Ketoacidosis and hypoglycemia of the diabetic child

Ambulatoriul Integrat al Spitalului Clinic Județean de Urgență „Sf. Spiridon”, Spitalul Clinic de Urgență pentru copii „Sf. Maria”, Iași, RomâniaIntroducere. Copilul cu diabet zaharat de tip 1 este expus cetoacidozelor și hipoglicemiilor, formele severe fiind urgențe terapeutice care pun în joc viața pacientului. Scopul lucrării: determinarea prevalenței cetoacidozelor și a hipoglicemiilor severe precum și identificarea cauzelor și a factorilor favorizanți ai acestor complicații. Material și metodă. Lotul de studiu a cuprins 119 copii și adolescenți cu diabet de tip1, analizându-se datele din fișele de dispensarizare și caietele de tratament ale acestora pe o perioada de 5 ani. Au fost incluși în studiu pacienții cu vârsta sub 19 ani și durata de evoluție a bolii de minimum 1 an. S-au analizat numai episoadele severe ce au impus internarea de urgentă urmarindu-se, de asemenea, determinarea etiologiei acestor complicații precum și stabilirea unor corelații cu anumiți parametri: vârstă, durata de evoluție a bolii, controlul metabolic, schema de tratament, sexul, mediul de proveniență. Teste de semnificaţie utilizate: coeficientul de corelaţie „Pearson” (r), testul F, testul c2 Rezultate si discutii. Din lotul de studiu, 15,3% dintre cazuri au prezentat cetoacidoze severe, cu un risc estimat uşor mai crescut la sexul feminin, la cei cu provenienţă rurală şi la adolescenții cu vârste de peste 13 ani. Riscul estimat de cetoacidoză severă a fost de 1,63 ori mai crescut la pacienții cu o vechime a diabetului de peste 5 ani. În ceea ce priveste hipoglicemiile severe, acestea au fost prezente la 28,6% dintre pacienti, care au prezentat simptome neuroglicopenice severe, fără diferenţe semnificative ale riscului estimat între sexe, dar cu un risc uşor mai crescut la copiii proveniţi din mediul urban și la cei cu vârste de peste 13 ani . Riscul estimat de hipoglicemie severă a fost de aproximativ 2 ori mai crescut la pacienții cu o vechime a diabetului de peste 5 ani. Concluzii. Episoadele severe de hipoglicemie sau cetoacidoză au efecte imediate privind prognosticul vital al pacienților dar și efecte la distanță asupra funcționalitații sistemului nervos (în cazul hipoglicemiilor severe). În concluzie, este esențial ca printr-o educaţie medicală continuă a pacienţilor diabetici să putem preveni aceste complicații.Introduction. The child suffering from type 1 diabetes isexposed to hypoglycemia and ketoacidosis, the severe forms being medical emergencies. Aim: to determine the prevalence of severe hypoglycemia and diabetic ketoacidosis and to identify the causes and the risk factors of these complications. Material and method: the data of 119 children and adolescents suffering from type 1 diabetes were analyzed for the latest 5 years (mandatory inclusion criteria have been: age under 19 and the evolution of disease for at least one year). There were analyzed only the cases with metabolic acute complications that led to hospital admission. These patients were investigated in order to determine the etiology of acute complications and also in order to establish a relationship between the onset of acute complications and certain parameters like age, duration of disease, metabolic control, insulin treatment, sex. Significance tests used have been: „Pearson” correlation coefficient (r), test F and c2 test. Results: 15,3% of patients presented diabetic ketoacidosis with a high relative risk in girls , in those from villages and in those older than 13 years .The estimated risk of ketoacidosis was 1,63 higher in those patients with a evolution of diabetes longer than 5 years. Regarding severe hypoglycemia with severe symptoms (seizures, coma), 28,6% of patients had at least one episode in the last 5 years, without significantly differences of relative risk between sexes but with a higher risk for children from urban setting and for those older than 13 years. In those patients with a duration of diabetes longer than 5 years, the estimated risk of severe hypoglycemia was double. Conclusions: Diabetic ketoacidosis and severe hypoglycemia are medical emergencies that present a risk for the patient’s vital prognosis but can also have long-term effects on the functioning of the nervous system ( in case of severe hypoglycemia ). It is very important to prevent these complications and we can achieve this through a continuous medical education

