Epilepsia Partialis Continua as a Sequelae of Measles Infection in Children With Hematolymphoid Malignancies.

PURPOSE: To share our clinical experience with the diagnosis and management of children with hematolymphoid malignancies presenting with epilepsia partialis continua (EPC) as a sequelae of measles infection. MATERIALS AND METHODS: In December 2022, a series of children in our hemato-oncology unit presented with focal status epilepticus with no conclusive evidence pointing toward any underlying etiology. One such child had a typical measles rash a few weeks before the onset of this focal status epilepticus. After a series of cases with a similar presentation, a clinical pattern suspicious for measles became evident. cerebrospinal fluid polymerase chain reaction was positive for measles virus with measles immunoglobin M detected in the serum. This led to the diagnosis of measles inclusion-body encephalitis in a series of children who presented with EPC over a period of 3 months. EPC is a rare manifestation of measles that is seen only in immunocompromised patients. RESULTS: Among the 18 children reported in this series, only 10 had a history of rashes. The rash was mostly transient and elicited only on retrospective history taking. Five of the 18 children who did not lose consciousness during the prolonged seizure episode survived the disease but had residual neurologic sequelae. Among the 18 children, two were unimmunized and immunization status could not be confirmed in three other children. CONCLUSION: This case series highlights the threats posed by measles infection in children with cancer who are immunosuppressed because of the underlying disease and ongoing chemotherapy. Loss of herd immunity because of declining measles immunization rates secondary to vaccine hesitancy and COVID-19 lockdown pose a greater risk of measles infection and its complications for patients with deficient immune systems.

A single-arm, prospective study comparing translaryngeal ultrasonography with direct visualisation by flexible laryngoscopy for vocal cord assessment in patients undergoing oesophagectomy or mediastinoscopy.

Background and Aims: Translaryngeal ultrasonography (TLUSG) for diagnosis of vocal cord palsy, a relatively new, safe and noninvasive bedside technique with minimal risk of respiratory infection transmission, has been effective in patients with thyroid disease. We studied its use as an alternative method to visual inspection by flexible laryngoscopy (FL) for vocal cord assessment in patients undergoing thoracic surgeries. Methods: After Institutional Ethics Committee approval and trial registration, in this single-arm, prospective study, the vocal cord function of 110 patients who underwent either total oesophagectomy or mediastinoscopy was assessed immediately after extubation by both FL and TLUSG. A follow-up assessment was done by laryngoscopy using Hopkin's endoscope (HL) and a repeat TLUSG. The primary outcome was the concordance between direct visualisation (FL or HL) and TLUSG. Results: Vocal cords were successfully visualised by TLUSG in 90% of male and all female patients. Findings of FL and TLUSG done at the first assessment matched in 89 (86.4%) out of 103 patients, and the degree of concordance was 0.69 (95% confidence interval [CI] =0.52-0.83). At the second assessment, HL and TLUSG findings matched in 83 (94.3%) out of 88 patients, and the degree of concordance was 0.89 (95% CI = 0.77-0.98). Conclusion: TLUSG is an effective noninvasive alternative to direct visualisation for vocal cord assessment in both male and female patients undergoing thoracic surgery.

DIAGNOSIS OF ACUTE APPENDICITIS AND APPENDICULAR PERFORATION: EVALUATION OF PLATELET INDICES AND RED CELL DISTRIBUTION WIDTH AS EMERGING BIOMARKERS.

BACKGROUND: Acute appendicitis is a common surgical emergency worldwide. Recent studies on hematological inflammatory markers concerning acute appendicitis have shown variable results. AIMS: The aim of this study was to evaluate pre-operative values of platelet indices such as mean platelet volume (MPV) and platelet distribution width (PDW), and red cell distribution width (RDW) in relation to the diagnosis of acute appendicitis and their efficacy as predictors of appendicular perforation. METHODS: A prospective observational study of 190 patients diagnosed with appendicitis and who underwent an appendectomy was undertaken and confirmed histopathologically. Preoperatively, blood samples of white blood cells (WBCs), platelet count, MPV, PDW, and RDW were analyzed using a Sysmex XN1000 analyzer machine. RESULTS: Of 190 patients, 169 had acute appendicitis, and 21 had perforated appendicitis. The mean age of patients was 28.04 ± 14.2 years. The male-to-female ratio was 1.5:1. The WBC (p<0.05), MPV (p<0.05), and PDW (p<0.05) were found to have higher statistically significant values in acute appendicitis and perforated appendicitis compared to the RDW (p>0.05). However, perforated appendicitis had a higher RDW value compared to acute appendicitis, which can be a predictive factor. CONCLUSIONS: The elevated value of MPV and PDW associated with leukocytosis can be used as supportive evidence for the clinical and radiological diagnosis of acute appendicitis and appendicular perforation. Thus, these values can be used as diagnostic cost-effective inflammatory biomarkers.

