Labial synechiae: a diagnostic conundrum

The purpose of this study was to shed some light on labial synechiae, which is a common yet unfamiliar condition seen initially by the family physician and ultimately by the paediatric urologist. It is often diagnosed incorrectly, leading to undue anxiety and stress for the unsuspecting parents, and results in multiple unnecessary lab investigations, hence, putting a burden on the healthcare system in general. After IRB approval, a retrospective chart review was performed over a period of 15 years (2007-2021), at The Indus Hospital, Karachi, Pakistan. The records of all female children who underwent examination under anaesthesia (EUA) for labial synechiae (n=29) were included in the study. Our results indicate that the primary healthcare physicians were unable to recognise labial adhesions at the time of initial presentation. We conclude that labial synechiae is a benign condition affecting female infants, but is not very well understood by healthcare workers in our part of the world.

Management of disorders of sex development - With a focus on development of the child and adolescent through the pubertal years

Disorders of sex development, congenital conditions in which chromosomal, gonadal or anatomic sex is atypical at birth, require urgent assessment by a multidisciplinary team, to define whether there is a life threatening disorder of congenital adrenal hyperplasia or a healthy child with a complex condition. Uncertainty, stigma and taboo complicate counselling which must be knowledgeable, comprehensive and sensitive to different circumstances, religions and cultures. This articles will discuss clinical and genetic diagnosis, decisions regarding sex of rearing, ethical dilemmas, medical management of the infant and of the child or adolescent presenting for the first time with a DSD. Surgical options, timing and management are outlined.

Urothelial carcinoma in children, case report with review of literature

Urothelial carcinoma is the third most prevalent malignancy in adults, accounting for 2.1 % of all cancerrelated deaths. The highest incidence in the 6th decade of life but it is rare in the paediatric population and its incidence is less than 1% constituting a very rare disease. We report the case of a 13 years old boy, who presented to the outpatient department at The Indus Hospital, Karachi, in May 2017, with the complaint of painless gross haematuria.

Post operative pain control in percutaneous nephrolithotomy

OBJECTIVE

To evaluate post-surgery pain relief in percutaneous nephrolithotomy cases.

METHODS

The case-control study was conducted at Indus Hospital, Karachi, from July 2014 to July 2015, and comprised patients undergoing percutaneous nephrolithotomy. The patients were randomized by snose protocol into two equal groups of cases and controls. The cases were given peri-tubal local anaesthetic infiltration of 0.25% bupivacaine, while the controls were given 10ml 0.9% normal saline infiltration. Post-operative pain was assessed using visual analogue scale.

RESULTS

Of the 68 patients, there were 34(50) in each of the two groups. Pain score was significantly less in the intervention group post-operatively at 6th and 12th hours (p<0.05). Also, total consumption of analgesics and demand of analgesic medication were also significantly low among the cases (p<0.05).

CONCLUSIONS

Bupivacaine infiltration into the peri-tubal track significantly reduced post-operative pain.

Development, validity and reliability of an URDU version of the International Prostate Symptom Score

OBJECTIVE

To develop and validate the Urdu version of the International Prostate Symptoms Score.

METHODS

The prospective study was conducted at Indus Hospital, Karachi, from January to April 2014, and comprised interviews of subjects at baseline and at 2 weeks for assessing the test-retest reliability. Patients presenting with lower urinary track symptoms and who were able to read Urdu were recruited as subjects. The reliability of the Urdu version of the International Prostate Symptoms Score was assessed by determining the internal consistency, and by assessing the test-retest reliability.

RESULTS

There were 58 subjects with a mean age of 61.53+/-9.99 years. There was no statistically significant difference in self-administered and assister filling total score (p=0.145) and quality of life (p=0.201). For reliability analysis, Cronbach's alpha coefficient was 0.756 total score and 0.622 for quality of life.

CONCLUSIONS

The Urdu version of the International Prostate Symptoms Score stood validated for assessing lower urinary track symptoms.

