2013, Vol 9, No 1
Pharmacological therapy of non-variceal upper gastrointestinal bleeding
Pediatr Med rodz Vol 9 Numer 1, p. 15–24
ABSTRACT

Upper gastrointestinal bleeding is a common gastroenterological emergency requiring proper management and urgent treatment. The vast majority of these haemorrhages are due to peptic ulcers, erosive gastritis and esophagitis as well as oesophageal and gastric varices. Diagnostic and/or therapeutic endoscopy is recommended within 24 h of presentation in all patients with symptoms of upper gastrointestinal bleeding. Initial pharmacological treatment includes volume resuscitation, hemodynamic stabilization and proton pump inhibitor (PPI) (bolus 80 mg) administration prior to endoscopy to downstage the bleeding lesion. In patients on anticoagulants correction of coagulopathy is recommended prior to endoscopy. High-doses of PPI (8 mg/h for at least 3 days) administration after endoscopic haemostasis promote clot stability by sustaining intragastric pH above 6. H. pylori is the key factor in peptic ulcer development and eradication is recommended immediately after feeding is restarted. Presented management reduces rebleeding rate. Despite this upper gastrointestinal bleeding still carries considerable rates of complications and mortality. To aim of this work was to review the currently available guidelines and recommendations in pharmacological managing in patients with non-variceal upper gastrointestinal bleeding.

Keywords: upper gastrointestinal bleeding, proton pump inhibitors, Helicobacter pylori, peptic ulcer, prokinetic agents
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Noncardiac chest pain
Pediatr Med rodz Vol 9 Numer 1, p. 25–31
ABSTRACT

Chest pain is always a symptom that requires careful diagnosis, accurate collection of medical interviews with the patient and the medical examination. This is one of the most common symptoms, which causes the appearance of anxiety in patients and becomes the cause of the notification to the doctor or to the hospital. Chest pain is commonly attributed to heart disease. However the cardiovascular etiology of the above disorders is one of many others etiology. Chest pain, despite different etiology, may be similar in feature and location, as a result of similar nerve supply, anatomy and the location of various structures inside the chest. The source of chest pain may be all the structures inside the chest, except the lung-parenchyma, which doesn’t have the painful nerve endings. The basic element in the differential diagnosis of pain in this location is the exclusion of life-threatening conditions: acute coronary syndrome, aortic dissection, pulmonary embolism, and pneumothorax. A patient with a chest pain can both occur in the cardiologist and a gastroenterologist, but also in the family doctor, paediatrician,  pulmonologist, neurologist, surgeon, orthopaedist, rheumatologist, dermatologist and psychiatrist. This interdisciplinary nature of the problem led the authors to discuss this topic. In the study, we focused on describing the noncardiac chest pain and the use of modern methods of diagnosis, mostly in terms of the gastrointestinal causes. In this study, the authors didn’t analyse the cardiovascular aetiology of those diseases.

Keywords: chest pain, gastro-oesophageal reflux disease, oesophageal manometry, pH-metry of oesophagus, oesophageal motility disorders
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Aetiology, symptoms and treatment of the infective endocarditis according to European Cardiology Society contemporary guidelines
Pediatr Med rodz Vol 9 Numer 1, p. 32–40
ABSTRACT

