Evaluation of Pathway to Diagnosis of Pediatric Brain Tumors in Tamil Nadu, India

PURPOSE

Delayed diagnosis and poor awareness are significant barriers to the early intervention of pediatric brain tumors. This multicenter observational study aimed to evaluate the baseline routes and time to diagnosis for pediatric brain tumors in Tamil Nadu (TN), with the goal of promoting early diagnosis and timely referrals in the future.

METHODS

A standard proforma was used to retrospectively collect information on demographics, diagnosis, referral pathways, and symptoms of incident pediatric brain tumor cases between January 2018 and October 2020 across eight tertiary hospitals in TN. Dates of symptom onset, first presentation of health care, and diagnosis were used to calculate total diagnostic interval (TDI), patient interval (PI), and diagnostic interval (DI).

RESULTS

A total of 144 cases (mean age, 6.64 years; range, 0-15.1 years) were included in the analysis. Among those, 94% (135/144) were from city/district areas, 40% (55/144) were self-referred, and 90% (129/144) had one to three health care professional visits before diagnosis. Median TDI, PI, and DI were 3.5 (IQR, 1-9.3), 0.6 (IQR, 0.1-4.6), and 0.6 (IQR, 0-3.3) weeks, respectively. Low-grade gliomas had the longest median TDI (6.6 weeks), followed by medulloblastomas (4.6 weeks) and high-grade gliomas (3.3 weeks). Average number of symptoms recorded was 1.7 at symptom onset and 1.9 at diagnosis.

CONCLUSION

Although there are some similarities with data from the United Kingdom, many low-grade and optic pathway tumors were unaccounted for in our study. DIs were relatively short, which suggests that infrastructure may not be a problem in this cohort. Increased training and establishment of proper cancer registries, combined with proper referral pathways, could enhance early diagnosis for these children.

Challenges in long-term control of hypercalcaemia with denosumab after haematopoietic stem cell transplantation for TNFRSF11A osteoclast-poor autosomal recessive osteopetrosis

Autosomal recessive osteopetrosis (ARO) is rare, involving increased bone density due to defective osteoclast differentiation or function, with several genetic subtypes.

Case

This child with compound heterozygous novel loss-of-function TNFRSF11A pathogenic variants causing osteoclast-poor ARO underwent haematopoietic stem cell transplantation (HSCT) aged 3.1 years and experienced episodic severe hypercalcaemia over 2.5 years. She initially presented aged 8 months with craniosynostosis and visual impairment and underwent surgery; no increased bone density evident on skull imaging nor variants in genes associated with craniosynostosis identified. She was subsequently referred for investigation of poor linear growth and low alkaline phosphatase. Clinical abnormalities included asymmetric pectus carinatum, thickened anterior tibia and wrists, and markedly delayed dentition. Skeletal survey revealed generalised osteosclerosis with undertubulation.

Management

She received haploidentical HSCT aged 3.1 years and developed hypercalcaemia (adjusted calcium 4.09mmol/L = 16.4mg/dL) Day 18 post-HSCT, unresponsive to hyperhydration and diuretics. Denosumab achieved normocalcaemia, which required 0.6mg/kg every 6 weeks long-term. The ensuing 2.75 years feature full donor engraftment, good HSCT graft function, skeletal remodelling with 2.5 years recurrent severe hypercalcaemia and nine fragility long bone fractures.

Conclusion

This case illustrates challenges of bone and calcium management in ultrarare TNFRSF11A-related OP-ARO. Craniosynostosis was an early feature, evident pre-sclerosis in osteopetrosis. Following HSCT, restoration of osteoclast activity in the context of elevated bone mass produced severe and prolonged (2.5 years) hypercalcaemia. Denosumab was effective medium-term, but required concurrent long duration (11 months) zoledronic acid to manage recurrent hypercalcaemia. Fragility fractures brought appreciable additional morbidity in the post-HSCT phase.

