Vol 10, No 5 (2019)

Original studies

Gastrointestinal risk factors for anemia in children with celiac disease

Shapovalova N.S., Novikova V.P., Revnova M.O., Gurina O.P., Dementieva E.A., Klikunova K.A.


With oral intake, iron absorption in patients with celiac disease (CD) is reduced due to the decreased absorption surface of the atrophic small intestine mucous membrane. Besides, there are additional risk factors for anemia whose mechanisms are unclear. The aim of this study was to evaluate gastrointestinal risk factors for anemia in children.

Materials and methods. The first group consisted of 58 children with newly diagnosed CD who did not adhere to the gluten-free diet (GFD). The second group included 49 children with CD who hasn’t been adhering to the GFD. The third group included 69 children with chronic gastritis (CG) without CD. In addition to the standard examination, which includes the determination of antibodies to tissue transglutaminase and histological examination of the duodenum mucous membrane, a histological evaluation of the gastric mucosa, determination of pepsinogen 1 and 2 and their ratio, antibodies to Castle’s intrinsic factor were performed. 

Results. The mean level of hemoglobin in the group 1 – 114,71120,10125,50 g/l, in the group 2 – 124,37128,74133,10 g/l, in the group 3 – 130,12133,78137,43 g/l (p1,2 = 0.013; p1,3 = 0,000; p2,3 = 0.083). A correlation analysis of the hemoglobin level and morphological parameters of the duodenal mucosa among the studied patients revealed an inverse moderate correlation between the hemoglobin level and the degree of the small intestinal atrophy according to Marsh r = –0.331, p = 0,000, crypt depth r = –0,439, p = 0,000, and a moderate direct with the ratio of villi:crypt r = 0.417, p = 0.000, with the height of the villi r = 0.366, p = 0,000. Additionally, a moderate direct correlation between the level of hemoglobin and the number of parietal cells was found to be r = 0.354, p = 0.037. In group 1, a significant inverse correlation between the level of hemoglobin and the level of antibodies to Castle’s factor r = –0.529, p = 0.006, was obtained for the level of antibodies in the Castle’s factor. 

Conclusion. Autoimmune gastritis may be an additional risk factor in combination with malabsorption, as a possible cause of anemia in children with CD.

Pediatrician (St. Petersburg). 2019;10(5):5-12
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Age aspects of the course of chronic otitis media with cholesteatoma in children (clinical and immunological characteristics)

Vlasova G.V., Pavlov P.V.


Cholesteatoma of the middle ear is the disease, the course and prognosis of which can not be considered without taking into account the patients age. In pediatric otorhinolaryngology, such patients require special attention due to the aggressiveness of cholesteatoma in children. The rapid growth and a high number of recurrences after surgical treatment are features of the course of this disease in children. The causes of the aggressiveness of this disease in children have not been studied. Objective: to identify clinical and immunological features in children with middle ear cholesteatoma in different age groups that contribute to the aggressive course of the disease. A retrospective analysis of 143 medical case reports of children from 1 to 17 years old who received surgical treatment of middle ear cholesteatoma was carried out in the Department of othorhinolaryngology (St. Petersburg State Pediatric Medical University) from 2000 to 2018. Comparative analysis of clinical manifestation, anamnesis of ear disease, concomitant diseases, immunological reactivity (the content of lymphocytes, their subpopulations and interleukin-2 in peripheral blood) and results of surgical treatment of middle ear cholesteatoma in different age groups has been performed. Cholesteatoma is more aggressive in young children. Frequent infections of the upper respiratory tract, eustachian tube dysfunctions, immune disorders in children under 7 years of age lead to an unfavorable course and prognosis of middle ear cholesteatoma.

Pediatrician (St. Petersburg). 2019;10(5):13-18
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The study of hydrogen sulfide in cord blood to predict the functioning of the ductus arteriosus in preterm infants

Kharlamova N.V., Fisuk J.A., Sitnikova O.G., Gorozhanina T.Z., Nazarov S.B.


