Latha Magatha Sneha

Financial burden faced by families due to out-of-pocket expenses during the treatment of their cancer children: An Indian perspective

Context: Life-saving cancer therapy is costly and may result in financial burden for these families. Financial costs for treating childhood cancer care are traditionally assessed based on the amount spent for diagnostic tests, hospitalization, and chemotherapy. The financial costs for travel, accommodation, out-of-pocket expenses for food, phone bills, and loss of income due to reduction or termination of parental employment are hidden nonmedical expenses that are rarely accounted for. Studies on the financial implications of pediatric cancer treatment are based on the Western model of healthcare with good government/state insurance coverage and hence literature on lifestyle implications for families in developing nations with limited resources is still scarce. Aims: The aim of this study is to find out the details of out-of-pocket expenses incurred by the families during their treatment of cancer children and its implications on their quality of life. Settings and Design: This study was conducted in a tertiary care center for pediatric malignancies for over 1-year period. Subjects and Methods: About seventy families whose children were diagnosed with acute leukemia and undergoing treatment at our center were asked to fill a questionnaire detailing their out-of-pocket expenses. Results: Nonmedical expenses accounts for about 46% of their monthly household income of parents from rural areas and 22% of their household income from urban areas. On an average, a family from rural area spends four times the normal amount spent on home for their daily food expenditure. Thirty-eight percent of families have borrowed money from money lenders with an average interest rate of about 12.5% which pushes them to a state of debt for the next few years. Conclusions: Out-of-pocket expenses contribute a significant proportion to the financial burden of the families with childhood malignancies and these invisible expenses should be recognized and provide adequate support to lessen the burden of this economic impact.

All that seems to be miliary mottling is not always due to tuberculosis: A case report

A 5-year-old child was presented to a general practitioner with cough and wheezing for a fortnight’s duration. He neither had a past history of wheezing nor a family history of bronchial asthma. There was no history of contact with tuberculosis. The only clinical findings were bilateral basal lung wheezing and crepitation. He did not improve with bronchodilator and antibiotic treatment. A chest radiograph revealed miliary mottling (Figure 1a). Blood parameters were normal, and the Mantoux test, gastric juice for acid fast bacilli and TB quantiferon test were negative. However since miliary mottling was seen, the child was treated empirically with anti-tuberculosis treatment but showed no improvement neither clinically nor radiologically. Further physical examination on review after 6 weeks revealed a 3 2 cm scalp swelling in the left parietal region. A skeletal survey then revealed two well-defined lytic lesions in the skull. (Figure 1b).The thoracic computed tomography (CT) showed randomly distributed nodular shadows in both lung fields (Figure 1c). Histopathological examination of the scalp swelling was suggestive of Langerhans’s cell histiocytosis (LCH). The only lesions found were those in the skull and the lungs. A lung biopsy was refused by his parents. The child was categorised as Group III LCH with high-risk organ involvement (Group III is single system and any risk organ involved; spleen, liver, hematopoietic system and lungs are classified as risk organs). He was started on Inj. Vinblastine and oral Prednisolone, and after 12 cycles the child showed healing radiologically. Currently, the child is on continuation phase with third weekly chemotherapy with Inj. Vinblastine, oral Prednisolone and daily 6 Mercaptopurine for 1 year. Since it is not an isolated pulmonary involvement and after 12 weeks of chemotherapy there is a reduction in the pulmonary lesion as seen in X-ray and CT films, a diagnosis of LCH with pulmonary involvement was made.

First Counseling Revealing the Diagnosis of Childhood Cancer: Parent Preferences From an Indian Perspective.