Diagnosis of acute appendicitis and appendicular perforation: evaluation of platelet indices and red cell distribution width as emerging biomarkers / Diagnóstico de apendicite aguda e perfuração apendicular: avaliação dos índices de plaquetas e distribuição de glóbulos vermelhos como biomarcadores emergentes

ABSTRACT BACKGROUND: Acute appendicitis is a common surgical emergency worldwide. Recent studies on hematological inflammatory markers concerning acute appendicitis have shown variable results. AIMS: The aim of this study was to evaluate pre-operative values of platelet indices such as mean platelet volume (MPV) and platelet distribution width (PDW), and red cell distribution width (RDW) in relation to the diagnosis of acute appendicitis and their efficacy as predictors of appendicular perforation. METHODS: A prospective observational study of 190 patients diagnosed with appendicitis and who underwent an appendectomy was undertaken and confirmed histopathologically. Preoperatively, blood samples of white blood cells (WBCs), platelet count, MPV, PDW, and RDW were analyzed using a Sysmex XN1000 analyzer machine. RESULTS: Of 190 patients, 169 had acute appendicitis, and 21 had perforated appendicitis. The mean age of patients was 28.04 ± 14.2 years. The male-to-female ratio was 1.5:1. The WBC (p<0.05), MPV (p<0.05), and PDW (p<0.05) were found to have higher statistically significant values in acute appendicitis and perforated appendicitis compared to the RDW (p>0.05). However, perforated appendicitis had a higher RDW value compared to acute appendicitis, which can be a predictive factor. CONCLUSIONS: The elevated value of MPV and PDW associated with leukocytosis can be used as supportive evidence for the clinical and radiological diagnosis of acute appendicitis and appendicular perforation. Thus, these values can be used as diagnostic cost-effective inflammatory biomarkers.

RESUMO RACIONAL: A apendicite aguda é uma emergência cirúrgica comum em todo o mundo. Estudos recentes sobre marcadores inflamatórios hematológicos relacionados à apendicite aguda mostraram resultados variáveis. OBJETIVOS: Avaliar valores pré-operatórios de índices plaquetários como volume médio de plaquetas (VPM) e largura de distribuição de plaquetas (PDW), largura de distribuição de hemácias (RDW) em relação ao diagnóstico de apendicite aguda e sua eficácia como preditores de apendicite perfuração. MÉTODOS: Estudo observacional prospectivo de 190 pacientes diagnosticados com apendicite e submetidos a apendicectomia confirmados histopatologicamente. Amostras de sangue pré-operatórias de glóbulos brancos (WBC), contagem de plaquetas, volume plaquetário médio (MPV), distribuição das plaquetas (PDW) e distribuição dos glóbulos vermelhos (RDW) foram analisadas usando uma máquina analisadora Sysmex XN1000. RESULTADOS: Foram incluídos 190 pacientes, sendo que 169 tiveram apendicite aguda e 21 tiveram apendicite perfurada. A média de idade dos pacientes foi de 28,04 ± 14,2. A proporção homem-mulher foi de 1,5:1. Verificou-se que WBC (p<0,05), MPV (p<0,05) e PDW (p<;0,05) têm valores estatisticamente significativos mais altos na apendicite aguda e na apendicite perfurada em comparação com o RDW (p> 0,05). No entanto, a apendicite perfurada apresentou um valor de RDW maior em comparação com a apendicite aguda, o que pode ser um fator preditivo. CONCLUSÕES: O valor elevado de MPV e PDW associado à leucocitose pode ser usado como evidência de suporte para o diagnóstico clínico e radiológico de apendicite aguda e perfuração apendicular. Assim, esses valors podem ser usado como biomarcadores inflamatórios diagnósticos de baixo custo.