The clinical manifestation of infective endocarditis is usually non-specific. The signs and symptoms may be due to various infections, auto-aggressive or rheumatologic diseases. In some cases symptoms of endocarditis can mimic neoplastic disease. It is essential to diagnose infective endocarditis correctly and start the treatment as soon as possible because the outcome of the disease may be severe or even fatal. The disease is caused by the vegetations, characteristic changes. Vegetation is a mass of different cells: platelets, inflammatory cells as well as fibrin and microorganisms. Lesions are usually found on the valves of the left heart and lead to local destruction of the inner layer of the heart muscle. Parts of vegetation may drift with the blood flow and become the cause of cerebral or peripheral thrombus. However neurological disorders such as temporary ischemic attack or stroke can by the first symptom of endocarditis, usually the disease starts with fever. Physician can also find a new murmur of valve regurgitation. It is important to emphasize that there is an growing number of endocarditis due to cardiosurgical and cardiological procedures, especially concerning prosthetic valve or permanent electrode implantation. Intravenous drug abuse by addicts also may lead to endocarditis, in those cases lesions are often found on the tricuspid and pulmonary valves. Generally the most common cause of infective endocarditis is Staphylococcus spp. Diagnosis of endocarditis is based on clinical investigation, echocardiography and blood cultures. Primary treatment consists of multidrug antibiotic therapy and has to be started as soon as possible. In some cases surgical intervention is necessary. As far as endocarditis is concerned it is also essential to know when patients should be given antibiotics as prevention treatment. The rules of prevention of endocarditis have changed many times for the last few years. In summary: although endocarditis is rare disease, it is often difficult to diagnose and may lead to death. Therefore it is important for physicians to have at least a basic knowledge of infective endocarditis.

Keywords: infective endocarditis, prosthetic valves, vegetation, prevention, antibiotics
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Significance of vitamin D in atopic disease in children
Pediatr Med rodz Vol 9 Numer 1, p. 41–45
ABSTRACT

Allergy constitutes an important problem in today’s world. Atopy, excessive IgE antibodies genetically determined production predisposition is usual basis for allergy. Atopic dermatitis, asthma, allergic rhinitis, allergic conjunctivitis, enteral allergy’s and nettle-rashes are the most common allergic diseases of child development age. Genetic factors, viral infections and environmental factors have proven influence in development of atopic diseases. Recently there is large interest in vitamin D3 (cholecalciferol) role in development of atopic diseases. Oral forms of vitamin D3 and its active metabolites and synthetic analogs are traditionally used to regulate calcium-phosphoric homeostasis. Vitamin D is typical inactive biologically prohormone created in skin tissues from steroid precursor. Two degrees of enzymatic hydroxylation (in liver and in kidneys) are needed to form main hormonally active form. 1.25(OH)2D is the most biologically active hormone. 25(OH)D and 1.25(OH)2D are marked in diagnostic goals. Large populations research point out strict correlation with long lasting vitamin D deficiency and metabolic disorders. Cholecalciferol serum deficiency increases autoimmune and infectious diseases risks. Vitamin D receptor (VDR) cholecalciferol stimulation is responsible for its actions exceeding mineral management. Children atopic diseases risk and low vitamin D pregnant women uptake correlation has been suggested. Recent researches show that cholecalciferol is autoimmune diseases immunoprotective factor, it limits Th1 immunological response and moves it into Th2 response domination. According to same quoted publications it appears that proper vitamin D supplementation can decrease risks of atopic and autoimmune diseases. There are also data suggesting increase of excidence of allergic diseases in case of excessive vitamin D supplementation.

Keywords: vitamin D, allergy, asthma, atopic, autoimmune reaction
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Application of twinkling artifact in ultrasonographic diagnostics of nephrolithiasis
Pediatr Med rodz Vol 9 Numer 1, p. 46–49
ABSTRACT

Twinkling artifact is a phenomenon used in ultrasound diagnostics including color Doppler. The look of the twinkling artifact depends majorly on the settings of the ultrasound scanner. This sign usually accentuates when the frequency of the transmitted ultrasonic beam is low and Doppler scale settings are high. Although this artifact is gaining more applications in ultrasound diagnostics, it is still unfamiliar phenomenon. It might be helpful in diagnostics of cholelithiasis and biliary lithiasis, adenomyomatosis and any parenchymal calcification in other organs. Application of twinkling artifact can also detect bowel gas or metallic foreign bodies. However, this artifact is used the most often to identify deposits in the urinary tract. Compared with X-ray of the abdomen and urography, ultrasonography with application of twinkling artifact can detect about 80% cases of urolithiasis. The concrement structure, its roughness and size are the most important factors involved in the development of this phenomenon. Twinkling artifact enables an early detection of calculus without acoustic shadow, deposits of small size and those located in the ureter. There is a suggestion that the presence or absence of color comet-tail artifact also depends on the chemical composition of the stone. Ultrasound enriched with application of the twinkling artifact should be an initial examination in the diagnostics of urolithiasis, in monitoring of the calculus evolution and in assessment of stones excretion after ESWL procedure.

