2011, Vol 7, No 3
Treatment of patient after myocardial infarction
Pediatr Med rodz Vol 7 Numer 3, p. 186-198
ABSTRACT

Coronary artery disease (CAD) or ischaemic heart disease caused by atherosclerosis is the most common form of cardiovascular disease. CAD leads to acute coronary syndrome which is the clinical syndrome caused by new or growing interruption or occlusion of blood supply to a part of the heart, causing heart cells to die and myocardial infarction. Patient after myocardial infarction is at great cardiovascular risk and has high possibility of next cardiovascular incidents, such as myocardial infarction, stroke or cardiovascular death. Correct treatment of patient after myocardial infarction facilitates cardiovascular risk reduction and improves the prognosis. Secondary prevention after myocardial infarction includes non-pharmacological management– modification of life style – and pharmacological treatment. The most important is elimination of risk factors: smoking cessation, proper control of blood pressure, normalization of cholesterol level, reduction of overweight and regular physical activity. Patient awareness and physician commitment are essential for achieving beneficial effects of secondary prevention after myocardial infarction. This paper describes the recommendations for patient after myocardial infarction as far as non-pharmacologic and pharmacologic treatment according to contemporary guidelines are concerned. There are specific situations, such as concomitant diseases: hypertension, diabetes, left ventricle dysfunction and heart failure, chronic kidney disease, chronic obstructive pulmonary disease that require modified approach.

Keywords: management after myocardial infarction, medical therapy, secondary prevention, diabetes, other concomitant diseases
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Pulmonary hypertension in children – symptomatology, diagnostics and treatment based on European Society of Cardiology guidelines. National Health Fund’s Program
Pediatr Med rodz Vol 7 Numer 3, p. 199-207
ABSTRACT

Pulmonary hypertension (PH) is a rare, incurable disease. In children, its most common form is the pulmonary arterial hypertension (PAH), caused by congenital heart diseases or occurring as the idiopathic/hereditary type. Pathological alterations are localised in peripheral pulmonary arteries and the mechanism responsible for their initiation is not entirely known. Pulmonary hypertension remains asymptomatic or oligosymptomatic for a long period of time. Its diagnosis and the determination of its aetiology require detailed diagnostically procedures, including: physical examination, transthoracic echocardiography, electrocardiography, chest X-ray, and finally, catheterisation of the “right heart” as a test necessary for the final confirmation of the diagnosis. Expanded diagnostic tests help to establish the causes of PAH. To determine the advancement stage and progress of the disease not only the clinical examination is vital, but also the results of a 6-minute walk test, echocardiography, haemodynamics and biochemical markers. Based on the advancement stage of the disease and the reactivity of pulmonary arteries, an appropriate therapeutic approach involving general guidelines, pharmacotherapy and possible interventional treatment is implemented. Currently applied pharmacotherapy does not allow the patient’s complete recuperation. However, due to the early determination of the diagnosis and faster implementation of specific therapy, the quality of life may be markedly improved. This may also decelerate the occurrence of complications, progress of the disease as well as decreased mortality. If pharmacological approach does not yield satisfactory results, palliative invasive treatment in the form of balloon atrioseptostomy or, ultimately, lung or lung and heart transplant should be considered.

Keywords: pulmonary hypertension, guidelines, children, diagnostic, treatment
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Treatment of haemangiomas in children with propranolol – a review
Pediatr Med rodz Vol 7 Numer 3, p. 208-211
ABSTRACT