Short stature in pediatric pathology

Clinica III Pediatrie, Spitalul Clinic de Urgenţe pentru Copii „Sf. Maria”, Iaşi, România, Disciplina Medicina de Familie, Universitatea de Medicina si Farmacie „Gr.T.Popa”, Iaşi, RomâniaTalia mică constituie o motivaţie relativ frecventă de adresabilitate la medic. De cele mai multe ori ea reprezintă doar o variaţie de la fiziologia normală mai curând decât o consecinţă a unei patologii reale. Dezvoltarea staturo-ponderală este condiţionată de factori genetici (“zestrea genetica”), factori de mediu şi psiho-sociali şi starea de sănătate a persoanei respective. Hipostatura reprezinta talia sub 2 deviaţii standard (sau sub percentila 3) comparativ cu media taliei pentru vârstă şi sex la persoane aparţinând aceluiaşi grup etnic şi rasial. Deficitul de creştere defineşte o rată de creştere inferioara velocitătii (vitezei) medii de crestere pentru vârstă şi sex. Dwarfism-ul, termen în general evitat, se referă la o hipostatura extremă (adultul cu talia sub 147 cm). Cauzele hipostaturii pot fi grupate în 3 categorii nonendocrine (intrauterine, psiho-sociale sau boli cronice: pulmonare, digestive, renale, cardiace, reumatice, neoplazice, genetice, displazii scheletale), endocrine (deficit/rezistenţă periferica la GH, hipotiroidism, sindrom Cushing, tulburări ale glandei paratiroide si vitaminei D) sau variante normale de hipostatura (familial, constituţional, idiopatic). Investigarea unui copil cu hipostatura presupune o anamneza completa (date legate de perioada perinatală, ancheta familială, consanguinitate, alimentaţie, condiţii psiho-sociale, boli preexistente), examen clinic amănunţit (indici antropometrici, velocitatea de creştere a taliei şi greutăţii, dezvoltare somatică si neuro-psihică, eventuale dismorfii), investigaţii paraclinice (biologice, hormonale, radiologice, genetice sau specifi ce pentru decelarea unor boli cronice). Hipostatura idiopatică reprezintă un diagnostic de excludere (după infirmarea cauzelor organice şi psiho-sociale). În concluzie, diagnosticul precoce şi corect al hipostaturii permite instituirea unui tratament precoce şi adecvat, cu eficienţă terapeutică maximă.Short stature is a motivation relatively frequent for addressability to the pediatrician. In most patients, it is just a variation of normal physiology rather than a true pathology. Stature-ponderal development is conditioned by genetic factors (heredity), environmental factors, psycho-social factors, and health status. Short stature is defined as absolute height below – 2 SDS (< percentile 3) for age, sex of people belonging to the same ethnic and racial group. Growth failure represents a growth rate below-average growth velocity for age and sex. Dwarfism, a term often avoided, refers to extreme short stature (height under 147 cm in adult). Etiology of short stature can be grouped into 3 categories: non-endocrine (intrauterine causes, psychosocial causes or chronic diseases: pulmonary, digestive, renal, cardiac, neoplastic, rheumatic, genetic diseases or skeletal dysplasia ), endocrine (deficiency or peripheral resistance for GH, hypothyroidism, Cushing syndrome, disorders of the parathyroid gland or D vitamin) or normal variations of hypostature (family, constitutional, idiopathic). A logical process of assessment is required for a child with short stature including a complete anamnesis (perinatal period, family history, consanguinity, nutrition, psycho-social condition, preexisting diseases), detailed clinical exam (auxological parameters, the growth velocity of the height, and weight, somatic and neuro-psychic development, dysmorphic features), laboratory procedures (biological, hormonal, radiological and genetic investigations, specific investigations for chronic diseases). Idiopathic short stature refers to hypostature without a cause (denial organic and psycho-social causes). In conclusion, early and correct diagnosis of short stature allows for appropriate treatment with optimal therapeutic effectiveness

