Unraveling chronic kidney disease in children: a surprising manifestation of celiac disease

Celiac disease, firstly described in children, is a type of T-cell enteropathy that occurs in individuals genetically predisposed to gluten exposure. The estimated global prevalence of celiac disease is continuously increasing. Although, traditionally, celiac disease was diagnosed in children with failure to thrive and digestive issues, it is now recognized that may present with a wide range of symptoms beyond gastrointestinal ones. Celiac disease continues to pose significant challenges due to the continuous advancement of knowledge in understanding its pathophysiology, diagnosing the condition, managing its effects, and exploring potential therapeutic approaches. The prevalence of celiac disease is increased among individuals with chronic kidney disease, also. The most frequent associations are with diabetic nephropathy, IgA nephropathy and urolithiasis. A gut-kidney axis has been recognized to play a significant role in chronic kidney diseases. This literature review aims to review the chronic renal pathology associated with celiac disease, with emphasis on childhood.

Celiac disease - a pluripathological model in pediatric practice

Being defined as an autoimmune, chronic pathology, frequently encountered in any age group, but especially in pediatrics, celiac disease (also called gluten enteropathy), is gaining more and more ground in terms of diagnosis, but also interest in research. The data from the literature of the last decades attest the chameleonic way of its presentation, there may be both classic onset symptoms and atypical symptoms. Given the impact played by celiac disease, especially in the optimal growth and development of children, the current narrative review aims to highlight the atypical presentation methods, intended to guide the clinician towards the inclusion of the pathology in the differential diagnosis scheme. To these we add the summary presentation of the general data and therapeutic lines regarding the underlying condition and the existing comorbidities. In order to place the related information up to date, we performed a literature review of the recent articles published in international databases. We bring forward the current theories and approaches regarding both classic celiac disease and its atypical manifestations. Among these we note mainly constitutional, skin or mucous, bone, neuro-psychic, renal, reproductive injuries, but also disorders of biological constants and association with multiple autoimmunities. Knowing and correlating them with celiac disease is the key to optimal management of patients, thus reducing the subsequent burden of the disease.

Current Approaches in the Multimodal Management of Asthma in Adolescents-From Pharmacology to Personalized Therapy

Asthma and adolescence are two sensitive points and are difficult to manage when they coexist. The first is a chronic respiratory condition, with frequent onset in early childhood (between 3 and 5 years), which can improve or worsen with age. Adolescence is the period between childhood and adulthood (12-19 years), marked by various internal and external conflicts and a limited capacity to understand and accept any aspect that is delimited by the pattern of the social circle (of the entourage) frequented by the individual. Therefore, the clinician is faced with multiple attempts regarding the management of asthma encountered during the adolescent period, starting from the individualization of the therapy to the control of compliance (which depends equally on the adverse reactions, quality of life offered and support of the close circle) and the social integration of the subject, communication probably having a more important role in the monitoring and evolution of the condition than the preference for a certain therapeutic scheme. Current statistics draw attention to the increase in morbidity and mortality among children with bronchial asthma, an aspect demonstrated by the numerous hospitalizations recorded, due either to an escalation in the severity of this pathology or to faulty management. The purpose of this article is to review the delicate aspects in terms of controlling symptoms and maintaining a high quality of life among teenagers.

Exploring a Complex Interplay: Kidney-Gut Axis in Pediatric Chronic Kidney Disease

The human intestinal microbiota is a highly intricate structure with a crucial role in promoting health and preventing disease. It consists of diverse microbial communities that inhabit the gut and contribute to essential functions such as food digestion, nutrient synthesis, and immune system development. The composition and function of the gut microbiota are influenced by a variety of factors, including diet, host genetics, and environmental features. In pediatric patients, the gut microbiota is particularly dynamic and vulnerable to disruption from endogenous and exogenous factors. Recent research has focused on understanding the interaction between the gut and kidneys. In individuals with chronic kidney disease, there is often a significant disturbance in the gut microbiota. This imbalance can be attributed to factors like increased levels of harmful toxins from the gut entering the bloodstream, inflammation, and oxidative stress. This review looks at what is known about the link between a child's gut-kidney axis, how dysbiosis, or an imbalance in the microbiome, affects chronic kidney disease, and what treatments, both pharmaceutical and non-pharmaceutical, are available for this condition.

The Disease with a Thousand Faces and the Human Microbiome-A Physiopathogenic Intercorrelation in Pediatric Practice

Numerous interrelationships are known in the literature that have the final effect of unmasking or influencing various pathologies. Among these, the present article aims to discuss the connection between systemic lupus erythematosus (SLE) and the human microbiome. The main purpose of this work is to popularize information about the impact of dysbiosis on the pathogenesis and evolutionary course of pediatric patients with SLE. Added to this is the interest in knowledge and awareness of adjunctive therapeutic means that has the ultimate goal of increasing the quality of life. The means by which this can be achieved can be briefly divided into prophylactic or curative, depending on the phase of the condition in which the patient is. We thus reiterate the importance of the clinician acquiring an overview of SLE and the human microbiome, doubled by in-depth knowledge of the physio-pathogenic interactions between the two (in part achieved through the much-studied gut-target organ axes-brain, heart, lung, skin), with the target objective being that of obtaining individualized, multimodal and efficient management for each individual patient.