Haemangiomas are the most common tumours of early childhood, affecting up to 10% of infants. Their natural history is very specific, leading to spontaneous resolution in 76% of patients by age of 7 year. Haemangiomas has been considered only a temporary cosmetic defect without an indication for any sort of treatment. On the other hand, many cases of haemangiomas leading to serious or deformity, due to particular location or caused complications. Haemangiomas, complicated by an to ulceration or bleeding, interfering with vital function, or causing a visible or predictable disfigurement are an indication for an early treatment. Treatment of these haemangiomas should be initiated early to prevent further growth and related complications. The method choice depends on numerous factors as child’s age, tumour localization or haemangiomas growth rate. In infants and children surgical treatment is of limited value. Such procedure could be considerate if tumour size allows to its complete resection or for removing of scars and another residual changes. Until recently steroids were the firstline in the treatment in children in complicated haemangiomas. Local steroid therapy is recommended in haemangiomas localized around eyes, nose and mouth. Actually it seems that propranolol plays a major role in treatment of haemangioma. The authors have focused in their review on clinical aspects of application of propranolol in children with haemangiomas presenting current treatment schedules and recommendations.

Keywords: haemangioma, infant, child, treatment, propranolol
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Allergen-specific immunotherapy in children
Pediatr Med rodz Vol 7 Numer 3, p. 212-217
ABSTRACT

Allergen-specific immunotherapy (ASI) allows for a treatment and influences on the course of, the allergic, IgE-dependent diseases. ASI induces allergen tolerance resulting in a reduction or disappearance of clinical symptoms of allergy. One hundred years ago, in 1910 exactly, Noon published his landmark study. Since then, the knowledge of its mechanisms, indications for ASI and routes of administration of allergen is systematically being broaden. Currently used forms of allergens allow to minimize serious side effects related to the ASI, which were observed in the initial trials of therapy. This paper presents current views on the pathomechanisms of immunotherapy, rules for an application of immunotherapy and possibility of using ASI in atopic diseases. The main reason for this form of a treatment is inability to eliminate the allergen from patient’s environment with a high probability of severe clinical symptoms after contact with the allergen. The best results are achieved in case of hypersensitivity to hymenoptera venom and treatment of allergic rhinitis, allergic conjunctivitis and asthma associated with allergy to grass pollen, trees, weeds and dust mites. Treatment of monoallergy gives better results compared to the sensitisation to multiple allergens. For some of the cases, due inability of pharmacotherapy or its ineffectiveness, one could consider usage of ASI for patients with allergy tied with other allergens. Currently this method is not approved for the treatment of food allergy. This paper quotes meta-analysis, carried out in recent years, evaluating the efficiency of the most popular current methods of immunotherapy – subcutaneous (SCIT) and sublingual (SLIT) – in the treatment of asthma and allergic rhinitis. The publications cited below clearly show that these methods are effective in reducing and eliminating allergy symptoms. This paper presents the latest promising route of administration allergen – percutaneous immunotherapy, particularly beneficial for younger patients. In the era of great advances in medicine, we can expect further improvements of ASI, elimination of serious side effects and widening group of patients eligible for this form of therapy.

Keywords: allergy, immunotherapy, subcutaneous immunotherapy, sublingual immunotherapy, pathogenesis
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Autoimmunological diseases in medical practice
Pediatr Med rodz Vol 7 Numer 3, p. 218-222
ABSTRACT

Autoimmunological diseases are becoming more common in everyday medical practice. It is a group of diseases which originate from coincidence of genetic and environmental factors. Autoimmunisation is an immunological reaction directed against organisms own antigene or group of antigenes. It is attributed to loss of distinguishing of own and else antigenes, which leads to destruction of body tissues. There are two main patomechanisms responsible for destruction of cells and tissues: cellular and humoral. Synergy of those mechanisms is responsible for occurrence of symptoms. Autoimmunological diseases occur in 3-8% of world population, more often in women. In recent years incidence of these diseases has been steadily rising. Occurrence increases with increase of latitude. They are characterised by chronic course with remissions and flares. They can result in disability or even death. Most diagnoses are established between puberty period, and retirement, so it affects mostly working people. Recently it has been noted that more than one autoimmunological disease can occur in one patient. This realisation can set physician on right course of diagnostic-therapeutic process, which facilitates right diagnosis and introduction of adequate treatment, which will hasten improvement of patients’ health and reduces sick absence. This paper is to remind of possibility of simultaneous occurrence of more than one autoimmunological disease.

