Search

Introduction. We aimed to determine the burden of respiratory disease by examining clinical profiles and associated predictors of morbidity and mortality of patients admitted to a Pediatric Intensive Care Unit (PICU) in Pakistan, a resource limited country. We also stratified the respiratory diseases as defined by the Pediatric Advanced Life Support (PALS) Classification. Methods. A retrospective study was conducted on children aged 1 month to 18 years who were diagnosed with respiratory illness at the PICU in a tertiary hospital in Karachi, Pakistan. Demographics, essential clinical details including immunization status, and the outcome in terms of mortality or survival were recorded. Predictors of mortality and morbidity including prolonged intubation and mechanical ventilation in the PICU were analyzed using the chi‐square test or Fischer's exact test as appropriate. Results. 279 (63.8% male; median age 9 months, IQR 4–36 months) patients were evaluated of which 44.2% were malnourished and 23.3% were incompletely immunized. The median length of stay in the PICU was 3 days (IQR 2–5 days). Pneumonia was the principal diagnosis in 170 patients (62%) and accounted for most deaths. 76/279 (27.2%) were ventilated, and 67/279(24.0%) needed inotropic support. A high Pediatric Risk of Mortality (PRISM) III score, pneumothorax, and lower airway disease were significantly associated with ventilation support. The mortality rate of patients was 14.3%. Predictors of mortality were a high PRISM III score (OR 1.179; 95% CI 1.024–1.358, P = 0.022) and a positive blood culture (OR 4.305; 95% CI 1.062‐17.448, P = 0.041). Conclusion. Pneumonia is a significant contributor of respiratory diseases in the PICU in Pakistan and is the leading cause of morbidity and mortality. A high PRISM III score, pneumothorax, and lower airway disease were predictors for ventilation support. A high PRISM III score and a positive blood culture were predictors of patient mortality in our study. [ABSTRACT FROM AUTHOR]

Dissertation writing is a process which has its own diction, structure and layout. The language in dissertations has to be in the cadre of academic English. The linguistic specifics of academic English have certain standard and field based norms in which nominalization is one of the very important characteristics in encoding research in dissertations. The current study has described the processes of nominalization by the addition of suffixes in the field of English studies in Pakistan. By utilizing Corpus-based research methodology, the study illustrates the categories and functions of different types of the processes of nominalization via suffixation in PhD dissertations. The study is significant in facilitating the understanding of scholars and researchers about the forms and functions of nominalization via suffixation in academic writing in English literature, linguistics and language teaching in Pakistan. [ABSTRACT FROM AUTHOR]

Congenital vallecular cyst is one of the rare etiologies of upper airway obstruction. Due to the scarcity of literature review, the exact incidence is not known. We report the case of a 10-month-old infant, who came to to Aga Khan University Hospital (AKUH) for the first time with signs of upper airway obstruction; was initially misdiagnosed as foreign body aspiration for which an emergency bronchoscopy was performed that did not reveal any foreign body. The patient was then managed in the pediatric intensive care unit, where he was diagnosed as a congenital vallecular cyst on a subsequent laryngoscopy after extubation failure. The cyst was aspirated and cauterized by the ENT team. The patient was successfully extubated without any signs of upper airway obstruction. In evaluating a child with signs and symptoms of upper airway obstruction, it is crucial to consider not only common causes like foreign body, acute epiglottitis, and croup, but also rare factors such as laryngeal cysts. [ABSTRACT FROM AUTHOR]

Writing discussion in dissertation, though has textual generics, yet is influenced by the context, research domain, and writers’ linguistic competence. In Pakistan, graduates, despite being non-native English writers, know about the generics of writing discussion; yet, their mother tongue and cultural context influence their writing. In order to compare and contrast the generics of writing discussion, and identify the commonalities and variation; this research aims to explore the academic move-structures in the discussion sections. By adopting Corpus-based research tools corpora of M.Phil.and Ph.D.dissertations from the field of English Linguistics and Education were compiled. Based on Yang and Allison (2003) modelthe data was analyzed through Antmover(text structure analyzer software). Different types of moves in discussion section, such as obligatory, conventional, and optional moves, were analyzed in accordance with the strategies of Kanoksilapatham (2005). The commonalities and contrast in the moves of writing discussion has enabled the researcher in identifying 5-moves generic pattern that can serve as a guideline for novice researchers in writing discussion of the dissertations in the fields of English Linguistics and Education in Pakistan. Furthermore, paying attention to the ways in which these disciplines use specific structural moves would facilitate researchers to become more aware of the need for employing these structural moves in properly discussing the data and results in research.

This paper aims at to analyze the causes of matrimonial failure in George Eliot’s Middlemarch among the central couples: Casaubon and Dorothea and Dr. Lydgate and Rosamond _ by applying Social Exchange Theory and its principles (rewards and costs, Comparison level, relational resources, trust and commitment and marital solidarity), through which their causes of failure of conjugal relationship are meticulously analyzed, and not fulfilling of these cause failure and fragility in central marriages in the novel.

