Management outcomes of pediatric and adolescent papillary thyroid cancers with a brief review of literature

Background: Papillary carcinoma of thyroid (PTC) is a rare disease in children and adolescents and contributes to about 1.5%–3% of all pediatric malignancies. To date, no randomized trial has ever been performed in the pediatric population and management of these patients has been extrapolated from adult practice. Materials and Methods: Retrospective analysis of the patients treated for PTC in the age <21 years, between the years 1998–2013 at a tertiary cancer center from India. Results: Sixty-seven patients were treated in the above said period with a male:female ratio of 1:1.6 and a median age of 18 years. Fifty-two (77.6%) patients clinically presented as a thyroid swelling with or without nodal swelling while 13 (19.4%) presented with isolated nodal swelling. Surgery was performed in 30 patients at a nononcological hospital and was subsequently referred to our center; more than half of them needed a completion surgery at our center. Pathologically, multifocal tumors were found in close to a quarter of the patients. Among the pathological variants, classical, follicular, and tall cell variants comprised 65.7%, 28.4%, and 5.9% of the cases, respectively. Nodal positivity was noted 71.6% of the cases of which 14.5% were N1a disease and the vast majority (85.5%) harboring N1b disease. The median follow-up period of the study cohort was 104 months during which there were 3 local, 6 nodal, and 2 systemic recurrences. The 5- and 10-year disease-free survival were found to be 85.9% and 81.4%, respectively. Univariate and multivariate analysis has shown no significant clinical and pathological feature defining the disease outcomes except for the T-stage. Logistic regression revealed extrathyroidal invasion and the age ≤ 15 years correlated with nodal positivity. Conclusion: Being a rare malignancy, pediatric and adolescent PTCs tend to behave differently from adult PTC with a seemingly aggressive clinical presentation; however, they are associated with excellent survival outcomes.

Florid Cemento-osseous Dysplasia.

Florid cemento-osseous dysplasia is a condition of the bone which is rare and usually affects jaw bones. It is classified as sclerosing osteitis, multiple exostoses, diffuse chronic osteomyelitis, and gigantiform cementoma. The age group varies from 19 to 76 years and mostly presents in the fourth and fifth decade. Most commonly affects middle-aged women. It is identified on radiographic examination and manifested as diffuse irregularly shaped radiopacities in the alveolar processes. It usually presents as a bilaterally symmetrical lesion. This lesion is benign and requires treatment only if symptomatic or for cosmetic reasons. We report a case of an uncomplicated florid cemento-osseous dysplasia in a 35-year-old woman the diagnosis of our case was made radiographically.

Glandular Odontogenic Cyst of Mandible: A Case Report.

Glandular odontogenic cysts (GOCs) are a very rare developmental cyst of the jaws. GOCs are intrabony solitary or multiloculated cyst of odontogenic origin. The importance of GOCs lies in fact that they exhibit a high propensity for recurrence. Thus, the oral physicians, radiologist, and oral pathologist play a major role in the definitive diagnosis of GOCs based on distinctive cases; though they are rare. In large part, this is due to the GOCs complex and frequently non-specific histopathology. This report describes a case of GOC occurrence in posterior mandibular angle region in a 43-year-old Irani Male, which was a rare site for its occurrence.

Rheumatic fever & rheumatic heart disease: The last 50 years.

Rheumatic fever (RF) and rheumatic heart disease (RHD) continue to be a major health hazard in most developing countries as well as sporadically in developed economies. Despite reservations about the utility, echocardiographic and Doppler (E&D) studies have identified a massive burden of RHD suggesting the inadequacy of the Jones’ criteria updated by the American Heart Association in 1992. Subclinical carditis has been recognized by E&D in patients with acute RF without clinical carditis as well as by follow up of RHD patients presenting as isolated chorea or those without clinical evidence of carditis. Over the years, the medical management of RF has not changed. Paediatric and juvenile mitral stenosis (MS), upto the age of 12 and 20 yr respectively, severe enough to require operative treatement was documented. These negate the belief that patients of RHD become symptomatic ≥20 years after RF as well as the fact that congestive cardiac failure in childhood indicates active carditis and RF. Non-surgical balloon mitral valvotomy for MS has been initiated. Mitral and/or aortic valve replacement during active RF in patients not responding to medical treatment has been found to be life saving as well as confirming that congestive heart failure in acute RF is due to an acute haemodynamic overload. Pathogenesis as well as susceptibility to RF continue to be elusive. Prevention of RF morbidity depends on secondary prophylaxis which cannot reduce the burden of diseases. Primary prophylaxis is not feasible in the absence of a suitable vaccine. Attempts to design an antistreptococcal vaccine utilizing the M-protein has not succeeded in the last 40 years. Besides pathogenesis many other questions remain unanswered.

