Efficacy of skin-to-skin vs. cloth-to-cloth contact for thermoregulation in low birth weight newborns: a randomized crossover trial

OBJECTIVE

Skin-to-skin contact (SSC) is effective to maintain normal temperature in low birth weight (LBW) newborns. However, there are several barriers related to privacy and space availability for its optimum utilization. We used cloth-to-cloth contact (CCC), i.e. placing the newborn in Kangaroo position without removing cloths as an innovative alternative to SSC to test its efficacy for thermoregulation and feasibility as compared to SSC in LBW newborns.

METHODS

The newborns eligible for Kangaroo Mother Care (KMC) in step-down nursery were included in this randomized crossover trial. Newborns received SSC or CCC as per randomization on the first day and then crossed over to other group on the next day and so on. A feasibility questionnaire was asked to the mothers and the nurses. Axillary temperature was measured at various time intervals. Group comparisons were made by either using independent sample t-test or Chi-square test.

RESULTS

A total of 23 newborns received KMC for total 152 occasions in the SSC group and 149 times in the CCC group. There was no significant temperature difference between the groups at any time-point. Mean (standard deviation) gain of temperature at 120 min in the CCC group [0.43 (0.34)°C] was comparable to the SSC group [0.49 (0.36)°C] (p = 0.13). We did not observe any adverse effect of CCC. Most mothers and nurses perceived CCC feasible in hospital settings and felt that it could be feasible in-home settings too.

CONCLUSION

CCC was safe, more feasible and not inferior to SSC for maintaining thermoregulation in LBW newborns.

A Study of Parental Stressors, Financial Issues as Stress Factor, and the Coping Strategies in the PICU

OBJECTIVE

To evaluate the stressors in parents of critically ill children admitted in PICU and the coping strategies used by them.

METHOD

Parents of children admitted to the PICU (at least 48 h) were administered Modified PSS: PICU scale (total 8 subscales, 42 items) and coping questionnaire (8 questions). A total score (Modified PSS: PICU score) and subscales mean scores were used to describe the stressors. The questionnaire was verbally administered to either one of the parents, in English or Hindi. The responses were assessed and analyzed.

RESULTS

Either of the parents (age 20 to 50 y, 29 mothers) of 102 children responded. The Modified Parental Stress Scale: PICU (PSS: PICU) score was 44 (± 11.2). Parental stress was related to severity of illness (p < 0.001). Procedures done on their child and the appearance of the child were most stressful. Fathers were more stressed about the procedures compared to mothers (p = 0.004). Middle-class parents were more stressed about financial issues compared to upper and lower socioeconomic class in response to the open-ended question. The most used coping strategies were "Trust in your God" (99%), "Communication with doctors and nurses" (97.1%), and "Sharing feelings with spouse" (94.1%). Mothers found sharing feelings with the spouse more helpful.

CONCLUSION

Parents of critically ill children are very stressed. Middle-class parents should also be taken care of in financial aspects. More attention should be given to the parents of children with severe illness. Parents should be communicated frequently. Encouraging faith in God and good communication can be helpful.

Assessment of front-line healthcare workers' Knowledge, Attitude and Practice after several months of COVID-19 pandemic

BACKGROUND

Frontline healthcare workers (F-HCWs) are at the forefront of medical care providers against the novel coronavirus 2019 (COVID-19) pandemic which has life-threatening potentials. Inadequate knowledge and incorrect attitudes among HCWs can directly influence practices and lead to delayed diagnosis, poor infection control practices, and spread of disease.

OBJECTIVES

The aim of this study was to assess the knowledge, attitude and practice (KAP) regarding the COVID-19 pandemic among the frontline healthcare workers (F-HCWs) working at a tertiary care hospital situated in eastern Uttar Pradesh and to identify the factors significantly associated with KAP.

METHODS

A cross-sectional study was conducted among 260 health care providers across eastern Uttar Pradesh including Basti city during December 2020. Data was collected using a self-primed pretested questionnaire from the FHCWs working at a tertiary care hospital of eastern Uttar Pradesh. In this survey, a convenience sampling method was adopted. 12 items on knowledge, 10 items on attitude, and 5 items on practices related to COVID-19. The other variables consisted of 4 items on socio-demographic attributes, p-value and 95% confidence intervals (CIs) were performed to assess the attitude and practices in relation to knowledge.

