Opioids for Pediatric Pain Management

Objectives: To study the efficacy and adverse effects of opioids in management of pain in children. Methods: A descriptive study was conducted in children aged below 15 years with moderate to severe pain, and response to opioids and adverse effects were assessed at 24, 48 and 72 hours after administration. Results: 100 children (68% males) with median (IQR) age of 6.5 (3.5,10) years were studied. 81% (n=81) children with moderate pain and 78.9% (n=15) with severe pain responded to opioids in 72 hours. Among children with severe pain of non-malignant origin, 80% (n=8) responded in 48 hours compared to 11.1% (n=1) with malignancy and this difference was statistically significant at 24 hours (P=0.005). Of children with severe pain 73.7% (n=14) developed adverse reactions compared to 30.9% (n=25) with moderate pain. Conclusions: Children with moderatesevere pain, either of malignant or non-malignant origin could be managed effectively with opioids without severe adverse effects.

Cowden syndrome with Lhermitte–Duclos disease presenting as ataxia.

Cowden syndrome or multiple hamartoma syndrome is a rare genodermatosis of autosomal dominant inheritance characterized by multiple hamartomatous lesions of ectodermal, mesodermal and endodermal origin. A 45-year-old man presented to us with a history of dural arteriovenous fistula and intracerebral bleed in the past with gradually progressive difficulty in walking. Magnetic resonance imaging (MRI) of the brain showed a heterogeneous lesion in the cerebellum which was diagnosed as adult Lhermitte–Duclos disease which is considered a component of Cowden syndrome. On examination we found florid skin and mucosal manifestations of Cowden syndrome. A family history of thyroid malignancy was also present. Using the Cleveland Clinic web calculator, the patient had an 82% chance of having a phosphatase and tensin homologue (PTEN) mutation.

Descriptive Epidemiology of Novel Influenza A (H1N1), Andhra Pradesh 2009-2010.

Background: The fi rst case of pandemic Infl uenza A (H1N1) in India was reported from Hyderabad, Andhra Pradesh on 16th May 2009. Subsequently, all suspected cases seeking treatment from A (H1N1) treatment centers and their contacts were tested. Laboratory confi rmed cases were hospitalized and treated with antivirals according to national guidelines. We reviewed the surveillance data to assess the morbidity and mortality due to A (H1N1) in the state of Andhra Pradesh (population-76,210,007) during the period from May 2009 to December 2010. Materials and Methods: We obtained the line-list of suspected (infl uenza like illness as per World Health Organization case defi nition) and laboratory confi rmed cases of A (H1N1) from the state unit of integrated disease surveillance project. We analyzed the data to describe the distribution of case-patients by time, place and person. Results: During May 2009 to December 2010, a total of 6527 suspected (attack rate: 8.6/100,000) and 1480 (attack rate: 1.9/100,000) laboratory confi rmed cases were reported from the State. Nearly 90% of the suspected and 93% of the confi rmed cases was from nine districts of Telangana region, which includes Hyderabad. Nearly 65% of total confi rmed cases were reported from Hyderabad. The attack rate was maximum (2.6/100,000) in the age group of 25-49 years. The cases peaked during August-October. 109 case-patients died (Case fatality ratio: 7%) and most (80%) of these patients had comorbid conditions such as diabetes (24%), chronic obstructive pulmonary disease (20%), hypertension (11%) and pregnancy (11%). Case fatality was higher (16%) among patients who were older than 60 years of age compared with other age groups. Conclusions: In Andhra Pradesh, H1N1 transmission peaked during August-October months and predominately affected adults. Case fatality was higher in patients older than 60 years with comorbid conditions.

Management of pain in leukemic children using the WHO analgesic ladder.

Objective. To ascertain the effectiveness of WHO analgesic ladder in pain management in children with leukemia. Methods. Children with leukemia who were referred to a pain and palliative care clinic attached to the Department of Pediatrics of a medical teaching hospital during a period of 6 months, were included in the study. Results. Thirty nine (39) children, who constituted 64% of children on treatment for leukemia, required referral to pain and palliative care services during the study period. Of these 92% had Acute Lymphocytic Leukemia (ALL) and 8% had Acute Non Lymphocytic Leukemia (ANLL). 95% of children had nociceptive pain and 5% had neuropathic pain. Step – 1 analgesia was effective in 12 (31%) children and 21 (54%) could be managed with Step – 2 analgesia. Step – 3 analgesia was required in only 6 (15%) children. Step 3 analgesia was required in children with neuropathic pain and bone pain. Conclusions. WHO analgesic ladder is effective in managing pain in children with leukemia. Majority of cases of cancer pain in children could be managed by the treating physician using non-opioids, weak opioids and adjuvants as per the WHO guidelines. Children with bone pain and neuropathic pain may require referral to specialist services and use of strong opioids like morphine. The study emphasizes the need for establishing specialist pain management services in all centres where children with cancer are treated.

Giant epithelioid leiomyoblastoma of the stomach--a diagnostic dilemma.

Epithelioid leiomyoblastoma (ELB) of the stomach is an uncommon slow growing smooth muscle tumour, attaining enormous size and presenting with bizzare symptoms. We report one such case which posed a diagnostic problem to both the clinician and the radiologist; the condition was diagnosed after laparotomy and histological examination.