Autoimmune pathology in type 1 diabetes in children and adolescents

Ambulatoriul Integrat al Spitalului Clinic Județean de Urgență „Sf. Spiridon”, Iași, România, Spitalul Clinic de Urgență pentru copii „Sf. Maria”, Iași, RomâniaDiabetul zaharat tip 1 este o boală autoimună caracterizată prin autodistrugerea mediată imun a celulelor beta pancreatice în cadrul unui proces inflamator cronic („insulita”). Detectarea markerilor de autoimunitate (auto Ac GAD, IAA, ICA, etc) reprezintă o dovadă certă în favoarea acestui mecanism. Cele aproximativ 50 gene de susceptibilitate pentru diabet poartă în acelaşi timp un risc înalt de dezvoltare și a altor boli autoimune concomitent sau la distanță de debutul diabetului. Deseori se remarcă tendinţa unei agregări familiale pentru bolile autoimune ceea ce reprezintă un argument în plus în favoarea predispoziţiei genetice. Se descriu 3 categorii de sindroame poliglandulare autoimune: tipul I (apare în mica copilărie), tipul II-IV (la copilul mare şi adult) și IPEX (la sugar, extrem de rar, cu evoluţie fatală). PAS tipul I (sindrom Witaker) se transmite autosomal recesiv, este monogenic şi asociază cel puţin 2 dintre următoarele afecţiuni: boala Addison, candidoza mucocutanată, hipoparatiroidism. Prevalența diabetului zaharat tip 1 este de 2-33%. În timp, se pot asocia şi alte afecţiuni autoimune endocrine (tiroidită, hipogonadism) sau nonendocrine (hepatită, gastrită, alopecia areată, vitiligo, cheratoconjunctivita). PAS tipul II-IV, cel mai frecvent sindrom poliglandular autoimun, apare predominant la sexul feminin fiind poligenic. Diabetul zaharat tip 1 reprezintă boala autoimună cea mai frecvent întâlnită (40-60%), deseori fiind prima care apare. PAS tipul II asociază boala Addison (70-100%) cu cel puţin o altă endocrinopatie autoimună, PAS III (subtipul cel mai frecvent întâlnit) reuneşte 41% din posibilele asocieri de boli autoimune, în care, o constantă o reprezintă tiroidita autoimună (70-75%) asociată cu hipo/hipertiroidie. În acest subtip lipseşte boala Addison. PAS tipul IV este un grup eterogen de boli autoimune, atipic, care reuneşte boli autoimune endocrine (ex. diabet zaharat tip 1) şi nonendocrine (ex. boala celiacă, gastrita autoimună). În concluzie, aproximativ o treime din pacienţii diabetici dezvoltă în timp boli autoimune glandulare (ex. tiroidita autoimună 15-30%, boala Addison 0,5%) sau nonendocrine (ex. celiachie 4-9%, gastrită autoimună/anemie pernicioasă 5-10%, vitiligo 2-10%, artrita reumatoidă). Detectarea din timp a autoanticorpilor specifici şi a afectării organice latente permite măsuri terapeutice precoce pentru a preveni agravarea bolii autoimune şi decompensarea diabetului.Type 1 diabetes is an autoimmune disease characterised by immune mediated self-distruction of pancreatic beta cells in a chronic inflammatory process („insulitis”). Detection of markers of autoimmunity (GAD, IAA, ICA) is a definite proof of this mechanism. The approximately 50 susceptibility genes for diabetes also carry a high risk for other autoimmune diseases in the same time with diabetes or away from the onset of diabetes. We often remark a family aggregation of autoimmune diseases and this is an additional argument for genetic predisposition. There are 3 categories of autoimmune polyglandular syndromes (PAS): type I (in first childhood), type II – IV (adolescent and adult) and IPEX (on infants, extremely rare but with fatal evolution). Type I PAS (Witaker syndrom) is an autosomal recessive and monogenic disease and associates at least two of the following conditions: Adisson disease, muco-cutaneous candidiasis, hypoparathyroidism. Prevalence of type 1 diabetes is 2 – 33%. In time other autoimmune endocrine diseases may be associated (thyroiditis, hypogonadism) or autoimmune non-endocrine diseases (hepatitis, gastritis, alopecia areata, vitiligo, keratoconjunctivitis). Type II-IV PAS, the most frequent polyglandular autoimmune syndrom, predominantly in the female, is polygenic disease. Type 1 diabetes is most frequent autoimmune disease (40 – 60%) and often is the first one to appear. Type II PAS associated Addison disease (70 – 100%) with at least another autoimmune endocrinopathy, type III PAS (the most frequent sub-type) meets 41% from possible autoimmune disease associations, but autoimmune thyroiditis (70-75%) with hypo/hyperthyroidism occurs constantly. In this sub-type Addison disease is not present. Type IV PAS is heterogeneous , atypical group of autoimmune diseases, including endocrine autoimmune diseases (type 1 diabetes) and non-endocrine autoimmune diseases (celiac disease, autoimmune gastritis). In conclusion, about one third of diabetic patients develop over timeendocrine autoimmune diseases (ex. Autoimmune thyroiditis 14 – 30%, Addison diseases 0,5%) or non-endocrine autoimmune diseases (ex. Celiac disease, autoimmune gastritis / pernicious anemia 5 – 10%, vitiligo 2 – 10%, rheumatoid arthritis). Early identification of specific autoantibodies and latent organic damage allows for adequate therapeutic measures to prevent worsening autoimmune disease and decompensation of diabetes

