón NAR, Blencowe N, Simon N, Aghtarafi N, Ghuman NK, Sharma N, Wijekoon N, Kumar N, Hassan N, Onyemaechi N, Prijović N, Özçay N, Goel N, Segaren N, Sharma N, Kalyva N, Palacios NM, Alonso NFP, Onyeagwara N, Petrucciani N, Daddi N, Lightfoot N, Power N, Segaren N, Starr N, Dreger NM, Cillara N, Colucci N, Eardley N, Tartaglia N, Zanini N, Bacalbasa N, Campuzano N, Mouawad N, Federico NSP, Tamini N, Mariani NM, Beasley N, Adu-Aryee NA, Burlov N, Dimitrokallis N, Gouvas N, Machairas N, Memos N, Thomakos N, Tsakiridis N, Schizas N, Börner N, Theochari N, Al-Saadi N, Glass N, Horesh N, R NE, Gahlot N, Ismail N, Aljirdabi N, Maria NUH, Trabulsi N, Akeel N, Borges N, Moda N, Redondo NV, Nyarko OO, Ginghina O, Enciu O, Okere O, Ekwunife OH, Quadri O, Ogundoyin O, Tucker O, Mateo-Sierra O, Azzis O, Ojewuyi O, Habeeb O, Idowu O, Elebute O, Agboola O, Ladipo-Ajayi O, Oyinloye O, Adebola O, Ekor O, Ogundoyin O, Salamanca O, Vergara-Fernandez O, Wafi O, Aladawi O, Bahassan OM, Tammo Ö, Ozkan OF, Williams OM, Salami O, Akinajo O, Sakhov O, Gallo O, Sole OM, Milella O, Alser O, Bettar OA, Alomar O, Osman OS, Aisuodionoe-Shadrach O, Basnayake O, Bozbiyik O, Hodges O, Ojo O, Yanık Ö, Mutlu ÖPZ, Kazan O, Calavia P, García PR, Urriza PV, Lopez PR, Christidis P, Dorovinis P, Kokoropoulos P, Mourmouris P, Papatheodorou P, Garg PK, Patel P, Vassiliu P, Campennì P, De Nardi P, Bernante P, Ubiali P, Baroffio P, Pizzini P, Sapienza P, Myrelid P, Chatzikomnitsa P, Tsiantoula P, Gada P, Avella P, Cianci P, Romero P, Méndez PS, Pazmiño PAF, Coughlin P, Kirchweger P, Pessaux P, Maguire PJ, Petrone P, Cullis P, Köglberger P, Marriott P, Nankivell P, Santos-Costa P, Martins PN, Panahi P, Botelho P, Teixeira P, Escobar P, Vázquez PJG, Gribnev P, Nolte P, Agbonrofo P, Bobak P, Choong P, Elbe P, Hutchinson P, Labib P, Paal P, Pockney P, Reemst P, Szatmary P, Vaughan-Shaw PG, Alexander P, Pucher P, Stather P, Foessleitner P, Winnand P, Zehnder P, Kruse P, Matos PAW, Lapolla P, Cicerchia PM, Solli P, Di Lascio P, Zarif P, Champagne PO, Anoldo P, Bertoglio P, Fransvea P, Familiari P, Lombardi PM, Stogowski PT, Bruzzaniti P, Tripathi P, D'sa P, Salunke P, Shah PA, Punjabi PPP, Christodoulou P, Hamdan Q, Tawalbeh R, Gadelkareem R, Awad R, Callcut R, Clegg R, Choron R, Payne R, Gefen R, Costea R, Drasovean R, Mirica RM, Ravindra R, Fajardo RT, Nunes RL, Aspide R, Lombardi R, Vidya R, Elboraei R, Saaid R, Ghodke R, Gupta R, Sharma RD, Lunevicius R, Kalayarasan R, Mohan R, Singh R, Sivaprakasam R, Seenivasagam RK, Rajendram R, Radulescu RB, Goicea R, Seshadri RA, Sarı R, Nataraja R, Aslam R, Abdelemam R, Shrestha R, Bharathan R, Pellini R, Guevara R, Agarwal R, Vissapragada R, Alharmi RA, Sayyed R, Browning R, Critchley R, Mallick R, Alarabi R, Beron RI, Függer R, Othman R, Saad R, Amores RR, Colombari RC, Radivojević RC, Patrone R, Novysedlák R, Palacios Huatuco RM, Baertschiger R, Liang R, Luckwell R, Escrevente R, Rezende RF, Cruz RP, Lenzi R, Rosati R, Donovan R, Egan R, Morris R, Page R, Seglenieks R, Unsworth R, Wilkin R, Skipworth RJ, Davies RJ, Bezirci R, Talwar R, Azami R, Bohmer R, Crichton R, Fruscio R, Hooker R, Jach R, Parker R, Pillerstorff R, Sinnerton R, Stabler R, O'connell RM, Ragozzino R, Tutino R, Angelico R, Cammarata R, Colasanti R, Macchiavello R, Peltrini R, Pirrello R, Vaschetti R, Pires RE, Papalia R, Arrangoiz R, Hompes R, Mittal R, Salah R, Pinto R, Flumignan R, Callan R, Cuthbert R, Dennis R, Scaramuzzo R, Macías RM, Sánchez R, Ogu R, Ramely R, Sgarzani R, Ramli R, Hillier R, Thumbadoo R, Ooi R, Abdus-Salam R, Masri R, Hodgson R, Mathew R, Wade R, D'archi S, Khan S, Ngaserin S, Kale S, Hassan S, Merghani S, Benamar S, Muhammad S, Badran S, Elsahli S, Heta S, Hammouche S, Baeesa S, Paiella S, Eldeen STEHT, Arkani S, Mittal S, Hirji S, Tebha S, Emile S, Dbouk S, Bandyopadhyay SK, Muhammad S, Olori S, Asirifi SA, Hailu S, Ling S, Newman S, Ross S, Wanjara S, Kumar S, Seneviratne S, Tamburello S, Suarez SB, Ingallinella S, Irshaidat S, Konswa S, Mambrilla S, Nasser S, Parini S, Pitoni S, Ornaghi S, Rodrigues SC, Abdelmohsen S, Aitken S, Tian S, Badiani S, Ahmad S, Swed S, Muthu S, Lakpriya S, Alzahrani S, Mikalauskas S, Lasrado S, Satoskar S, Bawa S, Altiner S, Garcia S, Stevens S, Demir S, Ken-Amoah S, Tranca S, Ziemann S, Awad S, Atici SD, Subramaniam S, Erel S, Jiang S, Efetov S, Efremov S, Katorkin S, Valladares SC, Contreras SM, Meriç S, Zenger S, Safi S, Leventoğlu S, Elsalhawy S, Shaikh S, Sheik S, Islam S, Shamim S, Waqar SH, Ahmad S, Farid S, Seraj SS, Sundarraju S, Karandikar S, Sambhwani S, Chopra S, Chowdhury S, Laura S, Ahmed S, Wason S, Tan SJH, Fraser S, Williams S, Ghozy S, Abdelmawgoud S, Shehata S, Sharma S, Ahmed S, Al-Touny SA, Ramzanali S, Nah SA, Jansen S, Rajan S, Dindyal S, Amin S, Ahmad S, Shoukrie SIM, Karar S, Patkar S, Abdulsalam S, Lin S, Hegde S, Fiorelli S, Quaresima S, Redondo SV, Palmisano S, Ruggiero S, Balogun S, Cais S, Cole S, Federer S, Le Roux S, Ippoliti S, Meneghini S, Viola S, Manfredelli S, Novello S, Gananadha S, Mesli SN, Kale S, Tani SI, Malik S, Anastasiadou S, Boligo S, Esposito S, Valanci S, Xenaki S, Pejkova S, Bandyopadhyay S, Trungu S, Basu S, Alkhatib S, Pérez-Bertólez S, Flores SL, Donoghue S, Lunca S, Orsoo S, Potamianos S, Devarakonda S, Suresh S, Croghan SM, Turi S, Capella S, Lucchini S, Magnone S, Salizzoni S, Scabini S, Scaringi S, Cioffi SPB, Seyfried S, Degener S, Potten S, Taha-Mehlitz S, Ali S, Angamuthu S, Mcaleer S, Knight SR, White S, Mantziari S, Kykalos S, Goh SK, Chowdhury SP, Ibrahim S, Elzwai S, Bansal S, Tripathy S, Amrayev S, Anwar SL, Banerjee S, Thakar S, Saeed S, Venkatappa SK, Das S, Techapongsatorn S, Dube SK, Lee S, González-Suárez S, Henriques S, Konjevoda S, Gisbertz S, Bravo SL, Mannan S, Bukhari SI, Zafar SN, Batista S, Chin SL, Arif T, Lawal TA, Aktokmakyan TV, Osborn T, Szakmany T, Sztipits T, Triantafyllou T, Valadez TAC, Singh T, Khaliq T, Patel T, Fadalla T, Jichi T, Sammour T, Al-Shaiji T, Naggs T, Barišić T, Nikolouzakis T, Bisgin T, Perra T, Uprak TK, Dagklis T, Liakakos T, Sidiropoulos T, Adjeso TJK, Dölker T, Oung T, Aherne T, Diehl T, Pinkney T, Raymond T, Rhomberg T, Schmitz-Rixen T, Madhuri TK, Lohmann TK, Yeoh T, Zaimis T, Bright T, Vilz TO, Glowka TR, Board T, Hardcastle T, Cohnert T, Mahečić TT, William TG, Klatte T, Abbott T, Watcyn-Jones T, Mendes T, Kulis T, Sečan T, Campagnaro T, Frisoni T, Simoncini T, Violante T, Safranovs TJ, Risteski T, Pang T, Akinyemi T, Yotsov T, Laeke T, Kochiyama T, Sholadoye TT, Alekberli T, Ezomike U, Giustizieri U, Grossi U, Köksoy ÜC, Bork U, Kisser U, Ronellenfitsch U, Saeed U, Bracale U, Jayarajah U, Rauf UHA, Bumbasirevic U, Ferrer UMJ, Ahmed U, Bello UM, Jogiat U, Sadia U, Galandarov V, Narayanan V, Calu V, Bianchi V, Ciniero V, Tonini V, Silvestri V, Vijay V, Dewan V, Lohsiriwat V, Thuduvage V, Mousafeiris V, Dragisic V, Sasireka V, Santric V, Kusuma VRM, Kolli VS, Alonso V, De Simone V, Picotti V, Martínez VM, Panduro-Correa V, Kakotkin V, Angulo VP, Turrado-Rodriguez V, Krishnamoorthy V, Ban VS, Shah V, Maiola V, Giordano V, La Vaccara V, Lizzi V, Papagni V, Schiavone V, Satchithanantham V, Garcia-Virto V, Jimenez V, Kumar V, Shelat V, Bhat V, Sodhai V, Graziadei V, Kutuzov V, Stoyanov V, Oktseloglou V, Flis V, Elhassan WAF, Yang W, Soon WC, Tashkandi W, Al-Khyatt W, Mabood W, Bijou W, Wijenayake W, D W, Krawczyk W, Atkins W, Bolton W, White W, Ceelen W, Vagena X, Gozal Y, Baba YI, Subramani Y, Jansen Y, Mittal Y, Kara Y, Zwain Y, Noureldin Y, Alawneh Y, Aydin Y, Lam YH, Tang Y, Lim Y, Dean Y, Tanas Y, Su YX, Fujimoto Y, Altinel Y, Frolova Y, Oshodi Y, Fadel ZT, Zahid Z, Elahi Z, Djama Z, Zaheen Z, Jawad Z, Demetrashvili Z, Gebremeskel Z, Gudisa Z, Alyami Z, Garoufalia Z, Li Z, Zimak Z, Radin Z, Balogh ZJ. Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries. Br J Surg 2023; 110:804-817. [PMID: 37079880 PMCID: PMC10364528 DOI: 10.1093/bjs/znad092] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. METHODS This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries. RESULTS In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. CONCLUSION This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.
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Ang CX, Mun WK, Aw MM, Lin D, Chong SL, Ong LY, Nah SA. Gastrointestinal transit time of radiopaque ingested foreign bodies in children: experience of two paediatric tertiary centres. Singapore Med J 2023:374495. [PMID: 37171420 DOI: 10.4103/singaporemedj.smj-2021-408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Introduction Foreign body (FB) ingestion is a common paediatric emergency. While guidelines exist for urgent intervention, less is known of the natural progress of FBs passing through the gastrointestinal tract (GIT). We reviewed these FB transit times in an outpatient cohort. Methods A retrospective review was performed on all children (≤18 years) treated for radiopaque FB ingestion at two major tertiary paediatric centres from 2015 to 2016. Demographic data, FB types, outcomes and hospital visits (emergency department [ED] and outpatient) were recorded. All cases discharged from the ED with outpatient follow-up were included. We excluded those who were not given follow-up appointments and those admitted to inpatient wards. We categorised the outcomes into confirmed passage (ascertained via abdominal X-ray or reported direct stool visualisation by patients/caregivers) and assumed passage (if patients did not attend follow-up appointments). Results Of the 2,122 ED visits for FB ingestion, 350 patients who were given outpatient follow-up appointments were reviewed (median age 4.35 years [range: 0.5-14.7], 196 [56%] male). The largest proportion (16%) was aged 1-2 years. Coins were the most common ingested FB, followed by toys. High-risk FB (magnets or batteries) formed 9% of cases (n=33). The 50th centile for FB retention was 8, 4 and 7 days for coins, batteries and other radiopaque FBs, respectively; all confirmed passages occurred at 37, 7 and 23 days, respectively. Overall, 197 (68%) patients defaulted on their last given follow-up. Conclusion This study provides insight into the transit times of FB ingested by children, which helps medical professionals to decide on the optimal time for follow-up visits and provide appropriate counsel to caregivers.