Leiomyoma of the urinary bladder

Leiomyoma of urinary bladder is a rare tumour with an incidence of < 0.5% of all the bladder tumours. We report a case of leiomyoma of bladder after taking written and informed consent from a 38 years old female, after obtaining the permission of the institutional review board (IRB). She presented in November 2015, with symptoms of obstructive lower urinary tract for 1 year followed by acute urinary retention. Physical examination was unremarkable. Ultrasound showed well circumscribed polypoidal growth in the bladder with mild hydronephrosis on the left side. CT scan abdomen and pelvis with contrast was done, which revealed well circumscribed, rounded soft tissue lesion of 4.4 x 4.5 cm at the posterior inferior surface of the bladder near the bladder neck. Initially TURBT was done but after 6 months patient again went into urinary retention so local excision of the tumour was done. Histopathology confirmed the diagnosis of leiomyoma of the bladder. The diagnosis and management of leiomyoma of the bladder is presented along with review the literature.

Comparison of position-related changes on uroflowmetric parameters in healthy young men

OBJECTIVE

To determine the mean difference in maximum urine flow rate and post-void residual urine volume in sitting as well as standing voiding position in healthy males.

METHODS

This descriptive, cross-sectional study was conducted at the Department of Urology, Indus Hospital, Karachi, from October 2013 to March 2014, and comprised healthy volunteers enrolled using non-probability, consecutive sampling technique. Each volunteer was asked to perform uroflowmetry in sitting and standing positions on two separate days, and a post-void residual volume was assessed after each test. The values of maximum flow rate, average flow rate, voiding volume, and post-void residue were compared between the different voiding positions.

RESULTS

A total of 50 volunteers were inducted. In standing position the maximum flow rate was 32.4±9.6 ml/sec, average flow rate 8.8±16.9 ml/sec, and post-void residue was 8.8±16.9ml. Similarly, in sitting position, the maximum flow rate was 14.8±5.4 ml/sec, average flow rate 14.8±5.4 ml/sec, and post-void residue was 6.6±9.4ml. A significant difference in both voiding positions was observed regarding the maximum flow rate, and average flow rate (p=0.001; p=0.003). However, the difference was not significant for voided volume (p=0.676), or post-void residual volume (p=0.771) in either position. Age-wise stratification of data showed significant difference in both younger and older age groups in terms of maximum flow rate (p=00.19). However, the average flow rate was only significantly different in younger age group (p=0.00). There was no difference in voided volume or post-void residue in either age group (p>0.05).

CONCLUSIONS

The standing voiding position in healthy people influenced uroflowmetry findings, and was associated with higher flow rates.

Renal aspergilloma presenting with pelvi-ureteric junction Obstruction (PUJO)

Primary renal aspergillosis, though a rare entity, is still seen in immune compromised individuals. Renal aspergillosis may lead to formation of focal abscesses, fungal bezoars and may cause ureteric obstruction. Treatment involves stabilization of patient and removal of fungal bezoars along with administration of anti-fungal agents. This report describes the case of localized primary renal aspergillosis with fungal bezoars formation in a 55 years old female, diabetic, hypertensive, who presented with upper urinary tract obstruction and was successfully managed by endoscopic removal of fungal bezoars and intravenous amphotericin followed by oral itraconazole.

Adrenal myelolipoma in a young male - a rare case scenerio

Adrenal myelolipomas are rare non functional benign tumours which are incidentally diagnosed in asymptomatic patients. Despite the fact that several theories have been discussed, the origin of myelolipoma remains unclear. Our patient, 19 years old male presented with history of abdominal pain for past 7 years. Computed tomography scan of abdomen with oral and intravenous contrast revealed well defined round heterogenous enhancing mass seen in right supra renal area involving the adrenal gland. Patient underwent surgery by open access through thoracoabdominal approach. Histopathology of resected mass showed myelolipoma along with trilineage haematopoesis with mature adipose tissues.

How to improve outcome in surgery for Proximal Hypospadias?

OBJECTIVE

To evaluate the role of subdartos fascial tissue as watertight layer in improving outcome for 2-stage proximal hypospadias surgery.

