Mirko Zibolen

Incidence of renal complications in Schönlein—Henoch purpura syndrome in dependence of an early administration of steriods

Between 1976 and 1986, the authors treated 33 children with Schönlein-Henoch purpura (S-H purpura), with physiological urinary finding on admission. Twentythree of them received prednisone already at the beginning of hospitalization, 10 were not given any prednisone at all. In patients with prednisone, nephropathy occurred only once (4.3%), in those without prednisone it occurred 5 times (50%), the incidence being thus significantly higher. Prednisone was administered in doses ranging between 1.0 and 2.5 mg/kg body mass/day, on an average for 21 days (first 10 days in the same dose, later in reduced doses). Since there is a general lack of data on the positive effect of steroids upon the prevention of nephropathies in S-H purpura, the authors recommend more thorough studies in the initial stage of the disease (before the development of nephropathies).

Bilateral endogenous endophthalmitis as a complication of late-onset sepsis in a premature infant

Endogenous endophthalmitis is a potentially blinding ocular infection resulting from the haematogenous spread from a remote primary source with a very poor prognosis in premature infants. The patient, a boy, was delivered by caeserean section in the 30th week of gestation because of massive bleeding caused by placenta abruptio. Birth weight was 1620 g, Apgar score 8 and 9 at 1 and 5 min respectively. His family history was unremarkable and prenatal evaluation was normal. The immediate after-birth adaptation of the baby was appropriate. Due to respiratory distress he required respiratory support by means of nasal CPAP (FiO2 0.21) for 2 days. The child did not show any clinical signs of infection; nevertheless, ampicillin was administered for antibiotic protection of the umbilical venous catheter. On the 4th NICU day, the white blood cell count revealed mild leukopenia and gentamicin was administered because of a suspected bacterial infection. The blood culture was sterile and gentamicin was withdrawn 3 days later. On the 10th NICU day there was a sudden onset of sepsis with a clinical picture of septic shock. Cefoperazon and netilmicin were started. Conventional mechanical ventilation was necessary because of respiratory failure. Two days later, blood and sputum cultures confirmed Pseudomonas aeruginosa sepsis. Antibiotic therapy was adjusted on the basis of the mean inhibitory concentration testing and ceftazidim and tobramycin were administered. At the same time, despite systemic antibiotic therapy and complete intensive care, the patient’s condition worsened and symptoms of ocular infection appeared. Both eyes were swollen and protruding with purulent conjunctivitis. Severe chemosis, hypopyon and cloudy corneas were also present. Conjunctival cultures revealed the same strain of Pseudomonas aeruginosa and topical tobramycin was administered. Over the subsequent 2 days, oedema and corneal haziness worsened and ultrasound examination of the eyes showed retinal detachment. Despite intensive conservative therapy, endophthalmitis progressed rapidly and resulted gradually in corneal perforation, eyeball atrophy and complete loss of vision.

Heart Rate and its Variability in Juvenile Hypertonics During Respiratory Maneuvers

In 27 children (14 juvenile hypertonics and 13 healthy control children, with the mean age 14.7 +/- 0.4 y. or 15.2 +/- 0.5 y., respectively, P greater than 0.05) the changes of heart rate (HR), its variability (HRV) during deep inspiration and subsequent expiration, Valsalvas maneuver, doubled breathing frequency and the deepening of breathing were studied. The resting supine mean HR was significantly higher (P less than 0.001) in hypertonics than in controls. Deep inspiration was in both groups accompanied with the HR increase. However, the percentage increase in hypertonics was significantly lower than in normals (P less than 0.02). With subsequent expiration, the HR fell in both groups. There was no significant difference between the percentage decreases in both groups (P greater than 0.05). During the Valsalvas maneuver, in the first phase the tachycardic response occurred, which was in hypertonics significantly less pronounced. After the recovery of breathing a bradycardic reaction occurred which was equal in both groups (P greater than 0.05). Both, in juvenile hypertonics and in controls the doubled frequency of breathing increased the mean HR and decreased the HRV. During the deepened breathing there was an increase in mean HR in both groups, and only in the controls there was an increase in HRV. Heart rate variability in hypertonics was lower than in the controls under all the conditions.