The Footprint of Microbiome in Pediatric Asthma-A Complex Puzzle for a Balanced Development

Considered to be of greater complexity than the human genome itself, the microbiome, the structure of the body made up of trillions of bacteria, viruses, and fungi, has proven to play a crucial role in the context of the development of pathological processes in the body, starting from various infections, autoimmune diseases, atopies, and culminating in its involvement in the development of some forms of cancer, a diagnosis that is considered the most disabling for the patient from a psychological point of view. Therefore, being a cornerstone in the understanding and optimal treatment of a multitude of ailments, the body's microbiome has become an intensively studied subject in the scientific literature of the last decade. This review aims to bring the microbiome-asthma correlation up to date by classifying asthmatic patterns, emphasizing the development patterns of the microbiome starting from the perinatal period and the impact of pulmonary dysbiosis on asthmatic symptoms in children. Likewise, the effects of intestinal dysbiosis reflected at the level of homeostasis of the internal environment through the intestine-lung/vital organs axis, the circumstances in which it occurs, but also the main methods of studying bacterial variability used for diagnostic purposes and in research should not be omitted. In conclusion, we draw current and future therapeutic lines worthy of consideration both in obtaining and maintaining remission, as well as in delaying the development of primary acute episodes and preventing future relapses.

Pediatric COVID-19 and Diabetes: An Investigation into the Intersection of Two Pandemics

Coronavirus disease 2019 (COVID-19) is a complex infectious disease caused by the SARS-CoV-2 virus, and it currently represents a worldwide public health emergency. The pediatric population is less prone to develop severe COVID-19 infection, but children presenting underlying medical conditions, such as diabetes mellitus, are thought to be at increased risk of developing more severe forms of COVID-19. Diabetic children face new challenges when infected with SARS-CoV-2. On one hand, the glycemic values become substantially more difficult to manage as COVID-19 is a predisposing factor for hyperglycemia. On the other hand, alongside other risk factors, high glycemic values are incriminated in modulating immune and inflammatory responses, leading to potentially severe COVID-19 cases in the pediatric population. Also, there are hypotheses of SARS-CoV-2 being diabetogenic itself, but this information is still to be confirmed. Furthermore, it is reported that there was a noticeable increase in the number of cases of new-onset type 2 diabetes among the pediatric population, and the complications in these patients with COVID-19 include the risk of developing autoimmune diseases under the influence of stress. Additionally, children with diabetes mellitus are confronted with lifestyle changes dictated by the pandemic, which can potentially lead to the onset or exacerbation of a potential underlying anxiety disorder or depression. Since the literature contains a series of unknowns related to the impact of COVID-19 in both types of diabetes in children, the purpose of our work is to bring together the data obtained so far and to identify potential knowledge gaps and areas for future investigation regarding COVID-19 and the onset of diabetes type 1 or type 2 among the pediatric population.

Is There a Potential Link between Gastroesophageal Reflux Disease and Recurrent Respiratory Tract Infections in Children?

BACKGROUND

The implications of gastroesophageal reflux disease in respiratory tract infections have been investigated over time. The aim of our study was to evaluate the relationship between these two pathologic entities and the outcome after proper antireflux treatment.

METHODS

A group of 53 children with recurrent respiratory tract infections admitted in the gastroenterology clinic of a children's hospital in North-East Romania was investigated for gastroesophageal reflux disease through 24 h pH-metry. Those with a Boix-Ochoa score higher than 11.99 received proton pump inhibitor treatment and were reevaluated after 2 months.

RESULTS

A total of 41 children were found with a positive Boix-Ochoa score. After 2 months of antireflux therapy, eight patients still had a positive Boix-Ochoa score.

CONCLUSIONS

Recurrent respiratory tract infections with symptoms resistant to treatment should be considered a reason to investigate for gastroesophageal reflux, because the symptoms may be due to micro- or macro-aspiration of the gastric refluxate or to an esophageal-bronchial reflex mediated through the vagal nerve.

Connection between Celiac Disease and Systemic Lupus Erythematosus in Children-A Development Model of Autoimmune Diseases Starting from What We Inherit to What We Eat

Celiac disease (CD) and systemic lupus erythematosus (SLE) are two diseases intensively studied in all age groups, with an increasing incidence at the global level, possibly due to the increased awareness of the diseases and their accurate diagnosis and as a consequence of the new research and innovation technologies that have appeared in medicine. The first is a controllable condition found in approximately 1% of the entire population in the form of a reaction to environmental stimuli affecting individuals with genetic susceptibility, causing gluten intolerance, gastrointestinal and extradigestive symptoms, starting from subclinical stages and culminating in severe malabsorption. On the other hand, lupus is an autoimmune disease with chameleon-like symptoms and found mainly in the female sex, which leaves its clinical mark on most organs, from the skin, eyes, and kidneys to the cardiovascular, pulmonary, neurological, osteoarticular, and hematological systems. Current studies focus on the correlation between celiac disease and other autoimmune pathologies such as autoimmune thyroiditis (Hashimoto and Graves-Basedow), type I diabetes, and systemic lupus erythematosus. The current review aims to present a summary of the data from the specialized literature regarding the intercurrents between celiac disease and lupus by analyzing the most recent studies published on PubMed.