Background: The first counseling or the exchange between the physician and the parent(s) of children with cancer is of vital importance as it sets the tone for the rest of the treatment. The goal of our study was to find out the preferences among parents of Indian children with cancer regarding communication and breaking of bad news when fully informed about the diagnosis. Materials and Methods: A sample of 60 parents who had been counseled within 3 months from diagnosis were interviewed with a prepared questionnaire directed at eliciting their experiences with the physicians who broke the bad news to them and also suggestions to improve the exchange. Results: Sixty parents of children diagnosed with cancer participated in the study. All parents agreed on the importance of first counseling and asked for a second round of counseling to reinforce concepts learned during the first counseling. An overall 83% of parents wanted a comparison with another child having the same diagnosis, 57% wanted immediate or extended family to be present, and 92% did not want support staff to be present during counseling. In all, 68% of parents did not want to reveal the diagnosis to the child, 77% wanted as much information about the disease as possible, including estimated cost of treatment, and 90% wanted access to other information services and information about other centers where treatment was available. Conclusions: Parents have preferences about the ways in which information is presented to them during the first counseling. Knowing these preferences will help physicians to better their ability to interact with parents in the future during first counseling and help them decide a culturally appropriate course of action.

Short stature and an interesting association

Untreated hypothyroidism in children usually results in delayed puberty, but juvenile hypothyroidism causes isosexual precocious puberty in a rare syndrome called Van Wyk Grumbach syndrome, with a complete reversal to the pre pubertal state following thyroid hormone replacement therapy. We report here, a 7-year-old girl who presented with short stature, constipation and isosexual precocious puberty due to the long standing untreated severe hypothyroidism with this syndrome.

Bilateral parotidomegaly as an initial manifestation of acute lymphoblastic leukemia in a child: A case report and review of literature

The more common causes of parotid enlargement in children are infections and inflammatory conditions. Primary neoplasms of the parotid glands are rare in pediatric age group; however, secondary malignancies have been reported in survivors of childhood leukemia. The parotid glands have been the sites of relapses in acute lymphoblastic leukemia (ALL) and acute myeloid leukemia. However, bilateral parotid involvement as an initial presentation of ALL is rarely reported. We present a case of an 8-year-old boy who presented with bilateral parotid enlargement as an initial manifestation of ALL. General physicians should be aware of this extramedullary presentation of acute leukemia when they see a child presenting with organomegaly or abnormal blood counts.

Indian Pediatric Postgraduate’s Perspective on Future Career Intentions

ObjectiveTo determine the factors that influence Pediatric residents to pursue a subspecialty career and establish their choice of future workplace.MethodsThe present questionnaire based study was conducted during a National level pediatric post graduate exam refresher course in Chennai, India and involved Pediatric residents from all parts of India. Datas was analysed with the statistical package for social sciences (SPSS, version 18.0).ResultsSeventy five respondents participated in the study. Eighty-nine percent of the female students reported that marriage has an influence on whether or not to do sub specialisation and their choice of it while 92% of the male students found it irrelevant. Fifty-one (male – 75%, female – 58%) students pragmatically cited “interest in the subject Pediatrics” when asked for the reason choosing Pediatrics as their future career. Neonatology was the most chosen speciality followed by Critical Care and Cardiology. When asked to indicate the most important factors that is likely to influence their decision whether or not to pursue sub speciality program, the largest proportion of students identified “financial reasons” (31; 41%) followed by “job opportunities” (16; 21%).ConclusionsPediatric residents should compulsorily be exposed to all subspecialties during their post-graduation. Adequate career guiding and exposure to various subspecialties will make the residents pursue subjects like Pediatric Nephrology, Hemato-oncology, Developmental Pediatrics and Hepatology which have less takers.

Bell's palsy in an adolescent girl - not always a neurologist's territory: A case report and review of literature

Infections, inflammatory, and autoimmune conditions are the well-recognized etiologies of acute facial nerve paralysis in children. Bells palsy is idiopathic peripheral facial nerve palsy. Cranial neuropathies do occur in children due to the central nervous system involvement by malignancies but uncommon in pediatric acute lymphoblastic leukemias and even rarer in acute myeloid leukemias (AMLs). We report a case of a 13-year-old girl who presented with acute facial nerve palsy, was being treated as Bells palsy elsewhere and was later diagnosed to have AML.

Old is still gold…knee hammer: A forgotten tool!!

In this era of the latest diagnostic technologies, meticulous clinical examination of the patient still is the golden principle of medical science and will never lose its importance. This case report highlights that detailed physical examination of the patient would have led to the identification of the etiology quite earlier and the significance of evaluating a child as a whole and not based on symptoms alone.