Diagnostic algorithm of hyperglycemia in children

Universitatea de Medicină şi Farmacie ”Grigore T.Popa”,Iaşi, România, Spitalul clinic de urgentă pentru copii “Sf.Maria”, Iaşi, RomâniaDefi nim hiperglicemia prin creşterea glicemiei a jeun peste 110 mg/dl sau printr-o glicemie oricand in cursul zilei peste 140 mg/dl. În practica pediatrică, aceste valori pot fi cauzate de anumite medicamente, de stres sau pun problema apariţiei diabetului zaharat. Dintre medicamentele care pot determina hiperglicemie menţionăm steroizii, tiazidele, hormonul de creştere şi unele antipsihotice. Acestea din urmă au fost asociate cu o incidenţă crescută a diabetului de tip 2 si cu înrăutăţirea controlului metabolic în diabetul de tip 1. Hiperglicemia de stres poate avea cauze minore, spre exemplu o infecţie de tract respirator superior, sau cauze severe, chirurgicale. Hiperglicemia din infecţiile minore poate anunţa apariţia unui diabet de tip 1 sau diabet MODY şi trebuie investigată ulterior. Dacă valorile glicemiei sunt peste 126 mg/dl a jeun şi peste 200 mg/dl în cursul zilei, se stabileşte diagnosticul de diabet zaharat. În peste 90% din cazuri, în copilărie şi adolescenţă se diagnostichează diabetul de tip 1, pe baza simptomelor tipice si prin confi rmarea patogeniei autoimune, respectiv a markerilor de autoimunitate. Există şi posibilitatea unui diabet secundar asociat anumitor afectiuni, cum ar fi fi broza chistică, talasemia, feocromocitomul sau afecţiuni genetice. Când valorile glicemiei a jeun sunt între 100-125 mg/dl, pentru a diferenţia diabetul zaharat de tip 2 de un diabet monogenic sau de un prediabet, se recomandă efectuarea testului oral de toleranţă la glucoză asociat cu determinarea hemoglobinei glicozilate A1c, a anticorpilor anticelule insulare ( ICA ), a anticorpilor antiinsulinici şi a peptidului C. În prezent, se remarcă o crestere a incidenţei diabetului zaharat de tip 2 la populatia pediatrică, şi anume la pacientii cu obezitate şi istoric familial pozitiv de obezitate şi/sau diabet de tip 2, cu valori normale sau crescute ale peptidului C şi fără autoanticorpi prezenţi. Diabetul de tip MODY apare la 2-3,5 % din cazurile de diabet zaharat, copiii având un fenotip extrem de variabil, nu prezinta autoanticorpi, iar transmiterea autosomal dominanta este demonstrata de istoricul familial de diabet la 2-3 generaţii. În concluzie, hiperglicemia la copil pune probleme de diagostic diferenţial între debutul diabetului zaharat, un diabet secundar, o hiperglicemie indusa medicamentos sau o hiperglicemie de stres.Hyperglycemia is defined as an increase of the fasting blood glucose level above 110 mg/dl or by random blood glucose level above 140 mg/dl. In pediatric practice, these values may be caused by certain medications, by stress or they may be an indication of diabetes mellitus. Here are some of the medications that may cause hyperglycemia: steroids, thiazides, growth hormone, and some antipsychotics. The latter was associated with an increased incidence of type 2 diabetes and with poor metabolic control in type 1 diabetes. Hyperglycemia caused by stress may have minor causes, for instance, an upper respiratory tract infection, or severe surgical causes. Hyperglycemia caused by minor infections may be the precursor of type 1 diabetes or of MODY diabetes and it should be further and more thoroughly analyzed. When the fasting blood glucose levels exceed 126 mg/dl and when the blood glucose levels are over 200 mg/dl at any time during the day, the diabetes mellitus diagnosis is set. Type 1 diabetes is diagnosed during childhood and adolescence in over 90% of the cases, based on specific symptoms and when confirmed by autoimmune pathogenicity, i.e. autoimmunity markers. There is also the possibility of secondary diabetes associated with certain conditions such as cystic fibrosis, thalassemia, pheochromocytoma, or genetic disorders. When fasting blood glucose levels are between 100-125 mg/dl, in order to distinguish type 2 diabetes from monogenic diabetes or from prediabetes, an oral glucose tolerance test is recommended together with the determination of glycosylated hemoglobin A1c, anti-islet cells (ICA), anti-insulin antibodies, and peptide C. Nowadays, there is an increase in the incidence of type 2 diabetes in the pediatric population, namely in patients with obesity and family history of obesity and/or type 2 diabetes, with normal or elevated C-peptide levels and no autoantibodies present. MODY diabetes occurs in 2-3.5% of the cases of diabetes, as children have a very variable phenotype, do not show autoantibodies, and dominant autosomal transmission is demonstrated by family history of diabetes in 2-3 generations. To conclude, hyperglycemia in children poses a differential diagnosis problem, as it is difficult to distinguish between the onset of diabetes mellitus, secondary diabetes, medication-induced hyperglycemia, or stress-caused hyperglycemia