Keywords: autoimmunological disease, autoimmune polyglandular syndrome, antibodies, epitopes, antigens
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Premedication for little invasive procedures performed in paediatric practice
Pediatr Med rodz Vol 7 Numer 3, p. 223-228
ABSTRACT

Assessing of possible profits and endangers of premedication performed for little invasive procedures in paediatrics are goal of this work. Lack of researches in that direction, made to base on researches concerning premedication of children for general anaesthesia and surgical procedures, there are various methods of sedation of children with applied with various drug used traditionally in anaesthesiological practice. Midazolam is best researched drug. On that issue it can be administrated trough IV, orally, rectal or with usage of transmucosal routes, nasal, sublingual or with usage of application on anterosuperior aspect of the child’s tongue route. All these methods gave similar sedation effect vs. placebo, but were variously tolerated by children depending on route of administration. Oral and rectal administration demands higher doses, which gave prolonged sedation effect and requires more time to achieve proper sedation. Transmucosal application methods allowed reduction of total dose, similar to intravenous route, and allowed early sedation onset. Lack of children cooperation makes sublingual route difficult to perform. Nasal route gave better effects, but in was poorly tolerated by children. It seemed technically more difficult to administrate drug through aliquots doses on anterosuperior aspect of the child’s tongue, but it appeared to connect advantages and eliminate disadvantages of previous forms of drug administration. Usage of opioids adapted in children premedication don’t seem to find usage in sedation of children in paediatric ward due to post operational tendency to cause nausea and vomiting, and appearance of respiratory disorders connected with these drugs usage. Usage of proper monitoring and preservation of safety precautions should be obligatory, due to adverse event including death of patient connected with irresponsible usage of sedation drugs by unprepared medical personnel and lack of preservation of safety precautions while dealing with children. Further research are necessary to set proper guidelines for premedication for little invasive procedures in paediatric practice.

Keywords: premedication, sedation, anaesthesiology, paediatrics, midazolam, opioids
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Acute kidney injury in children treated in intensive care unit – a prospective epidemiologic analysis
Pediatr Med rodz Vol 7 Numer 3, p. 229-235
ABSTRACT

Introduction: Acute kidney injury (AKI) is common in hospitalised in intensive care unit (ICU) patients. The reported prevalence of AKI in critically ill patients ranges from 5% to 31% in adult ICU and from 4.5% to 10% in paediatric ICU. The incidents of AKI in ICU depend on several reasons, such as the hospital reference level and structure (surgery clinics and A&E units). Aim of the study: Assess the prevalence of AKI in critically ill children in multidisciplinary hospital with nephrology unit. Methods: We performed a prospective, descriptive epidemiological study assessing incidence of AKI in paediatric ICU patients. The research was conducted over a 1/2-year period. All consecutive admissions to the PICU were included unless they met one of the exclusion criteria, i.e. age <4 weeks of birth, >18 years of age, brain death at entry, expected PICU stay of <24 hours. Patients were classified according to RIFLE score. Results: Acute kidney injury occurred in 13.1% of admissions. The main reason of admission when AKI occurred was congenital heart defect after cardiac surgery (88.5% cases). The mortality rate of patients who met RIFLE criteria for acute kidney injury was 34.6%. Renal replacement therapy was implemented in 30.7% cases of AKI (peritoneal dialysis and continuous venovenous hemodiafiltration) with mortality rate of 88.8%. Conclusions: The study has revealed that the szpitaprevalence of AKI in PICU in multidisciplinary hospital is high with significantly poor outcome. In such a place close interdisciplinary treatment including full availability of renal replacement therapy is a must.

