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Accurate calculation of set-up margin is a prerequisite to arrive at the most optimal clinical to planning target volume margin. The aim of this study was to evaluate the compatibility of different on-board and in-room stereoscopic imaging modalities by calculating the set-up margins (SM) in stereotactic body radiotherapy technique accounting and unaccounting for rotational positional errors (PE). Further, we calculated separate SMs one based on residual positional errors and another based on residual + intrafraction positional errors from the imaging data obtained in a dual imaging environment. A total of 22 lung cancer patients were included in this study. For primary image guidance, four-dimensional cone beam computed tomography (4-D CBCT) was used and stereoscopic ExacTrac was used as the auxiliary imaging. Following table position correction (TPC) based on the initial 4-D CBCT, another 4-D CBCT (post-TPC) and a pair of stereoscopic ExacTrac images were obtained. Further, during the treatment delivery, a series of ExacTrac images were acquired to identify the intrafraction PE. If a, b and c were the observed translational shifts in lateral (x-axis), longitudinal (y-axis) and vertical direction (z-axis) and α, β and γ were the rotational shifts in radians about the same axes, respectively, then the resultant translational vectors (A, B and C) were calculated on the basis of translational and rotational values. Set-up margins were calculated using residual errors post-TPC only and also using intrafraction positional errors in addition to the residual errors. Residual and residual + intrafraction SM were calculated from a dataset of 82 CBCTs and 189 ExacTrac imaging sessions. CBCT-based mean ± SD shifts in translational and rotational directions were 0.3 ± 1.8 mm, 0.1 ± 1.8 mm, − 0.4 ± 1.6 mm, 0.1 ± 0.4°, 0.0 ± 1.0° and 0.3 ± 0.7°, respectively, and for ExacTrac − 0.1 ± 1.8 mm, 0.2 ± 2.4 mm, − 0.6 ± 1.8 mm, 0.1 ± 1.2°, − 0.2 ± 1.3° and − 0.1 ± 0.6°, respectively. Residual SM without considering the rotational correction in x, y and z directions were 5.0 mm, 4.5 mm and 4.4 mm; rotation-corrected SM were 4.4 mm, 4.0 mm and 5.5 mm, respectively. Residual plus intrafraction SM were 5.5 mm, 6.6 mm and 6.2 mm without considering the rotational corrections, whereas they were 5.0 mm, 6.3 mm and 6.2 mm with rotational errors accounted for. Accurate calculation of set-up margin is required to find the clinical to planning target volume margin. Primary and auxiliary imaging margins fall in the range of 4.0 to 5.5 mm and 5.0 to 7.0 mm, respectively, indicating a higher SM for X-ray-based planar imaging techniques over three-dimensional cone beam images. This study established the degree of mutual compatibility between two different kinds of widely used set-up imaging modalities, on-board CBCT and in-room stereoscopic imaging ExacTrac. It also describes the technique to calculate the residual and residual plus intrafraction SM and its variation in a dual imaging environment accounting for rotational PE in stereotactic body radiotherapy of lung.

Objective: The novel coronavirus pandemic is ravaging throughout the world. It has infected more than 1.2 million people and killed more than 64,000. Frantic research is underway to find prevention and cure. Of late, Bacillus Calmette–Guérin (BCG) has been speculated as a possible protection from COVID-19. We sought to investigate the evidence behind the claim. Material and Methods: Data were collected regarding the total number of COVID-19 cases per million and total number of COVID-19 deaths per million in various countries. The BCG vaccination policies of these countries were also obtained. Results: It was seen that the countries with no universal BCG policy had a mean 1272.9 (median 795) cases per million and 80.7 deaths (median 18) per million population. On the contrary, the countries with a universal BCG vaccination policy had a mean 131.2 (median 40) cases per million and 4 deaths (median 1) per population. The difference is highly significant (P < 0.001). Conclusion: The data strongly support the hypothesis that BCG may offer protection from COVID-19. Heterologous protection offered by BCG through production of trained immunity, epigenetic reprogramming of monocytes, non-specific activation of NK cells, and increase of pro-inflammatory cytokines (particularly, tumor necrosis factor [TNF]-alpha and interleukin 1 beta) production may be the mechanism behind its cross- protection against the novel coronavirus.

Objective: The COVID-19 pandemic has hit countries such as Italy, Spain, France, UK, and the USA with great force, whereas the number of cases in countries such as India and most parts of Africa is comparatively lower. Such observation has made many people believe that the low-income countries may be more immune to COVID-19. Theories such as warm climate, weaker strain of the virus, and cross-protection by malaria have been popularly put forward. One such interesting theory is that since the general people of the low- income countries are mostly habituated to dwell in lesser hygienic condition and with lesser medical attention throughout their lifetime; hence, they have naturally acquired better immunity and more resilience against many infective diseases. Materials and Methods: We sought to investigate the above claim by comparing the case fatality rate (CFR) as well as number of cases per million population versus the gross domestic product at purchasing power parity per capita of different countries. Results: We found that while the number of cases showed a slight decline in the lower-income countries, the CFR was independent of the financial condition of the country. Conclusion: We conclude that the theory of better immunity in economically poor countries is a misconception. We suggest that people must come out of these misconceptions and resort to strict home isolation.