Mesenchymal stromal cells for acute graft-versus-host disease: response at 1 week predicts probability of survival

Mesenchymal stromal cells (MSCs) have been successfully used for the treatment of steroid-resistant graft-versus-host-disease (GvHD). However, the lack of early predictors of clinical responses impacts on the time at which to add further treatment and consequently the design of informative clinical trials. Here, we present the UK experience of one of the largest cohorts of GvHD patients undergoing MSC infusions so far reported. We show that clinical responses assessed as early as 1 week after MSC infusion predict patients' overall survival. In our cohort, cell dose, patients' age and type of organ involvement are crucial factors associated with clinical responses.

Incidence of Adenovirus Infection in Hematopoietic Stem Cell Transplantation Recipients: Findings from the AdVance Study

Adenovirus (AdV) is an increasingly recognized threat to recipients of allogeneic hematopoietic stem cell transplantation (allo-HCT), particularly when infection is prolonged and unresolved. AdVance is the first multinational, multicenter study to evaluate the incidence of AdV infection in both pediatric and adult allo-HCT recipients across European transplantation centers. Medical records for patients undergoing first allo-HCT between January 2013 and September 2015 at 50 participating centers were reviewed. The cumulative incidence of AdV infection (in any sample using any assay) during the 6 months after allo-HCT was 32% (95% confidence interval [CI], 30.9% to 33.4%) among pediatric allo-HCT recipients (n = 1736) and 6% (95% CI, 4.7% to 6.4%) among adult allo-HCT recipients (n = 2540). The incidence of AdV viremia ≥1000copies/mL (a common threshold for initiation of preemptive treatment) was 14% (95% CI, 13.0% to 14.8%) in pediatric recipients and 1.5% (95% CI, 1.1% to 2.0%) in adult recipients. Baseline risk factors for developing AdV viremia ≥1000copies/mL included younger age, use of T cell depletion, and donor type other than matched related. Baseline demographic factors were broadly comparable across patients of all ages and identified by multivariate analyses. Notably, the incidence of AdV infection decreased stepwise with increasing age; younger adults (age 18 to 34 years) had a similar incidence as older pediatric patients (<18 years). This study provides a contemporary multicenter understanding of the incidence and risk factors for AdV infection following allo-HCT. Our findings may help optimize infection screening and intervention criteria, particularly for younger at-risk adults.

High transplant-related mortality associated with haematopoietic stem cell transplantation for paediatric therapy-related acute myeloid leukaemia (t-AML). A study on behalf of the United Kingdom Paediatric Blood and Bone Marrow Transplant Group

Paediatric therapy-related acute myeloid leukaemia (t-AML) is rare and the outcome is poor. While allogeneic haematopoietic stem cell transplantation (HSCT) is generally the accepted modality of treatment, data regarding salvage chemotherapy, remission induction, conditioning regimens, transplant-related mortality and outcome is scarce. Between 2000 and2016, 36 children with t-AML were treated in seven UK paediatric HSCT centres. The most common salvage protocol for remission induction was FLAG with or without idarubicin and 28 patients were in complete morphological remission prior to BMT. Only 12 patients survived (33%). Transplant-related mortality (TRM) was the leading cause of death.

Incidence of infective endocarditis and its thromboembolic complications in a pediatric population over 30years

BACKGROUND

Pediatric infective endocarditis (IE) has been associated with high morbidity and mortality, mostly related to thromboembolic complications (TEC). The objective of our study was to describe the experience in children with IE and to review the changes over a thirty-year period, regarding origin of IE, incidence of vegetations, TEC and their respective morbidity and mortality rates.

METHODS

A retrospective chart review of children aged 0-18years with IE defined by the Duke Criteria and admitted to The Hospital for Sick Children, was conducted. Data were divided into three periods (P); P1 (1979-1988); P2 (1989-1998); and P3 (1999-2008).

RESULTS

The study included 113 patients, median age 7yrs.; females: 46 (41%), congenital heart defects 95 (84%), comparable in all periods. Overall, cardiac vegetations were found in 68/113 patients (60%); large vegetations (≥1cm) in 32 patients (28%). Fourty-five (45/133 [40%]) TEC were documented, 22 patients (20%) developed cerebrovascular events (CVE) and 23 patients (20%) had non-CVE. Patients diagnosed during P3 were older, had more vegetations (p<0.05), and a higher incidence of community acquired-IE (p<0.05). Overall, mortality was 15%, comparable in all periods. Significant risk factors for mortality were vegetations (HR 6.44; 95% CI: 2.07-20.01, p=0.002) and heart failure (HR 28.39; 95% CI: 10.49-76.85, p<0.001).