Advances in Understanding the Human Gut Microbiota and Its Implication in Pediatric Celiac Disease-A Narrative Review

Celiac disease (CD) is a multifactorial disorder, defined by a complex interplay of genetic and environmental factors. Both genetic predisposition and dietary exposure to gluten are essential factors in triggering CD. However, there is proof that their presence is necessary, but not sufficient, for disease development. Through gut microbiota modulation, several additional environmental factors have shown their potential role as co-factors in CD pathogenesis. The aim of this review is to illustrate the possible mechanisms that stand behind the gut microbiota's involvement in CD pathogenesis. Furthermore, we discuss microbiota manipulation's potential role as both a preventative and therapeutic option. The available literature provides evidence that even before CD onset, factors including cesarean birth and formula feeding, as well as intestinal infection exposure, amplify the risk of CD in genetically predisposed individuals, due to their influence on the intestinal microbiome composition. Active CD was associated with elevated levels of several Gram-negative bacterial genera, including Bacteroides, Escherichia, and Prevotella, while beneficial bacteria such as lactobacilli and bifidobacteria were less abundant. Viral and fungal dysbiosis has also been described in CD, evidencing specific taxa alteration. A gluten-free diet (GFD) may improve the clinical symptoms and duodenal histopathology, but the persistence of intestinal dysbiosis in CD children under a GFD urges the need for additional therapy. Probiotics, prebiotics, and fecal microbial transplant have demonstrated their efficacy in restoring gut microbiota eubiosis in adult CD patients; however, their efficacy and safety as adjunctive therapies to a GFD in pediatric patients needs further investigation.

Predictor Factors for Chronicity in Immune Thrombocytopenic Purpura in Children

(1) Background: Immune thrombocytopenia (ITP) is an acute autoimmune blood disorder that is the main cause of thrombocytopenia in children. It is characterized by a decrease in platelets below 100 × 10⁹/L, and limited evolution with severe complications such as intracranial hemorrhage. The chronic form is defined by the persistence of thrombocytopenia more than 12 months after diagnosis. (2) Methods: We performed a retrospective study over a period of 10 years (1 January 2011-31 December 2020) at the Emergency Clinical Hospital for Children "Sf. Maria", Iasi. The aim of the study was to describe the clinical characteristics and to determine the prognostic factors in immune thrombocytopenia in children. (3) Results: In this study we included 271 children with ITP, comprising 123 females (45.4%) and 148 males (54.6%). The remission rate was higher in males, being 68.9% compared to 56.1% in females. Children with ITP under 9 years of age had a higher remission rate. Children with a platelet count > 10 × 10⁹/L at diagnosis had a higher likelihood-of-remission rate compared to patients who presented initial platelet count below this value. (4) Conclusions: The risk factors highly suggestive for chronicity are: age at diagnosis, female sex, and the number of platelets at the onset of the disease.

The Role of Urinary NGAL in the Management of Primary Vesicoureteral Reflux in Children

Vesicoureteral reflux (VUR) is the most frequent congenital urinary tract malformation and an important risk factor for urinary tract infections (UTIs). Up to 50% of children with VUR may develop reflux nephropathy (RN), and the diagnosis and monitoring of renal scars are invasive and costly procedures, so it is paramount to find a non-invasive and accurate method to predict the risk of renal damage. Neutrophil gelatinase-associated lipocalin (NGAL) has already proven to be a good predictive biomarker in acute kidney injuries, but there are few studies that have investigated the role of NGAL in primary VUR in children. Our aim is to review the predictive value of urine NGAL (uNGAL) as a non-invasive biomarker of RN in children with primary VUR, as well as its ability to predict the evolution of chronic kidney disease (CKD). Based on our analysis of the available original studies, uNGAL can be an accurate and reliable biomarker of RN and its progression to CKD. Some studies suggested a good correlation between VUR severity and uNGAL levels, but other studies found no significant correlation. The relationship between VUR severity and uNGAL levels is likely complex and influenced by factors such as UTIs, the timing of the urine sample collection, and the age and overall health of the patient.

The Overlap of Kidney Failure in Extrapulmonary Sarcoidosis in Children-Case Report and Review of Literature

Sarcoidosis is a non-necrotizing granulomatous inflammatory multisystemic disorder of unknown etiology. In children, as in adults, it can involve a few or all organ systems to a varying extent and degree, entailing multisystemic manifestations. Kidney involvement in pediatric-onset adult-type sarcoidosis is rare, with a wide range of renal manifestations, most of them related to calcium metabolism. Children with renal sarcoidosis tend to be more symptomatic than adults, although male patients have a higher prevalence. We present the case of a 10-year-old boy who presented with advanced renal failure with nephrocalcinosis and important hepatosplenomegaly. The diagnosis was established by histopathological examination, with consequent cortisone therapy and hemodialysis. This review emphasizes that sarcoidosis should be considered in the differential diagnosis of pediatric patients with acute kidney insufficiency or chronic kidney disease of an unknown etiology. As far as we know, this is the first study regarding extrapulmonary sarcoidosis in children from Romania.

The Implication of the Gut Microbiome in Heart Failure

Heart failure is a worldwide health problem with important consequences for the overall wellbeing of affected individuals as well as for the healthcare system. Over recent decades, numerous pieces of evidence have demonstrated that the associated gut microbiota represent an important component of human physiology and metabolic homeostasis, and can affect one's state of health or disease directly, or through their derived metabolites. The recent advances in human microbiome studies shed light on the relationship between the gut microbiota and the cardiovascular system, revealing its contribution to the development of heart failure-associated dysbiosis. HF has been linked to gut dysbiosis, low bacterial diversity, intestinal overgrowth of potentially pathogenic bacteria and a decrease in short chain fatty acids-producing bacteria. An increased intestinal permeability allowing microbial translocation and the passage of bacterial-derived metabolites into the bloodstream is associated with HF progression. A more insightful understanding of the interactions between the human gut microbiome, HF and the associated risk factors is mandatory for optimizing therapeutic strategies based on microbiota modulation and offering individualized treatment. The purpose of this review is to summarize the available data regarding the influence of gut bacterial communities and their derived metabolites on HF, in order to obtain a better understanding of this multi-layered complex relationship.

