Aleksandra Simovic

Improvements in Neonatal and Childhood Medical Care – Perspective from the Balkans

Health services covering needs of pregnantwomen, newborns, infants, and preschool and school-age children in Serbia, are provided according to the plan of the compulsory health insurance (1). Such insurance premiums include the implementation of organized screening in health institutions of secondary and tertiary levels (prenatal examinations, mandatory screening for phenylketonuria and hypothyroidism, audiometric screening, ophthalmologic screening for retinopathy of prematurity, ultrasound screening for developmental dysplasia of the hip, central nervous system, etc.). Within the primary health care of newborn infants and infants, regular visits of the attending nurse aremandatory after discharge from thematernity ward. In later period, the chosen doctor does systematic and regular check-ups [complete blood count (CBC) in the age of 6months, 2 years, and 4 years] and follows the growth and psychomotor development of the child. In preschool and school, medical examinations are performed in dispensary (every other year). Chosen physician is obliged to refer to the additional examinations (speech therapist, dentist, physiatrists, ophthalmologist, and otolaryngologist) in the age of 4 years and before school enrollment. These screenings are used for early detection of functional disorders, in order to carry out structural analysis and preventive interventions to preserve the health of the youngest population in Serbia. At the same time, the protection from infectious diseases is carried out by vaccination, according to mandatory immunization calendar by age groups. This procedure is consistent with the recommendations of the Republic Institute for Health Insurance and European regional strategy “Health for All.” National public health strategy to cope with communicable diseases is funded by the Republic Institute for Health Insurance (2). Pregnant women and children in Serbia have the right to regular dental care from the compulsory health insurance (“health booklet”), within the framework of primary health care – the principle of the chosen dentist (3). In the preschools and schools, preventive dental examinations are periodically carried out, with immediate health and educational work with children. The aim is to adopt healthy eating habits, improving oral hygiene, and early caries prophylaxis (i.e., application of fluoride, sealants, etc.).

The treatment of hemangioma of the larynx in children is still a dilemma

1 University of Kragujevac, Faculty of Medical Sciences, Department of Paediatrics, Kragujevac, Serbia; 2 Clinical Centre of Kragujevac, Pediatric Clinic, Kragujevac, Serbia; 3 Clinical Centre of Kragujevac, Department of Clinical Pharmacology, Kragujevac, Serbia; 4 Clinical Centre of Kragujevac, Clinic for Otorhinolaryngology, Kragujevac, Serbia; 5 Clinical Hospital Center, Department of Child Surgery, Kosovska Mitrovica, Serbia; 6 University of Kragujevac, Faculty of Medical Sciences, Department of Anatomy, Kragujevac, Serbia

Sneezing - a symptom of respiratory or psychogenic superposition of illness in a teenager?

Introduction. The coincidental combination of allergic respiratory diseases and psychogenic or psychiatric illness is possible but rarely associated in a female teenager. Case report. A girl aged 12.5 years was admitted to the Pediatrics Clinic in the Clinical Centre Kragujevac with the main difficulty of sneezing as 10 sneezes in each of the 500–600 series a day, only in the waking state. Working diagnoses were tic disorders associated with Allergic rhinitis, asthma and biochemically determined rickets. The patient was treated with chlorpromazine, desloratadine, montelukast, fluticasone propionate, vitamin D, azelastine hydrochloride along with the elimination diet. After a year and a half, the patient rarely sneezed, but periods without sneezing were not longer than 3 months, and she ‘cleared her throat’ occasionally. Although her clinical condition is less severe now and without additional motor tics or symptoms of Tourettes disorder, because of its length we suspect the tic turned into a chronic vocal tic disorder. Conclusion. We reported a case of rare association between allergic rhinitis and condition of tic-related conversion in a female teenager and emphasized the necessity of revising the systematisation for the tic disorders and protocol for the allergic rhinitis in terms of their association.

Treatment of subacute osteoporotic vertebral compression fractures with Percutaneous vertebroplasty: A case report

Introduction. Percutaneous vertebroplasty (PVP), as a mini-invasive approach in the treatment of patients with osteoporotic vertebral compression fractures (OVCFs), provides stabilization of the spine and relives pain. The most commonly it is applied in the 3–6 weeks before bending of the spine. Complete cessation of pain is easier to achieve if you treat “less mature” fractures. The aim of the report is to show that PVP is effective and safe for old fractures too. Case report. A 77-old patient suffered from a stable compression fracture of 3th lumbar (L3) vertebral body after minor trauma. This fracture was clinically and radiologically diagnosed. The conservative treatment that included lumbo-sacral orthosis (LSO), analgesic drugs and physical therapy, was primarily applied due to permanent pain and type of fracture. After a period of two months, pain persisted, but it was localized in a thoracic spinal segment with radiologically diagnosed fractured bodies of 8th (Th8) and 10th (Th10), thoracic vertebra without neurological deficit. Thoraco-lumbo-sacral orthosis (TLSO) was prescribed and after six months the indication for vertebroplasty of the Th8 and Th10 vertebral body was given. The pain relief had been achieved and the patient was discharged from the Clinic for Orthopedics on the postoperative day 2, and was symptom free during the follow-up period. Conclusion. In patients with stable OVCFs, PVP is an effective therapy for reducing pain and improving mobility of 6 months old fractures.

