2011, Vol 7, No 4
Sequential differential diagnosis in patients with chest pain
Pediatr Med rodz Vol 7 Numer 4, p. 295-303
ABSTRACT

Chest pain is the most common cause of medical referral. Is one of the cardiac problems symptoms but it can be associated with other organs damage or failure. The prompt and accurate initial diagnosis is crucial to select high-risk patients and to commence appropriate management. The ability to distinguish the chest pain provoked by important cardiac disease from similar symptoms triggered by other organs disorders depends on clinical experience of the doctor and also on the skill to perform differential diagnosis. In the diagnostic workup it is necessary to take into account the chest pain characteristics, duration of chest pain, triggering and relieving factors. The symptoms and signs that may accompany the chest pain are of utmost importance as well as the results of accurate and specific diagnostic examinations. The life-threatening diseases are: unstable angina and myocardial infarction, aortic dissection, pulmonary embolism. After the above are excluded one should consider other causes such as pulmonary, gastrointestinal and musculoskeletal diseases. This paper outlines the sequential differential diagnosis of the most common causes of chest pain with the special emphasis of life-threatening disorders. Each described disease is thoroughly discussed including the chest pain characteristics, the most common accompanying signs and symptoms and the results of important and necessary examination, that allow to establish the correct diagnosis and to start the appropriate management.

Keywords: chest pain, myocardial infarction, aortic dissection, pulmonary embolism, pneumothorax
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Diagnosis and treatment of arterial hypertension in children and adolescents – what’s new?
Pediatr Med rodz Vol 7 Numer 4, p. 304-309
ABSTRACT
Hypertension begins in childhood and adolescence. Elevated blood pressure contributes to the early development of cardiovascular disease. It is important to develop guidelines on the optimal detection and management of arterial hypertension in this age group. Until recently general practitioners, paediatricians and other healthcare providers based on American guidelines published in 2004 by National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents in “Pediatrics” (Task Force). This guidelines presented hypertension definition in children and adolescents, determined methods of blood pressure measurement, diagnostic range and methods of treatment. In 2009 European Society of Hypertension recommendations on management of high blood pressure in children and adolescents were published in “Journal of Hypertension”. In Poland results of OLAF project were published in 2010. They present percentile values of blood pressure, height and weight as well as BMI, of Polish population aged 7-18 years. In United States, although they did not published another Task Force report yet, we can find new modifications of guidelines in recently published literature. We present here current knowledge about applicable recommendations.
Keywords: hypertension, risk factors, aetiology, treatment, diagnosis
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Combined therapy of arterial hypertension
Pediatr Med rodz Vol 7 Numer 4, p. 310-318
ABSTRACT
Primary arterial hypertension is a long-lasting elevation of blood pressure above the accepted numbers. It is one of the most common causes of mortality in the world. Not until the complications occur it may be symptomless, furthermore it coexists with other cardiovascular risk factors such as metabolic disorders. The aim of medical treatment is to reduce hypertension but also eliminate the risk factors by encouraging changes in the patient’s lifestyle (non-pharmacological actions) and introducing proper therapy. According to Polish Hypertension Society there are five major groups of hypotensive drugs. These are: thiazide diuretics (thiazide-like preferred), betaadrenolytics (vasodilatators preferred), calcium channel antagonists (dihydropiridine preferred), angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. Drugs from the groups above may be used as a monotherapy and also in various specific combination. In the uneventful hypertension the hypotensive therapy should be started from single medication chosen from five main groups of drugs, which have proved favorable influence on the reduction of cardiovascular mortality. But the majority of treated population needs more than one drug to control the hypertension. Then it is necessary to start the combined therapy and use medication in connections with regards to the favorable synergic and additive mechanism of action of each active substance. The remarkable advantages in efficiency, blood vessels protection and avoiding side effects are reached with the combination of angiotensin converting enzyme inhibitors and dihydropirydyne calcium channel antagonist. In the combined therapy it is always necessary to take into account the use of combined pill, because it essentially improves the effectiveness of hypertension treatment and raises the compliance.
Keywords: arterial hypertension, cardiovascular risk, pharmacotherapy, combined therapy, synergism
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Biomarkers of kidney injury
Pediatr Med rodz Vol 7 Numer 4, p. 319-325
ABSTRACT

