2009, Vol 5, No 4
Pertussis – not a specifically children’s disease, current prevention strategies
Pediatr Med rodz Vol 5 Numer 4, p. 240-244
ABSTRACT

Pertussis (whooping cough) is an acute infectious disease of children, the most dangerous for newborns and infants. Before common vaccinations were introduced, pertussis was an endemic disease of high morbidity, high death rate, especially in the first year of life, and numerous complications. After the vaccinations were introduced for some time downward tendency of pertussis morbidity was observed. Nowadays morbidity rate is growing (in Poland 3.45 in 2009 vs. 2.25 in 2008), and the reasons for this tendency could lie in the fast extinction of postvaccination response in older children, which makes them vulnerable to infections. In the last decade the increase in pertussis prevalence in adolescents and adults in observed. This fact calls for the intensification of researches into creating new vaccine designed for adolescents and adults. The introduction of 2 new dTap vaccines in the USA in 2005 based on tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine [Boostrix, GlaxoSmithKline (10-18 years of age) and Adacel, Sanofi Pasteur (11-64 years of age)], constitutes a first step towards the improvement of the epidemiological situation. The study presents pertussis prevalence in Poland and in the world, as well as current prevention strategies. Nowadays prevention based on the implementation an adult program (a cocoon strategy and a single booster dose dTap) in addition to childhood and adolescents vaccination seems to be the most effective strategy resulting in significant reduction of pertussis incidence in the all age groups.

Keywords: pertussis, children, adolescents, adults, vaccinations
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Comparison of effectiveness of primary angioplasty to thrombolysis and its relationship in context time delay: a meta-analysis
Pediatr Med rodz Vol 5 Numer 2, p. 245-249
ABSTRACT

Meta-analyses of the various randomised trials comparing thrombolysis and primary angioplasty have demonstrated substantial benefits from angioplasty in terms of mortality, non-fatal re-infarction and stroke, and they have also proved that angioplasty has lower recurrence rates and less residual stenosis. Despite the obvious clinical superiority of primary angioplasty, thrombolytic treatment is the default treatment option in many countries because of practical limitations on the use of percutaneous interventions including e.g. appropriately skilled staff. The choice of proper management also needs to consider the possible time delay in initiating reperfusion with primary angioplasty compared to thrombolysis. Reperfusion therapy has become the unquestionable gold standard for the early management of acute ST-segment elevation coronary syndromes. The advantages of this strategy rises exponentially, if the therapy will be initiated earlier. The highest number of patients saved by reperfusion therapy is within the first hour after symptom onset. The time interval which is creating a window of opportunity has aptly termed the “golden hour”. The mechanism of this benefit relates to maximizing myocardial salvage by early restoration of adequate coronary blood flow, resulting in preservation of left ventricular function, thereby enhancing both early and long-term survival. It is currently uncertain as to how to best handle patients with aborted myocardial infarction. A strong case for coronary angiography with a view to coronary intervention seems convinced, especially if there is a large initial territory of heart at risk. Failure to intervene could attenuate the initial prognostic benefit. The effect of angioplasty-related time delay in reducing the mortality benefit of angioplasty relative to thrombolysis has been demonstrated using metaregression methods.

Keywords: acute myocardial infarction, primary coronary angioplasty, reperfusion therapy, thrombolytics, metaanalysis
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Comparison of nitric oxide in exhaled air and pH of exhaled breath condensate in healthy children and children with asthma exacerbation
Pediatr Med rodz Vol 5 Numer 4, p. 250-253
ABSTRACT

