[Essential hypertension in children--risk factors and target organ damage]. / Hipertensiunea arteriala esentiala la copil--factori de risc si afectarea organelor tinta.

UNLABELLED: Regarding that systemic hypertension is an important condition in childhood, we try to clarify existing data about this pathology. MATERIAL AND METHODS: The aim of our study was to evaluate the incident cases of essential hypertension in children admitted during a four years period in the Children Hospital "Sf. Maria" Iasi, Romania. The study included 60 children with essential hypertension. RESULTS: 10 (16,7%) of children were in prehypertension group, 38 (63,3%) have stage 1 hypertension and 12 (20%) have stage 2 hypertension. We objectivate a different gender distribution - boy/girl: 1,5/1. The frequency of essential hypertension increased with age, the incidence was higher over 14 years. We established a statistically significant relationship between the essential hypertension body mass index and prematurity (gestation age under 37 weeks). Left ventricular hypertrophy was objectivated in 26,7% of cases. CONCLUSIONS: Essential hypertension in children is a pathology with increasing prevalence nowadays. This is due to synergic action of multiple risk factors involved. That is why is important to know and to prevent as much as possible this disease.

[Procalcitonine--early marker of neonatal infection]. / Procalcitonina marker rapid al infectiei neonatale.

UNLABELLED: Neonatal infection represents the third most important cause of mortality in Neonatal Intensive Care Units (NICU), following perinatal asphyxia and respiratory distress syndrome. The incidence varies according to the level of care, between 5% in level II neonatal wards and 20% in the NICUs. The lack of specific early markers for infection could be partially responsible for the lack of antibiotic treatment or unnecessary treatment. In this context, many variables were examined as markers for sepsis. Large concentrations of C-reactive proteine (CRP) and procalcitonine (PCT) were positively correlated with the severity of the infection and generally indicated a poor outcome. AIM: The aim of this study is to demonstrate the utility of PCT as a fast, early and routinely used marker of neonatal infection, correlated with CRP, clinical symptoms and blood cultures. MATERIALS AND METHODS: this is a retrospective-prospective study on 2 lots of newborns from two neonatal wards of different levels of care (Lot I - 32 newborns from the Cuza-Voda NICU in Iasi, born in 2010, Lot II - 127 newborns from the Buna Vestire Maternity in Galati, born during 2008-2009). PCT was assessed before the beginning of the antibiotic treatment in newborns with high risk of sepsis or newborns with proven sepsis as corroborated with complete blood counts, CRP, fibrinogen, clinical symptoms and blood cultures. RESULTS: Among risk factors for neonatal infection, those found more often in newborns with proven sepsis are: ruptured membranes over 18 hours (p=0.043), Gram-negative bacilli colonization (p=0.003), respiratory distress syndrome (p=0.0008), abdominal distention (p=0.0042), oedema (p<<0.05) and necrotizing enterocolitis (p<<0.05). High values for PCT in premature newborns show the high risk for infection for this category of newborns, due to immunological imaturity and the presence of risk factors. High sensitivity and specificity of PCT (specificity =88.98%, sensitivity=87.5%) showed that the accuracy of PCT assessment in studied lots was 88.68% during the 24-72 hours of life time frame. CONCLUSION: High serum levels of PCT in studied lots plead for the usage of PCT for the fast and early diagnostis of neonatal infection. In those cases with positive PCT and negative blood cultures or positive CRP and clinical symptoms of infection, PCT would be a useful tool, aiding in the initiation or termination of antibiotic treatment, which would ultimately lead to lowering costs. PCT as a screening tool for cases with risk factors for infection is still to be analysed in terms of costs versus benefits and the longterm implications of neonatal sepsis and antibiotic treatment.

[Effect of preoperative administration of prostaglandin E1 on cerebral blood flow in newborns with ductal-dependent congenital cardiac malformations]. / Efectele administrarii preoperatorii a prostaglandinei E1 asupra fluxului sanguin cerebral la nou-nascutul cu malformatie congenitala cardiaca ducto-dependenta.