Postoperative complications and critical care management after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy: A systematic review of the literature.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a comprehensive treatment option performed for peritoneal surface malignancies. Postoperatively almost all patients are transferred to the intensive care unit electively. AIM: To describe the common and rare postoperative complications, postoperative mortality and their critical care management after CRS-HIPEC. METHODS: The authors assessed 54 articles for eligibility. Full text assessment identified 14 original articles regarding postoperative complications and critical care management for inclusion into the final review article. RESULTS: There is an exaggerated metabolic and inflammatory response after surgery which may be termed as physiological in view of the nature of surgery combined with the use of heated intraperitoneal chemotherapy with/out early postoperative intravenous chemotherapy. The expected postoperative course is further discussed. CRS-HIPEC is a complex procedure with some life-threatening complications in the immediate postoperative period, reported morbidity rates between 12%-60% and a mortality rate of 0.9%-5.8%. Over the years, since its inception in the 1980s, postoperative morbidity and survival have significantly improved. The commonest postoperative surgical complications and systemic toxicity due to chemotherapy as reported in the last decade are discussed. CONCLUSION: CRS-HIPEC is associated with a varying rate of postoperative complications including postoperative deaths and needs early suspicion and intensive care monitoring.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in a 2-YearOld Child with Abdominopelvic Rhabdomyosarcoma: A Case Report of Anaesthetic Concerns.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a well-established multimodal treatment in patients with peritoneal surface malignancies in adults. Children younger than 3 years rarely undergo such extensive surgeries with heated chemotherapy infusion intraoperatively. Only one such case is reported in the literature for CRS-HIPEC for an abdominopelvic rhabdomyosarcoma in a child of 2 years or less. We present the case of a 2-year-old child with abdominopelvic rhabdomyosarcoma undergoing CRS-HIPEC and discuss the perioperative concerns and challenges.

Epidemiology and Predictors of Hospital Outcomes of Critically Ill Pediatric Oncology Patients: A Retrospective Study.

BACKGROUND: The number of pediatric oncology patients admitted to the intensive care unit (ICU) has increased, and their hospital outcomes are improving. Since scarce data are available about this patient population, we conducted this retrospective study to evaluate the epidemiology and predictors of hospital outcomes. MATERIALS AND METHODS: We included all children with cancers who were admitted to our ICU over 1 year. We excluded children admitted after elective surgery and those following bone marrow transplant. We collected data about demographics, admission diagnosis, type of malignancies, and ICU interventions. The primary outcome was the hospital outcome. The secondary outcomes were ICU length of stay (LOS), and ICU and hospital mortality. We analyzed the predictors of hospital outcome. RESULTS: Two hundred pediatric oncology patients were admitted from November 1, 2014 to October 30, 2015. Seventy-eight children had solid organ malignancies, and the rest had hematological malignancies. Hematooncology malignancy patients had significantly higher hospital mortality than those with solid organ malignancies. (61.5 vs 34.6%, p = 0.015). On multivariate regression analysis, mechanical ventilation [odds ratio (OR), 14.64; 95% confidence interval (CI): 1.23-165.05; p <0.030], inotropes (OR, 9.81; 95% CI: 1.222-78.66; p <0.032), and the presence of coagulopathy (OR, 3.86; 95% CI: 1.568-9.514; p <0.003) were independent predictors of hospital mortality. CONCLUSION: In this retrospective cohort of 200 children with malignancies, we found that children with hematologic cancer had significantly higher hospital mortality as compared to those with solid tumors. The need for mechanical ventilation, use of inotrope infusion, and coagulopathy were independent predictors of mortality. HOW TO CITE THIS ARTICLE: Bhosale SJ, Joshi M, Patil VP, Kothekar AT, Myatra SN, Divatia JV, et al. Epidemiology and Predictors of Hospital Outcomes of Critically Ill Pediatric Oncology Patients: A Retrospective Study. Indian J Crit Care Med 2021;25(10):1183-1188.

Compliance and perception about personal protective equipment among health care workers involved in the surgery of COVID-19 negative cancer patients during the pandemic.

BACKGROUND: Health care workers (HCWs) are at risk of getting infected while at work, for example, operating room (OR), hence it is pertinent that they don all the appropriate personal protective equipment (PPE) to minimize the chance of getting infected. METHODS: A COVID-19 specific briefing and debriefing form was created and used in the OR along with the World Health Organization surgical safety checklist to reinforce the use of appropriate PPE. An audit was subsequently done to understand the compliance to PPE use, followed by a survey based on the findings of the audit to understand the issues related to noncompliance. RESULTS: The form was used in 183 out of the 238 (77%) surgeries performed during a months' time. The overall compliance for PPE usage was 96.3%. Noncompliance was seen most often for eye protection (45/567) (P = .01). The survey revealed that this was mostly among surgeons mainly due to discomfort, poor visibility, and frequent fogging. CONCLUSIONS: Our HCW were adapting well to the new normal of donning appropriate PPE in the OR, except for the eye protection due to discomfort and visibility related issues. This is important to know so that necessary changes could be introduced to better the compliance.