Keywords: twinkling artifact, colour Doppler, abdominal ultrasound, nephrolithiasis, concrement
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Azithromycin in the treatment of pharyngitis and tonsillitis. From the point of view of bacteriologist and clinician
Pediatr Med rodz Vol 9 Numer 1, p. 50–56
ABSTRACT

Bacteriologist’s and clinician’s point of view to infection is variable. What about bacterial infection throat and tonsil? Characteristic: Bacteriologist: Acute pharyngitis and tonsillitis (APT) mainly caused by viruses (rhinovirus, adenovirus, influenza and parainfluenza viruses, RSV). Bacterial etiology is only in 10–30%. The most common bacterial etiologic factor is Streptococcus pyogenes. The gold diagnostic standard is the throat swab culture with antibiogram. Clinician: The infection usually occurs through droplets. The incubation period continues from 12 hours to 4 days. The diagnosis is based on symptoms: sore throat, fever, headache, malaise, slight enlargement of the cervical lymph nodes. On clinical examination: swollen and congested mucous membrane of the throat. Treatment: Bacteriologist: Correct swabbing the throat has a major impact on the entire diagnostic process. We take the swab from the surface or tonsil crypts. Swab is seeded and incubated at 35–37°C. The first assessment is in 18–24 hours. In the GP practice the rapid diagnostic tests (RADT streptococcal antigen detection clinic may be helpful. Clinician: the first step is limiting the spread of infec tion (elimination of contact), second – symptomatic treatment, if there is S. pyogenes etiology, the first-line treatment is fenoksymetylpenicylina (p.o. or .iv.) In case of hypersensitivity, macrolides should be used. Azithromycin: Bacteriologist: Azithromycin is macrolide, and including the spectrum of the most common pathogens causing pharyngitis and tonsillitis. Clinician: Azithromycin is an effective drug in APT, commonly used at a dose: in children (10 mg/kg once daily for three days), and adults (1×500 mg – three days). Recent studies suggest a better antibiotic activity double dose (cumulative dose – 60 mg/kg/treatment). These two approaches (bacteriologist and clinician) complement each other.

Keywords: pharyngitis, tonsillitis, symptoms, treatment, azithromycin
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Effectiveness of topically applied ketoprofen gel
Pediatr Med rodz Vol 9 Numer 1, p. 60–63
ABSTRACT

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in the management of acute and chronic pain. Conditions treated in this way include rheumatic diseases, and particularly degenerative disease, which is the third most common chronic disease in the general population. Selection of a NSAID requires consideration of several factors, e.g. patient’s age, type of pain (acute or chronic), coexisting diseases and concomitant medication. The incidence of degenerative disease increases with age, reaching 50–60% in persons over 75. In this age group, a frequent occurrence are comorbidities and comedications, which may considerably limit or even preclude systemic administration of NSAIDs. These patients may require – as first-line agents – topically administered NSAIDs. Ketoprofen gel provides the strongest analgetic and anti-inflammatory effect and a favourable safety profile. As concentration of the active substance in the skin, cartilage and meniscus is high and low in blood serum, ketoprofen is also recommended in the treatment of trauma pain.