METHODS

The experimental study was conducted at the Department of Urology, Indus Hospital, Karachi, and comprised an audit of patients with proximal hypospadias who underwent surgery from July 1, 2007, to December 31, 2011. The initial two-stage repair of proximal hypospadias led to a high rate of urethrocutanous fistula formation (Group A), and, thus, a modification was introduced and subdartos facial double layer was applied over the urethral suture line (Group B). The results were compared regarding age, type of hypospadias, graft failure and urethrocutanous fistula in these patients.

RESULTS

There were 27 patients in Group A and 16(59.3%) of them ended up having urethrocutanous fistula. Group B had 25 patients and only 2(8%) had fistula formation.

CONCLUSIONS

The application of dartos facial flap waterproofing layer reduced fistula rate.

Association of ABO and Rh blood groups with type 2 diabetes mellitus

OBJECTIVE

The phenotypic "ABO" blood groups are inherited antigenic substances which are found on the surface of red blood cells in addition to other tissues. Certain hypothesis advocates that genetic predisposition like "ABO" blood group would be associated with occurrence of diseases including type 2 diabetes. This study aimed to investigate the potential association between "ABO" and "Rhesus" blood groups with type 2 diabetes.

MATERIALS AND METHODS

We identified 47 research documents in a data based search including ISI-Web of Science, EMBASE and PubMed. Literature was explored using the key terms including "ABO blood groups" "type 2 diabetes". Studies in which "ABO" blood types and diabetes mellitus were discussed included without restrictions of research documents, types, status and language of the publications. Finally, 15 publications which matched our criteria were included, and remaining studies were excluded.

RESULTS

Blood group "B" was associated with high incidence of type 2 diabetes and blood group "O" has a minimum association with type 2 diabetes. Blood group "A" and "AB" were almost equally distributed in both diabetic and non-diabetic population. However, we were unable to find an association between "Rh+ve" and "Rh-ve" blood groups with type 2 diabetes.

CONCLUSIONS

Subjects with blood group "B" are at high risk while individuals with blood group "O" are at low peril of evolving type 2 diabetes. It is suggested that subjects with blood group "B" should be closely monitored by physicians as these subjects have an increased risk of type 2 diabetes.

Adrenocortical oncocytoma

Adrenocortical oncocytoma is an exceedingly rare pathological variant of an adrenal neoplasm. The pathogenesis of oncocytic neoplasms is poorly understood. Females have been reported to be affected 2.5 times more frequently than males, and left-sided lesions are more common than those on right side. This case describes a 20 years old female with right lumbar pain. She found to have a right adrenal gland mass measuring about 6 x 5 cm. A computed tomogram showed hypodense mass lesion 6 x 4.2 cm involving right adrenal gland. Differential diagnosis of non-functional adrenal adenoma was made. A laparoscopic right adrenalectomy was performed using the 3-ports lateral transperitoneal approach. Histopathology showed adrenocortical oncocytoma of adrenal gland.

Zinc supplementation fails to increase the immunogenicity of oral poliovirus vaccine: a randomized controlled trial

BACKGROUND

Polio eradication remains a challenge in Pakistan and the causes for the failure to eradicate poliomyelitis are complex. Undernutrition and micronutrient deficiencies, especially zinc deficiency, are major public health problems in Pakistan and could potentially affect the response to enteric vaccines, including oral poliovirus vaccine (OPV).

OBJECTIVE

To assess the impact of zinc supplementation among infants on immune response to oral poliovirus vaccine (OPV).

METHODS

A double-blind, randomized placebo-controlled trial was conducted in newborns (aged 0-14 days). Subjects were assigned to either receive 10mg of zinc or placebo supplementation daily for 18 weeks. Both groups received OPV doses at birth, at 6 weeks, 10 weeks and 14 weeks. Data was collected on prior immunization status, diarrheal episodes, breastfeeding practices and anthropometric measurements at recruitment and at 6 and 18 weeks. Blood samples were similarly collected to determine the antibody response to OPV and for micronutrient analysis. Logistic regression was used to determine the relationship between seroconversion and zinc status.