Integrating medical education with societal need.

This paper attempts to present a case for serious reforms in medical education with the primary purpose of sensitising future generations of medical graduates to what our society actually needs from healthcare providers. It is not meant to be a scholarly exploration of how healthcare should be provided in our country from the point of view of policy makers or professionals in the field of public health.

Obesity in children & adolescents.

Worldwide, obesity trends are causing serious public health concern and in many countries threatening the viability of basic health care delivery. It is an independent risk factor for cardiovascular diseases and significantly increases the risk of morbidity and mortality. The last two decades have witnessed an increase in health care costs due to obesity and related issues among children and adolescents. Childhood obesity is a global phenomenon affecting all socio-economic groups, irrespective of age, sex or ethnicity. Aetiopathogenesis of childhood obesity is multi-factorial and includes genetic, neuroendocrine, metabolic, psychological, environmental and socio-cultural factors. Many co-morbid conditions like metabolic, cardiovascular, psychological, orthopaedic, neurological, hepatic, pulmonary and renal disorders are seen in association with childhood obesity. The treatment of overweight and obesity in children and adolescents requires a multidisciplinary, multi-phase approach, which includes dietary management, physical activity enhancement, restriction of sedentary behaviour, pharmacotherapy and bariatric surgery. A holistic approach to tackle the childhood obesity epidemic needs a collection of activities including influencing policy makers and legislation, mobilizing communities, restructuring organizational practices, establishing coalitions and networks, empowering providers, imparting community education as well as enriching and reinforcing individual awareness and skills. The implications of this global phenomenon on future generations will be serious unless appropriate action is taken.

Malnutrition in children with congenital heart disease (CHD) determinants and short term impact of corrective intervention.

OBJECTIVE: To identify determinants of malnutrition in children with congenital heart disease (CHD) and examine the short-term effects of corrective intervention. METHODS: Patients with CHD admitted for corrective intervention were evaluated for nutritional status before and 3 months after surgery. Detailed anthropometry was performed and z-scores calculated. Malnutrition was defined as weight, height and weight/height z-score <or= -2. Determinants of malnutrition were entered into a multivariate logistic regression analysis model. RESULTS: 476 consecutive patients undergoing corrective intervention were included. There were 16 deaths (3.4%; 13 in-hospital, 3 follow-up). The 3-month follow-up data of 358 (77.8%) of remaining 460 patients were analyzed. Predictors of malnutrition at presentation are as summarized: weight z-score <or= -2 (59%): congestive heart failure (CHF), age at correction, lower birth weight and fat intake, previous hospitalizations, >or= 2 children; height z-score <or= -2 (26.3%): small for gestation, lower maternal height and fat intake, genetic syndromes; and weight/height z-score <or= -2 (55.9%): CHF, age at correction, lower birthweight and maternal weight, previous hospitalizations, religion (Hindu) and level of education of father.Comparison of z-scores on 3-month follow-up showed a significant improvement from baseline, irrespective of the cardiac diagnosis. CONCLUSIONS: Malnutrition is common in children with CHD. Corrective intervention results in significant improvement in nutritional status on short-term follow-up.

Consensus guidelines on pediatric acute rheumatic fever and rheumatic heart disease.