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Affiliation(s)
- Chen Xiang Ang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Win Kai Mun
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Diana Lin
- Department of Paediatrics, National University Hospital, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Lin Yin Ong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, Faculty of Medicine, University of Malaya, Malaysia
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Lim BLS, Narayanan V, Nah SA. Knowledge, attitude, and practices of operating theatre staff towards environmentally sustainable practices in the operating theatres. Pediatr Surg Int 2023; 39:152. [PMID: 36930355 DOI: 10.1007/s00383-023-05400-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Successful implementation of environmentally sustainable practices in the operating theatre (OT) requires stakeholder engagement. We evaluate the knowledge, attitudes, and practices of OT users in our institution towards sustainable practices in the OT. METHODS A survey was conducted among OT users in August 2022. Respondents completed a 44-question anonymised online survey covering sustainability in (1) knowledge, (2) attitude, (3) practice, and (4) proposed changes to current practices. Points were assigned to knowledge (15 points) and attitude (40 points) sections. Practice was evaluated based on proportion of measures practiced. Appropriate statistical tests were used, with significance p < 0.05. Data are presented as mean ± standard deviation (SD) or proportion (%). RESULTS Among 149 respondents were doctors (n = 76), non-doctors (n = 45), and medical students (n = 28). Doctors scored highest in knowledge of sustainability (8.58 ± 1.83) compared to non-doctors and medical students (7.62 ± 1.75, 8.39 ± 1.87). Positive attitudes towards sustainability correlated with years of experience (p < 0.01). Non-doctors were more likely to practice sustainable measures, versus doctors (61 vs 52%, p < 0.01). Most (69%) respondents were unwilling to adopt any practice changes. The least popular measure was replacement of standard hand scrubbing with alcohol-based hand rub, considered unsafe by 74% of respondents. CONCLUSION Despite positive attitudes towards sustainable measures, there remains wariness of practice changes, which should be addressed by educational campaigns.
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Affiliation(s)
- Bonnie L S Lim
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Vairavan Narayanan
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
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Tan WS, Md Hasan Z, Sanmugam A, Singaravel S, Abdullah MY, Nah SA. Anal canal and sphincter function in children with Hirschsprung disease after definitive surgery. J Pediatr Surg 2023; 58:241-245. [PMID: 36384936 DOI: 10.1016/j.jpedsurg.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Anorectal manometry may be useful to objectively evaluate anorectal function following definitive pullthrough for Hirschsprung Disease (HD) but there is little published data. Our study aims to investigate anorectal manometry findings and their association with bowel function. METHODOLOGY This was a prospective observational study. Convenience sampling method was used to recruit all HD patients who had definitive pullthrough from January 2019 to December2020 in our institution. High-resolution anorectal manometry (HRAM) was used to record anal resting pressure (ARP), length of high-pressure zone (HPZ), and presence/absence of recto-anal inhibitory reflex (RAIR). The Paediatric Incontinence/Constipation Scoring System (PICSS) was scored for all participants. PICSS is a validated questionnaire with scores mapped to an age-specific normogram to denote constipation, incontinence, and their combinations. Non-parametric and chi-square tests at significance p<0.05 were conducted to examine the relationship between PICSS categories and manometry findings. Ethical approval was obtained. RESULTS There were 32 participants (30 boys). Median age at participation was 26.5 months (range: 13.8-156). Twenty-four (75%) had transanal pullthrough, 8(25%) underwent Duhamel procedure. PICSS scored 10(31.3%) as normal, 8(25%) as constipation, 10(31.3%) as incontinent, and 4(12.5%) as mixed. RAIR was present in 12 patients (37.5%). HPZ, maximum ARP, mean ARP were comparable across all PICSS groups without statistically significant differences. Presence of RAIR was not significantly associated with any PICSS groups (p = 0.13). CONCLUSION Bowel function does not appear to be significantly associated with HRAM findings after definitive pullthrough for HD, but our study is limited by small sample size. RAIR was present in 37.5% patients after pullthrough. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Wei Sheng Tan
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Zulfitri Md Hasan
- Department of Paediatric Surgery, Hospital Tunku Azizah, Kuala Lumpur, Malaysia
| | - Anand Sanmugam
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Mohd Yusof Abdullah
- Department of Paediatric Surgery, Hospital Tunku Azizah, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
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Nah SA, Sanmugam A, Singaravel S, Zahari Z, Aziz DA. Sociodemographic factors affecting paediatric surgical training in Malaysia: Gender matters. J Pediatr Surg 2023; 58:299-304. [PMID: 36404187 DOI: 10.1016/j.jpedsurg.2022.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND A shortage of specialist paediatric surgeons in Malaysia led to establishment of a national postgraduate training programme in 2004. We aimed to identify sociodemographic factors impacting training experience, and to define pressure points during training to inform targeted trainee support strategies. METHODS We conducted an anonymized online survey in June 2021 on all programme graduates. Participants were asked for sociodemographic data, both current and during training. Likert scale responses were required for questions regarding adequacy of support received for family, health and personal issues during training. A free text response question soliciting suggestions for programme improvement was included. Data are reported as median (range). Chi-square/Fisher's exact tests for categorical variables and Mann-Whitney U tests for continuous variables were used, with p<0.05 significance. RESULTS Of 53 eligible participants, 52 (98%) responded, 24 (46%) were female. Marital status was similar between genders at entry, but female trainees were more likely to be unmarried on exit (p = 0.001), and less likely to have children while training (p = 0.017). Of the 6 female and 18 male trainees who had children while training, women were more likely to take parental leave (p = 0.01). The majority felt advice given regarding parental leave and managing training while having children were poor. In thematic analysis of free text answers, lack of hands-on experience was the most common concern. CONCLUSION Factors related to marriage and parenthood significantly associate with gender amongst trainees in Malaysia despite both genders being well represented. Concerns regarding adequacy of hands-on training highlight the need for educational innovations such as simulation models. LEVEL OF STUDY Level III.
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Affiliation(s)
- Shireen Anne Nah
- Division of Pediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
| | - Anand Sanmugam
- Division of Pediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Srihari Singaravel
- Division of Pediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Zakaria Zahari
- Department of Paediatric Surgery, Hospital Tunku Azizah, Kuala Lumpur, Malaysia
| | - Dayang Anita Aziz
- Paediatric Surgery Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Tan CY, Theseira AM, Ahmad Zubaidi S, Atiya N, Sanmugam A, Singaravel S, Nah SA. Universal COVID-19 pre-procedural swabs in children in a developing
country: A comparison of findings over two transmission waves. Proceedings of Singapore Healthcare 2022; 31:20101058221131656. [PMCID: PMC9527211 DOI: 10.1177/20101058221131656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim The Coronavirus disease (COVID-19) pandemic has strained healthcare systems
worldwide. Some institutions have implemented additional precautionary
measures such as pre-procedural swabbing (PPS) to reduce transmission in
patients and healthcare workers. We evaluate our experience with universal
pre-procedural screening for COVID-19 in low-risk pediatric patients. Methods We performed a retrospective review of patients aged 18 years and below who
underwent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
real-time reverse transcription-polymerase chain reaction (rRT-PCR) assay
swabs in our center over two waves (1st May 2020 to
31st July 2020 and 1st April 2021 to
30th June 2021). We included patients who underwent rRT-PCR
for SARS-CoV-2 prior to any procedures requiring general anesthesia and were
deemed low risk for COVID-19 according to our institutional screening
criteria. All study patients were followed up for 14 days
post-procedure. Results Of 2065 swabs done for patients aged 18 years and below during the study
period, 645 (31.2%) were pre-procedural swabs. Patients were aged 4.2 years
(median, interquartile range: 1.6 years–9.8 years). Two patients (0.3%)
tested positive for COVID-19 by PPS, detected during Period 2 – both had
risk criteria which were overlooked by healthcare workers. Within 14 days
post-procedure, 10 patients had unscheduled readmissions and 15 required
repeat rRT-PCR, all of which were negative. Conclusions In patients deemed low risk for COVID-19 infection according to our screening
criteria, routine pre-procedural swabbing returns a low positive rate. Our
findings can guide screening protocols at institutions that provide surgical
services during the COVID-19 pandemic.
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Affiliation(s)
- Chee Yang Tan
- Faculty of Medicine, University of Malaya, Kuala Lumpur,
Malaysia
| | | | - Syukri Ahmad Zubaidi
- Pediatric Surgery Unit, Department
of Surgery, University of Malaya Medical
Center, Kuala Lumpur, Malaysia
| | - Nadia Atiya
- Department of Medical Microbiology,
Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Anand Sanmugam
- Pediatric Surgery Unit, Department
of Surgery, University of Malaya Medical
Center, Kuala Lumpur, Malaysia,Division of Pediatric and Neonatal
Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Pediatric Surgery Unit, Department
of Surgery, University of Malaya Medical
Center, Kuala Lumpur, Malaysia,Division of Pediatric and Neonatal
Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Pediatric Surgery Unit, Department
of Surgery, University of Malaya Medical
Center, Kuala Lumpur, Malaysia,Division of Pediatric and Neonatal
Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia,Shireen Anne Nah, Department of Surgery,
Faculty of Medicine, University of Malaya, 50603 Lembah Pantai, Kuala Lumpur,
Malaysia.
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Rajasegaran S, Tan WS, Ezrien DE, Sanmugam A, Singaravel S, Nah SA. Utility of postoperative anorectal manometry in children with anorectal malformation: a systematic review. Pediatr Surg Int 2022; 38:1089-1097. [PMID: 35727358 DOI: 10.1007/s00383-022-05152-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Abstract
Children with anorectal malformation (ARM) often continue to have disturbances in bowel function long after reconstructive surgery. Anorectal manometry may be utilized to evaluate bowel function in these children. We aimed to describe the reported protocols and manometric findings in children with ARM post-reconstructive surgery and to investigate the correlation between manometric evaluation and bowel functional outcome. PubMed, EMBASE, and Google Scholar databases were searched from 1980 to 2021. Data were reviewed and extracted independently by two authors, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Included studies were English articles reporting postoperative assessment of children (≤ 18 years) with ARM using anorectal manometry. From 128 articles obtained in the initial search, five retrospective cohort studies and one prospective study fulfilled inclusion criteria. The rectoanal inhibitory reflex and mean anal resting pressure were parameters most often reported to correlate with postoperative bowel function. The least reported parameters among the studies were high-pressure zone, rectal volume, and rectal sensation. Anorectal manometry could be an objective method providing important information for personalized management of postoperative ARM patients with bowel function issues, but lack of standardized protocols limits a comprehensive analysis of their utility.
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Affiliation(s)
- Suganthi Rajasegaran
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Wei Sheng Tan
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Don Evana Ezrien
- Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Anand Sanmugam
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. .,Paediatric Surgery Unit, Department of Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.
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14
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Wong ZY, Low ZR, Chen Y, Danaee M, Nah SA. Meta-analysis of donor-recipient gender profile in paediatric living donor liver transplantation. Arch Dis Child 2022; 107:archdischild-2022-323892. [PMID: 35676083 DOI: 10.1136/archdischild-2022-323892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/21/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Paediatric living donor liver transplantation (LDLT) has gained popularity due to limited deceased donor organ supply. Some studies report inequalities in donor and recipient gender profiles, but data are sparse. We evaluated LDLT donor-recipient gender profiles, comparing country income categories and gender disparity level. DESIGN We performed a systematic review, searching PubMed, Embase and Cochrane databases for publications dated January 2006-September 2021. We included full-text English articles reporting gender in ≥40 universally sampled donor-recipient pairs. Search terms were permutations of 'liver transplant', 'living donor' and 'paediatric'. Countries were grouped as high/middle/low-income economies based on World Bank criteria and into groups based on deviation from gender parity in Gender Development Index (GDI) values (group 1 indicating closest to gender parity, group 5 indicating furthest). Proportions analysis with corresponding 95% CI were used for analysis of dichotomous variables, with significance when 95% CI did not cross 0.5. Data are reported as female proportion (%) and 95% CI. RESULTS Of 12 525 studies identified, 14 retrospective studies (12 countries; 6152 recipients and 6138 donors) fulfilled study inclusion criteria. Male recipient preponderance was seen in lower middle-income countries (all were also GDI group 5) (39.3 (95% CI 34.7 to 44.0)) and female recipient preponderance in GDI groups 1 and 3. Female donor preponderance was seen overall (57.4% (95% CI 55.1 to 59.6)), in middle income countries and in three of four GDI groups represented. CONCLUSION There are significant imbalances in recipient-donor gender profiles in paediatric LDLT that are not well explained. The reasons for overall female donor preponderance across income tiers must be scrutinised.