Hantavirus Infection in Children-A Pilot Study of Single Regional Center

BACKGROUND

Hantaviruses are infectious etiological agents of a group of rodent-borne hemorrhagic fevers, with two types of clinical manifestations in humans: hantavirus pulmonary syndrome (HPS) and hemorrhagic fever with renal syndrome (HFRS). According to available statistics, the disease occurs mainly in adults, but the lower incidence in the pediatric population might also be related to a lack of diagnosis possibilities or even unsatisfactory knowledge about the disease.

MATERIALS AND METHODS

The purpose of this study was to evaluate the cases of hemorrhagic fever with renal syndrome diagnosed and treated in the Department of Nephrology at St. Mary's Emergency Hospital for Children in Iasi, Romania, representative of the North-East of Romania. We also reviewed the specialized literature on the topic.

RESULTS

Between January 2017 and January 2022, eight cases of HFRS, all men, and seven from rural areas, aged 11-18 years old, were referred to our clinic because of an acute kidney injury (AKI). Seven cases were identified as Dobrava serotype while one case was determined by Haantan serotype.

CONCLUSIONS

HFRS should always be considered as a differential diagnosis when faced with a patient with AKI and thrombocytopenia. Dobrava serotype is the most common hantavirus subtype in the Balkans. For the specific prevention of human infections, mainly in high-risk groups, vaccines are needed. As far as we know, this is the first study on HFRS in Romanian children.

Helicobacter pylori Infection in Children: A Possible Reason for Headache?

(1) Background: The correlation between infection with Helicobacter pylori (H. pylori) and headache has been argued and explored for a long time, but a clear association between the simultaneous presence of the two in children has not been established yet. In this study, we aimed to explore this relationship in children from the Northeast region of Romania. (2) Methods: A retrospective study exploring the correlation between children having H. pylori infection and headache or migraine was conducted on a batch of 1757 children, hospitalized over 3 years in a pediatric gastroenterology department in Northeast Romania. (3) Results: A total of 130 children of both sexes had headache. From 130 children, 54 children (41.5%) also presented H. pylori infection. A significant association between headache and H. pylori infection (χ2; p < 0.01) was noticed. (4) Conclusions: More studies are needed on this relationship, and we emphasize the importance of further analyses, as they present great clinical importance for both prompt diagnosis and treatment.

Pitfalls of Thrombotic Microangiopathies in Children: Two Case Reports and Literature Review

Thrombotic microangiopathy can present itself in the form of several clinical entities, representing a real challenge for diagnosis and treatment in pediatric practice. Our article aims to explore the evolution of two rare cases of pediatric thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS) with extremely similar clinical pictures, which, coincidentally, presented at approximately the same time in our hospital. These cases and our literature review demonstrate the multiple facets of thrombotic microangiopathy, which can produce various determinations and salient manifestations even among the pediatric population. TTP and aHUS may represent genuine diagnostic pitfalls through the overlap of their clinical and biological findings, although they develop through fundamentally different mechanisms that require different therapeutic approaches. As a novelty, we underline that COVID-19 infection cannot be excluded as potential trigger for TTP and aHUS in our patients and we predict that other reports of such an association will follow, raising a complex question of COVID-19's implication in the occurrence and evolution of thrombotic microangiopathies. On this matter, we conducted literature research that resulted in 15 cases of COVID-19 pediatric infections associated with either TTP or aHUS. Taking into consideration the morbidity associated with TTP and aHUS, an elaborate differential diagnosis and prompt intervention are of the essence.

Palm-Plant Pain, Sign of a Severe Systemic Disease? Case Report and Review of Literature

Fabry disease is an X-linked lysosomal storage disease, second in prevalence after Gaucher disease. The onset of symptoms occurs in childhood or adolescence with palmo-plantar burning pains, hypo hidrosis, angiokeratomas, and corneal deposits. In the absence of diagnosis and treatment, the disease will progress to the late phase, characterized by progressive cardiac, cerebral and renal damage, and possible death. We present the case of an 11-year-old male boy who was transferred to the Pediatric Nephrology Department for palmo-plantar burning pain and end stage renal disease. Following the evaluations for the etiology of end stage renal disease we excluded the vasculitis, the neurologic diseases, extrapulmonary tuberculosis. Because of suggestive aspect at CT scan and lack of etiologic diagnosis of renal insufficiency we performed lymph node and kidney biopsy, with a surprising result for storage disease. The specific investigation confirmed the diagnosis.

Unusual Association of Diamond-Blackfan Anemia and Severe Sinus Bradycardia in a Six-Month-Old White Infant: A Case Report and Literature Review

Diamond-Blackfan anemia is a rare (6-7 million live births), inherited condition manifesting as severe anemia due to the impaired bone marrow production of red blood cells. We present the unusual case of a six month old infant with a de novo mutation of the RPS19 gene causing Diamond-Blackfan anemia who additionally suffers from severe sinus bradycardia. The infant was diagnosed with this condition at the age of four months; at the age of 6 months, she presents with severe anemia causing hypoxia which, in turn, caused severe dyspnea and polypnea, which had mixed causes (hypoxic and infectious) as the child was febrile. After correction of the overlapping diarrhea, metabolic acidosis, and severe anemia (hemoglobin < 3 g/dL), she developed severe persistent sinus bradycardia immediately after mild sedation (before central venous catheter insertion), not attributable to any of the more frequent causes, with a heart rate as low as 49 beats/min on 24 h Holter monitoring, less than the first percentile for age, but with a regular QT interval and no arrhythmia. The echocardiogram was unremarkable, showing a small interatrial communication (patent foramen ovale with left-to-right shunting), mild left ventricular hypertrophy, normal systolic and diastolic function, and mild tricuspid regurgitation. After red cell transfusion and appropriate antibiotic and supportive treatment, the child's general condition improved dramatically but the sinus bradycardia persisted. We consider this a case of well-tolerated sinus bradycardia and foresee a good cardiologic prognosis, while the hematologic prognosis remains determined by future corticoid response, treatment-related complications and risk of leukemia.