A 9-year-old girl patient presented with left-sided weakness and joint contractures developing over a period of 18 months. She was known to be suffering from β-thalassemia major and was on regular blood transfusions. Eighteen months ago, she had suffered from an episode of ischemic cerebrovascular accident affecting the right side of her brain. Magnetic resonance angiogram revealed vaso-occlusive disease affecting mainly the anterior cerebral circulation, resembling Moyamoya disease. She was advised to carry out regular physiotherapy but her parents discontinued it, which resulted in the gradual development of joint contractures and muscle wasting.

Excessive and unexplained cry is a common problem with infants. Most of the causes are benign or easily treatable, with exception of a few. However, we encountered a 5-month-old, otherwise healthy male infant, who used to cry inconsolably every day on the afternoon for about 3 hours and then used to fall asleep. This had been going on for the last 6 weeks. After waking up, infant seemed perfectly normal. History, physical examination, and routine investigations failed to diagnose the cause. An electroencephalogram showed epileptic abnormalities. The “crying episodes” disappeared after starting phenobarbitone. Although two of the four criteria for diagnosis of abdominal epilepsy (AE) are impossible to be met in an infant of this age (because he cannot speak out his ailments whether he is having abdominal pain, headache, dizziness, etc.); still we believe that this was a case of AE. Various case reports have stated that “sustained response to anticonvulsants has been accepted as one of the criteria for the diagnosis of AE.” We suggest AE to be kept in mind even when dealing with an infant of unresolved excessive crying.

Background: Kawasaki disease (KD) is a clinical diagnosis, with common confusion among other causes of febrile illnesses. There are no confirmatory laboratory parameters for diagnosing KD. Objective: To investigate whether low mean platelet volume (MPV) is associated more with fever due to KD than due to the other common causes. Methods: This retrospective case-control study was done on febrile children between 6 months and 6 years of age admitted from January 2015 to January 2017. The MPV values of 28 KD and 50 non-KD febrile children admitted to our hospital were obtained from the hospital records. The diagnosis of KD was accepted only when (1) two pediatricians had agreed upon the diagnosis independently based on the American Heart Association guidelines 2004, (2) no other cause of fever coexisted with KD in a particular patient, and (3) prompt clinical response within 48 h of administration of intravenous immunoglobulin. Using suitable statistical software, the range of MPV in KD fever and non-KD fevers was compared. Results : MPV was lower in the KD group (9.75±0.98 femtoliter) than in the non-KD fever group (11.14±1.53 femtoliter). From the receiver operating characteristic curve, it was found that at MPV ≤10.0 fl, KD can be diagnosed with 75% sensitivity and 80% specificity. This means that lower the value of MPV, lower is the probability that a non-KD patient will be wrongly diagnosed as KD. Conclusion: Our study shows that low MPV is associated with KD. Hence, a low MPV can raise the index of suspicion for KD in febrile children, especially in cases of incomplete KD. Further, prospective studies involving larger sample size are needed to ascertain its diagnostic utility.

Scrub typhus is a re-emerging threat throughout the world. The spectra of clinical pictures and possible complications are both varied and being increasingly reported. Acute disseminated encephalomyelitis (ADEM) is an infrequent demyelinating disorder of the central nervous system that is precipitated by infections and immunizations. There are only two documented cases of ADEM-associated scrub typhus published in the medical literature. We report the first pediatric case wherein a 5-year-old boy presented with high fever, altered sensorium, seizure, quadriparesis, and neck rigidity. He was ultimately diagnosed as a case of scrub typhus with ADEM. After treatment with intravenous doxycycline and methylprednisolone, the fever subsided but residual neurodeficits, such as inability to sit, stand, and talk, as well as bowel bladder dysfunctions persisted. He was subsequently transferred to long-term rehabilitation care.

Neonates with transplacentally acquired dengue infection often present with subtle features. We report two cases of severe neonatal dengue admitted during an outbreak in Kolkata. Both the mothers tested positive for dengue. Both neonates had thrombocytopenia, elevated liver aminotransferases, progressive pallor, and third space fluid loss. One neonate required inotropic support (dopamine infusion) to manage the shock while the other neonate had to be put on continuous positive airway pressure to manage the increasing respiratory distress. Both patients were successfully managed. Neonatal dengue is an important differential diagnosis of neonatal sepsis during an outbreak. Early diagnosis and appropriate fluid resuscitation can help in avoiding complications.

