Abstract Background: Patients scheduled for elective procedures require appropriate fasting to prevent complications like aspiration. In children, it is important to avoid over-fasting. The primary objective of this study was to determine whether we adhered to the fasting guidelines of the American Society of Anesthesiologists (ASA). The secondary objectives included identifying the reasons for any deviations from these guidelines and assessing the impact of fasting on a child’s preoperative and postoperative behavior. Materials and Methods: We collected data on preoperative fasting in 263 children aged 1 month to 18 years who were scheduled for elective surgeries over a year. We recorded details regarding preoperative fasting hours for solids, breast milk, clear fluids, and water. In addition, we noted any delay in scheduled time, preoperative and postoperative behavior, signs of dehydration, premedication, reasons why parents chose to feed their children during the preoperative period, postoperative analgesia, feeding in recovery, and recovery times. Results: We were able to strictly and partially comply with ASA guidelines on fasting in 65.7%, 84.2%, and 91.2% of cases for water/clear juice, breast milk, and solids, respectively. Even though we prioritized the smallest babies at the top of the list, instances of prolonged fasting still occur due to many reasons. Prolonged fasting can lead to abnormal behavior in children both preoperatively (10.7%) and, possibly, postoperatively (12.3%). Conclusion: With proper planning and communication, we can adhere to standard preoperative fasting guidelines. Avoiding excessive fasting helps keep children comfortable during the preoperative and postoperative periods.

Abstract Inflammatory linear verrucous epidermal nevus (ILVEN) is a rare variant of epidermal nevus, typically presenting during infancy or early childhood, and is characterized by unilateral, erythematous, hyperkeratotic, and verrucous plaques that follow the Blaschko lines. ILVEN is classically pruritic, with lesions that are often refractory to standard treatments. We report a 38-year-old woman with congenital, asymptomatic ILVEN confined to the leg. After decades of quiescence, rapid adult progression with bilateral hand lesions occurred. Histology revealed psoriasiform epidermal hyperplasia with alternating vertical tiers of parakeratosis and orthokeratosis. The parakeratotic zones were overlaid by areas of diminished or absent granular layer (hypogranulosis), while the orthokeratotic zones demonstrated retained hypergranulosis. Findings were consistent with ILVEN. Given the widespread lesions and absence of disabling symptoms, conservative management with acitretin was initiated. This case illustrates the clinical variability and mosaic inflammatory nature of ILVEN, highlighting atypical features such as adult onset, bilateral acral distribution, and lack of systemic manifestations. This unusual course expands ILVEN spectrum and supports molecular evaluation in atypical cases. Future studies on the genetic basis of ILVEN may guide targeted therapies and improve management of extensive or refractory cases.

Abstract Background: Urinary tract infection is a common problem in antenatal women, associated with serious morbidity in mother and baby. This study aims to describe the uropathogen profile noted in pregnant women visiting a secondary hospital in Southern India and the antimicrobial susceptibility pattern. This would be useful in the selection of antimicrobial agents for the initiation of empirical antibiotic therapy. Methods: A retrospective observational study was performed on data collected from 2017 to 2020. Urine cultures were performed on symptomatic pregnant women, those who were positive by a screening test, or those who had a history of previous preterm labor or preterm rupture of membranes. A total of 575 urine cultures had been performed in this period. Results: A total of 183 of the 575 (31.8%) samples sent for urine culture showed significant growth. The most common organism grown was Escherichia coli (45.1%), followed by Klebsiella spp. (15.6%) and Enterococcus spp. (7.8%). Among the E. coli, 20% were extended-spectrum beta-lactamase producers. E. coli was susceptible to amoxicillin–clavulanate (88%), gentamicin (88%), and nitrofurantoin (82%). Klebsiella spp. was susceptible to cefpodoxime and cotrimoxazole (92.3% each) and amoxicillin–clavulanate (84.6% each). There were no significant differences in perinatal outcomes between the patients who were culture positive and those who were culture negative. Conclusion: The absence of significant growth in 68% of specimens sent underlines the importance of microbiological testing before antibiotic administration. The most common organisms noted in our study population were E. coli, followed by Klebsiella. Amoxicillin–clavulanate, gentamicin, ciprofloxacin, and nitrofurantoin were noted to be good options for antimicrobial therapy.