Difficulties in Adaptation of the Mother and Newborn via Cesarean Section versus Natural Birth-A Narrative Review

Birth is a physiological act that is part of the morpho-functional economy of the maternal body. Each stage in the act of birth has a predetermined pathway that is neurohormonally induced and morpho-functionally established through specific and characteristic adaptations. Like maternity, childbirth also has an important impact on the maternal body as a biological structure and psycho-emotional behavior. Cesarean section performed at the request of the mother with no medical underlying conditions besides the prolonged hospitalization risk can also cause breathing problems in children, delayed breastfeeding, and possible complications in a future pregnancy. Vaginal birth remains the path of choice for a physiological evolution pregnancy. Although erroneously considered safe and easy today, cesarean section delivery must remain an emergency procedure or a procedure recommended for pregnancies where birth is a risk to the mother and to the child, as cesarean section itself is a risk factor for negative outcomes for both mother and baby. This review summarizes the impact that both cesarean section and natural birth have on mother and newborn in their attempt to adapt to postpartum events and extrauterine life.

Pediatric Systemic Lupus Erythematous in COVID-19 Era

Pediatric systemic lupus erythematosus is a chronic autoimmune disorder with a highly variable course and prognosis. It results in functional abnormalities in the immune system due to intrinsic factors and the use of immunosuppressive therapies associated with underlying comorbidities seem to increase the risk of severe COVID-19 and poor outcomes of the disease in pediatric systemic lupus erythematosus (SLE) patients. The aim of this review is to obtain a better understanding of the existing link between this new viral infection and pediatric lupus. We have analyzed the characteristics of newly diagnosed cases of pediatric SLE following COVID-19 which have been reported in the literature and which describe the impact that COVID-19 has on patients already suffering with pediatric SLE.

Iron Deficiency Anemia in Pediatric Gastroesophageal Reflux Disease

(1) Background: Gastroesophageal reflux disease (GERD) can cause several complications as a result of the acidic pH over various cellular structures, which have been demonstrated and evaluated over time. Anemia can occur due to iron loss from erosions caused by acidic gastric content. In children, anemia has consequences that, in time, can affect their normal development. This study evaluates the presence of anemia as a result of pediatric gastroesophageal reflux disease. (2) Methods: 172 children were diagnosed with gastroesophageal reflux in the gastroenterology department of a regional children's hospital in northeast Romania by esophageal pH-metry and they were evaluated for presence of anemia. (3) Results: 23 patients with GERD from the studied group also had anemia, showing a moderate correlation (r = -0.35, p = 0.025, 95% confidence interval) and lower levels of serum iron were found in cases with GERD, with statistical significance (F = 8.46, p = 0.012, 95% confidence interval). (4) Conclusions: The results of our study suggest that there is a relationship between anemia or iron deficiency and gastroesophageal reflux due to reflux esophagitis in children, which needs to be further studied in larger groups to assess the repercussions on children's development.

Full factorial design and dynamic modelling of silent and ultrasound-assisted lead and cadmium removal by porous biosorbent

Present work aimed to analyse single and competitive lead and cadmium batch adsorption, using experimental studies and mathematical modelling. The experiments were conducted in silent and ultrasound-assisted systems, in aqueous environment, using grinded hazelnut shells as porous biosorbent. The influence of process factors (pH, adsorbent concentration, adsorbent particle size, and initial species concentration in liquid phase) on species removal efficiency was evaluated when process equilibrium was attained. The statistical study, following a 2⁴ factorial experimental design, allowed the development of a model to predict variables influence. Based on the obtained results a deeper analysis of the separation efficiency, depending on process factors, was conducted. The dynamic study was performed based on experimentally obtained removal rates, modelled considering species diffusion, with reversible kinetics of sorption inside solid particles. Hence, the dynamics of removal efficiency was determined for several representative experiments. The equilibrium isotherms data, best fitted by an appropriate Langmuir model, were used in the dynamic model to reduce the number of model parameters which normally require experimental identification.

The Use of Clinical Scores in the Management of Immune Thrombocytopenic Purpura in Children

While the majority of children with recently diagnosed ITP have a benign, self-limiting condition, most often with a spontaneously recovery, 40% of children with ITP progress toward persistent ITP and 10-20% goes toward chronicity. Several clinical scores have been developed with the aim to perform a better monitoring outcome or to differentiate transient vs. persistent ITP (e.g., Donato score). Our paper aims to describe and to compare the most important scores used in the management of ITP in children: bleeding severity scores and chronicity prediction scores. These scores include a combination of different already known risk factors: age, gender, presence of a previous infections or vaccination, bleeding grade, type of onset, platelet count at diagnosis. The real utility of these scores has been a matter of debate and no consensus has been reached so far as to their necessity to be implemented as compulsory tool in the care of children with ITP.

Otitis Media and Obesity-An Unusual Relationship in Children

Otitis media (OM) represents a public health matter, being the main cause of preventable hearing loss in pediatric patients. Besides well-established risk factors for developing OM, such as craniofacial abnormalities, prematurity, low birth weight, or tobacco exposure, there is evidence that obesity could be associated with a high incidence of OM. Our aim is to perform a literature review on the state of current published research on the relationship between OM and obesity and to discuss the interconnectivity between these two entities. We conducted an electronic search in PubMed and EMBASE databases. Out of 176 references, 15 articles were included in our study. Our findings suggest that obesity and overweight might be risk factors for developing OM, and vice versa. The main mechanisms for developing OM in obese patients include alteration in cytokine profile, increased gastroesophageal reflux, and/or fat accumulation. Conversely, ear infections exposure might increase the risk of obesity, mostly by taste changes through middle ear cavity inflammation.

