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.

Hepatitis B in children with leukemia: the role of primary immunization

Background: Children with cancer have a greatly enhanced risk of contracting hepatitis B infection due to immunosuppression secondary to chemotherapy and radiotherapy, frequent blood transfusions, bone and peripheral vein punctures, tissue damage and mucositis. During the past 3 decades, multimodality therapy for childhood leukemia has resulted in markedly improved survival. Inspite of screening and immuno prophylaxis, hepatitis B infection rates in children with leukemia are high. In view of this, we decided to study the prevalence of hepatitis B among children with leukemia in our institution, and the possible risk factors.Methods: This was a cross sectional study carried out at a tertiary pediatric care center in North Kerala among 104 children between 1 and 12 years of age on treatment for leukemia.Results: Among the 104 children, only 17 (16.3%) had received primary immunization against hepatitis B. Of the 87 children who had not received primary immunization, 44.8% (n=39) developed hepatitis B, compared to 11.8% (n=2) in the vaccinated group (p=0.01).Conclusions: This study highlights the importance of primary immunization against hepatitis B in children with leukemia, and the need for universal coverage.

Pyoderma gangrenosum: A clinico-epidemiological study.

Background: Pyoderma gangrenosum is a neutrophilic dermatosis of unknown etiology, with inconstant systemic associations and a variable prognosis. Aims: To study the clinical features and systemic associations of pyoderma gangrenosum and its response to treatment. Methods: All patients diagnosed to have pyoderma gangrenosum at the dermatology department of the Government Medical College, Kozhikode, from January 01, 2005 to December 31, 2014 were included in this prospective study. Results: During the 10-year study period, 61 patients were diagnosed to have pyoderma gangrenosum. A male predilection was noted. The most common clinical type was ulcerative pyoderma gangrenosum (90.2%). More than 60% of patients had lesions confi ned to the legs; 78.7% had a single lesion and 27.9% had systemic associations. Most patients required systemic steroids. Patients with disease resistant to steroid therapy were treated with intravenous immunoglobulin G and split-thickness skin grafts under immunosuppression induced by dexamethasone pulse therapy. All except one patient attained complete disease resolution. Limitations: The main limitation of our study was the small sample size. Conclusions: The male predilection documented by us was contrary to most previous studies. We found split-thickness skin graft to be a useful option in resistant cases. More prospective studies may enable the formulation of better diagnostic criteria for pyoderma gangrenosum and improve its management.

Antihypertensive agents in systemic hypertension associated with Type 2 diabetes in a tertiary care hospital.

Background: Hypertension and diabetes mellitus are both chronic disorders and when they occur as co-morbidities create havoc by presenting with a plethora of morbidity and mortality. Both require drug treatment over a long period of time, which calls for stringent analysis of prescribing trends of the same. Objectives: The present study was intended to analyze prescribing pattern and establish prescribing trends of anti-hypertensive drugs (AHD) in hypertensive diabetic patients. Methods: The present study was a record based, randomized, non-interventional study of 2 years duration conducted at a tertiary care hospital of central India. Prescriptions from 400 case records of hypertensive diabetics were obtained from the medical record section. Demographic details, blood pressure, and AHDs prescribed were systematically entered in pre-validated case record form. All data were thoroughly analyzed for fallacies and appropriateness. Results: Among 400 patients, 221 were males, and 179 were females. Monotherapy was used in 366 (91.5%) patients while combination therapy was used in 34 (8.5%) patients. Most commonly used combination was angiotensin converting enzyme inhibitor (ACEI)+calcium channel blocker (CCB), while in monotherapy CCB≥ACEI>beta blocker>diuretic>angiotensin II receptor blocker were most commonly prescribed. Conclusion: The present study represents trend and attitude of physicians in prescribing AHDs. On comparing with Joint National Committee 7 guidelines, the majority of the cases deviated from the guidelines, mostly in a choice of AHDs and Fixed dose combination.

Role of Mean Platelet Volume in Ischemic Stroke.

The present study was done to study the role of Mean platelet volume in the pathogenesis,severity and outcome of ischemic stroke. The present prospective study comprised of 100 patients each of ischemic stroke with equal number of age and sex matched control group.Modified Rankin scale was used to assess the severity of stroke.Mean platelet volume and platelet count were lower and higher in the control group.PDW and PLCR were higher in the study group.57% stroke patients were independent at the end of first week.Patients with high Mean platelet volume did worse at the end of first week in comparison to the control group(p value=<0.05). Mean platelet volume bears an inverse relationship to the immediate outcome from ischemic stroke independent of stroke subtype.

Risk Factors for Scholastic Backwardness in Children.