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Affiliation(s)
- Zhen Yu Wong
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zhi Rong Low
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Mahmoud Danaee
- Department of Social & Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric & Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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15
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Kyaw L, Choo CS, Ong LY, Yap TL, Teo HJ, Nah SA. Management of acute testicular pain in children: changing trends with improvements in scrotal ultrasonography over 18 years. Singapore Med J 2022; 64:249-254. [PMID: 35196848 PMCID: PMC10144450 DOI: 10.11622/smedj.2022032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testicular torsion. We aimed to evaluate the performance of scrotal US in diagnosing testicular torsion over the past 18 years in our institution and determine the factors contributing to the length of wait times for it. METHODS A retrospective review was conducted of boys who presented with acute scrotal pain from 2014 to 2015. US reports, operative findings, final diagnosis and key time points of the patients' journey (time to emergency department consultation, time to admission, time to US and time to operating theatre [OT]) were collected. US performance results were compared with those observed in a historical cohort from 1998 to 2004. Wait times were compared between operated and non-operated patients. RESULTS Data from 519 boys with a mean age of 9.15 years was collected. Of these, 438 (84.4%) boys had undergone initial scrotal US; of these scrotal US cases, 28 were surgically explored, with 23 confirmed to have torsion. Another five cases were explored without prior US, and all were confirmed to have torsion. Performance analysis of US showed a sensitivity of 100% and a specificity of 98.8%. There was no significant difference between wait times of operated and non-operated patients. Time to US (p < 0.0001, r = 0.96) and time to OT (p < 0.0001, r = 0.64) correlated significantly with the total time from presentation to surgery. CONCLUSION There has been an improvement in the diagnostic performance of scrotal US for testicular torsion over the past 18 years. Quality improvement programmes targeted at reducing wait times for patients presenting with acute scrotum should target time to US and time to OT.
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Affiliation(s)
- Lin Kyaw
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Candy Sc Choo
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Lin Yin Ong
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore.,Division of Surgery, Duke-NUS Medical School, Singapore
| | - Te-Lu Yap
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore.,Division of Surgery, Duke-NUS Medical School, Singapore
| | - Harvey J Teo
- Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore
| | - Shireen Anne Nah
- Paediatric Surgery, KK Women's and Children's Hospital, Singapore.,Division of Surgery, Duke-NUS Medical School, Singapore.,Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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16
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Chung KJ, Chin YM, Wong MS, Sanmugam A, Singaravel S, Nah SA. Effectiveness of table salt versus copper sulphate in treating umbilical granuloma: A pilot randomized controlled trial. J Pediatr Surg 2022; 57:261-265. [PMID: 34838305 DOI: 10.1016/j.jpedsurg.2021.10.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Umbilical granuloma is a common infantile condition which usually responds to non operative management. Copper sulphate (CuSO4) is often used as chemical cauterization but can cause superficial skin burns. An alternative is table salt (NaCl), which osmotically dehydrates wet granulation tissue causing necrosis. We aimed to compare the effectiveness of NaCl versus CuSO4 in treating umbilical granuloma. METHOD We performed a multi centerrandomized controlled trial involving three regional pediatricsurgical units. We included children who presented with umbilical granuloma from December 2018 to May 2020. Children who received treatment prior to index visit were excluded. They were randomly allocated to receive NaCl (twice/day application for 5 days by caregiver) or CuSO4 (single application by clinician). Demographic data, compliance in the NaCl group by pill counting method, treatment outcomes, and complications were recorded. Treatment success was defined as complete lesion resolution. Partial or no response was considered treatment failure. Subsequent treatment then reverted to the respective center's routine management. RESULT We recruited 70 participants with 6 dropouts (2 defaulters, 1 vitellointestinal duct, 3 urachal remnants), leaving 64 subjects for final analysis: 31 NaCl, 33 CuSO4. Compliance rate of 77.4% was recorded for NaCl, with 6 (20%) 'poor compliance' participants stopping therapy before completion owing to complete resolution. NaCl group had a significantly higher complete resolution rate (90.4%) compared to CuSO4 (69.7%), p = 0.040. No NaCl participant developed complications versus 9% (n = 3) in CuSO4 (periumbilical superficial skin burn). CONCLUSION Table salt is an ideal treatment choice for umbilical granuloma as it is effective, safe, and readily available. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kuet Jun Chung
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Yen Ming Chin
- Department of Paediatric Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Mei Shinq Wong
- Department of Paediatric Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Anand Sanmugam
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Srihari Singaravel
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric and Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia.
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17
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Thambusamy E, Thambidorai CR, Nah SA, Gan CS, Wang J, Singaravel S, Sanmugam A. Intra-abdominal hypertension in neonates following congenital diaphragmatic hernia repair: Correlation with early postoperative respiratory and gastrointestinal outcomes. J Pediatr Surg 2022; 57:199-202. [PMID: 34857376 DOI: 10.1016/j.jpedsurg.2021.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 10/23/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Increased intra-abdominal pressure (IAP) is seen in patients after congenital diaphragmatic hernia (CDH) repair owing to reduction of thoracic contents into the relatively smaller abdominal cavity. In infants, IAP ≥11 mmHg is considered intra-abdominal hypertension (IAH). We aim to determine the incidence of IAH and its relationship with duration of ventilatory support, and gastrointestinal function post CDH repair. METHODS We prospectively recruited all neonates who had CDH repair in four hospitals in Malaysia from June 2018 to October 2020. Intra vesical pressure was used as a proxy for IAP and was measured for 5 consecutive days post surgery. The daily median value was used for analysis. We categorized IAP as <11 mmHg (no IAH), 11-15 mmHg (IAH), and >15 mmHg (severe IAH). Incidence of IAH, its effects on the duration of ventilatory support, and gastrointestinal function were studied. RESULTS There were 24 neonates included in this study. They were operated between day 1 and 6 of life (median: 4 days old). IAH was detected within the first 3 days post surgery, with 83% occurring on day one. Those requiring ventilatory support for more than 3 days contributed the largest proportion of IAH (n = 17, 71%). There was strong correlation between days of IAH and duration of ventilation (p < 0.001, r = 0.70). There was moderate correlation between days of IAH and duration taken to achieve full enteral feeding (p < 0.005, r = 0.70). CONCLUSION IAP measurement is a safe and useful adjunct in post CDH monitoring and in predicting ventilatory support requirements and the time needed to establish feeding.
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Affiliation(s)
- Elango Thambusamy
- Division of Paediatric And Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Shireen Anne Nah
- Division of Paediatric And Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chin Seng Gan
- Paediatric Intensive Care Unit, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Justin Wang
- Paediatric Intensive Care Unit, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Division of Paediatric And Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Anand Sanmugam
- Division of Paediatric And Neonatal Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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Wright NJ, Leather AJ, Ade-Ajayi N, Sevdalis N, Davies J, Poenaru D, Ameh E, Ademuyiwa A, Lakhoo K, Smith ER, Douiri A, Elstad M, Sim M, Riboni C, Martinez-Leo B, Akhbari M, Tabiri S, Mitul A, Aziz DAA, Fachin C, Niyukuri A, Arshad M, Ibrahim F, Moitt N, Doheim MF, Thompson H, Ubhi H, Williams I, Hashim S, Philipo GS, Herrera L, Yunus A, Vervoort D, Parker S, Benaskeur YI, Alser OH, Adofo-Ansong N, Alhamid A, Salem HK, Saleh M, Elrais SA, Abukhalaf S, Shinondo P, Nour I, Aydin E, Vaitkiene A, Naranjo K, Dube AM, Ngwenya S, Yacoub MA, Kwasau H, Hyman G, Elghazaly SM, Al-Slaibi I, Hisham I, Franco H, Arbab H, Samad L, Soomro A, Chaudhry MA, Karim S, Khattak MAK, Nah SA, Dimatatac DM, Choo CSC, Maistry N, Mitul AR, Hasan S, Karim S, Yousuf H, Qureshi T, Nour IR, Al-Taher RN, Sarhan OAK, Garcia-Aparicio L, Prat J, Blazquez-Gomez E, Tarrado X, Iriondo M, Bragagnini P, Rite S, Hagander L, Svensson E, Owusu S, Abdul-Mumin A, Bagbio D, Ismavel VA, Miriam A, T S, Anaya Dominguez M, Ivanov M, Serban AM, Derbew M, Elfiky M, Olivos Perez M, Abrunhosa Matias M, Arnaud AP, Negida A, King S, Fazli MR, Hamidi N, Touabti S, Chipalavela RF, Lobos P, Jones B, Ljuhar D, Singer G, Hasan S, Cordonnier A, Jáuregui L, Zvizdic Z, Wong J, St-Louis E, Shu Q, Lui Y, Correa C, Pos L, Alcántara E, Féliz E, Zea-Salazar LE, Ali L, Peycelon M, Anatole NK, Jallow CS, Lindert J, Ghosh D, Adhiwidjaja CF, Tabari AK, Lotfollahzadeh S, Mussein HM, Vatta F, Pasqua N, Kihiko D, Gohil H, Nour IR, Elhadi M, Almada SA, Verkauskas G, Risteski T, Peñarrieta Daher A, Outani O, Hamill J, Lawal T, Mulu J, Yapo B, Saldaña L, Espineda B, Toczewski K, Tuyishime E, Ndayishimiye I, Raboe E, Hammond P, Walker G, Djordjevic I, Chitnis M, Son J, Lee S, Hussien M, Malik S, Ismail EM, Boonthai A, Dahman NBH, Hall N, Castedo Camacho FR, Sobrero H, Butler M, Makhmud A, Novotny N, Hammouri AG, Al-Rayyes M, Bvulani B, Muraveji Q, Murzaie MY, Sherzad A, Haidari SA, Monawar AB, Samadi DAZ, Thiessen J, Venant N, Hospital SI, Jérémie N, Mbonicura JC, Vianney BJM, Tadesse A, Negash S, Roberts CA, Jabang JN, Bah A, Camamra K, Correa A, Sowe B, Gai A, Jaiteh M, Raymond KJ, Mvukiyehe JP, Itangishaka I, Kayibanda E, Manirambona E, Lule J, Costas-Chavarri A, Shyaka Gashugi I, Ndata A, Gasana G, Nezerwa YC, Simeon T, Muragijimana JDD, Rashid S, Msuya D, Elisante J, Solanki M, Manjira E, Lodhia J, Jusabani M, Tarmohamed M, Koipapi S, Souhem T, Sara N, Sihem B, Dania B, Toufik IA, Mounira BNEI, Habiba A, Aragão L, Gonçalves V, Lino Urquizo MM, Varela MF, Mercado P, Horacio B, Damiani A, Mac C, Putruele D, Liljesthrom K, Bernaus M, Jauri C, Cripovich A, Bianchin E, Puig MG, Andreussi L, Iracelay S, Marcos D, Herrera C, Palacios N, Avile R, Serezo B, Montoya D, Cepeda R, Vaquila J, Veronica S, Pardo L, Valeria P, Julio L, Martin AD, Lucio P, Gabriel C, Marianella D, Calderón Arancibia JA, Huespe E, Losa