2013, Vol 9, No 2
What is worth to remember during long-term treatment with proton pump inhibitors?
Pediatr Med rodz Vol 9 Numer 2, p. 126–132
ABSTRACT

Proton pump inhibitors (PPI) are widely used to treat patients with acid-related disorders because they are generally perceived to be safe and effective. However, as with any pharmacologic agent, they have the potential for side effects. Most of them are a direct consequence of inhibition of acid production by parietal cells (hypochlorhydria or reflex hypergastrinemia), but idiosyncratic effects, immunosuppression and other effects have also been proposed. Potential adverse events associated with PPI therapy include vitamin and mineral deficiencies, association with community-acquired infections including pneumonia and diarrhoea, hip or vertebral fractures and osteoporosis. Many studies have examined the side effects of long-term exposure. Almost all the existing data in this regard are based on observational studies that are susceptible to bias and confounding. It is important to remember that all drugs carry risk and PPI should not be denied to patients who are likely to benefit from them because of concerns about putative side effects. They should only be prescribed when there is an appropriate clinical indication and clinical guidelines can help. The lowest effective dose of PPI should be used. In event of drug-induced hypomagnesaemia or acute interstitial nephritis discontinuation of PPI is crucial. A number of simple and potentially effective preventive measures can be recommended for some of the safety concerns, even if we do not fully understand the mechanisms of most PPI-related safety issues.

Keywords: proton pump inhibitors, side effects, interstitial nephritis, hypomagnesaemia
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Combined assessment of chronic obstructive pulmonary disease according to GOLD report 2011
Pediatr Med rodz Vol 9 Numer 2, p. 135–143
ABSTRACT

In this paper authors present a new approach to chronic obstructive pulmonary disease patients according to GOLD report 2011. Chronic obstructive pulmonary disease is a global health problem. The BOLD study proved that prevalence of it vary across countries and this disease will be the fourth leading cause of death in 2030. The main cause of chronic obstructive pulmonary disease is tobacco smoking. GOLD report 2011 recommends that a clinical diagnosis of a disease should be considered in patients presenting such symptoms as dyspnoea, cough, sputum expectoration as well as relevant exposure to risk factors with the presence of persistent airflow limitation confirmed by post-bronchodilat or FEV1/FVC < 0.70. The FEV1 is an inadequate descriptor of the impact of chronic obstructive pulmonary disease on patients. It is a complex and heterogeneous disease and that is why the validated tests are proposed – i.e. BODE index, ADO and DOSE – to examine the impact of chronic obstructive pulmonary disease on patients. GOLD report 2011 recommends the use of two validated tests: mMRC questionnaire and COPD Assessment Test (CAT). Spirometric values are classified as GOLD 1 and 2 (mild and moderate) and GOLD 3 and 4 (severe and very severe). Exacerbations of chronic obstructive pulmonary disease are based on the individual patient’s history or FEV1. Finally, the chronic obstructive pulmonary disease patients are classified to category A, B, C or D. Pharmacological treatment should be based on an individualized assessment.

Keywords: GOLD report 2011, chronic obstructive pulmonary disease (COPD), cigarette smoking, combined assessment of COPD, categories A, B, C and D of COPD
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Review: Borrelia burgdorferi diagnostic methods
Pediatr Med rodz Vol 9 Numer 2, p. 144–149
ABSTRACT

Lyme borreliosis is an infectious disease caused by Borrelia burgdorferi sensu lato spirochetes and is transmitted to humans by the bite of an infected tick from the Ixodidae family, e.g. Ixodes ricinus, Ixodes scapularis, Ixodes persulcatus. The same species are responsible for causing Lyme borreliosis: B. burgdorferi sensu stricto, B. afzelii, B. garinii, B. bissettii and B. spielmanii. The infection develops in stages and has various manifestations in the human body. Lyme disease mainly affects the skin, joints, the nervous system and the heart. Different species are bound with different clinical manifestations: Borrelia afzelii usually cause acrodermatitis chronica athrophicans, Borrelia burgdorferi sensu stricto is a common agent of arthritis, neuroborreliosis can be caused by B. burgdorferisensu stricto, B. afzelii and B. garinii. Lyme disease is diagnosed based on symptoms, epidemiological history and laboratory tests, e.g. serological tests of the serum or PCR tests from patient tissues or ticks. The most common diagnostic method is the one recommended by the Robert Koch Institute in Berlin. It is a two-stage procedure based on testing by screening assay in the first stage (EIA, IIFA, ELISA tests) and verifying positive and borderline results by Western blot tests during the second stage. Due to high antigenic variability, Borrelia burgdorferisensu lato spirochetes have an ability to avoid defence mechanisms of an infected organism. This is the main cause of problems with interpretation of the clinical symptoms, diagnostics results and also with treatment of this infection.