Acute kidney injury (AKI) is a syndrome defined by acute increase of serum creatinine or decrease in glomerular filtration rate (GFR). AKI is common in patients undergoing cardiac surgery, imaging modalities and endovascular procedures with using iodinated contrast, those who suffer from sepsis and other critically ill patients. Serum creatinine, the current main diagnostic test for AKI, rises late in AKI pathophysiology and is not precise marker of acute changes in glomerular filtration rate. The serum creatinine measurements are confounded by a large number of variables, including age, gender, race, muscle mass, muscle metabolism, hydration status and medications. New studies presented laboratory markers of AKI detected in serum and urine. These include cystatin C, NGAL, KIM-1, L- FABP, IL-18 and others. These new biomarkers offer promise for early AKI diagnosis and for the depiction of severity of renal injury occurring with AKI. They can reflect the progression of AKI to chronic kidney disease (CKD). The aim of this article is to review specific biomarkers for early detection of AKI and progression to CKD.

Keywords: urinary biomarkers, acute kidney injury, chronic kidney disease, diagnostic test, NGAL
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Neutrophil gelatinase (NGAL) in acute kidney injury in children after cardiopulmonary bypass
Pediatr Med rodz Vol 7 Numer 4, p. 326-331
ABSTRACT
Acute kidney injury (AKI) is a frequent complication of cardiopulmonary bypass. The paucity of early, predictive, non-invasive biomarkers has impaired our ability to institute potentially effective therapy as soon as possible. The most promising new biomarker is neutrophil gelatinase-associated lipocalin (NGAL). The aim of the study was to assess the urine and serum level of NGAL in children undergoing cardiopulmonary bypass (CPB) due to severe congenital heart disease. Material and methods: We prospectively studied 48 children (17 girls and 31 boys) after CPB, which were divided in two group: with and without acute kidney injury defined as a 50% increase in serum creatinine from baseline. Serum and urine samples were collected before and after 2, 4, 12, 24, 48 hours of the CPB beginning. Results: Twenty-four (54%) children developed AKI. Serum NGAL rose from 26 ng/ml at baseline to 60 ng/ml after 2 and 65 ng/ml after 4 hours post-procedure outstripping creatinine rise (12 hours). Serum concentration was not different in both group (AKI and non-AKI). Urine concentration of NGAL rose in differently in both group (AKI, non-AKI) in 2 (median 62 vs 27 ng/ml; p=0.01) and 4 hours (median 28 vs 13 ng/ml; p=0.056). Conclusion: Urine and serum concentration of NGAL raises in children undergoing cardiopulmonary bypass. NGAL can be useful as a early biomarker of acute kidney injury.
Keywords: acute kidney injury, neutrophil gelatinase-associated lipocalin, children, cardiopulmonary bypass, cardiac surgery
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The reasons for cardiologic consultations during duty – analysis of own material
Pediatr Med rodz Vol 7 Numer 4, p. 332-337
ABSTRACT
The aim of the study: Analyse the causes of children sent to cardiologic consultations during the duty. Material and methods: The study group consists of 432 children (226 girls and 206 boys, average 9.8 years), which in 2009-2010 were sent from emergency ward to cardiac consultation. The basic study of the circulatory system was performed: physical examination, electrocardiogram and echocardiogram. In some patients there were additional blood samples for laboratory tests and chest radiographs performed. The results were analysed in age groups (infants, younger children and older children) as well as in the category of symptoms that were the reason for referral (syncope, fainting, chest pain, symptoms of heart defects, arrhythmia, hypertension). Results: The most common group were older children (257 cases – 60%) and sequentially 96 younger children (22%) and 79 infants (18%). In the category of symptoms the most frequent cause of cardiologic consultation of older children were fainting (which was found in 126 patients – 30% among all directed to the consultation) and the chest pain that occurred in 109 children (23%). In the youngest group the most common congenital heart disease was suspected. Other symptoms such as hypertension, arrhythmia, and myocardial disease occurred less frequently. Conclusions: The heart defects were the most common cause of referrals to cardiology consultation in infants group, while in the group of older children the main cause of referral were fainting and chest pain. Urgent hospitalisation was required only by more or less 10% of patients referred for cardiac consultation, within infants who required it five times frequently than children over 10 years of age.
Keywords: cardiologic consultation, children, emergency ward, chest pain, syncope
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Prophylaxis and non-pharmacological management in children with primary hypertension – the role of nurse
Pediatr Med rodz Vol 7 Numer 4, p. 338-343
ABSTRACT
Primary hypertension (PHT) is increasingly recognized in children and adolescents. There is usually a prehypertension or the first stage of the hypertension. As in adults it is associated with obesity, lifestyle and family having the disease. Organ complications states in more than 40% of the children already at the time of diagnosis of the disease. In PHT therapy important role take up non-pharmacological proceedings related to the modification of lifestyle and health-related behaviours. It is used in children with recognized prehypertension as the only form of therapy, but in confirmed hypertension as a complementary treatment. Not easy process of changing the lifestyle requires cooperation of health professionals with patients and their families. A special role in the non-pharmacological proceedings should take a nurse because of the direct and continuous contact with patient and their guardians. Detailed monitoring of people with recognized hypertension and prehypertension is necessary. It is also important to promote healthy lifestyle, early identification children’s risk of cardiovascular system diseases and taking up adequate interventions in appropriate time. In this paper rules of overweight/obesity (dietary changes, physical activity), sleep irregularities, behaviour disorders (type A behaviour) prophylaxis and treatment has been described. Also the negative impact on the development of the PHT by stimulants which adolescents use has been highlighted. Rules of the cooperation between nurse and PHT affected, which is crucial for effectiveness of decisions taken, has been shown. Necessity for health education in educational institutions and after – school activities has been underlined as well.
Keywords: primary hypertension, children, prophylaxis, non-pharmacological management, nurse’s role
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Endoscopic ultrasonography application in esophagus lesions diagnostics and therapy qualification
Pediatr Med rodz Vol 7 Numer 4, p. 350-355
ABSTRACT