Aim: To identify the risk factors for scholastic backwardness in children. Participants: Children in the 6-12 year age group attending regular schools and referred to the child guidance clinic for scholastic backwardness. Setting: Tertiary care hospital in South India. Methods: Participants were compared with an age-and sexmatched group of children with good academic performance, to ascertain risk factors for scholastic backwardness. Results: There were 75 boys and 35 girls in the study group. Among them 30 (27%) children had mental retardation, 39 (36%) had borderline intelligence and 12 (11%) had microcephaly. Undernutrition was noted in 36 (33%) children and 31 (28%) had stunted growth. 28 (26%) children had a history of chronic medical problems like epilepsy, bronchial asthma and congenital heart diseases. Visual, hearing and speech defects were present in 6 (6%), 5 (5%) and 12 (11%) children, respectively. Statistically significant differences were noted in the educational level and employment status of parents of children with scholastic backwardness and those with good academic performance. Conclusion: Social and family factors have a significant influence on the academic functioning of children.

Prevention of Mother to Child Transmission of Hepatitis B Infection.

The likelihood of developing chronic hepatitis B infection and its complications is most when infection is transmitted vertically. Awareness of the current recommendations for managing babies of mothers who are hepatitis B carriers is not universal, resulting in failure of follow up, despite the serious long term implications, including development of hepatic carcinoma. We review the current guidelines of managing babies born to mothers who are Hepatitis B carriers.

Deliberate Self Harm in Children.

Objective: To study the nature of deliberate self-harm (DSH) in children and to identify the associated factors. Setting: Child Guidance Clinic attached to the Department of Pediatrics of a teaching hospital in South India. Subjects: Children with history of deliberate self harm who were referred to the CGC for psychological evaluation during a 10 year period. Methods: Children and parents were interviewed together and separately and details regarding age, sex, family and school environment, stresses and nature of self harm were documented. Psychiatric diagnosis was made based on DSM IV diagnostic criteria. Results: Among the 30 children included in the study, 21 were boys and 9 were girls. Majority of children were between the ages of 11 and 13 years, the youngest being 6 years old. 76% of children had history of acute stressful life events and 62% of them had chronic ongoing stress. 62 % of children had stress in the family and 41% had stress at school. Stress in the family included death of a parent, conflicts with parents or siblings, mental illness in the family, parental alcoholism and parental disharmony. Stress at school included conflicts with classmates, punishment or negative comments by teachers and learning problems. Psychiatric disorders were present in 52% of children, the commonest being depressive disorder. The commonest mode of DSH was self poisoning, and rat poison (zinc phosphide) was the commonest substance used. Conclusions: Deliberate self harm occurs in young children and the risk factors are comparable to those in adolescents.

Cutaneous manifestations of chikungunya during a recent epidemic in Calicut, north Kerala, south India.

Background: There was a recent epidemic of chikungunya (CKG) in Calicut and other northern districts of Kerala, South India, affecting thousands of people. Aims: To study the cutaneous manifestations of CKG and to have a serological and histopathological correlation. Methods: A total of 162 patients (63 males and 99 females) with cutaneous manifestations of CKG were enrolled in the study and serological confirmation was done with capture IgM ELISA for CKG. Skin biopsy was done in all representative cases. Results: Cutaneous manifestations were found more in females. There were 23 children, the youngest being 39 days old. Generalized erythematous macular rash was the most common finding. Vesicles and bullae were also common especially in infants. Localized erythema of the nose and pinnae, erythema and swelling of the pre existing scars and striae and toxic epidermal necrolysis-like lesions sparing mucosae were the other interesting findings. Different types of pigmentation were observed with a striking nose pigmentation in a large number of patients, by looking at which even a retrospective diagnosis of CKG could be made. Hence we suggest this peculiar pigmentation may be called "chik sign". There was flare up of existing dermatoses like psoriasis, lichen planus and unmasking of Hansen's disease with type 1 reaction. Serological tests were positive in 97%. Some hitherto unreported histopathologic findings like melanophages in the erythematous rashes were observed. Conclusion: A spectrum of cutaneous manifestations of CKG with a wide variety of unusual presentations with confirmed serological and histopathological evidence was encountered.