JUSTIFICATION: Acute rheumatic fever and rheumatic chronic valvular heart disease is an important preventable cause of morbidity and mortality in suburban and rural India. Its diagnosis is based on clinical criteria. These criteria need verification and revision in the Indian context. Furthermore, there are glaring differences in management protocols available in literature. These facts prompted Indian Academy of Pediatrics to review the management of rheumatic fever. PROCESS: Management of Rheumatic fever was reviewed and recommendation was formulated at national consultative meeting on 20th May 2007 at New Delhi. OBJECTIVES: To formulate uniform guidelines on management of acute rheumatic fever and rheumatic heart disease in the Indian context. Guidelines were formulated for the management of streptococcal pharyngitis, acute rheumatic fever and its cardiac complication as well as secondary prophylaxis for recurrent episodes. RECOMMENDATIONS: (1) Streptococcal eradication with appropriate antibiotics (Benzathine penicillin single dose or penicillin V oral or azithromycin). (2) Diagnosis of rheumatic fever based on Jones criteria. (3) Control inflammatory process with aspirin with or without steroids (total duration of treatment of 12 weeks). (4) Treatment of chorea according to severity (therapy to continue for 2-3 weeks after clinical improvement). (5) Protocol for managing cardiac complication like valvular heart disease, congestive heart failure and atrial fibrillation. (6) Secondary prophylaxis with benzathine penicillin and management of anaphylaxis.

Obesity in Indian children: time trends and relationship with hypertension.

BACKGROUND: Limited data are available from India regarding the distribution and profile of childhood obesity and hypertension. We examined the time trends in childhood obesity in a representative sample of schoolchildren from Ernakulam District, Kerala and determined the relationship of obesity with blood pressure. METHODS: We used a stratified random cluster sampling method to select the children. Anthropometric data were collected from 24 842 students, 5-16 years of age, during 2003-04. Blood pressure and anthropometric data were collected from 20 263 students during 2005-06. Overweight and obesity were defined by body mass index for gender and age. Gender, age and height were considered for determining hypertension. RESULTS: The proportion of overweight children increased from 4.94% of the total students in 2003 to 6.57% in 2005 (OR: 1.36; 95% CI: 1.25-1.47; p < 0.0001). The increase was significant in both boys and girls. The proportion of overweight children was significantly higher in urban regions and in private schools, and the rising trend was limited to private schools. Systolic or diastolic incident hypertension was found in 17.34% of overweight children versus 10.1% of the remaining students (OR: 1.87; 95% CI: 1.60-2.17; p < 0.0001). CONCLUSION: Childhood obesity showed an increasing trend in a short period of 2 years. Hypertension was common in overweight children. The results suggest the need for greater public awareness and prevention programmes on childhood obesity and hypertension.

Device closure of residual ventricular septal defect after repair of tetralogy of fallot using the amplatzer duct occluder.

Residual ventricular septal defect after surgical repair for tetralogy of Fallot can occasionally be hemodynamically important requiring re-intervention. Transcatheter closure using ventricular septal defect devices is an attractive option for such defects. We describe two such cases where the Amplatzer duct occluder was used as an innovative, less costly alternative for closure of residual membranous ventricular septal defects. Complete occlusion of the residual ventricular septal defect with significant symptomatic improvement could be accomplished in both patients.

Massive primary chylopericardium in an infant.

We report a case of massive spontaneous primary chylopericardium in a 2-month-old infant who was successfully treated with thoracic duct ligation and creation of a posterior pericardial window.

A practical approach for the diagnosis and management of dilated cardiomyopathy.

Dilated cardiomyopathy (DCM) refers to a group of conditions of diverse etiology in which both ventricles are enlarged with reduced contractility. Certain correctable conditions associated with ventricular dysfunction can masquerade as DCM. Most of them can be identified with relatively inexpensive and readily available tests. A typical diagnostic work-up for a child with DCM also includes a number of investigations to identify the underlying cause, some of which are expensive and sophisticated. The average center in the developing world often does not have the facilities to carry out these investigations. The results of many of these investigations typically do not translate into a specific management strategy that makes a difference to prognosis. A significant number of children with DCM will eventually develop end-stage heart failure that requires cardiac transplantation with or without bridging procedures. This is an unrealistic option for the developing world. The management strategy of childhood DCM in the developing world needs to be tailored to the resources available with in a manner such that the overall prognosis is not substantially affected.

Bioptome-assisted coil occlusion of coronary artery fistula.

We describe a novel technique that allows controlled and precise delivery of single or multiple coils simultaneously for occlusion of a coronary artery fistula using a bioptome passed via a long sheath positioned at the distal end of the fistula. The fistula was balloon occluded distal to the take-off of the native branches before, during and after coil delivery in two patients.