Keywords: antigens, Borrelia burgdorferi sensu lato, Borrelia burgdorferi, borreliosis, diagnostics, ticks
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The role of Oxalobacter formigenes in formation of stones in urinary system
Pediatr Med rodz Vol 9 Numer 2, p. 150–153
ABSTRACT

Urolithiasis is a growing problem. With the progress of civilization the disease affects more and more people. The most common cause of urinary tract stones are calcium oxalate deposits, which are mostly formed on the basis of metabolic disorders such as hypercalciuria and hyperoxaluria. The concentration of oxalate in the urine is an important risk factor for the formation of calcium oxalate deposits, because even slight changes in the concentration of oxalate in the urine have a greater impact on the crystallization than comparable changes in calcium concentration. Oxalate lithiasis may be caused by: oxalate metabolic disorder, excessive consumption or increased absorption of oxalate in the gastrointestinal tract. The cause of hyperoxaluria may be a genetic defect (primary hyperoxaluria) or a variety of absorption and metabolism of oxalate disorders in the intestinal tract, or the excessive consumption as a result of improper diet (secondary hyperoxaluria). Bacteria Oxalobacter formigenes – described in the 1980s – colonizes the human gut, using oxalic acid as the sole source of energy. Conditions in which there is a reduced colonization of the colon by this bacterium may promote hyperoxaluria. Studies carried out so far have shown that Oxalobacter formigenes lowers the concentration of oxalate in the intestine, the absorption is reduced, and this lowers the excretion of oxalate in the urine. In the application of this bacterium as a probiotic low oxalate diet is important. We can expect that in the future Oxalobacter formigenes will be used in the treatment of calcium-oxalate stones.

Keywords: calcium oxalate nephrolithiasis, hyperoxaluria, oxalate, Oxalobacter formigenes, low oxalate diet
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Comparison of the estimating glomerular filtration rate in children by different methods
Pediatr Med rodz Vol 9 Numer 2, p. 154–159
ABSTRACT

Assessment of glomerular filtration rate (GFR) is a useful way to assess renal function regardless of age. The gold standard is to measure GFR by isotope method, which in view of the considerable inconvenience for the patient and the high cost, is used only in special clinical situations. In clinical practice, the so-called estimated glomerular filtration rate (eGFR) is used, calculated from serum creatinine level based on one of the many available formulas. In adults, MDRD and Cockcroft-Gault formulas are the most common. In children the commonly used formula to estimate GFR is the Schwartz formula, calculation of which only requires the serum creatinine level and height of the child. The limitations of the methods are their lack of precision, especially in patients with normal or slightly reduced GFR. Recently, in the literature there appeared reports of alternative methods for calculating the estimated GFR. In this paper we compare different ways of calculating eGFR in children with normal or mildly impaired renal function. To calculate eGFR three models were used: the modified Schwartz formula, a new generalized quadratic model by Gao et al. and the height-independent model proposed by Pottel et al. The obtained values were compared with obtained values by glomerular filtration isotope method. The most similar results to the standard were in the group, in which eGFR was calculated by method of Gao et al.