UNLABELLED: Although the absolute number of congenital structural heart disease has not changed over the years, more and more infants undergo surgical interventions in the neonatal period, increasing the number of children and adults with post surgical status of cardiac disorders. Prostaglandin E1 (PGE1) is the first line drug to maintain or reopen the ductus arteriosus, until surgical intervention can be made. Cerebral blood flow (CBF) is regulated by multiple factors, like pO2, pCO2, pH, cardiac output and systemic blood pressure. The aim of the study was to determine how CBF changes after PGE1 administration in these newborns. MATERIALS AND METHODS: We studied the pO2, pCO2, mean systemic blood pressure, and cerebral blood flow velocities by colored and pulsed Doppler ultrasonography in 36 newborns with ductal dependent cardiac malformation before and after prostaglandin E1 administration, and correlated them to normal values for the age. RESULTS: We found that cerebral blood flow velocities followed the variations of blood pressure in restricted pulmonary circulation; improvement of oxygenation went parallel with decrease of cerebral diastolic velocities, and in aortic coarctation cerebral velocities decreased after introduction of PGE1. CONCLUSIONS: PGE1 administration improved cerebral blood flow velocities in all forms of cardiac malformations, due to reorganization of cardiac output and changes in oxemia. Key

[Disorders of the acid-basic balance in the post-hypoxic suffering at newborn babies]. / Perturbari ale echilibrului acido bazic in suferinta posthipoxicu la nou-nascut.

UNLABELLED: The study aims to asses the acid-basic disorders and the blood gasses in the blood of the umbilical cord and their correlation with the evolution of the newborn baby in the maternity hospital. MATERIAL AND METHOD: 157 newborns with perinatal asphyxia hospitalized (2002-2005) in the Maternity of "Sf. Apostol Andrei" Clinical Emergency Hospital of Galati, following-up the gestation age, the Apgar score, the risk factors of perinatal asphyxia, the pH in the cord and the evolution of the blood gasses in the cord, the start and evolution of neurologic disorders. RESULTS: The main risk factors for the asphyxia production: prematurity (64% of the cases and 25% of the cases with gestation age below 30 weeks), HTA induced in pregnancy, IUGR 39.4%. The Apgar score at one minute: values between 0-3 (40.8% cases), progressively decreasing to 20 minutes in 1.3%. 50% of the new born babies showed severe acidosis in the cord: pH > 6, 9, hypoxia in the cord blood was of 75%. The neurologic disorders started from the birth in all cases, with evolution to decease in 25.5% of the cases, higher incidence in prematures and a significant correlation with the pH in the cord.

[Aspects of practical diagnosis in perinatal post-hypoxic cardiomiopathy]. / Aspecte practice de diagnostic in cardiomiopatia posthipoxica perinatala.

UNLABELLED: Retrospectively the Perinatal Post-Hypoxic Cardiac disorder, was researched in 32 newborn (ages 0-14 days), having a normal weight, with hypoxia at birth, Apgar score 3-7, requiring resuscitation at birth. The patients did not show signs of major cardiac suffering, except a systolic murmur, the neurologic manifestations prevailing. RESULTS: The investigations showed: cardiomegaly (46.9%); ECG: repolarization disorders of the left ventricle (LV) (43.5%); echocardiographic modifications in 67.2% of cases, mainly hypertrophic cardiomyopathy with septal predominance (59.3%) and LV diastolic dysfunction. The treatment with spironolactone generated the significant decrease of the septal myocardial hypertrophy and of the tricuspidien insufficiency, with the normalization of the LV diastolic function. CONCLUSION: The echocardiographic examination, as the main method of diagnosis and follow up of the cardiomiopathy induced by the perinatal hypoxia has to be performed right in the 1st week of life and later on up to the cure of the morphologic and functional cardiac modifications.

[Etiology and blood pressure patterns in secondary hypertension in children]. / Studiul etiologiei si caracteristicilor hipertensiunii arteriale secundare la copil.