Basic pathogenic mechanism of asthma is an inflammatory process taking place in a mucous membrane of a bronchial tree. Parameters, used to evaluate this process so far, aren’t objective enough and they are difficult to gain, especially in children. The possibility of an objective estimation of the inflammatory process in bronchial tree can influence more appropriate evaluation of a patient’s condition and make treatment of asthma more adequate. There were many researches published in last few years, seeking for such tools, which in an easy, noninvasive and cheap way would reflect the intensification of inflammation in respiratory system. Nitric oxide (NO) concentration in exhaled air is considered as one of such indicators. Its concentration depends on iNOS activity – an enzyme activated by inflammatory factors. It is measured with methods using chemiluminescency. Rise in its concentration suggests rise in inflammatory process of bronchia. The other marker of inflammatory state taken into consideration in many researches is pH of exhaled breath condensate (EBC), which is a derivative of fluid lining a surface of pulmonary alveoli. It is possible to measure concentration of many substances dissolved in it, but pH estimation is the easiest method of EBC evaluation. It was noticed that it falls in the run of diseases that go with inflammation in bronchial tree. Both mentioned methods are relatively cheap and easy to accomplish, even among pediatric population. The aim of this study was to evaluate NO and pH values in EBC in 17 children with asthma diagnosis and comparison of the results with values collected from a group of healthy children. Investigation was conducted at 26 children in the age from 8 to 17 year old. Between both groups of children it was gained statistically significant difference in values of NO concentration in exhaled air as well as pH of EBC. In the case of asthma exacerbation NO concentration was rising and pH value was falling, and both this parameters were correlating with each other. These results remain consistent with other researches using same parameters as indicators of bronchial and pulmonary inflammatory process intensification. They can become valuable and commonly used methods of evaluation of asthma.

Keywords: asthma, exhaled breath condensate, nitric oxide (NO), pH of exhaled breath condensate, asthma exacerbation
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Metabolic syndrome in children and adolescents – in own clinical observation
Pediatr Med rodz Vol 5 Numer 4, p. 254-258
ABSTRACT

Nowadays obesity became a pandemic condition all over the world including the pediatric population. Childhood obesity is not only the risk of obesity in the future but first of all the increased risk of cardiovascular and metabolic diseases. Early diagnostic of the risk factors of cardiovascular diseases included as criteria of metabolic syndrome, in spite of controversy in defining this condition, helps in differentiation of the patients from the high risk group. Aim of the study was to assess the presence of the metabolic syndrome criteria in obese patients admitted to Pediatric Clinic for diagnostic procedure. Materials and methods: There were 112 obese (mean BMI 31.4) aged 10-17 years patients admitted foe diagnostic procedure to Department of Pediatrics. The detailed anthropometric measurements (included BMI, central obesity), biochemical tests and blood pressure monitoring were carried out in all patients. IDF 2007 definition was applied for diagnosis. Results: Metabolic syndrome was confirmed in 10.7% with male predominance 16.6% vs. 3.8%. The elevated values of blood pressure were found in 23.2% (28.3% boys vs. 17.3% girls), dyslipidemia concerning triglycerides in 8.9% (13.3% boys vs. 3.8% girls) and low HDL-cholesterol in 6.3%. Impaired glucose tolerance was observed in 5.3%. Conclusions: The differentiation of the frequency certain metabolic syndrome’s criteria in regards to sex suggests unequal influence of genetic and/or environmental factors. The most important risk factors in our patients seemed to be visceral obesity and hypertension.

Keywords: metabolic syndrome, diagnostic criteria, obesity, cardiovascular risk
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Evaluation of the nutritional state and body composition in adolescents aged 16-18 beginning professionally designed fitness program
Pediatr Med rodz Vol 5 Numer 4, p. 259-263
ABSTRACT

Introduction: The obesity epidemic has begun in the 80s and is still spreading which makes it a serious social and medical problem for the contemporary world. WHO stated that obesity is a chronic disease which requires complex treatment (special diet, change in a life style, physical activity). Both, individual workout performed on the aerobic equipment and resistance training, are crucial for obesity treatment. Propagating healthy lifestyle and proper eating habits among the whole nation is the basis for preventing and curing obesity and overweight. Aim of paper: The aim of the research was to evaluate the diet and the body composition in a group of adolescence, aged 16-18 beginning yearly professionally designed fitness program. Material and methods: The group of 90 girls and 64 boys began a specially designed fitness program which lasted 12 months. The nutritional state together with the body composition was evaluated with the use of bioelectrical impedance method (equipment InBody 220, producer Biospace). Results: The average BMI of the beforehand mentioned group was 23.3 [kg/m2] in girls and 24.4 [kg/m2] in boys. Although the BMI was close to normal the average amount of body fat was too high in girls (28.7%). In the group of girls the BMI showed a proper weight, however the amount of body fat was too high, it was suggested that the amount of fat tissue was decreased while the amount of skeletal muscles was increased. These data show that the proper body proportions were shaken. Conclusions: Professional equipment used for evaluation of the body composition helps to create a detailed program for fat reduction and muscle tissue growth together with creating a professional individual training program.