Keywords: estimating glomerular filtration rate, creatinine clearance, children, chronic kidney disease, revised Schwartz formula
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Endoscopic ultrasonography in the diagnosis and treatment of duodenal lesions
Pediatr Med rodz Vol 9 Numer 2, p. 160–164
ABSTRACT

In presented study our main aim was to assess the diagnostic yield in submucosal lesions, duodenum wall thickening and surface roughness diagnostics with use of endoscopic ultrasonography. We analysed 41 patients (22 female and 19 male) hospitalized in Military Institute of Medicine in Warsaw between 2009 and 2012 because of duodenum lesion diagnosed in upper gastrointestinal tract endoscopy. In all patients endosonography was performed. In 32 (78.1%) cases organic lesion was diagnosed in gastrointestinal tract wall and in 9 (21.9%) cases normal anatomical structures were found. On the basis of ultrasonography procedure result patients were qualified to surgical, endoscopic or oncology treatment. In 20 (48.8%) cases the change was limited to the mucosa and submucosa and therefore subject to treatment/surveillance endoscopy. In other cases diagnosed infiltration beyond the muscle membrane (n = 21; 51.2%), qualifying of patients for surgery or oncology. Endoscopic ultrasound plays a key role in the diagnosis of submucosal lesions allow proper qualifications to appropriate treatment.

Keywords: submucosal lesion/tumour, endosonography, endoscopy, duodenum lesion
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The influence of regular physical activity on blood pressure and body composition in children attending sports school
Pediatr Med rodz Vol 9 Numer 2, p. 165–172
ABSTRACT

Introduction: Physical activity is considered to have influence on anthropometry and blood pressure. It is supposed that regular physical activity leads to better body composition and lowers blood pressure. The aimof the study: Evaluation of influence of regular physical activity offered by sports school on body composition and blood pressure in 14-year-old children. Material and methods: Twenty-five children from sports school participated in the study. Children were examined twice – interval was 12 months. Changes of anthropometric values, body composition and blood pressure values were analysed. Results: In whole group increase of systolic blood pressure was observed (p < 0.05), mainly in boys. Diastolic blood pressure didn’t change. Body composition changed negatively in whole group: fat mass increased (13% vs. 20%, p < 0.05), gain of fat mass was higher in girls (6% vs. 3%, p < 0.05). There was significant increase of BMI percentile in girls (37 vs. 49, p < 0.05), in boys this parameter didn’t change. Conclusion: Increased physical activity offered by sports school doesn’t improve nutritional status of 13–14-year-old girls and boys, whose body fat mass increase. School sport activity doesn’t reduce blood pressure in 13–14-year-old children, according to age standards. Centile values of boys systolic blood pressure were even higher.

Keywords: physical activity, blood pressure, body mass index, body composition, children
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Changes in resting electrocardiograms of young athletes after 8 months of physical training
resting ECG, cardiovascular adaptations to training, athletic training, adolescents, athletes
ABSTRACT

Introduction: Athletes often exhibit benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training. Cardiovascular examination of athletes (including ECG monitoring) is performed to take information about influence of physical activity on the functional conditions of circulatory system, and to identify underlying heart disease (especially in aspect of prevention of sudden cardiac death) requiring the extension of diagnostic workup. Aim of the study: The aim of this study was to evaluate changes in resting electrocardiograms in 14-year-old athletes. Materials and methods: Resting ECGs were assessed in 28 adolescents (14 boys and 14 girls) aged 14 years beginning education in sports lower secondary school of athletic profile. Results: The most common ECG changes among adolescent athletes after long-term physical training were: sinus bradycardia and sinus respiratory arrhythmia. The Sokolow-Lyon voltage criterion for left ventricular hypertrophy was fulfilled in 4 cases (in initial ECG in 10 cases) and for right ventricular hypertrophy – in 3 cases (in initial ECG in 9 cases). 16 athletes had signs of early repolarisation, usually in lateral leads. Conclusions: Changes in resting electrocardiograms in young athletes (especially sinus bradycardia, sinus respiratory arrhythmia, early repolarisation) are a result of physiological adaptation to exercise. Dynamic exercise seemed to reduce amplitudes of R and S waves in right and left precordial ECG leads and increase amplitude of T waves. The ECG can provide valuable information about electrical changes that are a result of regular training.