The article presents case studies of an eight-months-old male infant with bulging anterior fontanelle and a three-months-old male with two days history of episodic seizures. It states that the eight-months-old male infant, who was diagnosed with meningitis, was discharged after five days with an initial management involving supportive and symptomatic management. It adds that the initial management for the three-months-old infant diagnosed with meningitis are antibiotics and anticonvulsant.

Background: Deep neck space infections are uncommon in infants. Retropharyngeal abscess (RPA) is a deep space neck infection that can present with subtle signs and symptoms. Delay in diagnosis can lead to life-threatening complications. Here we describe life-threatening complication of retropharyngeal abscess. Case presentation: We report a life-threatening complication of retropharyngeal abscess in 10-month old Asian infant weighing 8.2 kg. The patient presented with fever, right-sided neck swelling, hoarseness of voice, and respiratory distress. The clinical and radiological findings were suggestive of airway obstruction complicated by retropharyngeal abscess. The patient was urgently taken to the operating room and underwent (grade 3) intubation. After stabilization, the patient underwent endoscopic trans-oral incision and drainage, during which 5 cc pus was aspirated. Antibiotics were prescribed for 2 weeks following the procedure based on the sensitivity result of the pus culture. Conclusion: In retropharyngeal abscess, a delay in diagnosis can result in life-threatening complications. This report highlights the importance of prompt recognition of a threatened airway and the management of retropharyngeal abscess by emergency physicians. If an emergency physician suspects RPA with airway obstructions, the airway should be immediately secured in a secure environment by otolaryngologist and an anesthesiologist. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various topics within the issue including the corporate governance, success in business, and securities exchange.

Cerebral venous sinus thrombosis is a rarely occurring condition. Pregnancy and postpartum are both known risk factors for cerebral venous sinus thrombosis. Early detection and treatment are critical, as CVST can be potentially life-threatening. Here, we present a case of a patient who developed left transverse and superior sagittal sinus thrombosis 15 days after normal vaginal delivery. The patient presented to the emergency department with complaints of irritability and an altered state of consciousness for two days. The patient also developed seizures extending from the lower limb to the upper body. Laboratory investigations revealed abnormalities in the complete blood count report and urine complete examination. The patient's coagulation profile was totally abnormal, indicating a presence of a thrombus. All the other diagnostic techniques, including Electrocardiogram, Carotid Doppler Scan, and Ultrasound abdomen, revealed no findings. However, Magnetic resonance venography + Magnetic resonance imaging showed partial superior sagittal sinus thrombosis in the anterior and upper parietal regions, right internal jugular vein thrombosis, and left transverse thrombosis with associated left parietal infarcts. The presence of thrombosis in sinuses and jugular vein resulted in seizures, altered state of consciousness, and other associated symptoms. The patient was treated with sodium valproate, heparin, and other medications accordingly. The above-mentioned case was unique due to the involvement of unusual sinuses (transverse sinus) as previous studies have only reported cases of thrombus presence in the superior sagittal sinus. This case study will discuss patient diagnosis and management with Heparin and Diazepam to stop altered state of consciousness and seizures in females.

Soil erosion is a serious environmental problem faced by district Chakwal. Unpredictable short term and high intensity rainfall, improper cultivation and deforestation have accelerated the soil erosion in the district. The agricultural productivity of the study area can be enhanced by understanding, estimating and controlling the root causes of soil erosion. This study was undertaken to estimate and spatially represent the rate of average annual soil erosion in Chakwal using GIS/RS techniques. The soil erosion was estimated using Universal Soil Loss Equation (USLE) model. To find out parameters of USLE, ASTER GDEM of 30 m resolution was used to estimate slope length and elevation of the study area. Landsat 8 satellite imagery of year 2019, was used to prepare land use map using supervised classification. Soil map with texture and geomorphology was used to identify soils of study area and rainfall data of last 7 years was also studied. Finally, the soil loss has been computed using raster calculator of ArcGIS 10.2 software. The average annual soil loss was predicted up to 268,619 tons/acre/year, of which maximum soil erosion was occurring near the steep slopes and river channels. It is necessary to adapt sustainable land management practices to reduce the risk of further soil erosion, by adopting rainwater harvesting and choosing right crops for suitable soil type

Soluble sugars and organic acids are the most abundant components in ripe fruits, and they play critical roles in the development of fruit flavor and taste. Some loquat cultivars have high acid content which seriously affect the quality of fruit and reduce the value of commodity. Consequently, studying the physiological mechanism of sugar-acid metabolism in loquat can clarify the mechanism of their formation, accumulation and degradation in the fruit. Minerals application has been reported as a promising way to improve sugar-acid balance of the fruits. In this study, loquat trees were foliar sprayed with 0.1, 0.2 and 0.3% borax, and changes in soluble sugars and organic acids were recorded. The contents of soluble sugars and organic acids were determined using HPLC-RID and UPLC-MS, respectively. The activities of enzymes responsible for the metabolism of sugars and acids were quantified and expressions of related genes were determined using quantitative real-time PCR. The results revealed that 0.2% borax was a promising treatment among other B applications for the increased levels of soluble sugars and decreased acid contents in loquats. Correlation analysis showed that the enzymes i.e., SPS, SS, FK, and HK were may be involved in the regulation of fructose and glucose metabolism in the fruit pulp of loquat. While the activity of NADP-ME showed negative and NAD-MDH showed a positive correlation with malic acid content. Meanwhile, EjSPS1, EjSPS3, EjSS3, EjHK1, EjHK3, EjFK1, EjFK2, EjFK5, and EjFK6 may play an important role in soluble sugars metabolism in fruit pulp of loquat. Similarly, EjPEPC2, EjPEPC3, EjNAD-ME1, EjNAD-MDH1, EjNAD-MDH5-8, EjNAD-MDH10, and EjNAD-MDH13 may have a vital contribution to malic acid biosynthesis in loquat fruits. This study provides new insights for future elucidation of key mechanisms regulating soluble sugars and malic acid biosynthesis in loquats.