Uncommon erythema multiforme in small children: experience of a single Romanian pediatric unit: Two case reports

RATIONALE

Erythema multiforme (EM) is an immune-mediated disease with mucocutaneous localization and plurietiologic determinism. The term "multiforme" refers to the variety of aspects that the lesions can take from patient to patient and during evolution in a single patient.

PATIENT CONCERNS

We have selected 2 cases of small children diagnosed with different etiology of EM to illustrate the importance of a correct and fast diagnosis. Case 1 involves a 2-year-old girl from a rural area who presented with fever and pruritic erythematous papular eruption. The onset of the symptoms was 3 days before presentation with fever and ulcerative lesions on the oral and labial mucosa, followed by the appearance of erythematous macular lesions, with progressive confluence to intense pruritic patches. The 2nd involves a 2-year-old boy with fever, loss of appetite, productive cough, and petechiae. He had corticosensible immune thrombocytopenia from the age of 6 months, with many recurrences. The patient received treatment with ampicillin/sulbactam and symptomatics for an erythemato-pultaceous angina. During the 2nd day of treatment the patient developed an erythematous macular eruption on the face, scalp, trunk, and limbs, with bullae formation.

DIAGNOSES

The 1st patient was diagnosed based on biologic findings: positive inflammatory syndrome, elevated level of anti-Mycoplasma pneumoniae immunoglobulin M antibodies and immunoglobulin E. Histopathologic examination described papillary dermal edema, inflammatory infiltrate, and lymphocyte exocytosis. In the 2nd case, the hemoleucogram identified 12,000/mm platelets and the medulogram aspect was normal. Serology for Epstein-Barr virus was negative. The diagnosis was EM secondary to M pneumoniae infection in case 1 and secondary to administration of ampicillin/sulbactam in case 2.

INTERVENTIONS

In both cases, etiopathogenic treatment consisting of steroidal antiinflammatory drugs, antihistamines was administered. Because of specific etiology, the 1st case received antibiotics.

OUTCOMES

The evolution was favorable in 10 to 14 days; the patients were discharged after etiopathogenic treatment consisting of steroidal antiinflammatory drugs, antihistamines, and/or antibiotics.

LESSONS

Performing a detailed clinical examination, medical history of drug use, infection or general diseases can establish a good diagnosis of EM. Histopathologic examination can help. The treatment is etiologic, pathogenic, and symptomatic. EM usually has a self-limited evolution.

Synthesis and electronic properties of polycyclic aromatic hydrocarbons doped with phosphorus and sulfur

Synthesis and physical properties of polyaromatic hydrocarbons containing phosphole and thiophene rings at the edge.

Endoscopic palliation of advanced esophageal cancer

Esophageal cancer represents one of the most aggressive digestive tumors, with a survival rate at 5 years of only 10%. Globally, during the last three decades, there has been an increasing incidence of the esophageal cancer, approx. 400,000 new esophageal cancers being currently diagnosed annually. This represents the eighth leading cause of cancer incidence and the sixth leading cause of cancer death overall. Taking into account the population's global aging and thus, the increase in the number of patients who will not bear surgery, PCT and radiation, or the fact that they do not want it especially because of deficiencies and associated pathology, the endoscopic ablative techniques with palliation purposes represent the alternative. If we refer to the Western Europe countries and North America, we notice an increase of esophageal adenocarcinoma rate versus squamous cancer. As for the Asian region, referring in particular to China and Japan, 9 out of 10 esophageal cancers are squamous cell carcinomas. For at least half of the patients with EC (esophageal cancer) there is no hope of healing because of the advanced regional malignant invasion (T3-4, N+, M+) with no chemo and radiotherapy response, poor preoperative patients' conditions or systemic metastasis. The low life expectancy does not justify the risky medical procedures, the goal of the therapy consisting in the improvement of the quality of life by eliminating dysphagia (reestablishing oral feeding) which represents the most common complication of EC, the respiratory tract complication caused by eso-tracheal fistulas or by eliminating chest pain. To treat dysphagia, which is the main target of palliation, combined methods like endoscopic, chemo and radio-therapy, can be used, each one with indications, benefits and risks.

Current endoscopic methods of radical therapy in early esophageal cancer

During the last three decades, there has been an increasing incidence of the esophageal cancer at the global level, approx. 400,000 new esophageal cancers being currently diagnosed annually. This is the eighth leading cause of cancer incidence and the sixth leading cause of cancer death overall. If we refer to the countries of Western Europe and North America, we could see an increase in the esophageal adenocarcinoma in detriment of squamous cancer. As for the Asian region, referring in particular to China and Japan, 9 out of 10 esophageal cancers are squamous cell carcinomas. Considering that the incidence of gastric cancer in Japan is very high, the endoscopic screenings performed inevitably led to an increased rate of early detection of esophageal cancer, reaching approximately 20% of all esophageal cancers detected. This has led to the possibility of developing therapeutic endoscopic techniques with radical visa that we will describe while presenting comparative data from literature. Currently, however, there are not enough data on the effectiveness of these types of therapies, compared to surgery, in order to be transformed into standard therapeutic endoscopic treatment for early esophageal cancer. However, the combined therapy, resection/ endoscopic ablation + chemoradiotherapy, appears as an alternative to be taken into account. Abbreviations EEC = esophageal early cancer, BE = Barrett's esophagus, HGD = High-grade dysphagia, EUS = Ultra sound endoscopy, CT = Computer tomograph, UGE = Upper gastro endoscopy, PET-CT = Positron Emission Tomography, FNAB = Fine needle aspiration biopsy, EMR = Esophageal mucosal resection, ESD = Esophageal submucosal dissection, SCC = Squamous cellular cancer, PCT = Poli-chemotherapy, RT- Radio-therapy.

