Use of Lung Ultrasound in Reducing Radiation Exposure in Neonates with Respiratory Distress: A Quality Management Project

Background and Objectives: Our quality management project aims to decrease by 20% the number of neonates with respiratory distress undergoing chest radiographs as part of their diagnosis and monitoring. Materials and Methods: This quality management project was developed at Life Memorial Hospital, Bucharest, between 2021 and 2023. Overall, 125 patients were included in the study. The project consisted of a training phase, then an implementation phase, and the final results were measured one year after the end of the implementation phase. The imaging protocol consisted of the performance of lung ultrasounds in all the patients on CPAP (continuous positive airway pressure) or mechanical ventilation (first ultrasound at about 90 min after delivery) and the performance of chest radiographs after endotracheal intubation in any case of deterioration of the status of the patient or if such a decision was taken by the clinician. The baseline characteristics of the population were noted and compared between years 2021, 2022, and 2023. The primary outcome measures were represented by the number of X-rays performed in ventilated patients per year (including the patients on CPAP, SIMV (synchronized intermittent mandatory ventilation), IPPV (intermittent positive pressure ventilation), HFOV (high-frequency oscillatory ventilation), the number of X-rays performed per patient on CPAP/year, the number of chest X-rays performed per mechanically ventilated patient/year and the mean radiation dose/patient/year. There was no randomization of the patients for the intervention. The results were compared between the year before the project was introduced and the 2 years across which the project was implemented. Results: The frequency of cases in which no chest X-ray was performed was significantly higher in 2023 compared to 2022 (58.1% vs. 35.8%; p = 0.03) or 2021 (58.1% vs. 34.5%; p = 0.05) (a decrease of 22.3% in 2023 compared with 2022 and of 23.6% in 2023 compared with 2021). The frequency of cases with one chest X-ray was significantly lower in 2023 compared to 2022 (16.3% vs. 35.8%; p = 0.032) or 2021 (16.3% vs. 44.8%; p = 0.008). The mean radiation dose decreased from 5.89 Gy × cm2 in 2021 to 3.76 Gy × cm2 in 2023 (36% reduction). However, there was an increase in the number of ventilated patients with more than one X-ray (11 in 2023 versus 6 in 2021). We also noted a slight annual increase in the mean number of X-rays per patient receiving CPAP followed by mechanical ventilation (from 1.80 in 2021 to 2.33 in 2022 and then 2.50 in 2023), and there was a similar trend in the patients that received only mechanical ventilation without a statistically significant difference in these cases. Conclusions: The quality management project accomplished its goal by obtaining a statistically significant increase in the number of ventilated patients in which chest radiographs were not performed and also resulted in a more than 30% decrease in the radiation dose per ventilated patient. This task was accomplished mainly by increasing the number of patients on CPAP and the use only of lung ultrasound in the patients on CPAP and simple cases.

Benzalkonium Chloride Poisoning in Pediatric Patients: Report of Case with a Severe Clinical Course and Literature Review

The use of disinfectants, particularly those containing quaternary ammonium compounds (QUACs), has dramatically escalated globally since the coronavirus disease 2019 pandemic. We report a case that highlights the risks associated with ingesting low-concentration QUAC solutions and emphasize the importance of effective management in resolving severe lesions without sequelae. A 17-month-old boy experienced severe respiratory failure after ingesting a disinfectant containing benzalkonium chloride (BAC). The child was initially treated at a local emergency department and was subsequently transferred to a pediatric poison center. Upon evaluation, the child was found to have grade III-A corrosive esophageal lesions and chemical pneumonitis. Several complications, including massive pneumothorax and candidemia, occurred during the clinical course of the disease. However, with timely medical intervention and appropriate supportive care, the patient completely recovered without any long-term sequelae. The properties of BAC and the comprehensive management approach may have been responsible for the patient's full recovery, despite the potentially life-threatening effects of ingesting disinfectants.

Acute liver failure secondary to toxic exposure in children

INTRODUCTION

Acute liver failure (ALF) is a syndrome defined by jaundice, coagulopathy (INR > 1.5) and hepatic encephalopathy in patients with no evidence of prior liver disease. Toxins and drugs are a frequent cause of ALF in children.

