Background: Presence of a giant occipital encephalocele poses a challenge for laryngoscopy by hindering optimal positioning. Intubations in different positions, assistance and modification of table surfaces have been reported with different rates of success and complications in such cases. Method: We used an adjustable horseshoe headrest as a positioning adjunct in airway management in a few cases during 2015 – 2016. Four babies were positioned with the help of the horseshoe headrest for direct laryngoscopy. These cases were then compared with previously conducted one more case whose trachea was intubated by the child’s head beyond the edge after an unsuccessful attempt in lateral position. Result: All four cases positioned with adjustable horseshoe head rest were intubated successfully with mean 2 ± 0.81 attempts with 2.25 ± 0.5 Cormack-Lehane laryngeal view. Significant complications were absent in the cases intubated by placing the head in horseshoe headrest as compared to the case performed in lateral position followed by placing the child’s head beyond the edge of the table with assistants supporting the baby. Conclusion: This clinical paper discusses this infrequently reported modification, and also compares it with other positions and modifications commonly used in clinical practice.

Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied presentations. However, clinical malaria or scrub typhus is unusual without fever. On the other hand, altered sensorium with or without fever, dehydration, hemorrhage and hemolysis may lead to low blood pressure. Presence of toxic granules and elevated band forms in such patients can even mimic sepsis. When such a patient is in the peripartum period, it creates a strong clinical dilemma for the physician especially in unbooked obstetric cases. We present such a case where a 26-year-old unbooked female presented on second postpartum day with severe anemia, altered sensorium, difficulty in breathing along with jaundice and gum bleeding without history of fever. Rapid diagnostic test for malaria was negative and no eschar was seen. These parameters suggested a diagnosis of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet) syndrome with or without puerperal sepsis. Subsequently she was diagnosed as having asymptomatic malaria and scrub typhus and responded to the treatment of it. The biochemical changes suggestive of HELLP syndrome also subsided. We present this case to emphasize the fact that mere absence of fever and eschar does not rule out scrub typhus. It should also be considered as a differential diagnosis in patients with symptoms and signs suggesting HELLP syndrome. Asymptomatic malaria can complicate case scenario towards puerperal sepsis by giving false toxic granules and band form in such situations.

Introduction: Surgical palliation of malignancy is defined best as a procedure used with the primary intention of improving Quality of Life (QoL) or relieving symptoms caused by an advanced malignancy. Surgical procedures for palliation include resections, reconstruction, functional repairs, drainage, and biopsy. Primary benefits include QoL improvement through symptom prevention or control, with survival advantage as a secondary benefit. Aim: To evaluate mortality (30 days and 6 months), length of hospital stay and Intensive Care Unit (ICU) stay and QoL among patients undergoing palliative surgery for advanced cancer. Materials and Methods: A retrospective study was conducted at Dr. B. Borooah Cancer Institute, India, from September 2020 to March 2021. The clinicodemographic profile, tumour type and staging, treatment, investigations, surgery, anaesthesia and complications were studied. The outcome was defined by mortality, length of hospital stay and quality of life. Descriptive statistics was used for analysis. A p-value of less than 0.05 was considered significant at 5% level of significance. Results: A total of 86 patients underwent palliative surgeries, out of which 52 (60.5%) were females and 34 (39.5%) were males with the mean age of 49.6±15.9 years. Among them, 8 (9.3%) died within 30 days of surgery and 11 (12.8%) at six months after surgery. There was a significant association of mortality with pallor, deranged Thyroid Stimulating Hormone (TSH), co-morbidities, chemotherapy, type of surgery and anaesthesia but not with age, sex, type and stage of cancer, American Society of Anaesthesiology (ASA) status and General Condition (GC) of the patient. The mean duration of postoperative hospital stay was 15.8 days and mean ICU stay was 0.8 day for all patients. Patients with pallor had longer duration of hospital and ICU stay. Type of surgery was significantly associated with hospital stay but not with ICU stay. On evaluating the quality of life using Eastern Cooperative Oncology Group (ECOG) score, it was seen that the number of patients with poor ECOG scores (3 to 5) increased significantly from 10 (11.63%) to 13 (15.12%) in the immediate postoperative period. Conclusion: Patient factors affected the outcome after palliative surgery more than surgical and anaesthetic factors. The high mortality rate of 12.8% warrants detailed prospective studies in the future.