Formulation of Research Question - Stepwise Approach.

Formulation of research question (RQ) is an essentiality before starting any research. It aims to explore an existing uncertainty in an area of concern and points to a need for deliberate investigation. It is, therefore, pertinent to formulate a good RQ. The present paper aims to discuss the process of formulation of RQ with stepwise approach. The characteristics of good RQ are expressed by acronym "FINERMAPS" expanded as feasible, interesting, novel, ethical, relevant, manageable, appropriate, potential value, publishability, and systematic. A RQ can address different formats depending on the aspect to be evaluated. Based on this, there can be different types of RQ such as based on the existence of the phenomenon, description and classification, composition, relationship, comparative, and causality. To develop a RQ, one needs to begin by identifying the subject of interest and then do preliminary research on that subject. The researcher then defines what still needs to be known in that particular subject and assesses the implied questions. After narrowing the focus and scope of the research subject, researcher frames a RQ and then evaluates it. Thus, conception to formulation of RQ is very systematic process and has to be performed meticulously as research guided by such question can have wider impact in the field of social and health research by leading to formulation of policies for the benefit of larger population.

Is tubularization of the mobilized urethral plate a better alternative to tubularization of an incised urethral plate for hypospadias repair?

INTRODUCTION: Trial of a new procedure of hypospadias repair based on the incorporation of the entire available innate urethral tissue for the formation of neo-urethra in patients with hypospadias. MATERIALS AND METHODS: Fifteen consecutive children, nine with distal hypospadias and six with proximal hypospadias (all with severe chordee), whose parents consented to application of a new procedure of hypospadias repair, were the study subjects. This procedure is inspired by Cantwell Ransley procedure for epispadias repair and Snodgras procedure for hypospadias repair. The entire urethral plate was mobilized (i.e., lifted off the corpora) distal to the urethral meatus and was tubularized in two layers; inner urethral skin and outer spongiosal tissue, in Duplay fashion. The repair was reinforced with dartos vascularized flap. The skin incisions on the urethral strip are guided by the disposition of the spongiosal tissue underlying the urethral plate (rather than the conventional U-shaped incision on either side of hypospadiac urethral meatus). In the patients with proximal hypospadias with severe chordee urethral advancement was combined to achieve orthoplasty and a single stage hypospadias repair. The catheter was removed on tenth postoperative day. RESULTS: Even in patients with proximal hypospadias with severe chordee, good single staged repair was achieved without resorting to dorsal plication that would have been necessary had any other methods based on the preservation of urethral plate was performed in these subjects. Therefore, the procedure was found to have an extended applicability to even those patients where tubularized incised urethral plate urethroplsty is not advised. All patients had good results (in 1 year follow-up), except in three early subjects of the series; two of whom developed minor urethrocutaneous fistulae (probably due to frank urinary leak secondary to repeated catheter blockade) and one developed partial glanular wound dehiscence. CONCLUSIONS: Though the authors have an initial limited experience with this procedure, the procedure is likely to have a promising future due to its versatility and utilization of the entire urethral tissue.

Omphalomesenteric duct cyst as a content of omphalocele.

A rare occurrence of an omphalomesenteric duct cyst in an exomphalos minor sac is reported herein. The noteworthy points in this case were an unusual presentation of the rarest variety of umbilical cord cyst. The tapering intra-abdominal end of the cyst was found to be attached to the ileal mesentry, thereby simulating a herniating mesenteric cyst till the histolopathological report resolved the issue.

A neonate with anorectal malformation with rare limb defects report of a case.

A 2-day-old male infant, born of a non-consanguineous marriage and uneventful pregnancy was found to have anomalies of vertebral, anal, cardiac, tracheo-esophageal, radial and limb (VACTERL) association. The striking feature was the simultaneous occurrence of two rare limb defects of right upper and lower limb in the baby who also had imperforate anus and ventricular septal defect. These limb defects were-meromelia of the right upper limb (due to transverse deficiency of right humerus and absence of all the bony elements distally), and a short right lower limb due to co-existence of proximal femoral hypoplasia and fibular hemimelia. We could not trace the co-existence of these rare skeletal defects in any case with VACTERL association in the existing English literature, as was observed by us. The simultaneous occurrence of the defects involving distant anatomic sites supports the hypothesis of 'axial mesodermal dysplasia' in our patient, rather than 'caudal regression syndrome', as is popularly held in patients with anorectal malformation (ARM). Further, it points to occurrence of an early embryonic insult, probably taking place at blastogenic stage, when the developing embryo can be considered a polytopic development field. However, in absence of antenatal history suggestive of exposure to a known teratogen and a chromosomal analysis, it appears that the spectrum of anomalies in this neonate might have resulted secondary to early amniotic leak and temporary oligohydramnios.

Temporary transgastric fistula occlusion as salvage procedure in neonates with esophageal atresia with wide distal fistula and moderate to severe pneumonia.

A method to achieve distal fistula occlusion by inflating the balloon of a catheter placed at the gastroesophageal junction via a transgastric route was tried in seven consecutive neonates with esophageal atresia and wide distal fistula. Due to associated moderate or severe pneumonia, these infants were at poor anesthetic risk for the definitive repair. The procedure was done under local anesthesia with mild sedation and took an average of half an hour for completion. Another feeding tube was negotiated through another gastrotomy across the pylorus to allow early enteral feeds. Temporary transgastric fistula occlusion (TTFO) allowed better ventilation of the hypocompliant lungs (by increasing resistance at the fistulous end), prevented lung injury due to aspiration of the refluxing gastric juices, and facilitated optimal ventilation by preventing epigastric distension. All study subjects survived this procedure except for one of our earlier study subjects who died of massive pneumothorax that was a procedure-related complication. None of the remaining subjects required mechanical ventilation either after TTFO or after the definitive esophageal repair that was carried out 5-7 days subsequent to TTFO, except for one other neonate with right lung aplasia who began deteriorating 48 h after thoracotomy and died of cardiac failure. There were no anastomosis-related problems among the survivors over a 12-month follow-up. The gratifying results of our study prompt us to suggest that this procedure deserves attention, and its role should be explored for salvaging neonates with type C esophageal atresia with wide fistula and pneumonia in developing countries with few neonatal intensive care services.