MATERIAL AND METHODS

The aim of our study was to establish the causes of toxic ALF in children followed up in our hospital in the period of January 2000 to August 2018. We retrospectively studied all hospital records of patients who developed ALF after mushroom/drug exposure and had been admitted to our hospital, the main pediatric toxicology center in north-western Romania.

RESULTS

In the last 18 years, 123 patients were admitted to our clinic with toxic ALF (89 patients secondary to mushroom ingestion and 34 patients after drug exposure). In the 2000-2012 period accidental mushroom poisoning was the leading cause of toxic ALF. Unfortunately, during the last years, voluntary drug ingestions have increased dramatically. The most commonly incriminated drug was acetaminophen (52.94%).

CONCLUSIONS

ALF in mushroom poisoning is associated with a high mortality in children, despite optimal medical therapy. This etiology was one of the most important causes of death in our cohort. The difficulty in accessing emergency liver transplantation is an obstacle common to many Eastern European pediatric centers. Fortunately, in the last 5 years the incidence of mushroom intoxications has decreased in our area. It is worrying that over the last few years there has been an increased incidence of toxic ALF after drug exposure (for suicidal purposes or due to lenient regulations for prescribing hepatotoxic medications).

Neutrophil Gelatinase-associated Lipocalin (NGAL) a Promising Biomarker for Early Detection of Nephrotoxic Injury

Renal toxic injury can neither be predicted nor quantified exactly by the serum creatinine level. NGAL is a promising biomarker for early detection of AKI due to different causes. Our objective was to evaluate it�s value in the setting of nephrotoxic injury. We performed an experiment in which we administered gentamicin, atropine and fipronil at different doses to the laboratory mice to quantify the evolution of creatinine and NGAL. Compared to creatinine, NGAL increased faster and was detected at elevated levels from the first 4 h after administration of both low and high dose gentamicin. Fipronil, atropine and the combination caused a significant increase in NGAL serum values at 4 hours, an increase that lasted up to 24 and 72 h , respectively, compared to the control group, Its highest levels were recorded at 4 h. Compared to creatinine, NGAL increased faster and was detected at elevated levels from the first 4 h after administration of fipronil, atropine and the combination of them.

Peripheral immune cell markers in children with recurrent respiratory infections in the absence of primary immunodeficiency

The immune system of a child has a degree of immaturity that is maintained until 6–7 years of age. Immaturity may be due to age-related functional disorders in the immune response. A healthy child can contract a series of infections which contribute to the maturation of the immune system during the pre-pubertal period. If repeated infections with prolonged or severe complications occur during childhood, the presence of an immunodeficiency should then be considered. Much more frequent than primary immunodeficiency are recurrent infections (frequently involving the upper respiratory tract), which are less severe and occur under the conditions of an immune system with no apparent major defects. A child can present with 4 to 8 episodes of respiratory infections within a year, during the first 5 years of its life. The average duration of infection is 8 days and up to 2 weeks; if the child presents with 3 episodes of acute infections over a period of 6 months, the respiratory infections are then considered recurrent. The aim of this study was to identify the immunological changes or deviations that cause this clinical syndrome in children. For this purpose, 30 children with recurrent respiratory infections and 10 healthy children were included. Immunoglobulin levels were examined and immunophenotyping was performed. We found that the serum immunoglobulin levels were in the normal range in 70% of the children. On the contrary, our data revealed changes in peripheral cell populations, the most important being the decrease in the T-cluster of differentiation (CD)8⁺ and total B cell percentages and the increase in the number of memory B cells. The data obtained herein indicated that the decrease in the number of total B cells was mainly due to the decrease in the number of naive IgD⁺ B cells. On the whole, the findings of this study indicate that recurrent respiratory infections may be associated with an altered cellular immune response. In such situations, the investigation of immunological parameters, such as T and B cell subtypes could complete the clinical diagnosis and guide the treatment strategy, thus increasing the quality of life of patients.