Increased urolithiasis in patients with alkaptonuria in childhood

To the Editor: There are reports on urolithiasis in alkaptonuria (AKU) in middle and late adulthood patients, who have already developed the full clinical picture of the disease (1–4). However, the occurrence of this complication in affected children has not been analysed so far. AKU has the world highest incidence in the Slovak Republic (1 in 19000 livebirths from 509192 studied individuals at the AKU Research Centre, Jessenius School of Medicine, University of Martin (5, 6)). Since 1968, when our project started, our centre has registered a total of 207 AKU patients, including 107 who are younger than 15 years of age (6). In the current study, we have included 21 AKU patients (10 males, 11 females), younger than 15 years of age. In all patients, the diagnosis of AKU was initially established by physical examination (7, 8, 5) and confirmed in each case by the examination of urine homogentisic acid (HGA) by a simple ‘dipstick’ test. This test is performed by a filtration paper strip pre-soaked in 10% NaOH solution (9). In a positive ‘dipstick’ test, the sample of urine is analysed chromatographically and when necessary also by quantitative examination of HGA concentrations. Ultrasonographic examination is most useful for the detection of urolithiasis in AKU as it can detect urolithiasis in its earliest stages of development. When ambiguous, a repeated ultrasonographic examination was performed 1 year later and in the case of a normal sonogram after a 3-year period. As a control group, a cohort of 2382 pediatric, ‘non-AKU’ patients, that were referred for routine sonographic examination to the Paediatric Department (University Hospital Martin) with a suspicion of an as yet undetermined urinary tract disorder, was utilized. For consistency, all ultrasonographic examinations were performed by the same specialist (MZ) for the last 7 years. Laboratory examinations consisted of basic urine investigations, including examination of the urine sediment, urine pH, qualitative screening for hereditary metabolic disorders, amino acid chromatography and the determination of mineral excretion. Creatinine, uric acid and quantitative proteinuria were not determined, since applied methods interfere in ‘alkaptonuric’ urine with HGA (10). Patient serum was used for mineralogram, alkaline phosphatases, creatinine and urea examinations. Urolithiasis was detected in 5 of 21 examined AKU patients (23.81%) (Table 1) and in 5 out of 2382 controls (0.21%; pB0.001, x=225.5, 1 DF). In a 12-year-old female AKU patient where we did not detect urolithiasis, the sonographic examination revealed an unilateral multicystic dysplastic kidney. The results of serum and urine examination in AKU patients with urolithiasis were within the normal range. The increased frequency of urolithiasis in AKU patients younger than 15 years (23.81%) suggests careful and repeated ultrasonographic and biochemical examinations for this important complication should start in early childhood.

Hyperbilirubinemia and phototherapy in newborns: Effects on cardiac autonomic control

BACKGROUND Neonatal jaundice and its phototherapeutic treatment can lead to several side effects involving activation of autonomic control mechanisms. AIM The aims of this study are to investigate the autonomic nervous system changes in icteric neonates using heart rate variability (HRV) and to assess the effect of phototherapy on short-term heart rate dynamics as an indicator of autonomic nervous control of cardiovascular system. METHODS HRV recordings from 20 icteric full-term neonates before, during and after phototherapy and from 20 healthy controls were analyzed. In addition to traditional time and frequency domain measures, heart rate complexity parameters including normalized complexity index (NCI), normalized unpredictability index (NUPI), pattern classification indices (0V%, 1V%, 2LV%, 2UV%) and irreversibility index (P%) on four time scales were evaluated. All measures were derived from data segments of 1000 RR intervals. RESULTS The analysis revealed higher values of 1V%, 2LV%, and lower P% in neonates with hyperbilirubinemia compared to controls. While HRV magnitude did not change, mean heart rate increased during and after the phototherapy. Nonlinear analysis showed a decrease of complexity, unpredictability and pattern classification measures 2LV% and 2UV%. In contrast, 0V% and irreversibility index P% were increased during and at least 30min after phototherapy. CONCLUSION The results suggest a shifted autonomic balance in icteric neonates compared to the controls and its further alterations during phototherapy. As the nonlinear HRV parameters are independent of the linear methods, they can provide new information about the cardiac regulatory mechanisms and their changes in neonates.

