Hematological Indices for Identifying Adverse Outcomes in Children Admitted to Pediatric ICUs.

BACKGROUND: The pediatric ICU (PICU) is a specialized area where critically sick children are managed. The mortality rates in PICUs are higher in developing countries as compared to developed nations. Many of these deaths could be prevented if very sick children were identified soon after they arrived at the health facility. Hematological indices like platelet lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) have been frequently used in adults as indicators of mortality. However, their use in the pediatric population is limited due to a lack of validated reference intervals. OBJECTIVE: The objective of the study is to assess the role of hematological indices in identifying adverse outcomes in terms of mortality in children admitted to the PICU. MATERIALS AND METHODS: It is a prospective, observational study done at a tertiary care hospital. All children aged one year to 12 years admitted to the PICU were enrolled in the study. A sample for complete blood count was taken within one hour of admission to the PICU. Children who had received blood products in the last two months, those on chronic medications (>two weeks) that can affect bone marrow cellularity, and known cases of hematological disorders such as megaloblastic anemia, hematological malignancies, immune thrombocytopenia, and aplastic anemia were excluded from the study. PLR, NLR, and platelets to mean platelet volume ratio (PLT/MPV) were determined and compared among the survivors and non-survivors. RESULTS:  Out of 275 enrolled patients, 119 (43.3%) patients expired during the study period. While PLR had high sensitivity and NLR had high specificity (85.71% and 92.31%, respectively) for predicting mortality, none of these parameters had a good area under the curve (AUC) in our study. PLT/MPV of ≥32 had a sensitivity of 39.5% and a specificity of 56.41% for predicting mortality. CONCLUSIONS: Hematological parameters have been used across the world to predict ICU mortality. PLR and NLR are simple hematological biomarkers, easy to calculate, and cost-effective, and ratios are better than individual parameters. More studies and stratified samples are required to evaluate the role of hematological markers in identifying the risk of mortality in children admitted to PICUs.

Clinico-cytomorphological Spectrum of Calcinosis Cutis.

Introduction: The deposition of calcium in the skin is known as calcinosis cutis. It can affect any part of the body and can mimic soft tissue or bony lesions clinically. Aim: To describe the clinical and cytomorphologic features of calcinosis cutis on fine needle aspiration cytology smears. Materials and Methods: A total of 17 cases reported as calcinosis cutis on fine needle aspiration cytology were reviewed for the available clinical and cytological details. Results: The cohort included both adult and pediatric patients. Clinically, the lesions appeared as painless swellings of variable sizes. The common sites affected were the scrotum, iliac region, scalp, pinna, neck, axilla, elbow, arm, thigh, and gluteal region. Aspirate was chalky white, paste-like in all the cases. The cytologic evaluation revealed amorphous crystalline deposits of calcium along with histiocytes, lymphocytes, and multinucleated giant cells. Conclusions: Calcinosis cutis has a wide spectrum of clinical presentations. Fine needle aspiration cytology is a minimally invasive approach for diagnosing calcinosis cutis, thus eliminating the need for more extensive biopsy procedures.

De novogenomic analysis ofEnterobacter asburiaeEBRJ12, a plant growth-promoting rhizobacteria isolated from the rhizosphere of Phaseolus vulgarisL.

