Treatment of rheumatic carditis

Rheumatic fever and rheumatic heart disease continue unabated in most of the developing nations, affecting young individuals. Focal outbreaks of smaller magnitude have also been reported since mid 1980s from industralized western nations, where this disease had almost disappeared. Introduction of penicillin in mid 1940s had markedly changed the natural history of rheumatic fever, although the incidence of rheumatic fever declined in developed nations before that, due to better living conditions. Treatment of rheumatic fever chiefly involves use of antibiotics (penicillin) to eradicater strepcocci, and antiinflammatory drugs like salicylates or corticosteriods. Patients with severe carditis, congestive heart failure and/or pericarditis are best treated with corticosteriods as these are more potent anti-inflammatroy agents than salicylates. Salicylates may be sufficient for cases with mild or no carditis. The treatmnet must be continued for 12 weeks. Several studies have shown that valvular regurgitation, and not myocarditis, is the cause of congestive heart failure in active rheumatic carditis. Therefore surgery with mitral valve replacement or repair is indicated in cases with intractable hemodynamics due to mitral regurgitation. Development of chronic valvular lesion after an episode of rheumatic fever is dependent upon presence or absence of carditis in the previous attack and compliance with secondary prophylaxis. Recurrences due to inadequate penicillin prophylaxis are responsible for hemodynamically significant chronic valvular lesions requiring surgery     

Understanding the development and prevention of type 2 diabetes in youth (part 1).

The prevalence of being at risk of overweight, overweight, pre-diabetes, and type 2 diabetes is increasing in the United States in youth. Primary care providers must understand how the emerging epidemic of type 2 diabetes developed during the past several decades to accurately diagnose it in young patients. Primary, secondary, and tertiary prevention interventions are needed to address the emerging epidemic of type 2 diabetes in youth. Primary prevention involves delaying the development of type 2 diabetes by reducing the prevalence of overweight. Secondary prevention is aimed at preventing those with pre-diabetes from developing diabetes, and tertiary prevention is aimed at preventing the complications of type 2 diabetes.     

Double or hybrid diabetes associated with an increase in type 1 and type 2 diabetes in children and youths

Abstract:  The increase in the incidence of type 1 diabetes (T1D), especially in children <5 yr of age, reported over the past decade can be attributed to changes in environmental factors (either quantitative or qualitative) rather than to an effect of genetic factors operating in such a short period of time. The notable increase in the incidence of type 2 diabetes (T2D) in children and adolescents is very likely the consequence of an increasing sedentary lifestyle and an increase in obesity, which has been occurring in developed countries. An increase in the number of children and adolescents with a mixture of the two types of diabetes has recently come to light (i.e., subjects who are obese and/or with signs of insulin resistance as well as positive for markers of autoimmunity to β cells), although the epidemiological data supporting such a conclusion are sparse. Under the current classification, it is difficult to define the type of diabetes affecting these young subjects, who might be classified as T2D because they are obese and insulin resistant but also as T1D because of the presence of autoantibodies to β cells. These subjects show an overlapping diabetes phenotype typical of both T1D and T2D, suggesting that the current classification of diabetes should be revised to take into account this new form of diabetes, which has been called 'double diabetes' or 'hybrid diabetes'. In this review, we report recent findings on the increasing rates of all forms of diabetes in the young population, including unpublished data collected in Russia.     

Primary health care: reality or utopia in a developing country?

Though it is 20 years since the acceptance, by member nations of WHO, of the concept of primary health care (PHC) as the best and cheapest means of achieving "Health for All in the Year 2000", most developing nations have made little or no progress toward its attainment. This is due, among other things, to a misconception of the meaning of PHC, by both developing and developed nations. While many developing nations see it as a new vertical programme, and therefore fail to integrate it into already existing ones, most developed nations take it, wrongly to mean that the developing nations should return to ancient, primitive medicine, which in earlier times led to high morbidity even in the developed nations. In the developing countries, there is still a disproportionately high concentration of resources in urban areas, and much more emphasis is still being placed on curative than on preventive measures. To achieve "Health for all in the Year 2000", therefore, a reorientation of both the developed and the developing nations is urgently needed.     

