2014, Vol 10, No 1
Asthma therapy with inhaled corticosteroids and long-acting β2-agonists – MART model
Pediatr Med rodz Vol 10 Numer 1, p. 15–24
DOI: 10.15557/PiMR.2014.0001

The authors of this paper present a few selected problems of inhaled combination therapy of asthma with corticosteroids (ICS) and long-acting β2-agonist (LAβA) in accordance with maintenance and reliever methods, also known as MART model. Since 2006, international guidelines for asthma management and prevention (Global Initiative for Asthma, GINA) have been recommending low dose ICS as the first-line therapy for patients with mild persistent asthma (the second step of therapy) and medium-dose ICS or a combination of ICS therapy with LAβAs as the preferred therapy for moderate asthma (the third step of therapy). ICS are the mainstay of asthma therapy because they are effective in controlling asthma symptoms and ventilatory parameters. LAβAs – salmeterol and formoterol – mainly present bronchodilator action for over 12 hours. This class of drugs is very important in asthma therapy since it allows for the reduction of the ICS dose. The fundamental feature of asthma is inflammation involving both large and small airways, while the term small airways refers to airways <2 mm in diameter. Involvement of small airways determines asthma severity. Epidemiological studies have shown that, overall, asthma is not adequately controlled in patients not only in clinical trials but “real-life” patients as well. The new model of asthma treatment (which refers to budesonide and formoterol) called maintenance and reliever therapy (MART) presents itself as highly effective and well-tolerated. This therapy model has been found to improve patients’ compliance, hence reducing the risk of therapy discontinuation and improving clinical asthma course. The Modulate platform technology allowed tailoring the particle size of formulated inhaled beclomethasone dipropionate and formoterol (BDF/F) fixed combination which provides a homogeneous distribution of the two active drugs throughout the entire bronchial tree. This extrafine formulation BDP/F has recently been assessed in asthmatics following the model maintenance and reliever therapy. The findings of this study show that the BDP/F combination used as maintenance and reliever therapy improved clinical symptoms of asthma and reduced the number of exacerbations. This model of asthma treatment using superfine BDP/F was well tolerated and can be recommended in asthmatics aged over 18 years.

Keywords: asthma, inhaled corticosteroids, long-acting β2-agonists, maintenance and reliever therapy
Rhinosinusitis – one of the most common infections of the upper respiratory tract
Pediatr Med rodz Vol 10 Numer 1, p. 25–31
DOI: 10.15557/PiMR.2014.0002

Rhinosinusitis is a one of the most common upper respiratory tracts diseases, which affects from 6% to 15% of human population. Presence of pathogens, ostial obstruction and impaired drainage from sinuses have vital importance in illness development. Moreover, the risk of rhinosinusitis is increased with the associated risk factor such as: allergic rhinitis, anatomic defects of nasal septum and nasal cavity, primary ciliary dyskinesia, gastrooesophageal reflux, laryngopharyngeal reflux, congenital and acquired immunodeficiencies, cigarette smoke exposure. Because of the time of the clinical symptoms duration we divided the disease into acute and chronic. Symptoms of less than 12 weeks duration are considered acute and it is definitely more likely associated with viral infection. Persistence of signs and symptoms for more than 12 weeks is diagnosed as chronic rhinosinusitis and is often complicated by bacterial infection (mainly Streptococcus pneumoniae and Haemophilus influenzae). No single symptom or sign is an accurate predictor as they are varied and depends on age and inflammation localization. The diagnosis of rhinosinusitis is initially a clinical one. Radiologic confirmation is required only if the patient does not improve with empiric therapy or if she/he appears extremely ill, not as a primary diagnostic tool. The vast majority of patients should be effectively treated by decongestants, analgesics, antipyretics, mucolytics and oral rehydration. The use of antibiotics should be considered if there is no improvement only after 7–10 days of symptomatic treatment. In presented article we also describe two cases of children hospitalized in 2013 in Paediatric, Nephrology and Allergology Clinic, Military Institute of Medicine, which quite good illustrate diagnostic problems caused by symptoms diversification and the recurrence of the disease.

