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Sunil Jain,1 Bhagya Kamal Jain,2 Prem Kamal Jain,3 Vishal Marwaha4 1Department of Paediatrics, Military Hospital Secunderabad, Telangana, India; 2Cloud, Google Inc, Hyderabad, Telangana, India; 3Department of Computational Biology, Indraprastha Institute of Information Technology, New Delhi, India; 4School of Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Cochin, Kerala, IndiaCorrespondence: Sunil Jain, Department of Paediatrics, Military Hospital Secunderabad, c/o 56 APO, Secunderabad, Telangana, 900 453, India, Tel +91 9651834341, Email sunil_jain700@rediff.comPurpose: Advances in bioinformatics, information technology, advanced computing, imaging techniques are changing fundamentally the way physicians define, diagnose, treat, and prevent disease. New disciplines – Artificial Intelligence, Machine Learning, Computational Biology – are improving healthcare. Digital health solutions have immense scope. Education and practice need to keep pace.Methods: We aimed at assessment of “Technology proficiency” required by medical graduates and its implementation, if found useful. All this in a conceptual framework of “TP” model, having categories (a) proper assessment (b) pertinent treatment (c) progress monitoring (d) prevention applications (e) professional standards. A search of the literature was performed using MedLine & Cochrane Central Register of Controlled Trials databases, for systematic reviews and meta-analysis articles published in the last five years using keyword “technology”. Analysis of those relevant to the role all medical graduates should play. An analysis of worldwide statutory medical institutions guidelines.Results: Twenty-three systematic studies and meta-analysis were studied. Eighteen show clear evidence for ‘Technology proficiency”, while 5 recommend further studies. The findings are discussed suiting the roles of doctors in the “TP” model. Medical institutions guidelines worldwide diligence suggests need of including “Technology proficiency” as a definite and distinct strategic plan. Medical Council of India mandates “use information technology for appropriate patient care and continued learning”. General Medical Council, UK and Medical Council India have been proactive in technology training. GMC recommends technology use for learning, prescribing, communication, and interpersonal skills. It should be expanding technology proficiency in practice as an essential professional capability.Conclusion: “Technology proficiency” is found pertinently fruitful. It should be included as a definitive requirement and a distinct strategic plan worldwide. Modern curriculum development is proposed (i) Educational goals and objectives as the proposed Conceptual framework “Technology proficiency” model (ii) Instructional strategies ‘Five Bs’ (iii) Implementation ‘Five Ms’.Keywords: assessment, treatment, monitoring, prevention, professional standards, curriculum

Objective Deficiencies of citrulline and arginine have been associated with adverse outcomes in preterm-infants (PI) and data regarding enteral supplementation in PI is unknown. Study Design: This randomized-controlled-trial [NCT03649932] included 42 PI (gestational age ≤ 33 weeks) randomized to receive enteral L-citrulline in low (100 mg/kg/day), medium (200 mg/kg/day) and high-dose (300 mg/kg/day) groups for 7 days. Plasma citrulline and arginine levels were obtained pre-and-post supplementation and efficacy was determined by a significant increase in levels after supplementation. A p

OBJECTIVE To determine neurodevelopmental outcomes of preterm infants born at

Patient safety is fundamental to high-quality patient care. Hospitalization has its inherent complications. Medical errors can further comprise patient safety. Hospitals provides an opportunity for practicing preventive medicine. Two important areas are (i) making treatment and hospitalization free from side-effects (ii) obviating medical errors. In hospitals these can have serious consequences. Patient safety compromise can occur at the individual or system level. A methodical model for this should include (i) Intervention design (ii) Intervention implementation (iii) Intervention institutionalization. Managerial perspective important for leadership and team work. Leadership can energize excellence in the coordination and mobilization of the large number of inter-dependent processes and resources needed for achievement of patient safety. Three-dimensional strategy for Leadership is suggested (i) Initiatives appealing (ii) Integrating all (iii) Incremental advancements. The ‘Five Es’ for Teamwork, and the ‘Five Cs’ for Organizational Change are elaborated. Artificial Intelligence has the potential to improve healthcare safety. AI enables analysis of data from multiple sources simultaneously using advanced algorithms. This identifies predictors and outcomes. Ensemble learning algorithms, used by advanced practitioners of machine learning, are useful with high final accuracy. Hence in matters of health these should be utilized. All this will make prevention targeted, better, and timely.