GN, Arancibia Gutiérrez E, Scherl H, Gonzalez DE, Baistrocchi V, Silva Y, Galdeano M, Medard P, Sueiras I, Romero Manteola E, Defago VH, Mieres C, Alberto C, Cornelli F, Molina M, Ravetta P, Patiño Gonzalez CC, Dallegre MB, Szklarz MT, Leyba MF, Rivarola NI, Charras MD, Morales A, Caseb P, Toselli L, Millán C, Junes MDC, Di Siervi O, Gilardi J, Simon S, Contreras CS, Rojas N, Arnoletto LB, Blain OE, Bravo MN, Sanchez N, Herrera Pesara LM, Moreno ME, Sferco CA, Huq U, Ferdousi T, Al-Mamun A, Sultana S, Mahmud R, Mahmud K, Sayeed F, Svirsky A, Sempertegui D, Negrete A, Teran A, Sadagurschi M, Popovic N, Karavdic K, Milisic E, Jonuzi A, Mesic A, Terzic S, Dendusic N, Biber E, Sehic A, Zvizdic N, Letic E, Saracevic A, Hamidovic A, Selak N, Horozic D, Hukic L, Muhic A, Vanis N, Sokolovic E, Sabic A, Becker K, Novochadlo Klüppel E, dos Santos Dias AIB, Agulham MA, Bischoff C, Sabbatini S, Fernandes de Souza R, Souza Machado AB, Werneck Raposo J, da Silva Augusto ML, Martins BM, de Souza Santos Ferreira M, Fernandes de Oliveira D, Silva dos Santos C, Ribeiro de Fernández y Alcázar F, Alves Dutra da Silva É, Furtado M, Tamada H, Silva Ferreira dos Santos M, Lopes de Almeida T, Oliveira de Andrade S, Gurgel do Amaral AC, Sartori Giovanoni L, de Deus Passos Leles K, Corrêa Costa E, Feldens L, Ferraz Schopf L, Soares de Fraga JC, Colombo de Holanda F, Brolin Santis Isolan PM, Loyola Ferreira J, Bruxel CL, Lopes Teixeira Ferdinando D, Zottis Barcelos F, Baseggio N, Knorr Brenner N, Trindade Deyl R, Dure C, Nunes Kist I, Bueno Mazzuca R, Bueno Motter S, Ramos Y, Suzana Trein C, Rezende Rosa B, de Assis Silva M, Menin FA, Semensato Carloni IC, Norberto da Silva JA, Gomes AL, Girão Tauffer M, Bassan Gonçalves PC, Nogueira Marques GM, Moriya E, Labonia C, Carrasco AL, Furtado Meyer K, Farion-Aguiar L, Amado F, Antunes A, Silva E, Telles L, Almeida G, Belmino Gadelha AA, de Azevedo Belesa F, Gonçalves da Cunha, Jr A, Souza Barros B, Zanellato JB, Guimarães P, Silva KID, Ribas B, Reuter C, Casado FT, Correa Leite MT, Testoni D, Guinsburg R, de Campos Vieira Abib S, Khodor Cury E, Dornellas do Nascimento S, Almeida Aguiar A, Melo Gallindo R, Gonçalves Borges C, Liu Y, Duote C, Wang J, Gao Z, Liang L, Luo W, Zhao X, Chen R, Wang P, Han Y, Huang T, Donglai H, Xiaodong G, Junjie C, Zhu L, Wu G, Bao X, Li H, Lv J, Li Z, Yong F, Gao ZC, Bai Q, Tang W, Xie H, Motee J, Zhu J, Wen G, Ruan W, Li S, Chen L, Huang S, Lv Z, Lu J, Huang L, Yu M, Dajia W, Bai YZ, Rincon LC, Mancera J, Alzate Gallego E, Torres-Canchala L, Silva Beltrán N, Osorio Fory G, Castaño Avila D, Forero Ladino AM, Gomez J, Jaramillo M, Morales O, Sanchez B, Tinoco Guzmán NJ, Castañeda Espinosa S, Prieto Vargas O, Pardo LM, Toral E, Cáceres Aucatoma F, Hinostroza D, Valencia S, Salinas V, Landivar Cino E, Ponce Fajardo GY, Astudillo M, Garcia V, Muñoz G, Verduga L, Verduga I, Murillo E, Bucaram E, Guayelema M, Marmol M, Sanchez J, Vergara C, Mena A, Velaña J, Salazar K, Lara S, Chiriboga E, Silva J, Gad D, Samy D, Elsadek MA, Mohammed HM, Abouheba M, Ali KO, Rashwan H, Fawzy OM, Kamel TM, Nemer R, Hassan MA, Falah EH, Abdelhady DS, Zain M, Ibrahim EAA, Elsiraffy OO, Aboelela A, Farag EM, Oshiba AM, Emam OS, Attia AM, Laymouna MA, Ghorab IA, Mohammed MM, Soliman NA, Ghaly KAE, Sadek K, Elsherbiny M, Saleh A, Sheir H, Wafa T, Elmenam MA, Abdelmaksoud S, Reda A, Mansour I, Elzohiri M, Waseem B, Elewaily M, El-Ghazaly M, Elhattab A, Shalaby A, Elsaied A, Adawy A, Sadek M, Ahmed MA, Herdan MO, Elassall GMH, Mohammed AA, Takrouney MH, Essa TM, Mahmoud AM, Saad AM, Fouly MAN, Ibrahim MA, Nageh M, Saad MM, Badr H, Fouda MF, Nofal AH, Almohamady H, Arafa MA, Amad M, Mansour MA, O'Connor J, O'Connor Z, Anatole N, Nkunzimana E, Machemedze S, Dieudonné L, Appeadu-Mensah W, Anyomih TTK, Alhassan P, Abantanga FA, Michael V, Mary Koshy R, Raj A, Kumar V, PT S, Prabhu PS, Vosoughi A, Al-Mayoof AF, Fadhle MJ, Joda AE, Algabri HNO, Al-Taher RN, Abdelhamid SS, Al-Momani HM, Amarin M, Zaghlol LY, Alsaadi NN, Qwaider YZ, Qutishat H, Aliwisat AH, Arabiat E, Bsisu I, Murshidi RM, Jabaiti MS, Bataineh ZA, Abuhayyeh HA, Quran TMA, Za'nouneh FJA, Alebbini MM, Qudah HA, Hussein OG, Murad AM, Amarin JZ, Suradi HH, Alzraikat SH, Omari RY, Matour BM, Al-Halbouni L, Zurikat RO, Yanis AH, Hussein SA, Shoubaki A, Ghanem WH, David K, Chitiavi SW, Mose M, Mugo R, Ndungu J, Mwai T, Shahbal S, Malik J, Chauhan N, Syovata F, Ochieng K, Omendo Liyenzero P, Hussain SR, Mugambi S, Ochieng R, Elkhazmi EOA, Khaled A, Albozidi A, Enbaya MB, Elgammudi M, Soula E, Khalel WIA, Elhajjaji YA, Alwaggaa NA, Ghayth S, Zreeg DA.S, Tantush SA, Bibas F, Layas T, Sharif RAM, Aljadidi WOFS, Tarek A, Ahmed H, Essamilghi KAM, Alfoghi M, Abuhlega MA, Arrmali S, Abduljawad FM, Alosta HM, Abuajaila A, Abdelmutalib F, Bashir F, Almengar I, Annajjar MH, Deyab A, Elzowawi F, Krayem Y, Drah W, Meftah A, Mohammed A, Arrmalli LA, Aljaboo H, Elayeb A, Altomi M, Altaweel A, Tumi M, Bazozi HM, Shaklawoon A, Alglaib MM, Elkaloush AA, Trainba S, Swessi H, Alnaeri A, Shnishah AE, Mustufa H, Gargum SA, Tarniba SA, Shalluf HA, Shokri HA, Sarkaz TL, Tababa O, Elhadi A, Naunova VC, Jovcheski L, Kamilovski M, Gavrilovska-Brzanov A, Latiff ZA, Pauzi SFM, Osman M, Lim F, Bakar AHA, Zaman ASK, Ishak S, Teo R, Qi DTTH, Othman MYB, Zahari DDZB, Hassan ZBM, Shan CH, Lechmiannandan A, Tamaddun HFB, Adanan MFSBM, Abdullah MYB, Junyi W, Nor MTM, Noor WR, Hassan MRB, Dalek NFRA, Hashim HHB, Zarwawi AZB, Vellusamy VMM, Yuen QS, Kannessan HA, Ramli NB, Bujarimin ASB, Anntinea J, Dass A, Khalid HM, Hanifah NABM, Jyun KWY, Razak RBA, Naim NABM, Hamzah SNABH, Vidal CRZ, Bracho Blanchet E, Dávila Perez R, Fernandez Portilla E, Villegas Silva R, Ibarra D, Calderon Moore A, Carrasco-Ortega C, Noguez Castillo M, Herappe Mellado D, Yanowsky Reyes G, Gonzalez Cortez LF, Santana Ortiz R, Orozco Perez J, Corona C.Rivera JR, Cardenas Ruiz Velasco JJ, Quiles Corona M, Peña Padilla C, Bobadilla Morales L, Corona Rivera A, Rios Flores IM, Aranda Sánchez CI, Ambriz-González G, Martínez Hernández Magro N, León Frutos FJ, Cárdenas Barón JDJ, González Ojeda A, Yarza Fernández J, Porras JD, Aguirre-Lopez P, Sánchez Paredes V, Montalvo Marin A, Diaz Gomez JM, Caamal LJ, Bulnes Mendizabal D, Sanchez Valladares P, Garcia Martinez H, Adesanya O, Olanrewaju M, Adegboyega R, Abdulraheem N, Aremo A, Dedeke F, Chukwuemeka ALJ, Mohammad MA, Lawalbarau A, Collins N, Ibukunolu O, Shonubi A, Ladipo-Ajayi O, Elebute OA, Seyi-Olajide J, Alakaloko F, Ihediwa G, Olayade K, Bode C, Ogundoyin O, Olulana DI, Egbuchulem IK, Kumolalo FO, Ulasi I, Ezomike UO, Ekenze SO, Nwankwo EP, Nwangwu EI, Chukwu I, Amah CC, Obianyo NE, Williams O, Osuoji RI, Faboya OM, Ajai OT, Abdulsalam MA, Agboola TH, Temilade BB, Osazuwa M, Salawu MM, Ejinkeonye EC, Yola MM, Mairami AB, Otuneye AT, Igoche M, Tanimola AG, Ajao EA, Agelebe E, Olori S, Mshelbwala PM, Osagie O, Oyinloye A, Abubakar AM, Oyebanji L, Shehu I, Cletus C, Bamanga A, Suleiman F, Adamu S, C.Nwosu D, S.Alkali Y, Jalo I, Rasaki A, T.Sambo Y, A.Mohammed K, M.Ballah A, Modekwe V, Ekwunife OH, Ezidiegwu US, Osuigwe AN, Ugwu JO, Ugwunne CA, Akhter N, Gondal MF, Raza R, Chaudary AR, Ali H, Nisar MU, Jamal MU, Pandit GS, Mumtaz U, Amjad MB, Talat N, Rehman WU, Saleem M, Mirza MB, Hashim I, Haider N, Hameed S, Saleem A, Dogar S, Sharif M, Bashir MK, Naumeri F, Rani Z, Baniowda MA, Ba'baa' B, Hassan MYM, Darwish A, Sehwiel AS, Shehada M, Balousha AG, Ajrami Y, Alzamari AAM, Yaghi B, Al-saleem HSHA, Farha MSA, Abdelhafez MOM, Anaya F, Qadomi AB, Odi AANB, Assi MAF, Sharabati F, Abueideh A, Beshtawi DMS, Arafat H, Khatatba LZA, Abatli SJ, Al-Tammam H, Jaber D, Kayed YIO, Abumunshar AA, Misk RA, Alzeer AMS, Sharabati M, Ghazzawi I, Darras OM, M.Qabaja M, Hajajreh MS, Samarah YA, Yaghi DH, Qunaibi MAF, Mayaleh AA, Joubeh S, Ebeido A, Adawi S, Adawi I, Alqor MOI, Arar AS, Awad H, Abu-Nejmah F, Shabana OS, Alqarajeh F, Alzughayyar TZ, Madieh J, Sbaih MF, Alkareem RMA, Lahlooh RA, Halabi YA, Baker W, Almusleh TFH, Tahyneh AAA, Atatri YYM, Jamie NA, Massry NAA, Lubbad W, A.Nemer A, Alser M, Salha AAS, Alnahhal K, Elmzyyen AM, Ghabayen ATS, Alamrain AAA, Al-Shwaikh SH, Elshaer OA, Shaheen N, Fares J, Dalloul H, Qawwash A, Jayyab MA, Ashour DA, Shaheen AA, Naim SRR, Shiha EA, Dammagh NMA, Almadhoun W, Al-Salhi AA, Hammato AY, Salim JM, Hasanain DK, Alwadia SMS, Nassar I, Al-Attar HM, Alshaikhkhalil HAA, Jamie YMKA, Ashour YS, Alijla SS, Tallaa MAE, Abuattaya AA, Wishah BD, ALDIRAWI MOHAMMEDA, Darwish AS, Alzerei ST, Wishah N, Alijla S, Garcia I, Diaz Echegaray M, Cañapataña Sahuanay VR, Trigoso Mori F, Alvarado Zelada J, Salinas Barreto JJ, Rivera Altamirano P, Torres Miranda C, Anicama Elias R, Rivera Alvarez J, Vasquez Matos JP, Ayque Rosas F, Ledesma Peraza J, Gutarra Palomino A, Vega Centen S, Casquero V, Ortiz Argomedo MR, Lapouble F, Llap Unchón G, Delgado Malaga FP, Ortega Sotelo L, Gamboa Kcomt S, Villalba Villalba A, Mendoza Leon NR, Cardenas Alva LR, Loo Neyra MS, Alanguia Chipana CL, Torres Picón CMDJ, Huaytalla Quiroz N, Dominguez D, Segura Calle C, Arauco J, Ormeño Calderón L, Ghilardi Silva X, Fernandez Wilson MD, Gutierrez Maldonado JE, Diaz Leon C, Berrocal Anaya W, Chavez Galvez P, Aguilar Gargurevich PP, Diaz Castañeda FDM, Guisse C, Ramos Paredes E, Apaza Leon JL, Aguilar Aguilar F, Ramirez De La Cruz R, Flores Carbajal L, Mendoza Chiroque C, Sulca Cruzado GJ, Tovar Gutierrez N, Sotelo Sanchez J, Paz Soldan C, Hernández Córdova K, Delgado Quinteros EF, Brito Quevedo LM, Mendoza Oviedo JJ, Samanez Obeso A, Paredes Espinoza P, de Guzman J, Yu R, Cosoreanu V, Ionescu S, Mironescu A, Vida L, Papa A, Verdeata R, Gavrila B, Muntean L, Lukac M, Stojanovic M, Toplicic D, Slavkovic M, Slavkovi A, Zivanovic D, Kostic A, Raicevic M, Nkuliza D, Sidler D, Vos CD, Merwe EV, Tasker D, Khamag O, Rengura C, Siyotula T, Jooma U, Delft DV, Arnold M, Mangray H, Harilal S, Madziba S, Wijekoon N, Gamage T, Bright BP, Abdulrahman A, Mohammed OAA, Salah M, Ajwa AEA, Morjan M, Batal MM, Faks V, Mouti MB, Assi A, Al-Mouakeh A, Tarabishi AS, Aljarad Z, Alhamid A, Khorana J, Poocharoen W, Liukitithara S, Sriniworn A, Nuntasunti W, Ngerncham M, Phannua R, Thaiwatcharamas K, Tanming P, Sahnoun L, Kchiche N, Abdelmoumen R, Eroğlu E, Ozen MA, Cömert HSY, İmamoğlu M, Sarıhan H, Kader Ş, Mutlu M, Aslan Y, Beşir A, Geze Ş, Çekiç B, Yalcinkaya A, Sönmez K, Karabulut R, Türkyılmaz Z, Şeref K, Altın M, Aykut M, Akan M, Erdem M, Ergenekon E, Türkyılmaz C, Keleş E, Canözer A, Yeniay AÖ, Eren E, Cesur İB, Özçelik Z, Kurt G, Mert MK, Kaya H, Çelik M, Karakus SC, Erturk N, Suzen A, Hakan N, Akova F, Pasaoglu M, Eshkabilov S, Yuldashev RZ, Abdunomonovich DA, Muslimovich AM, Patel A, Kapihya C, Ensar N, Nataraja RM, Sivasubramaniam M, Jones M, Teague W, Tanny ST, Thomas G, Roberts K, Venkatraman SS, Till H, Pigeolet M, Dassonville M, Shikha A, Win WSP, Ahmad ZAH, Meloche-Dumas L, Caouette-Laberge L, St-Vil D, Aspirot A, Piché N, Joharifard S, Safa N, Laberge JM, Emil S, Puligandla P, Shaw K, Wissanji H, Duggan E, Guadagno E, Puentes MC, Leal PO, Mendez Benavente C, Rygl M, Trojanová B, Berková K, Racková T, Planka L, Škvařil J, Štichhauer R, Sabti S, Macdonald A, Bouhadiba N, Kufeji D, Pardy C, Mccluney S, Keshtgar A, Roberts R, Rhodes H, Burns K, Garrett-Cox R, Ford K, Cornwall H, Ravi K, Arthur F, Losty P, Lander T, Jester I, Arul S, Gee O, Soccorso G, Singh M, Pachl M, Martin B, Alzubair A, Kelay A, Sutcliffe J, Middleton T, Thomas AH, Kurian M, Cameron F, Sivaraj J, Thomas MC, Rex D, Jones C, Bradshaw K, Bonnard A, Delforge X, Duchesne C, Gall CL, Defert C, Laraqui Hossini S, Guerin F, Hery G, Fouquet-Languillat V, Kohaut J, Broch