Protective effect of grape seed extract in experimental menopausal syndrome

Grape seed extract (GSE) is a natural product obtained from Vitis vinifera seeds; it has been used as adjuvant therapy in wide range of pathological conditions.

AIM

In the present study, we investigated the ability of GSE to improve the mental status on ovariectomized rats.

MATERIAL AND METHODS

GSE (10 mg/kg/day, 60 days long) was administrated orally on ovariectomized adult female rats; then the animals were investigated in open field. Additionally, were measured the hematological parameters, the plasma biochemistry, and the oxidative stress markers.

RESULTS AND DISCUSSION

Treatment of GSE improved the loco motor activity in the open field, the number of crossings were almost twice in GSE treated rats (22.25 +/- 8.75) compared to placebo group (13.00 +/- 2.62) (p < 0.05). Lipid peroxides were reduced up to 51.57% (p < 0.05), while hematology and plasma biochemistry remained almost unchanged.

CONCLUSION

GSE improve the mental status and reduced the level of oxidative stress in rats subject to experimental ovariectomy.

Multifactorial etiopathogeny of Henöch-Schönlein purpura in pediatric age

Henöch-Schönlein purpura is a small-vessel vasculitis characterized by an abnormal response of the immune system: immunoglobulin A (IgA), C3 and immune complex deposition in arterioles, capillaries and venules. The syndrome is mostly seen in children, but it may affect people of any age. It is more common in boys than in girls. The etiology of Henöch-Schönlein purpura is unknown. Multiple infectious agents as well as drugs, foods, and insect bites may trigger Henöch-Schönlein purpura. Susceptibility to HSP may have a genetic origin. Several reports suggest that deficiency of complement 4 (C4) from deletion of C4 genes predisposes patients to IgA nephropathy and HSP nephritis.

Etiopatogenia multifactorială a purpurei Henöch-Schönlein la vârsta pediatrică

Purpura Henöch-Schönlein (PHS) este o afecţiune a vaselor mici caracterizată printr-un răspuns anormal al sistemului imun: imunoglobulina A (IgA), fracţiunea a 3-a a complementului şi depunerea de complexe imune circulante în pereţii arteriolelor, venulelor şi a capilarelor. Sunt afectaţi predominant copiii, dar simptomatologia poate apărea şi la vârsta adultă. Boala este mai frecventă la pacienţii de sex masculin. Etiologia purpurei nu este deocamdată cunoscută, însă se pare ca există anumiţi factori de risc pentru apariţia acesteia: agenţi infecţioşi (Streptococ, parvovirusuri), înţepături de insecte, alimente sau medicamente (antibiotice, antihistaminice). Susceptibilitatea la PHS poate avea origine genetică. Numeroase rapoarte sugerează că deficienţa complementului (C4) datorată deleţiei genelor ce codează sinteza acestei fracţiuni determină predispoziţia la nefropatie IgA şi la nefrita Henöch-Schönlein.

[Surgical treatment of esophageal diverticula]

The aim of this paper is to evaluate the methods and therapeutic principles of esophageal diverticula pathology. We analyze the main pathological mechanisms which establish the therapeutic attitude linked with a complex pretherapeutic evaluation. In our study we enrolled 12 patients operated between 2001-2009 for esophageal diverticula with different topography. In this period of time there were much more patients diagnosed with this pathology, but the need for surgery was establish very tight regarding the actual practical guide which impose the identification and interception of physiological mechanisms by the surgical procedure. We highlight the particular technical details, as well as the important differences of postoperatory complications according to the topography of the diverticula pouch.

[Principles of treatment in locally advanced esophageal squamous cancer]

The diagnosis established in the symptomatic phase of this disease, most often occurs at advanced stage neoplasia. The purpose of this article is to establish the place and method of surgical and radio-chemo therapy in advanced loco-regional squamous esophageal neoplasm (stage IIB-III). Surgical treatment establishes the best results over long periods of time, however, this is done keeping in mind acceptable morbidity and mortality conditions. Multimodal treatment is encompassed in general efforts to achieve optimal results along with increasing the quantity and quality of life. Neoadjuvant radiochemotherapy (CRT) increases practitioners' possibility of resecting tumors, decreasing their size, and establishing proper means of local (radiotherapy) and systemic (chemotherapy) control. Great efforts are made in finding markers which lead to correct diagnosis and treatment options that will further permit nonresponsive radio and chemo therapy treated patients from experiencing unwanted toxicity. The role of adjuvant therapy is that of decreasing recurrence in patients with residual mediastinal disease after palliative surgical resection. Palliative treatment consists of improving dysphagia, and the quality of life using surgical, endoscopic, photodynamic, laser, radio and chemotherapy as alternatives.