Complete coverage of all infants, everywhere with wonderful evidence, and covering completely with first six months of exclusive breastfeeding and thereafter proper weaning while continuing breastfeeding up to 2 years of age or beyond is desirable. Reaching all rightly and robustly is required. All this will contribute greatly towards the growth & development of infants and grandly towards the Sustainable Development Goals. We propose the “ABC mothers” plan. Progress for required practices for results possible with making mothers—“Able for practices advantageous, bold with pertinent awareness, and confident with propitious attitude”. Strong efforts on sound footing are necessary for health of all our infants and happiness all around with sustainable development. Scientific infant feeding will contribute to advance the attainment of this. Medical education teaching best beneficial practices is for excellence. One promoting breastfeeding is the best. The US Surgeon General’s Implementation Strategies elaborate “Education content”, “Enabling competency”, & “Education continuing”. Competency-based curriculum for Indian Medical Graduates includes “to promote and support optimal breast feeding”. Need for inclusion in teaching curriculum across US, UK, & internationally has been documented. Given all the evidence for breastfeeding benefits, it should be a consistent essential component of training in all medical schools worldwide.

Safe, timely, and affordable surgical care is desirable worldwide, but is largely an unmet need. Surgical care is recognized as an important component of public health. Vision for sustainable surgical development is desirable, and general surgeons can contribute substantially toward this mission.In the absence of surgical care, case-fatality rates are high for common and easily treatable conditions. These include congenital anomalies, hernia, fractures, appendicitis, etc. Solution is surgical care. Results of surgery on time are rewarding.General surgeons, as per the Medical Council of India, are required to (1) recognize the health needs of the community and carry out professional obligations, (2) be competent, and (3) be aware of the contemporary advances and developments in the discipline concerned. All this ensures that the general surgeon should be able to treat almost all surgical conditions effectively.With timely, cautious, careful, and tactful surgeries, general surgeons should be able to deliver robust results both electively and in emergency. All this in the true spirit of “Vayam Sevaamahe – We are for service” the motto of the Association of Surgeons of India. General surgeons should boost the best what was termed “Professional patriotism” in the historic Flexner report.

With over three decades of participation in the Paralympic Games, twelve medalists and eighty-three Paralympians who have represented India, today the country’s improving success at each Paralympic event cannot be ignored. With a new disability rights law passed in 2016, athletes with disabilities are just beginning to be recognized in India as citizens who can raise the country’s profile in the sporting world. From India, there is nil research in Paralympic sport, and journalistic discourse is often focused on inspirational story reporting. Research on sport governance within this ecosystem will bring to discussion what is the governance framework that exists within the Paralympic world of newly developing countries like India. The purpose of this article is to provide an overview of sport governance in India’s Paralympic movement, the country’s legislation concerning the sporting rights of persons with disabilities (PwD), and to further highlight potential gaps that plague India’s Paralympic system from further developments. Collaborative efforts between the International Paralympic Committee and the Indian Government, increased efforts to train technical officials in India and emphasis on structuring state level governance standards are some of the recommendations from this research to sustain the Paralympic movement in India.

Background More than 1 in 4 preterm infants with bronchopulmonary dysplasia (BPD) develop BPD-associated pulmonary hypertension (BPD-PH) that is associated with significant morbidity. Data regarding neurodevelopmental outcomes with BPD-PH in preterm infants are lacking. Objectives To determine neurodevelopmental outcomes of preterm infants born < 29 weeks gestational age (GA) with BPD associated pulmonary hypertension at 18 to 24 months corrected gestational age (CGA). Design/Methods In this retrospective cohort study, preterm infants born < 29 weeks GA between January 2016 and December 2019 at level 3 Neonatal Intensive Care Units at Foothills Hospital in Calgary and the University of Texas Medical Branch (UTMB) in Galveston, who were evaluated at 18-24 months CGA in the neonatal follow-up clinics were included. We compared demographic factors, neurodevelopmental status including Bayley-III scores and sensory impairments between the two groups based on the presence of PH at 36 weeks CGA: Group I: BPD with PH and Group II: BPD without PH, using univariate and multivariable regression models. The primary outcome was a composite of death or neurodevelopmental impairments (NDI). NDI was defined as any cerebral palsy (GMFCS≥1), Bayley-III score < 85 on one or more of the cognitive, motor, or language composite scores, sensorineural or mixed hearing impairment or unilateral or bilateral visual impairment. Results Of 372 eligible infants, 118 (Group I [BPD-PH] =7, Group II [BPD with no PH] =111) were lost to follow up. Of the remaining 254 infants, 52 in Group I and 202 in Group II were followed at 18-24 months CGA. Group I and Group II had median (IQR) birth weight of 710g (323) and 815g (314) [p=0.004] and median gestational ages (IQR) were 25 weeks (2) and 26 weeks (2) [p=0.020], respectively . Rates of associated impairments are shown in Figure 1. Infants in BPD-PH group (Group I) were more likely to have mortality or NDI (adjusted Odds Ratio [aOR] 3.82; 95% CI: 1.17-12.41) (Table 1). Conclusion BPD-PH in preterm infants born < 29 weeks GA is associated with increased odds of the composite outcome of death or neurodevelopmental impairment and language delay at 18-24 months CGA.