A, Blanc T, Harper L, Delefortrie T, Ballouhey Q, Fourcade L, Grosos C, Parmentier B, Levard G, Grella MG, Renaux Petel M, Grynberg L, Abbo O, Mouttalib S, Juricic M, Scalabre A, Haraux E, Rissmann A, Krause H, Goebel P, Patzer L, Rolle U, Schmedding A, Antunez-Mora A, Tillig B, Bismarck SV, Barbosa PR, Knorr C, Stark D, Brunero M, Avolio L, Manni F, Molinelli M, Guazzotti M, Raffaele A, Romano PG, Cavaiuolo S, Parigi GB, Juhasz L, Rieth A, Strumila A, Dagilytė R, Liubsys A, Gurskas P, Malcius D, Mikneviciute A, Vinskaite A, Barauskas V, Vierboom L, Hall T, Beasley S, Goddard L, Stringer M, Weeratunga N, Adams S, Cama J, Wong M, Jayaratnam S, Kukkady A, Samarakkody U, Gerus S, Patkowski D, Wolny A, Koszutski T, Tobor S, Osowicka M, Czauderna P, Wyrzykowski D, Garnier H, Anzelewicz S, Marta O, Knurowska A, Weiszewsk A, Grabowski A, Korlacki W, Pasierbek M, Wolak P, Piotrowska A, Roszkiewicz A, Kalicińsk P, Trypens A, Kowalewsk G, Sigalet D, Alsaied A, Ali M, Alsaggaf A, Ghallab A, Owiwi Y, Zeinelabdeen A, Fayez M, Atta A, Zidan M, Radwan AS, Shalaby H, Abdelbaqi R, Alattas K, Kano Y, Sindi O, Alshehri A, Altokhais T, Alturki F, Almosaibli M, Krisanova D, Abbas W, Yang HB, Kim HY, Youn JK, Chung JH, Cho SH, Hwang IJ, Lee JY, Song ES, Arboleda J, Ruiz de Temiño Bravo M, Siles Hinojosa A, García M, Casal Beloy I, Oliu San Miguel D, Molina Vazquez ME, Alonso V, Sanchez A, Gomez O, Carrillo I, Wester T, Mesas Burgos C, Hagander L, Salö M, Omling E, Rudolfson N, Granéli C, Arnadóttir H, Grottling E, Abrahamsson K, Gatzinsky V, Dellenmark Blom M, Borbonet D, Puglia P, Jimenez Morejon V, Acuna G, Moraes M, Chan J, Brahmamdam P, Tom A, Sherer K, Gonzales B, Cunningham A, Krishnaswami S, Baertschiger R, Leech M, Williams R, Camp L, Gosain A, Mora M, Lyttle BD, Chang J, McColl Makepeace L, Fowler KL, Mansfield S, Hodgman E, Amaechi C, Beres A, Pernik MN, Dosselman LJ, Almasri M, Jain S, Modi V, Fernandez Ferrer M, Coon J, Gonzalez J, Honhar M, Ruzgar N, Coghill G, Ullrich S, Cheung M, Løfberg K, Greenberg J, Davenport K, Gadepalli S, Fox S, Johnson S, Pilkington M, Hamilton A, Lin N, Sola J, Yao Y, Davis JK, Langer M, Vacek J, Abdullah F, Khlevner J, Middlesworth W, Levitt M, Ahmad H, Siddiqui SM, Bowder A, Derks T, Amoabin AA, Pinar B, Owusu-Sekyere F, Saousen B, Naidoo R, Karamustafic A, Oliveira DPD, Motter SB, Andrade J, Šafus A, Langley J, Wilke A, Deya C, Murtadi HM, Berzanskis M, Calistus N, Ajiboye OS, Felix M, Olabisi OO, Erçin S, Muradi T, Burks SS, Lerma S, Jacobson J, Calancea C, Valerio-Vazquez R, Sikwete G, Sekyere O, Mbonisweni A, Syed S, Hyeon CS, Pajouhandeh F, Kunfah SMP. Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study. Lancet 2021; 398:325-339. [PMID: 34270932 PMCID: PMC8314066 DOI: 10.1016/s0140-6736(21)00767-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/10/2021] [Accepted: 03/25/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. METHODS We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. FINDINGS We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality. INTERPRETATION Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030. FUNDING Wellcome Trust.
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Mahat N, Zubaidi SA, Soe HHK, Nah SA. Paediatric surgical response to an 'adult' COVID-19 pandemic. Med J Malaysia 2021; 76:284-290. [PMID: 34031324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION The Coronavirus Disease 2019 (COVID-19) has dramatically affected global healthcare systems. We aimed to determine the response of our paediatric surgical fraternity to a disease that overwhelmingly affects adults. MATERIALS AND METHODS We conducted a cross-sectional questionnaire-based study over 6 weeks during a federally mandated lockdown. Using snowball sampling, we recruited paediatric surgeons, trainees and medical officers from paediatric surgical units in Malaysia. The anonymous online questionnaire covered sociodemographic information, changes in patient care, redeployment, concerns regarding family members, and impact on training. Mental well-being was assessed using the Depression, Anxiety and Stress Scale (DASS-21). Kruskal-Wallis, ANOVA and multiple regression analysis was used, with significance level 0.05. RESULTS Of the 129 eligible participants, 100(77%) responded. Junior doctors had clinically higher levels of depression, anxiety, and stress. Age <30 years was significantly associated with anxiety. Junior doctors believed that redeployment led to loss of surgical skills (p<0.001) and trainees felt that clinical application of knowledge had reduced (p<0.020). CONCLUSION Specific to our paediatric surgical community, this study highlights areas of concern, particularly among junior doctors. It is likely that recurrent cycles of the pandemic will occur soon. These issues must be addressed to preserve the mental and emotional well-being of all health care workers.
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Affiliation(s)
- N Mahat
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric Surgery, Kuala Lumpur, Malaysia
| | - S A Zubaidi
- University of Malaya Medical Centre, Faculty of Medicine, Department of Surgery, Division of Paediatric Surgery, Kuala Lumpur, Malaysia
| | - H H K Soe
- Melaka Manipal Medical College, Department of Community Medicine, Melaka, Malaysia
| | - S A Nah
- University of Malaya, Faculty of Medicine, Department of Surgery, Division of Paediatric Surgery, Kuala Lumpur, Malaysia.
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Sii CKS, Lee JA, Nah SA. Early experience with universal preoperative and pre-procedural screening for COVID-19 in low-risk pediatric surgical patients requiring general anesthesia. Pediatr Surg Int 2020; 36:1407-1411. [PMID: 33068142 PMCID: PMC7568455 DOI: 10.1007/s00383-020-04760-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The COVID-19 pandemic has placed extraordinary demands on healthcare services worldwide. Some have reported increased viral transmission to healthcare workers during aerosol-generating procedures such as intubation. We report our experience with universal preoperative and preprocedural screening for COVID-19 in children requiring general anaesthesia with low risk of having the infection. METHODS This was a data review involving children aged < 18 years undergoing procedures under general anaesthesia in our institution from 18th March to 31st May 2020 and deemed low risk for COVID 19 infection, as defined by our institutional protocol. Confirmation of COVID-19 was by real time reverse-transcription polymerase chain reaction with confirmation by nucleic acid sequencing. All patients were followed up 14 days post-swab. RESULTS Of the 66 children (median age 4.5 years, range 0-16.8) eligible for the study, 39 (60%) were male and infants (1-12 months) formed the largest group (n = 24, 36%). None were positive for COVID-19. On 14 day follow-up, none had symptoms related to COVID-19. CONCLUSION Our study shows that low risk asymptomatic children with no history of contact with COVID-19 patients test negative on universal screening. Larger studies are required to ascertain the role of screening prior to procedures done under general anaesthesia.
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Affiliation(s)
- Cornilia K. S. Sii
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Joo Ann Lee
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Sim SKR, Nah SA, Loh AHP, Ong LY, Chen Y. Mechanical versus Chemical Pleurodesis after Bullectomy for Primary Spontaneous Pneumothorax: A Systemic Review and Meta-Analysis. Eur J Pediatr Surg 2020; 30:490-496. [PMID: 31600803 DOI: 10.1055/s-0039-1697959] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Primary spontaneous pneumothorax (PSP) and its high recurrence rate pose a therapeutic challenge to both patients and their managing surgeons. Mechanical or chemical pleurodesis can be used to prevent recurrence, but the optimal treatment often remains a matter of debate. This meta-analysis aims to compare the outcomes between mechanical and chemical pleurodesis following bullectomy for PSP. MATERIALS AND METHODS Studies published up to 2019 were searched from Medline, Embase, Google Scholar, and Cochrane databases. A meta-analysis of randomized controlled trials (RCTs) and observational cohort studies (OCSs) comparing outcomes between mechanical and chemical pleurodesis for PSP was performed. RESULTS Seven studies (one RCT and six OCSs) were included, comprising 1,032 cases of mechanical (799 abrasions, 202 pleurectomies, and 31 unspecified abrasions/pleurectomies/both), and 901 cases of chemical (643 talc, 69 minocycline, and 189 unspecified talc/kaolin) pleurodesis. The recurrence rate of pneumothorax after chemical pleurodesis (1.2%) was significantly lower than mechanical pleurodesis (4.0%) (pooled odds ratio [OR] = 3.00; 95% confidence interval [CI] = 1.59-5.67; p = 0.0007; I 2 = 19%). Hospital stay was also slightly shorter in the chemical pleurodesis group (pooled mean difference [MD] = 0.42 days; 95% CI = 0.12-0.72; p = 0.005; I 2 = 0%). There was no statistically significant difference in postoperative complications (pooled OR = 1.18; 95%CI = 0.40-3.48; p = 0.76; I 2 = 71%) and operative time (pooled MD = 3.50; 95%CI = -7.28 to 14.28; p = 0.52; I 2 = 99%) between these two groups. CONCLUSION Chemical pleurodesis is superior to mechanical pleurodesis following bullectomy for PSP in reducing hospital stay and recurrence rate. However, more RCTs with longer follow-up are necessary to demonstrate the benefit of chemical pleurodesis for PSP.
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Affiliation(s)
- Sarah Kher Ru Sim
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Amos Hong Pheng Loh
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Lin Yin Ong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Yong Chen
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
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Sanmugam A, Vythilingam G, Singaravel S, Nah SA. Assess, adapt and act: a paediatric surgery division’s initial approach in a rapidly evolving pandemic. Pediatr Surg Int 2020; 36:925-931. [PMID: 32594243 PMCID: PMC7320241 DOI: 10.1007/s00383-020-04704-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE The COVID-19 pandemic has placed an unprecedented test on the delivery and management of healthcare services globally. This study describes the adaptive measures taken and evolving roles of the members of the paediatric surgery division in a developing country during this period. METHODS We adopted multiple adaptive strategies including changes to stratification of surgeries, out-patient services by urgency and hospital alert status, policy writing involving multidisciplinary teams, and redeployment of manpower. Modifications were made to teaching activities and skills training to observe social distancing and mitigate reduced operative learning opportunities. Roles of academic staff were expanded to include non-surgical duties. RESULTS The planned strategies and changes to pre COVID-19 practices were successful in ensuring minimal disruption to the delivery of essential paediatric surgical services and training. Despite the lack of established guidelines and literature outlining strategies to address the impact of this pandemic on surgical services, most of the initial measures employed were consistent with that of other surgical centres. CONCLUSION Changes to delivery of surgical services and surgical training warrant a holistic approach and a constant re-evaluation of practices with emergence of new experiences and guidelines.
