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Alpine meadows emerged as the hallmark vegetation type, embodying the essence of botanical richness. In this research endeavor, the focus was on exploring the intricate tapestry of alpine flora nestled within the Madhmaheshwar Valley, spanning elevations ranging from 3200 to 4950 meters above sea level. This comprehensive study yielded a trove of botanical insights, documenting an impressive assemblage of 462 distinct plant species. These species were carefully cataloged across 237 genera, encompassing a rich diversity represented by 61 distinct families. In the study area, the family Asteraceae was the dominant family with 58 species and 30 genera followed by Rosaceae with 33 species and 16 genera, and Ranunculaceae with 27 species across 15 genera. Among the genera Carex L., with 10 species, was the dominant, followed by Saxifraga Tourn. ex L., Gentiana Tourn. ex L., Pedicularis L., and Primula L. followed closely behind with nine species each. Additionally, Rhodiola L., Bistorta (L.) Scop., and Epilobium Dill. ex L. displayed their vitality with seven species each. The study used meticulous research methodology to categorize forest types based on floral diversity and altitude distribution. Rigorous verification processes ensured the reliability of findings, with specimens identified using up-to-date references and cross-referenced with authentic herbarium samples. Fieldwork occurred between early May and late October, aligning with seasonal accessibility due to heavy snowfall the rest of the year. Alpine meadows and scrubs dominated the study area, highlighting their resilience. Alpine plants showcased various adaptive morphologies, such as cushion-forming and mat-forming structures, with thick cuticles defending against desiccation. Despite harsh conditions, these plants displayed modified structures enabling growth and blossoming. Many were highly specialized, emphasizing unique adaptations to their habitats.

Objectives: We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. Methods: We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. Results: Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). Conclusion: Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

Abstract Background The European Society of Pediatric and Neonatal Intensive Care (ESPNIC) developed and validated a definition of pediatric refractory septic shock (RSS), based on two septic shock scores (SSS). Both bedside SSS (bSSS) and computed SSS (cSSS) were found to be strongly associated with mortality. We aimed at assessing the accuracy of the RSS definition on a prospective cohort from India. Methods Post hoc analysis of a cohort issued from a double-blind randomized trial that compared first-line vasoactive drugs in children with septic shock. Sequential bSSS and cSSS from 60 children (single-center study, 53% mortality) were analyzed. The prognostic value of the ESPNIC RSS definition was tested for 28-day all-cause mortality. Results In this septic shock cohort, RSS was diagnosed in 35 patients (58.3%) during the first 24 h. Death occurred in 30 RSS patients (85.7% mortality) and in 2 non-RSS patients (8% mortality), OR = 60.9 [95% CI: 10.5–676.2], p

Background: Internationally approved electrodiagnostic criteria for Guillain Barre syndrome lack in children. We intended to compare the diagnostic accuracy of the currently available five electrophysiological criteria for childhood Guillain Barre Syndrome (GBS) at the time of sentinel assessment. Methodology: In this single-center study, data of children diagnosed with GBS between January 2013 to December 2017 were retrieved. Patient charts were reviewed for clinical features, electrophysiological recordings. The electrodiagnostic results (4 motor nerves and two sensory nerves in upper limbs and lower limbs) were reanalyzed and were classified based on Dutch group; Ho; Hadden; Hughes and Rajabally criteria for GBS. Results: During this study period, of the 205 children with clinical features of GBS, 15 children had incomplete electrophysiological data, and four children were excluded due to missing data. The mean age of onset of the 186 children enrolled was 77 months; the median duration from symptom onset to electrodiagnostic evaluation was seven days; pure motor and motor-sensory form of GBS was seen in 71 and 115 children. Based on the Hadden criteria, a demyelinating pattern was noted in 57 children; axonal in 37; Inexcitable in 84 and Equivocal in 8 children. The sensitivity of the various criteria ranged from 71% to 100% for demyelination, 97% to 100% for axonal. The degree of agreement using Hadden and Rajabally criteria for Equivocal subtypes was 0.93. Conclusions: The Rajabally criteria showed the best sensitivity, specificity and diagnostic accuracy for electrodiagnosis of GBS in children when compared against Hadden criteria.

