Stefan Grosek

Severe Clostridium difficile-associated disease in children.

Three cases of Clostridium difficile-associated disease in children were detected within a short time interval. Intensive therapy was required in 2 cases with colectomy in one of them. One of the severe cases was community-acquired. Two patients had underlying diseases (Hirschprung disease, Down syndrome) and also tested positive for enteric viruses (rotavirus, calicivirus).

High-dose methylprednisolone in a pregnant woman with Crohn's disease and adrenal suppression in her newborn.

Background: The synthetic corticosteroid methylprednisolone is used for the treatment of acute exacerbations of Crohn’s disease, also in pregnancy. Its use is considered to be less harmful than the effect of active disease on the fetus. Adrenal suppression in a fetus due to administration of methylprednisolone has hitherto been rarely published. Objective: To present a case of neonatal adrenal suppression due to the use of high-dose methylprednisolone in late pregnancy of a woman with Crohn’s disease. Methods and Results: Clinical signs of adrenal suppression were observed in the newborn 3 h after birth. After hydrocortisone supplementation and intensive therapy the baby recovered completely. Conclusions: Life-threatening adrenal suppression, requiring hydrocortisone supplementation and intensive therapy, was observed and successfully treated in a newborn, whose mother had received high-dose methylprednisolone in late pregnancy.

Detection of human coronaviruses in simultaneously collected stool samples and nasopharyngeal swabs from hospitalized children with acute gastroenteritis

BackgroundHuman coronaviruses (HCoVs) are a well-known cause of respiratory infections but their role in gastrointestinal infections is unclear. The objective of our study was to assess the significance of HCoVs in the etiology of acute gastroenteritis (AGE) in children <6 years of age.MethodsStool samples and nasopharyngeal (NP) swabs collected from 260 children hospitalized for AGE (160 also had respiratory symptoms) and 157 otherwise healthy control children admitted for elective surgery were tested for the presence of four HCoVs using real time RT-PCR. Registered at ClinicalTrials.gov (reg. NCT00987519).ResultsHCoVs were more frequent in patients with AGE than in controls (23/260, 8.8% versus 4/151, 2.6%; odds ratio, OR 3.3; 95% confidence interval, CI 1.3–10.0; P = 0.01). Three of four HCoV-positive members in the control group, asymptomatic when sampled, recalled gastrointestinal or respiratory symptoms within the previous 14 days. In patients with AGE, HCoVs were present in NP samples more often than in stools (22/256, 8.6%, versus 6/260, 2.3%; P = 0.0004). In 5/6 children with HCoVs detected in stools, the viruses were also detected in NP swabs. Patients had a significantly higher probability of HCoV detection in stool (OR 4; 95% CI 1.4–15.3; P = 0.006) and also in stool and/or NP (OR 3.3, 95% CI 1.3–10.0; P = 0.01) than healthy controls. All four HCoVs species were detected in stool and NP samples.ConclusionsAlthough HCoVs were more frequently detected in patients with AGE than in the control group, high prevalence of HCoVs in NP swabs compounded by their low occurrence in stool samples and detection of other viruses in stool samples, indicate that HCoVs probably play only a minor role in causing gastrointestinal illness in children <6 years old.

Two episodes of systemic capillary leak syndrome in an 8-year-old boy, following influenza A virus infection.

Systemic capillary leak syndrome is a rare condition, characterized by hypotension, edema, hemoconcentration and hypoalbuminemia. We describe 2 episodes of systemic capillary leak syndrome, following influenza A virus infection, occurring during 2 subsequent influenza seasons, in an 8-year-old boy.

Diagnostic and therapeutic value of naloxone after intoxication with tramadol in a young girl

Tramadol therapy has gained wide popularity in the last few years, not only with regard to cancer patients on chronic pain therapy, but also in other acute or chronic pain problems. It is an atypical analgesic, which is contraindicated in infants below 1 year of age. Tramadol has a dual mechanism of analgesic action. It inhibits re-uptake of norepinephrine and serotonin, in addition to m-opioid receptors agonism. The former action is mostly due to the parent compound tramadol, while its metabolite O-demethyltramadol (M1) exerts its primary action at the m-opioid receptor. Tramadol metabolite M1 is mainly formed by genetically polymorphic cytochrome P450 (CYP) 2D6. In extensive CYP2D6 metabolizers the analgesic effects of tramadol are superior to those in poor metabolizers. Unintentional intoxication with severe central nervous system (CNS) depression and seizures has been reported in small children. We report a case of tramadol intoxication in which treatment with naloxone was diagnostic and therapeutic.

Prolonged prostaglandin E1 therapy in a neonate with pulmonary atresia and ventricular septal defect and the development of antral foveolar hyperplasia and hypertrophic pyloric stenosis

Abstract Prostaglandin E1 (alprostadil) is widely used for maintaining the patency of ductus arteriosus in ductus-dependent congenital heart defects in neonates to improve oxygenation. Among more common side effects are fever, rash, apnoea, diarrhoea, jitteriness, and flushing. More severe side effects are brown fat necrosis, cortical hyperostosis, and gastric outlet obstruction, most commonly the result of antral foveolar hyperplasia or hypertrophic pyloric stenosis. We report on an infant with a ductus-dependent congenital heart defect who developed symptoms and sonographic evidence of focal foveolar hyperplasia and hypertrophic pyloric stenosis after prolonged treatment with prostaglandin E1. Gastrointestinal symptoms persisted after corrective cardiac surgery, and pyloromyotomy was required. Study of the case and of available literature showed an association between the total dose of prostaglandin E1 administered and duration of treatment and the development of gastric outlet obstruction. We conclude that if patients are treated with a prostaglandin E1 infusion, careful monitoring for symptoms and signs of gastric outlet obstruction is required.