UNLABELLED: Most studies regarding the etiology of hypertension in children have found a frequency of secondary hypertension 4 to 9 times greater the than in adults (70-90% vs. 10%), with a probability of identifying an underlying disease inversely related with the age and directly related with the severity of hypertension. MATERIAL AND METHOD: The purpose of this study is to establish the causes and the patterns of hypertension in a group of 256 children, admitted during a five-year period in the Children's Hospital "Sf. Maria" Iasi, Romania. RESULTS: The frequency of secondary hypertension is 4 times greater than essential hypertension. The most frequent causes of secondary hypertension are renal parenchymal disease (83.2%) and cardiovascular disease (coarctation of the aorta) (11.4%); less frequent have been diagnosed neurologic (1%) and endocrinologic diseases (1.5%). Most of the assessed cases (referred to our hospital for different other reasons) have been found with stage 1 and 2 of hypertension right from the moment of admission (88.3%). We established a statistically significant relationship between the severity of hypertension and the secondary type of hypertension, meaning : the higher the blood pressure (BP)--the higher chances of diagnosing an underlying cause of hypertension. Among the secondary causes, the renal or non-renal etiology did not significantly influence the BP values at the moment of admission. Among the different histological types of chronic glomerulonephritis, focal segmental glomerulosclerosis presented with a significant higher BP comparing with the other types. CONCLUSION: the frequency of hypertension increased with age: 92.6% of essential hypertension cases belong to age 11-18, 59.2% of renal hypertension cases belong to age 11-18. The exception came from cardiovascular hypertension, which fit into age group 0-6 year old (p < 0.05%). The gender had no significant influence of the etiology of hypertension.

[Arterial stiffness in pediatric hypertension]. / Complianta vasculara în hipertensiunea arteriala la copil.

Non invasive assessment of large arteries structure and function is a valuable tool for early detection of athero/arteriosclerosis and the cardiovascular risk. The vascular injury is mainly represented by increased arterial stiffness (increased pulse wave velocity--PWV), increased peripheral arteries reflectivity (Aix) and the occurrence of significant atheromatosis (increased clMT). Although well described in adult, there are few data in children regarding the impact of uremia on vascular structure and function. This paper is an overview of the main determinants of arterial compliance in children, focusing on recent data describing the repercussions of hypertension and renal failure in this age group. To date, our group has performed the only case control study in children in order to describe the arterial stiffness, the reflective properties of peripheral arteries as well as the carotid intima-media thickness on 18 children under chronic dialysis treatment (hemodialysis and peritoneal dialysis). Comparing with control cases the dialysed children had a significantly higher PWV and Aix, which reinforce that uremia is associated with arterial stiffness even in children. There were no significant differences on IMT and PWV between hemodialysed and peritoneal dialysed children. In contrast with adult patient data, there was no favourable impact of hemodialysis session over PWv and Aix.

[Cardiac arrhythmia in amitriptyline poisoning in children]. / Tulburari de ritm cardiac in intoxicatia cu antideprin la copil.

UNLABELLED: Amitriptyline (Antideprin) determines severe intoxications, especially because of its cardiac side effects. METHOD: We studied 8 children (2-14 years old) admitted with signs of amitriptyline intoxication. RESULTS: The clinical picture revealed altered general status, generalized hypertonia, arterial hypotension up to collapse, mydriasis, coma and cardiac arrhythmia. ECG monitoring showed ventricular premature beats, isolated, couplets and triplets, ventricular tachycardia and torsade des points, severe ventricular repolarisation disturbances with diffuse subendocardial ischemia. The treatment consisted in: gastric lavage with activated charcoal, alkalinisation with sodium bicarbonate, antiarrhythmic drugs and sustained vital functions. All cases recovered in 4-6 days. CONCLUSION: The severity of amitriptyline intoxication requires continue clinical and ECG monitoring, for early detection of some life threatening cardiovascular events. Thus, the treatment will be started early and will alleviate the severe prognosis of this intoxication.

[Clinical and developmental aspects of cardiac involvement in infant of diabetic mother]. / Aspecte clinice si evolutive ale afectarii cardiace la noul nascut din mama diabetica.