CONCLUSIONS

Over the study period, we report a growing incidence of community acquired pediatric IE in older children accompanied by an increasing rate of TEC. Heart failure and vegetations were associated with an increased mortality. These preliminary data need to be confirmed by prospective data.

Stress and Stressors among Medical Undergraduate Students: A Cross-sectional Study in a Private Medical College in Tamil Nadu

Background:

Medical education is perceived as being stressful, and a high level of stress may have a negative effect on cognitive functioning and learning of students in a medical school.

Objectives:

To (a) assess the perceived stress among medical undergraduate students, (b) identify the sources of stress, and (c) find an association of perceived stress with sociodemographic characteristics and various stressors.

Materials and Methods:

A cross-sectional study was conducted among medical undergraduate students in a private medical college in Tamil Nadu. A total of 750 medical students from 1^st year to final year were invited to participate in the study. Self-administered questionnaire was used to collect data regarding sociodemographic profile, perceived stress using perceived stress scale-14 and academic, psychosocial and environmental stressors. Descriptive statistics was used to describe the sociodemographic characteristics, sources of stress and perceived stress. Logistic regression analyses were carried out to assess determinants of stress.

Results:

The overall response rate was 93.33% (700 out of 750 students). The mean perceived stress score was 25.64 ± 5.44. Higher age-group, year of studying bachelor of medicine and bachelor of surgery, vastness of academic curriculum, fear of poor performance in examination, lack of recreation, loneliness, family problem, and accommodation away from home were important determinants of perceived stress.

Conclusions:

The perceived stress was higher among higher age group and final year medical students. Academic, psychosocial, and environmental stressors are associated with perceived stress. Reframing the academic curriculum and examination patterns, incorporating recreational and sports activities, and establishment of counseling cells in the institution is needed.

Role of Community in Swachh Bharat Mission. Their Knowledge, Attitude and Practices of Sanitary Latrine Usage in Rural Areas, Tamil Nadu

BACKGROUND

In most developing countries, open defecation is the 'way of life'. This practice is considered as the most serious health and environmental hazard. Prime Minister of India launched the "Swachh Bharat Mission" to accelerate the efforts for achieving universal sanitation coverage and to put focus on sanitation.

OBJECTIVE

To find the knowledge, attitude and practices of sanitary latrines usage in rural area, Tamil Nadu.

MATERIALS AND METHODS

This was a cross sectional study conducted among rural population in Kuthambakkam village, Tamil Nadu. There were a total of 1175 households in Kuthambakkam village. These households were serially numbered and of these a sample of 275 households were selected for the study using simple random sampling technique by lottery method. A structured questionnaire was used to collect information regarding the background characteristics, their knowledge, attitude and practices towards sanitary latrines usage. Descriptive statistics were calculated for background variables, the prevalence of sanitary latrines usage and open air defecation. Association between factors responsible for open air defecation was found by using chi square test.

RESULTS

The prevalence of usage of household sanitary latrine and community latrines was 62.5% and 4.3% respectively. The prevalence of open air defecation among the study participants was 33.1%.Significant association was found between low standard of living and open air defecation practice.

CONCLUSIONS

To solve the problem of underutilization of sanitary latrines, planning and conducting Information Education Communication activities is very essential. Effective political and administrative support is needed to scale up the sanitation program.