Armed Forces doctors are often required to treat children affected in war, combat, and disasters. Tender care & comprehensive tact is needed for children. Acquisition of these qualities comes with knowledge, its application, and practicing skills. Throughout history, children have been victims of armed conflict. War-related injuries are more severe as compared to the civilian sector injuries. Penetrating injuries are associated with significant damage to local structures, whereas blast injuries are associated with less local injury and more multisystem trauma. Children are not small adults. The differences have important practice implications. Identifying and correcting physiological compromise improves outcomes. The examination and vital sign data can be interpreted only if the caregiver has a thorough understanding of normal values. Identification & treatment of what is killing the patient is done in primary survey. Secondary survey, extremity trauma, fracture biomechanics, & burns peculiarities need attention. Care of the injured patient is a dynamic process. Frequent monitoring required for proper response. Small infants have a narrow margin for error. Combat trauma provides multiple opportunities for improvement. Continuation of research will ensure ongoing progress and further improvement in the outcomes of both military and civilian casualties.

ObjectivesTo evaluate whether a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty offers superior outcomes to traditional outpatient physiotherapy.DesignA prospective, single-blind, two-arm randomised controlled superiority trial.Setting14 National Health Service physiotherapy departments in the UK.Participants621 participants identified at high risk of a poor outcome after knee arthroplasty using a bespoke screening tool.InterventionsA multicomponent home-based rehabilitation programme delivered by rehabilitation assistants with supervision from qualified therapists versus usual care outpatient physiotherapy.Main outcome measuresThe primary outcome was the Late-Life Function and Disability Instrument (LLFDI) at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function), Knee injury and Osteoarthritis Outcome Score Quality of Life subscale, Physical Activity Scale for the Elderly, 5 dimension, 5 level version of Euroqol (EQ-5D-5L) and physical function assessed using the Figure of 8 Walk test, 30 s Chair Stand Test and Single Leg Stance.Results621 participants were randomised between March 2015 and January 2018. 309 were assigned to CORKA (Community Rehabilitation after Knee Arthroplasty) home-based rehabilitation, receiving a median five treatment sessions (IQR 4–7). 312 were assigned to usual care, receiving a median 4 sessions (IQR 2–6). The primary outcome, LLFDI function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference=0.49 points; 95% CI −0.89 to 1.88; p=0.48). There were no statistically significant differences between the groups on any of the patient-reported or physical secondary outcome measures at 6 or 12 months.There were 18 participants in the intervention group reporting a serious adverse event (5.8%), only one directly related to the intervention, all other adverse events recorded throughout the trial related to underlying chronic medical conditions.ConclusionsThe CORKA intervention was not superior to usual care. The trial detected no significant differences, clinical or statistical, between the two groups on either primary or secondary outcomes. CORKA offers an evaluation of an intervention utilising a different service delivery model for this patient group.Trial registration numberISRCTN13517704.