Global warming negatively affects plant growth due to the detrimental effects of high temperature-induced heat stress. Rhizobium inoculation (RI) and exogenous melatonin (MT) have shown a positive role in resisting abiotic stress. However, their synergistic effect on avoiding heat-induced damages in Medicago truncatula has not been studied yet. Hence, the objective of the present study was to evaluate the impact of these amendments (RI and MT) to ameliorate the heat damages in Medicago truncatula. The study was comprised of two factors: (1) heat-induced stress: (i) optimum temperature (26 ± 1°C): (23 ± 1°C) (day: night), (ii) moderate heat (35 ± 1°C): (28 ± 1°C), and (iii) severe heat (41 ± 1°C): (35 ± 1°C) for 72 h, and (2) amendments: (i) no RI + no MT (NRI + NMT), (ii) Rhizobium inoculation (RI), (iii) 60 μM melatonin (MT), and (iii) RI + MT. Results showed that the combined application of RI and MT was better than their individual applications, as it prevented heat-induced membrane damages by declining the hydrogen peroxide (34.22% and 29.78%), superoxide anion radical (29.49% and 26.71%), malondialdehyde contents (26.43% and 21.96%), and lipoxygenase activity (44.75% and 25.51%) at both heat stress levels as compared to NRI + NMT. Moreover, RI + MT treated plants showed higher antioxidative and methylglyoxal detoxification enzymes (Gly I and Gly II) activities under heat stress. While, NRI + NMT treated plants showed a higher level of methylglyoxal contents (47.99% and 46.71%) under both levels of heat stress. Relative to NRI + NMT plants, RI + MT pretreated plants exhibited improved heat tolerance as indicated by higher chlorophyll (37.42% and 43.52%), carotenoid contents (32.41% and 47.08%), and photosynthetic rate (42.62% and 64.63%), under moderate and severe heat stress, respectively. Furthermore, RI + MT pretreated plants had considerably higher indole-3 acetic acid and abscisic acid concentrations under moderate (54.02% and 53.92%) and severe (68.36% and 64.61%) heat stress conditions. Similarly, plant dry biomass, NPK uptake, nitric oxide, and nitrate reductase activity were high in RI + MT treated plants, under both levels of stress. Therefore, this study advocates the positive synergistic effect of RI and MT pretreatment against moderate and severe heat-induced stress and for possible maintenance of plant growth under changing scenarios of global warming.

In this letter, we propose an end-to-end multi-modal based convolutional self-attention network to perform power control in non-orthogonal multiple access (NOMA) networks. We formulate an energy efficiency (EE) maximization problem, and we design an iterative solution to handle this optimization problem. This solution can provide an offline benchmark but might not be suitable for online power control, therefore, we employ our proposed deep learning model. The proposed deep learning model consists of two main pipelines, one for the deep feature mapping where we stack our self-attention block on top of a ResNet to extract high quality features, and focus on specific regions in the data to extract the patterns of the influential factors (interference, quality of service (QoS), and the corresponding power allocation). The second pipeline is to extract the shallow modality features. Those features are combined and passed to a dense layer to perform the final power prediction. The proposed deep learning framework achieves near optimal performance, and outperforms traditional solutions and other strong deep learning models such as PowerNet and the conventional convolutional neural network (CNN). [ABSTRACT FROM AUTHOR]

Alterations in land use and land cover, either natural or anthropogenic can disturb the balance of fragile ecosystems. Climate change plays a unique role in governing the structure and state of land features and alters the structure of ecosystem as well as its services required by earth. Human health and environment are matter of concern due to changes induced by human in its natural environment (Jat et al., 2008). Human has an urge to remain near nature, for that they shift from dense urban areas to less dense areas (Western, 2001). So is the case of new housing societies where the land mafias intimate the people about new settlements (Zaman and Baloch, 2011), which are made by cutting the forests, removing trees and disturbing the ecosystem. For proper planning and management of natural resources, it is necessary to study the land cover and its associated changes (Asselman and Middelkoop, 1995). Modelling of changes within land cover to identify environmental trends on the local, national or regional level, have been realized in the scientific community (Nath et al., 2020). GIS/RS provides continuous change dynamics (Berlanga-Robles and Ruiz-Luna, 2011) of land cover/land use, i.e. by satellite monitoring (Ruiz-Ruano et al., 2016). The understanding of land cover changes is necessary for decision making (Lu et al., 2004) in the natural resource management (Seif et al., 2012). This study was carried out to identify the impact of changes in climate upon land use and land cover of Chakwal district from 1995 to 2020. Geospatial techniques were applied to estimate the differences in land features, using different time interval satellite datasets (Table 1). Six major classes of land features including, agriculture, bare land, built-up, forest, shrubs/grass and water were selected for this study, with respect to time.