THE IMPORTANCE OF VIRAL ETIOLOGY DETERMINATION IN SEVERE LOWER RESPIRATORY TRACT INFECTIONS IN INFANTS AND CHILDREN

Introduction. Community-acquired pneumonia is one of the leading causes of death worldwide in children under 5 years. In practice, viral detection using multiplex PCR is becoming increasingly used, it is most useful to understand the epidemiology and impact of viruses on the pediatric population but there are still many debates regarding the influence of viral detection on patient care. Objectives. In this study we aimed to analyze the impact of viral etiology determination on the duration of hospitalization and on the administered treatment. Material and methods. The selection criteria was: children between 0-5 years with severe lower respiratory tract infection. We have analyzed three groups of patients: a group with specified viral infection, a second group with unspecified viral infection and a third group with bacterial infection. Results. In the analyzed period 72 children under 5 years of age who have shown signs of acute respiratory failure have been diagnosed with a specific viral infection, only 2% of the total viral infections. The main etiology was represented by respiratory syncytial virus (RSV) in 73.5% of cases, followed by Influenza 11%, Parainfluenza 4.2%, metapneumovirus (hMPV), Rhinovirus, Adenovirus and Bocavirus all with 2.8%. Within the unspecified viral infection group antibiotics were used in 85.5% (n = 53) of the cases. Within the specified viral infection group although viral etiology was firmly established antibiotics usage rate was higher 92% (n = 57). Duration of hospital stay was 2,5 days higher in the viral specified group compared with the unspecified one. Thus we found that although the diagnosis of viral infection was certainly given because of severe clinical picture and young age of children the expenses were 30% higher. Conclusions. In our study, RSV is the most common virus involved in the etiology of viral LRTI and is encountered in the most severe forms of the disease especially in young infants and prematures. Antibiotics are commonly used in the severe forms of LRTI, even if the viral etiology is certain and the groups of antibiotics used are similar. Determination of viral etiology has not reduced hospitalization, nor has led to changing of physician therapeutic approach.

IMPORTANŢA DIAGNOSTICULUI ETIOLOGIC ÎN INFECŢIILE VIRALE SEVERE ALE TRACTULUI RESPIRATOR INFERIOR LA SUGAR ŞI COPIL

Introducere. Pneumonia comunitară reprezintă una din cauzele principale de deces în lume la copii cu vârsta sub 5 ani. Detecţia virală prin PCR multiplex este din ce în ce mai utilizată în practică; ea este utilă pentru a înţelege epidemiologia şi impactul virusurilor asupra populaţiei pediatrice, însă există în continuare multe discuţii legate de modul în care detecţia virală influenţează modul efectiv de îngrijire al pacientului. Obiective. În studiul efectuat ne-am propus analiza impactului pe care l-a avut identificarea etiologiei virale asupra duratei spitalizării şi asupra tratamentului administrat pe parcursul internării în spital. Material şi metodă. Am efectuat un studiu retrospectiv pe o perioadă de 4 ani, au fost selectaţi copii între 0-5 ani cu infecţie severă de tract respirator inferior. Am comparat 3 grupuri: un grup cu infecţie virală specificată, un grup cu infecţie virală nespecificată şi un grup cu infecţie bacteriană. Rezultate. În perioada analizată 72 de copii ce au prezentat semne de insuficienţă respiratorie acută au avut stabilit un diagnostic etiologic concret de infecţie virală, doar 2% din totalul infecţiilor virale diagnosticate în spital. Etiologia principală a fost reprezentată de virusul sinciţial respirator (VSR) în 73,5% dintre cazuri, urmat de Influenza cu 11%, Parainfluenza cu 4,2%, Metapneumovirusul (HMPV), Rinovirus, Bocavirus şi Adenovirus, toate cu 2,8%. În cadrul infecţiei virale nespecificate s-au folosit antibiotice în 85,5% (n = 53) dintre cazuri. În cadrul infecţiei virale specificate, deşi etiologia virală a fost certă, rata de folosire a antibioticelor a fost mai ridicată de 92% (n = 57) Durata spitalizării a fost în medie de cu 2,5 zile mai lungă în cadrul lotului cu infecţie virală specificată, faţă de lotul cu infecţie virală nespecificată. Deşi diagnosticul de infecţie virală a fost cert, dat fiind tabloul clinic sever şi vârsta mică a copiilor, cheltuielile realizate pentru cei cu infecţie virală specificată au fost cu 30% mai mari faţă de cei cu infecţie virală nespecificată. Concluzii. În studiul efectuat VSR este virusul cel mai frecvent implicat în etiologia ITRI virale, fiind implicat în forme severe de boală mai ales la sugarii mici şi foştii prematuri. Antibioterapia este utilizată în mod frecvent în formele severe de ITRI, chiar dacă etiologia virală este certă şi cunoscută, clasele de antibiotice folosite fiind asemănătoare. Determinarea etiologiei virale nu a redus spitalizarea şi nici nu a dus la schimbarea atitudinii terapeutice a medicului curant.

