A rare case of ischaemic stroke following cervical spine manipulation in an adolescent girl

Stroke in children is associated with a multitude of risk factors compared to risk factors of adult stroke such as hypertension, diabetes or atherosclerosis. A 15-year adolescent girl presented with acute onset weakness involving right upper and lower limb. She complained of neck pain and fever 2 days before the onset of hemiparesis for which her parents took her to traditional healer who performed neck manipulation after which she developed vomiting, tingling numbness and weakness of right upper and lower limb. There was no history of preceding headache, ear discharge or any other contributory history. Clinical examination revealed Glasgow Come Scale 12/15, power of grade 2/5 in right upper limb and 3/5 in right lower limb, exaggerated deep reflexes, extensor plantar reflex, right sided ptosis and right sided upper motor neuron facial palsy. CT scan brain showed right cerebellar and occipital infarct with posterior inferior cerebellar artery territory involvement. MRI Brain and MR Angiogram showed wedge shaped infarct involving right posterior inferior cerebellum, inferior vermis, ventral aspect of superior medulla, paracentral pons, right cerebral peduncle, tectum of both halves of midbrain with no internal hemorrhage and no vessel abnormality and right vertebral artery was not visualized. Her coagulation profile and cardiac work up were normal. She was treated with antiplatelet drugs, anticoagulants and physiotherapy following which the child gradually improved over a period of one month. In this case, with a positive history of neck manipulation authors can conclude that the etiology of young stroke wasinduced byneck manipulation. This case has been reported to increase awareness about the ill effects of neck manipulation and counsel parents against performing such procedures for children. Early recognition of pediatric stroke is critical for immediate diagnosis, imaging and treatment with better outcomes.

A study on parental perspectives towards childhood fever

Background: Parents play an important role in recognizing and treating paediatric fever as well as initiating home treatment. Their knowledge and attitude can greatly influence paediatric fever treatment and parental phobia may at times lead to overtreatment of fever. Objectives of this study was to assess the knowledge, attitudes and practices of parents towards childhood fever. Methods: This cross-sectional observational study was conducted in the Paediatric department at Saveetha Medical College, Chennai. Data collection from parents was done using a questionnaire to study the knowledge, attitude and practices of parents towards fever and its management in children. Data analysis was done using SPSS 16 software.Results: Total 100 parents participated in the study, most of participants were mothers (69%) and 51% were between 20-30 years. 67% parents believed that fever could cause harmful effects like convulsions and delirium whereas 61% parents believed that consumption of large doses of antipyretic is harmful. Majority of parents 87% were aware that vaccinations can cause fever. Around 82% of parents declared that they had sleepless nights whenever their child was febrile. Majority of the parents 95% stated that they confirmed the presence of fever in their child by tactile assessment. About half the parents preferred using injections for reducing fever than oral medications.Conclusions: The study revealed presence of high levels of anxiety in majority of parents highlighting the need for reassurance and counsel ling by health professionals. Since most of the parents relied on tactile assessment for fever, there is a need to educate them about proper use of a thermometer for accurate detection and better assessment of fever.

A case of twenty nail dystrophy affecting a 12 year old boy

Nail diseases in children may be congenital or acquired and occurs in 3 to 11% of pediatric population. Twenty nail dystrophy is a nail disorder with a classical presentation, often affecting all twenty nails. It is an idiopathic disorder in childhood but can be associated with other diseases such as lichen planus, alopecia areata, psoriasis, eczema, IgA deficiency, atopic dermatitis, ichthyosis vulgaris and vitiligo. Twenty nail dystrophy is otherwise called trachyonychia. Typically, the condition is bilateral and symmetrical affecting all the nails of hands and feet. It is cosmetically disfiguring and can be source of anxiety for children and parents, which can impact further the quality of life. Twenty nail dystrophy is of two types, based on the clinical presentation namely opaque or shiny trachyonychia. Since this nail disorder is associated with a number of dermatologic diseases, children require long term follow up. We report a case of a 12-year-old boy with a three-year history of twenty nail dystrophy with no relevant family history of skin or nail diseases. The child had isolated nail manifestation without any other dermatologic condition. Twenty nail dystrophy is a self-limiting disease, which is treated conservatively. The aim of this report is to highlight importance of a thorough physical examination to diagnose nail disorders in early stages, which will be helpful to clinicians to distinguish the different nail conditions and associated illness and decide on the correct management. It is important to counsel the family about the benign nature of the disease and good prognosis.