There are conventional methods available for designing of flexible pavement based on the past experience whereas for the design of Cement Treated Base (CTB) and Cement Treated Sub Base (CTSB) layers no such conventional methods are available. Use of cement stabilization in granular material is an effective technique to increase the stiffness of base and sub base layers and also in the thickness reduction in comparison to conventional layers. Furthermore, cement base layers can improve the fatigue behaviour of asphalt surface layer and subgrade rutting over the short and long term. In our country, there is no performance data available for CTB and CTSB layers in in-situ conditions. This paper deals with the investigation of the resilient modulus (MR) of stabilized pavement layers through field data collection on in-service flexible pavement sections which may be useful for design purpose. The main objective of this research study is to make a comparison of MR values for cement stabilized layers using non-destructive method viz. Falling Weight Deflectometer (FWD) and destructives test method through cores. The field data has been collected from State Highway (SH) and Major District Road (MDR) around Lucknow, Uttar Pradesh. No visual distress was observed on both the road sections at the time of field surveys. Two study sections on SH and one on MDR of about 500 m length has been identified for the study. The in-situ cores were obtained from CTB and CTSB layers which were tested for determination of MR values through Unconfined Compressive Strength (UCS) as per IRC:37-2018. FWD deflection data was used for determination of MR values using backcalculation software for CTB and CTSB layers. Furthermore, the thickness and the properties of each layer were determined by conducting test pits on the existing pavement.

Context: Adolescent health information within new global health initiatives is advocated. Global School-based Student Health Survey (GSHS) is among young people 13 to17 years. Early prevention and promotion is beneficial. Aim: To find health behaviors and protective factors at different adolescence physiological stages. Settings and Design: School-based survey in an Army Public School. Methods and Materials: The study parameters were dietary behaviors, hygienic practices, mental health, physical activity, and protective factors. A total of 1232 adolescents were surveyed. Early adolescence (10–13 years) participants were 760 and middle adolescence (14–17 years) were 472. Male: female ratio was 1.819:1. Statistical Analysis: Calculation of percentage ± Standard error using standard methods. Results: The study reveals interesting trends. There is a disparity between body mass index (BMI) findings and effort direction for weight. There is a sharp rise in girls making efforts to lose weight from early to middle adolescence (27.8% and 40.7%, respectively). Hygienic practices are marginally short of 100%. Worry causing the inability to sleep at night most of the time or always reported by 9.2–18.7%. There is a sharp rise in the number of girls feeling this from early to middle adolescence (9.8%–18.7%). Adolescents spending three or more hours per day doing sitting activities are 25.6–38.6%. This is rising from early to middle adolescence, and sharply in girls. Protective factors are trending towards the positive side. Conclusions: First, for advancements of adolescents' health, top priorities are (i) Popularizing importance of ideal BMI, (ii) Betterment of mental health for a smooth transition across stages and being proactive for preventing worsening, (iii) Promoting physical activity early and sustaining efforts, especially amongst girls. Second, the 'GSHS Questionnaire' needs to be modified for fruits and vegetable consumption to how many servings/what part of plate and include questions for details of physical activity likings of girls.

In a quest of search for a new burning rate modifier for composite propellant, strontium titanate (SrTiO3), a perovskite oxide has been chosen for evaluation in a composite propellant formulation based on its other catalytic applications. Initially, SrTiO3 was characterized for particle size, morphology and material/phase identification (using XRD). By varying SrTiO3 content in a standard composite propellant, different compositions were prepared and their performance and processing parameters like the end of mix (EOM) viscosity, mechanical properties, density, burning rate, pressure exponent (n-value), etc. were measured. The results reveal that 2% SrTiO3 causes more than 12% enhancement in propellant burning rate (at 70 ksc pressure) in comparison to the standard propellant composition. The pressure exponent also increases to 0.46, whereas the standard composition was having its value as 0.35. Keywords: Strontium titanate, Ammonium perchlorate, Composite propellant, Burning rate

Introduction: Pediatric surgery provides the opportunity to intervene positively in a variety of disorders that can have a long-term impact. It becomes important to systematically analyze the features of & amp; facilities for Paediatric surgery at a referral hospital. Objective: The objective of this study was to evaluate the significance of pediatric surgery under vast circumstances. Materials and Methods: All children aged 0–10 years who were operated in a tertiary care hospital were studied.The International Statistical Classification of Diseases and Related Health Problems 10th Revision (International Classification of Diseases [ICD]-10)-WHO Version (2016) was used to group the cases, which included terminology from the ICD-11 Beta Draft. Results: “Developmental anomalies” made up 79.1% of the cases, while “acquired conditions requiring surgical intervention” made up 20.9%. The common congenital malformations were those of the genital organs (17%), followed by those of the digestive (13%) and nervous system (13%), urinary system (12%), circulatory system (8%), and cleft lip and palate (7%). Cleft lip and palate repair, as well as genital, digestive, nervous, urinary, and musculoskeletal system defects, should all be part of the essential surgery package for congenital anomalies. Referral to superspecialty center is required only for “congenital malformations of the circulatory system.” Conclusion: The majority of the workload (79.1%) is due to "developmental abnormalities," indicating a need for expertise in repairing these, as well as restoring anatomy for optimal growth and physiological function. The essential surgery package for congenital anomalies at the second- and third-level hospitals should include expertise for anomalies of all systems. Inclusion of indirect inguinal hernia in the Chapter 20 ‘Developmental anomalies’ (ICD-11) will contribute to correct international comparisons and guide planning.