Keywords: rhinosinusitis, acute, chronic, diagnostic criteria, treatment
Enuresis in children – definitions and treatment standards
Pediatr Med rodz Vol 10 Numer 1, p. 32–35
DOI: 10.15557/PiMR.2014.0003

Nocturnal enuresis in Poland concerns about 300 000 of 5–14-year-old children (SMG/KRC report). Opinion about psychical background of enuresis, which was obligatory earlier, cannot be confirmed in recent investigations. Lately new standardization documents were published. One of them was prepared by International Children’s Continence Society (ICCS) and published in 2006 and 2007. Periodic incontinence was divided into day and nocturnal, and nocturnal incontinence was called enuresis. Enuresis we can treat as both sign and disease. It is divided into primary and secondary, monosymptomatic and nonmonosymptomatic. In Poland document called Guidelines for evaluation and treatment concerned children with enuresis was published in 2012. It was prepared by expert groups of Polish Children’s Urology Society and Polish Children’s Nephrology Society. Enuresis is the term which define urinary incontinence while asleep in a child aged at least 5 years. We present here abbreviated version of pathogenesis, diagnostic methods and treatment of nocturnal enuresis.

Keywords: nocturnal enuresis, children, terminology, diagnostics, treatment
How to differentiate vomiting in neonates and infants? Part I. Pathophysiology. Inflammatory and neurological causes of vomiting
Pediatr Med rodz Vol 10 Numer 1, p. 36–40
DOI: 10.15557/PiMR.2014.0004

Vomiting (emesis) is the forceful expulsion of the contents of stomach through the mouth and sometimes the nose. The content of the vomit may be of medical interest. Vomiting can be dangerous if the gastric content gets into the respiratory tract. Vomiting child is at risk of developing and may alter the electrolyte status dehydration. It is normal for newborn and infants to vomit. In most cases, the vomiting will last no longer than one or two days and is not a sign of anything serious. Gastro-oesophageal reflux and food allergy in infancy are common presentations that require considered management. However, persistent vomiting can sometimes be a sign of something more serious, such as a severe respiratory or urinary tract infection, viral gastroenteritis infection, infection of central nervous system. One of the most serious causes of vomiting in infants are elevated intracranial pressure and occlusion of the gastrointestinal tract. In all cases general practitioner has a key role in identifying whether a child needs further investigation and management.

Keywords: vomiting, newborn, infant, viral gastroenteritis, otitis acuta, pertussis, meningitis, intracranial hypertension
How to differentiate vomiting in neonates and infants? Part II. Gastroenterological and allergological causes of vomiting
Pediatr Med rodz Vol 10 Numer 1, p. 41–44
DOI: 10.15557/PiMR.2014.0005

The most frequent cause of vomiting in infants are feeding mistakes. Recognising them need thoughtful analysis of way of feeding and preparing food. Optimal conditions for such evaluation is child observation for few days. Disturbances in mother–child connection can also cause more frequent vomiting. The most of infant vomiting incidents are not result of any disease, but only of physiological immaturity of proximal part of gastrointestinal tract. Gastro-oesophageal reflux is considered normal, temporary, as a consequence of anatomical and functional immaturity of younger infants gastrointestinal tract. The treatment of children with gastro-oesophageal reflux is needed only in case of clinical symptoms appearance such as: physical development disturbances, restlessness, problems with swallowing, wheezing, cough or apnoea, or when it leads to complications as: oesophagitis, narrowing of oesophagus or Barrett’s oesophagus. Second most frequently diagnosed vomiting cause in infants are variable clinical manifestations of food allergy. Immune reaction to food proteins can cause less than 1% of vomiting and diagnosis need to be confirmed in the elimination and provocation test. Many more diseases of gastrointestinal tract can lead to vomiting. Among them can be found infectious gastritis and inflammation of bowels, non-specific bowel inflammations, food intolerances as well as extrahepatic cholestasis and pancreatitis.

Keywords: vomiting, newborn, infant, gastro-oesophageal reflux, food allergy, lactose intolerance
How to differentiate vomiting in neonates and infants? Part III. Surgical causes of vomiting
Pediatr Med rodz Vol 10 Numer 1, p. 45–49
DOI: 10.15557/PiMR.2014.0006

Vomiting in newborns and infants is an important clinical problem. It can be a sign of serious illnesses, life-threatening conditions and require urgent diagnosis and treatment. Knowledge of the specific causes of vomiting in the first year of life provide the diagnosis. Most of surgical causes of vomiting is associated with conditions that cause occlusion of the gastrointestinal tract. Vomiting newborn should be suspected of congenital digestive tract malformation, especially if early onset of symptoms are observed. In infancy one should remember about pyloric stenosis and intussusception. In both groups vomiting can be a symptom of incarcerated hernia or Hirschsprung disease. Vomiting newborns or infants require careful assessment, diagnosis and finding the optimal treatment. Differential diagnosis of vomiting and identification life-threatening diseases that require urgent surgical interventions could be a challenge.