Background and Purpose: Haemophilus influenzae type b (Hib) infection occurs mostly in children and is transmitted from person to person through the respiratory pathway. Hib strain is associated with meningitis or encephalitis. It is not an uncommon infection, particularly, in the developing world. This prospective cohort study was done with the aim of describing imaging findings in patients with Hib meningoencephalitis. Materials and Methods: In a prospective cohort study, consecutive children admitted in the pediatric emergency unit with acute febrile encephalopathy were enrolled. The clinical details, CSF analysis, and microbiological and serological investigations were recorded on a case record proforma. Children with confirmed Hib meningoencephalitis were included in this study. Clinicoradiological features were assessed. Results: A total of 16 patients with acute febrile encephalopathy, in whom CSF latex agglutination, CSF culture, or CSF multiplex PCR were positive for H. influenzae were included in this study. All these children were investigated with magnetic resonance imaging (MRI) brain. Important imaging findings were meningitis, predominantly around frontoparietal lobes (43%), cerebritis (28%), ventriculitis (14%), and subdural collections (21.5%). One patient had features consistent with acute disseminated encephalomyelitis (ADEM) while four patients had normal MRI scan. Conclusions: H. influenzae is still a common cause of meningitis in infants and children in the developing world. We have tried to study the most common MRI features associated with Hib infection to help radiologists alert the treating clinicians to further investigate these patients for appropriate prognostication.

Background and Purpose: Epstein–Barr virus (EBV) meningoencephalitis can have variable and nonspecific brain magnetic resonance imaging (MRI) findings in children. This study was done with the purpose of describing brain MRI findings in children with EBV meningoencephalitis. Materials and Methods: The study included 45 pediatric patients that presented with variable neurological symptoms and were found to have EBV meningoencephalitis based on positive EBV deoxyribonucleic acid (DNA) in the cerebrospinal fluid. All these patients had undergone brain MRI. Clinical and radiological features were evaluated. Results: Fever was a presenting feature in all cases. Signs of meningitis and raised intracranial pressure (ICP) were seen in 24 (53.3%) cases, encephalopathy in 15 (33.3%), and seizures were present in 33 (73.3%). MRI was abnormal in 29 (64.4%) patients. The cortical/subcortical pattern was diagnosed in 9 (20%) cases, white matter involvement in 7 (15.5%), basal ganglia in 5 (11.1%), thalamic involvement in 4 (8.8%), brain stem involvement in 2 (6.2%), substantia nigra involvement in 2 (4.4%), and cerebellar involvement in 2 (4.4%). Diffusion restriction was present in 11 (24.4%) cases and susceptibility changes in 7 (15.5%). Meningeal enhancement was present in 10 (22.2%) cases. In addition, brain abscess and subdural effusion/empyema were present in 1 (2.2%) case each. Conclusion: Pediatric EBV meningoencephalitis has varied clinicoradiological spectrum and there is no specific MRI pattern to characterize the meningoencephalitis on imaging. Common MRI findings include cortical-subcortical involvement, white matter changes, basal ganglia, and thalamic involvement.