Complications during the course of Percutaneous Coronary Interventions (PCI) are common. One of the complications is iatrogenic Left Main Coronary Artery (LMCA) dissection, which is considered as lethal in nature and prevails in around 0.07% PCI cases. Timely diagnosis and immediate revascularisation is mandatory to manage LMCA dissection in order to avoid worsening of patient’s haemodynamic condition and to re-establish antegrade coronary blood flow. Here, the author report a case of catheter-induced iatrogenic LMCA dissection developed during stenting of a lesion in Left Anterior Descending (LAD) coronary artery of a 32-year-old male patient. The patient was managed by implantation of two Matrix (Sahajanand Medical Technologies, Pvt., Ltd., Surat, India) Bare Metal Stents (BMS) using double barrel technique to treat the dissection in left main coronary bifurcation. The patient was regularly followed-up and even after 12 years of the index procedure, the angiographic data revealed good patency of stents in LMCA without any major cardiac events.

Purpose Advanced methodical learning and optimised learning leads to better-trained doctors. Such teaching typically comprises the illustration of features and access to facilities. This article explores the role of “Special clinics” in medical education. The role of sophisticated “Special clinics” is to provide vigour and vibrancy in treating and teaching as well as advancing the art and science of medicine. All this contributes towards the current evidence indicating benefits of reducing hospitalization. Methods This article comprises an analysis of the guidance produced by leading medical education institutions. Findings are presented in the perspective of a relevant theoretical framework around “Special clinics”, in light of the available evidence and personal experience. Results The implementation and potential impacts of “Special clinics” are presented within the context of the “4SAs”, a favoured teaching mnemonic: 1) Scientific Approach: medical education rules and regulations reflecting scientific reasoning in support of “Special clinics”, 2) Setting Advantages: the mechanisms by which “Special clinics” are conducive to and contribute towards increasing the capacity to comprehensively treat complex disorders in the outpatient setting, avoiding hospitalization and its associated risks, as well as expenditure, 3) Sophistication Advantages: tools and techniques to ensure advanced clinical skills teaching including novel outpatient technologies, understanding the need for focussed study and practice, and exploiting the advantages of internationalization of medical education, and 4) Successes and Advancements: opportunities to observe experts providing specialist care of the highest standard. The use of a focussed approach aims to explore and advance frontiers of medical education. Conclusion “Special clinics” will soon form a major component of the hospital workload and play a crucial role in medical education. They provide the advantage of condition-specific patient-centered care, the motivation for excellence. Clinical skills learnt by medical students in “Special clinics” will undoubtedly contribute to long-term improvements in the medical care., Video Abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/ZM-TLlS02rQ

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p

Purpose Current recommendations for ‘Febrile seizures’ management include emergency first aid and treatment along with intermittent prophylaxis. Evidence of practices, efficacy, side-effects, and complications should lead to refined and rational management strategies. Patients and Methods Study of cases referred and treated at a tertiary level hospital, providing referral services to a large state in India. Evidence sought for the research questions identified, these were (i) immediate treatment: First aid components and practices; response to drug treatment (ii) intermittent prophylaxis: effectiveness, compliance, and side-effects (iii) complications arising due to treatment side-effects: quantifying the number of cases of CNS infections missed as a result of alterations in consciousness levels due to benzodiazepines. Results A total of 85 febrile seizure cases were studied. Full correct “First Aid” was provided by only 13 parents. Total 35 cases (41.18%) had seizures lasting more than 05 minutes. Emergency treatment for these included rectal diazepam in 14 cases with 57.14% success in terminating seizure, and intranasal midazolam in 21 cases with 71.43% success. The cases with persisting seizures were managed as status epilepticus treatment algorithm. Intermittent prophylaxis prevented recurrence of seizures in 90%, however side-effects were reported in 36.36%. There was no case of CNS infection missed. Conclusion Safe and effective management strategy should include “Health education” for correct first aid and ‘Protocols’ for timely and correct emergency treatment by parents/pre-hospital teams/emergency duty doctors. Intermittent prophylaxis is effective but refinements needed to minimize side-effects. Vigilant clinical monitoring obviates the fear that treatment may mask CNS infection., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/psIZo8G-_N8

