Muhammad Arif Mateen Khan

Penetrating pharyngeal injuries in children: trivial trauma leading to devastating complications

Pharyngeal perforations are uncommon in children and are usually secondary to instrumentation or external penetrating injuries. A delay in management can lead to life-threatening complications such as retropharyngeal abscess, mediastinitis, and airway compromise. We report three children who had pharyngeal perforation due to apparently innocuous injury and who developed serious complications. A high index of suspicion for a significant pharyngeal injury, use of lateral soft-tissue x-ray films of the neck, and flexible endoscopy in the emergency room can assist in early diagnosis when evaluating patients with oropharyngeal and penetrating neck injury. Prompt administration of broad-spectrum antibiotics, local drainage, and debridement can evert life-threatening complications.

Prevalence and demographics of anxiety disorders: a snapshot from a community health centre in Pakistan.

BackgroundThe developing world is faced with a high burden of anxiety disorders. The exact prevalence of anxiety disorders in Pakistan is not known. There is a need to develop an evidence base to aid policy development on tackling anxiety and depressive disorders in the country. This is the first pilot study to address the prevalence of anxiety disorders and their association with sociodemographic factors in Pakistan.MethodsA cross-sectional study was conducted among people visiting Aga Khan University Hospital (AKUH), a tertiary care facility in Karachi, Pakistan. The point prevalence of anxiety amongst the sample population, which comprised of patients and their attendants, excluding all health care personnel, was assessed using the validated Urdu version of the Hospital Anxiety and Depression Scale (HADS). The questionnaire was administered to 423 people. Descriptive statistics were performed for mean scores and proportions.ResultsThe mean anxiety score of the population was 5.7 ± 3.86. About 28.3% had borderline or pathological anxiety. The factors found to be independently predicted with anxiety were, female sex (odds ratio (OR) = 2.14, 95% CI 1.36–3.36, p = 0.01); physical illness (OR = 1.67, 95% CI 1.06–2.64, p = 0.026); and psychiatric illness (OR = 1.176, 95% CI 1.0–3.1, p = 0.048). In the final multivariate model, female sex (adjusted odds ratio (AOR) = 2, 95% CI 1.28–3.22) and physical illness (AOR = 1.56, 95% CI 0.97–2.48) were found to be significant.ConclusionFurther studies via nationally representative surveys need to be undertaken to fully grasp the scope of this emerging public health issue in Pakistan.

Colonic perforations in enteric fever.

We report a case of multiple colonic perforations in a 5-year-old boy due to typhoid fever. The main objective is to present the occurrence of this complication and discuss the management. The patient was admitted with nine days history of high-grade fever and abdominal pain. On examination, he was very sick looking child with acute abdomen. After initial workup and resuscitation, laparotomy was performed which revealed multiple colonic perforations with feacal peritonitis. The case revealed that one must not forget to inspect entire intestine including colon, as there may be perforations present in the large bowel.

Point-of-care lactate measurement in resource-poor settings

Early identification of sepsis and septic shock, along with its aggressive goal directed therapy, is proven to improve outcomes in paediatric patients.1 The American College of Physicians and Surgeons has published clinical guidelines that have been incorporated into the American Heart Association Paediatric Advanced Life Support courses, which indicate early recognition and management of septic shock in the paediatric age group improves survival in a community-based setting.1 Although a diagnosis of septic shock in adults requires cardiovascular dysfunction and hypotension, it is much harder to identify in children and is likely evolving long before any clear systemic, clinical decompensation.1 Emergency departments (EDs) around the world are the main entry point to hospitals and deal with a high throughput. In low-and-middle-income countries (LMICs), this burden is compounded by resource restraint. Factors such as the transport of the testing samples to the primary testing facility result in an inevitable delay to report the result, which, in turn, leads to a delay in the initiation of the appropriate management of the patient. Aggressive therapy with fluid resuscitation and possible inotropic support drastically reduces the mortality rate: with each passing hour of unrecognised and untreated cases, the mortality increases twofolds.1 The capacity to make rapid decisions and start appropriate treatment early in time may decrease the patients stay in the ED, reducing the financial strain and occupancy burden in the presence of limited resources. …

Congenital prepubic sinus—An aborted dorsal urethral duplication or a cloacal remnant?

BACKGROUND Congenital Prepubic Sinus (CPS) is an uncommon urogenital anomaly characterized by a blind tract between the skin over the pubis to anterior of the urinary bladder, Urethra or umbilicus. We report four such cases to emphasize varied clinical presentation and embryological conundrum. METHODS Following Ethical Review Committee (ERC) approval, medical records of pediatric patients (<16 years) presenting with CPS (identified through operating room records and Hospital Information Management System (HIMS) between 1994 and 2018 were reviewed for demographics, clinical presentation, investigations including histopathology, management and outcome. RESULTS Four cases of CPS, 3 females and 1 male, age range 9 months to 13 years were managed over 25-years. Clinical presentation includes a discharging sinus and recurrent episodes of cellulitis and abscess formation in pubic area and labia majora. Urological investigations were mostly normal. Insertion of lacrimal probe or plastic sheath of intravenous cannula through the sinus opening was useful to determine the course of sinus and aid its excision. Histology of excised sinus highlights the possible embryological origin. CONCLUSIONS CPS is a rare anomaly with varied clinical presentation. It seems CPS is an aborted urethral duplication (Stephen Type 3) or a Cloacal remnant. Complete excision of the tract in the reported cases was curative. TYPE OF STUDY Case series. LEVEL OF EVIDENCE IV.

Recurrent and acquired tracheoesophageal fistulae (TEF)—Minimally invasive management

OBJECTIVE Recurrent and acquired fistulae are a serious complication of congenital esophageal atresia and tracheoesophageal fistula (TEF) repair and foreign body ingestion (FBI) (e.g., button battery). We report our experience with a minimally invasive approach to recurrent and acquired TEF. METHODS Medical records of patients referred for management of recurrent and acquired TEF between 2003 and 2015 were reviewed retrospectively. Patients underwent endoscopic procedures (de-epithelization of fistulous tract and fibrin tissue adhesive-TisseelR) under general anesthesia. RESULTS Nine children (7 male, 2 female) with age range 3months to 3years (mean 1.5year) were managed. TEF closed spontaneously in four patients, whereas in 5 patients the TEF closed after combined endoscopic procedure. Three patients required repeat endoscopic procedures. Follow-up ranged between 7months to 10years (mean 4.2years). CONCLUSIONS Active observation and repeat combined endoscopic procedures are safe alternatives to open surgical repair of acquired and recurrent TEF. LEVEL OF EVIDENCE Level IV study.

Protean and intangible manifestation of renal stones in children

In the last decade, renal stones are being diagnosed more frequently in children across the globe. Children with renal stone often present with non-specific and subtle symptoms. Diagnosis of urolithiasis in children therefore requires a high index of suspicion especially for those living in endemic regions and with a positive family history. Additionally, management requires judicious use of radiological imaging by treating physicians.