Endoscopic ultrasonography – EUS is the imaging procedure that combines endoscopy and ultrasonography. Submucous tumour means lesion protruding to gastrointestinal tract lumen with normal or pathologically changed mucous membrane. Location of such lesions is gastrointestinal tract wall but could be the result of extraintestinal lesion pressure. In presented study our main aim was to assess the diagnostic yield in submucous lesions, esophagus wall thickening and surface roughness diagnostics with use of endoscopic ultrasonography. We analysed 47 patients (24 male and 23 female) hospitalised in Military Institute of Medicine in Warsaw between 2009 and 2011 because of esophagus lesion diagnosed in upper gastrointestinal tract endoscopy. In all patients endosonography was performed. In 27 cases (57%) organic lesion was diagnosed in gastrointestinal tract wall. In 4 cases (9%) organic lesion localised outside of a gastrointestinal tract and in 16 cases (34%) normal anatomical structures were found. On the basis of ultrasonography procedure result patients were qualified to surgical, endoscopic or oncology treatment. All lesions of rough surface require further diagnostic procedures and qualification to endoscopic or surgical procedures because of high risk of malignancy. All submucous lesions appeared to be non-malignant lesions and as such do require endoscopic or ultraendoscopic surveillance.

Keywords: submucous lesion, tumour, endosonography, endoscopy, esophagus lesion treatment
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Smart drugs – a new threat to the adolescents’ health
Pediatr Med rodz Vol 7 Numer 4, p. 356-360
ABSTRACT

Smart drugs haven’t disappeared from Polish market and from young people’s live despite of becoming illegal in 2010. Today, the Internet offers to the teenagers at east eight Polish-language e-shops with cheap handling and shipping to Poland. Composition of the smart drugs is not fully recognized, because is constant changing. In offer we can find it as drought plants (such as Spice), tablets (party pills), powders. It is selling as a collectibles, not for human consumption. Smart drugs include both synthetic chemicals and powdered seeds or drought plants known as a strong psychostimulants or hallucinogens. It imitates the effect of taking popular drugs as marijuana, opium, amphetamine or ecstasy. Like other psychostimulants can cause addiction with long-term use, or can leads to experiment with “hard drugs”. In addition to stimulating, relaxing, hallucinogenic activities, smart drugs cause many side effects from both groups of mental and serious somatic disorders, can leads to serious disturbances of consciousness, arrhythmias or respiratory distress. The clinical diagnosis is based on clinical symptoms and information of the unknown substance ingestion. Due to the lack of specific antidotes, the treatment is only symptomatic and supportive virtual functions. The psychological or psychiatric consultation is often needed.

Keywords: smart drugs, psychoactive substances, hallucinogens, Internet, poisoning
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The occidental and intentional intoxications as a reason of hospitalisation in The Department of Paediatrics and Developmental Disorders of Children and Adolescents, The Children’s Teaching Hospital of The Medical University in Bialystok in 2006-2010
Pediatr Med rodz Vol 7 Numer 4, p. 361-365
ABSTRACT
Introduction: Poisoning in children and adolescents is a serious clinical, psychological and legal problem.