Eucalyptus tree was first planted in Pakistan in the 1980sunder the project of Pakistan Forest Institute sponsored by United States Agency for International Development. It is not native to Pakistan's environment, so it has become a threat to the ecosystem. A mature Eucalyptus tree shape is like a shrub or tall tree. It is centered by the number of controversies like allelopathy, loss of soil fertility, the substitution of conventional forests and causing various hydro-ecological imbalances of an ecosystem. Eucalyptus tree consumes three times more water in arid and semi-arid environments, because of vapor pressure deficit. About 80% of Pakistan's area is present in the semi-arid and arid climate. Pakistan is facing a serious water shortage and rapid groundwater level depletion in many parts of the country. It is believed that species of Eucalyptus tree are extracting more groundwater than water recharge. Therefore, the present study is conducted to identify the adverse impacts of Eucalyptus plantation on the groundwater level of Lahore. Six parks in Lahore were selected as study sites, i.e., Gulshan-e-Iqbal Park, Bagh-e-Jinnah, Jillani Park, Nawaz Sharif Park, Jallo Park, and Johar Town Park. A total of 3,484 Eucalyptus trees were identified with different age groups. These trees belong to the species of Eucalyptus camaldulensis, Eucalyptus citriodoraandEucalyptus sideroxylone. The study reveals that since 1990, the groundwater level has significantly reduced in study sites. It is recommended that Eucalyptus trees may be replaced with other indigenous species so that the rate of groundwater depletion can be slowed down

Cold stress is an adverse environmental condition that limits the growth and yield of leguminous plants. Thus, discovering an effective way of ameliorating cold-mediated damage is important for sustainable legume production. In this study, the combined use of Rhizobium inoculation (RI) and melatonin (MT) pretreatment was investigated in Medicago truncatula plants under cold stress. Eight-week-old seedlings were divided into eight groups: (i) CK (no stress, noninoculated, no MT), (ii) RI (Rhizobium inoculated), (iii) MT (75 μM melatonin), (iv) RI+MT, (v) CS (cold stress at 4 °C without Rhizobium inoculation and melatonin), (vi) CS+RI, (vii) CS+MT, and (viii) CS+RI+MT. Plants were exposed to cold stress for 24 hrs. Cold stress decreased photosynthetic pigments and increased oxidative stress. Pretreatment with RI and MT alone or combined significantly improved root activity and plant biomass production under cold stress. Interestingly, chlorophyll contents increased by 242.81% and MDA levels dramatically decreased by 34.22% in the CS+RI+MT treatment compared to the CS treatment. Moreover, RI+MT pretreatment improved the antioxidative ability by increasing the activities of peroxidase (POD; 8.45%), superoxide dismutase (SOD; 50.36%), catalase (CAT; 140.26%), and ascorbate peroxidase (APX; 42.63%) over CS treated plants. Additionally, increased osmolyte accumulation, nutrient uptake, and nitrate reductase activity due to the combined use of RI and MT helped the plants counteract cold-mediated damage by strengthening the nonenzymatic antioxidant system. These data indicate that pretreatment with a combined application of RI and MT can attenuate cold damage by enhancing the antioxidation ability of legumes.

Nowadays, environmental pollution due to discharge of organic pollutants from food, textile, and pharmaceutical industries into clean water and development of contagious diseases due to pathogenic organisms provide impetus to material researcher to fabricate novel design for efficient photocatalyst and antimicrobial agents. In this regard, designing a core-shell heterojunction catalyst based on metal oxides is considered an auspicious approach. In present study, combating the problems of singular oxides, core-shell PANI-CeO 2 -Fe 2 O 3 –NiO nanocomposite (PCFN) and CeO 2 –Fe 2 O 3 –NiO nanocomposite (CFN) was synthesized through sol-gel and oxidative polymerization route with cetyletrimethylammonium bromide (CTAB) as surfactant. The XRD, FTIR, and Raman confirmed the formation of nanocomposites with core-shell morphology composed of PANI (shell) and oxides (Core) in PCFN with a particle size of 52 nm (TEM). Surprisingly, PCFN has lower band gap, e−/h+ recombination, and larger charge transfer character than CFN. The decomposition test using MB and MO dyes showed that PCFN degraded 99%, 98%, while CFN degraded only 73% and 54%, respectively, under 50 min sunlight illumination. The reusability was assessed up to 7th cycle for PCFN. The influence of operational parameters (catalyst dose, dye concentration, pH) was tested for PCFN. Further, the antimicrobial action against S. aureus (gram + ve), E. coli (gram -ve) were also tested. The supreme performance of PCFN has been credited to heterostructure dual Z-scheme formation and core-shell morphology supported with PANI, which suppresses the e−/h+ recombination process by promoting their separation. The present finding indicated that the PCFN is a promising modifier for bacterial disinfection and acts as a superb photocatalyst through core-shell formation with PANI support. • Synthesis of core-shell PANI-CeO 2 -Fe 2 O 3 –NiO nanocomposite via solution method. • Enhanced photodegradation of MB and MO dyes under natural sunlight. • The higher ability to inhibit the growth of S. aureus and E. coli bacterial strains. • Dual Z-scheme heterostructure formation leads to better charge transfer. • Efficient catalyst for dye pollutant elimination and bacterial disinfection. [ABSTRACT FROM AUTHOR]