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Affiliation(s)
- Anand Sanmugam
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ganesh Vythilingam
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Srihari Singaravel
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shireen Anne Nah
- Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Hui WJ, Pikkarainen M, Nah SA, Nah SNJ, Pölkki T, Wang W, He HG. Parental Experiences While Waiting For Children Undergoing Surgery in Singapore. J Pediatr Nurs 2020; 52:e42-e50. [PMID: 31983480 DOI: 10.1016/j.pedn.2020.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/03/2020] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE To explore the experiences and needs of parents while waiting for their children undergoing surgery. DESIGNS AND METHODS A descriptive qualitative study was conducted. A purposive sample of 11 parents who went through their first waiting experiences during their children's surgeries in a Singapore public hospital was recruited. Children younger than or equal to 16 years of age were included. A semi-structured interview guide facilitated the individual face-to-face interviews. Thematic analysis was used. RESULTS Four themes were identified: "Care and care provision affecting waiting experiences", "Parental concerns and surgery affecting waiting experiences", "Coping strategies used during waiting periods" and "Recommendations to improve waiting experiences". Pre-operative instructions, the professionalism of medical teams, and a lack of timely updates affected parental experiences. Parents expressed their worries. The complexities and types of surgery influenced how they felt. Their concerns included potential complications, surgical outcomes, anesthesia-related side effects, and post-operative care including pain. They spent their waiting times eating, resting, using their smart devices, and coping with a support system. Environmental improvements, more updates, and mobile applications were recommended by the participants. CONCLUSION For a parent, the wait during his/her child's surgery can be unsettling. Our results give insights into parental waiting experiences and needs during their children's surgeries. PRACTICE IMPLICATIONS These findings can guide the improvement of the current practise based on our evidence or the implementation of newer technology to provide better waiting experiences for parents during their children's surgeries and to enhance the quality of clients' experiences in the hospital.
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Affiliation(s)
- Wen Jing Hui
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Nursing, KK Women's and Children's Hospital, Singapore
| | - Minna Pikkarainen
- Martti Ahtisaari Institute, Oulu Business School, University of Oulu, Finland; VTT Technical Research Centre of Finland, Finland; Faculty of Medicine, University of Oulu, Finland.
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore; Department of Surgery, Faculty of Medicine, University of Malaya, Malaysia.
| | | | - Tarja Pölkki
- University of Oulu, Finland; Department of Children and Women, Oulu University Hospital, Finland.
| | - Wenru Wang
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Health System, Singapore.
| | - Hong-Gu He
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; National University Health System, Singapore.
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Kyaw L, Pereira NK, Ang CX, Choo CSC, Nah SA. Parental preferences in treatment of acute uncomplicated appendicitis comparing surgery to conservative management with antibiotics and their views on research participation. Eur J Pediatr 2020; 179:735-742. [PMID: 31897841 DOI: 10.1007/s00431-019-03555-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/12/2019] [Accepted: 12/20/2019] [Indexed: 12/29/2022]
Abstract
Studies show that conservative management in acute uncomplicated appendicitis (AUA) is an alternative to surgery. This study aims to determine factors affecting parental preference in management of AUA and their decision for research participation. We conducted surveys on parents whose children were admitted with suspicion of appendicitis but later confirmed not to have appendicitis. Information on appendicectomy versus conservative treatment with antibiotics was provided using a fixed script and standard information leaflet. Questionnaires covered factors influencing decisions, opinions regarding research, treatment preference and demographic data. We excluded parents not fluent in English. Of 113 respondents, 71(62.8%) chose antibiotics, 39(34.5%) chose appendicectomy, and 3(2.7%) had no preference. Reasons given for choosing antibiotics were fear of surgical risks and preferring less invasive treatment. Those choosing appendicectomy expressed preference for definitive treatment and fear of recurrence. Majority were against randomisation (n = 89, 78.8%) and blinding (n = 90, 79.7%). Over half found difficulty involving their child in research (n = 65, 57.5%). Most thought that research is important (66.4%) and beneficial to others (59.3%). Parents who perceived their child as healthy found research riskier (p = 0.039). Educated parents were more likely to find research beneficial to others (p = 0.012) but less accepting of randomisation (p = 0.001).Conclusion: More parents appear to prefer conservative treatment for acute uncomplicated appendicitis. Researchers must consider parental concerns regarding randomisation and blinding.What is Known:• Conservative management of acute uncomplicated appendicitis in paediatric patients is safe and effective, sparing the child the need for an operation; however, neither conservative nor surgical management is proven to be superior.• Randomised controlled trials provide the highest level of evidence, but it is challenging to recruit paediatric patients as participants in such clinical trials.What is New:• More parents prefer conservative management of uncomplicated appendicitis over surgical management for their children due to fear of surgical risks and complications• Randomisation in trial design is significantly associated with a parent's decision to reject their child's participation in a clinical trial.
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Affiliation(s)
- Lin Kyaw
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Natalie Kate Pereira
- School of Applied Science, Temasek Polytechnic, 21 Tampines Ave 1, Singapore, 529757, Singapore
| | - Chen Xiang Ang
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Candy S C Choo
- Department of Paediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Division of Surgery, Duke-NUS Medical School, 8 College Rd, Singapore, 169857, Singapore. .,Paediatric Surgery, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia.
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25
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Ng GYH, Nah SA, Teoh OH, Ong LY. Primary spontaneous pneumothorax in children: factors predicting recurrence and contralateral occurrence. Pediatr Surg Int 2020; 36:383-389. [PMID: 31993738 DOI: 10.1007/s00383-020-04619-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The risk factors for recurrence in primary spontaneous pneumothorax (PSP) in children are not well known. We aimed to identify possible risk factors, and to evaluate the utility of computerised tomography (CT) scans in predicting future episodes. METHODS We reviewed children aged < 18 years admitted to our institution for PSP from 2008 to 2017, excluding those with malignancies. Basic demographic data were extracted. Clinical data collected include pneumothorax laterality, CT results, treatment protocols and recurrences. RESULTS 63 patients were included, 19 (30.2%) of whom had CT scans. A total of 41 surgeries were performed. The median (interquartile range) age was 15.4 years (14.9-15.9), and body-mass index was 17.9 kg/m2 (15.8-19.3). 56 (88.9%) patients were male. Median follow-up duration was 19.8 months (11.6-35.9). Multivariate logistic regression analyses identified surgery in the first episode as a predictor for a subsequent contralateral occurrence (odds ratio [95% confidence interval] 32.026 [1.685-608.518], p = 0.021). No predictors for ipsilateral recurrence were found. CT scans were 76.5% sensitive for bleb detection, and predicted poorly for occurrence (positive predictive value 14.3%, likelihood ratio 1.1). CONCLUSION This is the first study demonstrating that surgery at first presentation appears to predict for occurrence of PSP on the contralateral lung. CT appears to be ineffective in detecting blebs and predicting PSP occurrence.
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Affiliation(s)
- Glenn Yang Han Ng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,General Paediatrics Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore.,Paediatric Surgery Unit, Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Oon Hoe Teoh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Respiratory Medicine Service, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Lin Yin Ong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore. .,Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
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Amuddhu SK, Chen Y, Nah SA. Inpatient Admission versus Emergency Department Management of Intussusception in Children: A Systemic Review and Meta-Analysis of Outcomes. Eur J Pediatr Surg 2019; 29:7-13. [PMID: 30130824 DOI: 10.1055/s-0038-1668145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Recent literature advocates outpatient emergency department (ED) management of intussusception citing low recurrence rates and postreduction events after uncomplicated ileocolic reduction. However, few studies include both inpatient and outpatient cohorts. We performed a systematic review and meta-analysis to compare recurrence rates and length of hospital stay between the groups. MATERIALS AND METHODS Studies published in English up to January 2018 were searched from Medline, Embase, Google Scholar, and Cochrane databases, using a combination of the terms 'intussusception,' 'reduction,' and 'management'. A meta-analysis of studies comparing outcomes after successful intussusception reduction in children between inpatients and ED patients was performed. RESULTS No randomized controlled trials (RCT) were found. Nine observational studies (eight retrospective and one prospective) were included, comprising 546 inpatients and 776 ED cases. There was no statistical difference in overall recurrence rate between inpatients (8.8%) and ED (10.1%) (pooled odds ratio [OR] = 1.09; 95% confidence interval [CI] 0.74-1.62; P = 0.66; I 2 = 0). Five studies reported early recurrence (<48 hours) with no difference (pooled OR = 1.27; 95% CI 0.46-3.48; P = 0.65; I 2 = 0). Five studies reported postdischarge recurrence rate with no difference (pooled OR = 1.57; 95% CI 0.71-3.48; P = 0.27; I 2 = 34%). Five studies reported recurrence requiring surgery with no difference (pooled OR = 0.99; 95% CI 0.32-3.06; P = 0.99; I 2 = 0). Methods of reduction were air, barium, or other contrast enema. CONCLUSION Management of intussusception in the ED after uncomplicated reduction appears acceptable. However, evidence levels are low, and RCT should be performed to adequately evaluate the safety of outpatient management of pediatric intussusception.
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Affiliation(s)
- Sanjena Kumar Amuddhu
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | - Yong Chen
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Yap TL, Fan JD, Chen Y, Ho MF, Choo CS, Allen J, Low Y, Jacobsen AS, Nah SA. A novel noninvasive appendicitis score with a urine biomarker. J Pediatr Surg 2019; 54:91-96. [PMID: 30391151 DOI: 10.1016/j.jpedsurg.2018.10.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/01/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of our study was to develop an appendicitis score incorporating a urine biomarker, Leucine rich alpha-2-glycoprotein (LRG), for evaluation of children with abdominal pain. METHODS From January to August 2017 we prospectively enrolled children aged 4-16 years old admitted for suspected appendicitis. Urine samples for LRG analysis were obtained preoperatively and quantified by enzyme-linked immunosorbent assay (ELISA) after correction for patient hydration status. The diagnosis of appendicitis was based on operative findings and histology. Logistic regression was used to identify prospective predictors. RESULTS A total of 148 patients were recruited, of which 42(28.4%) were confirmed appendicitis. Our Appendicitis Urinary Biomarker (AuB) model incorporated urine LRG with 3 clinical predictors: 'constant pain', 'right iliac fossa tenderness', 'pain on percussion'. Area under the ROC curve for AuB was 0.82 versus 0.78 for the Pediatric Appendicitis Score (PAS) on the same cohort of patients. A model-calculated risk score of <0.15 is interpreted as low risk of appendicitis. Sensitivity for the AuB at this cutoff was 97.6%, specificity 37.7%, negative predictive value 97.6%, positive predictive value 38.3%, and negative likelihood ratio 0.06. CONCLUSION The noninvasive AuB score appears promising as a diagnostic tool for excluding appendicitis in children without the need for blood sampling. TYPE OF STUDY Study of diagnostic test. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Te-Lu Yap
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore.
| | | | - Yong Chen
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | | | - Candy Sc Choo
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - John Allen
- Duke-NUS Graduate Medical School, Singapore
| | - Yee Low
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | | | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
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Qadri SK, Logarajah V, Nah SA, Jamuar SS. Feeding difficulty in an infant: an unusual cause. BMJ Case Rep 2018; 2018:bcr-2018-225289. [PMID: 30139785 DOI: 10.1136/bcr-2018-225289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 10-month-old girl, with spondyloepiphyseal dysplasia congenita and posterior cleft palate had presented at 23 days of life with history of feeding difficulties. A diagnosis of oropharyngeal dysphagia and gastro-oesophageal reflux disease was made, for which she was started on nasogastric tube feeding and oral ranitidine. However, she continued to have poor development of oropharyngeal skills, persistent reflux as well as poor growth and was planned for gastrostomy at 10 months of age. She underwent soluble upper gastrointestinal contrast study prior to gastrostomy placement to rule out anatomical causes of vomiting, which showed the greater curvature of the stomach to be lying above the lesser curvature, suggesting a diagnosis of gastric volvulus, likely chronic, given that she did not have a history of abdominal distension, irritability or recurrent vomiting. On diagnosis of gastric volvulus, our patient underwent laparoscopic gastrostomy creation and is doing well postoperatively.
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Affiliation(s)
- Syeda Kashfi Qadri
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore.,Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Veena Logarajah
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore.,Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore.,Surgery Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Saumya Shekhar Jamuar
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore.,Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
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29
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Nah SA, Ong CCP, Saffari SE, Ong LY, Yap TL, Low Y, Jacobsen AS. Anorectal malformation & Hirschsprung's disease: A cross-sectional comparison of quality of life and bowel function to healthy controls. J Pediatr Surg 2018; 53:1550-1554. [PMID: 28916047 DOI: 10.1016/j.jpedsurg.2017.08.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/14/2017] [Accepted: 08/21/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with anorectal malformation (ARM) and Hirschsprung's disease (HD) face long-term disturbance in bowel function even after definitive surgery. This study evaluates the quality of life (QOL) of patients with ARM and HD, and compares them to healthy controls using self-report questionnaires. METHODOLOGY A prospective study was performed recruiting patients with ARM or HD from September 2013 to December 2014 who had primary surgery done in our institution at least 2 years prior to participation. Age-matched and gender-matched controls were enrolled from our patients with minor outpatient complaints. All participants completed the following PedsQL™ scales (maximum score 100): 4.0 Generic Core Scales, 3.0 General Well-Being (GWB) Scale and 2.0 Family Impact (FI) Module. All were also scored on bowel function (BFS), with a maximum score 20. Appropriate statistical analysis was performed, with significance level <0.05. RESULTS There were 193 participants: 87 controls, 62 ARM, 44 HD. When comparing Core, GWB and FI scores, there were no significant differences between groups although controls had best scores indicating best QOL and general wellbeing, with least impact of the child's health on the family. BFS was significantly different with controls having best and ARM worst scores. There were no significant differences in scores between parent and child indicating intradyad consistency. There was significant positive correlation between BFS and Core (p<0.0001), and between BFS and GWB scores (p<0.005); and significant negative correlation between BFS and FI scores (p<0.0001). CONCLUSIONS Bowel function impacts quality of life. Those with ARM and HD can achieve good quality of life comparable to controls, based on patient and caregiver self-reported outcomes. TYPE OF STUDY Prospective comparative study LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Caroline C P Ong
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | | | - Lin Yin Ong
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Te-Lu Yap
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Yee Low
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore
| | - Anette S Jacobsen
- Department of Paediatric Surgery, KK Women's & Children's Hospital, Singapore.