The authors evaluated the main clinical and evolutive aspects of heart involvement in the newborn of diabetic mother (IDM). We studied the files of 35 IDM in a 4 years period; they were investigated the first week of life and at 6-12 months (18 cases). Most of the patients were asymptomatic/signs of extracardiac suffering; 15 had a systolic murmur. ECG: left ventricle (LV) hypertrophy (8) and LV repolarization disturbances (19 cases). Chest X-ray: cardiomegaly (9 cases). Echocardiography: hypertrophic cardiomyopathy (HCM), especially septal (25 cases, 71%); LV diastolic dysfunction (19-35) and normal systolic function; pulmonary hypertension (3), other congenital heart diseases (8 cases). The control revealed the alleviation of the LV walls size and LV diastolic function. The high incidence of the cardiac manifestations in IDM and the risk of occurrence of some severe problems, require a complete cardiological exam from the first few days of life and a follow-up schedule until the normalization of the cardiac parameters.

[Arrhythmic cardiomyopathy. Case report]. / Cardiomiopatia aritmica. Prezentare de caz.

An 11 year-old boy was admitted with incessant sinus node reentrant tachycardia and secondary dilated arrhythmic cardiomyopathy, treated by radiofrequency ablation. Two years later he was admitted with incessant automatic atrial tachycardia and arrhythmic cardiomyopathy; a second catheter ablation procedure failed, but the third one, performed four month later, was successfully and resulted in a restoration of a normal sinus rhythm and a complete regression of arrhythmic cardiomyopathy.

[Aspects of left ventricular function in children with chronic renal failure]. / Particularitati ale functiei ventriculului stâng la copiii cu insuficienta renala cronica.

OBJECTIVE: To present the main morphological and functional cardiac modifications in children with chronic renal failure (CRF) and the effect of hemodialysis on systolic function of the left ventricle (LV). METHODS: 22 patients (5-19 years) with CRF of different degrees of severity. 16 of them were included in a hemodialysis (HD) program and they were followed-up for at least 1 year. The systolic and diastolic function of the LV were investigated by echocardiography (echo) 2D and Doppler. RESULTS: Although the clinical signs of cardiac suffering were rare, echo detected concentric hypertrophy (9 cases), dilated cardiomyopathy (4 cases), mitral and tricuspidian regurgitation and pulmonary hypertension (3 cases) and pericardial effusion (10 cases). Systolic function was normal in most of the cases, but the diastolic function (evaluated by E/A ratio, isovolumic relaxation and deceleration time) was modified in 10 cases. The HD session induced the improvement of the LV systolic function parameters and the decrease of right ventricle dimensions. CONCLUSIONS: Echocardiography has a higher sensitivity compared to ECG and chest X-ray in evaluation of the LV function, mainly in the cases without cardiac symptoms. An efficient chronic HD program and also a complex antihypertensive treatment contribute to the alleviation of the LV function. For the HD session, echo is useful in monitoring the systolic LV function.

[The assessment of left ventricular function in cardiac and extracardiac disorders in children]. / Evaluarea functiei ventriculului stâng în afectiuni cardiace si extracardiace la copil.

The left ventricle (LV) suffers during various cardiac and extracardiac diseases. After the description of the cardiac performance during human development, the authors present the assessment of the left ventricle function in some cardiac and also extracardiac disorders of the child. There are listed the changes in myocardial structure, systolic and diastolic function in hypertrophy and dilation of the LV determined by systemic diseases that affect the pediatric patients and can lead to severe cardiac failure.

[Risk factors in child and adolescent with systemic hypertension]. / Factori de risc în hipertensiunea arteriala la copil si adolescent.