Objectives: To identify system-based factors contributing to Emergency Department (ED) admissions of children with diabetic ketoacidosis (DKA) and related complications with emphasis on parental and physician awareness and prereferral management. Materials and Methods: A prospective observational root cause analysis study of all consecutive admissions of children with DKA to pediatric ED of a tertiary care referral hospital in northern India over a period of 1 year (July 2010–June 2011). Prehospital, health-care system, referral, follow-up, and continuum of care related details were obtained through direct interview of parents and physicians and/or field observations for all enrolled children. Results: Of the 30 children enrolled, 26 (86.6%) were referrals; 16 (61.5%) from first, 7 (26.9%) from second, and 3 (11.5%) from third health-care facility. More than half (n [%], 18 [60%]) had new onset diabetes and belonged to lower socioeconomic strata. Twenty-two (73.3%) were complicated DKA; shock (n [%], 19 [63%]), hypokalemia (n [%], 11 [36%]), and CE (n [%], 3 [10%]) were the most common complications. Most parents were ignorant of diabetes, its symptoms or complicating DKA. Nearly, half of the cases remained undiagnosed (n = 11) at first contact health-care facility; more so for new onset as compared to known diabetes (9/18 vs. 2/8; P = 0.022). The referring hospitals had limited facilities for rapid blood glucose estimation (n [%], 12 [40%]), blood gas analysis (n [%], 6 [20%]) and insulin infusion. On univariate analysis, patients with missed/delayed diagnosis more often had severe and complicated DKA. Conclusion: Parental ignorance, lower socioeconomic status, lack of clinical experience, and limited primary health-care facilities were root causes for severe and complicated DKA.

Pediatric TBI is common all over the world including India. It is associated with mortality and long tenn morbidity; especially at risk are boys, aged 1-4 years. Children are quite different from adult in tenn of anatomy physiology and psychological effect of TBI. TBI in children is often diffuse, having more cerebral edema and raised ICP as compared to adult. Most common cause of pediatric TBI is fall. Most of the TBI related fatalities are due to motor vehicle injury First step of management is evaluation and stabilization of life-threatening condition. So, stabilization of airway and cervical spine, breathing and assisted ventilation, circulation and maintenance of cerebral perfusion pressine and control of active bleeding are important stabilization steps. After stabilization one should get details history and examination to assess the trauma severity. A noncontrast CT head should be obtained before shifting to PICU. The goal of intensive care management is to maintain cerebral perfusion pressure, decreased ICP and prevent further cerebral. Neurointensive care includes monitoring and treatment of raised ICP and seizure, and removal of mass effect by neurosurgeryeons. There are pediatric TBI guideline given in 2012 and many review articles by anestheticsfrom anesthesia perspective. The objective of this review is to give a practical overview of pathophysiology and management of severe TBI for pediatric intensivist.

Background: Vascular air embolism is being progressively reported as a nonfatal event with increase in use of computed tomography (CT) as a diagnostic modality. This study was undertaken to study the frequency and site of vascular air embolism in patients undergoing contrast-enhanced CT (CECT) and analyze CT parameters that influence its prevalence and final outcome. Materials and Methods: This was a prospective study approved by departmental ethics committee. Presence and location of air emboli in 200 patients who underwent CT scan of chest on a 64 detector scanner was recorded. We analyzed the role of various factors that could influence the prevalence of air embolism after injection of contrast in CECT scans. These factors included the amount of contrast injected, rate of flow of injection of contrast, site of injection of contrast, and size of intravenous access line. Results: Iatrogenic vascular air emboli were seen in 14 patients (7% of total). The locations of air emboli were main pulmonary artery in 12 (6% of total), left brachiocephalic vein in 3 (1.5% of total), right atrial appendage in 4 (2% of total), and superior vena cava (SVC) in 1 (0.5%) patient. There was no association between volume of contrast, flow rate, site and size of intravenous access, and presence of air emboli. Conclusion: Radiologists as well as referring physicians should be aware of vascular air embolism, which can occur after contrast injection in patients undergoing CT scan. Age, volume of contrast, flow rate of pressure injector, and site and size of venous cannula do not influence the likelihood or incidence of detection of venous air emboli on CT scans.

