Prema Menon

Effect of propranolol vs prednisolone vs propranolol with prednisolone in the management of infantile hemangioma: a randomized controlled study.

AIMS AND OBJECTIVES The purpose of this study was to compare the efficacy of orally administered propranolol versus prednisolone versus both in the treatment of potentially disfiguring or functionally threatening infantile hemangiomas. MATERIAL AND METHODS A prospective study of 30 patients aged 1 week-8 months was randomized into three equal groups. These were as follows: A, propranolol (2-3 mg/kg/d); B, prednisolone (1-4 mg/kg/d); and C, receiving both for a minimum duration of 3 months. Dimensions, color, consistency, ultrasonography, photographic documentation based on Visual Analogue Scale (VAS) were recorded before and periodically after starting treatment. A minimum 75% improvement was considered as success with no regrowth up to 1 month of stopping treatment. RESULTS Mean initial response time (days) in A (4.1±3.3 SD) and C (4.7±3.4SD) was significantly lower than B (9.78±7.8SD) (p<0.047). Significant change in consistency was noted very early in A (24 hours) compared to B and C (8 days). VAS results are as follows: (a) color fading--significant reduction in A within 48 hours compared to B and C (p=0.025), (b) flattening--more significant and earlier in A and C than B (p<0.05), and (c) mean reduction in size: significant in A and C at 3 months (p=0.005, p=0.005), 6 months (p=0.005, p=0.008), 12 months (p=0.005, p=0.008), and 18 months (p=0.02, p=0.04), whereas in B, it was seen only at 6 months (p=0.008). CONCLUSIONS Propranolol had a consistent, rapid therapeutic effect compared to prednisolone. A combination of the two had a comparable but not higher efficacy than propranolol alone. Prednisolone was associated with a higher number of complications, thereby decreasing patient compliance.

Beware of neonatal appendicitis

We report a neonate with acute appendicitis who was mistakenly diagnosed and treated initially as neonatal necrotizing enterocolitis. The diagnostic dilemma of this rare and life-threatening condition in premature babies and newborns is underlined. Awareness of this rare condition and possible differential diagnosis in this age group is also discussed.

Posterior urethral valves: incidence and progress of vesicoureteric reflux after primary fulguration

This is a prospective study of 20 cases of posterior urethral valves (PUV) presenting between the ages of 12 days and 5.5 years (median 15 months) in order to determine the incidence and progress of vesicoureteric reflux (VUR), hydronephrosis (HN), and renal functional status. The efficacy of fulguration as the sole modality of treatment for PUV was assessed in terms of improvement or disappearance of VUR over a 6-month follow-up period. VUR was present in 60% of the patients, being unilateral in 41.7%. Out of 19 renal units with VUR, reflux subsided in 31.5% by 3 months and 78.94% by 6 months. The blood urea and serum creatinine levels, which were raised in 50% of the patients at presentation, came down to normal by 6 months in all the cases. Improvement in glomerular filtration rates (GFR) was noted in all the children at each follow-up and was found to be statistically significant (p<0.01). HN was present in all the patients at presentation and was bilateral in 90%. It decreased significantly during the follow-up period, though its complete disappearance was seen only in one case. Vesicoureteric reflux dysplasia syndrome (VURD) was present in two cases. Our study showed that VUR disappeared in a majority of the cases by 6 months once adequate urethral patency was restored, although hydronephrosis persisted.

Gastric augmentation in isolated congenital microgastria

A 10-month-old boy with isolated congenital microgastria is reported. This is an extremely rare condition with only 2 previous similar case reports. The patient was treated successfully with early gastric augmentation. Although the embryologic origin of this anomaly was widely believed to be in the fourth week of gestation, the anatomic features in the current case point to the arrest of development at least after the eighth week of fetal life.

Pancreatitis with panniculitis and arthritis: a rare association

A case of pancreatitis with polyarthritis and panniculitis is reported because of its rarity and the severe nature of the disease.

Congenital microgastria with esophageal stenosis and diaphragmatic hernia

A rare case of congenital microgastria in association with distal esophageal stenosis and left-sided congenital diaphragmatic hernia is reported. Other features included megaesophagus and asplenia. The probable causative factors are discussed.

Meckel’s diverticulum with segmental dilatation of the ileum: radiographic diagnosis in a neonate

We report a neonate with segmental dilatation of the ileum and a Meckel’s diverticulum that was diagnosed preoperatively on the plain abdominal radiograph.