RESULTS

Overall, 404 subjects were recruited. At recruitment, seropositivity was already high for poliovirus (PV) serotype 1 (zinc: 91.1%; control: 90.5%) and PV2 (90.0%; 92.7%), with lower estimates for PV3 (70.0%; 64.8%). By week 18, the proportion of subjects with measured zinc levels in the normal range (i.e. ≥60 μg/dL) was significantly greater in the intervention group compared to the control group (71.9%; 27.4%; p<0.001). No significant difference in seroconversion was demonstrated between the groups for PV1, PV2, or PV3.

CONCLUSIONS

There was no effect of zinc supplementation on OPV immunogenicity. These conclusions were confirmed when restricting the analysis to those with measured higher zinc levels.

Multiple novel astrovirus species in human stool

Diarrhoea remains a significant cause of morbidity and mortality in developing countries where numerous cases remain without identified aetiology. Astroviruses are a recently identified cause of animal gastroenteritis which currently includes two species suspected of causing human diarrhoea. Using pan-astrovirus RT-PCR, we analysed human stool samples from different continents for astrovirus-related RNA sequences. We identified variants of the two known human astrovirus species plus, based on genetic distance criteria, three novel astrovirus species all distantly related to mink and ovine astroviruses, which we provisionally named HMOAstV species A-C. The complete genome of species A displayed all the conserved characteristics of mammalian astroviruses. Each of the now three groups of astroviruses found in human stool (HAstV, AstV-MLB and HMOAstV) were more closely related to animal astroviruses than to each other, indicating that human astroviruses may periodically emerge from zoonotic transmissions. Based on the pathogenic impact of their closest phylogenetic relatives in animals, further investigations of the role of HMOAstV, so far detected in Nigeria, Nepal and Pakistan, in human gastroenteritis are warranted.

Special issues related to hematopoietic SCT in the Eastern Mediterranean region and the first regional activity report

Although several centers are now performing allogeneic hematopoietic SCT (HSCT) in the Eastern Mediterranean (EM) region, the availability is still limited. Special issues including compatible donor availability and potential for alternative donor programs are discussed. In comparison to Europe and North America, differences in patterns of diseases and pre-HSCT general status, particularly for patients with BM failure, are described. Other differences including high sero-positivity for CMV, hepatitis B and C infection, and specific observations about GVHD and its relation to genetically homogeneous communities are also discussed. We report that a total of 17 HSCT programs (performing five or more HSCTs annually) exist in 9 countries of the EM region. Only six programs are currently reporting to European Group for Blood and Marrow Transplantation or Center for International Blood and Marrow Transplantation Research. A total of 7617 HSCTs have been performed by these programs including 5701 allogeneic HSCTs. The area has low-HSCT team density (1.56 teams per 10 million inhabitants vs 14.43 in Europe) and very low-HSCT team distribution (0.27 teams per 10 000 sq km area vs <1-6 teams in Europe). Gross national income per capita had no clear association with low-HSCT activity. Much improvement in infrastructure and formation of an EM regional HSCT registry are needed.

Epilepsy: public knowledge and attitude in a slum area of Karachi, Pakistan

BACKGROUND

Epilepsy is a common but widely misunderstood illness. Consequently, epileptics suffer from considerable stigmatization in society. Since no studies have detailed the misperceptions about epilepsy in our community, it is not possible to provide focused intervention aimed at eliminating this prejudice.

PURPOSE

To assess the knowledge and attitude regarding epilepsy in an adult population of a Karachi slum area.

METHODS

A face-to-face interview was conducted on 487 consenting adult non-epileptics (305 males; 182 females) who were conveniently sampled. Chi-square test was employed to calculate the variability in knowledge and attitude with demographic and other variables.

RESULTS

In all, 12.5% had never heard about epilepsy. Among the rest, 66.7% identified epilepsy as being non-infectious, while 28.2% were unaware of any treatment available for it. Among the other 71.8%, 62.7% were aware of the existence of anti-epileptic drugs. Religious/spiritual treatment was chosen as the most effective treatment by 33.1%. Males were more likely to identify epilepsy as being non-infectious (p=0.02). Nearly 18% of the respondents would not object to their child marrying an epileptic, 69.5% did not want to socially isolate the epileptics, 83.1% said epileptics could receive academic education, 85.6% said they could perform activities of daily life and 62.4% said they could become useful members of the society. Those who considered epilepsy to be infectious were more likely to carry negative attitudes towards epilepsy (p<0.01 with four attitudes).