Principiile monitorizării combinate impedanţ-pH-metrie la copii: indicaţii, avantaje şi limitări

Metoda de investigaţie standard în cazul suspiciunii unui reflux gastroesofagian este reprezentată de pH-metria esofagiană. Cu toate acestea, marea majoritate a episoadelor de reflux la sugari şi copii sunt slab-acide (pH>4), iar simptomele extradigestive pot fi declanşate de către episoade de reflux atât acid, cât şi slab-acid. Pentru a depăşi aceste aspecte, o nouă metodă a fost dezvoltată în ultimii douăzeci de ani şi supusă evaluării ştiinţifice: impedanţa esofagiană. În combinaţie cu pH-metria esofagiană standard, aceasta aduce mult mai multe informaţii decât simpla pH-metrie, deoarece permite analiza refluxului non-acid şi a asocierii temporale dintre acesta şi simptome. Informaţia analizată precizează compoziţia bolusului (gaz, fluid, solid), înălţimea, durata refluxului şi timpul de clearance al bolusului. Deşi nu sunt încă disponibile valori pentru limitele normalului în populaţia pediatrică, impedanţ-pH-metria promite să devină noul gold-standard în investigarea refluxului gastroesofagian.

Principles of combined esophageal impedance-PH monitoring in children: indications, benefits and limitations

The standard test for suspected gastroesophageal reflux is pH monitoring. However, the majority of gastroesophageal reflux episodes in infants and children are nonacidic (pH > 4) and extraesophageal symptoms apparently can be caused by both acidic (pH < 4) and nonacidic reflux. In order to overcome these aspects, a new technique has been developed and placed under scrutiny in the past twenty years: multichannel intraluminal impedance. Combined with standard pH recording, it provides more information than simple pH measurement because it allows the study of non-acid reflux and the temporal association between symptoms and nonacid reflux. Data can be analyzed for bolus composition (gas, fluid, solid) and reflux height, duration, and clearance. Although normal values for the pediatric population are not yet available, combined multichannel intraluminal impedance and pH measurement has the potential to become the new “gold standard” for gastroesophageal reflux testing.

Esophageal Multichannel Intraluminal Impedance and pH Monitoring in the Evaluation of Achalasia and Gastroesophageal Reflux Disease in a Child with Down Syndrome: a Case Report

We report the case of a rare association between achalasia and Down syndrome in a child presenting with symptoms that suggest a gastroesophageal reflux. Evaluation of the patient with 24-hour multichannel intraluminal impedance and pH recording and upper endoscopy lead to the diagnosis of achalasia. However, the persistence of the symptoms after the concurrent surgical myomectomy and fundoplication has led to repeat pH-impedance monitoring testing and endoscopy, which identified the presence of gastroesophageal reflux disease. We emphasize in this paper the importance of multichannel intraluminal impedance and pH monitoring in detecting esophageal motility disorders.

Nefropatiile toxice în intoxicaţiile acute la copil şi adolescent – prevalenţă, cauze şi factori de risc