Keywords: vomiting, newborn, infant, digestive system abnormalities, pyloric stenosis, intussusception
How to differentiate vomiting in neonates and infants? Part IV. Metabolic, endocrinologic and cardiovascular causes of vomiting
Pediatr Med rodz Vol 10 Numer 1, p. 50–54
DOI: 10.15557/PiMR.2014.0007

Vomiting in the infant is a common and nonspecific symptom of a multitude of disorders that can range from mild, self-limited illnesses to severe, life-threatening conditions. Less common causes of vomiting include inherited metabolic defects and diseases of endocrine and cardiovascular system. Disorders of proteins metabolism (e.g. phenylketonuria, maple syrup urine disease, urea cycle disorders, organic acidemias) are uncommon but can manifest with vomiting in newborns and younger infants. Infants with galactosemia can develop symptoms (recurrent vomiting) in the first few days after initiating milk feeding. Symptoms associated with lipid metabolism disorders (e.g. fatty acid beta-oxidation defects or Smith-Lemli-Opitz syndrome) in some cases can concern the digestive system. Emesis is also one of the most frequent symptoms associated with hypercalcaemia due to vitamin D intoxication. Salt wasting forms of endocrinological diseases (with metabolic acidosis and electrolyte disturbances: high potassium and low sodium), including congenital adrenal hyperplasia due to 21-hydroxylase deficiency, are often associated with emesis and severe dehydration. Recurrent vomiting can rare be caused by a variety of heart diseases, e.g. myocardial infarction, myocarditis. Congenital defects of the aortic arch, also known as vascular rings, can cause compression of the oesophagus and result in symptoms like dysphagia or vomiting. Clinical signs of hypertensive crisis in infants (usually due to renal vascular abnormalities, acute or chronic renal parenchymal diseases and aortic coarctation) very often include nausea and vomiting as well.

Keywords: emesis, infants, inherited metabolic defects, endocrinological diseases, cardiologic diseases
Practical aspects of treatment of constipation in children
Pediatr Med rodz Vol 10 Numer 1, p. 55–60
DOI: 10.15557/PiMR.2014.0008

Chronic constipation is one of the most common complaints among children. It is a cause of about 3% visits in paediatric outpatient clinic. The problem, which is often belittled, is an unpleasant and persistent complaint for both child and its family. The causes of constipation may be both organic and non-organic. Among non-organic problems, the most important is probably the chronic retention of faeces, which is made by incorrect hygienic habits, incorrect diet, and insufficient physical activity. The problem often appears when child’s environment changes, for example when child goes to kindergarten or school, which are the places where child for different reasons prevents from defecating. However, to make the final diagnosis, the organic causes should be definitely rejected, because they require causal treatment. Treatment of the most common functional constipation needs complex pharmacological and non-pharmacological methods. The therapy of constipation is usually long. The aim of therapy is to consolidate such model of defecation when child regularly deposits soft faeces without unpleasant pain. Extremely important is also a psychological support for whole family, often absorbed in difficult child’s problem. To achieve the therapeutic success a patient and conscientious cooperation between doctor and patient and his family is required, because positive and permanent effects of treatment are reached after a relatively long time.