CONCLUSIONS

Considerable gaps exist in the community's knowledge about epilepsy. Some of these may explain the prevalence of negative attitudes towards this ailment.

Bladder hemangioma as a cause of massive hematuria in a child. A case report and literature review

A 12-year-old girl with bladder hemangioma presenting with massive hematuria is described. The patient was previously operated for removal of cystic hygroma from the chest wall. The association of those two pathological entities suggests possible common etiology and pathogenesis and the various therapeutic options are reviewed.

Blood pressure and its correlates in the population of Multan, Pakistan

In a randomly selected sample of 1579 individuals (male = 1334 and female = 245), aging from 14 to 65 years and representing all the socioeconomic groups of Multan, age (Yr), height (cm), weight (kg), BMI (kg/ml) and blood pressure (mmHg) were recorded. Height was measured on a Holtain portable stadiometer, weight on beam scale and blood pressure was recorded with sphygmomanometer as per auscultatory method. The correlation coefficient between different independent (age, height, weight and BMI) and dependent (SBP, DBP and MAP) parameters in male, female and total population were calculated and strong association between different parameters was observed (p < 0.001 or p < 0.05). The regression equations (simple and multiple) were worked out. The regression coefficient of different independent parameters with dependent parameters are higher in female except for height and age-weight and age-BMI had higher contribution in female as compared with that of male.

Lower pole heminephrectomy: its role in treating nonfunctioning lower pole segments

PURPOSE

We assessed the role and long-term outcome of lower pole heminephrectomy in the treatment of nonfunctioning lower renal moieties in children with duplex kidneys.

MATERIALS AND METHODS

Between 1979 and 1994, 54 lower pole heminephrectomies were performed in 53 patients 1 to 192 months old (mean age 54) with duplex systems. A total of 15 patients was prenatally diagnosed, while the others presented with a urinary tract infection (36), orchiepididymitis (1) and failure to thrive (1). The surgical technique was essentially similar to that of upper pole heminephrectomy.

RESULTS

Operative course was uneventful except for intraoperative bleeding in 5 cases, which necessitated blood transfusion, and a postoperative urinary tract infection in 1. Followup ranged from 3 to 168 months (mean 56.9). Postoperative renograms available in 34 cases showed unchanged differential function in 12 and an ipsilateral 2 to 14% decrease (mean 5.65%) in 22. No late complications were detected except in 1 patient, who had postoperative urinary tract infections and subsequently underwent removal of the ureteral stump. Our series includes 4 patients with solitary ipsilateral upper poles (after the contralateral kidney was removed or nonfunctioning) who had good renal function at long-term followup despite the reduced parenchymal mass.

CONCLUSIONS

Based on our experience it seems that lower pole heminephrectomy is the treatment of choice in cases of nonfunctioning dilated lower segments of duplicated kidneys.

Diagnoses of acute lower respiratory tract infections in children in Rawalpindi and Islamabad, Pakistan

A hospital-based inpatient and outpatient study of 1,492 cases of acute lower respiratory tract infection (ALRI) was conducted from November 1986 to March 1988 in two hospitals in Rawalpindi and Islamabad, Pakistan. Specimens of nasopharyngeal aspirate were processed for viral studies in all cases; blood cultures were performed in 1,331 cases; and urine was obtained for detection of bacterial antigen in 378 cases, but 227 of these samples had bacterial contamination and were discarded. Respiratory syncytial virus was identified in 33% of cases, and Haemophilus influenzae and Streptococcus pneumoniae were identified in 9.6% and 9.9% of cases, respectively. Nonencapsulated H. influenzae accounted for 32% of the Haemophilus isolates, and type b was the only encapsulated H. influenzae strain identified. Of the S. pneumoniae serotypes isolated, 31% are not included in the currently available polyvalent pneumococcal vaccine. No clinical characteristic was demonstrated to be a reliable indicator for bacterial ALRI.