[Long-term survival after eso-gastrectomy for esophagogastric junction adenocarcinoma--prospective study]

Detection of the esophagogastric junction adenocarcinoma in symptomatic stage determine a low survival. The aim of the study was to identify the prognostic factors after eso-gastrectomy for esophagogastric junction adenocarcinoma. There was done a prospective study of a 43 patients with esophago-gastric resections and abdomino-mediastinal lymph nodes dissection between 2001 and 2006 at the General and Esophageal Surgery "St. Mary" Clinical Hospital: 25 patients with transhiatal total gastrectomy, 6 patients with total gastrectomy and distal esophagectomy by separated incisions, abdominal and thoracic, 3 patients with total gastrectomy and subtotal esophagectomy by abdomino-cervical approach, 9 patients with subtotal esophagectomy by abdomino-cervical approach with cu small gastric curvature resection, radical resections in 22 patients. The patients were followed by clinic, endoscopic, TC exam and tumoral markers. There were done complex statistic analysis using SPSS 16.0. The mean interval of the surveillance was 24 months (6 - 60 months). 1 year survival was 77,74%. Long-term survival was influenced by age (p_value = 0.0129), tumoral grading (p_value = 0.0297), the number of lymph nodes metastasis (p_value = 0.0029) and pT stage (p_value = 0.0139), and was not dependent on Siewert type, ASA class, surgical approach, resection type, the number of the dissected lymph nodes, abdominal or mediastinal. In locally advanced esophagogastric junction adenocarcinoma, the frequency of lymph nodes metastasis (81%) especially in patients with tumoral type III and unfavorable results of surgical treatment as unique therapeutically method show the necessity of a multimodal approach pre and post-operatory by using selection methods with a good prediction of neoadjuvant treatment.

[Total duodenal diversion in hiatal hernia with pathological duodenoesophageal reflux (preliminary results)]

For some patients, reflux disease means also duodenogastric, as well as gastroesophageal reflux; they may suffer because of duodenoesophageal reflux. For these patients, a simple surgical restoration of the cardial competence may prove to be insufficient; on the contrary, an indirect approach, using vagotomy and duodenal diversion may be a good therapeutical option in selected cases. In our hands, total duodenal diversion has already proven to be a good technical solution for the surgical treatment of the postoperative reflux disease, so we decided to expand its first choice indications to hiatal hernia cases, in the presence of duodenoesophageal reflux. Therefore, our study presents the results of the first 7 cases, operated on since 1995. No case had been gastric operated before, but 4/7 had already suffered a cholecystectomy. Duodenoesophageal reflux is discussed: etiopathogenesis related to surgical approach, using standard antireflux surgery (failures of the hiatal techniques and their causes) or total duodenal diversion (technical aspects, antireflux efficiency, secondary functional effects, pros and cons, therapeutical indications).

Monolayer properties of archaeol and caldarchaeol polar lipids of a methanogenic archaebacterium, Methanospirillum hungatei, at the air/water interface

Monolayer studies at the air/water interface were carried out on the major tetraether (caldarchaeol-) derived phosphoglycolipid, Glcp-alpha(1-2)-Galf-beta(1-1)-caldarchaeol-phosphoglycerol (PGC-I), the major diether (archaeol-) derived glycolipid, Glcp-alpha(1-2)-Galf-beta(1-1)-archaeol (DGA-I), the major archaeol-derived phospholipids, phosphatidyl-N,N dimethylaminopentanetetrol (PPDAA) and phosphatidyl-N,N,N-trimethylaminopentanetetrol (PPTAA) and the minor caldarchaeol-derived glycolipid, Glcp-alpha(1-2)-Galf-beta(1-1)-caldarchaeol (DGC-I) isolated from the methanogenic archaebacterium, Methanospirillum hungatei. The compression isotherms obtained showed that the two tetraether lipids had molecular surface areas about twice those of the diether lipids at all surface pressures, suggesting that both polar headgroups of the tetraether lipids are anchored into the aqueous subphase, even at the collapse pressure pi c. A U-shaped hydrocarbon chain conformation thus appears to be preferred for the tetraether lipids at the air/water interface, rather than an extended chain arrangement. The compression isotherms of the two tetraether lipids PGC-I and DGC-I were very similar at pH 0, both molecules being uncharged, but at pH 5.6 or 8, PGC-I films were much more expanded than the neutral DGC-I, due to ionization of the phosphate group in PGC-I and the resulting charge-charge repulsion. Monolayers of the zwitterionic diether phospholipids PPDAA and PPTAA were much less compressible than the glycosylated lipids, PGC-I, DGC-I and DGA-I, because the latter lipids contain the more compressible diglycosyl headgroup, oriented in horizontal conformation at low surface pressures, compared to the lower compressibility of the zwitterionic headgroup in the vertical conformation, particularly at pH 0 and 5.6.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of stearic acid monolayers upon the procaine adsorption from underlying alkaline aqueous solutions

Adsorption of procaine at the air/water interface and its penetration into stearic acid monolayers from aqueous subphase of pH 8 are studied by measuring surface tension of aqueous procaine solutions and by recording surface pressure vs. mean molecular area curves for stearic acid monolayers spread onto procaine solutions of different concentrations. The amount of procaine in the interface is derived by means of Gibbs' equation. Results are compared to those obtained earlier at pH 2 and on unbuffered subphases. With increasing pH an increasing procaine adsorption and procaine penetration is observed. This phenomenon is interpreted in terms of protolytic equilibria in which participate both surfactants procaine and stearic acid.

[Epidemic focus of Q fever in a rural location in the Suceava district]

A Q fever epidemic focus with 46 cases was detected in a rural locality among the workmen of livestock farms. In 33 cases, the subclinical and inapparent form of the disease was detected by serologic tests, performed in the focus. Complement fixation antibody titers persisting in very high titers, a retrospective diagnosis of infection may be established even 3-4 months after the onset of the disease.

[Therapeutic results in an epidemic outbreak of dysentery]

The therapeutical results obtained in an epidemical outbreak of dysentery caused by Shigella flexneri type 2 A are reported, emphasizing the bacteriological failure of the treatment with Furazolidin in 52.1% of the cases and the good results obtained with Neomycin (Mycerine).