Dermatological side effects of brimonidine: a report of three cases.

Brimonidine is a potential first line therapy for primary open angle glaucoma (OAG) and ocular hypertension (OHT). It is known to cause various ocular and systemic side effects. Being a newer drug, the whole spectrum of its adverse effects is not known. The dermatological side effects caused by brimonidine have rarely been reported before. We present three OAG patients who presented to us with contact dermatitis of periorbital skin and lichen planus of nail following the use of topical brimonidine (0.2% twice a day) for more than six months. These side effects slowly disappeared on discontinuing the drug but reappeared on reintroducing topical formulation. Such side effects from the use of brimonidine have not been reported before.

Perineal accessory scrotum.

A boy with perineal accessory scrotum but without any other congenital anomaly is being described. He presented with a rugose skin tag on a midline perineal mound and the diagnosis could be confirmed by the histological findings of subcutaneous smooth muscles. Other reports of perineal scrota have been reviewed and a simple classification has been proposed for such cases, based on the appearance of the accessory scrotum and the associated anomalies.

Unusual presentation of gastric duplication cyst in a neonate with pneumoperitoneum and vertebral anomalies.

An unusual case of communicating, tubular gastric duplication (GD) of the greater curvature of the stomach presenting with pneumoperitoneum is described. The pneumoperitoneum resulted due to simultaneous mechanical rupture of stomach and its duplication cyst due to birth trauma and vigorous post delivery resuscitation. No case of this kind has been reported earlier in English literature, though instances of ulcerative perforation of neonatal stomach and GD are known. There was radiographic evidence of multiple thoracic vertebral anomalies, again a rare occurrence with GD cyst. Further, a diagnostic dilemma was faced in this patient as the presence of radiographic sign of "gastric bubble" on plain radiographs in this patient suggested the source of free intraperitoneal air to be extragastric and the diagnosis could be made only at surgery. The authors have reviewed the pertinent literature on neonatal gastric perforation and GD cysts and uphold "split notochord" theory as etiology for GD in this patient.

Large benign cystic teratoma of the mesosigmoid causing intestinal obstruction: report of a case.

We report the case of a large benign cystic teratoma of the mesosigmoid in a 2-year-old child. To the best of our knowledge, this type of lesion has never been described in the English literature, although there are a few reports of teratomas arising from the greater and lesser omentum. There was diagnostic confusion due to the rarity of a teratoma arising from the peritoneal folds and also because calcification was not detected radiologically. A brief review of the literature on the diagnosis and treatment of similar lesions is presented.

Risk factors for mortality within first 24 hours of head injury.

OBJECTIVE: Immediate or instantaneous death following cranial trauma occurs due to unpreventable primary brain insults. However, death occurring within 24 hours of head injury can be averted by timely institution of the therapeutic measures that could prevent secondary brain insults. From the management point of view, this is the most important subset of all head injured patients. Therefore, it is important to study risk factors associated with such deaths. METHODS: In a retrospective study undertaken at Trauma Center, Safdarjang Hospital, New Delhi, the demographic characteristics, neurological and radiological findings were studied for 100 head injured children admitted in the pediatric surgical ward, who later died after surviving the initial neurosurgical resuscitation. Death occurring within first 24 hours of head injury was defined as "early" death; and "late death", if it occurred thereafter. RESULTS: Bivariate analysis revealed the severity of head injury GCS<=8 (OR: 3.09; 95% CI: 1.22-7.8), a finding of diffuse brain edema, (OR: 3.73; 95% CI: 0.95-14.74), midline shift (OR: 4.8; 95% CI: 1.03-22.37) on cranial CT scans were found to be statistically associated with early deaths. Child's age or gender, the mode of injury and the presence of extracerebral injuries were not found to be significantly associated. When these variables were simultaneously considered in a multivariate logistic regression model, the diffuse brain edema on head CT scan was found to be both clinically and statistically significant of early death (Adj. OR: 527; 95% CI: 1.23-22.6). However, absence of hemorrhagic contusion was clinically important predictor of an early death (Adj. OR: 6.45; 95% CI: 0.68.-62.5) though not statistically significant

A survivor following repair of laryngotracheo-esophageal cleft: lessons learned.

A survivor, following successful repair of laryngotracheo-esophageal cleft extending up to cervical trachea, is being described. The cleft was repaired with anterior laryngofissure approach, using no interposition of tissue between trachea and esophagus. The patient had an uneventful recovery, short hospitalization, and satisfactory outcome on follow-up for over 1-1/2 years, as of now. Optimum ventilation was achieved intra-operatively via an endotracheal tube passed through operative field, following visualization of the cleft. Postoperatively, mechanical ventilation was given via nasotracheal tube left indwelling in trachea following completion of tracheal repair. Early nutrition through enteral route was started 72 hours postoperatively by drip feeds (using infusion pump) through a soft nasogastric tube that was left indwelling following esophageal repair. This maneuver, along with positional and medical therapy, helped us to gain control over gastro-esophageal reflux that is known to be incapacitating in these patients. The authors recommend a reexamination of existing management strategies for patients with laryngotracheo-esophageal clefts and suggest that conservative approach in dealing with associated problems can help decrease morbidity in these patients.