Keywords: acute kidney injury, children, intensive care, epidemiology
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Utility of abdominal ultrasound as a screening test in children
Pediatr Med rodz Vol 7 Numer 3, p. 236-240
ABSTRACT

Abdominal ultrasound is extremely useful in paediatrics. It can be used not only to diagnose diseases but also as a screening test. Objectives: The aim of this study was to prove that abdominal ultrasound in children can be used as a screening test. Methods: One hundred seventy-five children were examined. These were patients who never had such a test before; 29% of them were infants, 71% constituted children over 1 year. Results: In 14% of examined children abnormalities were detected. The most common anomaly was renal dilatation. The abnormalities in abdominal ultrasound were found in 19.3% of examined girls and in 10.3% of boys. Among the infants it was 27.4% and among children over 1 year – 9.7%. Discussion: In examined group of patients significantly more abnormalities were detected in group of children under 1 year. Taking sex to consideration, major percentage of anomalies were found in girls. Big group constituted patients with renal dilatation and patients with double kidneys. One of conducted exam detected abdominal tumour that didn’t show any symptoms. Summation: It is reasonable to use the abdominal ultrasound in children as a screening test in their early years, because it helps to diagnose a variety of conditions and congenital disorders that unfold furtively and don’t show any symptoms.

Keywords: abdominal ultrasound, children, screening test, congenital disorders, abdominal tumour
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Congestive heart failure – optimal treatment according to contemporary guidelines – the case report
Pediatr Med rodz Vol 7 Numer 3, p. 241-246
ABSTRACT

Coronary artery disease (CAD) or ischaemic heart disease caused by atherosclerosis is the most common form of cardiovascular disease. CAD leads to acute coronary syndrome which is the clinical syndrome caused by new or growing interruption or occlusion of blood supply to a part of the heart, causing heart cells to die and myocardial infarction. Myocardial infarction destroys normal myocardium and leads directly to heart failure. This paper describes the case of male patient who in the age of 56 suffered from huge myocardial infarction, which caused important heart contractility disturbances, essential reduction in ejection fraction and provoked symptomatic heart failure. Despite fast revascularization and optimal pharmacotherapy patient remained in class III NYHA classification. As the next step in therapeutic procedure patient underwent the implantation of cardioverter-defibrillator with cardiac resynchronization. After 2 years from this procedure big clinical progress was observed. Now patient remains in class I NYHA classification. Also improvement of left ventricle function in echocardiography was observed. Correct qualification to applied treatment determined its safety and legitimacy, and resulted in good clinical effect of treatment the patient with heart failure. Such effectiveness is very important for the patient’s follow-up and good prognosis due to cardiovascular risk reduction.

Keywords: myocardial infarction, heart failure, cardioverter-defibrillator, cardiac resynchronization therapy, CRT-D
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The course and diagnosis of EBV infections in children – clinical observations
Pediatr Med rodz Vol 7 Numer 3, p. 247-252
ABSTRACT

Epstein-Barr virus (EBV) infections in children are usually asymptomatic and occur in almost the entire population. If the infection occurred at a later age, in adolescents and adults, it can lead to infectious mononucleosis (IM). A typical symptom is long-lasting fever, which is of concern, especially in younger patients and those who do not respond to antibiotic therapy. The paper presents the characteristics, epidemiology, and pathophysiology of EBV infection. It is described both common and rare features of the most common form of symptomatic infections – infectious mononucleosis. IM is suspected primarily in children with fever, sore throat and enlarged lymph nodes, liver and spleen. EBV infection can cause mucocutaneous manifestation, weakness and myalgia; hepatitis is relatively less common and can lead to liver failure. Laboratory diagnosis is primarily an assessment of morphology and peripheral blood smear, with the presence of the predominant atypical lymphocytes. Evaluation of serum transaminases level (elevated in infectious mononucleosis), and serological tests for the presence of antiviral antibodies are also crucial. If the heterophil test is negative in the patients with symptoms suggesting IM, one should carry out EBV-specific antibody tests. Antibodies to viral capsid antigen (VCA) appear as the first. The paper reports three cases of infectious mononucleosis and diagnostic problems associated with them.