Keywords: fitness, obesity, cardio training, functional training, plyometric training
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The clinical investigation and echocardiography value in accuracy of Marfan’s syndrome diagnosis
Pediatr Med rodz Vol 5 Numer 4, p. 264-270
ABSTRACT

Introduction: Marfan’s syndrome is a heritable multisystem connective tissue disorder resulting from mutations in the gene for fibrillin-1 (FBN1). This disorder shows a high degree of clinical variability both between and within families. Affected patients are at risk for severe skeletal, cardiovascular and ocular problems. The diagnosis is usually based on clinical features. Material and method: We reviewed the clinical and molecular data of 8 patients who was hospitalised in Paediatric Cardiology Department in Katowice. There were 5 boys and 3 girls, 9-17 years old, referred for FBN1 analysis because they fulfilled the diagnostic criteria for Marfan’s syndrome. The clinical diagnosis and the family history was made by the criteria of the Ghent nosology. Mutation analysis of the FBN1 gene were identified by DHPLC screening of all 65 exons and adjacent intron sequences, followed by direct sequencing of aberrant fragments. Results: All of the patients presented typical clinical manifestation of Marfan’s syndrome. There was no child with the neonatal Marfan's syndrome. Four of them, including 3 persons who were siblings, had a positive family history. Pathogenic mutations were found in the 4 patients and probably pathogenic mutations in the 4 patients too. Conclusions: The clinical diagnosis using the Ghent nosology corresponds to the molecular analysis. Specific genetic tests are difficult of access and expensive so they are not necessary in patients who fulfilling the diagnostic criteria for Marfan’s syndrome.

Keywords: Marfan’s syndrome, children, Ghent nosology, molecular diagnosis
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Assessment of preventive oral health program in patients with mental retardation
Pediatr Med rodz Vol 5 Numer 4, p. 271-275
ABSTRACT

The purpose of the study was to evaluate the efficacy of the program by assessing the caries prevalence DMFT (decayed, missing and filled teeth) and periodontal status CPITN (community periodontal index of treatment needs) indices. Fissure sealant retention was also assessed in vivo. Material and method: Preventive program consisted of supervised tooth brushing twice a day, tooth brushing with Duraphat paste (Colgate-Palmolive, Poland Sp. z o.o.; concentration of fluoride 5000 ppm), on 10 occasions over a year and sealant application to sound posterior teeth. For fissure sealing two different materials: Fuji VII and Helioseal F, were used by means of a split-mouth model. Altogether 87 teeth were sealed in 15 female patients age 16 to 25. A full oral examination was carried out before initiating the program and after two years of its application. Results: The preliminary examination showed a high (8.24) mean DMFT, a high (52.08%) percentage of bleeding quadrants and 22.2% calculus presence. After this 2 year preventive program no caries was detected in the fissure sealed teeth and material was present in 90.7% of those sealed with Fuji VII and 83% with Helioseal F. Bleeding and calculus presence decreased to 42.8% and 20.8% respectively. Conclusions: A combination of topical fluoridation and fissure sealing appears to be an effective method of caries prevention in people with mental retardation.