Keywords: non-steroid anti-inflammatory drugs, degenerative disease, E2 prostaglandins, acute pain, chronic pain
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Pain control and pain intensity comparison in patients taking ketoprofen prolonged-release capsules with or without additional application of ketoprofen in the form of gel
Pediatr Med rodz Vol 9 Numer 1, p. 64–68
ABSTRACT

Pain is integral part of the human life. It is a common disease symptom manifested by most patients visiting clinics. It is a warning signal of a danger or a bodily injury. Occurrence of pain is associated with worse quality of life and negative emotions in the patient. Development of a pain-eliminating therapeutic option is still the biggest challenge to specialists. The purpose of this paper is to evaluate pain control and motor function control in patients taking ketoprofen in the form of prolonged-release capsules with or without applying additionally ketoprofen in the form of gel. The author discusses the efficacy of the pain therapy regime in two therapeutic groups. One group was given combined therapy with the use of ketoprofen in the form of both capsules and gel. The other group was given monotherapy using ketoprofen tablets only. Analysis of obtained results indicates that in both therapeutic groups, the effects of pain in major areas of the subjects’ lives have decreased significantly, their motor functions have improved, and they have gained a better control over pain. Improvement in the abovementioned aspects was however greater in the combined therapy group (capsule + gel). Analysis of the problem is presented basing on a research project conducted by the company Health Data Management in the time from February to July 2011. Data were collected with the use of a questionnaire survey. The study included 3129 patients and 214 physicians.

Keywords: pain control, motor function control, non-steroidal anti-inflammatory drugs (NSAID), ketoprofen, combined therapy
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Pertussis as a reason of cough in children hospitalised in Paediatric, Nephrology and Allergology Clinic, Military Institute of Medicine from 2009 to 2013
Pediatr Med rodz Vol 9 Numer 1, p. 73–77
ABSTRACT

A retrospective analysis of medical data of 157 children, suspected for pertussis, aged from 1 month to 17 years, hospitalised in Paediatric, Nephrology and Allergology Clinic, Military Institute of Medicine from January 2009 to March 2013 was undertaken. Information concerning age, sex, duration of cough, presented symptoms and laboratory tests results were analysed. Statistical analysis was performed using standard statistical software (Statistica PL). The significance level was set as p<0.05. Pertussis, as a reason of cough, was found in 31 cases. Statistical analysis showed no significant differences between patients with acute and chronic cough, as far as a frequency of pertussis infection is concerned. Gender was not associated with the pertussis infection (p>0.05). Occurrence of cough and apnea was strongly associated with positive pertussis serologic laboratory tests. The statistical significance between low amount of white blood cells and low Biernacki’s test rate and positive pertussis serologic laboratory tests was found. This finding does not fit to a classical course of disease. The reason of this discrepancy may be a fact, that in analyzed group only two children were not vaccinated (under the age of 2 months). The classical course of disease is observed only among unvaccinated patients. Among children diagnosed due to recurrent respiratory tract infections 8.3% had positive pertussis serologic laboratory tests.

Keywords: chronic cough, acute cough, recurrent respiratory tract infections, pertussis, apnea
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Aggression and violence in family and psychophysical development and public functioning of children
Pediatr Med rodz Vol 9 Numer 1, p. 78–86
ABSTRACT

Background: The violence happens in every social group with a comparable frequency Environmental differences concern only a way of displaying the violence, rather than its straining. It is a process which is constantly growing stronger, however, effects of the violence applied by the perpetrator depend on the age and the stage of the developmental child. Therefore the aim of the study was to get to know negative effects of aggression and violence in family on psychophysical development and social functioning of children. Material and methods: Examination research amongst 237 pupils at the age of 14, II class of three junior secondary schools of the Warmian-Mazurian province. Questionnaire for parents, children, teachers and pedagogues were used for examinations. Analysis of documentation from health centres, pedagogic-education, psychological, institutions dealing with problems of children (police, education centres, psychological clinics etc.) was conducted. Two psychological tests were also used. The method of a statistical analysis was accepted a method of the diagnostic survey. Results: Signs of violence and aggression in family were stated at almost a half of children of examined population. In addition only a half of children showed directly the presence of the phenomena. Violence and aggression in family twice more often regards girls than boys. It is associated with drinking problems. Correlations between the frequency of applying the violence towards the child and a spouse were noticed. It causes disorders of all aspects of life of the child increasing both morbidity and public functioning. There is a relationship between violence and factors such as: low social-economic status, the country environment and the unemployment. Conclusion: The results of examination have showed explicitly that aggression and violence in family exerts characteristic and adverse impact on all aspects of life of child. Increases both morbidity of children (somatic and psychophysical) which manifests mainly in the form of psychosomatic manifestations or family and public functioning.