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30
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Wong MKY, Sivasegaran D, Choo CSC, Nah SA. Parental Internet Use and Health Information Seeking Behavior Comparing Elective and Emergency Pediatric Surgical Situations. Eur J Pediatr Surg 2018; 28:89-95. [PMID: 28662533 DOI: 10.1055/s-0037-1604021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION This study evaluates usage patterns of online health information in parents with children undergoing elective or emergency surgical procedures. MATERIALS AND METHODS We prospectively surveyed parents of children admitted to our institution for common emergency (appendicectomy, abscess drainage, gonadal torsion) or elective (herniotomy, orchidopexy) operations between March and September 2016. Each completed an anonymized modification of a previously published survey comprising 19 questions on demographic data, Internet usage, and review of Internet resources. Chi-square tests were used for categorical data with p < 0.05 considered significant. RESULTS Eighty-four parents were surveyed: 50(59.5%) elective and 34(40.5%) emergency procedures, with no refusals. Majority were mothers (n = 53; 63.1%). Despite high home Internet availability (n = 81; 96.4%) and high casual Internet usage rates (74 parents, 88.1%, reported daily use), just 38 (76%) parents from the elective group and 24 (70.6%) from the emergency group went online to access their child's admitting condition. Friends and family were more likely to be approached for information in elective (n = 27; 54%) and emergency groups (n = 24;70.6%) than general practitioners or other health care workers. When condition-specific online information was sought, more than 95% felt that the information concurred with the doctor's. Most common reasons were for more information on the condition (n = 56; 90.3%) and on medical treatment (n = 52; 83.9%). Eighteen (18/62; 29%) parents reported excessively technical information. No significant difference in behavior was found comparing elective and emergency groups. CONCLUSION Approximately one quarter of parents do not access condition-specific online medical information despite high Internet penetration rates. More than half depend on friends and family for additional information, reflecting societal and cultural norms in our population. Surgeons must incorporate awareness of these behaviors during counselling.
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Affiliation(s)
- Michael Kien Yee Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Daveraj Sivasegaran
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Candy Suet Cheng Choo
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Nah SA, Ong CCP, Lie D, Marimuttu VJ, Hong J, Te-Lu Y, Low Y, Jacobsen AS. Understanding Experiences of Youth Growing Up with Anorectal Malformation or Hirschsprung's Disease to Inform Transition Care: A Qualitative In-Depth Interview Study. Eur J Pediatr Surg 2018; 28:67-74. [PMID: 28837998 DOI: 10.1055/s-0037-1605351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The impact of anorectal malformation (ARM) or Hirschsprung's disease (HD) in children continues into adulthood despite early surgical correction. We aimed to explore the physical, social, and emotional impacts of these conditions on youth to inform best transition care strategies. MATERIALS AND METHODS Eligible participants were those aged between 14 and 21 years who had undergone surgery for ARM/HD in our institution. We conducted one-on-one in-depth interviews to saturation using a question guide developed from literature review and clinician expertise. Deidentified transcripts were coded by four coders (two pediatric surgeons, one psychiatrist, and one qualitative expert) for major themes using a constant comparison approach. A theoretical model for understanding the transition experience was developed using grounded theory. RESULTS Out of 120 patients identified as eligible, 11 youth (6 males) participated in the study. Interviews lasted from 50 to 60 minutes. Four major themes emerged: (1) social support (subthemes: family as core, friends as outer support), (2) cognitive and emotional change (subthemes: realization/recognition of illness, matching emotional response), (3) impact of physical symptoms (subthemes: adverse effects of abnormal bowel habits, gaining bowel continence control leading to overall feeling of control, need to keep disease private), and (4) healthcare providers (viewed as important information sources). Themes did not differ by gender. CONCLUSION Our model suggests that participants' understanding of bowel disease evolved over time with a "lightbulb" moment in preteens or early teens accompanied by increasing disease ownership and self-management. Clinicians should independently engage with patients in late childhood to address evolving emotional and information needs and encourage increasing autonomy. Future studies should explore communication approaches to meet transition needs of patients.
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Affiliation(s)
- Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Caroline C P Ong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Desiree Lie
- Clinical Health Services and Implementation Research Core, Duke-NUS Medical School, Singapore, Singapore
| | | | - Julian Hong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yap Te-Lu
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Low
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Singh RR, Nah SA, Roebuck DJ, Eaton S, Pierro A, Curry JI, Barnacle A, Chippington S, Stuart S, Gibson C, Cross KMK, Stanwell J, Yardley IE, Kiely EM, De Coppi P. Double-blind randomized clinical trial of percutaneous endoscopic gastrostomy versus radiologically inserted gastrostomy in children. Br J Surg 2017; 104:1620-1627. [DOI: 10.1002/bjs.10687] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/26/2017] [Accepted: 07/02/2017] [Indexed: 12/31/2022]
Abstract
Abstract
Background
The aim of this RCT was to determine whether radiologically inserted gastrostomy (RIG) in children is associated with more complications than percutaneous endoscopic gastrostomy (PEG).
Methods
Children at a single tertiary children's hospital requiring a primary gastrostomy were randomized to PEG or RIG. Patients were followed by assessors blinded to the insertion method. Complications were recorded, assigned a severity score, and analysed by zero-inflated Poisson regression analysis on an intention-to-treat basis, adjusting for length of follow-up.
Results
Over a 3-year period, 214 children were randomized (PEG, 107; RIG, 107), of whom 100 received PEG and 96 RIG. There was no significant difference in the number of complications between PEG and RIG groups (P = 0·875), or in the complication score: patients undergoing RIG had a 1·04 (95 per cent c.i. 0·89 to 1·21) times higher complication score than those who underwent PEG (P = 0·597). Only age had an independent significant effect on complication score, with older patients having a 0·97 (0·95 to 1·00) times lower complication score per year.
Conclusion
PEG and RIG are both safe methods of gastrostomy insertion with a low rate of major complications. Registration number: NCT01920438 (http://www.clinicaltrials.gov).
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Affiliation(s)
- R R Singh
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - S A Nah
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - D J Roebuck
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - S Eaton
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - A Pierro
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - J I Curry
- Department of Paediatric Surgery, UCL Great Ormond Street Institute of Child Health and Great Ormond Street Hospital for Children, London, UK
| | - A Barnacle
- Great Ormond Street Hospital for Children, London, UK
| | - S Chippington
- Great Ormond Street Hospital for Children, London, UK
| | - S Stuart
- Great Ormond Street Hospital for Children, London, UK
| | - C Gibson
- Great Ormond Street Hospital for Children, London, UK
| | - K M K Cross
- Great Ormond Street Hospital for Children, London, UK
| | - J Stanwell
- Great Ormond Street Hospital for Children, London, UK
| | - I E Yardley
- Great Ormond Street Hospital for Children, London, UK
| | - E M Kiely
- Great Ormond Street Hospital for Children, London, UK
| | - P De Coppi
- Great Ormond Street Hospital for Children, London, UK
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Chiang LW, Lee CY, Krishnaswamy G, Nah SA, Kader A, Ong C, Low Y, Phua KB. Seventeen years of Kasai portoenterostomy for biliary atresia in a single Southeast Asian paediatric centre. J Paediatr Child Health 2017; 53:412-415. [PMID: 27859955 DOI: 10.1111/jpc.13379] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/08/2016] [Accepted: 09/02/2016] [Indexed: 11/26/2022]
Abstract
AIM Biliary atresia (BA) has preponderance in Asian populations with Kasai portoenterostomy (KP) regarded as the first-line standard of care. Yet reports from Southeast Asia remain scant. This study reviews the demographics, short- and medium-term outcomes for our cohort, and evaluates prognostic factors for outcome. METHODS All patients diagnosed with BA between January 1997 and December 2013 were included. Clinical data were obtained from medical records. Jaundice clearance was defined as total bilirubin < 20 µmol/L within 6 months after KP. Two-year and 5-year native liver survival (NLS) were determined. Prognostic factors examined included gender, ethnicity, associated anomalies, age at KP, post-KP cholangitis and clearance of jaundice within 6 months. RESULTS Of 58 patients studied, 31(53.4%) were male. Median age at time of KP was 53 days (range: 28-127). Ethnic distribution showed 32 (55.2%) Chinese, 16 (27.6%) Malays and 10 (17.2%) others. Twenty-one (36.2%) patients achieved jaundice clearance by 6 months. Two-year NLS rate was 36 out of 50 (72%), while 5-year NLS rate was 16 out of 35 (45.7%). Only clearance of jaundice within 6 months had a significant association with NLS (P = 0.006). All other factors showed no significant impact on outcome. CONCLUSIONS Our short- and medium-term outcomes after KP for BA are comparable with those reported by most international centres. However, prognostic factors such as age at KP, cholangitis episodes and associated anomalies did not show significant correlation; only clearance of jaundice within 6 months was significantly predictive of NLS.
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Affiliation(s)
- Li Wei Chiang
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Chuan Yaw Lee
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Gita Krishnaswamy
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Shireen Anne Nah
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Ajmal Kader
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Christina Ong
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Yee Low
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | - Kong Boo Phua
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore
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Nah SA, Ong SS, Lim WX, Amuddhu SK, Tang PH, Low Y. Clinical Relevance of the Nonvisualized Appendix on Ultrasonography of the Abdomen in Children. J Pediatr 2017; 182:164-169.e1. [PMID: 28010937 DOI: 10.1016/j.jpeds.2016.11.062] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/19/2016] [Accepted: 11/23/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in children with right lower quadrant pain. STUDY DESIGN We reviewed 1359 children admitted for abdominal pain between January and December 2013 who had abdominal ultrasound imaging for right lower quadrant pain. Patients who had scans for genitourinary symptoms or intussusception were excluded from the study. When the appendix was not visualized, secondary signs indicating right lower quadrant inflammatory pathology were noted. RESULTS Of all admissions for abdominal pain, 810 had ultrasound scans. Thirty-eight did not evaluate the appendix and 131 were excluded for suspected intussusception, leaving 641 reports for children with a median age of 10.8 years (range, 1.3-21.3); 297 were boys (46.3%). There were 17 of 160 patients with a nonvisualized appendix (10.6%) who underwent appendectomy. Of these, 14 had secondary signs on ultrasound imaging and 3 (1.9%) had normal ultrasound reports. The 3 patients with normal ultrasound imaging had computed tomography imaging confirming appendicitis. There were 51 patients with a partially visualized appendix. The segment of appendix that could be seen was normal in 34 patients, none of whom had appendectomy. The remaining 17 had appendectomy, in whom the appendix seemed to be inflamed in 13 and equivocal in 4, all with histologically confirmed appendicitis. Overall, 232 children underwent appendectomy; 58 had no ultrasound imaging done, and 5 had a histologically normal appendix (overall negative appendectomy rate, 2.2%). Only 35 of 1359 patients (0.03%) had computed tomography scans. CONCLUSION In patients with a nonvisualized appendix on ultrasound imaging and no evidence of secondary inflammatory changes, the likelihood of appendicitis is less than 2%. Generous use of ultrasonography as an adjunct to clinical examination can achieve low negative appendectomy rates without underdiagnosis of acute appendicitis.
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Affiliation(s)
- Shireen Anne Nah
- Pediatric Surgery, KK Women's and Children's Hospital, Singapore.
| | - Sophie Sihui Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wei Xiang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Phua Hwee Tang
- Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Yee Low
- Pediatric Surgery, KK Women's and Children's Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore
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Yap BKY, Nah SA, Chen Y, Low Y. Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications. Pediatr Surg Int 2017; 33:217-228. [PMID: 27889821 DOI: 10.1007/s00383-016-4028-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 01/16/2023]
Abstract
PURPOSE We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone. METHODS We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT. RESULTS We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43-2.87, p ≤ 0.0001, I 2 = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28-4.05, p = 0.005, I 2 = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43-2.78, p < 0.0001, I 2 = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62-3.11, p = 0.42, I 2 = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35-1.68, p = 0.46, I 2 = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean). CONCLUSIONS Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.
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Affiliation(s)
- Brendan K Y Yap
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Shireen Anne Nah
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
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Lian BSY, Cheong YL, Low Y, Nah SA. Testicular atrophy: A complication of non-mumps orchitis after scrotal exploration for presumed testicular torsion. Proceedings of Singapore Healthcare 2016. [DOI: 10.1177/2010105815624426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
An acute illness related to the scrotum is a common paediatric surgical emergency. Difficulty in ruling out testicular torsion means that scrotal exploration is often performed for other scrotal pathologies, including orchitis. The clinical course of orchitis is usually benign and long-term sequelae are rare. We describe two adolescent boys, previously vaccinated for mumps, whom had scrotal exploration for presumed testicular torsion. Both were found intraoperatively to have orchitis, and both subsequently developed testicular atrophy, within 2 months post-surgery. These cases demonstrate the rare, but potentially devastating, complication of testicular atrophy that may arise in non-mumps orchitis. The causative pathophysiology may involve some degree of testicular compartment syndrome and subsequent ischaemia. Patients must be made aware of the potential for this outcome and be advised on testicular self-examination after surgery.