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

Role of environmental chemicals in the development of obesity

Universitatea de Medicină şi Farmacie ”Grigore T. Popa”, Spitalul clinic de urgență pentru copii “Sf. Maria”, Iaşi, RomâniaNumeroşi factori pot avea un rol în dezvoltarea obezităţii – principala problemă de sănătate publică a secolului 21. Ipoteza mediului obezogen sugerează că expunerea prenatală şi precoce la diferite substanţe, cum ar fi chimicale, ce determină disrupţie endocrină pot predispune la creşterea masei grase şi exces ponderal. Lista chimicalelor studiate ca posibili obezogeni continuă să crească şi include dietilstilbestrolul (DES), bisfenolul A (BPA), ftalaţii, organotinele, eterii difenil-polibrominaţi (PBDEs), chimicalele polifluoroalkil (PFCs), organoclorinele (OC) pesticidele şi bifenil-policlorinatele (PCBs). Diverse mecanisme explică rolul chimicalelor obezogene, majoritatea având efecte disruptive asupra homeostaziei balanţei energetice, metabolismului glucozei şi lipidelor şi controlului adipogenezei. Aceste chimicale afectează mecanismele epigenetice, structurale şi funcţionale care controlează homeostazia energetică, metabolismul lipidic, reglarea apetitului şi adipogeneza. Expunerea la aceste chimicale are efecte diferite: în cursul perioadei fetale şi copilăriei efectele pot fi ireversibile şi pot persista in perioada de adult, iar expunerea la doze mici în cursul perioadelor critice ale diferenţierii pot schimba programarea dezvoltării şi pot cauza obezitate. Fumatul matern prenatal este asociat cu apariţia în creştere a supraponderalităţii la copil şi adolescent. Unele consecinţe asupra sănătăţii pot deveni aparente nu numai în copilărie, ci şi în perioada de adult. Alte chimicale au impact asupra retardului de creştere intrauterină, greutăţii mici la naştere şi prematurităţii, fi ind documentate ca factori predispozanţi ai obezităţii. Concluzie. Obezitatea epidemică ar putea fi considerată o boală complexă multifactorială. Efectul potenţial al chimicalelor asupra dezvoltării obezităţii este mare şi sunt necesare mai multe studii asupra expunerii chimice în timpul dezvoltării pre- şi perinatale şi apariţiei obezităţii mai târziu.Numerous factors may have a role in the development of obesity - the principal public health disease of the 21st century. The environmental obesogen hypothesis suggests that prenatal or early-life exposure to certain substances as endocrine- disrupting chemicals may predispose individuals to increased fat mass and excess weight. The list of chemicals studied as possible obesogens continues to grow and includes diethylstilbestrol (DES), bisphenol A (BPA), phthalates, organotins, polybrominated diphenyl ethers (PBDEs), polyfluoroalkyl chemicals (PFCs), organochlorine (OC) pesticides, and polychlorinated biphenyls (PCBs). Diverse mechanisms explained the role of obesogen chemicals, the majority having disruptive effects on the homeostasis of energy balance, glucose and lipid metabolism, and control of adipogenesis. These chemicals disrupt some epigenetic, structural, and functional mechanisms, which control energy homeostasis, lipid metabolism, appetite regulation, and adipogenesis Exposure to these chemicals has different effects: during fetal and infancy periods may be irreversible and long-lasting for adulthood and exposure to low doses during critical times of differentiation can change the developmental programming and may result in obesity. Prenatal maternal smoking is associated with increased occurrence of overweight among children and early adolescents. Such health consequences may become apparent not only in childhood but also in adulthood. Other chemicals have an impact on intrauterine growth retardation, low birth weight, and prematurity which are documented as predisposing factors for obesity. Conclusion. The obesity epidemic should be considered a multifactorial complex disorder. The potential effect of chemicals on the developmental programming of obesity is great and there are necessary more studies on chemical exposures during pre- and perinatal development to assess later obesity