Malnutrition and bone disease are common in adults with chronic pancreatitis (CP). We studied the nutritional status and bone mineral density (BMD) of children with CP and the factors predicting them.CP children were prospectively evaluated with a detailed questionnaire, anthropometry, 25-hydroxy vitamin D, fecal elastase and BMD [total body less head (TBLH), spine and hip] by dual energy x-ray absorptiometry. Body mass index (BMI) Z score of -1 to -1.9, -2 to -2.9 and-3 was taken as mild, moderate and severe malnutrition respectively. Low BMD and osteoporosis were defined as per International Society for Clinical Densitometry.83 children (46 boys, 14[4.3-21]years) with CP were enrolled. Majority had Cambridge IV (51,62.2%) or III (15,18.3%) changes. 34(41%) had undernutrition (mild-37.3%, moderate-2.4%, severe-1.2%). Overweight and obesity were present in 3.6% and 1.2% cases. BMI had a significant correlation with haemoglobin, serum albumin, percentage body fat and BMD. A majority had low fecal elastase (69 [84.1%],100 μg/g) and vitamin D deficiency (70[84.3%],20 ng/ml). 9 cases had a history of fractures. 14/75(18.6%) cases had low TBLH-BMD and this group had a lower BMI (-1.3[-1.9 to 0.34] vs 0.8 [-2.1 to 5.50; p = 0.03) than patients with normal BMD. There was no difference in age, disease duration, vitamin D, fecal elastase and Cambridge grade between normal and low BMD.41% CP children have undernutrition with a majority having mild undernutrition. Nearly 20% have low BMD, with osteoporosis in none. Subjects with low BMI have lower BMD and percentage body fat.

Aim: To compare characteristics of Desflurane with Isoflurane under low flow anaesthesia using equilibration time. Material and methods: This prospective study was done the Department of AnaesthesiaMetro Hospital and Cancer Research Center, Jabalpur, Madhya Pradesh, India 100 healthy patients of either sex scheduled for routine surgeries, American Society of Anesthesiologists (ASA) physical status I and II, age 20–60 years, and hemoglobin more than 10 g/dL were include in this study. Patients were randomly allocated to two groups. Group I received desflurane as the inhalational anesthetic agent with minimal flow anesthesia (n=50). Group II received isoflurane as anesthetic agent with minimal flow anesthesia (n=50). Results: 100 adult patients were studied. The groups were randomly divided into two groups of 50 patients each. Mean of time taken for equilibration of the volatile anesthetic agent in the desflurane group was 5.23 ± 1.63 min and in the isoflurane group was 17.011±9.64 min, and the difference was statistically significant (P< 0.001). At 5, 20, 60, and 120 min, mean end-tidal concentrations (in kPa) of desflurane were not changed much and were 4.68 ± 0.80, 4.78 ± 0.62, 4.38 ± 0.61 and 4.15 ± 0.62, respectively. In the isoflurane group, variation were significant over time and were 0.77 ± 0.17, 0.93 ± 0.17, 0.73 ± 0.19 and 0.74 ± 0.19 at 5, 20, and 120 min intervals, respectively. Uptake of nitrous oxide was 80% and above by the time equilibration of any of the agents occurred. In both the groups, end-tidal to inspired nitrous oxide ratio was found to be 0.77 ± 0.14 in 5 min duration and 0.96 ± 0.03 by 12 min. Nitrous oxide concentration also fell over the time, and it was difficult to maintain nitrous oxide at 66 vol.% . It ranged between 42.30 ±4.57 and 61.20 ± 4.56. In long duration, minimal flow anesthesia nitrous oxide end-tidal concentration found to be