AIM: Environmental stresses such as water deficit induced stress are one of the major limiting factors in crop production. However, some plant growth-promoting rhizobacteria (PGPR) can promote plant growth in such adverse condition. Therefore, the objective was to isolate rhizospheric bacteria from Phaseolus vulgaris L. growing in a drought-affected soil and to analyze its plant growth promoting (PGP) efficacy to black gram (Vigna mungo L.) and Bhut jolokia (Capsicum chinense Jacq.). Whole-genome sequencing of the potential bacteria was targeted to analyze the genetic potential of the isolate as a plant growth-promoting agent. METHODS AND RESULTS: The isolate Enterobacter asburiae EBRJ12 was selected based on its PGP efficacy, which significantly improved plant growth and development. The genomic analysis revealed the presence of one circular chromosome of size 4.8 Mb containing 16 genes for osmotic stress regulation including osmotically inducible protein osmY, outer membrane protein A precursor ompA, aquaporin Z, and an operon for osmoprotectant ABC transporter yehZYXW. Moreover, the genome has a complete genetic cluster for biosynthesis of siderophore Enterobactin and siderophore Aerobactin.The PGP effects were verified with black gram and Bhut jolokia in pot experiments. The isolate significantly increased the shoot length by 35.0% and root length by 58.0% of black gram, while 41.0% and 57.0% of elevation in shoot and root length were observed in Bhut jolokia compared to non-inoculated plants. CONCLUSIONS: The EBRJ12 has PGP features that could improve the growth in host plants, and the genomic characterization revealed the presence of genetic potential for plant growth promotion.

Iron Profile in Term Small for Gestational Age Infants at 10 Weeks of Age and Correlation With Maternal Iron Profile : A Prospective Cohort Study.

BACKGROUND: Term small for gestational age (SGA) babies are at risk for developing iron deficiency anemia. The association between maternal and infant iron stores is not clear. OBJECTIVE: To assess proportion of term SGA neonates developing iron deficiency anemia by 10 weeks of age, and measure correlation between iron profile and hepcidin of babies at birth and at 10 weeks of age with maternal iron profile. DESIGN: Prospective cohort study conducted from November, 2018 to April, 2020. PARTICIPANTS: 120 term SGA babies and their mothers. INTERVENTION: Hemogram, iron profile and serum hepcidin (every fourth case) estimated in mother, cord blood and baby at 10 weeks. Babies developing anemia at 6 weeks detected by hemogram and ferritin were started on iron supplementation and excluded from the study. OUTCOME: Proportion of babies developing iron deficiency anemia at 10 weeks of age. RESULTS: 35 (29.2%) of 120 term SGA babies developed anemia (hemoglobin <9 g/dL) at 6 weeks. Proportion of infants who developed iron deficiency anemia (hemoglobin <9 g/dL and serum ferritin <40 µ/dL) at 6 and 10 weeks of age was 14.2% and 23.3%, respectively. No significant correlation was found bet-ween hemoglobin, iron and hepcidin of the baby in cord blood and at 10 weeks of age with that of mothers. Serum hepcidin in babies at birth (137.5 ng/mL) were higher than maternal values (128 ng/mL). CONCLUSION: A significant proportion of term SGA infants deve-loped anemia during early infancy, irrespective of maternal iron status.

Effect of convalescent plasma therapy on mortality in moderate-to-severely Ill COVID-19 patients.

INTRODUCTION: The role of plasma therapy in the management of the COVID-19, pandemic has been speculated. However, in view of the varied response regarding its effectiveness from various multicenter studies, there is a need to conduct more single center population-specific studies. We, thus, aimed to assess the role of convalescent plasma therapy in COVID-19 patient management in a single -center. METHODS: This retrospective study was conducted using records of all COVID-19 patients who received plasma therapy over a period of 6 months in a dedicated COVID-19 hospital in Delhi. Information pertaining to transfusion, disease severity, associated comorbidities, the treatment given and patient outcome were recorded. Data was analyzed using SPSSv23. RESULTS: Of the141 patients who received plasma therapy, 62% were discharged after treatment. Mortality was found to be significantly higher in patients > 60 years of age (p < 0.001), those with severe COVID-19 infection (p < 0.05) and pre-existing renal disease (p < 0.05). The admission-transfusion interval was significantly correlated to mortality and was a sensitive parameter for predicting outcome at cut off value of < 5 days (p < 0.001). There was no significant association of mortality with patient blood group, plasma antibody levels or donor hemoglobin levels. CONCLUSIONS: We report improvement and recovery in a large number of patients who received convalescent plasma within the first 5 days of hospitalization with moderate to severe disease. Further research to compare dosage and administration protocols to delineate role of CCP in survival of COVID-19 patients is needed before it is prematurely shelved.

