Infekcija bakterijom Clostridium diffi cile u djece: značajke i liječenje – istraživanje u jednom centru u Rumunjskoj

The incidence of Clostridium diffi cile infection (CDI) in children is progressively increasing. The study evaluated the characteristics and antibacterial treatment of CDI at a Romanian pediatric gastroenterology department. We performed a retrospective study to analyze cases diagnosed with CDI, identifi ed through immunoassays for Clostridium diffi cile toxins in stools, between January 1, 2005 and December 31, 2015. Eighty-nine episodes of CDI were diagnosed in 73 patients. We noticed an increasing incidence reaching maximum in 2014 with 6.9 cases/1000 patients. Almost 40% of patients had community-acquired CDI. The most frequently associated comorbidities were infl ammatory bowel disease and cow’s milk allergy. There was a small percentage of recurrent episodes (24.2%). Metronidazole was administered as fi rst-line treatment in 49.2% of mild/moderate cases and proved eff ective in 79.4% of these. More than 70% of all patients in which metronidazole was not effi cient had comorbidities, compared to 22.2% of patients where metronidazole was effi cacious. The alternative was vancomycin which cured the disease in all cases. In severe forms, a combination of intravenous metronidazole and oral vancomycin was the effi cient solution. Oral vancomycin was the effi cacious treatment for the fi rst recurrence. We report an increasing incidence of CDI in Romanian children. The failure rate for metronidazole treatment was low, thus metronidazole may be safely recommended for the fi rst episode of mild/moderate CDI. Vancomycin proved eff ective in all cases, regardless of the fi rst episode or recurrence, and may be used effi ciently as fi rst-line treatment.Incidencija infekcije bakterijom Clostridium diffi cile (CDI) u djece u progresivnom je porastu. U ovom istraživanju procijenjene su značajke i antibakterijska terapija CDI na jednom odjelu pedijatrijske gastroenterologije u Rumunjskoj. Provedeno je retrospektivno istraživanje u kojem su analizirani slučajevi CDI utvrđeni na osnovi imunoloških testova na toksine Clostridium diffi cile u stolici od 1. siječnja 2005. do 31. prosinca 2015. godine. U 73 bolesnika dijagnosticirano je 89 epizoda CDI. Zabilježena je rastuća incidencija CDI s najvišom stopom 2014. godine sa 6,9 slučajeva na 1000 bolesnika. CDI stečena u zajednici utvrđena je u gotovo 40% bolesnika. Najčešće pridružene istodobne bolesti bile su upalna crijevna bolest i alergija na kravlje mlijeko. Postotak ponovljenih epizoda bio je nizak (24,2%). Metronidazol kao terapija prvog izbora davao se u 49,2% blažih/umjerenih slučajeva i pokazao se učinkovitim u 79,4% njih. Istodobno prisutne bolesti zabilježene su u više od 70% bolesnika u kojih metronidazol nije bio učinkovit u usporedbi s 22,2% bolesnika kod kojih je metronidazol bio učinkovit. Alternativna terapija bio je vankomicin koji je izliječio bolest u svim slučajevima. U teškim oblicima bolesti kombinacija intravenskog metronidazola i peroralnog vankomicina pokazala se učinkovitim rješenjem. Peroralni vankomicin bio je učinkovit u liječenju prve ponovljene epizode bolesti. Ukazuje se na rastuću incidenciju CDI kod rumunjske djece. Stopa neupješnog liječenja metronidazolom bila je niska pa se ovaj lijek može sa sigurnošću preporučiti za liječenje prve epizode blaže/umjerene CDI. Vankomicin se pokazao učinkovitim u svim slučajevima bez obzira na to radi li se o prvoj ili ponovljenoj epizodi bolesti i može se učinkovito primijeniti kao terapija prvog izbora

UNDERNUTRITION AND OBESITY IN PEDIATRIC PATIENTS ADMITTED IN A ROMANIAN HOSPITAL

Aims. The determinants of children nutrition status varies around the globe in relation with socio-economic particularities, dietary habits and family lifestyle. The present study attempted to evaluate the changes and determinants of nutritional status of a representative children population from South Romania. Materials and methods. A prospective cross section study was performed in Grigore Alexandrescu Emergency Children’s Hospital from Bucharest between December 2010-February 2011. We enrolled 1529 children and anthropometric, dietary assessment and interview schedule were used for all the participants. Study design was similar with the one used in 2005, on similar condition (timing and participants). The population was divided in 2 age groups: 0-2 years and 2-18 years. Data analyze used SPSS software and the Data Analysis module of MICROSOFT EXCEL 2007. Chi-Squared Test was performed for hypothesis testing involving nominal variables (categorical), non-parametric Wilcoxon-Mann-Whitney Test for comparing values of two independent cohorts, Independent Sample T Test for comparing average values of two independent cohorts, and the ‘Correlate’ function /Pearson coefficient for proving associations between the parameters being considered. Results. The overall rate of undernutrition was 11% while 13% subjects were obese/overweight. Half of subjects with undernutrition came from low-income families. Compared to non-obese children, obese subjects regularly consume sweets and hyper caloric drinks (p<0.001), spend more time watching TV and less time doing physical activity (p<0.001). Comparing data 2005/2011 we revealed that there is a decreasing level of malnutrition for both age groups and there is a warring prevalence of overweight/obese children. Conclusions. Almost a quarter of subject had nutritional status modifi cations. Inappropriate dietary habits (hypercaloric, hyperglucidic) and sedentary lifestyle were the main determinants of overweight/ obesity. This study provides data for national database and it represents an important argue in order to establish children nutritional diseases prevention programs