• Carboxymethyl cellulose (CMC) effect was studied on mango under ambient storage. • CMC reduced weight loss, disease occurrence, hydrogen peroxide and malondialdehyde. • CMC delayed green color loss and suppressed carotenoids accumulation in mango peel. • CMC reduced softening enzyme activity and showed higher antioxidant enzyme activities. • CMC treatment could be considered suitable to delay ripening and softening of mango. The effect of carboxymethyl cellulose [(1%) CMC] was evaluated on mango fruits under storage at 20 ± 1 °C for 20 days. The CMC coating noticeably reduced weight loss and disease incidence. Application of CMC delayed climacteric peak of ethylene and respiration rate with significantly reduced relative ion leakage, malondialdehyde, superoxide anion and hydrogen peroxide content. The treated mangoes showed significantly lower L*, a*, b* and total carotenoids. The CMC treatment reduced the increase in cellulase, pectin methylesterase and polygalacturonase activity that delayed softening of mango fruits. In addition, activities of peroxidase, catalase, ascorbate peroxidase and superoxide dismutase were substantially higher in CMC-treated mango fruits. The treated fruits showed significantly lower soluble solids and higher titratable acidity which thereby reduced the ripening index of mangoes. In conclusion, CMC treatment could be considered a potential pre-storage treatment to delay postharvest ripening and to conserve the eating quality of ambient stored mango fruits. [ABSTRACT FROM AUTHOR]

Paediatric acute liver failure (PALF) is a rare yet severe condition that is associated with high mortality. Apart from liver transplant, no specific therapy exists, particularly in developing countries. Evidence suggests that removal of damage-associated molecular patterns, cytokines, toxins, and other metabolites that accumulate due to impaired liver function can enhance natural recovery. Plasmapheresis can be used to remove these products; however, there is limited evidence to support this approach. This case series discusses three critically ill patients with acute liver failure who underwent plasmapheresis. The patients included a seven-year-old boy (Case 1), a 17-year-old boy (Case 2), and a 16-monthold boy (Case 3). Two patients showed significant improvement in bilirubin level, coagulation profile, inotropes requirement, and Glasgow coma scale score. Unfortunately, one patient with PALF, complicated with multi-organ dysfunction, died due to refractory shock on the fourth day of hospitalisation. Our findings illustrate that early use of therapeutic plasmapheresis in PALF can lead to improvement in clinical outcome. It may serve as a bridging therapy for liver transplant and for the spontaneous regeneration of the patient's liver.