Renaissance of family medicine in Romania during Covid-19 era

In this paper, we would like to share the experience we had in Romania during the pandemic and how we reacted locally to the challenges induced by this tragic, difficult to control period. We are located in a large urban area and the office is part of a polyclinic. The number of patients registered is over 2600, with a relatively equal distribution by age categories.http://deepblue.lib.umich.edu/bitstream/2027.42/163516/1/Popa_DB_Final.pdfDescription of Popa_DB_Final.pdf : Main ArticleSEL

Role of nurses' electrocardiography competency in emergent situations

Electrocardiography is an essential tool in emergency care and monitoring of patients with severe cardiovascular diseases. Nurses are at the center of this evaluation and play an important role in the outcome of therapy. Data shows that nurses are limited in their ability to record and interpret electrocardiography diagrams accurately. Little is known about the role nurses play in electrocardiographic evaluation in an emergency. This narrative literature review assesses the competency of nurses in electrocardiography in an emergency, the implications for medical practice, and tries to identify possible improvement solutions

Évaluation de la tension artérielle et de la pression du pouls dans le syndrome métabolique

Objectif. L’objectif de notre étude est d’évaluer la pression artérielle et la pression différentielle chez les patients atteints du syndrome métabolique (SM), afin de déceler et de prévenir les complications cardiovasculaires qui peuvent survenir chez ces patients. Matériels et méthodes. L’analyse des cas‑témoin a été faite sur un total de 1528 patients, dans un cabinet de médecine familiale, les sujets étant répartis en deux groupes: le lot avec SM et le groupe témoin (sans SM). Le groupe avec SM se composait de 388 patients diagnostiqués selon les critères harmonisés. Le groupe témoin sans SM était composé de 1140 patients n’ayant pas présenté au moins trois critères diagnostiques du syndrome métabolique. Résultats. La pression différentielle, les valeurs calculées pour les patients atteints de syndrome métabolique ont été généralement plus élevées que le taux moyen escompté à 40 mmHg, avec une valeur moyenne de 47,86 ± 12,02 mmHg. Le groupe de contrôle a une valeur moyenne (40,28 ±12.20 mmHg) du pouls, une pression significativement plus faible (p<0.0001). Conclusions. La tension différentielle est associée aux complications cardiovasculaires positives, en particulier chez les personnes âgées et surtout aux valeurs supérieure ou égale à 60 mmHg, mais cette association n’est pas indépendante de la tension artérielle

Flow Cytometry Analysis of Pparα Receptors in Metabolic Syndrome / Studiul Receptorilor Pparα prin Metoda Citometriei în Flux în Sindromul Metabolic

Introducere. Sindromul metabolic (SM) reprezintă o asociere de alterări metabolice independente cu risc cardiovascular crescut. Receptorii activați de inductorii proliferării peroxizomilor-alpha (PPARα), membri ai superfamiliei receptorilor nucleari cu rol de factori de transcripţie , sunt implicați în reglarea metabolismului lipidic și inflamație în diferite tipuri de celule și reprezintă una din țintele terapeutice în SM. Am analizat expresia PPARα în leucocitele pacienților cu SM, îndreptându-ne spre implicarea PPARα în această patologie. Material și metoda. Studiul s-a desfășurat pe un număr de 57 pacienți adulți recrutați după semnarea consimțământului informat, investigați pentru evidențierea SM conform criteriilor Federației Internaționale de Diabet (IDF) și care au fost grupați în două loturi: lotul SM (26 pacienți) și lotul de control, fără SM (31 subiecți). Au fost determinați parametrii clinici și de laborator utilizați curent în evaluarea SM. În populațiile de leucocite circulante ale pacienților au fost evaluate nivelurile de expresie a două molecule, PPARα și CD36, printr-o metodă optimizată de citometrie în flux . Semnificația diferențelor dintre valorile parametrilor măsurați a fost stabilită prin analiza statistică, utilizând programul SPSS și teste statistice simple (Pearson, t-Student, Chi-test). Rezultate și discuții. Când am comparat nivelul de expresie a PPARα în eozinofile, am obținut a reducere semnificativă a intensității medie de fluorescență (p<0.05) pentru PPARα în lotul MS versus lotul martor. Concluzii. Studiul nostru este primul care arată că nivelul de expresie a PPARα în eozinofile este diminuat semnificativ la pacienții cu SM. Diferențele de expresie ale acestor molecule cheie în leucocitele circulante (ca diferite specii de PPAR, CD36 și altele) ar putea deveni evocatoare pentru disfuncția endotelială și obezitate și ar putea fi utile în elaborarea unei decizii terapeutice

