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Background As the COVID-19 pandemic completes 1 year, it is prudent to reflect on the challenges faced and the management strategies employed to tackle this overwhelming health care crisis. We undertook this study to validate our institutional protocols, which were formulated to cater to the change in volume and pattern of neurosurgical cases during the raging pandemic. Methods All admitted patients scheduled to undergo major neurosurgical intervention during the lockdown period (15 March 2020 to 15 September 2020) were included in the study. The data involving surgery outcomes, disease pattern, anesthesia techniques, patient demographics, as well as COVID-19 status, were analyzed and compared with similar retrospective data of neurosurgical patients operated during the same time period in the previous year (15 March 2019 to 15 September 2019). Results Barring significant increase in surgery for stroke (P = 0.008) and hydrocephalus (P

Both the self inflating bag and the T-piece resuscitator are recommended for neonatal resuscitation, but many health care workers are unfamiliar with using the latter. A prospective, comparative, observational study was done to determine the ease and effectiveness of training of health care personnel in the two devices using infant training manikins.100 health care workers, who had no prior formal training in neonatal resuscitation, were divided into small groups and trained in the use of the two devices by qualified trainers. Assessment of cognitive skills was done by pre and post MCQs. Psychomotor skill was assessed post training on manikins using a 10-point objective score. Acceptance by users was ascertained by questionnaire. Assessments were also done after 24 h and 3 months. Comparison was done by Chi square and paired t-tests.Pre-training cognitive tests increased from 3.77 (+1.58) to 6.99 (+1.28) on day of training which was significant. Post training assessment of psychomotor skills showed significantly higher initial scores for the T-piece group (7.07 + 2.57) on day of training. Reassessment after 24 h showed significant improvement in cognitive scores (9.89 + 1.24) and psychomotor scores in both groups (8.86 + 1.42 for self inflating bag and 9.70 + 0.57 for T-piece resuscitator). After 3-6 months the scores in both domains showed some decline which was not statistically significant. User acceptability was the same for both devices.It is equally easy to train health care workers in both devices. Both groups showed good short term recall and both devices were equally acceptable to the users.

Introduction: Diagnosis of bacterial infections remains one of the greatest challenges in medical science, especially in children, in whom clinical signs are often nonspecific. The currently used sepsis screen has poor predictive value. Recently introduced marker procalcitonin (PCT) with high sensitivity and specificity is evaluated as early marker of serious bacterial infection in children. Materials and Methods: Children up to 5 years of age presenting with features of Systemic Inflammatory Response Syndrome(SIRS) were evaluated clinically and underwent standard sepsis screen namely total leukocyte count (TLC), peripheral blood smear for band count, C-reactive Protein (CRP) and newer tests like procalcitonin (PCT) and Interleukin-8 (IL-8). Results were analyzed using SPSS14.0. Results: One hundred patients suspected of sepsis were evaluated. Maximum cases were below one year (37%) with mean age of 27 months. Male:female ratio was 1.5:1. Respiratory system was the commonest system involved in (54%) followed by gastrointestinal (20%), genitourinary (10%) and central nervous system (5%). Seventy two cases were found to have confirmed sepsis, proven by blood culture (34%) and other investigations. Fifty two cases were diagnosed by conventional markers, while newer markers in 60 cases. Diagnostic evaluation revealed that newer markers have higher sensitivity and specificity as compared to conventional sepsis screen. Conclusion : Procalcitonin is a useful marker for diagnosis of serious bacterial infections in children and in combination with IL8 has a higher sensitivity and specificity as compared to standard sepsis screen. Therefore it is recommended that procalcitonin should be used for the screening of sepsis in children so that the treatment can be started earlier in order to prevent morbidity and mortality. DOI: http://dx.doi.org/10.3126/jnps.v33i2.7988 J Nepal Paediatr Soc. 2013; 33(2):106-109

To study the prevalence of covert or early renal involvement among human immunodeficiency virus (HIV) positive children. A cross-sectional observational study was carried out on 250 HIV positive children (2–18 y) on follow-up in a tertiary care hospital from January 2014 through June 2015. Those who met the study criteria were evaluated for microalbuminuria and glomerular and tubular dysfunctions. Fifty-one out of two hundred fifty (20%) children were found to have microalbuminuria though none had any other evidence of renal dysfunction. The incidence of microalbuminuria in children on Anti Retroviral Therapy (ART) and those not on ART was 20% and 21% respectively. Neither was there any difference in those with a CD4 count ≤500/cu mm compared with those with counts >500/cu mm. However, the overall CD4 counts were significantly lower in children with microalbuminuria. Microalbuminuria was detected in 20% of asymptomatic HIV positive children suggesting early glomerular dysfunction and need for regular screening and follow-up.