Extracorporeal membranous oxygenation (ECMO) in neonates and children experiences of a multidisciplinary paediatric intensive care unit

Extracorporeal membranous oxygenation ECMO was applied in 18 patients. All children had deep hypoxia and 80% probability of dying. Average duration of ECMO in newborns was 131 hours, and in older patients 253 hours. Seven patients were discharged from the intensive care unit (late survivors), 5 of them are in perfect somatic and mental condition. IVAN VIDMAR ( )•

Experiences of Slovene ICU Physicians with End-of-Life Decision Making: A Nation-Wide Survey

Background Advances in intensive care medicine have enormously improved ability to successfully treat seriously ill patients. However, intensive treatment and prolongation of life is not always in the patient’s best interest, and many ethical dilemmas arise in end-of-life (EOL) situations. We aimed to assess intensive care unit (ICU) physicians’ experiences with EOL decision making and to compare the responses according to ICU type. Material/Methods A cross-sectional survey was performed in all 35 Slovene ICUs, using a questionnaire designed to assess ICU physician experiences with EOL decision making, focusing on limitations of life-sustaining treatments (LST). Results We distributed 370 questionnaires (approximating the number of Slovene ICU physicians) and 267 were returned (72% response rate). The great majority of ICU physicians reported using do-not-resuscitate (DNR) orders (97%), withholding LST (94%), and withdrawing antibiotics (86%) or inotropes (95%). Fewer ICU physicians reported withdrawing mechanical ventilation (52%) or extubating patients (27%). Hydration was reported to be only rarely terminated (76% of participants reported never terminating it). In addition, 63% of participants had never encountered advance directives, and 39% reported to “never” or “rarely” participating in decision making with relatives of patients. Nurses were reported to be “never” or “rarely” involved in the EOL decision making process by 84% of participants. Conclusions Limitation of LST was regularly used by Slovene ICU physicians. DNR orders and withholding of LST were the most commonly used measures. Hydration was only rarely terminated. In addition, use of advance directives was almost non-existent in practice, and the patients’ relatives and nurses only infrequently participated in the decision making.

Methylprednisolone, cortisol and the cell-mediated immune response in children after ventricular septal defect repair

Abstract Background: This study evaluated the effects of methylprednisolone on cortisol and cell-mediated immune response (T-lymphocytes and HLA-DR+ monocytes) in peripheral blood after open-heart surgery with cardiopulmonary bypass (CPB) for ventricular septal defect. Methods: A prospective observational study was carried out in a tertiary multidisciplinary neonatal and paediatric intensive care unit. Ten children under 2 years of age received methylprednisolone succinate (30 mg/kg body weight) in CPB priming solutions before the CPB system was connected to the patient during surgery. Before and immediately after and at 24 and 96 h after the operation, T-lymphocytes and HLA-DR+ monocytes were measured by flow cytometry, and methylprednisolone, methylprednisolone succinate and cortisol in blood plasma were assayed by liquid chromatography-mass spectrometry. Results: The children were divided into groups with normal cardiac index (CI) and low CI. No significant differences in methylprednisolone and cortisol concentrations before and after surgery were found between the two groups. The normal CI group exhibited more than a three-fold decrease in T-lymphocytes 24 h after surgery and a two-fold decrease in HLA-DR+ monocyte fluorescence immediately after surgery. Conclusions: Children with normal and low CI were differentiated by T-lymphocytes and HLA-DR+ monocytes. Since no differences in methylprednisolone exposure and cortisol plasma levels between the low-CI and normal-CI groups were found, it can be concluded that factors other than methylprednisolone must contribute to differences in the cell-mediated response. Clin Chem Lab Med 2007;45:1366–72.

Narrowing of the Diagnostic Gap of Acute Gastroenteritis in Children 0-6 Years of Age Using a Combination of Classical and Molecular Techniques, Delivers Challenges in Syndromic Approach Diagnostics.

Background: Twenty-five percent to 50% of acute gastroenteritis (AGE) cases remain etiologically undiagnosed. Our main aim was to determine the most appropriate list of enteric pathogens to be included in the daily diagnostics scheme of AGE, ensuring the lowest possible diagnostic gap. Methods: Two hundred ninety seven children ⩽6 years of age, admitted to hospital in Slovenia, October 2011 to October 2012, with AGE, and 88 ⩽6 years old healthy children were included in the study. A broad spectrum of enteric pathogens was targeted with molecular methods, including 8 viruses, 6 bacteria and 2 parasites. Results: At least one enteric pathogen was detected in 91.2% of cases with AGE and 27.3% of controls. Viruses were the most prevalent (82.5% and 15.9%), followed by bacteria (27.3% and 10.2%) and parasites (3.0% and 1.1%) in cases and controls, respectively. A high proportion (41.8%) of mixed infections was observed in the cases. For cases with undetermined etiology (8.8%), stool samples were analyzed with next generation sequencing, and a potential viral pathogen was detected in 17 additional samples (5.8%). Conclusions: Our study suggests that tests for rotaviruses, noroviruses genogroup II, adenoviruses 40/41, astroviruses, Campylobacter spp. and Salmonella sp. should be included in the initial diagnostic algorithm, which revealed the etiology in 83.5% of children tested. The use of molecular methods in diagnostics of gastroenteritis is preferable because of their high sensitivity, specificity, fast performance and the possibility of establishing the concentration of the target. The latter may be valuable for assessing the clinical significance of the detected enteric, particularly viral pathogens.