The hemodynamically significant functioning ductus arteriosus in premature infants can cause many complications and worsen the prognosis for life and health. Therefore, the determination of a high risk of the functioning of the ductus arteriosus is an urgent problem of the early neonatal period. Characteristic echocardiographic manifestations of a functioning ductus arteriosus is a lower stroke volume, higher pressure in the pulmonary artery and aorta. In the framework of this study, the frequency of the functioning ductus arteriosus in deeply premature infants was revealed. It was found that the concentration of hydrogen sulfide in umbilical cord blood in lower preterm infants with a functioning arterial duct is lower than in newborns without a functioning arterial duct. It is shown that the concentration of hydrogen sulfide in cord blood can be used for early detection of this condition. A method for predicting the functioning of the arterial duct has been developed, which consists in calculating the prognostic index D taking into account the gestational age, weight and height of the newborn, as well as the concentration of hydrogen sulfide in cord blood.

Pediatrician (St. Petersburg). 2019;10(5):19-26
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Remodeling of the heart and main vessels in patients with marfanoid habitus

Timofeev E.V., Malev E.G., Parfenova N.N., Zemtsovsky E.V.


For many hereditary connective tissue disorders (HCTD), especially Marfan syndrome, remodeling of the heart and main vessels is described, which is manifested by a decrease in the systolic function of the left ventricle and expansion of the thoracic aorta. Evaluation of morphometric characteristics of the heart and main vessels in patients with other HCTD, in particular – marfanoid habitus (MH) has not been previously carried out. 

Materials and methods. We examined 90 young men and 74 young women between the ages of 18 to 25 years, 111 patients older age groups with stable over coronary heart disease (mean age 64.6 ± 6.2 years) and 9 patients with verified Marfan syndrome (mean age 27.9 ± 9.3 years). All survey phenotypic and performed anthropometric survey identifying bone signs of dysembryogenesis as well as Echocardiography study on standard protocol. 

The results. Patients with MH as compared with control group revealed a relatively larger diameter of aortic root (30.4 ± 4.7 vs 28.0 ± 3.6 mm, p = 0.03) and the ascending aorta (26.6 ± 4.9 vs 24.6 ± 3.2 mm, p = 0.05). Also young with MH turned out to be significantly thicker myocardium of left ventricular posterior wall (8.3 ± 0.8 vs 7.7 ± 1.1 mm, p = 0.02) and interventricular septum (8.8 ± 1.2 vs 8.2 ± 1.1 mm, p = 0.04). When performing correlation analysis identified reliable positive correlation between such highly specialized bone signs as high palate (r = 0.31), infundibular deformation of the chest (r = 0.43), arachnodactyly (r = 0.45) and Z-test (p < 0.05 for all). Expansion of the aorta (Z-criterion >2.0) have found 24% of older patients with MH. 

Conclusion. In patients with MH revealed significant structural changes of heart and main vessels which are progredient character – thickening of the left ventricular myocardium and expansion of the aortic root.

Pediatrician (St. Petersburg). 2019;10(5):27-34
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Myopia-causing social and hygienic factors in urban schoolchildren

Gorbachevskaya I.N., Orel V.I., Brzheskiy V.V., Ershova R.V.


Myopia in schoolchildren is a serious problem. The frequency of its detection in the lower grades of the school is 6–8%, and by the end of school – at least 25–30%. In special school this indicator reaches 50%, which is associated with more intense and longer visual loads, prolonged work at the computer and more frequent use of other electronic storage media. The genesis and progression of myopia is largely due to the intensive educational process in which schoolchildren are involved already from the first year of study, as well as to the corresponding violations of the hygiene of their visual work at close range. The article presents the results of a retrospective analysis of case histories of 53 school-age children living in St. Petersburg. The role of socio-hygienic factors related to the schoolchildren’s connected their family life (including material well-being) and the availability of modern technical means (computers, video game consoles, mobile phones, etc.) was studied. An analysis of “external” factors (deficient physical activity of the child, change of the daily regimen, later visit of the child’s parents by an ophthalmologist), which have a negative impact on the development and progression of myopia in schoolchildren, was also relevant. Based on the results of the study, recommendations were developed for the observation and correction of myopia in schoolchildren.