Antimicrobial resistance (AMR) is a critical global health issue, driven by the misuse and overuse of antibiotics across human, animal, and environmental sectors. Among the most pressing concerns is the rise of AMR in Gram-negative bacteria (GNB)–notably Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, and Pseudomonas aeruginosa. These pathogens are often multidrug-resistant (MDR) or extensively drug-resistant, leaving clinicians with limited therapeutic options and patients with poor prognoses. Resistant Gram-negative bacterial infections are consistently associated with prolonged hospital stays, increased intensive care unit admissions, higher mortality rates, and substantial financial burdens for both healthcare systems and patients. MDR GNB infections, in particular, can extend hospitalization by up to 2 weeks and increase costs by USD 4000–9000 per patient, depending on the infection site and resistance profile.[1,2] In India and other low- and middle-income countries (LMICs), where out-of-pocket healthcare expenditure is high, such infections often lead to catastrophic health spending. Direct costs include extended hospitalizations, the use of expensive last-line antibiotics like ceftazidime-avibactam or colistin, and intensive supportive care for complications such as sepsis or organ failure. Indirect costs–ranging from lost productivity to long-term disability and postdischarge rehabilitation–are less quantifiable but significantly contribute to the economic impact.[3] Carbapenem-resistant Enterobacterales and A. baumannii are particularly concerning, with mortality rates ranging from 30% to over 50%, especially in cases of bloodstream infections or ventilator-associated pneumonia.[4,5] Diagnostic delay, presence of severe comorbid conditions, limited antimicrobial availability, and inappropriate empiric therapy often lead to worse outcomes and inflated treatment costs.[6] Despite the magnitude of the problem, investments in antimicrobial stewardship, infection prevention, and rapid diagnostics remain insufficient. A study from Southeast Asia demonstrated that targeted antimicrobial stewardship interventions reduced antibiotic usage and costs by nearly 20% without compromising clinical outcomes.[7] Unfortunately, access to new and effective antibiotics remains inequitable. Advanced agents like cefiderocol and meropenem–vaborbactam are often unavailable in LMICs due to high costs and regulatory delays. Consequently, clinicians may resort to less effective or more toxic therapies, compounding both clinical failures and financial strain. A WAY FORWARD Addressing the rising cost of resistant Gram-negative bacterial infections requires a comprehensive, multisectoral approach. Health systems must integrate AMR cost tracking, expand investments in stewardship, diagnostics, and surveillance, and improve access to last-line antibiotics through subsidies or pooled procurement. Insurance reforms are essential to protect patients in low-resource settings from catastrophic expenses. Simultaneously, accelerating diagnostic innovation, enforcing strict antimicrobial stewardship, investing in next-generation therapies such as phage or antibody-based treatments, and strengthening infection control measures are critical. Global collaboration is vital to harmonize data sharing and coordinate international efforts to combat AMR effectively. The World Bank has projected that by 2050, drug-resistant infections could cause a 3.8% drop in global GDP and push up to 28 million people into extreme poverty annually.[8] This economic dimension of AMR must no longer be an afterthought. Every resistant infection averted is a life saved and a cost avoided. The global health community must urgently align clinical practice, policy, and economic strategy to mitigate the growing toll of GNB

Abstract This case series presents four uncommon vascular anomalies of the carotid arterial system identified during routine cadaveric dissections. We describe atypical spatial arrangements between the internal carotid artery (ICA) and external carotid artery (ECA), including instances where the ICA is positioned medially relative to the ECA, and pronounced ECA curvature forming a 6.2 cm S-shaped loop. In addition, two rare branching configurations were noted: a linguofacial-laryngeal trunk giving rise to the lingual, facial, and superior laryngeal arteries, and an ascending pharyngeal-occipital trunk. These findings were observed in cadavers aged 65–72 years. The observed vascular irregularities have significant implications for head-and-neck surgeries, such as thyroidectomy, laryngectomy, and carotid endarterectomy, as well as for radiological assessments and interventional techniques. We explore the developmental origins of these anomalies, likely stemming from irregular vascular migration during embryogenesis. This series emphasizes the importance of clinicians recognizing potential carotid artery deviations to prevent procedural complications and optimize patient outcomes. By thoroughly documenting these cases, we contribute to the expanding knowledge base on vascular anomalies and their clinical significance.

We report a case of acute leukoencephalopathy with restricted diffusion (ALERD) in a 2½-year-old male who presented with fever, seizures, and altered sensorium. Cerebrospinal fluid showed lymphocytic pleocytosis, whereas brain magnetic resonance imaging revealed T2 hyperintensities with restricted diffusion in cortical and subcortical regions. The patient was treated with antiseizure medications, acyclovir, methylprednisolone, and intravenous immunoglobulin. This case highlights the importance of early recognition and prompt treatment of ALERD in children, emphasizing the need for increased awareness among pediatric healthcare providers to improve patient outcomes.