Obiective. Incidenţa şi prevalenţa reală a afectării renale în cadrul intoxicaţiilor copilului nu este pe deplin cunoscută, modificările funcţionale şi structurale renale cauzate de nefrotoxine sunt nespecifice şi de multe ori etiologia toxică este trecută în plan secund. Studiul de faţă îşi propune evaluarea prevalenţei nefropatiilor toxice la copii spitalizaţi pentru intoxicaţii acute, etiologia, aspectele clinice şi paraclinice, factorii de prognostic pozitiv sau negativ, frecvenţa folosirii tehnicilor de epurare extrarenală şi impactul acestora asupra supravieţuirii. Material şi metodă. Am realizat un studiu observaţional, retrospectiv, bicentric pe o perioadă de 10 ani, pe un lot ce a cuprins 82 de pacienţi între 0-18 ani din două centre antitoxice pediatrice: în cadrul secţiei de Toxicologie a SCUC „Grigore Alexandrescu“, Bucureşti şi în cadrul secţiei de Nefrologie şi Toxicologie Pediatrică din cadrul Spitalului Clinic de Urgenţă de Copii din Cluj-Napoca. În lotul de studiu au fost incluşi pacienţi cu intoxicaţie acută ce au prezentat în evoluţie injurie renală acută definită după criteriile AKIN. Rezultate. Prevalenţa injuriei renale acute toxice a fost de 1%. Etiologia acesteia este dominată de medicamente – 36,6% urmate de ciuperci – 24,4%, insecticide – 18,3% şi alcooli cu 11%. În procente mult mai mici au fost implicate substanţele caustice, hidrocarburile, substanţele methemoglobinizante şi plumbul. În grupul intoxicaţiilor medicamentoase au predominat intoxicaţiile plurimedicamentoase, urmate de intoxicaţiile cu antibiotice, cel mai frecvent fiind implicată gentamicina. În cazul intoxicaţiilor plurimedicamentoase substanţele cel mai frecvent implicate au fost: combinaţii de AINS cu Paracetamol şi Metamizol. În cadrul intoxicaţiilor cu ciuperci în majoritatea cazurilor au fost implicate ciupercile cu durată de incubaţie lungă, cel mai probabil Amanita Phalloides. Etiologia intoxicaţiilor cu alcooli a cuprins cel mai frecvent etilenglicolul. În intoxicaţiile cu insecticide etiologia a fost reprezentată mai ales de către insecticidele organofosforice şi carbamate. Pe lotul studiat de 82 de cazuri, s-au înregistrat 26 de decese, mortalitatea a fost de 32%. Au reprezentat factori de risc pentru deces următorii: oliguria, anuria, edemele, manifestările hemoragice, polipneea, semnele de şoc, coma, hepatocitoliza şi insuficienţa hepatică. Metodele de epurare extrarenală sau substituţie renală au fost aplicate în 41% din cazuri. Ele nu au reprezentat factori de protecţie pe lotul studiat. Concluzii. Intoxicaţiile acute la copil înregistrează o creştere importantă în ultimii ani în toată ţara. Cazurile cu injurie renală acută toxică au un prognostic de multe ori rezervat, astfel că acestea, precum şi factorii de risc asociaţi trebuie identifi cate şi diagnosticate rapid în vederea instituirii unui tratament ierarhizat precoce şi eficient.

Acute kidney injury in children and adolescent poisoning – prevalence, etiology and risk factors

Objectives. The incidence and prevalence of renal disease in actual children poisoning is not fully known because renal structural and functional changes caused by nephrotoxins are nonspecific and toxic etiology is often overshadowed. This study aims to assess the prevalence of toxic nephropathies in a pediatric population, the etiology, clinical and laboratory aspects, prognostic factors, frequency of use of extra renal epuration techniques and their impact on survival. Materials and methods. We conducted an observational, retrospective, multicentric study, over a period of 10 years, between 2003 and 2012, on 82 patients aged 0-18 years from two pediatric poison centers: the department of Toxicology SCUC “Grigore Alexandrescu” Bucharest and the Department of Pediatric Nephrology and Toxicology at the Emergency Clinical Hospital for Children in Cluj-Napoca. In the study group were included patients with acute intoxication who presented acute kidney injury defined by the AKIN criteria. Results. The etiology of poisoning that have associated acute kidney injury is dominated by drugs – 36.6%, followed by mushrooms – 24,4%, insecticides – 18.3% and alcohols – 11%. In smaller percentages we noted poisonings with caustic substances, hydrocarbons, nitrites and lead. Looking in detail we can observe that for the etiology of drug poisonings multidrug intoxications prevailed followed by poisonings with antibiotics most commonly gentamicin. In the case of multi drug poisonings the substances most frequently involved were: combination of Paracetamol, NSAIDs and Metamizol. In mushroom poisonings, in most cases were involved mushrooms with long incubation period probably Amanita Phalloides. For the Insecticide poisonings the etiology was represented mainly by organophosphorus and carbamate insecticides. The etiology of alcohol poisoning most commonly included cases of ethylenglycol. On the group of 82 cases studied, 26 deaths were recorded, mortality was 32%. We observed that oliguria, anuria, edema, hemorrhagic manifestations, polypnea, signs of shock, coma, and hepatic hepatocytolisis were risk factors for death in our study. The methods of extrarenal epuration or renal replacement treatment were carried out in 41% of cases. They were not protective factors in the study group. Conclusions. Acute poisoning cases in children show a significant increase in recent years in our country. The cases of toxic acute renal injury often have severe prognosis. Associated risk factors should be identified and diagnosed quickly to establish aprioritized early and effective treatment.