RESULTS

Of the total 260 study population, 228 were interviewed online, 32 were self-administered. Knowledge and attitude of the nursing staff were highest but practice score was best for residents. Among different age groups knowledge, attitude and practices scores were highest for 35-45, 45-60 and 25-35 age groups respectively. Respondents having 5-10 years of experience had the best knowledge and the attitude score was highest for HCWs having 10-20 years' experience but the practice score was higher for HCWs having more than 20 years' work experience. Overall knowledge score of respondents having strong correlation with attitude (p<0.05) and to the practice (p<0.05).

CONCLUSION

In this survey many F-HCWs reported adequate overall knowledge with a positive attitude and adopted appropriate practices. The F-HCWs with a higher level of education and more years of experience in health care facilities had better KAP towards COVID-19.

Cystoscopic transurethral incision in simplex and duplex ureteroceles-is it the definitive procedure?

OBJECTIVE

The aim of this study is to evaluate the efficacy of primary cystoscopic transurethral incision (CTUI) in the management of paediatric ureteroceles. The secondary aim is to compare the efficacy of CTUI between simplex and duplex systems.

PATIENTS AND METHODS

This is a retrospective review of consecutive paediatric patients requiring surgical intervention for ureterocele. Data collected for analysis included demographics, diagnostic, pre-operative investigations, operative interventions and postoperative variables.

RESULTS

Over a 19-year period, 79 consecutive cases were identified, and 42 were male (53.2%). The mean follow-up was 6.7 years. Seventy-three (92.4%) cases underwent primary CTUI; 50 of these cases (68.5%) required no further procedures during the study period. Sixty-one cases were treated by endoscopic intervention alone (77.2%). Forty-one (51.9%) cases had a simplex system, and 38 (48.1%), a duplex system. There was no statistically significant difference in the efficacy of primary CTUI in simplex vs duplex systems. Of the 20 patients who had pre-operative and postoperative micturating cystourethrograms performed, seven (35%) developed de-novo postoperative vesicoureteric reflux after CTUI.

CONCLUSION

Primary CTUI is a safe, minimally invasive procedure that is definitive in the majority of children presenting with a ureterocele that requires intervention. There was no difference in success of primary CTUI between simplex or duplex systems.

Making a Simple A+B→C Reaction Oscillate by Coupling to Hydrodynamic Effect

We present a new mechanism through which chemical oscillations and waves can be induced in batch conditions with a simple A+B→C reaction in the absence of any nonlinear chemical feedback or external trigger. Two reactants A and B, initially separated in space, react upon diffusive contact and the product actively fuels in situ convective Marangoni flows by locally increasing the surface tension at the mixing interface. These flows combine in turn with the reaction-diffusion dynamics, inducing damped spatiotemporal oscillations of the chemical concentrations and the velocity field. By means of numerical simulations, we single out the detailed mechanism and minimal conditions for the onset of this periodic behavior. We show how the antagonistic coupling with buoyancy convection, due to concurrent chemically induced density changes, can control the oscillation properties, sustaining or suppressing this phenomenon depending on the relative strength of buoyancy- and surface-tension-driven forces. The oscillatory instability is characterized in the relevant parametric space spanned by the reactor height, the Marangoni (Ma_{i}) and the Rayleigh (Ra_{i}) numbers of the ith chemical species, the latter ruling the surface tension and buoyancy contributions to convection, respectively.

Abdominoscrotal hydrocele--is there a place for conservative management?

Abdominoscrotal hydrocele (ASH) is an uncommon entity. It consists of large inguinoscrotal swelling which is dumbbell shaped, and in theory, communicates with its intra-abdominal component. Although various theories have been proposed, the aetiology is still unclear. To date, the only reported management is by surgical excision. Spontaneous resolution has not been documented in the literature. We present a case of proven abdominoscrotal hydrocele successfully managed by conservative approach.