A prospective study was made on 1068 pupils, aged between 10-15 years (group I). From this group 995 pupils were examined after four to seven years (group II). Their age was between 16-19 years. The study contained: anthropometric data, blood pressure (BP) and pulse measurements, and a standard record using the epidemiologic interview method. For each pupil we determined the following familial and personal antecedent of cardiovascular disease, especially arterial hypertension; alimentary habits (salt and hydro-carbonate excess); consumption of coffee and cigarettes; physical activity; tendency to sedentarism; school or family stress; and behaviour type. Data were worked out and interpreted, using epidemiologic and statistic methods in Epi Info 6 program. The prevalence of genetic factors (4% in group I and 4.3% in group II), consumption of salt (38% in group I and 35% in group II), obesity (1.5% in group and 1.4% in group II), sedentariness (4.8% in group I and 6.8% in group II), stress (9.8% in group I and 10.5% in group II), with behaviour type A (41% I group and 52% in group II) all presented almost equal values in the two groups regardless of age or BP level. The statistical study of the influence of the risk factors on BP values, using student's t test has demonstrated the contributory part of the genetic factor, the excess of sweets and stress. The deleterious effects of arterial hypertension risk factors, which can begin early in childhood demonstrate the necessity for responsible parties (family, school, doctors, etc.) to be aware of these risk factors and assist in their control.

[The morphofunctional characteristics of cardiac involvement in arterial hypertension in children]. / Particularitati morfo-functionale ale afectarii cardiace în hipertensiunea arteriala la copil.

UNLABELLED: The aim of the study was to investigate the main morphofunctional aspects of the cardiac involvement in systemic hypertension in child. METHODS: 48 children with aged ranging between 2 months-18 years, diagnosed with systemic hypertension (SH), were followed up more than 1 year (with treatment) and investigated by clinical examination and noninvasive methods. The etiology of SH was: * secondary SH (40 cases): acute (8) and chronic nephropathy (20), 13 cases being dialysed; coarctation of aorta (10) and pheochromocytoma (2 cases) and * essential SH (8 cases): "borderline" type and also confirmed. RESULTS: The echocardiographic findings had a superior sensibility to ECG and chest X-ray findings, concerning cardiac involvement in SH, especially in the secondary forms, with high values of systolic and/or diastolic blood pressure and with a long period of evolution: hypertrophy of the left ventricle (LV) (31 cases = 65%) with septal predominance (10); * alteration of diastolic function of LV (11), but with normal systolic function of LV (all the cases). These changes have not been observed in acute nephropathy or they were unsignificant in essential SH. Repeated echocardiography after minimum 6 months proved a varied regression of hypertrophy of LV and improved diastolic function of LV in children who received antihypertensive therapy, including spironolactone and/or angiotensin converting enzyme inhibitors. CONCLUSION: Because such cardiac involvement are important and of greater risk factor for the hypertensive patients, the early diagnosis by echocardiography, the follow up of the evolution and the diminish of cardiac disorders by the treatment mentioned above, may improve the prognosis of the disease.

Etiological, clinical and pathomorphological aspects of acute respiratory distress syndrome in children.

Acute respiratory distress syndrome (ARDS) is the result of severe injuries of different etiologies of the capillary system in patients with previously healthy lungs, resulting in noncardiogenic pulmonary edema. The authors studied 42 infants in whom the histopathologic aspects were suggestive for ARDS. The etiologic factors of this syndrome were: severe gastroenteritis with hypovolemic or endotoxic shock (13 cases), sepsis (9 cases), fulminans purpura (2 cases), severe neurological disorders (13 cases), pulmonary infections (5 cases). In such conditions, if the infant presents hyperpnea followed by generalised cyanosis, refractory to oxygen therapy, and if there are clinical and radiologic signs of acute pulmonary edema, the diagnosis of ARDS must be considered and a complete intensive care therapy is compulsory in order to alleviate the severe prognosis of this syndrome.

Value of intravenous ATP in the diagnosis and treatment of tachyarrhythmias in children.

Actual researches show that adenosine and its forerunner, ATP, can realise a nodal block in intravenous (i.v.) administration. This effect, even if transient, is of particular usefulness in the therapy of paroxysmal supraventricular tachycardia (PST) in children and adults. 1 mg/kg ATP was administered i.v. to 51 children (aged 3 months to 15 years) admitted to the Intensive Care Unit for severe regular paroxysmal tachyarrhythmias with clinical and ECG symptoms. In 31 cases, the P wave was absent on ECG. In 6 of 31 cases in whom wide QRS complexes were found (over 0.10 sec), a WPW syndrome (4 cases) or bundle branch block (2 cases) was associated. Rapidly i.v. administration monitored electrocardioscopically was followed by ending of PST in 43 children, including those with wide QRS complexes. The highest effectiveness was in junctional tachycardia by re-entering mechanism. The drug was well tolerated, had no side effects or hemodynamic disturbances and this is very important, because in 12 infants already existed symptoms of congestive cardiac failure at their admission. The use of i.v. digoxin with/without propranolol was necessary in 8 cases, in which the repeated ATP administration was ineffective. We consider that i.v. ATP administration in regular tachyarrhythmias in children is very useful for the proper diagnosis of the types with wide QRS complexes and/or when the P wave did not appear on the ECG, and also for the treatment, because ATP has a high effectiveness and an excellent tolerance.