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Affiliation(s)
- Bertrand SY Lian
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yee Ling Cheong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Yee Low
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
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Abstract
INTRODUCTION Testicular atrophy (TA) is a significant complication in patients who undergo salvage procedures for testicular torsion. Studies on outcome focus on factors predicting testicular viability during scrotal exploration but few assess factors predicting TA in patients who undergo salvage procedures. We assess the incidence of TA after salvage and identify associated factors. MATERIALS AND METHODS With ethical approval, we reviewed patients who underwent salvage for testicular torsion in our institution from 2001 to 2013. Data was collected on patient demographics, duration of pain, sonographic findings, postoperative complications, and follow-up assessment of TA (defined as difference in testicular volume > 50% compared with the contralateral testis, based on measurement by Prader orchidometer or by ultrasound). We excluded patients with torted undescended testis, those under 1 month, and those with follow-up < 6 months. Chi-square or Mann-Whitney U tests were used as appropriate with significance level < 0.05. RESULTS Of 85 patients who had scrotal exploration for testicular torsion, 53 had testicular salvage. Overall, 16 patients defaulted or had < 6 months follow-up, leaving 37 patients who were studied, median age 12 years (range, 0.5-16.0 years) at presentation. Median follow-up was 12.5 months (range, 6-88 months). A total of 20 patients (54%) developed TA. Median duration to TA was 12.5 months (range, 2-88 months). All had clinical evidence of atrophy by 14 months, except two who initially defaulted follow-up, but were diagnosed with TA at 35 and 88 months postoperatively when presenting with unrelated complaints. Factors associated with TA were duration of pain > 1 day (p = 0.004) and heterogeneous echogenicity on ultrasound (p = 0.001). Sonographic evidence of reduced vascularity was not predictive. Of 11 that had pain > 1 day, 10 (91%) had TA. No testes survived when pain ≥ 3 days. CONCLUSION Half of patients with testicular torsion undergoing salvage surgery will develop testicular atrophy, even when intraoperatively assessed as viable, and should be counseled accordingly. Duration of pain > 1 day and sonographic heterogeneous echogenicity are predictive. Salvage rates are dismal when duration of symptoms exceeds 1 day.
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Affiliation(s)
- Bertrand S Y Lian
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Caroline C P Ong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Li Wei Chiang
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Rambha Rai
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Abstract
INTRODUCTION This study evaluates the demographics of paediatric pedestrian injuries with the aim of identifying the group of children who is most vulnerable and the risk factors for major trauma (MT). METHODS Data was extracted from the integrated trauma system of a regional paediatric referral hospital. All paediatric cases involving road traffic accidents from January 2011 to December 2013 were studied. Demographics, injury mechanism, treatment and outcome were evaluated. Patients were categorised as MT or non-MT (NMT) based on their Injury Severity Score, admission to the intensive care unit, type of surgery (e.g. life/limb-saving) and death. Data analysis was done using nonparametric tests and Fisher's exact test. RESULTS A total of 261 children were admitted for pedestrian injuries during the study period. The median age was ten years (range 14 months-16 years) and the median weight was 42.4 (range 8.6-93.7) kg. Half (i.e. 50.2%) of the children were primary-schoolers. The majority of the accidents occurred on roads (i.e. 83.1%), between 12 pm and 6 pm (i.e. 52.8%). Among the 261 children, 177 (67.8%) were unaccompanied by an adult at the time of the accident; 17 (6.5%) children sustained MT, while 244 (93.5%) suffered NMT. MT patients were more likely to have lost consciousness (p < 0.001) and been flung (p = 0.001). CONCLUSION Most paediatric pedestrian injuries involved primary-schoolers walking home from school unaccompanied by adults. This information should inform future road safety campaigns. Being flung and loss of consciousness predicted MT in children who sustained pedestrian injuries.
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Affiliation(s)
- Xun Yi Jasmine Feng
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - York Tien Lee
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Yea-Chyi Lin
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Li Wei Chiang
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
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Yap TL, Chen Y, Low WWX, Ong CCP, Nah SA, Jacobsen AS, Shen L, Low Y. A new 2-step risk-stratification clinical score for suspected appendicitis in children. J Pediatr Surg 2015; 50:2051-5. [PMID: 26477755 DOI: 10.1016/j.jpedsurg.2015.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 08/24/2015] [Indexed: 12/29/2022]
Abstract
AIM The aim of this study was to develop a new Children's Appendicitis Score (CAS) by combining 3 inflammatory markers and a set of predictors for suspected appendicitis in children. METHODS 374 children aged 4-16years with suspicion of appendicitis were prospectively enrolled for the derivation cohort. Demographic characteristics, clinical features, laboratory, and histology data were collected. The outcome measure was the histological presence or absence of appendicitis. Backward logistic regression was employed to select predictors for construction of a score. Diagnostic performance of CAS was compared with the Pediatric Appendicitis Score (PAS) on a separate validation cohort. RESULTS The combination of normal white blood cell count (WBC), neutrophil percentage, and C-reactive protein (CRP) had a 100% negative predictive value for appendicitis. We assigned 'coefficient A' as 'zero' when all triple markers were negative and 'one' when any one markers was positive. A second component of 6 predictors was identified for construction of the 'raw score': Localized right-lower-quadrant pain, generalized guarding, constant characteristic of pain, pain on percussion or coughing, WBC≥14000/L and CRP≥24g/L. CAS was generated by multiplying 'coefficient A' by 'raw score'. CONCLUSION CAS is superior to PAS in ruling out appendicitis. Risk stratification of equivocal patients could guide the need for further diagnostic imaging examination.
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Affiliation(s)
- Te-Lu Yap
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore.
| | - Yong Chen
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Wilson Wei Xin Low
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | | | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Anette S Jacobsen
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Liang Shen
- Department of Biostatistics, National University Health System, Singapore
| | - Yee Low
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
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Chen Y, Nah SA, Chiang L, Krishnaswamy G, Low Y. Postoperative steroid therapy for biliary atresia: Systematic review and meta-analysis. J Pediatr Surg 2015; 50:1590-4. [PMID: 26143225 DOI: 10.1016/j.jpedsurg.2015.05.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 05/18/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND/OBJECTIVES Adjuvant steroid therapy has become popular in the postoperative management of biliary atresia. However, the benefits of steroid therapy are still not clear. We performed a systematic review and meta-analysis to determine the effect of steroids on bile drainage posthepatoportoenterostomy. METHODS Studies published from 1968 to 2014 were searched from MEDLINE, EMBASE, Google scholar and Cochrane databases. A meta-analysis of randomized controlled trials (RCT) and observational studies comparing bile drainage between steroid and nonsteroid therapies posthepatoportoenterostomy was performed. RESULTS Seven studies (2 RCTs and 5 observational studies) were included, comprising 259 cases of nonsteroid and 228 cases of steroid therapies. There was no statistical improvement in jaundice clearance in the steroid group [pooled odds ratio (OR)=1.51; 95% confidence interval (CI) 0.95-2.41; P=0.08; I(2)=30%]. Among 7 studies, 4 studies applied similar moderate high-dose steroid regimens (prednisolone 4-5mg/kg/day for 1-2 weeks followed by weeks of tapering dosage). However, these moderate high-dose regimens demonstrated improved jaundice clearance at 6 months posthepatoportoenterostomy (pooled OR=1.59; 95% CI 1.03-2.45; P=0.04; I(2)=0%). A subgroup analysis also showed that the effect of those moderate high-dose steroids was more pronounced in infants operated on by 70 days of age (pooled OR=1.86; 95% CI 1.08-3.22; P=0.03; I(2)=0%). CONCLUSION Moderate high-dose steroid therapy improves jaundice clearance, especially for infants who undergo hepatoportoenterostomy by 70 days of age. However, more RCTs with longer follow-up are necessary to demonstrate the effect of steroids on the long-term outcomes of biliary atresia.
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Affiliation(s)
- Yong Chen
- Department of Pediatric Surgery. KK Women's & Children's Hospital, Singapore
| | - Shireen Anne Nah
- Department of Pediatric Surgery. KK Women's & Children's Hospital, Singapore
| | - Liwei Chiang
- Department of Pediatric Surgery. KK Women's & Children's Hospital, Singapore
| | - Gita Krishnaswamy
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | - Yee Low
- Department of Pediatric Surgery. KK Women's & Children's Hospital, Singapore.
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Seow-En I, Loh AHP, Lian DWQ, Nah SA. Thyroglossal duct cyst carcinoma: diagnostic and management considerations in a 15-year-old with a large submental mass. BMJ Case Rep 2015; 2015:bcr-2015-210923. [PMID: 26150648 DOI: 10.1136/bcr-2015-210923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A 15-year old boy presented with a 2-year history of a painless slowly enlarging submental neck mass. Head and neck imaging showed a multicystic mass with a central solid component that was closely applied to the hyoid bone. Core needle biopsy under general anaesthesia revealed a papillary thyroid neoplasm. The mass was resected and frozen section histology confirmed papillary carcinoma. Intraoperatively, enlarged cervical lymph nodes were palpable. Bilateral neck dissections and total thyroidectomy with parathyroid reimplantation were performed. On histological examination, the thyroid gland was not involved. The patient recovered uneventfully from the surgery and is planned for radioactive iodine therapy and thyroxine suppression, with subsequent follow-up with serum thyroid-stimulating hormone and thyroglobulin for surveillance. We review the literature and discuss challenges in the diagnosis and surgical management of this rare entity in the paediatric age group.
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Affiliation(s)
- Isaac Seow-En
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Amos Hong Pheng Loh
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Derrick Wen Quan Lian
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Abstract
BACKGROUND/PURPOSE The purpose of this study was to evaluate parental retention of possible surgical complications in children undergoing emergency laparoscopic appendectomy. METHODS A prospective pilot study involving parents whose children had emergency laparoscopic appendectomy was performed. Parents were counseled regarding 7 potential complications of laparoscopic appendectomy. They were asked to recall this list immediately after the consent process (immediate recall, IR) and before discharge from inpatient stay (delayed recall, DR). A score (0-7) was awarded indicating the number of correct answers. For each recall, parents were also reminded on complications they omitted (prompted recall). One surgeon administered all consents in person. Demographic data were collected. Data were reported as median (range). RESULTS Twenty-one mothers and 10 fathers were recruited, aged 42 years (30-54). Nine (29%) had university or post-graduate education. Score for IR was 2 (0-6). Five (16%) parents scored 0. Upon prompting after IR, 20 (65%) parents had no impression of at least 1 complication. Score for DR was 2 (0-7), while 7 (23%) parents scored 0. At prompting after DR, 25 (81%) had no memory of at least one complication. Eight (26%) demonstrated improved DR scores. Scores were not affected by patient demographics or time between interviews. CONCLUSIONS There is poor parental retention of information provided during operative consent. Hence, proper documentation of this process is essential.
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Affiliation(s)
- Fay Xiangzhen Li
- KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
| | - Shireen Anne Nah
- KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899
| | - Yee Low
- KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899.
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Nah SA, Giacomello L, Eaton S, de Coppi P, Curry JI, Drake DP, Kiely EM, Pierro A. Surgical repair of incarcerated inguinal hernia in children: laparoscopic or open? Eur J Pediatr Surg 2011; 21:8-11. [PMID: 20938898 DOI: 10.1055/s-0030-1262793] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The management of Incarcerated Inguinal Hernia (IIH) in children is challenging and may be associated with complications. We aimed to compare the outcomes of laparoscopic vs. open repair of IIH. METHODS With institutional ethical approval (09SG13), we reviewed the notes of 63 consecutive children who were admitted to a single hospital with the diagnosis of IIH between 2000 and 2008. Data are reported as median (range). Groups were compared by chi-squared or t-tests as appropriate. RESULTS · Open repair (n=35): There were 21 children with right and 14 with left IIH. 2 patients also had contralateral reducible inguinal hernia. Small bowel resection was required in 2 children. · Laparoscopic repair (n=28): All children had unilateral IIH (19 right sided, 9 left sided). 15 children (54%) with no clinical evidence of contralateral hernia, had contralateral patent processus vaginalis at laparoscopy, which was also repaired. The groups were similar with regard to gender, age at surgery, history of prematurity, interval between admission and surgery, and proportion of patients with successful preoperative manual reduction. However, the duration of operation was longer in the laparoscopy group (p=0.01). Time to full feeds and length of hospital stay were similar in both groups. Postoperative follow-up was 3.5 months (1-36), which was similar in both groups. 5 patients in the group undergoing open repair had serious complications: 1 vas transaction, 1 acquired undescended testis, 2 testicular atrophy and 1 recurrence. The laparoscopic group had a single recurrence. CONCLUSION Open repair of incarcerated inguinal hernia is associated with serious complications. The laparoscopic technique appears safe, avoids the difficult dissection of an oedematous sac in the groin, allows inspection of the reduced hernia content and permits the repair of a contralateral patent processus vaginalis if present.
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Affiliation(s)
- S A Nah
- UCL Institute of Child Health & Great Ormond Street Hospital for Children, Unit of Paediatric Surgery, London, United Kingdom
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