2009, Vol 5, No 2
Actual recommendations on diagnosis and treatment of high blood pressure in children and adolescents (part two – therapy)
Pediatr Med rodz Vol 5 Numer 2, p. 75-79
ABSTRACT

The aim of therapy in case of arterial hypertension is not only lowering blood pressure, but first of all, diminishing cardiovascular morbidity and mortality. Cardiovascular risk factors probably are greater in children than in adults, as the disease starts early and lasts longer. Rules of pharmacologic and nonpharmacologic therapy are similar to those used in internal medicine. In all patients therapeutic lifestyle changes should establish the base of treatment. In the moment when indications for antihypertensive drug therapy appear paediatricians use the same pattern as accepted in internal medicine. Still we should remember that no data are available on the long-term effects of antihypertensive drugs on growth and development. Acceptable drug classes for use in children include ACE inhibitors, angiotensin receptor blockers, b-blockers, calcium channel blockers and diuretics. Some drugs have a long history of safety and efficacy and these drugs remain appropriate for paediatric use. It will take longer for paediatricians to have opportunity for use of new therapeutic tools as direct renin inhibitors, new inhibitors of aldosterone receptor or angiotensin immunotherapeutic vaccine.

Keywords: hypertension, children, adolescents, nonpharmacologic therapy, pharmacologic therapy
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Aliskiren – first in the new class of antihypertensives
Pediatr Med rodz Vol 5 Numer 2, p. 80-82
ABSTRACT

Aliskiren is the first in a new class of antihypertensives – the direct renin inhibitors. It took a long time to discover it, mainly because of difficulties with creating an oral form with good bioavailability. It has been approved for the treatment of primary hypertension in United States and Europe in 2007. It provides good blood pressure efficacy, has good tolerability and small amount of undesirable side effects. Blocking renin, it prevents conversion of angiotensinogen to angiotensin I. First clinical trials concerning its use alone or in combination with ACEI or ARB give hope for greater reduction in blood pressure and more renal and cardiovascular protection that provided by ACEIs and ARBs. The ongoing clinical trial programme ASPIRE HIGHER will investigate the potential of aliskiren in improvement of renal and cardiovascular protection. Preliminary results are very promising. Aliskiren diminishes plasma renin activity from 50 to 80% in hypertensive patients after oral administration. It diminishes systolic and diastolic blood pressure. After single dose the effect of the drug lasts for 24 hours. Whole therapeutic effect is observed after two weeks.

Keywords: arterial hypertension, direct renin inhibitor, renin-angiotensin-aldosterone system, albuminuria, kidney protection
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What determines achieving asthma control?
Pediatr Med rodz Vol 5 Numer 2, p. 83-90
ABSTRACT

According to current asthma management guidelines, achieving and maintain asthma control is the main goal of asthma treatment. GINA 2006 defines five steps of intensity of asthma treatment and selection of treatment options is made on the basis of asthma control level. It is recommended using reliever medication and asthma control medication as asthma pharmacotherapy. On account of the key role of airway inflammation in pathogenesis of asthma inhaled corticosteroids are the most effective anti-inflammatory medication for asthma treatment. The GOAL study shows that the majority of patients were able to achieve asthma control. However, despite the availability of very effective medications in some patients asthma remains poorly controlled. There is opinion that successful treatment in asthma is not only provided with appropriate pharmacotherapy. Report GINA pays attention to importance of close partnership between doctor and patient, self-management education and creation written self-management action plan in achieving asthma control. Reasons for uncontrolled asthma are numerous. The main cause is patient non-compliance with therapy and may be split into drug-dependent and drug-independent nonadherence. There are also other factors which may contribute to asthma symptoms and exacerbations including allergen exposure, comorbid conditions and active and passive smoking. Recognition and elimination these factors reduce need for medication and improve asthma control.

Keywords: asthma control, asthma management guidelines, GINA, asthma treatment, therapy compliance, factors determining asthma control
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Asthma – from severity to control. The methods of asthma control assessment
Pediatr Med rodz Vol 5 Numer 2, p. 91-97
ABSTRACT

According to the first asthma management guidelines, treatment of asthma depends on its severity define by clinical symptoms and lung function parameters. In fact, asthma is a variable disease and might change over time, which highlights the need for patient’s clinical condition assessment continuously and for medication adjustment. However, asthma severity level does not flexibly reflect the response to treatment. Therefore, current statement of world expert recommends a change in approach to asthma management and submits achieving asthma control over establishment its severity, distinguishing totally controlled asthma, partially controlled and uncontrolled asthma. GINA 2006 formulates achieving optimal asthma control status of disease as the main goal of asthma treatment. Asthma control refers to the degree to which symptoms of asthma are minimised by therapeutic intervention and it is better if concerns also pathological and physiological markers. According to updated assumptions, the definition of asthma control level is the basis of choosing and modification of asthma pharmacotherapy. Accurate assessment of asthma control improves effectiveness of treatment. Several methods are available to specifically assess asthma control, including assessment of clinical parameters (daytime and nocturnal symptoms, bronchodilator intake), lung function (PEF and FEV1), underlying airway inflammation (bronchial hyper-responsiveness, induced sputum eosinophilia, exhaled nitric oxide concentration). Subjective methods are also available such as questionnaires or short asthma control tests (ACT, ACQ, ATAQ). Currently there is no clear statement which parameters or its combination could be considered as the most reliable tool of asthma control assessment. According to multidimensional pathogenesis of asthma, to get asthma control full picture it seems to be sensible to connect objective and subjective parameters.