Background: Clozapine (CLZ) is the drug of choice for the management of schizophrenia that does not respond to first-line treatments. 40%–70% of patients on CLZ do not have significant improvement and require augmentation. This study aimed to identify factors associated with inadequate response to CLZ in treatment-resistant patients. Methodology: Seventy-four outpatients with a diagnosis of treatment-resistant schizophrenia on CLZ were included in the study. The Positive and Negative Syndrome Scale (PANSS) and Addenbrooke’s Cognitive Examination (ACE III) were used for assessment of the severity of psychosis and cognitive functioning, respectively. A specific pro forma for documenting sociodemographic and clinical details was also used. Results: Seventeen (22.97%) of the participants were found to have a poor response to CLZ. The majority were male with a mean age of 39.11 years (standard deviation [SD] = 9.63). The mean CLZ level was 625.53 ng/mL (SD = 398.59). The mean total PANSS score was 35.07 (SD = 3.65). Cognitive deficits were identified in 51.4% by the ACE III. Younger age at the onset of illness and poor medication adherence were found to have a significant association with inadequate response to CLZ ( P < 0.05). Conclusions: Modifiable factors that contribute to CLZ resistance, such as medication adherence, must be effectively managed. Early identification of patients with an inadequate response to CLZ is essential to institute alternate pharmacological and nonpharmacological strategies that will help improve patient outcomes.

Background: The foramen magnum (FM) serves as a critical anatomical conduit between the cranial cavity and vertebral canal, transmitting vital neurovascular structures. Its morphometric characteristics hold significant implications across multiple disciplines, including neurosurgery, forensic anthropology, and evolutionary biology. Despite numerous studies on basic dimensions, comprehensive analyses incorporating multiple parameters remain limited. The present study aimed to conduct a detailed morphometric analysis of the FM using Vernier calipers, measuring and correlating multiple parameters (anteroposterior [AP] diameter, transverse [TV] diameter, area, circumference, and shape index [SI]). In addition, we investigated sexual dimorphism in FM dimensions and classified FM shapes to analyze their distribution. Methodology: A cross-sectional study of 100 dry skulls (60 male and 40 female) was conducted. Precise measurements were obtained using Vernier calipers (0.01 mm precision) and flexible tape. Parameters included AP diameter (basion–opisthion), TV diameter (maximum width), area (π × AP/2 × TV/2), circumference, and SI (TV/AP × 100). Statistical analysis employed SPSS V25 (mean ± standard deviation, Pearson correlation, t -tests; P < 0.05 significant). Results: In the present study, the mean foramen magnum dimensions were as follows: anteroposterior diameter (AP) = 34.8 ± 2.3 mm, transverse diameter (TV) = 29.5 ± 1.9 mm, area = 823.6 ± 45.2 mm², and circumference = 112.4 ± 6.8 mm. A strong positive correlation was observed between AP and TV ( r = 0.72, P < 0.001). Sexual dimorphism was significant ( P < 0.05) for all parameters except the shape index (SI). The most common shape was oval (65%), followed by round (20%) and irregular (15%). Conclusion: The study provides comprehensive morphometric data demonstrating consistent dimensional relationships through strong parameter correlations, significant sexual dimorphism with larger male dimensions, and predominant oval morphology with notable variability. The findings of the present study enhance understanding of FM anatomy with applications in surgical planning, forensic identification, and anthropological research.

Abstract Background: Medical clearance for patients presenting with psychiatric-like illnesses has been a topic of debate for years. This study aimed to determine the predictors of diagnosing psychiatric illness in the emergency department (ED). Methods: The study included patients aged ≥13 years presenting to the adult ED with psychiatric-like illness over 1 year (January 01, 2019–December 31, 2019). Medical charts were reviewed, and multiple variables were coded and analyzed. Results: Our study included 361 patients, constituting 0.89% of the total ED visits. The majority (335 patients, 92.8%) were diagnosed with primary psychiatric illnesses, while 26 patients (7.2%) had underlying medical conditions contributing to their symptoms. Bivariate and multivariate logistic regression analysis identified the predictors for initial psychiatric diagnoses, including abnormal behavior (odd’s ratio [OR]: 8.29; 95% confidence interval [CI]: 2.04–33.65; P < 0.01) and substance abuse (adjusted OR: 17.27; 95% CI: 3.88–76.88; P < 0.01). Notable findings involved family history or previous psychiatric illness (OR: 2.32; 95% CI: 0.59–6.09; P < 0.01), absence of medical comorbidities (adjusted OR: 2.47; 95% CI: 1.05–5.86; P < 0.01), and no new medication initiation before illness (OR: 6.43; 95% CI: 1.52–27.18; P < 0.01), normal sensorium (adjusted OR: 2.84; 95% CI: 0.81–10.00; P < 0.01) and intact orientation (adjusted OR: 6.73; 95% CI: 1.24–36.42; P < 0.01) demonstrated statistically significant predictors of an initial psychiatric diagnosis in the ED. Conclusion: Significant predictors of initial psychiatric illness included abnormal behavior, substance abuse, family psychiatric history, absence of major medical conditions, no recent medication changes before illness onset, normal sensorium and orientation, and normal laboratory markers at presentation.