Urban water tariff structure and cost recovery opportunities in India

Given the high level of capital investment and the history of government subsidized services, full cost pricing of water services has yet to take hold in India. As a result, it remains broadly underpriced leading to public perception that water is "free" The current tariff levels in India are too low to cover even operating costs. This paper examines the existing Indian urban water tariff models (fixed tariff, volumetric tariff, increasing block tariff etc.), their relevance and problems. It was found that none of the tariff structures could satisfy all the design objectives (cost recovery, economic efficiency, equity, affordability etc.). Also subsidies are not explicit and well targeted for poor population. There are several studies and issues that do demonstrate the opportunities for tariff increase and improved cost recovery. This paper highlights the results of such studies and brings out issues needing consideration. Improved cost recovery would lead to improved financial status of the water utilities. Also, subsidies, if designed suitably and well targeted, would serve the concerns of the economically weaker sections. Such reform process would eventually lead to socio-economic sustainability.

Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) in siblings: case report and review of the literature

PURPOSE

Report of MMIHS in siblings with emphasis on diagnostic aspects in antenatal scanning and genetics.

METHOD

Two case reports and review of the literature

RESULTS

The firstborn child of this family was a female infant with a postnatal diagnosis of MMIHS. In the consecutive pregnancy frequent antenatal scans were performed, which showed normal fetal anatomy until 19 weeks' gestation. The pregnancy was carried on and at 36 weeks' gestation dilatation of the renal collecting system and dilated loops of bowel were seen, suggestive of MMIHS.

CONCLUSION

Prenatal diagnosis of MMIHS remains difficult. Further research into the genetics of this condition is necessary and would be an important tool in counselling parents with an affected child in view of the chances having an affected child at subsequent pregnancies. A multi-centre collection of a genetic pool from parents may be helpful for future research.

Urachal remnants: an enigma

AIM

To determine what should be done with incidentally discovered urachal remnants.

MATERIALS AND METHODS

A 10-year retrospective study revealed 24 patients with urachal remnants. The histology of the urachal remnants was reviewed. A review of the data on urachal carcinoma in adults diagnosed and treated during the same period in an adjacent adult hospital was carried out. A review of the literature was also performed.

RESULTS

In the 23 patients where histology was available 17 had normal urothelial lining and 6 (25%) showed abnormal epithelium. This included colonic epithelium, small intestinal epithelium and squamous epithelium. Four of the patients with abnormal epithelium were in the group of "incidental removals". During the 10-year period, 4 cases of urachal carcinoma were managed at the adult urology centre. Three had extensive disease at presentation. Two died of the disease while the third died of myocardial infarction 5 months after resection. Only one was alive at one-year follow-up. The occurrence of such documented complications makes a strong case for "prophylactic" surgery when urachal remnants are diagnosed incidentally or recognised during other operative procedures. All paediatric patients who underwent excision of urachal remnants had an uncomplicated clinical course.

The management of a postdural puncture headache in a child

We present a case of an 11-year old girl who underwent an elective pyeloplasty and had an epidural catheter placed for per- and postoperative analgesia. Postoperatively she developed a postural headache and severe nausea, and a diagnosis of postdural puncture headache (PDPH) was made. Her symptoms failed to respond to conservative management. An epidural blood patch was performed with immediate and complete resolution of her symptoms. We present this case to highlight the occurrence of PDPH in children and to outline the considerations for management.

Oesophageal atresia: a handshake with malrotation

Oesophageal atresia and tracheo-oesophageal fistula patients are known to have associated anomalies. Malrotation is a dangerous diagnosis to miss. The association of oesophageal atresia and tracheo-oesophageal fistula with malrotation is known but not quantified and certainly not emphasised enough in the literature. We retrospectively studied our population of oesophageal atresia and tracheo-oesophageal fistula patients to look for an associated malrotation. Ninety-one patients with oesophageal atresia were reviewed during 1978 - 1997, of whom 60 patients had an upper gastrointestinal study. Three of these patients (5 %) were noted to have malrotation. We would recommend a routine post-operative upper gastrointestinal study to look for abnormalities of intestinal rotation along with other information that can be obtained by the study. We also recommend that in patients with pure atresia, at the time of gastrostomy, intestinal rotation should be determined. All clinicians dealing with infants with oesophageal atresia should be aware of this association.