Hospital infections rate and health staff density in a Neonatology Department

Objective. The aim of our study was to compare staffing trends for physicians and nurses with hospital infections (HIs) rate at a neonatology department of tertiary care health facility. Methods. The prospective cohort study was conducted at Neonatology Department, Clinical Centre Kragujevac, Serbia. The incidences of neonates with HIs were calculated for each of the quarters during the 5-year period. The data about the number and structure of staff for each quarter of the study period were collected from the official work schedule lists of the department. Results. This study registered a total of 272 HIs occurring in 264 neonates. The incidence rate of patients with HIs was 13.36% and the incidence density of HIs was 5.85 per 1,000 patient-days. In the observed period the trend of incidence rate of patients with HIs was stable, but the trend of incidence density of HIs was increasing, however without statistical significance. The highest incidence rates of patients with HIs were recorded in the third quarter of all observed years respectively: 17.44% in 2012, 16.74% in 2013, 23.47% in 2014, 18.18% in 2015 and 22.74 in 2016. The average number of nurses in the first shift ranged from 5.0 to 7.0, but in second shift was 3.0 to 4.0 only, and the least number of nurses worked in the third quarter of each year. The average number of physicians in the first shift ranged from 2.33 to 4.47 and they were also the fewest in numbers in the third quarter. We observed strong negative correlation between the average incidence rate of patients with HIs and the average number of nurses in the first shift (r=-0.977, p=0.023). Conclusion. Optimal nurse and physician staffing of neonatal departments in developing countries and the avoidance of inter-quarter variations in number of staff at duty would decrease the incidence of HIs and probably create overall savings of the hospital budget.

Is it Possible to Predict Mortality in Preterm Neonates, Based on a Single Troponin I Value at 24 h?

To the Editor: An early detection of post-asphyxia syndrome in preterm neonates is very difficult; especially when it is known that a low Apgar score (AS) is not always a consequence of perinatal asphyxia [1, 2]. There are insufficient number of studies, linking bad outcome of post-asphyxia with serum concentrations of cardiac troponins in neonates, and their values have not been precisely defined [3–5]. The experimental group in our study consisted of 45/70 male and 25/70 female preterm neonates; gestational age 31.7±3.36 wk; body weight 1849±699.09 g; 5-min AS 5 (5–7); lactate levels in the first 6 h after birth 5.5 (4.4-8.2) mmol/L. Primary resuscitation was required in 25/70, the use of inotropes in 34/70 and conventional mechanical ventilation in 51/70 patients. The outcome was fatal in 12/70. The control group consisted of 23/38 males and 15/38 females, gestational age 32.4±3.25 wk; body weight 1957± 687.45 g; 5-min AS 8 (8–8); lactate levels 0.9 (0.8–1.2) mmol/L. All patients only required basic intensive care (diffuse oxygen in the incubator FiO2<40 %). Cardiac troponin-I ultra (CTNU) values at 24 h were significantly higher in the experimental group: 0.02 (0.01–0.062) mcg/L, when compared to the control group: 0.01 (0.01–0.01), while CTNU values did not correlate significantly with serum lactate (r=0.191, p=0.121) and 5-min AS (r=0.05, p=0.683) (Table 1). Hypotensive patients had significantly higher levels of CTNU (median 0.04 mcg/L; 0.01 to 0.13 mg/L, p=0.009) compared to those without inotropic therapy (0.01 mcg/L; 0.01–0.037 mcg/L). CTNU was negatively correlated with ejection fraction (EF) of left ventricle [63.18 % (47.5– 74.11); r=−0.479; p=0.0005], while there was no significant difference between ventilated (respiratory distress was 62/70) and non-ventilated subjects (r=0.356). Increase of CTNU >0.045 mcg/L was a significant predictor of fatal outcomes [Confidence Interval 79 %; sensitivity 66.7 %; specificity 79.3 %; positive predictive value (PPV) 91.8%; negative predictive value (NPV) 38.1%], while 5-min AS <4.5was a less reliable predictor of mortality (p=0.024), if compared to lactate (p=0.004), and CTNU (p=0.002).

Secondary Haemophagocytic Lymphohistiocytosis – The Differential Diagnosis Dilemma In Paediatrics

ABSTRACT Secondary haemophagocytic lymphohistiocytosis (SHFLH) is a rare, potentially fatal disorder, most commonly caused by the Epstein–Barr virus. It is characterized by neoplastic proliferation of cells that belong to the monocyte–macrophage system and by varied clinical expression. A girl aged 3 years and 7 months was hospitalized due to continuing high febricity, yellow skin colouring, hepatosplenomegaly and cytopenia in a complete blood count (CBC). Four weeks before hospitalization, she had a lacunar angina and lymphadenopathy. A low number of erythrocytes, leukocytes and thrombocytes were noted in CBC, with anaemia and the presence of virocytes in a peripheral blood smear. Biochemical blood analyses indicated hyperbilirubinaemia, increased values of transaminases, lactic dehydrogenase, ferritin, triglycerides, D-dimer, acceleration of the activated partial thromboplastin time and decreased values of fibrinogen, with increased values of C-reactive protein and procalcitonin. Using an ultrasound examination of the abdomen, hepatosplenomegaly was perceived; using echocardiographic examination, pericardium layering was noticed; and using a roentgen graphic picture of the lungs, the presence of pleural effusion was detected. In a bone marrow biopsy, the percentage of blasts did not exceed 25%, and rare chemophagocytes were noticed. Using serologic tests, positivity to Epstein-Barr virus in IgM class was demonstrated. According to the criteria by Histiocyte Society, there were sufficient criteria to establish a diagnosis of SHFLH. With the exception of symptomatic therapies, according to the protocol for SHFLH treatment, a double antibiotic therapy and IV immunoglobulins were given, to which the patient responded with a clinical and laboratory recovery. Therefore, there was no demand for a treatment protocol with cytostatics or bone marrow transplantation. To resolve a differential diagnosis dilemma in solving cases of uncertain febrile neutropenia.