Aim: To compare a combination of isobaric Levobupivacaine with fentanyl and dexmedetomidine. Material and methods: This was a prospective, randomized, and double blinded clinical comparative study conducted in the Department of Anaesthesiology Metro Hospital and Cancer Research Center, Jabalpur, Madhya Pradesh, India. The study population consisted of 180 adult patients who were classified as American Society of Anesthesiologists (ASA) physical status I or II, undergoing elective lower limb orthopaedic surgery under spinal anesthesia. The study participants were randomly divided into three groups. Group A: 0.5% Levobupivacaine Isobaric 2.5ml+ 0.5ml normal saline (total volume is upto 3.0 ml). Group F: 0.5% Levobupivacaine Isobaric 2.5ml + 25mug fentanyl (test solution will diluted with normal saline to total volume of 3.0ml). Group D: 0.5% Levobupivacaine isobaric 2.5ml +5 mcg dexmedetomidine (test solution will diluted with normal saline to total volume of 3.0 ml. Result: The mean time for onset of sensory block was 10.74 ±4.11 min in the saline group and 8.56±2.89 min in the dexmedetomidine group and 2.18±1.32 min in the fentanyl group. The mean time taken to achieve maximum sensory block in group A was 15.78±4.93 min, in group D was 13.36±3.62 min and in group F it was 5.42±1.87 min so maximum sensory block was achieved earlier in group. Peak level of sensory block attained in the fentanyl group was T4 and the peak level of sensory block in dexmedetomidine group was T6 and in the saline group peak level was T8. So the highest sensory block was attained in the fentanyl group. Conclusion: Dexmedetomidine group has longer onset of and duration of sensory block and effective postoperative analgesia and fewer side effects as compared to fentanyl group.

Knowing current trends for timely comprehensive action for health promotion practices is an important prerequisite for medical practitioners and policy makers.A survey of mothers at a Tertiary Care Hospital in central India.On the knowledge front83.75% of the mothers studied showed good knowledge about breastfeeding and complementary feeding. Similar, but not as encouraging, were the results about attitude, with 76.25% of mothers having a positive attitude. The results of the practices part were varied. The WHO indicators assessed were 'early initiation of breastfeeding' (68.75%), 'exclusive breastfeeding under 6 months' (85%) (however exclusive breast feeding for first 6 months was carried out by only 36.25%), 'introduction of solid, semi-solid or soft foods' (48.75%), 'continued breastfeeding at 1 year' (63.75%) and 'continued breastfeeding at 2 years' (6.25%).There is a discrepancy between knowledge and practices. The exclusive breast feeding rates are far from the ideal and there is a decline of continued breast feeding beyond 15 months. This calls for sustained efforts with the aim - 'cover all and cover completely'. The ideal WHO indicator for exclusive breast feeding should be 'exclusive breastfeeding for first 6 months' which will provide information about the completeness of this ideal practice.

Background: The current happenings in the country for the good should be of importance in the crucial places and the criticalphases of life, i.e., hospitals and during hospitalization, even for normal life processes. The current “Clean India Campaign” isa catalyst for hospitals for improvements in hygiene. Objective: The objective of this study is to define and describe the impactof multifaceted infection control and hygienic practices by all on hospital-acquired infections (HAIs) in the pediatric age group.Materials and Methods: Implementation of multifaceted infection control policies was ensured along with the health educationfor hygienic practices by all, including attendants of patients and patients when possible. These were rigorously enforced withthe renewed enthusiasm since the launch of “Clean India Campaign” from January 2015. The setting was “Paediatric Wing” of atertiary care hospital catering to a large army cantonment, and also, referred cases. The outcome measures were the incidence ofHAIs. Results: The incidence rate of HAIs was 2.91% (July 2013-December 2014) and declined to 1.59% (January 2015-June2016) (relative risk: 0.547, 95% confidence interval: 0.409-0.733; p=0.0001). The most significant decline in HAI in our studyhas been in that of gastrointestinal infections (RR: 0.428%, 95% CI: 0.241-0.761; p=0.0034). Overall, the results of preventiveactions were rewarding (RR: 0.547, 95% CI: 0.409-0.733; p=0.0001). Conclusion: The mission “Clean India Campaign” and theWHO’s vision “clean care is safer care” lead to prevention and reduction of HAIs. Implementation of multifaceted infection controlinterventions is impactful. Hygienic practices teaching should be for both caregivers and caretakers.