Objective: To study the baseline cytokine levels and their correlation with severity of illness and mortality in critically ill children with severe sepsis. Design: Subgroup analysis of a randomized, doubleblind, placebo-controlled trial. Setting: Pediatric intensive care unit of a tertiary care teaching hospital in North India. Patients: Fifty children, 3 months-12 years, with severe sepsis. Material and Methods: Blood was collected at admission for estimation of pro-inflammatory (IL-6, IL-12p70, IL-17, and TNF-α) and anti-inflammatory (IL-10 and TGF-β1) cytokines. Primary outcome: To find out correlation between cytokine levels with severity of illness (PRISM III score). Secondary outcomes: To compare cytokine levels among survivors and non-survivors. Results: Baseline pro-inflammatory cytokine levels [median (IQR)] were IL-6: 189 (35-285) pg/ml, IL-12p: 48 (28-98) pg/ml, IL-17: 240 (133-345) pg/ml, and TNF-α: 296 (198-430) pg/ml; anti-inflammatory cytokine levels were IL-10: 185 (62-395) pg/ml, and TGF-β1: 204 (92-290) ng/ml. The median (IQR) PRISM III score was 15 (12-20). Pro-inflammatory cytokines showed positive correlation with PRISM III score: IL-6 (Spearman's correlation coefficient, ρ=0.273, p=0.06), IL-12 (ρ=0.367, p=0.01), IL-17 (ρ=0.197, p=0.17), and TNF-α (ρ=0.284, p=0.05); and anti-inflammatory cytokines showed negative correlation: IL-10 (ρ= -0.257, p=0.09), and TGF-β (ρ= -0.238, p=0.11). The mortality was 10% (n=5). Among non-survivors, the levels of pro-inflammatory cytokines were significantly higher as compared to survivors [IL-6: 359 (251-499) vs. 157 (97-223) pg/ml, p=0.000; IL-12p70: 167 (133-196) vs. 66 (30-100), p=0.000; IL-17: 400 (333-563) vs. 237 (122-318), p=0.009; and TNF-α: 409 (355-503) vs. 330 (198-415), p=0.002, respectively]. Conclusion: In critically ill children with severe sepsis, pro-inflammatory cytokines showed a positive correlation with severity of illness and were significantly higher among non-survivors.

Plasma levels of 25-hydroxyvitamin D [25(OH)D] were measured by competitive Electrochemiluminescence Immunoassay (ECLIA) in 92 children (67 boys, 25 girls) aged 3 months to 12 years at admission to hospital (timepoint 1, T1) and at discharge (timepoint 2, T2). There was a significant fall in the mean 25(OH)D from T1 (71.87 ± 27.25 nmol/L) to T2 (49.03 ± 22.25 nmol/L) (mean change = 22.84 nmol/L, P value = 0.0004). Proportion of patients having VDD (levels

WHO-defined pneumonias, treated with antibiotics, are responsible for a significant proportion of childhood morbidity and mortality in the developing countries. Since substantial proportion pneumonias have a viral etiology, where children are more likely to present with wheeze, there is a concern that currently antibiotics are being over-prescribed for it. Hence the current trial was conducted with the objective to show the therapeutic equivalence of two treatments (placebo and amoxycillin) for children presenting with non-severe pneumonia with wheeze, who have persistent fast breathing after nebulisation with salbutamol, and have normal chest radiograph.This multi-centric, randomised placebo controlled double blind clinical trial intended to investigate equivalent efficacy of placebo and amoxicillin and was conducted in ambulatory care settings in eight government hospitals in India. Participants were children aged 2-59 months of age, who received either oral amoxycillin (31-54 mg/Kg/day, in three divided doses for three days) or placebo, and standard bronchodilator therapy. Primary outcome was clinical failure on or before day- 4.We randomized 836 cases in placebo and 835 in amoxycillin group. Clinical failures occurred in 201 (24.0%) on placebo and 166 (19.9%) on amoxycillin (risk difference 4.2% in favour of antibiotic, 95% CI: 0.2 to 8.1). Adherence for both placebo and amoxycillin was >96% and 98.9% subjects were followed up on day- 4. Clinical failure was associated with (i) placebo treatment (adjusted OR = 1.28, 95% CI: 1.01 to1.62), (ii) excess respiratory rate of >10 breaths per minute (adjusted OR = 1.51, 95% CI: 1.19, 1.92), (iii) vomiting at enrolment (adjusted OR = 1.49, 95% CI: 1.13, 1.96), (iv) history of use of broncho-dilators (adjusted OR = 1.71, 95% CI: 1.30, 2.24) and (v) non-adherence (adjusted OR = 8.06, 95% CI: 4.36, 14.92).Treating children with non-severe pneumonia and wheeze with a placebo is not equivalent to treatment with oral amoxycillin.ClinicalTrials.gov NCT00407394.