Inflammation is an important aspect of the pathophysiology of bronchial asthma and measurement of inflammatory markers of airways can aid in management. Nitric oxide measurement in exhaled breath is a non-invasive method of determining airway inflammation which can be used in assessing severity and response to treatment in children with bronchial asthma.Thirty children in the age group 6-14 years with previously or newly diagnosed bronchial asthma reporting for the first time to a tertiary care hospital constituted the study group. Assessment was done by history, clinical examination, spirometry and measurement of fractional excretion of nitric oxide (FeNO) before commencement of treatment as per standard guidelines and on follow up at 2 to 4 weeks intervals for a minimum of three times.There was significant correlation between FeNO values, spirometry parameters and clinical profile in the first visit before the initiation of therapy. Children with higher FeNO in the first visit responded better to Inhaled Corticosteroids (ICS) with good clinical and spirometry responses and fall in FeNO on second visit. However, in subsequent visits no significant correlation was observed between clinical control, FeNO levels and spirometry.High FeNO values at first presentation could give us a clue as to whether or not a child would respond to ICS but FeNO monitoring may not be helpful in long term follow up as various other factors can affect its value.

A 04-year-old child sustained a severe head injury as a result of a fall from the fourth floor to a cemented surface on 20 Sep 2011. Prompt resuscitation by the pediatric team and decompressive craniectomy followed by elective ventilation resulted in remarkable recovery of both the motor deficit (Hemiplegia) and Dysphasia.

Symptoms and signs of infection are non-specific in neonates. Hence, neonates, especially low birth-weight and premature ones, often receive empirical antibiotics. This study was conducted to assess the use of antibiotics in newborns with a birth-weight of2000 g at a tertiary care service hospital.All infants2000 g at birth admitted to NICU were include Data on symptoms, investigations for infection and use of antibiotics were collected in addition to baseline data. The data of those surviving to discharge was analyzed.Out of 52 eligible infants, 3 died; thus data from 49 neonates was analyzed. Preterm infants formed 89.8% of this group while 36.73% were Small for Gestational Age (SGA). Symptoms were present in 22 (44.9%) of whom 13(59.1%) received antibiotics. Lower birth weight, lower gestational age and male sex predisposed to increased antibiotic use. A total of 21 courses of antibiotics were administered which averaged to 1.6 course or 15 days of therapy per patient. The most common combination used was cefotaxime-amikacin in 42.9% followed by ampicillin-gentamicin in 33.3%. The overall mortality for this group was 5.8% while mortality due to infection was 1.9%.Attention to asepsis in the NICU, close monitoring and judicious use of antibiotics only when indicated can result in decreased empirical use of antibiotics and better outcome. Low birth-weight, prematurity and male sex are significantly associated with antibiotic use in this study.

Wegener's granulomatosis, characterized by multisystem granulomatous inflammation and necrotising vasculitis, is rarely seen in children and, to date, there are less than 100 cases reported in the world literature in children under 15 years of age. No published Indian report is available. We report a case of a 13-year old boy who presented with typical features, had a rapid course and succumbed due to massive pulmonary hemorrhage.

Despite extensive research into its patho-physiology, investigations and treatment, sepsis remains an important cause of neonatal morbidity and mortality. The incidence in developing countries is 10 times that in the developed world. A large number of pro-and anti-inflammatory cytokines (interleukins, eicosanoids, tumour necrosis factor-alpha, nitric oxide) have been identified, the interplay of which leads to the Systemic Inflammatory Response Syndrome (SIRS) which can have devastating consequences on all systems of the body. In India the common organisms include Staphylococcus, E coli, Klebsiella and Candida. A number of maternal and neonatal risk factors have been identified. The initial signs and symptoms are subtle and can easily be missed. Early investigations and screening tests are important and a promising number of new tests are being studied. The gold standard for diagnosis is a positive culture from a body fluid or local source in the presence of SIRS. The threshold for starting antibiotics should be low in high-risk neonates and broad spectrum antibiotics covering the likely organisms should be given intravenously in all suspected cases in a hospital setting. This should be continued for at least 24-48 hours (till negative reports are available) in suspected cases and for 2-3 weeks in proven cases. Prophylaxis is aimed at preventing nosocomial and cross infections. Strict hand-washing, meticulous asepsis protocols, identification of high risk groups and prompt and better screening tests are essential in controlling this problem.