Keywords: bronchial asthma, asthma severity, asthma control, recommendations for asthma management, criteria of asthma assessment
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Influence of cigarette smoke on asthma
Pediatr Med rodz Vol 5 Numer 2, p. 98-101
ABSTRACT

It is valued that near 10-15% children have diagnosis of asthma up to 10 years old. Cigarette smoke breathing increases signs and it makes treatment of asthma difficult. It concerns equal active smoking as well as passive cigarette smoke breathing in. Cigarette smoke exposure can cause progress of chronic inflammatory states of respiratory tract and in consequence can lead to COPD or cause asthma exacerbation and more severe course of asthma. Negative results of smoking concern also pregnancy outcome and further child development. Near 30% of asthma treated patients admit smoking or is exposed on passive smoking. Similar percent of smokers can appear among pregnant women. Cigarette smoke exposed children have greater number of asthma exacerbations comparing to non exposed asthma children, they also have greater number of hospitalisations per year and need greater average dose of corticosteroids in standard treatment sustaining clinical symptoms remission. There is proved positive correlation between level of nicotine metabolite – cotinine in children urine and number of smoked cigarettes by their parents. Researches on cotinine levels in active and passive smokers urine show direct correlation with progress of respiratory tract pathology, particularly with more severe outcome and more difficult treatment of asthma. Cigarette smoke disturbs respiratory tract physiology, which effects with lesser response to classic corticosteroid asthma treatment and suggest including antileukotriene drug AT such patients due to modification of pathological influence on respiratory tract cigarette smoke toxic substances.

Keywords: cotinine, cigarette smoke, active smoking, passive smoking, asthma
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Gastro-oesophageal reflux disease and bronchial asthma
Pediatr Med rodz Vol 5 Numer 2, p. 102-107
ABSTRACT

Bronchial asthma and gastro-oesophageal reflux disease are often coexisting disease entities. Reflux is thought to be a potential factor stimulating or aggravating asthma. This hypothesis is based on both pathophysiological premises and clinical examinations. In an experimental study, it was indicated that the acidification of the lower part of the oesophagus causes an increase in bronchial reactivity. Several mechanisms are suggested to explain this phenomenon, of which the most essential are the nervous, inflammatory and microaspiration theories. It was also indicated that unspecific tests for bronchial hyperreactivity could induce reflux episodes, which argues for the role of asthma itself in inducing GERD. Weakening of anti-reflux mechanisms is brought about by an increase in negative pressure in the chest and the “air trap”, related to exacerbations of asthma, and also by some oral bronchodilating drugs, especially theophylline. Both diseases can interact with each other on the basis of a vicious circle, which result in therapeutic implications. However, there is no explicit data from randomised studies concerning the effectiveness of pharmacological and surgical anti-reflux treatment. The latest data from the literature does not prove the positive results of such a therapy in the group of difficult asthma, in which implementation of treatment with large doses of IPP has been recommended so far. There is still no convincing data concerning the role of non-acid and/or biliary reflux in asthma. It is necessary to improve and standardise diagnostic methods and therapeutic protocols allowing us to single out a group of patients in whom the anti-reflux therapy will bring the best effects for the control of asthma.

Keywords: gastro-oesophageal reflux, extra-oesophageal manifestation, asthma, bronchial hyperreactivity, anti-reflux therapy
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Skin conditions in chosen viral diseases
Pediatr Med rodz Vol 5 Numer 2, p. 108-112
ABSTRACT
Skin eruptions at children are frequent cause of physician visits. Many diseases may be the reason and differential diagnosis includes allergic, dermatological, infectious, rheumatological and even oncological diseases. Differentiation between these demands wide knowledge from many areas of medicine and clinical experience. More or less characteristic dermatological changes are often seen in many viral conditions. In this work there are described some of viral diseases: erythema contagiosum, pityriasis rosea and molluscum contagiosum. Skin eruptions in their course are very characteristic that their became essential for the right diagnosis. However, the diagnosis is frequently incorrect, maybe because they are relatively rare conditions but in children population they can be seen quite often. For example erythema contagiosum in cyclic pattern, every few years causes epidemy. Molluscum contagiosum frequency constantly rises for last few decades. These diseases has usually mild course and don’t need any treatment. But there is a group of ill people requiring special attention and medical care because of atypical course or probability of serious consequences. In children with immunological deficiency all of these diseases can become generalised and serious condition. Pregnant women after contact with erythema contagiosum are at risk of foetal hydrops and should be carefully observed. Molluscum contagiosum in gender areas suggest possibility of sexual way of infection so other venereal diseases should be suspected. Knowledge of characteristic course of described conditions and proper diagnosis allows to avoid unnecessary wide differential diagnostic procedures. Identification of patients from risk groups gives them proper further treatment and ensures about mild course in remained group of patients.
Keywords: erythema contagiosum, parvovirus B19, arthropathy, aplastic crisis, pityriasis rosea, molluscum contagiosum
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Seasonal affective disorder – selected diagnostic and therapeutic issues
Pediatr Med rodz Vol 5 Numer 2, p. 113-119
ABSTRACT