Introduction: Magnetic resonance imaging (MRI) is a common procedure in tertiary care neonatal intensive care units (NICUs). MRIs aid in detailing structural anatomy and are increasingly utilized for prognostication. Keeping babies calm and motion-free in the MRI suite is challenging, and various approaches have been adopted to obtain the best image quality. We share our experience of intervention bundle for procedural sedation with the novel use of buccal midazolam in our NICU for babies undergoing MRI., Methods: This single-center quality improvement project comprised two epochs. Epoch 1 from April 2018 to December 2020 provided baseline data regarding sedation use and helped identify causes for suboptimal images and the adverse event rate. Following the implementation of an interventional bundle comprising specific midazolam dose recommendations tailored to background risk factors and streamlining the procedural sedation process, similar comparative data were collected in epoch 2 (May 2021 to December 2022) after a washout period., Results: Of 424 patients, 238 and 108 had MRI done under either procedural sedation protocol or feed and wrap technique in epoch 1 and 2, respectively. After excluding babies whose MRIs were performed under sedative infusions, 30 (13%) babies had adverse events in epoch 1, while only 8 (7%) events occurred in epoch 2. There was also a 37% improvement in the documentation of procedural sedation between the two epochs., Conclusion: Procedural sedation with buccal midazolam under neonatologist supervision is safe, efficient, and effective in babies undergoing MRI in this single-center study. More extensive studies may be warranted to assess the suitability of this sedation modality for broader use., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Objectives: To evaluate nationwide pediatric critical care facilities and resources in Pakistan., Design: Cross-sectional observational study., Setting: Accredited pediatric training facilities in Pakistan., Patients: None., Interventions: None., Measurements and Main Results: A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring., Conclusions: There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure., Competing Interests: Dr. Latif’s institution received funding from the Bill and Melinda Gates Foundation; he received support for article research from the Bill and Melinda Gates Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: Most biomarker studies of sepsis originate from high-income countries, whereas mortality risk is higher in low- and middle-income countries. The second version of the Pediatric Sepsis Biomarker Risk Model (PERSEVERE-II) has been validated in multiple North American PICUs for prognosis. Given differences in epidemiology, we assessed the performance of PERSEVERE-II in septic children from Pakistan, a low-middle income country. Due to uncertainty regarding how well PERSEVERE-II would perform, we also assessed the utility of other select biomarkers reflecting endotheliopathy, coagulopathy, and lung injury., Design: Prospective cohort study., Setting: PICU in Aga Khan University Hospital in Karachi, Pakistan., Patients: Children (< 18 yr old) meeting pediatric modifications of adult Sepsis-3 criteria between November 2020 and February 2022 were eligible., Interventions: None., Measurements and Main Results: Plasma was collected within 24 hours of admission and biomarkers quantified. The area under the receiver operating characteristic curve for PERSEVERE-II to discriminate 28-day mortality was determined. Additional biomarkers were compared between survivors and nonsurvivors and between subjects with and without acute respiratory distress syndrome. In 86 subjects (20 nonsurvivors, 23%), PERSEVERE-II discriminated mortality (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.72-0.94) and stratified the cohort into low-, medium-, and high-risk of mortality. Biomarkers reflecting endotheliopathy (angiopoietin 2, intracellular adhesion molecule 1) increased across worsening risk strata. Angiopoietin 2, soluble thrombomodulin, and plasminogen activator inhibitor 1 were higher in nonsurvivors, and soluble receptor for advanced glycation end-products and surfactant protein D were higher in children meeting acute respiratory distress syndrome criteria., Conclusions: PERSEVERE-II performs well in septic children from Aga Khan University Hospital, representing the first validation of PERSEVERE-II in a low-middle income country. Patients possessed a biomarker profile comparable to that of sepsis from high-income countries, suggesting that biomarker-based enrichment strategies may be effective in this setting., Competing Interests: Drs. Famularo’s, Kazi’s, Parkar’s, Thompson’s, and Yehya’s institutions received funding from the National Heart, Lung, and Blood Institute. Drs. Kazi, Parkar, Thompson, and Yehya received support for article research from the National Institutes of Health. Drs. Parkar’s and Yehya’s institutions received funding from Pfizer outside of the scope of this work. Dr. Thomas received funding from Bayer AG. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Introduction: Retinopathy of prematurity (ROP) is a multifactorial disease and a preventable cause of blindness in childhood. Hyperoxia and hypoxia can cause retinal neovascularization resulting in retinal detachment and blindness if left untreated. Besides oxygen treatment, other reasons for ROP development are well known. We prospectively adopt various strategies to keep oxygen saturation (SpO 2 ) within targets , between 91 and 95% for those on supplemental oxygen. By adapting this, we postulated that the incidence of severe ROP might be reduced., Methods: 2018-2019 provided pre-intervention and 2020 post-intervention data for the project. For all babies (≤32 weeks, ≤1,500 g with FiO 2 >0.21), target SpO 2 between 91 and 95% was measured as a percentage of time spent within and outside target SpO 2 during 1-4 weeks of life., Results: 112 and 60 preterm neonates were screened for ROP during the pre- and post-intervention phase. Twenty neonates (18.3%) during pre-intervention and 16 (26.7%) in the post-intervention phase developed severe ROP requiring treatment. Despite a statistically significant increase of 10 percent points in time spent within target SpO 2 (91-95%) in the post-intervention phase ( p < 0.05), the incidence of severe ROP did not decline. Using a multivariate model, odds of ROP development decreased with gestational age (25%) while increasing with PDA requiring treatment (4.33 times) and glucose ≥10 mg/dL (4.15 times), considering one variable at a time, keeping others constant., Conclusion: Our QI project showed successful attainment of maximum time; the SpO 2 remained within targets during supplemental oxygen; however, the incidence of severe ROP had not declined. Factors other than SpO 2 might be responsible for a high incidence of ROP in our neonatal intensive care unit., Competing Interests: None of the authors have any conflict of interest., (Copyright © 2022 by The Author(s). Published by S. Karger AG, Basel.)

Objective: To determine the performance of a commercially available risk analytic tool (IDO2) to estimate the risk for SVO2 < 40% in patients admitted in cardiac intensive care unit (CICU)., Methods: Medical and T3 records of all patients (aged 1 day to 12 years, weight >2 kg) who received care in the CICU between October 1st, 2019 and October 1st, 2020, had SvO2 lab(s) drawn during CICU course and whose data was transmitted to T3, were included. The average IDO2 Index was computed in the 30-min period immediately prior to each SvO2 measurement and used as a predictor score for SvO2 < 40%., Results: A total of 69 CICU admissions from 65 patients, median age 9.3 months (interquartile range 20.8) were identified. Surgical and medical patients were 61 (88%) and 8 (12%) respectively; 4 (5.7%) patients had single ventricle physiology. Tetralogy of Fallot n = 23 (33.3%) and ventricular septal defects 17 (24.6%) were major cardiac diagnosis. Sixty-one (89.9%) of the admissions were successfully discharged from the hospital. Of the 187-total included SvO2 labs, 17 (9%) were <40%. The AUC of estimating SvO2 < 40% IDO2 was 0.87 [confidence interval (CI): 0.79-0.94]. Average IDO2 above 75 had the highest absolute risk (42.11, CI: 20.25-66.50) and highest RR (4.63, CI: 2.31-9.28, p -value < 0.0001) of SvO2 < 40%., Conclusion: IDO2 performed well in estimating low SvO2 (<40%) in pediatric patients presenting to a CICU in a low resource setting. Future work is needed to determine the effect of this risk analytic tool on clinical outcomes in such a setting., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Abbas, Hussain, Shahbaz, Siddiqui and Hasan.)