The growing among of young patients accidental and intentional intoxicated is recorded in Europe. The group of small children is dominated by accidental poisoning, and a leading problem among teenagers becomes suicide attempts, experimenting with drugs, narcotics and alcohol. Objectives: The objective of this study was a retrospective analysis of hospitalization, which was caused by poisoning, drugs, narcotics and ethanol intoxication during the years 2006-2010, in The Department of Pediatrics and Developmental Disorders of Children and Adolescents, The Children’s Teaching Hospital of The Medical University in Bialystok. The analysis included age, sex, place of residence, the nature of poisoning (accidental, intentional), the type of xenobiotic. On the basis of psychological and/or psychiatric consultation intentional poisonings were selected from a suicide and narcotic attempt. Results: During 5 years, at the Clinic was hospitalized amount of 305 children from 6 weeks to 18 years caused by acute xenobiotic intoxication, including 95 of accidental poisoning, 210 intentional poisoning. Boys accounted for 34% (n = 104) patients, 66% girls (n = 210). Conclusions: During the 5-year follow-up significantly increased the number of patients hospitalized at the Clinic because of poisoning. The most common reason was the consumption of medical drugs. The incidence of poisoning was related to age, gender and place of residence. The largest group was consisted of 16 years old girls living in urban areas.
Keywords: poisoning, xenobiotic, suicide attempt, psychoactive substance, gastric lavage
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Occurrence of caffeinism features in adolescents and young adults declaring frequent consumption of soft drinks containing caffeine
Pediatr Med rodz Vol 7 Numer 4, p. 366-371
ABSTRACT
Introduction: Over the past few years there has been a significant increase in consumption of caffeinated beverages,especially among children and adolescents. This trend is worrisome, and numerous studies point to the negative impact of excess supply of caffeine on various aspects of human functioning. In order to analyse this problem a proper study was conducted which aim was to assess the problem of addiction to caffeine among adolescents and young adults with particular emphasis on the characteristics of people declaring frequent consumption of soft beverages. Material and methods: Based on the review of literature about caffeinism authors constructed a questionnaire survey and identified the following inclusion criteria: 1) declaration of consuming soft beverages, 2) age 13-30 years. Diagnostic survey was conducted on a group of 118 people. Demographic variables were also controlled. Results: The most frequently declared potential symptoms of caffeinism were: headache, irritability and explosiveness, sleep problems, insomnia, palpitations and accelerated heartbeat, but these results differed within age groups. Conclusions: Excessive intake of soda products and exposure to high doses of caffeine can be an important environmental factor in the formation and maintezawierająnance of chronic diseases and addictions, also can be associated with poor dietary behaviours. Therefore it is important to prevent and rise awareness of children, adolescents and their parents about the dangers of excessive supply of products containing caffeine as well as further research on the effects of caffeine on the psychophysical functioning in this age group.
Keywords: caffeine, caffeinism, youth, addictions
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Internet addiction (netaholics) in the secondary school adolescents – impact on the health and psychosocial skills
Pediatr Med rodz Vol 7 Numer 4, p. 372-377
ABSTRACT