Pediatrician (St. Petersburg). 2019;10(5):35-41
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Diagnosis and treatment of upper gastrointestinal bleeding in patients with acute cerebrovascular accident

Korolev M.P., Spesivtsev Y.A., Fedotov L.E., Klimov A.V., Terekhov I.S., Kondratyev A.N., Daliev B.B., Doniyarov S.K.


Bleeding from the upper gastrointestinal tract is one of the most dangerous complications in patients with acute CVA (ischemic and/or hemorrhagic type). The combination of these conditions requires special attention in the diagnosis and choice of treatment methods. Central Nervous System pathology makes diagnosis, choosing methods of treatment and the use of drug more complicated to surgeons in the postoperative period. With onset of hemorrhage, antithrombotic treatment should be canceled, that can negatively affect the results of treatment of patients with ischemic type of cerebral vascular accident. The use of anti-ulcer drugs, namely proton pump inhibitors, may increase the risk of hospital-acquired pneumonia, Clostridium difficile infections, and cardiovascular diseases. These factors force us to consider issues related to diagnosis and treatment plans in this group of patients. The most promising direction in the treatment of patients with ischemic or hemorrhagic stroke in combination with gastroduodenal bleeding is the identification of risk factors for upper gastrointestinal bleeding, early endoscopic diagnosis and treatment, performing preventive treatment. The article presents a brief review of domestic and foreign literature, some issues of etiology and pathogenesis of gastroduodenal bleeding in patients with cancer, the results of our own research, capabilities of modern endoscopy in the diagnosis and treatment of gastrointestinal bleeding in this group of patients. The algorithm of management of patients with a combination of bleeding from the upper gastrointestinal tract and CNS pathologies.

Pediatrician (St. Petersburg). 2019;10(5):43-50
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Features of the manifestation of type 1 diabetes in children and teenagers in the Perm Region

Khudorozhkova O.M., Smirnova E.N.


Clinical manifestations of type 1 diabetes mellitus (type 1 diabetes) in children largely depend on the age of the child and the degree of decompensation of metabolic processes at the time of its diagnosis. Early detection of diabetes and early treatment can improve the prognosis of the disease and reduce the risk of further complications and adverse outcomes. 

The purpose of this work: to identify the features of the manifestation of type 1 diabetes in children in the Perm Region, who fell ill from 2002 to 2017.

Methods. The data of anamnesis, clinical and instrumental methods of research were analyzed in 378 patients with newly diagnosed diabetes mellitus type 1 in the period of hospitalization from 2002 to 2017 (378 people). 

Results. It is revealed that boys and girls get diabetes with the same frequency. The incidence of disease in recent years among rural residents remains at a lower level than in the cities of the region. There is a high incidence of disease throughout the year, regardless of the season. Initiating factors are infectious diseases, as well as various stressful situations. A standard examination in patients revealed changes corresponding to the state of hyperglycemia. One third of patients had ketoacidosis of varying severity. In 11% of children, diabetes mellitus was suspected during routine follow-up. Among the comorbidities most frequently encountered are problems of the nervous system and other endocrine diseases. Almost a quarter of patients had burdened heredity according to type 1 diabetes. When comparing the data of anamnesis and manifestation of type 1 diabetes with the data of other regions, no significant difference was found.

Pediatrician (St. Petersburg). 2019;10(5):51-56
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Predictors of the development of cardiac arrhythmias in women after induction of superovulation in vitro fertilization

Vakareva V.V., Avdeeva M.V., Scheglova L.V., Bondarev S.A., Voronkov P.B.