Keywords: resting ECG, cardiovascular adaptations to training, athletic training, adolescents, athletes
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The assessment of level of anxiety and depression in parents of children with nephrotic syndrome – coping with them and methods of support
Pediatr Med rodz Vol 9 Numer 2, p. 179–185
ABSTRACT

Objective: Idiopathic nephrotic syndrome of childhood has been described as a recurrent disease with detrimental influence on child health and family settings. Authors assessed the level of anxiety and depression in group of parents of nephrotic children. Material and methods: The study was a cross-sectional clinical trial of parents (46 subjects) whose children suffer from nephrotic syndrome in relation to parents of healthy children. All parents filled: original questionnaire concerning of clinical course of the disease, State-Trait Anxiety Inventory, Beck Depression Inventory and Courtauld Emotional Control Scale Inventory. Twenty parents of healthy children consisted a control group. Results: Parents whose children suffer from the nephrotic syndrome indicate significantly higher level of depression (Beck Depression Inventory 8.7 vs. 4.9, t = 2.18, p < 0.05). Fathers showed subjective sense of controlling their emotions when compared to mothers – CECS, total in fathers (55.1 vs. 47.2, t = 2.53, p < 0.05). Mothers have higher level of anxiety as a trait (STAI – trait 45.7 vs. 36.1, t = 3.19, p < 0.05) and as a state (STAI – state 42.8 vs. 33.4, t = 2.8, p < 0.05) and also the depression level (10.62 vs. 4.86, t = 2.66,p < 0.05). Parents who blame themselves of being responsible for the child’s disease during first episode of the disease have statistically higher depression level. Conclusions: Parents of nephrotic children showed significantly higher level of depression when compared to parents of healthy children. Authors suggest to take care of mothers whose children suffer from the nephrotic syndrome to help them to decrease the level of anxiety and depression and fathers, because they have tendency of damming up their feelings.

Keywords: nephrotic syndrome, anxiety, depression, parental attitude, children
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Orbital cellulitis as a complication of ethmoiditis in a 6-year-old patient – case report
Pediatr Med rodz Vol 9 Numer 2, p. 187–192
ABSTRACT

Ethmoid sinuses are one of the first formed of all the paranasal sinuses, therefore they are most frequently affected by inflammation when it comes to children. The diagnosis of acute ethmoiditis is based mainly on clinical presentation. Due to the specific anatomical conditions of the ethmoid sinuses, inflammation is spreading fast onto the orbital structures and the surrounding tissues. It is estimated that in approximately 91% of cases, orbital cellulitis is related to sinusitis. This work aims at drawing attention to the importance of early diagnosis and appropriate treatment of a common illness that is acute rhinosinusitis. The presented case report discusses the course of the disease in a 6-year-old boy who additionally developed orbital cellulitis – a rare complication that concerns approximately 0.5–3.9% of all cases. We can distinguish two types of orbital complications: preseptal cellulitis (anterior to the orbital septum) and posterior to the orbital septum ex. orbital cellulitis (inside the septum). The first group contains inflammatory eyelid oedema, relatively mild and most frequently observed, characterized by favourable prognosis. The complications belonging to the second group are decidedly less frequent and more serious. These are: orbital cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus thrombosis. What helps to differentiate between the two groups are proptosis, eye movement disorder and decreased visual acuity. The systemic treatment consists in the parenteral administration of broad spectrum antibiotics. Despite available modern treatment options one should not forget the fact that late intervention may lead to septic complications such as meningitis, cavernous sinus thrombosis or osteomyelitis. Moreover, discontinuation of treatment may cause permanent, but very rare sequelae including loss of vision and glaucoma. Therefore, acute ethmoiditis is to be treated as a paediatric and rhinological emergency condition.