The referral pattern for undescended testes in Auckland

AIM

To accurately audit the age at orchiopexy at our institution and then to analyse the referral pattern specially related to the age of the patient.

METHODS

A retrospective review of hospital records was performed. Data were obtained from the hospital database based on the procedure code of orchiopexy. Mean and median values were calculated for age at referral, time between clinic visit and referral (T1) and between clinic visit and operation (T2).

RESULTS

The mean age at referral was 42.6 months (median 23, range 0 - 179.1 months). The mean time T1 was 2.6 months (median 1.7, range 0 - 16.9 months). The mean time T2 was 7.0 months (median 3.3 months).

CONCLUSION

There is a need to increase awareness about undescended testes amongst all parties involved in the health care of children.

Metastatic adenocarcinoma rib presenting as chondrosarcoma

A case of chondrosarcoma rib which turned out to be a case of metastatic adenocarcinoma on histopathological examination is being presented.

Cricketing injuries in children: from the trivial to the severe

AIM

To describe the nature of acute cricketing injuries in children presenting to the emergency department of a tertiary level children's hospital. Two cases of severe injuries during a cricket game are reported.

METHOD

A retrospective review of presentations to the emergency department from 1993 to April 1998.

RESULTS

Sixty cases of cricketing injuries were reviewed. Injuries to the head, hands and forearms were most common. Most injuries were caused by being hit by a ball. A high proportion of cases required operative intervention. Length of stay in hospital was only overnight in most cases. The two case reports highlight unusual but severe injuries that caused significant morbidity to the patients involved.

CONCLUSION

Although cricket is, by and large, a safe sport, this report will raise awareness of the variety of injuries that can be suffered by children playing the game.

Rhabdoid tumour of the kidney: a diagnostic challenge and a fatal outcome

Rhabdoid tumour of the kidney is not common. Presentation of such a lethal tumour along with blunt abdominal trauma is even rarer. We report such a case of Rhabdoid tumour of kidney which presented as renal trauma, and discuss the diagnostic difficulties and rapidly fatal outcome.

Congenital cystic adenomatoid malformation and extralobar sequestration occurring independently in the ipsilateral hemithorax

We report a case of congenital cystic adenomatoid malformation (CCAM) and extralobar pulmonary sequestration (EPS) occurring independently in the ipsilateral hemithorax. A literature search using Medline, Winspirs 2.0, found 14 previously reported cases of CCAM within an EPS. There are no reports of each form of congenital pulmonary abnormality occurring separately in the same patient.

Pleuropulmonary blastoma: four cases

Pleuropulmonary blastoma (PPB) is a rare malignant neoplasm affecting children. A retrospective review was carried out of patients diagnosed as having PPB at one institute over a period of 16 years. The presentation, diagnosis, treatment, and family history were studied. PPB usually presents with symptoms and signs of respiratory tract infection, and the diagnosis may be delayed. There are no distinguishing clinical features or imaging studies. The diagnosis is made on histologic examination of tumour material and is sometimes difficult to differentiate from benign cystic lung lesions. The treatment is primarily complete excision of the tumour, followed in some cases by intense chemotherapy. PPB is a strong predictor of the presence of tumours in close relatives. Four patients treated at our institute are discussed along with a review of the literature.

Porcine liver esterase-catalyzed enantioselective hydrolysis of a prochiral diester into its optically pure (S)-ester acid, a precursor to a growth hormone secretagogue

A limited screen of several commercially-available and internally-produced lipases and esterases identified porcine liver esterase as a suitable biocatalyst for the enantioselective hydrolysis of a diester into its (S)-ester acid with high optical purity (99%). This (S)-ester acid is a precursor to an experimental growth hormone secretagogue. After identifying xanthan gum as the best emulsifier and optimizing the reaction conditions, hydrolysis rates of 1 g/l.h and final (S)-ester acid (ee > 99%) titers of about 8.5 g/l were routinely achieved. This process supported the production of preparative amounts of optically pure (S)-ester (ee > 99%) with a high reaction yield of 82%. Upon purification, the (S)-ester was successfully used in the subsequent synthetic steps to yield the growth hormone secretagogue.