Depression has since long remained an up-to-date and inexhaustible topic. A steady increase is still observable in the number of scientific studies exploring various facets of clinical manifestations, aetiology, mechanisms and determinants of depression. This paper elaborates on a particular type of depression – seasonal affective disorder (SAD). This condition usually lasts from a few weeks to a few months and occurs most often in the third decade of life, seldom in children. The diagnosis is from 2 to 3 times more frequent in women. After diagnosis and launching treatment, the symptoms can persist from 2 to 11 years. Some people fully recover from the disorder, or present only mild symptoms. As many as approximately 33% to 44% of patients, develop the major depression episode. In the world statistics the seasonal depression, apart from allergies and AIDS, is placed on the 4th position in the most common health issues. Even up to 10% of people in Poland, feels that the shortening of the day is linked to their general well-being and displays more or less severe symptoms of this condition. This study is a review of the latest literature on the pattern of the seasonal affective disorder. The aetiology of SAD, its psychopathological manifestations and differential diagnosis criteria will be discussed. Practical implications will also be suggested with regard to coping with the symptoms, possibilities of preventing relapses and specificity of the professional counseling for people suffering from SAD.

Keywords: seasonal affective disorder, depression, affective disorder, aetiology, diagnosis, therapy
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Twenty-seven years old woman with pulmonary tuberculosis
Pediatr Med rodz Vol 5 Numer 2, p. 120-125
ABSTRACT

Bronchiectasis are irreversible, local extension of bronchi, usually accompanied by infection. In about 50% of cases its origin remains unknown. Cystic fibrosis is an inherited chronic disease caused by defective gene and it affects mostly the lungs and digestive system. Chlamydophila pneumoniae is a bacteria transmitted through droplets which can cause atypical pneumonia. Globally, 9.2 million new cases occurred in 2006, of which 7% million cases were in HIV-positive people. The Stop TB Strategy is WHO’s recommended approach to reducing the morbidity and mortality. DOTS goal is to dramatically reduce the global burden of tuberculosis by 2015 by ensuring all TB patients, including those co-infected with HIV and those with drug-resistant TB, benefit from universal access to high-quality diagnosis and patient-centered treatment. We investigated a 27 years old woman with underdiagnosed bronchial asthma who was admitted to hospital due to recurrent episodes of shortness of breath. She was treated with antibiotics and steroids but in spite of this her state worsened and chest radiograms showed progression of the illness. She was diagnosed for cystic fibrosis, chlamydial pneumonia and idiopathic bronchiectasis. Finally, the microbiological detection of acid-fast bacilli (AFB) using The BACTEC radiometric method allowed for TB diagnosis which was later on confirmed by positive cultures for M. tuberculosis. The patient was treated for six months and we noted clinical and radiological improvement of her health.

Keywords: bronchial asthma, chlamydial pneumonia, bronchiectasis, pulmonary tuberculosis, cystic fibrosis
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Rare causes of urolithiasis exampled by patients with hyperparathyroidism and suspected of Williams’ syndrome
Pediatr Med rodz Vol 5 Numer 2, p. 126-130
ABSTRACT

Urolithiasis is a significant and a common health problem in children’s nephrology and urology. Taking into account the consequences, such as colic renal pain, recurrent urinary tract infection and renal failure, fast diagnosis and treatment of urolithiasis is needed. Hypercalciuria is the most common metabolic abnormality in patients with calcium kidney stones. Hypercalciuria may be caused by increased intestinal calcium absorption, decreased renal calcium reabsorption or hyperparathyroidism. A serum calcium level is steady and is regulated by the actions of parathyroid hormone, vitamin D3 and the opposing effect of calcitonin. We describe two clinical cases that demonstrate uncommon aetiology of urolithiasis: the male patient with recurrent urolithiasis caused by hyperparathyroidism due to parathyroid gland hyperplasia and the female patient with hypercalcaemia accompanied by urolithiasis and Williams syndrome suspicion. Hyperparathyroidism is characterised by high serum calcium level, hypercalciuria, elevated PTH and renal metabolite of vitamin D3 concentration. The clinical manifestation of Williams’ syndrome include distinct facial appearance associated with cardiovascular anomalies, intermittent hypercalcaemia and hypercalciuria, neurodevelopmental and gastrointestinal tract abnormalities. A characteristic behavioural profile, in children with Williams’ syndrome, is observed and called “cocktail party”.

Keywords: rolithiasis, hypercalciuria, hypercalcaemia, hyperparathyroidism, Williams’ syndrome
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