Keywords: developmental disability, oral health, dental sealants, glassionomer cements, composites
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Hibernating myocardium as a probable cause of ventricular arrhythmia in a 17-year-old male patient – a case report
Pediatr Med rodz Vol 5 Numer 4, p. 276-280
ABSTRACT

Ventricular arrhythmias represent one of the most essential problem in paediatric cardiology because of different aetiology and hemodynamic consequences, sometimes leading to cardiac sudden death. Premature ventricular contractions are often caused by an underlying disease e.g. myocarditis, cardiomyopathy, tumours of heart, myocardial ischemia, congenital and acquired heart diseases. Ventricular arrhythmia is common after cardiac surgery, particularly in specific cardiac abnormalities, such as tetralogy of Fallot. Simple ventricular arrhythmia may be seen in routine resting electrocardiograms in children with normal cardiac findings. There are usually isolated monomorphic premature ventricular contractions, sometimes in the form of couplet-triplet but even nonsustained ventricular tachycardia can be recorded. This paper presents case of asymptomatic ventricular arrhythmias in a 17-year-old male patient with signs of hibernating myocardium in myocardial perfusion scintigraphy.Authors pay attention that even though ventricular arrhythmia seems to be innocent, arrhythmogenic substratum always should be searched.

Keywords: ventricular arrhythmias, myocardial perfusion scintigraphy, hibernating myocardium, children
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Breath holding spells in a 13-month-old girl, improvement during iron supplementation – a case report and a literature review
Pediatr Med rodz Vol 5 Numer 4, p. 281-285
ABSTRACT

Breath holding spells (BHS) are observed in otherwise healthy infants and preschool children. Attacks are typical. They begin with crying usually caused by anger, less commonly by minor trauma. Then they are followed by noiseless state of expiration, with typical change of skin colour, loss of consciousness and postural tone. In severe cases, associated with central nervous system ischaemia, convulsions appear (severe breath holding spells). BHS are frequent reason for referring children to paediatric cardiologist or neurologist to exclude heart disease or epileptic seizures. BHS are divided into three types depending on colour of the skin during the attack: pallid, cyanotic or mixed. Their aetiology is still unclear. Autonomic nervous system dysregulation may play an important role in the pathophysiology of BHS. Several reports suggest the association between iron deficiency and increased frequency of BHS. We present a case of 13-month-old child referred to the cardiology clinic with a three months history of numerous syncopes. During one of the spells, 24-hour holter ECG monitoring showed 16-seconds of asystole. In our patient Iron therapy reduced number and severity of the breath holding spells during 10 months follow-up period.

Keywords: breath holding spells, asystolia, anaemia, iron supplementation, permanent pacing
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Pacemaker implantation in patient with Morgagni-Adams-Stokes syndrome mimicking epilepsy
Pediatr Med rodz Vol 5 Numer 4, p. 286-290
ABSTRACT

We present a case of 70 years old man with heart conduction disturbances in whom neurological disorder has been previously recognized. The principal causes of loss of consciousness are vascular, cardiac and neurological disorders, rarely metabolic and psychogenic causes occur. In more than ten per cent the cause is not recognized. Diagnosis is based mainly on clinical history, physical examination and noninvasive diagnostic tests, also specialist evaluation. In some cases invasive tests are conclusive. Typical symptoms accompanied by loss of consciousness, such as rapid onset, presence of prodromal signs, cyanosis or pallor, seizures and urinary incontinence, are not specific and can occur in all cases with different intensification, not depending on the cause. In the current case in our patient the presence of convulsive syncope mimicking epilepsy in clinical presentation caused a delay of proper cardiologic diagnosis. The final diagnosis was based on clinical evaluation and noninvasive diagnostic tests. The confirmation of diagnosis was recording total A-V block without substitute rhythm in 24-h Holter monitoring during a syncopal episode. In a patient with trifascicular block in ECG and syncope without other cause of events should be implanted pacemaker according to the Guidelines of the European Society of Cardiology of 2007. A loss of consciousness is an important clinical problem because they are relatively frequently in a daily practice, they are associated with injuries and they can lead to invalidity or event a death of a patient. In most cases even not clear cause can be recognized thanks to diagnostic tests and experience of a doctor and their knowledge of EBM.