Introduction: The dynamic of the rapid development in informative and media areas nowadays have changed the form of functioning in modern world. The good example for this phenomenon is Internet. Widespread access to Internet has been available only for about 20 years but its impact is clearly noticeable in almost each aspect of the life in the whole society. The children and adolescents constitute the most vulnerable group to be subject for Internet usage. The misuse of Internet might be hazardous to their somatic health and psychosocial development, including the risk of Internet addiction. Objectives: The assessment of the potential risk of Internet addiction in secondary school pupils. Methods and material: The group of 102 (43% girls, 57% boys) adolescents aged 17-19 years (mean age 18,3) assessed by the Kimberly Young’s Test and the original questionnaire. Results: There was found that 20% of examined youth meet the inclusion criteria for the risk group of Internet addiction. More then 20 hours a week being online declared 22% and the boys prevailed in this group 78% vs. 22% girls respectively. There was observed the tendency to prolong online time in spite of the previous planning, This reduced the active forms of spending leisure time and limited the direct communication within the peers’ group. The analysis of the kind of activity online revealed the differences related to sex. The boys preferred computer games 59% and visiting erotic websites 10%. Among the girls the most popular were website with music 70%, Internet searching engines 55%, auction portals 50% and chat rooms 50%. More than 30% of the respondents have suffered of somatic symptoms due to the prolonged computer usage. Conclusions: The misuse of the Internet causes the negative outcomes concerning the somatic and psychosocial aspects of the health in the adolescents. There is necessity of developing the wide media education as the tool for the prophylaxis and hazardous Internet usage by the adolescents.