OBJETIVOS: Descrever a epidemiologia, as características clínicas e o tratamento do dengue e das síndromes do choque associadas ao dengue. FONTES DOS DADOS: Para esta revisão de literatura, foi feita uma pesquisa no Pubmed e nos websites da Organização Mundial da Saúde (OMS) e OPAS usando os termos dengue e síndrome do choque associada ao dengue. A informação foi complementada com a experiência pessoal dos autores. SÍNTESE DOS DADOS: O dengue é a mais importante doença viral transmitida por artrópodos em seres humanos. A doença se manifesta de diversas formas, variando desde uma síndrome viral não-diferenciada até febre hemorrágica e choque grave. O dengue é uma enfermidade autolimitada, não específica, caracterizada por febre, cefaléia, mialgia, e sintomas constitucionais. As formas mais graves (febre hemorrágica e síndrome do choque) podem levar a um comprometimento multissistêmico e ao óbito. O diagnóstico precoce e um acompanhamento contínuo do agravamento e da resposta ao tratamento são necessários em todos os casos. A OMS recomenda uma abordagem escalonada para o manejo, adequada para as formas mais leves e para o choque precoce. Nas formas mais graves, é preciso uma abordagem agressiva de reanimação com fluidos e de suporte à falência de órgãos em pacientes em estado crítico. As pesquisas sobre as diferenças fisiopatológicas entre o choque do dengue e o choque séptico, seleção de fluidos, agentes inotrópicos e técnicas de suporte a órgãos podem beneficiar os pacientes em estado crítico. CONCLUSÕES: Não há uma terapia específica para infecções causadas pelo dengue. Um bom tratamento de suporte pode salvar vidas mas, em última análise, as iniciativas de controle do vetor e de prevenção contra picadas do mosquito podem trazer os maiores benefícios.OBJECTIVES: To describe the epidemiology, clinical features and treatment of dengue fever and dengue shock syndrome. SOURCES: To prepare this review, a literature search was made on Pubmed and on the World Health Organization (WHO) and PAHO websites using the terms dengue and dengue shock syndrome. This information was complemented with personal practice. SUMMARY OF THE FINDINGS: Dengue is the most important arthropod-borne viral disease of humans. Its presentation is protean and varies from an undifferentiated viral syndrome to hemorrhagic fever and severe shock. Dengue fever is a self-limiting, nonspecific illness characterized by fever, headache, myalgia, and constitutional symptoms. Its severe forms (hemorrhagic fever and shock syndrome) may lead to multisystem involvement and death. Early diagnosis, close monitoring for deterioration and response to treatment are necessary in all cases. WHO has provided a stepwise approach to management that is useful for milder forms and early shock. In the more severe forms aggressive fluid resuscitation and support for failing organs is necessary for the critically ill patient. Research addressing pathophysiological differences between dengue shock and septic shock, choice of fluids, inotropes and techniques of organ support are likely to yield benefits for the critically ill. CONCLUSIONS: There is no specific therapy for dengue infections. Good supportive care may be lifesaving, but ultimately initiatives aimed at vector control and prevention of mosquito bites may provide the greatest benefits.