Implications of nutrition during pregnancy on future child

Universitatea de Medicină şi Farmacie „Grigore T. Popa”, Departamentul Medicina mamei şi copilului, Disciplina Pediatrie, Iaşi, România, Spitalul de Urgenţă pentru Copii „Sf.Maria”, Secţia clinică Pediatrie III, Iaşi, România, Universitatea de Medicină şi Farmacie „Grigore T. Popa”, Disciplina Medicină de familie, Iaşi, RomâniaStatusul nutriţional şi starea de sănătate înainte şi în primele 2 luni de sarcină influenţează dezvoltarea embrionului şi riscul de complicaţii în timpul sarcinii. Obiectivele nutriţiei în sarcină sunt: naşterea unui copil sănătos cu greutate normală, cu riscuri minime pentru sănătatea mamei; creşterea corespunzătoare în greutate a gravidei; aport caloric, de vitamine şi minerale suplimentar pentru gravidă; înţelegerea necesarului nutriţional modificat din cursul sarcinii. Nutriţia maternă înainte / în timpul sarcinii influenţează evoluția sarcinii; dezvoltarea fetală; dezvoltarea copilului în primii ani de viață, precum şi viaţa adultului. Nutriţia în sarcină depinde de: statusul economic, mediul social /cultural, obiceiurile alimentare ale femeii. Dieta maternă în sarcină influențează direct creşterea fetală, marimea şi sănătatea nou-născutului. O dietă inadecvată în sarcină afectează sănătatea mamei, creşte riscul de complicaţii (naştere laborioasă, deces), afectează sănătatea copilului în perioada de sugar şi mica copilărie, conducând la anemie, rahitism, imunitate scăzută şi infecții. O femeie bine nutrită are complicaţii puţine/rare în sarcină şi risc scăzut de prematuritate. Alimentația unei femei însărcinate diferă de cea a populației generale. Nevoile energetice suplimentare sunt necesare dezvoltării fătului şi anexelor sale (2200 – 2900 kcal/zi în total), dar proporţia de proteine, glucide, lipide rămâne aproximativ aceeași. Câştigul ponderal trebuie să permită: naşterea unui copil cu stare de sănătate bună, cu greutatea de 3.1-3.6 kg, evitarea unui surplus de greutate maternal după sarcină, reducerea riscului de boli cronice la copil. Concluzii. Sănătatea fătului depinde de statusul nutriţional al mamei înainte şi în timpul sarcinii. O femeie bine nutrită înainte de concepţie intră în sarcină cu rezerve de nutrienţi care acoperă nevoile fătului, fără a afecta sănătatea mamei. O femeie bine nutrita înseamnă un copil sănătos.The nutritional status and health status before and during the first 2 months of pregnancy influence the development of the embryo and the risk of complications during pregnancy. The goals of nutrition in pregnancy are: the birth of a healthy child of normal weight, with minimal risks to the mother’s health; appropriate increase in pregnancy weight; caloric intake, vitamins and minerals in addition to pregnancy; understanding of the nutritional needs modified during pregnancy. Maternal nutrition before / during pregnancy influences the evolution of pregnancy; fetal development; the development of the child in the first years of life, as well as the life of the adult. Pregnancy nutrition depends on: economic status, social / cultural environment, women’s eating habits. The maternal diet in pregnancy influences the direct creation of the fetus, the size and health of the newborn. An inadequate diet in pregnancy affects the health of the mother, the risk of complications (labor births, deeds), affects the health of the child during sugar and early childhood, leading to anemia, rickets, low immunity and infectious. A well-nourished woman has few / rare complications in pregnancy and low risk of prematurity. The diet of a pregnant woman differs from that of the general population. The additional energy needs are necessary for the development of the fetus and its attachments (2200 – 2900 kcal / day in total), but the proportion of proteins, carbohydrates, lipids remains approximately the same. The weight gain must allow: the birth of a child in good health, weighing 3.1-3.6 kg, avoiding an excess of maternal weight after pregnancy, reducing the risk of chronic diseases in the child. Conclusions. The health of the fetus depends on the nutritional status of the mother before and during pregnancy. A well-nourished woman before conception is in charge of nutrient reserves that cover the needs of the fetus, without affecting the health of the mother. A well-nourished woman means a healthy child

