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Objective: To describe the comorbidities in children with cerebral palsy (CP) and determine the characteristics associated with different impairments., Design: Cross-sectional study., Setting: Tertiary care referral centre in India., Patients: Between April 2018 and May 2022, all children aged 2-18 years with a confirmed diagnosis of CP were enrolled by systematic random sampling. Data on antenatal, birth and postnatal risk factors, clinical evaluation and investigations (neuroimaging and genetic/metabolic workup) were recorded., Main Outcome Measures: Prevalence of the co-occurring impairments was determined using clinical evaluation or investigations as indicated., Results: Of the 436 children screened, 384 participated (spastic CP=214 (55.7%) (spastic hemiplegic=52 (13.5%); spastic diplegia=70 (18.2%); spastic quadriplegia=92 (24%)), dyskinetic CP=58 (15.1%) and mixed CP=110 (28.6%)). A primary antenatal/perinatal/neonatal and postneonatal risk factor was identified in 32 (8.3%), 320 (83.3%) and 26 (6.8%) patients, respectively. Prevalent comorbidities (the test used) included visual impairment (clinical assessment and visual evoked potential)=357/383(93.2%), hearing impairment (brainstem-evoked response audiometry)=113 (30%), no understanding of any communication (MacArthur Communicative Development Inventory)=137 (36%), cognitive impairment (Vineland scale of social maturity)=341 (88.8%), severe gastrointestinal dysfunction (clinical evaluation/interview)=90 (23%), significant pain (non-communicating children's pain checklist)=230 (60%), epilepsy=245 (64%), drug-resistant epilepsy=163 (42.4%), sleep impairment (Children's Sleep Habits Questionnaire)=176/290(60.7%) and behavioural abnormalities (Childhood behaviour checklist)=165 (43%). Overall, hemiparetic and diplegic CP and Gross Motor Function Classification System ≤3 were predictive of lesser co-occurring impairment., Conclusion: CP children have a high burden of comorbidities, which increase with increasing functional impairment. This calls for urgent actions to prioritise opportunities to prevent risk factors associated with CP and organise existing resources to identify and manage co-occurring impairments., Trial Registration Number: CTRI/2018/07/014819., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pancreaticojejunostomy (PJ) is the ''Achilles heel" of pancreaticoduodenectomy (PD) which affects perioperative as well as oncological outcomes. However, there is a lack of information about the superiority of the type of anastomosis in terms of overall morbidity and postoperative pancreatic fistula (POPF) after PD. Here, we compare the outcomes of modified Blumgart PJ with the dunking technique of PJ., Methodology: A case-control study of a prospectively maintained database of 25 consecutive patients undergoing modified Blumgart PJ (study group) and 25 patients who underwent continuous dunking PJ (control group) between January 2018 to April 2021 was done. Between groups, comparisons were made for the duration of surgery, intraoperative blood loss, original fistula risk score, overall complications as graded by Clavien Dindo (CD), POPF, post pancreatectomy haemorrhage (PPH), delayed gastric emptying (DGE), and 30-day mortality at 95% confidence level., Results: Among 50 patients, 30 (60%) were male. The most common indication for PD was ampullary carcinoma (44% in the study group vs. 60% in the control group). The duration of surgery was approximately 41 minutes longer in the study group compared to the control (p = 0.02), while the intraoperative blood loss was similar between the two groups (496.00 ± 226.35 ml vs 508.00 ± 180.67 ml, p = 0.84). While there was no significant difference in mean fistula risk score between the two groups, the POPF (8% vs 32%, p = 0.03), PPH (0% vs 20%, p =0.02), and overall major complications (CD≥ III) according to CD Grading (12% vs 40%, p = 0.02) were significantly lower in the study group. Similarly, the duration of hospital stay in the study group was 4.64 days shorter than the control group (p = 0.001). However, there was no significant difference in the 30-day mortality between the two groups., Conclusions: Modified Blumgart pancreaticojejunostomy has better perioperative outcomes in terms of procedure-specific complications like POPF, PPH, overall major postoperative complications, and duration of hospital stay., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Adhikari et al.)