Keywords: Epstein-Barr virus, infectious mononucleosis, diagnosis, lymphadenopathy, fever
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Diagnostic and clinical difficulties in the patient with staghorn urolithiasis in the course of cystinuria – case report
Pediatr Med rodz Vol 7 Numer 3, p. 253-256
ABSTRACT

Cystinuria is a metabolic disorder leading to urine excretion of large amounts of cystine. Autosomal recessive genetic disorder is characterised by an impaired transport of cystine located in the proximal renal tubule and gastrointestinal tract. Cystine reaches high concentration within the urine and is insoluble enough to form stones. For diagnosis important are positive family history, the cyanide-nitroprusside positive test result and determination of cystine excretion in 24-h urine collection. Diagnosis can be confirmed by microscopic urine examination, which reveals typical hexagonal cystine crystals. Genetic tests can also be performed, but they are not necessary to plan treatment. Stone analysis should be performed, but we should keep in mind that all patients may form stones of compositions other than cystine. Treatment should be performed throughout patients life. Nevertheless recurrence rate is up to 60%. Recommended is low salt diet, urine alkalinization to pH values at least 7.5, application of chelating agents if the cystine excretion exceeds 3 mmol/day. Most cystinuria patients require multiple urological interventions with minimal invasive methods. We present here diagnostic and therapeutic difficulties in patient with cystinuria.

Keywords: cystinuria, staghorn urolithiasis, diagnosis, treatment, ESWL
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Hypocalcaemia accompanied by mild immune deficiency and lesions in central nervous system – case report of primary hypoparathyroidism
Pediatr Med rodz Vol 7 Numer 3, p. 257-260
ABSTRACT

Introduction: There is a huge variety of hypocalcaemia aetiologies. Out of all these reasons hypoparathyroidism is one of the rarest. The most common cause of this malfunction is accidental excision of parathyroid gland during thyroid gland surgery. Inflammation or metabolic disorders are very rare. When we diagnose hypoparathyroidism, polyendocrine syndromes must be always taken into account and we are obliged to check whether other endocrine glands work properly. Hypocalcaemia can be asymptomatic. However some most common signs of this disorder are: laryngospasm, muscle cramps (especially during physical effort), tetany, nutritional problems among infants, convulsions, paraesthesia, Trousseau and Chvostek symptoms, longer QT>450 ms. Aim of the study: We present the case of 8 year old child suffering from idiopathic hypoparathyroidism, epilepsy and immune deficiency. This case is quite interesting as the most spectacular hypocalcaemia symptom which tetany is, was initially taken for epilepsy. Epilepsy was diagnosed after the boy choked because of the braces which misplaced during the night. As a result his central nervous system suffered from short-lived oxygen deficiency. Maybe these two diseases (hypoparathyroidism and epilepsy) coexist or epilepsy was just a mask of severe hypocalcaemia? Conclusions: Diagnosing epilepsy we cannot omit tests concerning calcium and phosphate blood levels.

Keywords: hypocalcaemia, hypoparathyroidism, epilepsy, immune deficiency, children
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Cerebral sinus thrombosis in the course of nephrotic syndrome – a case report
Pediatr Med rodz Vol 7 Numer 3, p. 261-264
ABSTRACT

