Paediatrician最新文献

In recent years, considerable effort has been devoted to the study of those core elements necessary to define a reference standard of health for adolescents. In our program, indices of adolescent disability were developed based on an analysis of 12 years of data from approximately 75,000 teenage patients. In-hospital (14,000), ambulatory (15,000), and community based (50,000) adolescent contacts offered differing indices of disease. Targeted screening efforts produced significant epidemiologic data and generated recommendations for adolescent ambulatory screening standards which were then applied to such community experiences as school health programs and urban group home settings. Both demonstrated significant levels of disability in excess of 50% of the populations studied. Alternatively, review of more complex problems observed within a hospital setting specific for adolescents revealed significant chronic disability. Clearly the health requirements of the adolescent are extensive but effective interventions must be based on carefully considered indicators of unmet needs.

Particular problems under discussion in the field of infant nutrition today are the following. (1) The frequency of breastfeeding including the effect of promotion to uncrease it. (2) The protein requirement of low birth weight infants including relevant parameters for evaluation of the requirement. Recent studies indicate that the protein requirement of low weight is only slightly higher (or may be the same) as that supplied by breast milk. (3) The tolerance for intake of certain nutrients in early infancy - mainly protein and minerals - in relation to the development of organ functions, including homeostatic disturbances that may arise when the tolerance is exceeded. Adverse effects of a too high protein intake are particularly acidosis and increased osmolar load on kidney function. Excess mineral adds to the renal solute load, implying a threat to water balance. (4) The introduction of Beikost, when and why, and (5) Atherosclerosis as a problem for the pediatrician. The need for identification of risk factors, especially screening for hyperilipidemia, in early life and for recommendation of dietary measures instituted in early childhood has to be further studied.

There is good, controlled evidence which suggests that cyclophosphamide, and perhaps related drugs, have a definite role in the treatment of nephrotic children with the minimal change lesion. This role is one of secondary treatment, and the drugs should not be used as a first line of attack; they should be employed only when corticosteroid resistance or toxicity is a problem. In a few patients, azathioprine or 6-mercaptopurine may have a role in minimising corticosteroid toxicity, but the remission induced in relapsing children is no more durable than that after corticosteroids. Chlorambucil must be given in doses, and for periods long enough to run the risk of neoplasia, particularly leukaemia; there does not appear to be a place for its use in nephrotic children unless the duration of remission can be shown to be longer than that obtainable with cyclophosphamide. There is no evidence that any immunosuppressive agent has a place in the management of children with idiopathic glomerular disease showing structural alterations in the glomeruli. Children with systemic lupus erythematosus and nephritis may benefit from the addition of cytotoxic agents to their corticosteroid regime, although the indications for this are not clear, and controlled evidence is lacking.

The most outstanding aspects of congenital or fetal syphilis, emphasizing its epidemiology, clinical aspects, diagnosis, prevention and treatment, are studied. The authors point out the increasing frequency of this treponematosis, which should still be considered as a worldwide endemic disease, though it is foreseeable and tractable. Some new data about the problem are provided, apropos of recent observations.

The achieved or achievable standard of vaccination measures against bacterial infections is discussed with reference to 3 groups of vaccines. The first group involves well established and commonly used vaccines such as BCG and DPT vaccines. The second group includes newer vaccines or vaccines that are under development, for instance vaccines against meningococci, pneumococci, H. influenzae and enteropathogenic E. coli. The third group covers vaccines whose realisation at present appears to be difficult or hardly feasible, for instance vaccines against enterotoxins of enteropathogenic organisms, against lues, gonorrhea or, example, against organisms of hospital infections.

This commentary discusses the issue of continuous medical education in pediatrics from the perspective of a practitioner who desires to see the recertification process as a rewarding practical experience, inexpensive, adjusted to the needs of his community and, most particularly, a process designed and delivered by the medical institutions and experts of his state and county, independent of the national organizations and boards.

An up-to-date review of the clinical diagnostic and treatment of infectious mononucleosis, emphasizing on new etiological concepts (Epstein-Barr virus) and pathogenetic (T and B lymphocytes) interaction is presented.

The wide utilization of renal biopsy and the introduction of electron microscopic and immunohistologic methods has allowed better definition of the clinico-pathological conditions associated with the nephrotic syndrome (NS). Two major categories of facts can be differentiated. In the first one, diffuse lesions of glomeruli, either secondary to specific diseases, or apparently primary diseases such as membranous or membrano-proliferative glomerulonephropathy (GN) are responsible for the increased permeability of the glomerular capillaries. In most of these, there is evidence that immunological mechanisms play a role in the injury of the glomerular capillary. Any of the following clinical symptoms are suggestive of this category of NS: an acute nephritic onset, a moderate NS, macroscopic hematuria, marked hypertension and/or renal insufficiency, poorly selective proteinuria and decreased plasma C3 levels. Patients affected with any of these glomerulopathies usually do not respond to steroids. In the second one, usually referred to as the idiopathic nephrotic syndrome (INS) the mechanism of glomerular capillary alteration is unknown and the nephrotic syndrome is more marked. Minimal change NS (MCNS) accounts for the great majority of INS and is characterized in most cases by a selective proteinuria, the absence of hematuria, a good response to steroids and a good prognosis. However, in some instances, renal biopsy reveals either diffuse mesangial proliferation (DMP) or focal glomerular sclerosis (which may be superimposed on MCNS or on DMP). In both instances, hematuria may be present and 50--75% of patients do not respond to steroids and have a poor prognosis. There is still considerable controversy about the exact relationship between these 3 patterns. We believe that they are not distinct entities but represent variants of the same disease. In addition to these 2 major categories of NS, there are, in infancy, 2 conditions associated with a NS of poor prognosis: congenital NS of Finnish type and infantile mesangial sclerosis. Since steroid-sensitive nephrosis is by far the commonest cause of NS especially in young children up to 8 years, a renal biopsy should be performed only in 2 instances: (a) when the clinical symptoms suggest diffuse glomerular lesions, and (b) when steroid resistance has been demonstrated.

The haemolytic uraemic syndrome is an acute illness characterised by the occurrence of renal injury, haemolytic anaemia with red cell fragmentation and thrombocytopenia. Haemorrhagic diathesis, arterial hypertension and neurological manifestations often complicate the acute phase of the disease. In this article, we shall discuss in more detail the aspects of this phase. Data obtained in 72 patients treated at the Wilhelmina Children's Hospital in Utrecht, from 1964 to 1977, are used to illustrate the characteristics of the disease.