Background: A new health system for the 21st century should be based on the best scientific knowledge, according to the Institute of Medicine, US. Objective: We have evaluated the effectiveness of asthma clinic providing comprehensive care based on the best available scientific evidence. Materials and Methods: This intervention study was conducted in a tertiary care hospital having a devoted asthma clinic for the comprehensive management. All children diagnosed as having asthma were included, and data of cases managed from July 2014 to June 2016 were analyzed. Intervention - comprehensive management of asthma including assessment, monitoring, health education, avoidance of triggers, management of comorbid conditions, appropriate medications, written asthma action plan, and counseling for follow-up. Outcome measures were treatment direction, asthma control, emergency visits, and hospitalizations. Results: 260 children were treated over a 2-year period. The effects of focused approach with progressive expertise lead to statistically significant benefits over the two successive years from July 2014 to June 2015 and July 2015 to June 2016. These were in: (i) Treatment direction: Cases requiring stepping up of treatment decreased from 36.49% to 17.24% (relative risk [RR]: 0.473 [95% confidence interval {CI}: 0.249-0.895]); p=0.01229, (ii) asthma control: Cases with not well-controlled asthma decreased from 16.44% to 7.02% (RR 0.427: [95% CI: 0.199-0.914]); p=0.045, (iii) emergency department visits decreased from 35.62% to 21.05% (RR 0.591: [95% CI: 0.39-0.897]), p=0.00766, (iv) hospitalizations decreased from 16.44% to 5.26% (RR 0.32: [95% CI: 0.135-0.757]), p=0.00462. Conclusion: Establishing an asthma clinic and progressive expertise leads to significant beneficial results.

Background & Aims Data on minimal hepatic encephalopathy (MHE) in children is scarce. We aimed to study MHE in children with chronic liver disease (CLD) and to validate non-invasive objective tests which can assist in its diagnosis. Methods We evaluated 67 children with CLD (38 boys; age 13 [7–18] years) and 37 healthy children to determine the prevalence of MHE. We also assessed the correlation of MHE with changes in brain metabolites by magnetic resonance spectroscopy ( 1 HMRS), diffusion tensor imaging (DTI) derived metrics, blood ammonia and inflammatory cytokines (interleukin-6 [IL6], tumor necrosis factor alpha [TNF-α]). In addition, the accuracy of MR-based investigations for diagnosis of MHE in comparison to neuropsychological tests was analysed. Results Thirty-four (50.7%) children with CLD had MHE on neuropsychological tests. MHE patients had higher BA (30.5 [6–74] vs. 14 [6–66]μmol/L; p =0.02), IL-6 (8.3 [4.7–28.7] vs. 7.6 [4.7–20.7]pg/ml; p =0.4) and TNF-α (17.8 [7.8–65.5] vs. 12.8 [7.5–35]pg/ml; p =0.06) than No-MHE. 1 HMRS showed higher glutamine (2.6 [2.1–3.3] vs. 2.4 [2.0–3.1]; p =0.02), and lower choline (0.20 [0.14–0.25] vs. 0.22 [0.17–0.28]; p =0.1) and myo-inositol (0.25 [0.14–0.41] vs. 0.29 [0.21–0.66]; p =0.2) in MHE patients than those without MHE. Mean diffusivity (MD) on DTI was significantly higher in 6/11 brain areas in patients with MHE vs. no MHE. Brain glutamine had a significant positive correlation with blood ammonia, IL-6, TNF-α and MD of various brain regions. Neuropsychological tests showed a negative correlation with blood ammonia, IL6, TNF-α, glutamine and MD. Frontal white matter MD had a sensitivity and specificity of 73.5% and 100% for diagnosing MHE. Conclusions In children with CLD, 50% have MHE. There is a significant positive correlation between markers of hyperammonemia, inflammation and brain edema and these correlate negatively with neuropsychological tests. MD on DTI is a reliable tool for diagnosing MHE. Lay summary Fifty percent of children with chronic liver disease develop minimal hepatic encephalopathy (MHE) and perform poorly on neuropsychological testing. These children have raised blood ammonia, inflammatory cytokines and mild cerebral edema on diffusion tensor imaging as compared to children without MHE. The higher the ammonia, inflammatory cytokines and cerebral edema levels the poorer the performance on neuropsychological assessment. The estimation of mean diffusivity on diffusion tensor imaging is an objective and reliable method for diagnosing MHE.