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Objectives Critically ill children and neonates routinely receive opioids and benzodiazepines for analgesia and sedation in the pediatric intensive care unit (PICU). Prolonged opioid therapy often leads to tolerance and is associated with iatrogenic withdrawal syndrome (IWS) when opioids and benzodiazepines are weaned or discontinued. Our aim is to study the incidence, risk factors and outcome of IWS following use of a withdrawal protocol on pediatric patients after cardiac surgery. Methods We prospectively included all postoperative pediatric patients who developed IWS after being assessed by the Withdrawal Assessment Tool (WAT-1) score (WAT-1 ≥3) over 9 months. Unit-based withdrawal management protocol was used. Patients’ outcome was assessed by duration to be completely off opioids & benzodiazepines, duration of ICU and hospital stay. Results 432 patients were admitted during study period. Twenty-five patients (5.8%) developed IWS. The mean age and weight was 15.2 ± 31.4 months and 6.9 ± 7.7 kg respectively. 60% of the patients who developed withdrawal had previous ICU admissions with exposure to sedatives. In the IWS group the mean duration for use of fentanyl and midazolam infusions was 8.6 ± 5.1 & 9.6 ± 6 days respectively. The mean duration for completely stopping opioids and benzodiazepines was 17.2 ± 6.8 days with a mean duration of ventilation of 8.2 ± 6.8 days. The mean ICU and hospital stay for IWS patients was 26.5 ± 21.9 and 31.5 ± 21.1 days respectively. There was statistically significant difference in the mean age, and duration of use of sedatives between the patients who developed IWS and those who did not with P-value of 0.003 and < 0.0001, respectively. Conclusion Withdrawal syndrome after pediatric cardiac surgery prolongs ICU and hospital stay. Our data shows that younger age and longer duration for use of sedatives seem to be risk factors for developing withdrawal syndrome.

Physiological adaptations to external stressors can reveal socio-cognitive health in infancy. With the use of thermal imaging and behavioural analyses, the current study examined the arousal markers accompanying infants' interactions with a familiar and an unfamiliar person. To address the current research question, the mother and a complete stranger interacted with 2 to 3 month-old infants (N= 10, 2 boys)in three different conditions: Neutral, Play, and Compliment. Behavioral analyses showed that overall gaze was longer to the Stranger compared to the Mother independent of condition. Physiological findings showed that skin temperature was significantly higher with the stranger independent of condition. The regions of the face that passed the significance threshold included the maxillary area, the nose, and the forehead. Both behavioral and physiological findings emphasize the ability of the infant to distinguish between a familiar and an unfamiliar person. Most importantly, however thermal imaging has proven to be a promising tool in physiologically differentiating between variable social conditions in very young infants opening up a new experimental portal for identifying healthy physiological development. How to cite this article: Ioannou S, Morris P, Hassanain H, et al. Under the skin: Exploring 2-month-olds' thermal reactions in different social interactions with mother and stranger.

Candida auris is a relatively new species of the Candida genus that is rapidly spreading in healthcare institutions across the globe. It is exceedingly difficult to identify with standard laboratory procedures and is challenging to treat due to its resistance to most antifungals. Moreover, it quickly colonizes on the surfaces in hospitals and ICUs and causes repeated infections, despite regular hospital disinfection. This grim occurrence of multidrug-resistant yeast has now become imperative to report, as its true prevalence remains unclear. Only some reports have been published in Saudi Arabia and here we present a case of C. auris candidemia identified in our hospital.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare disease with an unknown etiology which most commonly results in subacute diplopia and ataxia. Diagnosis is achieved through a triad of the following findings: lymphocytic pleocytosis with increased CD4+ T cells on cerebrospinal fluid (CSF) analysis; perivascular punctate and curvilinear hemorrhages in the pons, medulla, or cerebellum on magnetic resonance imaging (MRI) with contrast; and the cessation of symptoms after the initiation of corticosteroids. Here, we report the case of a 23-year-old male who presented with non-specific signs and symptoms, including diffuse weakness in all limbs, ataxia, and slurred speech. The diagnosis was achieved through a contrast MRI of the brain, suggestive of brainstem encephalitis, and a CSF analysis, which revealed elevated glucose and protein levels. Intravenous methylprednisolone was administered for five days and resulted in acute improvement of the patient's clinical status. Repeat CSF analysis and MRI of the brain with contrast two weeks later showed resolution of previous findings. CLIPPERS syndrome is a newly identified disease thought to cause a predominantly inflammatory reaction in the pons, medulla, cerebellum, and supratentorial region. MRI with contrast tends to reveal a "salt and pepper appearance" in a punctate and curvilinear fashion. The hallmark of treatment is corticosteroid therapy, and discontinuation of therapy should be done with caution as relapse of the syndrome with corticosteroid withdrawal has been documented.