Keywords: Internet, addiction, netaholics, adolescents, internet activity forms
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The estimation of AMOKSIKLAV QUICKTAB safety profile in outpatient setting
Pediatr Med rodz Vol 7 Numer 4, p. 378-388
ABSTRACT
Introduction: Amoxicillin and clavulanic combination possess bactericidal effect against many bacterial species. Amoksiklav QUICKTAB , combining these two substances in oral dispersible tablets, is a new form. The aim of the study was to analyse this confection safety profile and tolerance in Polish population outpatient setting. Material and method: The retrospective observational study governed data from Amoksiklav QUICKTAB adult patients treatment realized in outpatient setting. The demographic and anamnestic data ecommended control visit, self-estimated treatment tolerance and patient’s compliance. Data obtained were statistically analysed with Statistica 9.0 PL software. Results: In 76% of cases Amoksiklav QUICKTAB was recommended in upper respiratory tract infections, over 8% of total cases it was the second antibacterial cure. The most often regimen was 2×1000 mg per 7 days. A control visit was recommended in over 70% of patients, more often in the elder ones. Then 90% of patients reported drug usage straight to recommendation. Most of patients tolerated this formulation very well or well. Adverse effects were registered in less than 2% of cured patients with mild intensity in a half of them, there were no side effects another from previously described. Conclusions: Amoksiklav QUICKTAB in dose of 650 mg and 1000 mg is a safe formulation. It does not cause any other side effects than previously recorded for such combination of active substances. The treatment is mostly well tolerated, the tolerance is connected with the age of patient and concomitant diseases. Oral dispersible tablet is more preferable by the older patients.
Keywords: amoxicillin/clavulanic acid, oral dispersible tablets, post-marketing study, safety profile, outpatient setting
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The use of loratadine in the therapy of ambulatory patients aged from 2 to 18 years
Pediatr Med rodz Vol 7 Numer 4, p. 389-393
ABSTRACT
Background: Loratadine, a histamine H1 receptor antagonist of II generation, is used in allergic diseases therapy in adults and children older than 2 years. The aim of this study was to analyse the therapeutic indications, efficacy and tolerance of loratadine in the outpatient paediatric population. Material and methods: Forty-four thousand seven hundred and thirty patients aged 2-18 years, treated with loratadine participated in the survey. Results: Indications for loratadine were: chronic allergic (23%) or seasonal (52.5%) rhinitis, chronic idiopathic urticaria (15%), acute respiratory tract infections (3.9%), asthma (1.9%), atopic dermatitis (1.9%), acute urticaria (1.4%) and nasal polyps (0.4%). Syrup was most commonly used in children younger than 12 years with body mass below 30 kg (48.8%), while tablets – mainly in bigger children (in 65.5% of children younger than 12 years with body mass over 30 kg and in 98.2% aged 13-18 years). Ninety-seven point four percent patients followed the therapeutic recommendations during the follow-up. In the remaining group (2.6%) were using drug irregularly, discontinued treatment after symptoms subsided or due to adverse reaction. Loratadine was effective (at least moderate improvement achieved) in 94.6% patients with seasonal allergic rhinitis, in 90.3% cases with chronic allergic rhinitis and 87.8% with chronic idiopathic urticaria. Intolerance was found in 9% of patients, most often in children younger than 12 years with body mass below 30 kg (18.1%). Conclusions: 1) Loratadine is mainly used in children for therapy of seasonal allergic rhinitis. 2) It is effective in seasonal and chronic allergic rhinitis and chronic idiopathic urticaria therapy. 3) The symptoms of intolerance are most common in young children.
Keywords: loratadine, children, therapeutic indications, efficacy, tolerance
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Calcium-phosphate balance in dialysed children within first two years of dialysis
Pediatr Med rodz Vol 7 Numer 4, p. 344-349
ABSTRACT

Introduction: The calcium-phosphate metabolism play an important role in the live of children deciding on the structure and growth of the skeleton. Calcium-phosphate disturbances are serious complication in children with chronic kidney disease during dialysis. Objective: The aim of the study was to assess calcium-phosphate disturbances in dialysed children in the first two years of renal replacement therapy. Material and methods: The study group consisted of 32 patients, 25 male (78%) and 7 female (22%), including 27 peritoneal dialysis (84%) and 5 (16%) – hemodialysis patients. Age of children at the inclusion of renal replacement therapy ranged from 1 month of age to 235 months of age. The study was conducted as a retrospective analysis of medical records of patients in the dialysis center for children. The period of analysis covered the years 2000-2011 and referred to indicators of calcium-phosphate homeostasis, the clinical markers of osteodystrophy, clinical data in the 3-month intervals and also assessed available pharmacological treatment. Results: We didn’t observed significant differences in the most of analyzed parameters in calcium-phosphate homeostasis. Mean values of these indices for two years of analysis remained at the recommended level. Only the alkaline phosphatase activity rose during the observation period as the concentration of bicarbonate did. Among the phosphate binders, calcium carbonate was used most frequently. The percentage of patient treated with active metabolites of vitamin D increased significantly up to 100%. Conclusions: The efficacy of treatment of calcium-phosphate metabolism in children on dialysis is sufficient to maintain the recommended values of all biochemical indices in minority of patients. They require significantly higher number of drugs. However, clinical consequences of renal osteodystrophy were rare in the study period.