The article presents the results of a clinical and instrumental examination of 80 healthy women (average age 32,31 ± 3,57 years) in order to assess the heart rhythm disturbances after induction of superovulation during in vitro fertilization. All women were examined twice – before and after induction of superovulation during extracorporeal fertilization. Clinical and instrumental examination included: electrocardiography at rest; echocardiography; 24-hour ECG monitoring with heart rate variability analysis; 24-hour blood pressure monitoring. Induction of superovulation is associated with a significant increase in mean daily HR max (р < 0,01), and consequently with an increase in myocardial oxygen demand. It has been established that induction of superovulation contributes to the development of supraventricular arrhythmias (р < 0,01) and an increase in episodes of apnea/hypnea (р < 0,01). Regression analysis revealed predictors of supraventricular arrhythmias after induction of superovulation, including adverse circadian heart rate profile, adverse circadian blood pressure profile, impaired autonomic regulation of heart activity (р < 0,01). It was shown that the appearance of rhythm disturbances is associated with both the initial functional state of the cardiovascular system and its response to the induction of superovulation. It was established a correlation between the estradiol concentration and the increase of daily average heart rate after induction of superovulation (r = 0,30, р < 0,05), apnea/hypnea index after induction of superovulation (r = 0,34, р < 0,05). Conclusion. Superovulation induction may exacerbate existing chronic cardiovascular diseases. Due to the adverse effect of superovulation induction on the daily heart rate profile, women need to evaluate the functional state of the cardiovascular system during in vitro fertilization planning. This will prepare the woman for the upcoming procedure and avoid adverse reactions from the cardiovascular system in response to stimulation of superovulation in vitro fertilization.

Pediatrician (St. Petersburg). 2019;10(5):57-65
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Alcoholic lung injury

Davydova Z.V., Yagmurov O.D.


The article presents modern data on pathomorphological changes in lung tissue formed under the influence of acute and chronic intoxication with ethanol and its metabolites. At autopsy of the persons abusing alcohol, along with defeat of a brain, heart, a liver note considerable changes in lungs. It was found that ethanol is excreted by the lungs and kidneys unchanged. The lungs are actively involved in the conversion of ethanol into carbon dioxide. The toxic effect of ethanol and its metabolites increases the permeability of the vascular wall, which leads to the accumulation of protein in the lung tissue with the development of pronounced dystrophic and destructive changes with the formation of subsequent pneumosclerosis. Alcohol negatively affects the function of alveolar macrophages, which have an important role in protecting the lungs. Under the influence of ethanol in macrophages, biochemical processes are slowed down, expressed in a sharp decrease in their phagocytic activity and ability to move. In turn, it is necessary to note the studies that reflect the data on the influence of alcohol on the lung surfactant, which stabilizes the surface tension in the alveoli and counteracts the transudation of fluid into the alveoli. Alcohol adversely affects the phospholipids included in the surfactant and disrupts the process of its formation. Alcohol intoxication is the cause of 60% of comatose States, and obturation-aspiration complications are the leading form of respiratory disorders. Alcohol-induced disorders of the mucociliary apparatus contribute to the ingress of foreign particles into the respiratory tract. The defeat of these protective mechanisms in combination with a decrease in the overall immune reactivity of the body cause the development of a number of pathological changes in the lungs. Thus, the study of morphological features of lung injuries in acute ethanol poisoning is of fundamental importance in elucidating the links of pathogenesis of terminal States, their justified therapy.

Pediatrician (St. Petersburg). 2019;10(5):67-72
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Fecal blood tests-screening methods for identification of pre-tumor changes and tumors at the early stage

Novikova V.P., Drygin A.N.