Keywords: aggression, violence, family, psychophysical development, public functioning
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Infantile hypertrophic pyloric stenosis – case report
Pediatr Med rodz Vol 9 Numer 1, p. 87–90
ABSTRACT

Hypertrophic pyloric stenosis is one of the most common congenital defects in infants. The incidence of infantile hypertrophic pyloric stenosis (IHPS) is approximately two to five per 1000 births per year. IHPS is characterized by a progressive hypertrophy of pyloric muscle. Etiopathogenesis of this disease is still unknown. Abnormalities of ganglion cells development, increased local production of growth factors, altered nitric oxide production and genetic factors have been implicated in the pathogenesis. IHPS typically presents with progressive projectile vomiting leading to dehydration that usually commences between third and eighth week of life. Severe infection, disease with increased intracranial pressure, and metabolic diseases should be considered in the differential diagnosis. The classic hypochloremic, hypokalemic, metabolic alkalosis is not a common findings which may be due to more early detection rate of IHPS. Ultrasonography (US) is the standard diagnostic procedure. Pyloric thickness of 3 mm or higher and length of 15 mm or higher by ultrasonography is widely accepted as diagnostic criteria for pyloric stenosis. Pyloromyotomy by Ramstedt has been the standard treatment of IHPS, however laparoscopic pyloromyotomy is becoming more common. The paper presents a case of a 21-days-old newborn diagnosed due to intensive regurgitation, weakness and apathy.

Keywords: infantile hypertrophic pyloric stenosis, pyloric stenosis, pyloromyotomy, projectile vomiting, gastrointestinal motility
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Celiac disease – return to the years seventies. Eleven-month-old girl with celiac disease crisis – case report
Pediatr Med rodz Vol 9 Numer 1, p. 91–96
ABSTRACT

Celiac disease is an autoimmune disorder, which occurs not only in children’s population but also among adults. Its frequency permanently rise. The reason of celiac disease in an autoimmune process, which is began by contact of gluten from diet with mucous membrane in bowel. Clinical feature of celiac disease is very different, therefore it should interest physicians of various speciality. Often the symptoms are not from alimentary canal, which suggest to make the screening test on a larger scale. In diagnostics the genetic test HLA-DQ2/-DQ8 are more popular. The new guidelines made in 2012 suggest to begin the diagnostics with the genetic test in some cases. The main treatment of celiac disease is a gluten-free diet, which is based on elimination wheat, rye, barley and oat. The occurrence of gluten in great number of groceries, makes the diet extremely challenge for parents and patients. Only diet respected for whole life makes the chance of good function and grow. The paper presents the case report of 11-month-old girl at the time of diagnosis of celiac disease, with serious diarrhoea, peripheral oedema, dehydration, and severe electrolytes disturbances, which is a rare clinical manifestation nowadays. Such situation was common in the years seventies XX century, because gluten introduction into diet of the newborn was too early.