Objective: To study the epidemiological profile, clinical presentation, laboratory markers, treatment outcomes, complications and prognosis of scrub typhus among children presenting to this tertiary care hospital. Method: A cross sectional study was carried out in a tertiary care paediatric hospital between May 2015 and April 2016 on children between 1 month and 12 years who presented with fever and various clinical features suggestive of rickettsial infections. They were included as a convenience sample and tested for scrub typhus by Weil-Felix test as well as IgM ELISA. Children testing positive for scrub typhus were recruited for further study and observed for the various outcome measures. Results: There were 136 children between 1 month and 12 years presenting with fever and clinical features suggestive of rickettsial infections during the study period. Of these, 46 children tested positive for scrub typhus and were included in the study. No patient refused to participate or withdrew from the study. The mean age of the children was 5.5 years, 61% were male, 91% had rural habitats and admissions peaked between August and December. Mean duration of fever before presentation was 10.3 days. Fever (100%), oedema (45.6%), irritability (45.6%), abdominal pain (39.1%), conjunctival congestion (36.9%), vomiting (34.8%), maculopapular rash (32.6%), headache (21.7%), altered sensorium (17.4%), cough (15.2%), eschar (13%) and seizure (10.8%) were the main symptoms. Lymphadenopathy (73.9%), hepatomegaly (71.7%) and splenomegaly (52.1%) were the main signs. Elevated C-reactive protein (100%), anaemia (78.3%), hyponatraemia (73.9%), hypoalbuminaemia (65.2%), leucocytosis (56.5%), transaminitis (32.6%) and thrombocytopenia (17.4%) were important laboratory features. All were IgM ELISA positive and 42 were Weil-Felix test positive. Fever subsided between 24 to 48 hours in the majority. Doxycycline and azithromycin showed similar efficacy. There was no mortality. Conclusion: Scrub typhus is prevalent among children presenting to this tertiary care hospital in Kolkata, India. Sri Lanka Journal of Child Health, 2019; 48(2): 155-159

Typhoid fever is very common in children, with abdominal pain occurring in 21% of patients. The occurrence of acute pancreatitis in typhoid is a rare complication, especially in preschool children. Knowledge of this condition is necessary for proper management, as well as to avoid unnecessary laparotomy. In this article, we describe the case of a 5-year-old girl who was diagnosed with this condition. She was managed conservatively with ceftriaxone and supportive measures, following which she had a completely recovery.

Scrub typhus is an endemic disease of Asian Pacific region, affecting about 1 million people every year. Although it remarkably recovers with doxycycline, the mortality in untreated cases may be as high as 40 to 45%. Owing to the lack of diagnostic facilities for scrub typhus in most places, it is very important to recognize the clinical features. A typical eschar is pathognomonic of the disease. However, this is very rare to be found on the face, and hence can lead to confusions. We present the case of a boy who presented three eschars on the upper lip and was diagnosed as a case of scrub typhus. He responded dramatically with intravenous doxycycline and the eschars healed spontaneously over the next 2 to 3 weeks.

The aim of this article is to derive and verify a mathematical formulation for the reduction of the six-dimensional (6D) positional inaccuracies of patients (lateral, longitudinal, vertical, pitch, roll and yaw) to three-dimensional (3D) linear shifts. The formulation was mathematically and experimentally tested and verified for 169 stereotactic radiotherapy patients. The mathematical verification involves the comparison of any (one) of the calculated rotational coordinates with the corresponding value from the 6D shifts obtained by cone beam computed tomography (CBCT). The experimental verification involves three sets of measurements using an ArcCHECK phantom, when (i) the phantom was not moved (neutral position: 0MES), (ii) the position of the phantom shifted by 6D shifts obtained from CBCT (6DMES) from neutral position and (iii) the phantom shifted from its neutral position by 3D shifts reduced from 6D shifts (3DMES). Dose volume histogram and statistical comparisons were made between and . The mathematical verification was performed by a comparison of the calculated and measured yaw (γ°) rotation values, which gave a straight line, Y = 1X with a goodness of fit as R 2 = 0.9982. The verification, based on measurements, gave a planning target volume receiving 100% of the dose (V100%) as 99.1 ± 1.9%, 96.3 ± 1.8%, 74.3 ± 1.9% and 72.6 ± 2.8% for the calculated treatment planning system values TPSCAL, 0MES, 3DMES and 6DMES, respectively. The statistical significance (p-values: paired sample t-test) of V100% were found to be 0.03 for the paired sample and 0.01 for . In this paper, a mathematical method to reduce 6D shifts to 3D shifts is presented. The mathematical method is verified by using well-matched values between the measured and calculated γ°. Measurements done on the ArcCHECK phantom also proved that the proposed methodology is correct. The post-correction of the table position condition introduces a minimal spatial dose delivery error in the frameless stereotactic system, using a 6D motion enabled robotic couch. This formulation enables the reduction of 6D positional inaccuracies to 3D linear shifts, and hence allows the treatment of patients with frameless stereotactic radiosurgery by using only a 3D linear motion enabled couch.