Comparison of Doppler parameters of central versus intraparenchymal renal arteries in physiologically normal newborns

Background: Changes in renal arterial Doppler flow may identify parenchymal disease, but in newborns knowledge of normal physiological parameters is a prerequisite for correct interpretation. Objective: To evaluate renal blood flow in healthy newborns by means of Doppler US. Materials and methods: On the fourth day of life we examined 100 normal term newborn infants (200 kidneys). Blood flow in the central renal arteries was compared with that in the intraparenchymal arteries. Maximum systolic velocity (Vmax), end-diastolic velocity (Ved), mean flow velocity (Vmean), resistive index (RI) and pulsatility index (PI) were assessed. Results: All parameters were significantly higher in the central renal arteries than in the intraparenchymal arteries (RI 0.78±0.07 vs 0.62±0.05, P<0.0001; PI 1.84±0.52 vs 1.09±0.18, P<0.0001). Conclusions: Physiological data are presented that are necessary for the correct interpretation of neonatal Doppler US.

Renal Doppler ultrasonography in infants with hydronephrosis

The objective was to evaluate the importance of obstruction in unilateral hydronephrosis by using renal Doppler ultrasonography. A total of 19 infants were examined. It was revealed that patients of group withobstruction have in the affected kidney a higher mean resistive index [RI= 0.77 ± 0.04] than in the healthy kidney [RI = 0.69 ± 0.02] [p < 0.001]. In patients of group with nonobstructive dilatation this difference was not observed. In infants it is not possible to evaluate only absolute changes of the resistive index. It is much more useful to compare values of RI of both kidneys using the above indices. The determination of RI, RIR and delta RI can be helpful in distinguishing obstructed from non-obstructed hydronephrosis.

Time irreversibility of heart rate oscillations in newborns – Does it reflect system nonlinearity?

Abstract The aim of our research was to find out if the time irreversibility as a sign of specific class of nonlinear dynamics is present even in the newborns heart rate oscillations. Multiscale irreversibility indices (Portas index P %, Guzik index G % and Ehlers index E ) of the heart rate signals were computed in 20 healthy neonates. The presence of system nonlinearity was assessed by surrogate data analysis. The results of our analysis revealed asymmetrical nature of heart rate oscillations present in the majority of neonatal heart rate recordings. Moreover, time irreversibility index P % was able to detect shift of sympathovagal balance toward sympathetic dominance in newborns. Our findings support the concept of nonlinearity as a universal feature of the biological control system even in the early stage of the system maturation. This finding supports the application of nonlinear methods to heart rate variability analysis.

Physiological changes in blood flow velocities in the superior mesenteric and coeliac artery in healthy term fetuses and newborns during perinatal period.

Objective. The aim was to describe the course of physiological changes in coeliac artery (CA) and superior mesenteric artery (SMA) blood flow velocities (BFVs) during the perinatal period in healthy term fetuses and infants as it has not been studied in detail so far. Methods. This prospective Doppler ultrasound study included 50 infants. The examinations were performed in a fetus after the completion of 36.0 gestation weeks before the onset of labor and in infants postnatally at the ages of 2, 24, and 72 h. Results. The end-diastolic velocity (EDV) in the CA was generally higher than in the SMA (p < 0.001). The EDV in the SMA decreased postnatally (8.4 vs. −7.2, p < 0.001) and showed negative values in 92% of infants. By 24 h of postnatal age, EDV in the SMA had become positive in all of the infants (mean 13.8 cm/s, p < 0.001). The EDV in CA had only positive values. The changes in EDV in both vessels were reflected by changes in the resistance index in inverse manner. Conclusions. BFV in the CA and SMA changed dramatically in the perinatal period; the most remarkable changes occurred within the first 24 h of life.

Accuracy of transcutaneous bilirubin measurement in newborns after phototherapy

Objective:We tested the accuracy of transcutaneous bilirubin (TcB) measure in newborns undergoing phototherapy.Study Design:In a prospective study of 150 term Caucasian neonates, 255 measurements of total serum bilirubin (TSB) and TcB concentration were obtained 2 h after discontinuing phototherapy. TcB measurements obtained on the forehead, sternum, abdomen and covered lower abdomen were statistically compared with the corresponding TSB.Result:TcB consistently underestimated TSB levels significantly. The smallest but significant difference between TSB and TcB was found on the lower abdomen. The correlation between TSB and TcB was found to be moderately close (r=0.4 to 0.5). TcB measurements were inaccurate, regardless of phototherapy technique (Bilibed, conventional phototherapy).Conclusion:Phototherapy significantly interferes with the accuracy of transcutaneous bilirubinometry. TcB measurements performed 2 h after stopping phototherapy were not reliable, even if they were carried out on the unexposed body area. TSB assessment remains necessary, if treatment of hyperbilirubinemia is being considered.