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Sharma et al.)

Background: Survey-based studies have examined the timing of receiving periconceptional folic acid supplementation. To assess the impact of the periconceptional folic acid supplementation, a postulate that multigravida mothers are more likely to have received the supplementation and the level of serum folic acid in them assayed during the first trimester is likely to be higher than primigravida mothers was put forth. Serum folic acid levels were measured in primigravida and multigravida mothers during the first trimester., Methods: One hundred twenty primigravida and multigravida mothers registered at antenatal clinic of a tertiary care referral centre were included. Serum folic acid assay from samples collected during the first trimester was carried out by chemiluminescence immuneassay. The mothers were followed up during subsequent OPD visits, during admission for delivery and through mobile phones for assessing the delivery outcomes. World Health Organization cutoff values for serum folic acid were used to analyse the results., Results: None of the mothers received folic acid supplement before conception. Mean interval from last menstrual period to receiving the first dose of folic acid supplementation was 71.2 days in primigravida and 67.6 days in multigravida mothers. Overall, 21/120 (17.5%) of primigravida mothers and 34/120 (28.3%) of multigravida mothers had serum folic acid values less than 6 ng/ml (deficiency and possible deficiency)., Conclusion: None of the mothers received folic acid supplements before conception. Significant proportion of mothers, particularly the multigravida having less than normal levels serum folic acid indicates correctable lacunae amenable for preventive intervention., Competing Interests: The authors have none to declare., (© 2021 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd.)

Introduction and Importance: Intra-ampullary papillary tubular neoplasms (IAPNs) are relatively rare kind of neoplasms occurring in the region of the papilla which exhibit significant malignant transformation. The patient was concerned about his pain and the possibility of malignancy., Case Presentation: We report a case of a 47-year-old male who presented with persistent upper abdomen pain. Following detail investigations, he was diagnosed as IAPN and managed by transduonal ampullectomy (TDA)., Clinical Discussion: The insidious onset of IAPN along with its high risk of malignancy makes it mandatory for its proper treatment. Although, endoscopic approach is advantageous for initial therapy, it has some technical difficulties. Hence TDA forms the cornerstone in the management of IAPN with good prognosis., Conclusion: Transduodenal ampullectomy is a safe and feasible option for IAPN. It can be the first choice of treatment in selected cases where endoscopic papillectomy is not available., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The screening tests used for pre-operative evaluation of airway to predict difficult laryngoscopy and intubation have variable diagnostic accuracy. The unanticipated poor laryngeal view is gold standard for defining difficult intubation. We aimed to find out the prevalence of difficult laryngoscopy and intubation, which airway parameter better predicts difficult intubation and whether difficult laryngoscopy is associated with difficult intubation or not., Methods: This analytic cross sectional study was conducted in 665 ASA I/II adult patients, aged 18-65, without obvious airway pathology undergoing elective surgery under general anesthesia. The pre-operative screening tests included mouth opening, modified mallampatti, ratio of height to thyromental distance, sternomentaldistance and upper lip bite test. Cormack-Lehane grade III/ IV was defined as difficult laryngoscopy and potentially difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and area under curve at 95% confidence interval was calculated for all five screening tests., Results: The prevalence of difficult laryngoscopy and intubation was 6.6% (44 cases). The upper lip bite test because of its highest specificity, positive predictive value, negative predictive value, accuracy and area under curve (99.7%; 93.9%; 99.7%; 95.2%; 85.1% respectively) with moderate level of sensitivity (70.5%) was better predictor of difficult intubation than other tests. The difficult laryngoscopy was associated with difficult intubation (p=0.00)., Conclusions: The prevalence of difficult laryngoscopy and intubation was 6.6%.The upper lip bite test was a better predictor of difficult intubation and there was a significant association of difficult laryngoscopy with difficult intubation.