Keywords: celiac disease, gluten, diagnostics, HLA-DQ2/-DQ8, gluten-free diet
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Erythromelalgia – painful erythema of the extremities
Pediatr Med rodz Vol 9 Numer 1, p. 97–101
ABSTRACT

Erythromelalgia is a rare disease of unclear etiology, characterized by recurrent erythema, burning pain and warmth of the affected extremities. In erythromelalgia we can distinguish primary and secondary form. Secondary forms occur in the course of myeloproliferative disorders, systemic connective tissue disease, diabetes mellitus type 1 and 2, multiple sclerosis, neuropathies, infectious diseases, embolism, as well as trauma. Symptoms of EM result from pathological misdistribution of skin microvascular blood flow and dysfunction of adrenergic neurons. Primary EM develops due to mutation in SCN9A, the gene that encodes alpha subunit of the voltage-gated channel Nav 1.7. Erythromelalgia diagnosis based on clinical criteria. May the pain recurring character, usually occur symmetrically, often on the lower extremities than the upper, increases with increased ambient temperature during exercise, leaving the limbs down at night and after drinking alcohol. Only brings cool relief. Although described many trials of EM there is no conclusive data to support the efficacy of any of the drug. Due to the nagging aches and pains, and as a consequence of the significant impairment of the people affected by this disease erythromelalgia treatment focuses on the use of analgesics. In this paper authors reported 2 cases of primary familial erythromelalgia and difficulties with achieving a significant improvement with the currently available treatment, in an attempt to monitor the thermographic study treatment.

Keywords: erythromelalgia, erythema, limb pain, microcirculation, analgesia, thermographic examination
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Nutrition and fertility. Diet of women in the reproductive period
Pediatr Med rodz Vol 9 Numer 1, p. 102–106
ABSTRACT

Proper nutrition and lifestyle prior to and during pregnancy are extremely important for the developing foetus and influence the course of pregnancy and health of the pregnant woman. Currently, the age of women in the reproductive period varies between 15 and 49 years of age. Because the reproductive period spans such a wide age range, there are different problems typical for a given age, which affect procreation. It is of key importance that women planning to become pregnant change their lifestyles and follow a proper diet about six months before the conception. A rational diet should include five meals a day and be balanced in terms of nutritional value. The number of calories in the diet should be adjusted individually for each woman with regard to the type and frequency of physical activity. Special attention should be paid to variety in the diet. While selecting products for the diet, the following should be taken into consideration: allergy and intolerance, the necessity of using low-GI food. It is also important for a woman planning pregnancy to pay attention to the type of fat used. It is necessary to eliminate trans fats often contained in industrially-produced pastries, sweets, chips, fast foods, powdered soups, hard margarines. These fats should be replaced with products rich in mono- and polyunsaturated fatty acids. While choosing protein products women should include various sources of protein, both animal and plant. Thus, the diet should contain low-fat poultry, veal, as well as limited amounts of low-fat pork and beef, fish – mainly sea fish, eggs and leguminous plants (bean, pea, lentil, chick-pea, soya). Products rich in complex carbohydrates should make up more than 50% of the energetic intake. It is advisable to choose whole-grain bread, buckwheat, millet, pasta, cereals. The intake of protein, fat, carbohydrates, vitamins and minerals and fibre should comply with nutrition standards and be adjusted to vitamin and mineral deficiencies, age, physical activity. In case of a poorly balanced diet or vitamin and mineral deficiencies it is recommended to take advice from the doctor about the type of supplement and its dosage. Not less than three months before conception, each woman should take 0.4 mg of folic acid daily. In the period from September to April supplementation with vitamin D3 is also advisable. The dosage should be individually adjusted after testing D3 vitamin level in blood. A well-balanced diet provides the appropriate amount and quality of protein, fat, carbohydrates and fibre, and includes products being sources of vitamins and minerals. A diet rich in products containing B vitamins, folic acid and its derivatives, antioxidants, iron and deprived of excessive caffeine and alcohol seems to be of great importance in the prevention of infertility. For practical reasons, it is important that both doctors and other persons involved in the counselling related to period prior to pregnancy are aware of healthy eating habits and women’s needs for energy, nutrients, vitamins and minerals before conception.

Keywords: procreation, pregnancy planning, proper nutrition, balanced diet, risk factors for the development of abnormalities of pregnancy, complications of pregnancy
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