[Frequency and severity of rotavirus acute gastroenteritis hospitalized in Bucharest, Romania. Results of a case-control study]

BACKGROUND

rotavirus gastroenteritis is an emergent condition of morbidity at global level; WHO is currently recommending integration of rotavirus vaccination into the regions and states where rotavirus infection is identified as a public health priority problem.

OBJECTIVE

analyzing the frequency and clinical severity of rotavirus gastroenteritis in pediatric inpatients and commenting the programmatic signification of the analysis' results.

METHODS

descriptive retrospective study followed by case-control study upon the cohort of patients hospitalized in the year 2008, for acute diarrhoeal disease (ADD) of infectious nature in the biggest university clinic for children from Bucharest municipality. Rotavirus etiology was sustained on the ground of rotavirus antigen's detection, through immune chromatography assay, in the feces of patients with ADD clinical syndrome. The predictor factor for clinical severity was prolonged hospitalization, defined as any duration of hospitalization longer then the value calculated at 75 percentile, in the studied cohort. For the case-control study each case of rotavirus enteritis (Code ICD-10: A08.0) has been matched by age and gender with one control, selected at random from the list of patients with ADD of different etiology than the case.

RESULTS

in 2008 in our clinic, a lot of 684 of children was hospitalized for at least 24 hours, for infectious ADD, in which the median age was 8 months and the prevalence of male gender was 49%. In this lot, the prevalence of rotavirus enteritis was 12.7%. Cases of rotavirus enteritis have been admitted all year round, monthly highest prevalence being of 40%. The risk of prolonged hospitalization in patients discharged with the diagnosis of rotavirus enteritis was 2.36 higher (95% Confidence Interval: 1.17-4.78; p < 0.01) than in the same age and gender children hospitalized for ADD of other etiologies.

CONCLUSIONS

our study found an annual prevalence of 2.7%, a monthly maximum prevalence of 40% and a risk of prolonged hospitalization of rotavirus enteritis of 2.36 times higher then in ADD cases of other etiologies. In our opinion, these findings encompass objective arguments sustaining that in Bucharest, the rotavirus infection represents a public health problem, with high priority in allocation of health resources, mainly for surveillance and routine immunization.

[Factors influencing the use of systemic antibiotics in hospitalized pediatric patients in Bucharest, Romania]

BACKGROUND

Formulation of effective strategies for prudent usage of antibacterial agents involves knowing of the factors that are modulating the variability of usage rate.

OBJECTIVE

analysis of the factors what modulate the usage rate's variability of antimicrobials prescribed to hospitalized children from Bucharest municipality.

METHODS

A statistically representative sample (n=895) has been extracted from the cohort of children discharged during October 2008 from the Bucharest's main pediatric university clinic. Demographic, clinic and pharmacological relevant data, captured by reviewing the subjects' medical charts were entered in an Epi Info database. For each enrolled subject the density rate of antimicrobial consumption has been calculated by dividing the pooled number of hospital days in which the subject received at least one dose of each individual antimicrobial agent, by the number of days of hospitalization. For the analysis of antimicrobials usage rate's variability, a rate higher the value calculated at 75 percentile has been defined as overuse. Personal, clinical and prescription characteristics significantly associated, in univariate analysis, with overuse status, were analyzed lately for independent association, by unconditional logistic regression.

RESULTS

to the sample's subjects up to 31 individual antimicrobials owning to the J01 group (antimicrobials for systemic use) of the ATC (Anatomical Therapeutic Chemical) classification promoted by World Health Organization were prescribed. In total, in the sample a number of 2607 days of antimicrobial therapy was cumulated, in 60% of these 5 antimicrobials agents were administered: ceftriaxone, gentamicine, cefoperazone, cefazolin and cefuroxime. Antimicrobials overuse was observed in 37% of subjects. By univariate analysis the overuse was significantly associated (p < 0,05) with the following characteristics of the subjects: age under one, with a trip in ICU, diagnosed with LRTI, with a hospitalization longer than 5 days, exposed to more than two antimicrobials agents during the same hospitalization episode and treated with 3rd generation cephalosporins. However, by multivariate analysis, only factors related to antimicrobials prescribing style remained independently associated with overuse status.