Role of dietary habits and diet in caries occurrence and severity among urban adolescent school children

To identify the role of dietary habits (type of diet, skipping meals, snacking in-between meals and frequency of visits to fast food restaurants) in caries occurrence and severity. To explore the correlation between frequency of intake of selected foods and dental caries. A cross-sectional study was carried out on adolescent children (n = 916) of age 13-19, following a two-stage random sampling technique. Data were collected using a pretested questionnaire. Questionnaire included demographic details, dietary habits of children and food frequency table that listed selected food items. The dependent variable-dental caries was measured using the decayed, missing, filled teeth (DMFT) index. The prevalence of dental caries in this study population was 36.7% (95% confidence interval: 33.58-39.82). The mean DMFT was 1.01 (±1.74). No statistically significant difference found between caries occurrence and type of diet (P = 0.07), skipping meals (P = 0.86), frequency of eating in fast food stalls (0.86) and snacking in between meals (0.08). Mean DMFT values were higher among nonvegetarians and among children who had the habit of snacking in between meals. Frequency of intake of selected food items showed that mean frequency intake of carbonated drinks and confectionery was higher among children who presented with caries when compared to caries-free children (P = 0.000). Significant correlation found between mean DMFT and mean frequency intake of carbonated drinks and confectionery. Odds ratios were calculated for the same for frequency ≥4 times/day for confectionery and ≥4/week for carbonated drinks and results discussed. Frequent intake of carbonated drinks and confectionery is harmful to oral health that eventually reflects on general health. Educating the adolescent children on healthy dietary habits should be put in the forefront.

Pocket Money: Influence on Body Mass Index and Dental Caries among Urban Adolescents

OBJECTIVE

To explore the influence of pocket money on Dental Caries and Body Mass Index.

MATERIALS AND METHODS

A cross-sectional study was conducted wherein urban adolescent schoolchildren of age 13-18(n=916) were selected by two stage random sampling technique. Dental caries was measured using the DMFT Index. The children's nutritional status was assessed by means of anthropometric measurements. Body Mass Index using weight and height of children was evaluated using the reference standard of the WHO 2007.

RESULTS

RESULTS showed that 50% of children receive pocket money from parents. The average amount received was Rs. 360/month. There was a significant correlation between age and amount of money received (r=0.160, p=.001). The average amount received by male children was significantly higher (Rs. 400) when compared to female children (Rs. 303). It was observed that income of the family (>30,000 Rs./month) and socioeconomic status (Upper class) was significantly dependent on the amount of money received by children (p<0.05). There was no significant difference in the occurrence of caries among children receiving pocket money or not. When BMI categories and pocket money were considered, statistically significant difference was seen among overweight and obese and normal weight children (p<.05). Higher proportion (40.1%) of overweight and obese adolescent children frequented the fast food restaurants every week when compared to the underweight (31.7%) and normal weight children (29.9%).

CONCLUSION

Adolescent children receiving pocket money from parents could influence their eating habits in turn affect general health. Parents and teachers should motivate children on healthy spending of their pocket money.

A rare case of peripheral T-cell lymphoma in 1-year-old child

Peripheral T-cell lymphoma (PTCL) represents approximately 12% of lymphoid neoplasms. They are even rarer in children and represent only 1% of Non-Hodgkin's lymphoma in this age group. We report a case of PTCL in a 1-year-old female child for its rarity.

Splenic hamartoma in a child in the era of PET-CT

We present a case of a healthy 7-year-old female with an incidental finding of a growing splenic lesion, diagnosed as a splenic hamartoma after splenectomy. This case highlights the diagnostic challenge of splenic lesions and that the role of positron emission tomography/computerized tomography (PET/CT) in defining splenic lesions in the pediatric population remains to be defined.

Improved outcome from invasive adenovirus infection in pediatric patients after hemopoietic stem cell transplantation using intensive clinical surveillance and early intervention

Adenovirus is a common cause of morbidity and mortality after hemopoietic stem cell transplantation in children. Recently the incidence, risk factors, and outcome of such infections have been better defined using improved virologic detection methods, in particular polymerase chain reaction. We have introduced intensive virologic surveillance for adenovirus in our institution including at least weekly polymerase chain reaction testing of blood and stool samples. We report on 71 prospectively monitored transplants, including 40 from unrelated donors. In total, there were 8 cases of invasive adenovirus infection, 3 of whom died. Mortality was less than in previous studies as cases were managed with antiviral chemotherapy and reduction of immune suppression. In fatal cases, there was concurrent difficult graft versus host disease making withdrawal of immune suppression therapy impossible. We describe 2 cases of graft failure in association with adenovirus viremia and its treatment that were successfully managed with further donor cell infusion.