Incidence of spinal cord injuries in Constanta County (Romania) between 2017-2021

The purpose of this study was to investigated cases of spinal cord injury (SCI) during the years 2017-2021, in Constanta County (Romania) to update the data on SCI and thus identify the SCI trends in this region of Romania. Methods: The study retrospectively analysed patients with SCI in Constanța County, whose data (medical records) were provided to us by the Romania Motivation Foundation. This analysis was made for the period January 1, 2017 - August 31, 2021. Results: Ninety-six new traumatic cases of SCI were reported between 2017 and 2021 in Constanța County. It was found that the annual incidence is 2.48 per hundred thousand inhabitants. The male / female ratio was 5:1 and the mean age at injury was 33.52 ± 15.1 (33.41 ± 14.80 for men and 33.92 ± 16.01 for women). The most common cause of injury was unintentional fall (48.95%), followed by road accidents (39.58%), stab wounds (4.16%), gunshot wounds (3.12%) and injuries caused by diving 2.08%). Fifteen patients (15.62%) were quadriplegic, and 81 patients (84.37%) were paraplegic. The most common level of lesions was C4 (33.33%) in tetraplegics and T12 (25.92%) in paraplegics. The most common associated injury was head trauma (15.8%), followed by limb fractures (9.5%). The incidence rate of SCI in Constanta County increased (p <0.05) and the highest increase in the incidence of spinal cord injuries was observed among patients in the age groups 29 - 49 years. Conclusions: Due to the existence of limitations, it is difficult to obtain accurate epidemiological data for SCI. Therefore, more studies are needed to provide a large amount of data and evidence. Our data indicate the need to take measures both for prevention and to provide specialized care for this type of traumatic pathology

Multiple Bone Metastatic Invasion with Clinical Implications due to Ductal Mammary Carcinoma – Case report and Short Literature Review

Multidisciplinary approach of clinical cases in rehabilitations units can be very complex and divers. Method: We present a case of a woman 30 years old, whose oncological histo-ry begins 9 years ago, when the diagnosis of invasive ductal mammary infiltrating ca-nelular carcinoma grade I was made and treated by tumorectomy (lumpectomy). The pa-tient refused oncological treatment at that time and resorted to alternative medicine dur-ing a period of 7 years: diet without sugar and animal products; regular vitamin B17 treatments; almond kernel cure; high-dose intravenous vitamin C treatment for; intrave-nous ozone therapy; apitherapy with bee venom; oral administration of cannabis oil dur-ing the past four years until now; physical therapy. Results: The evolution is marked by the appearance of multiple bone metastatic lesions. The most worst clinical consequence was a hyperalgesic cervicobrachial neuralgia, due to multiple C6-T3 lytic lesions diag-nosed 2 years ago and C7 compression (close to spinal cord injury), situation which had as medical approach two surgeries interventions, radiotherapy and chemotherapy. Con-clusions: The rehabilitation program was adapted to every stage of clinical evolution and was marked by many complications. All the steps were made for functional improvement and for increase the quality of life

POSIBILITĂŢI DE PROMOVARE TURISTICĂ A MUNICIPIULUI CLUJ-NAPOCA

POSSIBILITIES OF TOURISTIC PROMOTION OF THE CLUJ-NAPOCA TOWN This paper is focusing on the possible promotion strategies that Cluj-Napoca, as an old traditional and cultural town, could use for putting it on the map of the most requested cities for tourists. Unfortunately, at least at the moment, it seems that day-by-day problems keep authorities too busy to look at the touristic potential of Cluj-Napoca and to try to ingenuously promote it

RECENT DATA ON TYPE 1 DIABETES MELLITUS IN CHILDREN

The paper reviews present and principal aspects of type 1 diabetes mellitus in children. There are presented: epidemiology of type 1 diabetes mellitus, with important geographical variations that the magnitude of the problem, main etiopathogenical aspects (genetical, immunological, environmental), etiologic classification of diabetes according to ISPAD 2000 Guidelines with main disease mechanisms and clinical features in children. The authors also discuss laboratory diagnosis and complex therapy of diabetes, which lies on the therapeutic triad: insulin therapy with available products, diet and exercise along with pacient education and self-monitoring. There are also mentioned acute and chronic complications, autoimmune associated diseases, legal matters and prognosis of this disease with immune pathogenic features in focus