Clear Cell Variant of Squamous Cell Carcinoma of Eyelid, Mimicking Sebaceous Carcinoma: A Rare Case Report.

Clear cell variant of squamous cell carcinoma (SCC) is an extremely rare neoplasm. Here, we report a case of clear cell variant of SCC which presented as an eyelid nodule. A 56-year-old male presented with a painless, small, pedunculated nodule in the left upper eyelid. On microscopic evaluation, tumor cells were arranged in nests and lobules with few foci of necrosis. Tumor cells were polygonal in shape, having abundant clear and vacuolated cytoplasm with peripherally pushed hyperchromatic nuclei. Two main differential diagnoses considered were sebaceous carcinoma and clear cell variant of SCC. On immunohistochemistry, tumors cells were negative for androgen receptor. A final diagnosis of clear cell variant of SCC was made. In a malignant eyelid tumor with clear cell morphology, a differential diagnosis of clear cell variant of SCC should be kept in mind before making a diagnosis of sebaceous carcinoma because sebaceous carcinoma possesses a poorer prognosis.

Reduced fetal urine production rate-An early marker of fetal inflammatory response syndrome in preterm premature rupture of membranes: Prospective cohort study.

OBJECTIVE: To find association between fetal urine production rate (FUPR) and fetal inflammatory response syndrome (FIRS) in preterm premature rupture of membranes (PPROM). METHODS: A prospective cohort study of 70 pregnant women with PPROM at 28-34 weeks of pregnancy was conducted. FUPR was calculated by performing serial fetal bladder volume measurements ultrasonographically and was repeated weekly until delivery. After delivery, cord blood interleukin-6 (IL-6) levels were measured. Placental tissue histopathology was performed and neonatal outcomes were noted. RESULTS: Out of 70 recruited patients with PPROM, 44 had evidence of FIRS (62.86%). Mean FUPR at the time of delivery was significantly reduced in neonates with evidence of FIRS compared with the Non-FIRS group (13.89 ± 8.06 ml/h vs. 25.89 ± 4.94 ml/h). Out of 41 patients with reduced FUPR, 39 neonates had FIRS whereas only five out of 29 neonates with normal FUPR had FIRS (P < 0.001). Severe neonatal morbidity was found in 24 out of 41 (58.54%) neonates with reduced FUPR prenatally. The occurrence of respiratory distress syndrome, necrotizing enterocolitis, and sepsis was significantly high in neonates with reduced FUPR. CONCLUSION: Reduced FUPR is strongly associated with FIRS in cases of PPROM and hence can be used as an early predictor of adverse neonatal outcomes.

Cytological diagnosis of juvenile xanthogranuloma: A rare histiocytic disorder.

Juvenile xanthogranuloma (JXG) is a rare type of non-Langerhan cell histiocytic disorder, which is mostly confined to skin of head and neck. It is a self-limiting benign condition, which does not require surgery. We present a case of 8-month-old girl child with multiple yellowish brown colored papules over scalp, face, and neck. A clinical diagnosis of cutaneous mastocytosis was made. Fine-needle aspiration cytology (FNAC) smears showed foamy macrophages along with mixed inflammatory infiltrate and few touton giant cells. A diagnosis of JXG was rendered which was confirmed on histopathology and immunohistochemistry.Juvenile xanthogranuloma can be diagnosed on FNAC based on its characteristic cytologic features; however, it requires a high index of suspicion by cytopathologist. Cytological diagnosis of JXG can save the patient from unnecessary surgical biopsy or excision.

Neutrophil-to-lymphocyte ratio and platelet indices in pre-eclampsia.