Pain after posterolateral versus nerve-sparing thoracotomy: A randomized trial.

OBJECTIVES: Post-thoracotomy pain leads to patient discomfort, pulmonary complications, and increased analgesic use. Intercostal nerve injury during thoracotomy or its entrapment during closure can contribute to post-thoracotomy pain. We hypothesized that a modified technique of posterolateral thoracotomy and closure, preserving the intercostal neurovascular bundle, would reduce acute and chronic post-thoracotomy pain. METHODS: We randomized 90 patients undergoing posterolateral thoracotomy for pulmonary resection at a tertiary level oncology center to standard posterolateral (control arm) or modified nerve-sparing thoracotomy. All patients received morphine via patient-controlled analgesia pumps. The primary outcome was the worst postoperative pain score in the first 3 postoperative days. Secondary outcomes included the average pain score and analgesic requirements in the first 3 postoperative days and the incidence of post-thoracotomy pain 6 months after surgery. RESULTS: No significant differences were seen between the groups in acute or chronic post-thoracotomy measured by the numeric rating scale. There was no difference seen in the worst (mean) postoperative pain scores (3.71 vs 3.83, difference 0.12; 99% confidence interval [CI], -0.7 to +0.9; P = .7), average (mean) pain scores in the first 3 postoperative days (1.77 vs 1.85, difference 0.08; 99% CI, -0.4 to +0.6; P = .69), mean consumption of morphine (mg/kg) (1.45 vs 1.40, difference -0.05; 99% CI, -0.4 to +0.3; P = .73), or incidence of chronic postoperative pain (37.8% vs 40%, difference 4.9%; 99% CI, -22.8 to +30.7%; P = .73). CONCLUSIONS: The modified nerve-sparing thoracotomy technique does not reduce post-thoracotomy pain compared with standard posterolateral thoracotomy.

Fatal Postoperative Hemolysis Due to Severe Falciparum Malaria.

A 60-year-old apparently healthy female patient underwent mastectomy for breast cancer. She had sinus tachycardia and no other abnormal finding in the preoperative period. However, the immediate postoperative course was stormy with the development of anemia, thrombocytopenia, hemolysis, and renal failure with severe metabolic acidosis. Peripheral blood smear revealed the presence of ring forms of Plasmodium falciparum. Multiorgan failure and death occurred within 36 h of surgery in spite of initiation of antimalarial agents. Diagnosis of malaria should be kept in mind in the event of development of sudden unexplained deterioration or multiorgan dysfunction associated with thrombocytopenia, hemolysis, and severe metabolic acidosis, even in previously asymptomatic patients, especially in residents or recent travelers of the malaria-endemic area.

Does tranexamic acid reduce blood loss during head and neck cancer surgery?

BACKGROUND AND AIMS: Transfusion of blood and blood products poses several hazards. Antifibrinolytic agents are used to reduce perioperative blood loss. We decided to assess the effect of tranexamic acid (TA) on blood loss and the need for transfusion in head and neck cancer surgery. METHODS: After Institutional Review Board approval, 240 patients undergoing supramajor head and neck cancer surgeries were prospectively randomised to either TA (10 mg/kg) group or placebo (P) group. After induction, the drug was infused by the anaesthesiologist, who was blinded to allocation, over 20 min. The dose was repeated every 3 h. Perioperative (up to 24 h) blood loss, need for transfusion and fluid therapy was recorded. Thromboelastography (TEG) was performed at fixed intervals in the first 100 patients. Patients were watched for post-operative complications. RESULTS: Two hundred and nineteen records were evaluable. We found no difference in intraoperative blood loss (TA - 750 [600-1000] ml vs. P - 780 [150-2600] ml, P = 0.22). Post-operative blood loss was significantly more in the placebo group at 24 h (P - 200 [120-250] ml vs. TA - 250 [50-1050] ml, P = 0.009), but this did not result in higher number of patients needing transfusions (TA - 22/108 and P - 27/111 patients, P = 0.51). TEG revealed faster clot formation and minimal fibrinolysis. Two patients died of causes unrelated to study drug. Incidence of wound complications and deep venous thrombosis was similar. CONCLUSION: In head and neck cancer surgery, TA did not reduce intraoperative blood loss or need for transfusions. Perioperative TEG variables were similar. This may be attributed to pre-existing hypercoagulable state and minimal fibrinolysis in cancer patients.