[White-coat arterial hypertension in children and adolescents]. / Hipertensiunea arteriala de "halate albe" la copil si adolescent.

Although intensively discussed and finally accepted in the last years "white coat phenomenon" (WCF) still raises the question of the benefit of diagnosing it in pediatric patients as its possible link with the subsequent essential hypertension is not clear yet. This study included 1068 schoolchildren (aged 10 to 16 years) submitted to a screening program for detecting the in time variations of blood pressure (BP). When the study was started WCP was present in 60 children (5.6%) and when it ended its frequency raised to 8.73%. In 14 of 60 children (23.3%) WCP progressed to borderline or confirmed essential hypertension, incidence higher that that of similar forms of essential hypertension occurring in patients with normal BP levels (20 of 955 = 2.05%). With time, the frequency of borderline and confirmed essential hypertension has also increased: 5.11% at the first determination to 7.85% at last one. The high frequency of WCF and associated with the high frequency of its progression to essential hypertension support the idea that WCP has a predictive value for the development of essential hypertension. An early diagnosis and the prevention of other risk factors may lower the frequency of essential hypertension in adults.

Clinical and evolutive aspects in ventricular preexcitation syndromes in child.

Ventricular preexcitation syndromes (VPS) are very important between cardiac rhythm disturbances in childhood, because their presence can change the clinical and ECG picture and thus the treatment can be very difficult. The authors studied 58 cases of VPS in children (2 weeks-15 years old) admitted in a period of 3 years. The surface ECG showed VPS aspects: in 30% of cases we noticed WPW syndrome type B and the rest presented VPS with Mahaim pathways and Lown-Ganong-Levine syndrome. 4 cases were familial and 1 child a hidden WPW syndrome. In 65% of cases the cardiac symptoms put the diagnosis and 1/3 of cases were discovered by common ECG. The most important cardiac sign of the children with WPW syndrome was the paroxysmal supraventricular tachycardia, 4 cases presenting wide QRS complex. Others types of VPS were without clinical symptoms. The intravenous administration of digoxin + propranolol was the therapy of choice for paroxysmal supraventricular tachycardia in infants and children until 2-3 years old, and propranolol and chinidine after this age. The children older than 2-3 years and/or those with ineffective preventive for recurrent treatment received dysopiramide and specially amiodarone with satisfactory results; it was not necessary the surgical ablation of the aberrant pathway. Ventricular preexcitation syndromes and wrong treatment can induce severe ventricular arrhythmia, so all the tachyarrhythmias with unknown etiology and especially those with wide QRS complex must be investigated very carefully, using and Holter test and the endocavitary electrophysiology, for a correct medical and/or surgical treatment.

[Myocardial infarct in children. The anatomicoclinical aspects]. / Infarctul de miocard la copil. Consideratii anatomo-clinice.

Nine cases of myocardial infarction in the newborns (8 cases aged between 7 days and 6 months) and infants (1 case aged 12 years and 6 months) were followed up for 15 years. The etiology was different: mediocalcosis of the coronaries, congenital abnormalities of the heart marked hypertrophy of left ventricular myocardium (endocardial fibroelastosis or nonobstructive hypertrophic cardiomyopathy) severe hypoxia (severe acute bronchopneumopathies), and AAR, cardioarticular form, with multiple attacks in the infant. The ECG aspects were not specific in most children and clinically the prevailing finding was severe decompensated cardiac failure. The main etiologies and the inducing mechanisms of myocardial infarction in children are presented.