Mortality due to cancer of the rectal colon is currently increasing in all groups of the adult population. Various screening methods are used to identify the pre-tumor and early stages of the development of tumor pathology of the colon: occult blood tests in feces, computer colonography (virtual colonoscopy), colonoscopy, DNA testing, tumor marker M2-PK (tumor fractional pyruvate kinase fraction M2). All of these colorectal cancer screening methods give good results, but there is no consensus among experts regarding the choice of the most optimal method. One of the first tests to detect hidden blood in the stool was biochemical tests: guaiac test (gFOBT – guaiac fecal occult-blood test ), in which hemoglobin in the stool was detected by a biochemical method that exploited the pseudoperoxidase activity of hemoglobin and the Gregersen reaction, which is a benzidine test in which benzidi was used instead of guaiac resin And instead of a hydrogen peroxide – barium peroxide. Enzyme-linked immunosorbent assays, in contrast to biochemical ones, use antibodies specific only to human hemoglobin, which excludes false-positive results obtained using the biochemical method. The FIT test (Fecal Immunochemical Test or Immunochemical Fecal occult blood test) specifically determines human hemoglobin in feces at lower threshold values (40–300 μg HB/1 g feces) compared to g-FOBT. Due to its high accuracy, Enzyme-linked immunosorbent assays are successfully used to detect occult blood in inflammatory bowel diseases, allergic enteropathies, acute intestinal infections, and erosive gastritis.

Pediatrician (St. Petersburg). 2019;10(5):73-78
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Glycated proteins

Danilova L.A.


Glycation is a biological reaction that occurs in all proteins. This reaction proceeds more slowly in healthy subjects and more rapidly in patients suffering from a hyperglycemia. Glycated proteins cannot fulfill their functions that could lead to metabolic disorders. The process of glycation leads to building of advanced glycation end-products (AGEs). The structure of AGEs has not been fully researched yet. Glycated proteins have diagnostic meaning in different health conditions and not only in patients with diabetes mellitus. Determination of glycated proteins level (hemoglobin and plasma proteins) in diagnostics of diabetes mellitus and the effectiveness of its treatment; measurements of glycated proteins could be used as a predictor of different illnesses and their complications. Glycated hemoglobin was researched in children with diabetes mellitus of different severity. It has been shown that the level of glycated proteins does not always correlate with blood sugar level. Results of glycated proteins measurements in patients with thyroid disorders shows that the glycation takes place not only in patients with diabetes mellitus, but also with other illnesses without hyperglycemia. Our research in patients with diabetes mellitus has shown that the measured level of glycated proteins and plasma proteins could be more significant in the course of disease than the level of blood sugar. Compensation of diabetes mellitus in children in regard of the blood sugar level does not always correlate with the level of glycated proteins. This assumption could lead to the conclusion that only the combination of measurements like blood sugar, glycated hemoglobin and glycated proteins could give a full picture of disease compensation.

Pediatrician (St. Petersburg). 2019;10(5):79-86
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Clinical psychology

The system of self-attitude, attitude towards significant people and the world of adolescents who are maltreated in the family

Zemlianykh M.V., Izotova M.H.


The article is devoted to the study of self-attitude and the attitude towards significant people and the world of adolescents who are exposed to such types of abuse in the family as physical and emotional abuse. 172 adolescents of age 12–15 years were studied. The main group consisted of 86 adolescents who are under the school monitoring and defined as the “being in a difficult life situation” and also adolescents, who are exposed to emotional and physical violence in the family ( the cases were registered by school social service). The control group was formed from 86 adolescents who were not exposed to emotional violence and physical punishment in the family. The following research methods were used: empirical (observation, conversation, questioning, testing), questionnaires – Self – attitude inventory (S.R. Pantileev); “Diagnostic of the level of empathy” inventory (I.M. Yusupova); aggression status inventory (Bass–Durkee Hostility inventory); projective method “Incomplete sentences” (M. Saks, S. Levy), projective drawing technique “My world” (E.S. Romanova, T.I. Cake). Statistical processing was performed using a non-parametric test for two independent variables, U-Mann–Whitney. As the main psychological consequences, a high degree of dissatisfaction with oneself, negative attitude towards parents to a greater degree towards fathers, weak expression of empathy, high aggressiveness, sensitivity and suspiciousness, negative vision of the surrounding world were revealed.

Pediatrician (St. Petersburg). 2019;10(5):87-92
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Clinical observation

Pituitary gigantism. The possibility of medical treatment

Tyrtova L.V., Olenev A.S., Parshina N.V., Skobeleva C.V.