Introduction: General anesthesia is feared to have adverse feto-maternal outcomes compared to neuraxial anesthesia. It is recommended to keep rate of caesarean sections under general anesthesia below 5% and 15% for elective and emergency caesarean sections respectively. This study was conducted to find out the prevalence of caesarean sections under general anesthesia at a tertiary care center in western Nepal., Methods: A descriptive cross-sectional study was conducted among caesarean sections conducted at Manipal Teaching Hospital, Pokhara, Nepal from January 2014 to December 2017. Ethical approval was taken from the Institutional Review Committee with reference number MEMG/IRC/GA/122. All the caesarean sections conducted during this study period were included in the study using whole sampling method. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Data for each patient was subsequently entered into an Excel spreadsheet and analyzed using Statistical Package for Social Sciences version 20., Results: Among 3613 cases, caesarean sections under general anesthesia was observed in 175 (4.84%) in our center over a period of four years at 95% Confidence Interval (4.13-5.55%). The yearly variations ranges from 2.83% to 8.99%. The rate of general anesthesia was found slightly higher in elective 31 (5.82%) as compared to emergency caesarean section 144 (4.67%)., Conclusions: The four year medical records of our institution showed fluctuating trend of caesarian sections under general anesthesia. The rate of general anesthesia for emergency caesarian section was within the recommended rate while it was slightly higher in elective caesarian section.

Objective: To evaluate the efficacy of gastric lavage (GL) in preventing feed intolerance in babies born through Meconium stained amniotic fluid (MSAF)., Study Design: In this randomized trial conducted at a tertiary care hospital, neonates born of MSAF after 34 weeks period of gestation requiring routine care were randomly allocated to GL with 10 ml/kg of normal saline. The control group did not receive GL. The subjects were monitored for first 24 hours in predefined time epochs. The primary outcome was incidence of feed intolerance which was defined as vomiting or abdominal distension more than 2 cm from baseline measure. Babies were also monitored for potential adverse events due to GL and total duration of hospital stay., Results: Baseline parameters were comparable. The incidence of feed intolerance was not significant in the GL group [4.6% vs 9.2%; RR 0.92 (0.29-3)]. There were no adverse events secondary to GL. The duration of hospital stay was comparable between groups., Conclusion: GL in neonates born of MSAF does not reduce feed intolerance.

Introduction: Shivering is an unpleasant experience after spinal anesthesia. We conducted this study to evaluate the efficacy of ondansetron, ketamine and tramadol for prevention of shivering., Methods: In this randomized controlled study, 120 patients aged 18-65 years of American Society of Anesthesiologist (ASA) physical status I and II undergoing various surgical procedures were included and allocated alternately to one of the 4 groups; Normal saline (Group1), Ondansetron 4mg (Group2), Ketamine 0.25mg/kg (Group3) and Tramadol 0.5mg/kg (Group4). Incidence of shivering, effect on hemodynamics, nausea, vomiting, sedation and emergence reactions were recorded. Data was analyzed using SPSS (The Statistical Package for Social Sciences) version 20.0 software., Results: The patients were comparable in terms of demographic variables, baseline temperature, type of surgery, median level of sensory blockade, duration of surgery and anesthesia. Shivering was present in 17 (56.7%), 5 (16.7%), 3 (10%) and 3 (10%) patients respectively in Group 1, 2, 3 and 4 which was statistically significant when compared to Group 1 (P=0.00) The odds of NS and ondansetron, NS and ketamine, NS and tramadol was 6.53, 11.76 and 11.76 respectively which showed that study drugs were effective in preventing shivering. None of the patients were sedated in Group 1 and 2. Mild to moderate sedation was present in Group 3 and 4 (P=0.00). None of the patients had drug related adverse reactions., Conclusions: Prophylactic use of ondansetron, low doses of ketamine and tramadol is effective in preventing shivering post spinal anesthesia without untoward effects.