Keywords: constipation, symptoms, diagnostics, treatment, fibre
Basic symptoms and differentiation of inflammatory bowel diseases
Pediatr Med rodz Vol 10 Numer 1, p. 61–66
DOI: 10.15557/PiMR.2014.0009

Ulcerative colitis (colitis ulcerosa, CU) and Crohn’s disease belong to a group of nonspecific inflammatory bowel diseases characterized by chronicity and unknown aetiology. Due to their heterogeneous pathogeneses, their clinical pictures and clinical courses vary. This results in diagnostic difficulties that are encountered despite the availability of a number of specialized tests in contemporary medicine. It is known that a condition necessary to establish a definitive diagnosis is to confirm the presence of a nonspecific inflammatory bowel disease in a histopathological examination, but laboratory tests are helpful in the initial diagnosis and demonstrate the extent and severity of the inflammatory process. C-reactive protein is the indicator of the inflammatory process, and anaemia that occurs in ulcerative colitis is due to both the chronicity of the disease and iron deficiency secondary to blood loss. Laboratory diagnosis is also applicable in the evaluation of parenteral complications concerning the liver, bile ducts, and osteoporosis. Abnormal liver function tests are frequent in inflammatory bowel diseases and may be caused by an ongoing inflammatory process typical of these diseases as well as by the pharmacological treatment implemented. Although new methods, such as computed tomography, magnetic resonance imaging and positron emission tomography, are used in diagnosing gastrointestinal diseases, endoscopy with histopathological analysis of the collected samples still is (and will be for a long time) a primary diagnostic method in the process of diagnosing, monitoring the course of treatment and oncological surveillance.

Keywords: gastrointestinal diseases, Crohn’s disease, ulcerative colitis, endoscopy, treatment
Spontaneous drainage of pancreatic abscess into digestive tract
Pediatr Med rodz Vol 10 Numer 1, p. 67–70
DOI: 10.15557/PiMR.2014.0010

The progress of the modern graphic technology is connected with better diagnosing of the pseudocyst of the pancreas in clinical practice. The pancreas pseudocysts are diagnosed accidentally in 20% of the patients in ultrasound examination, computed tomography, magnetic resonance imaging or endosonography; 24% of the patients reveal such abnormality in autopsy examinations. Pseudocyst is a complication occurring in 7–15% of acute pancreatitis patients. Usually they dissolve spontaneously, however, pseudocysts of diameter higher than 6 cm have a 30–50% risk of complications such as: rupture, bleeding and infection. Pseudocyst can turn in abscess in few weeks since acute pancreatitis. In this article we would like to present a case of spontaneous drainage of pancreatic abscess into gastric lumen. The treatment options for this entity are dictated by the severity of symptoms, the size of the pseudocyst, the ductal anatomy, and the surgical expertise available. Surgical drainage using open laparotomy or percutaneous drainage were the chosen treatment options. In most of the cases open surgical drainage should be reserved for patients in whom pancreatic necrosis, abscess, haemorrhage, or rupture of pseudocyst occurs. Transmural drainage using approach endoscopic ultrasound guidance is a technically feasible, minimally invasive, and safe procedure for drainage of pancreatic pseudocyst.

Keywords: spontaneous drainage, pancreatic abscess, fistula, endoscopy, computed tomography
Usefulness of abdominal computed tomography with multiplanar and three-dimensional reconstruction in the diagnosis of complex malformations of the urinary tract in children
Pediatr Med rodz Vol 10 Numer 1, p. 71–77
DOI: 10.15557/PiMR.2014.0011

Modern diagnostics of kidneys and urinary tract defects in children covers a wide range of examination, first of all of diagnostic imaging. They are designed mainly to detect specific diseases but they are also useful in monitoring treatment, predicting the risk of developing chronic kidney disease and its multiorgan long-term effects. The correct interpretation of images of the urinary system requires the knowledge of kidneys, ureters, bladder and urethra, anatomy with all kinds of the most common varieties of their construction. Malformations of the urinary tract are the most common congenital anomalies. Most of them are asymptomatic, which may hinder the identification and implementation of appropriate procedure. Early diagnosis and appropriate treatment of urinary tract defects is essential in prognosis, gives a chance to maintain renal function, and thus to normal development of the child. The article describes the cases of clinical diagnostic steps successively achieved in particular health problem, in which the key element proved to be computed tomography (TK). TK allows a good assessment of the anatomy of the kidney and urinary tract. Progress in the field of diagnostic imaging and the prospect of new technical possibilities of tests gives clinicians many diagnostic and therapeutic opportunities and helps to improve the standard of care in children with nephrological problems.