Rupture of the right hemidiaphragm due to blunt trauma in children: a diagnostic dilemma.

Abstract The diagnosis of right-sided diaphragmatic rupture (RDR) due to blunt abdominal trauma is often missed in the acute setting, especially in the absence of other thoracoabdominal injuries. We describe two such children. The problems associated with the diagnosis and management of RDR are discussed to emphasize the need to have a high index of suspicion for this entity.

Congenital pouch colon associated with anorectal agenesis (pouch colon syndrome)

Dear Sir, The review article by Rajiv Chadha on ‘‘Congenital pouch colon associated with anorectal agenesis’’ (Pediatr Surg Int 2004; 20:393–401) was interesting. We would like to mention the following observations regarding this disease. Four types of congenital pouch colons (CPC) have been described [1]. In type I, the entire colon is converted into a pouch; in type II, the caecum enters into a pouch; and in type III, at least 10–15 cm of normal colon is present proximal to the pouch. In a type IV pouch colon, only the terminal portion of the colon, i.e. rectum and sigmoid, is transformed into a pouch. The author states that only 7.8% cases of CPC have been reported outside India. We are of the opinion that the incidence in the West is much higher than the one quoted, as many cases of type IV CPC are being inappropriately labelled as rectal ectasia/megarectum-megasigmoid. The case reports of Cloutier et al. [2], Peña et al. [3], and several others are a case in point [4–9]. Children who continued to suffer from severe constipation and overflow incontinence following previous surgery for low/intermediate anorectal malformations (ARM) were referred to these authors. There was no anal stricture, and all children had normal sphincter contraction and sensation. Contrast enemas showed massive stool-filled rectosigmoid with abrupt transition to normal-sized proximal colon. Following excision of the dilated bowel, all the children improved. This abrupt change in the diameter of the bowel is a classical feature of CPC [1]. Girls with anovestibular fistula may not decompress well despite an adequate anal opening. To avoid the abovementioned problem, we routinely perform a barium enema prior to anorectoplasty to rule out a CPC. Over the years, we have observed a striking trend of reducing severity of pouch colon—e.g. from type I towards type IV—in our part of the world. Although only one case of type IV CPC was seen out of a total of 56 cases between 1968 and 1984, the figure rose to 46 out of a total of 81 cases between 1985 and 1999 [10]. A study from another tertiary centre in India also showed that out of 41 cases of CPC, 51% were type IV pouch colon [11]. Whether this change is due to improving nutrition in the community or diminishing effect of the causative agent is unknown. The cases reported in the Western literature also appear to be corresponding to type IV pouch, which is usually associated with low/intermediate ARM. Increased awareness of this entity is essential to avoid postoperative problems of severe constipation in this subgroup of patients with ARM as exemplified in the reported cases [2–9]. Excellent results can be obtained by complete excision of the pouch in all cases of type IV CPC prior to anoplasty.

Surgical management and outcome analysis of stage III pediatric empyema thoracis.

Aim: Report of 125 pediatric patients of empyema thoracis treated by open decortication, highlighting the presentation, delay in referral, operative findings, the response to surgical intervention and follow-up. Materials and Methods: All the children who underwent open decortication for stage III empyema thoracis during the study period were included. Preoperative workup included hemogram, serum protein, chest radiographs and contrast-enhanced computed tomographic (CECT) scan of the chest. Results: One hundred and twenty-five patients (81 males, 44 females) (age 3 months–12 years, mean 4.9 years) were operated during a 4.5-year period. Among them, two children underwent bilateral thoracotomies. Also, 81.6% patients were referred 3 weeks after the onset of disease (mean duration 9 weeks). Intercostal chest drainage (ICD) had been inserted in (119) 95% cases. Thickened pleura, multiloculated pus and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in 10 patients and empyema necessitatis in 2. Decortication, removal of necrotic tissue and closure of air leaks was performed in all the patients. Necrotizing pneumonia was seen in (35) 27.5% cases. Mean duration of postoperative ICD was 7 days. Follow-up ranged from 3 months to 4 years (mean 12 months). There was no mortality. Six patients had proven tuberculosis. Conclusions: The duration of the disease had a direct relationship with the thickness of the pleura and injury to the underlying lung. Delayed referral causes irreversible changes in the lung prolonging recovery. Only 18% presented within the early period of the disease. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.