Role of intraoperative sentinel lymph node mapping in the management of carcinoma of the esophagus

Precise evaluation of lymph node status is one of the most important factors in determining clinical outcome in treating gastro-intestinal [GI] cancer. Sentinel lymph node [SLN] mapping clearly has become highly feasible and accurate in staging GI cancer. This study aims to investigate the feasibility and accuracy of detection of SLN using methylene blue dye in patients with carcinoma of the esophagus and assess its potential role in determining the rational extent of lymphadenectomy in esophageal cancer surgery. Thirty-two patients of esophageal cancer diagnosed on endoscopic biopsy were enrolled in this prospective study. After laparotomy, patent methylene blue was injected into the subserosal layer adjacent to the tumor. SLNs were defined as blue stained nodes within a period of 5 min. Standard radical esophagogastrectomy with lymphadenectomy was performed in all the patients. All the resected nodes were examined postoperatively by routine hematoxylin and eosin stain for elucidating the presence of metastasis, and the negative SLNs were examined further with cytokeratin immunohistochemical staining. SLNs were detected in 26 [81.25%] patients out of 32 patients who were studied. The number of SLNs ranged from 1 to 4 with a mean value of 1.7 per case. The SLNs of esophageal cancer were only found in N1 area in 21 [80.77%] cases, and in N2 or N3 area in only 19.33%. The overall accuracy of the procedure was 75% in predicting nodal metastasis. SLN had a sensitivity of 85.7% in the case of squamous cell carcinoma and 92.86% in the cases of adenocarcinoma of the esophagus. The accuracy of the procedure for squamous cell carcinoma and adenocarcinoma was 60% and 76.47%, respectively. SLN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with esophageal cancer and may indicate rational extent of lymphadenectomy in these patients. SLN mapping provides [right nodes] to the pathologists for detailed analysis and appropriate staging, thereby helping in individualizing the multi-modal treatment for esophageal cancer

Acute disseminated encephalomyelitis presenting as acute psychotic disorder.

A 5 year old boy and a 10 year old girl presented with acute onset of psychotic disorder, which occurred one week after an upper respiratory infection. MRI images of brain were consistent with the diagnosis of acute disseminated encephalomyelitis (ADEM) in both cases. ADEM is one of the differential diagnoses to be considered when acute psychotic disorder occurs during childhood.

Revesz syndrome.

A 5-year-old girl was admitted with pallor, hypopigmented sparse hair, tongue ulcers, atrophic nail changes, hypoplastic anemia and bilateral exudative retinopathy. A diagnosis of Revesz syndrome was made. She had the additional features of retinal detachment and retinitis pigmentosa, which are hitherto unreported in this syndrome.

Poland syndrome (anomaly) with congenital hemangioma: a new association.

Unilateral defect of pectoral muscle and ipsilateral syndactyly constitute Poland syndrome. Absence or hypoplasia of the breast and nipple, axillary hair loss and dermatoglyphic abnormalities have also been reported in this syndrome. The primary defect could be in the development of the proximal subclavian artery with early deficit of blood flow to the distal limb and the pectoral region, resulting in partial loss of tissue in those regions. However, the association of congenital hemangioma with Poland sequence has not been observed so far. Such an association is being reported here in a 1-year-old infant, second-born of nonconsanguineous parents, who also had polydactyly instead of the documented syndactyly.

Focal dermal hypoplasia (Goltz syndrome).

A 7-year-old girl born of non-consanguineous marriage was evaluated for facial dysmorphism. She had multiple skeletal anomalies like hypoplasia of the right mandible, narrow nasal bridge with broad tip and unilateral notching of the right ala nasi, concomitant squint and low set ears. She also had generalized hypopigmented, atrophic linear macules, multiple papillomas, fat herniations, umbilical hernia, hypoplastic nails, cicatricial alopecia, mild mental retardation, 'lobster-claw' hand and osteopathia striata of long bones, pointing to a diagnosis of Goltz syndrome. The unusual features noted were absence of the left first rib and aortic regurgitation.

Hemihypertrophy and primary small intestinal lymphangiectasia in incontinentia pigmenti achromians.

A rare occurrence of primary small intestinal lymphangiectasia in an 8-year-old girl with incontinentia pigmenti achromians is reported. In addition, she had right sided hemihypertrophy. Though intestinal lymphangiectasia is known to have a few syndromic associations, its co-existence in a child with incontinentia pigmenti achromians has not yet been reported in the literature. Hemihypertrophy is also extremely rare in the latter and only very few instances of an association between the two have been documented previously.

Nalidixic acid induced pseudotumour cerebri in children.

Nalidixic acid, the quinolone frequently used in the treatment of acute dysentery, is now emerging as an important cause of pseudotumour cerebri in infants and young children. A study of 20 such cases showed that all the patients had received a higher than recommended dose of nalidixic acid and that 85% of them were given the drug unnecessarily (i.e., for acute watery diarrhoea). A high concentration of the drug in the commercial preparations as well as the lack of awareness about this among doctors, especially the general practitioners, is the possible contributory factor leading to this situation. A simple measure of bringing down the concentration of nalidixic acid in the available preparations and sticking to oral rehydration solution alone in the treatment of acute watery diarrhoea, can bring down the incidence of this condition.