A female child presented with clitoromegaly due to virilisation caused by congenital adrenal hyperplasia (CAH). After correction of the endocrine imbalance, clitoral reduction was done by the ventral approach. The advantages of the ventral approach over the traditional dorsolateral approach are discussed.

Auto immune haemolytic anemias (AIHA) are rare in childhood [1]. They usually present with pallor, icterus, hepatosplenomegaly and a positive direct antiglobulin (DAT or Coombs) test. Various modalities of treatment have been tried for severe cases with certain amount of success. We report a case of AIHA which initially presented in the neonatal period, was of a severe degree and responded dramatically to intravenous Immunoglobulins. Case Report Baby B. a male neonate, was born uneventfully of a non-consanguineous marriage and was well till 21 days of life when he presented at a hospital outside Mumbai with fever and jaundice of a few days duration. There was no feed refusal or evidence of sepsis. He was found to be anaemic with a Hb of 8 gm/dl. Investigations for haemolysis including a DAT done after an initial blood transfusion were negative. Baby's blood group was B +ve and mother's was AB+ve. Serum bilirubin was 15 mg/dl (indirect positive). Septic screen was negative. Platelet count was normal. Though a definite diagnosis at the time of first presentation at the peripheral hospital could not be made, he required 9 blood transfusions over the next 14 days just to maintain his hemoglobin at 7 gm/dl. He was then transferred to Mumbai for further investigations and management. On admission to INHS Asvini he was pale, mildly icteric and irritable. Weight was normal for age and he was accepting feeds well. There was no evidence of infection. Serum bilirubin was 5 mg/dl. His Hb was 8.5 gm/dl. Peripheral smear showed a normochromic, normocytic anaemia with no evidence of haemolysis. However, Coombs Test (DAT) was repeatedly positive. Reticulocyte count was 2%. G6PD screening test was negative. Osmotic fragility and hemoglobin electropheresis were normal for age. Since his hemoglobin remained the same over the next two weeks without requirements of blood transfusion, he was discharged without any specific treatment but with advice to follow-up after two months (Table 1). In January ’97, at the age of 3 months, he again presented with similar complaints of pallor, irritability and jaundice and was found to have a Hb of 5 gm/dl. There was no evidence of prior drug ingestion or viral infection. He was given 3 blood transfusions and was then transferred to Mumbai. Here he was found to have a Hb of 3.5 gm/dl with hepatosplenomegaly (liver being 4 cm and spleen, 7 cm). Reticulocyte Production Index (Reticulocyte Count % × Observed Hb/Expected Hb × 1/µ) was 4. Peripheral smear showed evidence of haemolysis in the form of normoblastemia, polychromasia and misshapen red blood cells. Bone marrow examination (which was done as part of work-up to rule out paroxysmal nocturnal hemoglobinuria) showed erythroid hyperplasia. DAT was repeatedly positive. Indirect antiglobulin test on patient's serum was weakly positive and patient's serum showed weak reactivity by enzyme technique at 37 ° C, confirming the diagnosis of auto immune haemolytic anaemia due to warm antibodies. The patient was started on oral Prednisolone at 3 mg/Kg/day. After two weeks of steroids his blood pressure, which was previously normal, increased to 110/70 mm of Hg (90th percentile for age) and hence Prednisolone was decreased to 2 mg/Kg/day following which his blood pressure returned to 90/60 mm of Hg. Folic acid supplements were also given. This was continued for a further 4 weeks but no improvement was seen in the haemoglobin and the patient required 2 small transfusions (15 ml/Kg/transfusion) per week to maintain his Hb at 7-8 gm/dl. He was then given intravenous Immunoglobulins in the dose of 400 mg/Kg/day for 5 days and steroids were continued. Thereafter he showed a dramatic improvement and his transfusion requirement decreased to 1 transfusion every 2 weeks for the next 6 weeks after which he went into complete remission and has remained asymptomatic since. His Hb has been maintained at 11-12 gm%, reticulocyte count is less than 1%. hepatosplenomegaly has regressed and he is thriving well with normal development. Corticosteriods were given for 12 weeks and then tapered and stopped. TABLE 1 123