OBJECTIVE: To compare the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and platelet indices between women with pre-eclampsia and normotensive pregnant women. METHODS: A cross-sectional study conducted from January to July 2017 at a tertiary care hospital in Delhi, India. The study compared pregnant women aged 18-40 years with pre-eclampsia diagnosed at term with healthy pregnant women matched for gestational age. Venous blood samples were drawn and complete blood count was analyzed. The parameters recorded were hemoglobin, red cell distribution width (RDW), platelet count, mean platelet volume (MPV), plateletcrit, and platelet distribution width. RESULTS: There were 67 women included in each group. NLR was higher in women with pre-eclampsia compared with the control group (6.8 ± 7.6 vs 3.0 ± 0.98; P=0.001). Both PLR (14.18 ± 14.4 vs 9.54 ± 3.6; P=0.012) and MPV (9.45 ± 1.19 vs 9.02 ± 1.1; P=0.029) were higher in the study group compared with the control group. Platelet count was lower in pre-eclamptic women compared with the control group (188 ± 89.7 vs 200.1 ± 62.36; P=0.014). RDW was also higher in the study group (P=0.025). CONCLUSIONS: The present study found that the inflammatory markers NLR, PLR, RDW, and MPV were higher in women with pre-eclampsia. Measuring NLR and PLR may be useful in predicting pre-eclampsia among women at high risk during prenatal follow-up.

Primary extraneural ependymoma of the broad ligament: A rare entity.

Extraneural broad ligament ependymoma is a rare entity. Herein, we present a case of unusually large broad ligament ependymoma in a 32-year-old female with pain and lump in the lower abdomen. Contrast-enhanced computed tomography abdomen revealed multiple heterogeneously enhancing pelvic masses with lobulated surface in bilateral adnexa along with multiple peritoneal nodules. Her relevant serum tumor markers were unremarkable. Core biopsy revealed tumor composed of elongated cells arranged predominantly in true and pseudoperivascular rosettes. The histopathological differentials included ependymoma, primitive neuroectodermal tumor, and teratoma with neural differentiation. Results of immunohistochemistry favored the diagnosis of ependymoma. Surgical exploration and optimal cytoreduction were done, and a final diagnosis of primary broad ligament ependymoma with peritoneal metastasis was made. The patient received six cycles of adjuvant chemotherapy and is doing well after 8-month follow-up. The present case highlights the diagnostic workup and management of a rare and an unusually large broad ligament ependymoma with peritoneal metastasis.

Aggressive osteoblastoma of the acetabulum: A diagnostic dilemma.

Osteoblastoma is a rare tumor and represents about 0.8% of all bone tumors. The aggressive variant is even rarer and difficult to diagnose. We present a case of a 17 year old male with a tumor of the acetabulum with characteristic epithelioid osteoblasts and other features of an aggressive osteoblastoma. It is important to recognize this entity as it can be clinically confused with an osteosarcoma. Our case not only showed epithelioid morphology but also had vacuolated cytoplasm, which simulated a mucin secreting adenocarcinoma. Since treatment and prognosis for these entities is strikingly different, an accurate diagnosis becomes all the more important. This case emphasizes the need for better co-ordination between the clinician and pathologist and use of histochemical stains and immunohistochemistry apart from routine histopathology for arriving at a final diagnosis. It is essential to have a close follow-up of the patient to look for recurrence of the tumor.

Subungual Melanoma is Not so Rare: Report of Four Cases from India.

Subungual melanoma (SUM) is an uncommon form of acral melanoma that arises within the nail matrix. The incidence for acral melanomas is similar worldwide, however, the proportion is higher in dark-skinned individuals. The subungual form represents approximately 2% of cutaneous non-sun-induced melanomas in the western world and up to 75% in Africans, 10% in Japanese, and 25% in the Chinese. No specific figures are available from the Indian subcontinent; however, the authors could trace three anecdotal case reports published over the last two decades. A general reluctance to biopsy a nail lesion to confirm the diagnosis may be contributing to the missed diagnosis. We report four cases of SUM of the big toenails seen over a period of 2.5 years. They were three women and one man with an age ranging from the 4th to 7th decade and disease duration of 6-18 months. The lesion involved the big toe in all and two patients had liver and lymph node metastasis at the time of presentation. Awareness among dermatologists regarding clinical manifestations, high index of suspicion for acral pigmented lesions, and nail bed biopsy may help in the early diagnosis and management and can prevent mortality.