Hypernatremia is a potentially serious condition in both term and preterm babies, which can lead to severe and permanent neurological damage. There are many physiological changes in sodium homeostasis that occur soon after birth. Understanding this physiological process, early anticipation of hypernatremia and familiarization with the neonatal management of hypernatremia can prevent mortality and long-term morbidity associated with this condition. This review aims to provide a practical and understandable approach to the diagnosis and management of hypernatremia in neonates., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 by S. Karger AG, Basel.)

A spatial modulation (SM) scheme has been developed as a hopeful candidate for spectral and energy-efficient wireless communication systems, as it provides a great judgment for the system performance, data transmission rate, receiver complexity, and energy/spectrum efficiency. In SM, the data is conveyed by both habitual M-ary signal constellations and the transmit antennas indices. Therefore, the system data rate improvement due to the side information bits transmitted, encapsulated in indices of the transmit antennas, improves the SM transmission efficiency compared to the different MIMO players. The information bits transmitted over the antenna index and data symbol constellation using M-ary signal performance have different levels of bit error rate (BER) performance. This paper proposes unequal error protection (UEP) scheme for image transmission over the Internet of Underwater Things (IoUTs) using SM. The Set Partitioning in Hierarchical Trees (SPIHT) coders encode the underwater image and classify the encoded bits in two categories: critical and uncritical bits. The critical bits are transmitted over the SM index bits and have a low BER while the uncritical bits are transmitted over high order M-ary signal constellation to resolve the underwater acoustic channel bandwidth limitation problem. The proposed SM-UEP technique has been developed carefully with enough justification and evaluation over the measured underwater acoustic channel and the simulated channel. The simulation results show that the proposed SM-UEP can increase the average peak signal-to-noise ratio (PSNR) of the reconstructed received image considerably, and significantly., Competing Interests: The authors declare no conflicts of interest.

Hypoglycemia may lead to neurological impairment; therefore, high-risk newborns are screened postnatally. However, hypoglycemia monitoring protocols often do not include cord blood acidosis as a risk factor. The study aimed to find an association between asymptomatic cord blood acidosis and hypoglycemia. All healthy term infants born at McMaster Children Hospital, Hamilton, Canada, between October 2013 and September 2014, who had umbilical cord blood pH <7.0 or base excess <12 mmol/L were studied. Infants with evidence of hypoxic-ischemic encephalopathy, birth weights outside of 10th to 95th percentiles for gestation, mothers with preeclampsia, diabetes or taking a -blockers at the time of the birth were excluded. Hypoglycemia was defined as blood glucose <2.6 mmol/L in the first two hours of life. One hundred sixtysix infants met the cord blood gas criteria, but only 16 had hypoglycemia. Although infants with mild perinatal depression are at risk for hypoglycemia, a significant association could not be proved.

In this paper, a novel time-frequency signature using resonance-based sparse signal decomposition (RSSD), phase space reconstruction (PSR), time-frequency distribution (TFD) and manifold learning is proposed for feature extraction of ship-radiated noise, which is called resonance-based time-frequency manifold (RTFM). This is suitable for analyzing signals with oscillatory, non-stationary and non-linear characteristics in a situation of serious noise pollution. Unlike the traditional methods which are sensitive to noise and just consider one side of oscillatory, non-stationary and non-linear characteristics, the proposed RTFM can provide the intact feature signature of all these characteristics in the form of a time-frequency signature by the following steps: first, RSSD is employed on the raw signal to extract the high-oscillatory component and abandon the low-oscillatory component. Second, PSR is performed on the high-oscillatory component to map the one-dimensional signal to the high-dimensional phase space. Third, TFD is employed to reveal non-stationary information in the phase space. Finally, manifold learning is applied to the TFDs to fetch the intrinsic non-linear manifold. A proportional addition of the top two RTFMs is adopted to produce the improved RTFM signature. All of the case studies are validated on real audio recordings of ship-radiated noise. Case studies of ship-radiated noise on different datasets and various degrees of noise pollution manifest the effectiveness and robustness of the proposed method., Competing Interests: The authors declare no conflict of interest.

The integral image, an intermediate image representation, has found extensive use in multi-scale local feature detection algorithms, such as Speeded-Up Robust Features (SURF), allowing fast computation of rectangular features at constant speed, independent of filter size. For resource-constrained real-time embedded vision systems, computation and storage of integral image presents several design challenges due to strict timing and hardware limitations. Although calculation of the integral image only consists of simple addition operations, the total number of operations is large owing to the generally large size of image data. Recursive equations allow substantial decrease in the number of operations but require calculation in a serial fashion. This paper presents two new hardware algorithms that are based on the decomposition of these recursive equations, allowing calculation of up to four integral image values in a row-parallel way without significantly increasing the number of operations. An efficient design strategy is also proposed for a parallel integral image computation unit to reduce the size of the required internal memory (nearly 35% for common HD video). Addressing the storage problem of integral image in embedded vision systems, the paper presents two algorithms which allow substantial decrease (at least 44.44%) in the memory requirements. Finally, the paper provides a case study that highlights the utility of the proposed architectures in embedded vision systems.