Keywords: dialysis, children, osteodystrophy, parathyroid hormone, parathormone, complications
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Atopic dermatitis – a report of severe case at 7-year-old girl – case report
Pediatr Med rodz Vol 7 Numer 4, p. 394-400
ABSTRACT

Atopic dermatitis (AD) is a chronic, inflammatory dermatological disease with intermittent course, very dry skin and pruritus. Prevalence rates for atopic dermatitis in children is increasing and range from 1 to about 20%. The previous studies indicates that genetic factors, environmental factors, infectious factors and immunological mechanisms are important in the pathogenesis of atopic dermatitis. Depending of the child’s age we can distinguish three stages of the disease. Typical affected skin areas in infants include the face, chest and extensor surfaces of the extremities whereas in the older children lesions are seen mostly over the flexor surfaces (antecubital and popliteal fossa) around the wrists and ankles. The earliest lesions are in the form of papules with erythema and exudation, but with time it forms crusted plaques and repeated rubbing of the skin makes lichenification. The diagnosis is based on clinical feature. Hanifin and Rajka Diagnostic Criteria listed below are the most commonly used one. These are also the criteria proposed by the American Academy of Dermatology in 2003. The disease is often accompanied by eosinophilia, elevated immunoglobulin E and positive skin prick tests. In the thesis we have presented the most frequent diseases requiring differentiation from AD. Treatment of atopic dermatitis includes systematic skin moisturizing and, in acute phase, the use of anti-inflammatory drugs (glucocorticosteroids and calcineurin inhibitors), antibacterial medications and anti-histaminics. The paper also discusses the severe form of AD proceeding with extreme eosinophilia and hypergammaglobulinaemia E in 7-year-old girl hospitalised in the Department of Paediatrics WIM.

Keywords: atopic dermatitis, hiper-IgE syndrome, seborrheic dermatitis, scabies, treatment of atopic dermatitis
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Chest pain – similar symptoms but different diagnosis and clinical outcomes – case reports
Pediatr Med rodz Vol 7 Numer 4, p. 401-408
ABSTRACT

Chest pain is one of the most frequent symptoms of cardiac disease, but it can be also provoked by other reasons. It is not easy to establish the cause of chest pain, nevertheless it plays a key role in the diagnostic workup. In the differential diagnosis first of all it is necessary to take into account the most common diseases and those which may be fatal or detrimental for the patient’s health. The most important are myocardial ischaemia and myocardial infarction. During the clinical assessment it is necessary to consider the possible reason of the chest pain originated deep from the chest (aorta, pulmonary artery, mediastinum, oesophagus, trachea, bronchi, pleura), from the chest wall (sensor nerves, chondrocostal junctions, spine, skin), from the abdomen (stomach, duodenum, pancreas, gall bladder) and also symptoms of psychological origin. In the diagnostic process it is necessary to take into account the chest pain characteristics, duration of chest pain, triggering and relieving factors and also coexisting symptoms. A subject with chest pain should be treated as a patient of high cardiovascular risk until the diagnostic management is terminated. The precise differential diagnostics allows to establish the correct diagnosis and to initiate the appropriate treatment. This paper describes five patients with a chest pain. Despite similar symptoms every patient has different disease and the clinical outcome was completely different in every case.

Keywords: chest pain, myocardial infarction, pericarditis, aortic dissection, pulmonary embolism
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Lyme borreliosis – not only endemic area disease – case report
Pediatr Med rodz Vol 7 Numer 4, p. 409-414
ABSTRACT