Gartner's duct cyst with unilateral renal dysplasia presenting as an introital mass in a new born

A persistent Gartner's duct cyst associated with ipsilateral renal agenesis or dysplasia is rare. A vaginal cyst at the introitus as the presenting complaint is very rare, and has not been previously described in a neonate. Sepsis despite the presence of renal agenesis, or non- or poorly functioning renal tissue, is an indication for ureterectomy or nephroureterectomy on the affected side.

Multiple organ malrotation syndrome with duodenal atresia: a case report

Duodenal atresia (DA) can be associated with multiple anomalies. Multiple organ malrotation syndrome (MOMS) involves laevoversion of the liver and gall bladder and dextroversion of the stomach and spleen. We report a case of MOMS with DA. Embryologic aspects, investigation, and treatment are discussed.

Is central venous access in childhood osteomyelitis associated with increased morbidity?

Children with osteomyelitis need treatment with intravenous antibiotics for protracted periods. An implanted central venous line (CVL) is a good method to deliver this treatment. Between 1992 and 1996, 17 patients with osteomyelitis had 20 surgically inserted Hickmann-type CVLs. The outcome of these lines was studied. Patients ranged from 1 month to 14 years of age and the duration of use of the CVL ranged from 6 to 180 days. One CVL was removed because of line sepsis and 1 was removed because of exit-site infection. We conclude that surgically inserted Hickmann-type CVLs in children with a pre-existing focus of infection in the form of osteomyelitis did not result in increased morbidity in terms of line sepsis, and served the purpose of prolonged administration of antibiotics very well.

Gonadal preservation in a simple testicular cyst

The authors report a case of a simple testicular cyst in a 16-week-old infant. Preoperative ultrasonography helped to diagnose this condition accurately. Gonadal preservation and enucleation of testicular cysts are possible with a careful surgical approach, and orchiectomy is not necessary.

Post circumcision meatal stenosis: 12 years' experience

AIMS

To study the presentation of meatal stenosis as a complication of circumcision done in boys of neonatal or nappy age.

METHODS

A total of 50 patients were studied. These patients had meatotomy performed to treat meatal stenosis. All the patients had circumcision during the neonatal period or in the nappy age. Meatal stenosis was defined as change in the appearance of the delicate lips of the urinary meatus, with loss of elliptical shape to a circular shape because of fibrosis or scarring, with visually apparent narrowing. Patients with this appearance and no symptoms, but who had presented with a hernia, undescended testes or some other unassociated condition and had meatotomy were for the purpose of this study classed as the incidental group. Patients who were symptomatic and had the meatal stenosis as defined above were classed as the symptomatic group.

RESULTS

Sixteen patients (total n = 50) had the diagnosis of meatal stenosis made incidentally. Thirty four patients, (68% of the total treated by meatotomy) presented to the clinic, being symptomatic due to meatal stenosis. The median age at presentation of the symptomatic group was 48 months (range 3 months-13 years) following circumcision. In all the symptomatic patients meatotomy alleviated the symptoms. All the operated patients were seen between one to three months following the operation and discharged. There were no late presentations with recurrence of meatal stenosis or complications of the treatment.

CONCLUSION

Meatal stenosis is an under recognised complication of circumcision done in neonatal and nappy aged boys. Symptomatic presentation from meatal stenosis can be very late.

Is a normally functioning gastrointestinal tract necessary for normal growth in late gestation?