Keywords: paranasal sinuses, ethmoiditis, proptosis, orbital cellulitis, orbital complications
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Syndrome of unspecific symptoms after an exposure to toxic cyanobacteria – case presentation
Pediatr Med rodz Vol 9 Numer 2, p. 193–196
ABSTRACT

Environmental pollution results in increasing frequency of cyanobacteria blooms occurrence in water reservoirs. Many genera of cyanobacteria may produce toxins which are dangerous for animal and human health. Intoxication may be a result of drinking contaminated water, eating contaminated fish or seafood but also due to skin exposure in recreational water during cyanobacteria bloom. Signs and symptoms of intoxication are unspecific and vary from less serious like skin irritation to death. Accept from confirmation of having contact with contaminated water or food there are no diagnostic tests available. In Poland cyanobacteria blooms occur especially during heat waves. Bellow we present a case of a girl who suffered from an unspecific syndrome after returning from holidays at The Baltic Sea during cyanobacteria bloom occurrence. Few days after swimming in the sea she presented feeling unwell, with fever, skin irritation, visual disturbances, joint pain, slightly elevated inflammatory indicators and proteinuria. On the basis of clinical presentation and results of additional tests we excluded respiratory, gastrointestinal and urinary tract infection. Signs and symptoms disappeared spontaneously within few days of observation. The fact that cyanobacteria bloom occurrence is increasing over the last few years indicates that cyanobacteria intoxication should be taken under consideration while diagnosing unspecific syndrome in children coming back from holidays at the seaside.

Keywords: cyanobacteria, cyanotoxins, intoxication, fever, children
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Osteonecrosis of the jaws related to bisphosphonate therapy. Cases’ report
Pediatr Med rodz Vol 9 Numer 2, p. 197–200
ABSTRACT

Bisphosphonates are strong inhibitors of osteoclasts. They are used in therapy of osteoporosis, Paget’s disease and imperfect osteogenesis. They prevent the loss of bone mass, pain and hypercalcaemia caused by multiple myeloma and metastases of systemic cancer. The widening of indications for use of bisphosphonates is supported by their solid safety profile. Oncologic patients receiving high intravenous doses of bisphosphonates are more prone to side effects of the therapy than patients who take these medicaments orally. One of the most serious side effects is osteonecrosis of the jaws. The description of the correlation between bisphosphonates and osteonecrosis of jaw was first described in 2003. This side effect is described frequently. The ailments are oppressive and reduce patients’ quality of life and include pain, swelling, ulceration, exposure of bone, fistulae and pathological fractures. The treatment of bisphosphonate-related osteonecrosis of the jaws is difficult and uncertain. Conservative treatment and symptom reduction is the main course of action. Discontinuation of bisphosphonates is controversial (due to their accumulation in the bones). It is crucial patients are prepared to bisphosphonate therapy: dental examination and treatment of all dental diseases is recommended. This requires strict cooperation between oncologists, orthopaedics and maxillofacial surgeons. The aim of this study is the presentation of three cases of bisphosphonate-related osteonecrosis of the jaws.

Keywords: bisphosphonate, osteonecrosis, jaws, systemic cancer, osteoporosis
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Intensification of pharmacological therapy in a patient with angina pectoris and advanced coronary artery disease (without the possibility to conduct revascularisation)
Pediatr Med rodz Vol 9 Numer 2, p. 201–204
ABSTRACT

In the last decades, the introduction of statins, benefits of angiotensin-converting enzyme inhibitors, coronary artery revascularisation or prophylactic programmes brought about the breakthrough in treating diseases of the circulatory system, in particular ischaemic heart disease. The basis for treating stable coronary artery disease is the administrations of drugs, such as: antiplatelet drugs, statins and angiotensin-converting enzyme inhibitors (particularly in concomitant indications) as medicines the improve survival as well as symptomatic drugs, particularly beta blockers, which may additionally influence the prognosis of patients with the history of heart attack. On the other hand, symptomatic patients with advanced coronary artery disease in whom revascularisation is not possible or burdened with too great risk and patients who do not consent to the procedure constitute a major therapeutic challenge for attending physicians. In such situations, additional options are worth considering, such as the application of metabolic drugs which are described in the standards as drugs added to the therapy conducted so far or used as substitutes in case of intolerance of current treatment. The management of the patient with coronary artery disease presented in this paper constitutes an example that pictures a difficult case of coronary artery disease treatment and a situation in which metabolic drugs are used.

Keywords: coronary artery disease, revascularisation, trimetazidine, metabolic drugs, myocardial infarction
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