Keywords: urinary tract, children, diagnostics, malformations, computer tomography
Application of thermography in the diagnosis of the algodystrophic syndrome type I  in 42-year-old patient
Pediatr Med rodz Vol 10 Numer 1, p. 78–84
DOI: 10.15557/PiMR.2014.0012

Algodystrophic syndrome entity (type I) has not fully known pathogenesis and course. It is characterized by severe pain of the distal part of limb, oedema, vasomotor dysfunction and impaired efficiency. These symptoms occur after trauma, thoracic surgeries, myocardial infarction, stroke, peripheral nerve damage, less common in the course of venous or arterial thrombosis. Pathomechanism of the disease is unclear, but the most important factor of its pathogenesis seems to be a disorder of the autonomic nervous system. Limb pain and swelling, in the typical cases, are accompanied by vasomotor disturbances, restricted mobility, increased sensitivity to pressure and temperature changes. The course of the disease can be divided into three periods: I – acute period, II – dystrophic period, III – atrophic period. Apart from the vasomotor form, we can distinguish paralytic form (after a stroke) and toxic (druginduced). The majority of patients has emotional lability, hyperreactivity and a tendency to anxiety and depression. Imaging studies are useful in the diagnosis. The effectiveness of treatment depends on the period in which the diagnosis is made. The sooner patients are treated, the outcomes are better. Analgesics and sympatholytics are used in this therapy. Good effects of decongestants, anti-inflammatory medications and stimulating bone calcification treatment are obtained after the application of an alternating magnetic field of low frequency, low-energy laser, whirlpool limbs massage, affected limb exercises. We present a case of 42-year-old man with algodystrophic syndrome, in which the diagnosis was made in the advanced second stage of the disease. Pharmacological treatment and physiotherapy had been used for 3 months and led to a significant improvement, which is well illustrated by the thermographic examination.

Keywords: algodystrophy syndrome, post-traumatic osteoporosis, Sudeck’s disease, acute bone loss, thermal imaging study
Medical records in electronic form. Problems with implementing a duty
Pediatr Med rodz Vol 10 Numer 1, p. 85–90
DOI: 10.15557/PiMR.2014.0013

The article is devoted to implementation of a duty of maintaining electronic medical records. The date of the duty’s commencement is not known but the very coming into existence of the duty is quite possible. The duty of maintaining electronic medical records means that every medical documentation, namely either the collective or individual medical documentation, made and kept in electronic version – computer files. The significant problem is a phenomenon of paper documents annexed to electronic documentation. One can also find in the text some considerations about admissibility of writing electronic documentation on paper after the entry into force of a duty of maintaining electronic medical records. The premises of admissibility of maintaining electronic medical records have been analysed as well.

Keywords: medical records in electronic version, medical records, medical records in paper version, archiving of records, ICT system (Information and Communication Technologies)
Neurofeedback in the treatment of patients diagnosed with ADHD – a review of research
Pediatr Med rodz Vol 10 Numer 1, p. 91–96
DOI: 10.15557/PiMR.2014.0014

Attention-deficit/hyperactivity disorder (ADHD) is a chronic disorder of multifactorial aetiology, usually recognized in childhood but also occur in adulthood. Diagnostics of ADHD is complex and requires a comprehensive approach considering interview and observations from different sources. In patients with ADHD more frequently co-occur antisocial behaviour, addiction to alcohol and drugs, depression, and increased risk of suicide. Treatment of ADHD requires a comprehensive approach that involves the use of psychoeducation, behavioural therapy and pharmacotherapy. Standard pharmacological treatment and psychological therapy are often insufficient. The drugs increase the risk of side effects and their use is limited due to the limitations of the reimbursement. The most serious adverse effects include the possibility of psychostimulant drugs addiction, inhibition of growth, insomnia, lack of appetite, dysphoria, anticholinergic symptoms and extrapyramidal symptoms. Studies of children with ADHD have demonstrated characteristic abnormalities in EEG in specific locations of the brain. Neurofeedback, a type of behavioural therapy, is one of the non-standard treatment for ADHD. The essence of neurofeedback is modelling behaviour through effects on the bioelectric activity of the brain. In comparison with pharmacotherapy it is a relatively cheap method – even if the costs are not reimbursed – not overloading for the patient and safe (has few side effects). There is no, however, well-documented studies of effectiveness this method in ADHD so in the review we focused on the methodology, critically referring to results not derived from controlled trials.

Keywords: attention-deficit/hyperactivity disorder, ADHD, neurofeedback, nonpharmacological interventions, treatment efficacy