IRRITABLE BOWEL SYNDROME – DIAGNOSIS AND TREATMENT IN FAMILY MEDICINE PRACTICE

Irritable bowel syndrome (IBS) is one of the most common diseases of gastro-enterology, associating abdominal pain, transit disorders and changes in the consistency of the stools. Material and method. The study included 200 patients suffering from IBS, selected from a total of 2,300 patients of a family medicine practice in urban area. For diagnosis and classification, Rome III criteria and Bristol scale were used. For a subgroup was applied a questionnaire for the evaluation of quality of life, QoL. Treatment was initiated on three levels. Results. The incidence of the disease during the 3 years of study (2013-2016) was 2.9%. The type of IBS most often encountered was the one with dominance of constipation (IBS-C 32.5%), followed by the alternating form (IBS-A 26%), mixed (IBS-M-24%) and the dominance of diarrhea (IBS-D 18.5%). Form with more severe impact on the quality of life is IBS-C – 52.24 score, and most easily tolerated IBS-A – 69 score. Treatment was initiated at the on level I at 33% of the patients at the on level II to 36 %, and on level III to 31% of the patients. Maximum efficiency of treatment scores were obtained from patients on treatment level III. Complete remission of symptoms is obtained only in 9.5% of total patients. Conclusions. SII is a common condition in family medicine practice, due to changes in the modern diet. The diagnosis can be facilitated by the application of questionnaires, and treatment is based on changes in lifestyle and on pharmacological agents

The Quality of Life of Patients with Hereditary Nonpolyposis Colorectal Cancer Undergoing Preoperative Chemoradiation

Of all the neoplastic sites, colorectal cancer (CRC) is one of the most common cancers in the family. Studies estimate that approximately 30% of all the CRC cases are a hereditary form of the disease with a potentially high impact on the quality of life (QoL), with a high risk of recurrence, and with bio&ndash;psycho&ndash;social functioning. The aim of the study was to assess the QoL of colorectal cancer patients with genetic risk by using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaire version QLQ-CR29. Materials and methods: The cross-sectional, single-center study was performed on a group of 32 patients with genetic risk of colorectal cancer, who underwent preoperative chemoradiation and surgery. Results: The series of values for the scores on the symptom scale varied between 15 and 30, and the average level of symptom scores did not differ significantly between gender (22.0 vs. 22.75; p = 0.636), highlighting a moderate impairment of QoL. Scores for the emotional functioning scale were significantly lower in men (10.33 vs. 13.25; p = 0.049), as were the scores for the physical functions (15.67 vs. 19.15; p = 0.039), showing a decrease in QoL. Conclusions: The overall score showed an average QoL in patients with colorectal cancer with genetic risk, highlighting significant differences in psycho-emotional functioning between women and men

Management of Hyponatremia in Heart Failure: Practical Considerations

Hyponatremia is commonly encountered in the setting of heart failure, especially in decompensated, fluid-overloaded patients. The pathophysiology of hyponatremia in patients with heart failure is complex, including numerous mechanisms: increased activity of the sympathetic nervous system and the renin–angiotensin–aldosterone system, high levels of arginine vasopressin and diuretic use. Symptoms are usually mild but hyponatremic encephalopathy can occur if there is an acute decrease in serum sodium levels. It is crucial to differentiate between dilutional hyponatremia, where free water excretion should be promoted, and depletional hyponatremia, where administration of saline is needed. An inappropriate correction of hyponatremia may lead to osmotic demyelination syndrome which can cause severe neurological symptoms. Treatment options for hyponatremia in heart failure, such as water restriction or the use of hypertonic saline with loop diuretics, have limited efficacy. The aim of this review is to summarize the principal mechanisms involved in the occurrence of hyponatremia, to present the main guidelines for the treatment of hyponatremia, and to collect and analyze data from studies which target new treatment options, such as vaptans

The Significance of Low Magnesium Levels in COVID-19 Patients

Magnesium is the fourth most common mineral in the human body and the second richest intracellular cation. This element is necessary for many physiological reactions, especially in the cardiovascular and respiratory systems. COVID-19 is an infectious disease caused by SARS-CoV-2. The majority of people who become ill as a result of COVID-19 have mild-to-moderate symptoms and recover without specific treatment. Moreover, there are people who develop severe forms of COVID-19, which require highly specialized medical assistance. Magnesium deficiency may play a role in the pathophysiology of infection with SARS-CoV-2. The primary manifestation of COVID-19 remains respiratory, but the virus can spread to other organs and tissues, complicating the clinical picture and culminating in multiorgan failure. The key mechanisms involved in the disease include direct viral cytotoxicity, endothelial dysfunction, and exaggerated release of inflammatory cytokines. The aim of this review was to summarize the available data regarding the role of magnesium in COVID-19 patients and its particularities in different clinical settings

Recognition and Management of Serotonin Toxidrome in the Emergency Department—Case Based Review

Serotonin syndrome (SS) is a clinical toxidrome with high variability in clinical practice. It develops due to increased serotonin levels in the central nervous system. With an underestimated frequency, SS can develop following an overdose, a therapeutic dose increase, or drug to drug interaction of at least one serotonergic agent. It can present with autonomic signs, neuromuscular changes and an altered mental status. However, history and clinical examination are key features to formulate the diagnosis. Treatment options consist of supportive measures, discontinuation of the offending agent and certain therapeutic agents previously reported to improve outcomes. Physicians have limited experience with SS, partially due to the lack of its identification in clinical practice. Therefore, we have integrated, in a narrative review, the case of a young male with SS following an atypical antipsychotic overdose superimposed on chronic treatment with agents previously known to produce SS