A rare case of Sprengel deformity associated with spondylocostal dysostosis in a four-year child

Sprengel deformity is a complex congenital anomaly affecting one or both scapulae with mispositioning and dysplasia of scapula. It occurs due to failure of descent of scapula during intrauterine development and is the commonest congenital skeletal deformity of the scapula, often associated with other skeletal deformities. spondylocostal dysostosis is a rare genetic disorder which is characterized by malformation of the bones of the spine and ribs. It occurs in approximately 1 in 2,00,000 people worldwide. In spondylocostal dysostosis, affected children have wedge shaped vertebrae along with ribs that are fused, forked or sometimes missing. Based on the severity of the defect's children may present with short stature, scoliosis or hypoplasia of lungs causing difficulty in breathing and recurrent respiratory tract infections. Management of both these skeletal deformities depends on their severity and the presence of associated deformities. Surgical intervention might be required for cosmetic and functional recovery of the shoulder. Authors had a rare and interesting case of a 4-year-old boy who had features of Sprengel deformity affecting left scapula which was associated with features of spondylocostal dysostosis.

Distancing sedation in end-of-life care from physician-assisted suicide and euthanasia

Lipuma equates continuous sedation until death (CSD) to physician-assisted suicide/euthanasia (PAS/E) based on the premise that iatrogenic unconsciousness negates social function and, thus, personhood, leaving a patient effectively 'dead'. Others have extrapolated upon this position further, to suggest that any use of sedation and/or opioids at the end of life would be analogous to CSD and thus tantamount to PAS/E. These posits sit diametrically opposite to standard end-of-life care practices. This paper will refute Lipuma's position and the posits borne from it. We first show that prevailing end-of-life care guidelines require proportional and monitored use of sedatives and/or opioids to attenuate fears that the use of such treatment could hasten death. These guidelines also classify CSD as a last resort treatment, employed only when symptoms prove intractable, and not amenable to all standard treatment options. Furthermore, CSD is applied only when deemed appropriate by a multidisciplinary palliative medicine team. We also show that empirical data based on local views of personhood will discount concerns that iatrogenic unconsciousness is tantamount to a loss of personhood and death.

Opioid use amongst cancer patients at the end of life

<p><b>INTRODUCTION</b>Concerns about the life shortening effect of opioids is a well known fact in the medical world when considering administration of these drugs for symptom alleviation at end of life. This study described the patterns of opioid use among cancer patients referred to a hospital-based specialist palliative care service for symptom management. This study also examined whether opioid use among terminally ill cancer patients during the last 2 days of life had any influence on survival.</p><p><b>MATERIALS AND METHODS</b>A retrospective review of case notes of patients who were diagnosed with terminal cancer and had passed away in a 95-bedded oncology ward between September 2006 and September 2007 was conducted. Data were collected on patients' characteristics and patterns of opioid use including opioid doses and dose changes at 48 hours and 24 hours before death.</p><p><b>RESULTS</b>There were 238 patients who received specialist palliative care, of whom 132 (55.5%) were females. At 48 hours and 24 hours before death, 184 (77.3%) patients and 187 (78.6%) patients had received opioids, respectively. The median daily doses at 48 hours and 24 hours were 48 mg and 57 mg oral morphine equivalent doses (OME), respectively. Indications for opioid use were pain (41.1%), dyspnoea, (29.1%) and both dyspnoea and pain (30.8%). In the fi nal 24 hours, 22.3% patients had a reduction in their mean opioid dose while 22.7% required an increase in their mean opioid dose. Increased age was associated with decreasing opioid doses (P = 0.003). Patients with spinal metastases required higher doses of opioids (P = 0.03) while those with lung metastases required lower doses (P = 0.011). Survival analysis using Kaplan-Meier survival curve revealed no significant survival difference between those who were on opioids and those who were not. Log rank test (Mantel-Cox) (P = 0.69).</p><p><b>CONCLUSION</b>Our results showed that opioids are safe medications for symptom alleviation in terminally ill cancer patients during the last days of life and have no deleterious influence on survival.</p>