CONCLUSIONS

In children hospitalized in Bucharest, the antimicrobial agents' consumption is modulated by factors which are specific for this category of patients, factors broadly internationally recognized. Particularly, through multivariate analysis, we found that the factors related with antimicrobials prescription's style explained with the most fidelity the variation of usage density rate in the child hospitalized in Bucharest. The analysis of the modulators of the usage rate's variability is essential for issuing and evaluation of effective interventions focused on antimicrobials' prudent use.

Mortality rate in acute poisoning in a pediatric toxicology department

INTRODUCTION

Acute poisoning, an important health issue in children can result in some cases in severe evolution and even death.

OBJECTIVE

The aim of the study is to analyze cases of death caused by acute poisoning which occurred in a ten-year-period in a Pediatric Toxicology Department in Bucharest.

METHODS

For the purpose of the study all medical records of the deceased patients with acute poisoning between 1995-2004 were analyzed with particular focus on the following criteria: etiology, age, social environment, type of intoxication (unintentional or intentional).

RESULTS

Between 1995-2004, 46 fatal cases were recorded out of a total 8802 cases of acute poisoning (0.52%). The main two causes of death by acute poisoning were: caustics (16 cases--34.78%) and mushrooms (12 cases--26.08%), followed by carbon monoxide (7 cases 15.11%), pharmaceuticals (5 cases--10.86%), ethanol (2 cases--4.34%), pesticides (2 cases--4.34%), nitrites (1 case--2.17%) and lead tetraethyl (1 case--2.17%).

CONCLUSIONS

Although morbidity in acute poisoning is still high, mortality is low, the registered average being 0.52%. The main agents causing death are caustics and mushrooms, and the most affected age group is that between 1 and 5 years of age.

[Long-term treatment with desmopressin in children with primary nocturnal enuresis. An international multicenter study]

BACKGROUND

Desmopressin (an analogue of antidiuretic hormone) holds an important place in the treatment of primary nocturnal enuresis. According to some long-term trials its action is mainly symptomatic. The benefit of treatment and persistence of the effect in relation to the expected decline of enuresis in 15% children/1 year is discussed.

METHODS AND RESULTS

The open multicentre trial lasted 42 months. In the first stage 265 patients (164 boys, 101 girls) aged 9.4 +/- 2.8 (5-18 years) were given desmopressin (nasal drops) to achieve a 4-week dry integral. Enuresis stopped in 207/265 (78.1%) children within six (median) weeks of treatment after an effective dose of 10.5 micrograms (median) based on titration. During the second stage 55/265 children (25 boys and 30 girls) proceeded with treatment for 2-30 (median 12) months, one boy did not complete the trial. An effective dose was administered for 3.5 months (median) and then the dose declined depending on the effect by 3.5 micrograms (1 drop) per months (median). In the titration stage enuresis receded in 89.1% (49/55) children. After the first year of the trial there were 72.7% responders (p < 0.001, as compared with the assumed decline), after two years 70.9% (p < 0.01) and after three years 61.1% children (p < 0.05). The trial was completed by 61.1% (33/54) children as respondents. 23 of them 17-38 months after termination of treatment. 29.6% (16/54) patients were relapsing responders on long-term treatment, 5.6% (3/54) patients completed the trial as partial responders and 3.7% (2/54) children as non-responders. Minor side-effects were recorded during the titration stage in 4.5% children, during long-term treatment 5.4% children. The osmolality of morning urine increased during treatment regardless of the final effect (p < 0.01). The authors did not find a significant relationship between age, sex, familial incidence of enuresis, period of treatment and the achieved effect.

CONCLUSIONS

The authors provided evidence of a rapid onset of the effect of desmopressin and a high effectiveness throughout the trial. The osmolality of the morning urine was not a reliable predictive factor of the effect. In the authors opinion long-term treatment is important for development of regulation and regression of complaints. During a relapse the authors recommend return to maintenance treatment and gradual discontinuation after 6-12 months. Desmopressin treatment is in the authors' opinion safe, well tolerated and very useful.