Objective: To assess the cost of treatment for families of children hospitalised in paediatric intensive care unit of a tertiary care teaching hospital., Methods: The retrospective cohort study was conducted in Aga Khan University Hospital, Karachi, and comprised record of all children admitted to the paediatric intensive care unit from January 1 to June 30, 2013. Demographic data, diagnosis at the time of admission, co-morbidity, length of stay in intensive care and outcome were recorded. The record of all hospital charges for each day the patient was cared for were also recorded. The finance department itemised the cost into major categories like pharmacy, radiology, laboratory, etc. SPSS 19 was used for statistical analysis., Results: Record of 148 patients represented the study sample. Of them, 98(66%) were males. Overall median age was 2.7 yrs (interquartile range: 1 month to 16 years) and 93(62.8%) were below 5 years of age. Median length of stay was 3.5 days (range: 2-5 days) and total patient days in intensive care were 622. The median cost per admission was PKR 217,238 (range: (114,550-368,808) and mean cost per day was PKR 57,535 (43,911-85,527). The major cost distributions were bed charges PKR 8,092,080 (18.02%), physician charges PKR 6,398653(14.25%), medical-surgical supplies PKR 8,000772(17.8%), laboratory charges PKR 8,403,615(18.9%) and pharmacy charges PKR 5,852.226(13.03%)., Conclusions: The cost of paediatric intensive care unit was expensive. Cost distribution was almost evenly distributed. Hence, a better admission policy is needed for resource utilisation and cost-effectiveness.

Brain electrical activity recorded via electroencephalogram (EEG) is the most convenient means for brain-computer interface (BCI), and is notoriously noisy. The information of interest is located in well defined frequency bands, and a number of standard frequency estimation algorithms have been used for feature extraction. To deal with data nonstationarity, low signal-to-noise ratio, and closely spaced frequency bands of interest, we investigate the effectiveness of recently introduced multivariate extensions of empirical mode decomposition (MEMD) in motor imagery BCI. We show that direct multichannel processing via MEMD allows for enhanced localization of the frequency information in EEG, and, in particular, its noise-assisted mode of operation (NA-MEMD) provides a highly localized time-frequency representation. Comparative analysis with other state of the art methods on both synthetic benchmark examples and a well established BCI motor imagery dataset support the analysis.

Objective: To determine the need of bone marrow examination in children with idiopathic thrombocytopenic purpura (ITP) at initial presentation., Study Design: Descriptive study. PLACE AND DURATION OF THE STUDY: Pediatric Units of Children Hospital, Islamabad, from January 1999 to December 2003., Patients and Methods: All children, clinically suspected to have ITP, who underwent bone marrow examination, were included After reviewing the file records of these patients for history, examination and investigations, a predesigned proforma was filled and data was analyzed, using SPSS version 10 for statistical analysis. The results were reported in the form of frequencies, percentages and mean., Results: A majority of the children were between 48 to 96 months, with a mean age of 54.43 months. Male to female ratio was 1.45:1. Mean platelet count was 33861/mm(3). None of the bone marrow results showed the presence of abnormal cells consistent with hematological malignancy. ITP was the final diagnosis in 52 patients. One patient was diagnosed to have megakaryocytic hypoplasia. Bone marrow aspiration in one patient was hypoplastic, and subsequently, he was diagnosed to have aplastic anemia on trephine biopsy., Conclusion: Bone marrow aspiration should not be a part of routine work-up for diagnosing ITP in children and should be reserved for those children having atypical clinical and laboratory features.

Objective: To find the association between iron deficiency anemia and febrile convulsions among children presenting at the Aga Khan University Hospital, Karachi., Design: Case control study., Place and Duration of Study: Paediatric Department of the Aga Khan University Hospital, Karachi, from January 2001 to December 2001., Patients and Methods: A total of 60 patients fulfilled the study criteria of febrile seizure or any febrile illness. These were divided into two groups with children having febrile seizures comprised the cases while those having only febrile illness with no seizures comprised the controls. Both groups had equal number of children matched for age and gender. Workup for seizures and iron deficiency anemia was done and data was analyzed using SPSS version 10., Results: The mean age for cases (group A) was 22.97+/-9.52 months while that for controls (group B) was 22.77+/-11.33. There was also no significant difference in the gender distribution in the two groups. Iron deficiency anemia was significantly more frequent among the cases as compared to the controls as evident from parameters studied i.e. hemoglobin <10 g/dl (p-value= <0.000), hematocrit <30% (p= <0.01), MCV <70 fL (p=<0.002), MCH<24 pg (p= <0.001) and serum ferritin <10 ng/ml (p= <0.000)., Conclusion: Plasma ferritin level was significantly lower in cases as compared to controls suggesting that iron deficient children are more prone to febrile seizures. A follow-up study of patients found to be iron-deficient at the time of a first febrile seizure to determine the incidence of subsequent febrile seizures after treatment for iron deficiency would be of great interest.