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

Background: Studies on Bubble Continuous Positive Airway Pressure (B-CPAP) as respiratory support for neonates are few. The aim of our study was to determine the efficacy and safety of B-CPAP in preterm neonates requiring respiratory support., Methods: A prospective observation study was done on 50 preterm babies requiring respiratory support for mild to moderate respiratory distress. Support was given with short, nasal cannulae. Surfactant was administered when indicated. Monitoring was done clinically, with pulse oximeter, radiologically and with blood gases. Staff members were also asked their views. Follow-up was done for 3 months., Results: The mean gestational age was 32.46 (+3.23) weeks and mean birth weight 1454.4 (+487.42) g. Respiratory Distress Syndrome was the commonest indication (30/50). The mean maximum pressure was 6.04 cm H2O and mean maximum FiO2 was 72.16%. Mean maximum paO2, paCO2 and mean minimum paCO2 were 92.93 mm Hg (+16.97), 52.36 mm Hg (+ 7.78) and 36.46 mm Hg (+ 4.95) respectively. Early initiation resulted in lesser duration of support. Failure rate was 30%. Apnoea, >1 dose surfactant and late initiation had a statistically higher incidence of failure. Main complications were skin abrasions (30%), feed intolerance (26%) and gastric distension (26%). Survival rate was 94%. 68% of staff felt that it was as easy to use and 88% felt it was more reliable than standard CPAP., Conclusions: Bubble Continuous Positive Airway Pressure is safe, efficacious and easy to use in preterm neonates with mild to moderate respiratory distress.

Background: Role of vitamin A in reducing the mortality in infants more than six months of age is well known. Supplementing newborn infants with vitamin A within 48 hours of birth reduces infant mortality by almost a quarter, with the greatest benefit to those of low birth weight (LBW). Studies that could highlight deficiency states in neonates, particularly LBW babies by objective measurement of vitamin A levels would help in formulating the recommendations to supplement these babies with vitamin A., Methods: Cord blood plasma vitamin A levels of 154 LBW babies with birth weight in the range of 1505-2455 were analysed for plasma vitamin A (retinol) levels by HPLC method. Samples of 55 babies with normal birth weight were also analysed. LBW babies were divided into two subgroups of preterm LBW and LBW-term small for gestational age (SGA)., Results: Of the 154 babies with LBW, 92 were preterm LBW and 52 were LBW-term SGA. Mean cord blood plasma vitamin A levels were significantly lower in the preterm LBW group (n = 92) compared to levels observed in babies with normal birth weight (n = 55) and LBW-term SGA subgroups (n = 62). There was no significant difference in the mean vitamin A values between the normal birth weight babies and LBW-term SGA group. There was significant positive correlation of cord blood vitamin A levels with birth weight in the entire set of (n = 154) LBW babies (r=0.37, P < 0.0001)., Conclusion: This study revealed significantly lower cord blood vitamin A levels in the preterm LBW babies. The level of vitamin A in LBW babies also correlated with their birth weight. There are enough evidence to support causative association between vitamin A deficiency state and neonatal morbidity. Simple interventions like vitamin A supplementation during a crucial stage of an infant's life may be beneficial in the long run. There is a need to establish norms for vitamin A levels and seriously examine the role of vitamin A supplementation for LBW babies during the immediate postnatal period.

We describe a case of mucus plug in the right main bronchus with ipsilateral obstructive emphysema and contralateral opaque hemithorax in an 18-month-old girl who presented with respiratory distress. The role of multi-detector CT scan with multi-planar reconstructions and virtual bronchoscopy is highlighted.

Recognition of childhood stroke is difficult. Newer diagnostic modalities like magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have made this task much easier. Head trauma usually causes hemorrhage. We are presenting seven cases of mild head injury presenting as ischamic stroke. Neuroimaging suggested infarct involving left basal ganglia and internal capsule in five and bilateral involvement in two cases. MRA done in three was normal.