Lyme boreliosis is a multiorgan disease, transmitted by ticks, which is caused by the bacteria Borrelia burgdorferi. The increase of morbidity is recorded and the area of occurrence includes nowadays all territory of Poland. The clinical picture is very differentiated. Symptoms depend on the duration of illness and the level of involvement of different systems. The disease may affect the skin, joints, nervous system as well as the heart. Information about epidemiology, pathogenesis and virulence of Borrelia burgdorferi were presented. The authors disscused characteristic manifestations and methods of identification. Recommended antibioticotherapy was also taken into consideration, depending on the patient’s age and the stage of illness. In the article a 11-yearold boy’s case was presented. The child was admitted to hospital due to arthralgia, a characteristic circular rash and an episode of high fever. He had a history of a tick bite 5 weeks earlier. He did not travel outside Warsaw. Basic tests were performed and they did not show any abnormalities. Disseminated Lyme borreliosis with arthritis was diagnosed. Ceftriaxon was applied and resolution of symptoms was achieved. Later in the result for Borrelia burgdorferi infection a high level of IgM was indentified. After admitting full treatment a decreasing titer of antybodies was observed and the patient did not present any abnormal signs.

Keywords: Lyme disease, Borrelia burgdorferi, erythema migrans, ticks, Ixodes ricinus
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Legionella pneumophila infections – case report
Pediatr Med rodz Vol 7 Numer 4, p. 415-419
ABSTRACT

Legionella pneumophila is an intracellular pathogen which lives in the water environment. It invades human bodies through water aerosol inhalation, rarely through aspiration. It spreads out in the organism by blood, lymphatic system or through continuity. There are two forms of Legionella infections legionnaires disease and Pontiac fever. Extrapulmonary forms occur very rarely. Complications may occur as atelectasis, pleural effusion, adhesions, lung abscesses, pleural empyema, bronchopulmonary fistulas and in consequence even multiorgan failure. In the diagnosis of a Legionella infection isolation and microbial cultures, genetic methods and serological tests are used. In the treatment macrolides and in severe form fluorochinolons are efficient. Trimethoprim + sulfamethoxazole is an alternative treatment. In the article 14 years old boy case was presented. The child was admitted to hospital due to high fever, weakness, vomiting, headache and abdominal pain. Series of tests were performed to explain the cause of the ailments. Series of tests were performed to explain the cause of his complaints. High level of inflammation markers as well as leukopenia and thrombocytopenia were detected. Next there was a sudden onset of severe cough and a maculopapular rash. In additional tests involvement of the cardiovascular system was suspected. Due to suspected atypical infection macrolide was applied. The condition improvement and resolution of symptoms were achieved. Later the result for Legionella pneumophila infection was received and it indicated the possibility of this aetiology.

Keywords: Legionella, legionellosis, legionnaires disease, Pontiac fever, diagnostics of legionellosis
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Fundamental breastfeeding value for child health and development
Pediatr Med rodz Vol 7 Numer 4, p. 420-426
ABSTRACT

Breastfeeding is a gold standard of feeding newborn and infants that brings optimal somatic- psychomotor development and cognitive ability. Mother milk is species specific for human infants and also their irreplaceable, optimal food. Every child has natural right for his mother milk. The act of breastfeeding itself, as a mode of mother-infants interaction, may favour cognitive development. Taking milk directly from the breast has profound effects on both mother and her child. According to WHO and AAP recommendations breastfeeding should be the only food during first 6 months of life, and after introduction of complementary, solid food, this should be prolonged up to 12 months or longer. Unique value of mother milk depends on many specific bioactive agents that create requirement for optimal somatic and mental development. It is the most optimal food for brain development. Breastfeeding is irreplaceable source of immunoglobulins, bioactive growth promoters and anti-inflammatory agents, live activated leukocytes and immunomodulatory agents as well. Longchain polyunsaturated fatty acids (LCPUFAs) in human milk have an effect on the chemical composition of the brain and enhance retinal and cortical function. This immunological properties are not to reconstruct on the formula. Specific properties of mother milk could significantly prevent or reducing the death rate of children under five. In this article short survey of breastfeeding concerning papers and the most important WHO, UNICEF worldwide recommendations, programs, declarations and strategies on the promotion, protection and support of breastfeeding and International Code of Marketing of Breast-milk Substitutes are presented.

Keywords: breastfeeding, act of breastfeeding, immunological properties of mother milk, breastfeeding child’s development, International Code of Marketing of Breast-milk Substitutes
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