Pituitary gigantism is a disease caused by an excess of growth hormone and characterized by tallness with a proportional increase in all parts of the body. Almost always in patients with pituitary gigantism found pituitary adenoma, producing growth hormone (somatotropin). In rare cases, there is excess production of somatoliberin by the hypothalamus or tumors outside the brain. Somatotropinoma can be sporadic or caused by a disease with genetic defects: multiple endocrine neoplasia type 1, McCune–Albright syndrome, Carney complex, X-LAG syndrome, AIP-mutation. All associated with genetic defects somatotropinoma more invasive and less amenable to drug therapy than sporadic. Clinical recommendations (protocols) for the treatment of pituitary gigantism in children currently does not exist. The issue of preliminary medical treatment to improve the outcome of neurosurgical interventions has not been resolved, and further methodologically based studies are needed to clarify this point. The article presents a clinical case of pituitary gigantism caused by pituitary adenoma, which produces growth hormone in a 12-year-old boy. The diagnosis was established on the basis of clinical and anamnestic, laboratory data and magnetic resonance imaging. Clinical and laboratory manifestations of hypopituitarism and diabetes insipidus, visual field disorders, neurological symptoms, as well as signs of genetic diseases in the patient were not noted. Treatment with bromocriptin gave a partial positive effect: the size of the formation in the pituitary gland decreased, but the target hormonal parameters were not achieved. A trial administration of octreotide subcutaneously was carried out, as a result of which the level of growth hormone decreased to the target values, no side effects of the drug were noted, which led to the choice of a conservative method as the first line of therapy. The decision to treat with bromocryptine in combination with octreotide extended action. The dynamics of tumor size on the background of conservative therapy will answer the question of the need for subsequent neurosurgical treatment.

Pediatrician (St. Petersburg). 2019;10(5):93-99
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The results of efferent therapy by woman with HIV infection, with amniotic fluid outflow at 23 weeks with growth retardation syndrome of 2 fetus

Vetrov V.V., Ivanov D.O., Reznik V.A., Romanova L.A., Melashenko T.V., Shandrenko K.A., Krivolesova T.A.


In the article presents data on the management of a 48-year-old patient with HIV infection, urogenital infection with pregnancy, which occurred as a result of IVF, with premature effusion of amniotic fluid at 23 weeks of pregnancy with the syndrome of growth retardation of 2 fetus in monochoric diamniotic twins. After the discharge of the amniotic fluid, the patient was treated for six days in an infectious hospital, then transferred to the perinatal center, where blood tests noted moderatemanifestations of endotoxicosis, increased levels of aminotransferases and an inflammatory reaction of the body. The course of treatment included detoxification methods (plasmapheresis, hemosorption, photomodification of blood with ultraviolet, laser rays), which contributed to the normalization of blood tests, prolongation of pregnancy for another three weeks in the absence of septic complications after operative childbirth in the mother and in newborn girls. At birth, 1 child’s weight, body length and Apgar score were 750 g., 29 sm. and 3/5 points, respectively, in 2 children – 590 g., 30 sm. and 1/3 points, respectively. The children required treatment from resuscitators, at the second stage of nursing, from rehabilitation specialists.

Pediatrician (St. Petersburg). 2019;10(5):101-104
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Anniversary of professor of internal medicine Eduard Zemtsovsky

Timofeev E.V., Reeva S.V.


The paper presents a short survey of medical, research and educational activity of professor Zemtsovsky. Edward Veniaminovich Zemtsovsky is an avowed authority in our country in diagnostics and treatment of congenital connective tissue disorders. He has coauthored the first Russian recommendations for congenital connective tissue disorders diagnostics and treatment. Nowadays professor Zemtsovsky continues active research and pedagogical activity. He is a merited example of outstanding professional course of life.

Pediatrician (St. Petersburg). 2019;10(5):105-108
pages 105-108 views

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