Keywords: loss of consciousness, seizures, heart conduction disturbances, complete atrioventricular block, cardiac pacing
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Behçet’s disease in a 15 years old boy: case report
Pediatr Med rodz Vol 5 Numer 4, p. 291-295
ABSTRACT

Behçet’s disease (BD), usually occurring in eastern Asia, the Middle East and eastern Mediterranean, is rarely reported in children in Central and Northern Europe. The disease can be diagnosed on the basis of certain symptoms according to international criteria, when other explanations are not available or convincing. BD is characterized by a triad of recurrent aphthous stomatitis, genital ulceration, skin and eye lesions. The aetiology is unknown, but systemic vasculitis is the main pathology. Case report: A 15 years old male was found to suffer from recurrent oral and scrotal ulcerations and episodes of acute epididymitis of unknown origin. In the course of the disease, an episode of erythema nodosum was also noted. On ophthalmologic examination, hypopyon and acute uveitis were reported. The patient fulfilled the criteria for BD (Criteria of the International Study Group for the Diagnosis of Behçet’s Disease, 1990). Although the clinical course of the disease was typical for BD, the diagnosis was formulated only after about 12 months. Conclusions: BD is incidentally reported in children in Central Europe although this type of vasculitis plays an important role in the differential diagnosis in patients with recurrent oral and genital ulcerations.

Keywords: Behçet’s disease, children, systemic vasculitis, diagnostic criteria, clinical signs
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55 years old patient with lung cancer – diagnostic problems
Pediatr Med rodz Vol 5 Numer 4, p. 296-300
ABSTRACT

Lung cancer is the most common neoplasm on over the world and remains the leading cause of cancer death in both men and women. The predominant cause of lung cancer is exposure to tobacco smoke. The methods using for diagnosis and monitoring of the disease are based on radiological, cytological and histopathological examinations. The prognosis for survival in lung cancer is very poor which is mostly caused by late diagnosis when the disease gets the last phases. The prevention methods used for early detection of lung cancer include X-ray chest examination, cytological sputum examination and chest computer tomography (CT). In that article we present the case of history of 55 years old patient, heavy smoker, who was admitted to the hospital because of tumour of right lung and right hilus showed on chest X-ray. The bronchoscope revealed extended changes in bronchium for the left lower lobe, which were not present on chest X-ray but only in later done CT. If there were no changes in right lung, probably the diagnostic examinations in that patient, with high risk of lung cancer, would be performed much later. That is because the present guidelines do not recommend that low-dose CT should be used to screen for lung cancer.

Keywords: lung cancer, bronchoscopy, computer tomography
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Schwartz-Bartter syndrome in patient with small cell lung cancer
Pediatr Med rodz Vol 5 Numer 4, p. 301-304
ABSTRACT

The lung is the most common site of cancer in the world today and it has a poor survival rate. The best way of reducing the lung cancer occurrence is giving up the habit of smoking. It is necessary to establish routine ways of early diagnosis according to clinical symptoms and chest radiography in general practice. It is said to be a main key of right timing of the adequate therapy. In a minority of patients with tumours, signs and symptoms develop that cannot be explained on the basis of either the mass effect produced by the primary tumour (or its metastases) or the production of a hormone normally associated with the tissue type that has given rise to the malignant tumour. These are known as paraneoplastic syndromes and may cause various symptoms. They may lead also to hyponatremia via the ectopic production of ADH. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is an important and common electrolyte disorder in tumour patients and one that has been reported in association with small cell lung cancers (SCLC). Schwartz et al. presented the first clinical case of a patient with ectopic SIADH in 1957, when he described two patients with lung cancer who developed hyponatremia associated with continued urinary sodium loss. We describe the patient with small cell lung cancer with SIADH. In chest radiogram as well as in computed tomography the pathological mass was described, later diagnosed as SCLC. The patient developed different neurological and psychical disorders that partially were improved after treatment.

Keywords: lung cancer, Schwartz-Bartter syndrome, hyponatremia, neurological disorders, paraneoplastic syndromes
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