Bilateral Cystic Lymphangioma of Ovary Associated with Chylous Ascites.

Intraabdominal cystic lymphangiomas are rare and are located in retroperitoneum, mesentery, omentum and other visceral organs. Lymphangiomas of the ovary are rare and are usually unilateral. Cases with bilateral cystic lymphangiomas of the ovary are reported very rarely in literature. We report a rare case of bilateral cystic lymphangioma of ovary associated with chylous ascites in a 35-year-old lady who presented with complaints of severe dysmenorrhoea and oligomenorrhoea since 6 months with history of chyluria for the past 3 years.

Spontaneous rupture of pyometra - a rare cause of peritonitis in elderly female.

The incidence of spontaneous perforations in pyometra is rare, being 0.01-0.5% in gynaecological patients. However, they are more common in postmenopausal females and their incidence is 13.6%. Here, we are reporting a rare case of peritonitis with a pneumoperitoneum in an elderly female, which was caused by a spontaneous perforation of pyometra. A 74-years old postmenopausal female with uncontrolled diabetes mellitus was admitted to surgical emergency with signs of diffuse peritonitis and she was in shock. After resuscitation, an emergency laparotomy was performed because of suspicion of a hollow viscous perforation with peritonitis. At laparotomy, about 2000ml of purulent fluid was found to be present in peritoneal cavity, while alimentary tract was intact. A rent with a diameter of 0.8 cm was found on fundus of uterus. A total abdominal hysterectomy with a bilateral salphingo oophorectomy was performed. Patient got discharged on 12(th) post-operative day without major complications. Histopathological studies revealed endometritis and myometritis, with no evidence of malignancy.

Cronkhite-Canada syndrome: a report of two familial cases.

Cronkhite-Canada syndrome (CCS) is a rare syndrome first described in 1955. Since then, over 400 cases worldwide have been reported in the literature. The disease is characterized by diffuse gastrointestinal polyposis, dystrophic changes of the fingernails, alopecia, cutaneous hyperpigmentation, diarrhea, weight loss, and abdominal pain. An autoimmune etiology is suspected. The workup is based on history and physical examination, imaging, and endoscopy with biopsy to confirm gastrointestinal polyposis. Nutritional support and corticosteroids are the mainstay of treatment. Here, we describe two familial cases-one a 50-year-old male patient with chronic diarrhea and epigastric pain since 1.5 years with hyperpigmentation of the hand and foot, alopecia, anorexia, hypogeusia, and weight loss; other case was his 22-year-old son who was asymptomatic, with mild alopecia and hyperpigmentation over his face and hands. Gastrointestinal endoscopy showed multiple polyps in both the cases.

Paratesticular leiomyosarcoma: a case report.

Paratesticularleiomyosarcomas are rare neoplasms. Radical orchidectomy and high ligation of cord followed by surveillance is the treatment of choice. Here we report a 73-year-old man who presented with a 2-year history of painless lump in the left hemiscrotum. A left radical orchiectomy with high ligation of the spermatic cord was performed. The histo-pathological and immunohistochemistry evaluation revealed a moderately differentiated leiomyosarcoma of paratesticular region. The patient is still alive with no evidence of local recurrence and distant metastasis after seven years of follow-up.

Persistent müllerian duct syndrome: a case report.

Persistent Müllerian duct syndrome is a rare form of internal male pseudohermaphroditism caused by defects in synthesis or action of Müllerian-inhibiting factor, due to which Müllerian duct derivatives, such as uterus, fallopian tube, and upper vagina, are normally present in 46XY males. Here, we report a 26-year-old male with right-sided obstructed inguinal hernia with left undescended testis. On exploration, hernial sac containing bowel loops, uterus with fallopian tubes, upper vagina, and testes were present.

Neuroleptic malignant syndrome: A diagnostic challenge.

We report the case of a 7-year-old girl operated for craniopharyngioma who developed hyperkalemic cardiac arrest in the post-operative period. She was diagnosed as Neuroleptic malignant syndrome (NMS) and the causative drug was carbamazepine. It was essentially a diagnosis of exclusion, and treatment was mainly supportive in form of withdrawal of the neuroleptic medication (carbamazepine) and administration of dantrolene and bromocriptine. Although, relatively uncommon, NMS can be fatal. NMS presents a clinical challenge as the patient outcome depends on its prompt recognition and treatment.