CELIAC DISEASE CASE FINDING STRATEGY IN ROMANIAN SYMPTOMATIC CHILDREN

Objectives. Pediatricians face various challenges in different stages of celiac disease (CD) diagnosis. Whom to test is intensely debated because of CD’s heterogenous clinical spectrum. The main purpose of the study was to identify symptoms or symptom associations that should initiate an active strategy of CD early diagnosis in Romanian children. Material and method. We conducted a prospective study in “Grigore Alexandrescu” Emergency Children’s Hospital. From March 2013 until February 2014, 249 children with symptoms/signs at risk of CD were included. Results. CD was diagnosed in 11 (1/21 patients evaluated). One in 12.6; 16; 18; 18.5 and 18.5 children respectively with chronic diarrhea, low stature, growth failure, recurrent abdominal pain and constipation had CD. Certain symptom associations increased the risk: classical symptom associations (chronic diarrhea and weight loss), as well as other associations: recurrent abdominal pain and weight loss, constipation and weight loss, constipation and refractory iron deficiency anemia. Conclusion. Active screening among patients with symptoms and especially symptom associations at risk of CD would improve diagnosis rates in pediatric CD

ULCERATIVE COLITIS AND CROHN DISEASE IN CHILDREN – AN EVOLVING PROBLEM IN ROMANIA

Objectives. In the past few years we observed an increase in the number of patients with infl ammatory bowel disease. We aimed to determine the epidemiology of this pathology among children in Romania over a 10 years period. Matherial and methods. The survey was conducted in Pediatric Gastroenterology Departments in Bucharest. We selected patients beeing carred for infl ammatory bowel disease in 2011. A similar study, performed 10 years ago in 2001, reported the same epidemiologic characteristics and comparative data were available. Results. In 2001 we report 74 cases of infl ammatory bowel disease, while there were 21 cases mentioned in 2001. We identifi ed 35 cases of Crohn disease (47.29%) and 39 patients with ulcerative colitis (52.7%). The previous study reported 17 (81%) and 4 (19%), respectively. The mean age of onset of symptoms is 10.2 while in 2001 this was 13.2 years. Conclusions. Infl ammatory bowel disease has tripled in the last 10 years. Ulcerative colitis is still the most frequent form but we report a growing number of cases with Crohn disease

MÜNCHAUSEN SYNDROME – A QUESTION OF MEDICAL ETHICS?

“Factitious disorder” or “unnatural, artificial, fake disorders” as Münchausen syndrome (MS) and Münchausen syndrome by proxy (MSBP) represent severe mental disorders in which a person tries to convince those around him/her that he/she or the person depending on him/her is sick, without the purpose of obtaining benefits. Patients with disorders such as MS or MSBP may arise a series of controversies and appeals from the simple question of patient status to confidentiality issues, privacy, medical malpractice or participation and involving of the medical team at the suffering of the patient. Recognition of the phenomenon of simulation depends heavily on experience of the physician, but the existence of elements of guidance and personality traits of patients or parents are important. Many issues of ethics and medical deontology arise in diagnosis, evolution and treatment of these syndromes, many becoming subject to medical or legal disputes. The problem is more delicate and involves many consequences in terms of child protection in MSBP, considered the only form of lethal, highly complex mistreatment and abuse. Ethical, medical and ethics issues are different in the two types of diseases, but medical staff involvement and participation in perpetuation of the symptomatology is a common character, much debated. Despite the controversy, many of these issues remain unresolved and there are no clear guidelines so doctors can give an appropriate response

MUNCHAUSEN SYNDROME BY PROXY – A REAL PEDIATRIC PROBLEM?

Munchausen syndrome and Munchausen by proxy syndrome belong belong to a group of disease called “factitious disorder” and are severe mental disorders having the “end” position for a healthy person to become patient, respectevely to “create” a disease to another person, asking or requiring medical intervention for him/her. Munchausen syndrome by proxy is rare, but it is diffi cult to be recognized and confi rmed, is a form of abuse, particularly against children, potentially lethal, often misunderstood. Many methods are used by adults counterfeiters to induce a false child’s condition: poisoning, injury, producing bleeding, infection. Complaints exposed by the mothers as belonging to the child are not for a personal benefi t, but are justifi ed by a desire to be a “hero” mothers and to play the role of the people most attached and thoughtful of their child. Diagnosis should include evaluation of the child, parents and family and is based on suggestive elements: child with multiple health problems that do not respond to treatment or recur under proper therapy, laboratory investigations discrepancies, child’s signs and symptoms disappear in the absence of the parent. The false disease of the child, intentionally distorted described by adult, do not realy affect him/her, but the diagnostic process and medical treatment can cause pain and discomfort. Ethical and legal issues associated with MSBP involves healthcare professionals by the medical consequences on the child as a result of false complains described by the parent. Education of patient, family and medical personnel is a very important step in the recognition, prevention and treatment of MSBP