Ichthyosis Uteri Associated with Endometrial Adenocarcinoma: A Case Report.

The replacement of the entire or extensive parts of endometrial lining by stratified squamous epithelium is a rare entity known as ichthyosis uteri. It is considered to be a benign condition but may be associated with dysplastic changes and primary squamous cell carcinoma of the endometrium. Its association with endometrial adenocarcinoma is very rare. The aetiology of this condition is not clearly understood till date. We report a case of ichthyosis uteri associated with endometrial adenocarcinoma in a 70-year-old female who presented with complaint of per-vaginal bleeding for six months and underwent hysterectomy after being diagnosed with endometrial carcinoma. Microscopic examination of sections revealed endometrioid adenocarcinoma International Federation of Gynaecology and Obstetrics (FIGO) Grade 3 along with extensive replacement of the endometrial lining by stratified squamous epithelium, consistent with ichthyosis uteri. Although ichthyosis uteri is considered benign and its malignant potential is yet to be established, its association with endometrial malignancies, both squamous and adenocarcinoma, necessitates extensive sampling of the uterus if any focus of squamous metaplasia is identified in a hysterectomy specimen, to rule out a co-existing carcinoma.

Seroprevalence & changing trends of transfusion-transmitted infections amongst blood donors in a Regional Blood Transfusion Centre in north India.

Background & objectives: Transfusion-transmitted infections (TTIs) are the major problem associated with blood transfusion. Accurate estimates of risk of TTIs are essential for monitoring the safety of blood supply. The present study was undertaken to determine the percentage of voluntary donors (VDs) and replacement donors (RDs) and also, to estimate and compare the seroprevalence and changing trends of TTIs amongst VDs and RDs in a regional blood transfusion centre in north India. Methods: This retrospective study was based on the records of all voluntary and replacement donations which were collected from January 2008 to December 2014 in a Regional Blood Transfusion Centre placed in a tertiary care hospital in Delhi, India. Results: Of the total 220,482 donations, 163,540 (74.17%) were voluntary and 56,942 (25.83%) were replacement donation. The overall seroprevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and malaria were 0.32, 1.61, 0.73, 1.62 and 0.06 per cent, respectively. Furthermore, the TTIs were more frequently encountered in RDs in comparison to VDs. Interpretation & conclusions: The increase in public awareness regarding voluntary blood donation, meticulous donor screening, counselling and use of highly sensitive tests can help in reducing the risk of TTIs.

Myoepithelial carcinoma of the tongue- spindle cell morphology with high mitosis: A case report and review of literature.

Myoepithelial carcinomas represent <1% of salivary gland tumors. Tongue is a rare site of occurrence. We present a case of a 30 year old female with myoepithelial carcinoma seen over dorsum of tongue with predominantly spindle cell morphology with clear cytoplasm and mitotic count of 6-7/10 hpf. We need to differentiate it from a spindle cell squamous cell carcinoma which can be seen at this location, i.e., tongue. In our case, there was no connection of the tumor with overlying squamous epithelium.

Intraparenchymal Angiomatous Meningioma: A Diagnostic Dilemma.

Meningioma arises from the arachnoid cap cells of the cerebrum. Intraparenchymal meningiomas or meningiomas without dural attachment are rare. We report a case of 40-year-old male who presented with a history of headache, dizziness and gradual loss of vision since one year. Clinicoradiological diagnosis of a high grade glioma was considered. Tumour was excised and haematoxylin and eosin stained sections revealed a tumour comprised predominantly of variable sized blood vessels showing hyalinization in a background of plump spindle cells with oval vesicular nuclei. In view of these features angiomatous meningioma was suspected. However, to confirm the diagnosis, a panel of immunohistochemical markers including vimentin, EMA and GFAP was done and a final diagnosis of angiomatous meningioma was offered. Angiomatous meningioma is a rare variant of meningioma and even much rarer in the intraparenchymal location. Angiomatous meningioma should be considered in the differential diagnosis of highly vascular intraparenchymal brain tumours.