It is known that neonates with congenital abnormalities of the intestine tend to be growth-retarded. We wished to explore the hypothesis that normal fetal gut function is needed for normal growth in late gestation. If this is true, then different populations of babies with different congenital gut abnormalities would be expected to have similar impairments of growth and be small at birth. This growth retardation would be more marked in term than in preterm babies and would be independent of other congenital anomalies. To test these hypotheses, we examined 43 babies born with gastroschisis (GS) in Auckland, New Zealand; 69 babies born with GS in Birmingham, England; and 60 babies born with intestinal atresia (IA) in Auckland. For Auckland babies with GS, the mean weight standard deviation score (WSDS) (i.e., birth weight relative to the mean birth weight for gestation) for term babies was lower than that for preterm babies (-0.932+/-0.180 vs -0.064+/-0.237, P=0.014). This was also true for Birmingham babies with GS (-0.991+/-0.193 vs -0.36 +/-0.153, P=0.028). For babies with IA, the mean WSDS for term babies was lower than that for preterm babies (-0.627+/-0.266 vs 0. 057+/-0.211, P=0.034). There was no significant difference between the mean WSDS of babies with and without major congenital abnormalities (-0.402+/-0.201 vs -0.271, P=0.70). Our results demonstrate that term babies born with GS are significantly growth-retarded compared with premature babies born with GS. Term babies born with a proximal IA are also growth-retarded. This strongly suggests that in late gestation, the normal growth is dependent on a normally functioning gastrointestinal tract that allows exposure of the proximal intestinal mucosa to ingested amniotic fluid.

Are babies with gastroschisis small for gestational age?

A large proportion of babies with gastroschisis (GS) have low birth weights. It is not clear, however, whether only certain subgroups or the whole population of babies with GS have low birth weights. The aim of this study was to ascertain if the birth weights of babies with GS are significantly lower than those of the general population and to determine if the birth weights of babies with GS from two different populations were significantly different. From 1969 to 1995, 44 babies with GS were treated at Auckland Children's Hospital, New Zealand. From 1980 to 1993, 69 babies were treated at Birmingham Children's Hospital, England. For each group, the mean birth weight relative to the mean birth weight for gestation (WtStdev) was significantly different from zero (Auckland = -0.806, Birmingham = -0.762, P < 0.001, one-sample analysis). The mean WtStdev scores from each centre were not significantly different from each other. Our data demonstrate that the birth weights of babies with GS are significantly lower than those of the general population and are similar in different populations. These findings support the notion that a normally functioning intestinal tract is essential for normal fetal growth.

Duodenal atresia: a comparison of three modes of treatment

To determine the most successful mode of treatment, 33 consecutive cases of duodenal atresia treated by duodenoduodenostomy and not associated with other gastro-intestinal anomalies were analysed retrospectively. These patients have been placed in a nonrandomised fashion into one of three groups: Group A: Duodenostomy (side to side) with gastrostomy and transanastomotic feeding tube (n = 12); Group B: Duodenoduodenostomy (diamond shape) with jejunostomy feeding tube (n = 12); Group C: Duodenoduodenostomy (diamond shape) only (n = 9). A nasogastric tube was used in all cases. There was no difference between the groups for gestational age, birthweight, and age at operation. The outcome measures used to compare these groups were the time taken to achieve full preanastomotic feeds and the duration of hospital stay. There was no difference in time taken to achieve full pre-anastomotic feeds between Group A and Group B. Patients in Group C took significantly less time to achieve full pre-anastomotic feeds than either of the other two groups (p < 0.05, Mann-Whitney U). The duration of hospital stay was also significantly shorter for patients in Group C (median = 12 days) than for patients in either Group A or B (median = 24, 20 days respectively) (p < 0.05, Mann-Whitney U).

Partial or near-total pancreatectomy for nesidioblastosis?

We report on 11 consecutive cases of nesidioblastosis successfully managed, in a 22-year period from 1972-1993 at The Children's Hospital, Birmingham, England. In the pre-operative period all patients were managed by constant glucose administration ( > 10 mg/kg/min) and hyperglycaemic agents such as diazoxide, glucagon, growth hormone and somatostatin either singly or in combination. Seven patients underwent partial pancreatectomy, 2 of whom needed a subsequent near-total resection; 4 others had a near-total pancreatectomy as the primary procedure. The 5 patients who have had partial pancreatectomies are healthy and on no regular medication. Of the 6 patients who had near-total pancreatectomy 3 require insulin for diabetes mellitus and 3 are on pancreatin for pancreatic exocrine deficiency. We recommend partial pancreatectomy as the first operation in the treatment of nesidioblastosis.