The aim of the case report is presentation of a rare complication of nephrotic syndrome in form of cerebral sinovenous thrombosis. Ten years old boy, who had been suffering from nephrotic syndrome (biopsy showed minimal changes disease) since he was two, was admitted to the hospital in heavy clinical status with headache, vomiting, disorder of speech and consciousness. Relapse of the nephrotic syndrome began about 2 weeks earlier with heavy proteinuria. Then he was treated by high-dose of steroids (prednisone 40-60 mg/d). Because of changes in the clinical status (aphasia, stereotypic movements without sinus of local brain lesions) the computer tomography was performed. It confirmed only cerebral oedema (near subcortical nuclei). MRI revealed a thrombosis in the left sigmoid, transverse and rectus sinus. Heparin therapy was started and was continued by low molecular weight heparin and oral anticoagulants. Patient required also an intubation for 7 days. Complete renal response was achieved 16 days after admission. Described complicated relapse of nephrotic syndrome didn’t cause any neurological defect in 24-month observation period. Nephrotic syndrome is associated with increased risk of thromboembolic complications. Cerebral sinovenous thrombosis is rare but required increase diagnostic vigilance, because the course is very serious. Early diagnose and intensive therapy enable recovery without any permanent neurological disorders.

Keywords: nephrotic syndrome, cerebral sinus thrombosis, complications, anticoagulative treatment, immunosuppressive treatment
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Medical problems of aggression and violence in children in family
Pediatr Med rodz Vol 7 Numer 3, p. 265-270
ABSTRACT

Violence is a timeless process going beyond ethnic, racial, age, national, socioeconomical limits and conditions. CBOS (Polish Public Opinion Research Centre) data shows that every five Pole beats children once a month or more frequently. Over 25% of teenagers meet violence in their families. The basic problem which does not allow to estimate the size of phenomenon completely is notification of violence cases to the law enforcement bodies – only every seven case is reported to the police in the USA, in Poland the notification is much lower. The effects of hurting a child remain in physical and mental sphere for long years. In such children speech defects, weepiness, fearfulness, oversensitivity or indifference, lack of reaction on an adult’s smile or voice, backward of motricity development, sleeping and eating disorders are usually observed. Children experiencing violence complain much more frequently about ailments such as stomachache, headache, infections of urinary system, traumas, asthma, recurrence of airway infections, vomiting, bed-wetting, period disorders. Emotional disorders provoked by violence are also defined as post-traumatic stress disorder syndrome (PTSD). From a psychiatric point of view in a child or an adolescent experiencing the long-term trauma it leads over time to complex post-traumatic stress disorder (DESNOS). Whereas traumatic events connected with parents’ alcoholic problems experienced in childhood cause syndrome of psychopathological symptoms and behaviour disorders called Adult Children of Alcoholics (ACoA).

Keywords: aggression and violence in family, children’s mental and somatic state, children’s development, DESNOS, ACoA
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Hypromellose in pharmaceutical technology of capsules and other medicinal product dosage forms
Pediatr Med rodz Vol 7 Numer 3, p. 271-276
ABSTRACT

Hypromellose – hydroxypropyl methylcellulose (HPMC) – is a semisynthetic polymer produced by chemical modification of the naturally occurring cellulose. HPMC have been used as thickening and gelling agent, carrier, stabilizer, bulking agent, binder, rheology modifier and adhesion increasing agent. Progress in pharmaceutical technology of medicinal product dosage forms leads to frequent use of HPMC, not only as a substitute for gelatin in capsule technology, but also as a polymer, which is able to develop new modified and controlled release dosage forms. Hypromellose capsules are manufactured using similar technological devices to traditional gelatin capsules. The main advantages of HPMC capsules over gelatin capsules could be because of their low moisture, non susceptibility to proteolytic degradation, and non-animal source. HPMC capsules for enteric and colonic delivery are claimed by using coating polymeric materials of different pH-solubility. Hypromellose are used to production of capsule shells in capsule-in-capsule technology. HPMC capsules are recommended for use in dry powder inhalers, especially for hygroscopic materials. This is because the HPMC capsules have relatively very low moisture content in comparison to gelatin capsules. The aim of this paper is to review the properties and applications of hypromellose, particularly with attention to HPMC use in pharmaceutical technology of capsules and other medicinal product dosage forms.

Keywords: hypromellose, capsules, pharmaceutical technology, modified release, Polish Pharmacopoeia
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