Breast-feeding and health in the 1980s: a global epidemiologic review

In view of the significant and articulate minority view among pediatricians that breast feeding is not "worth the bother" in developed countries, this review of the literature delves into the evidence from both developed and developing countries for the advantages of breastfeeding, both in infants and for long-term health. Infants in developed settings experience twice the hospitalization rate and more severe illness from lower respiratory tract infection, primarily respiratory syncytial virus. In developing countries the mortality risk is 4-fold. for otitis media, the relative risks were 3.3-4.3 for Finnish infants. Bacterial meningitis and/or bacteremia had a 4-fold risk for hospitalization in a Connecticut study, and a 3-fold relative risk in 2 developing country studies. Human milk was the best preventative for bacteremia and necrotizing enterocolitis in prematures in British neonatal units. A 20-fold reduction in neonatal deaths occurred in Philippine study of breastfeeding, especially in low birth weight babies. Diarrhea causes the most infant mortality in developing nations, where bottle-feeding raises rates 14-fold. In the U.S. estimated relative risks is 3.7 for diarrheal mortality. Sudden infant death is about 1/5 less common in U.S. breast fed babies than in bottle fed. There is evidence for better long-term health after breast feeding in disorders such as celiac disease, Crohn disease, ulcerative colitis, insulin-dependent diabetes mellitus, thyroid disease, malignant lymphoma, chronic liver disease, atopic dermatitis, and food allergies. The design of good studies of protection conferred by breast feeding, and the possible modes of action of breast milk are discussed.     

Human breast milk: current concepts of immunology and infectious diseases

Overall, the evidence for a protective effect of breast milk is unequivocal. With convincing data from both developed and developing nations, this information can be generalized to all populations and used to encourage both increased rates of breastfeeding as well as increased duration of nursing, especially in high-risk populations. Multiple studies directly support the concept of a positive dose–response relative to the amount of breast milk ingested and the benefit received. Evidence from specific studies supports exclusive breastfeeding through 6 months of age. There are also data from studies supporting the concept that any amount of breastfeeding can provide some immune protective benefits. Basic laboratory data document the importance of breast milk both supplementing the infant’s mucosal and systemic immune systems during this period of developmental deficiency, as well as demonstrating the beneficial influence of breast milk on the mucosal environment and directly on the ongoing normal development of the infant’s gastrointestinal tract and immune systems.Clinicians can utilize this information to accurately and effectively communicate the existing knowledge about the benefits of breast milk to their patients and families, to discuss the advantages of breastfeeding specifically as it relates to each particular mother–infant dyad, and to provide ongoing support and encouragement to all breastfeeding mothers.     

Epidemiology of childhood type 2 diabetes and obesity

Abstract:  Over the last decade, it has become apparent that type 2 diabetes extends not only into the young adult population but is also found in adolescents and even, occasionally, in children. The limited data that are currently available present a rather uncertain picture, with a rather wide range of prevalences and incidences of type 2 diabetes in children and adolescents. Not surprisingly, the majority of the cases, and the highest prevalences, have been found among ethnic groups known to be at high risk of adult type 2 diabetes. Nevertheless, even in European populations, where the prevalence of type 2 diabetes remains very low among children and adolescents and certainly is considerably smaller than type 1 diabetes, there are several cases reported. The risk factors for type 2 diabetes in children and adolescents are, as expected, similar to those seen in adults, with obesity being almost always present. In utero exposure to hyperglycemia now appears to be an additional risk factor to having a family history of diabetes and suggests that better management of diabetes in pregnancy and prevention of gestational diabetes may reduce the risk of diabetes developing in the offspring.     

The judicious use of antibiotics—An investment towards optimized health care

During the past century the excitement of discovering antibiotics as a treatment of infectious diseases has given way to a sense of complacency and acceptance that when faced with antimicrobial resistance there will always be new and better antimicrobial agents to use. Now, with clear indications of a decline in pharmaceutical company interest in anti-infective research, at the same time when multi-drug resistant micro-organisms continue to be reported, it is very important to review the prudent use of the available agents to fight these micro-organisms. Injudicious use of antibiotics is a global problem with some countries more affected than others. There is no dearth of interest in this subject with scores of scholarly articles written about it. While over the counter access to antibiotics is mentioned as an important contributor towards injudicious antibiotic use in developing nations, as shown in a number of studies, there are many provider, practice and patient characteristics which drive antibiotic overuse in developed nations such as the United States. Recognizing that a thorough review of this subject goes far and beyond the page limitations of a review article we provide a summary of some of the salient aspects of this global problem with a focus towards readers practicing in developing nations.     

Adolescents on basal‐bolus insulin can fast during Ramadan

Al‐Khawari M, Al‐Ruwayeh A, Al‐Doub K, Allgrove J. Adolescents on basal‐bolus insulin can fast during Ramadan. Fasting during Ramadan is a major tenet of the Muslim religion. All adults after the age of puberty are required to do so if health permits. However, there are exemptions to this requirement and having a chronic condition such as diabetes is one. Nevertheless, many adults and adolescents feel obliged to fast during Ramadan even though there is no absolute need to do so. This obligation must be respected. There are few data to support this practice in those whose condition, such as diabetes, potentially makes them vulnerable to developing problems during prolonged fasting. This study was designed to examine the ability and safety of young people with diabetes to be able to fast if they so desire. Two groups of patients were studied, those on a multiple injection, so‐called basal‐bolus, regimen and those on a ‘conventional’ twice daily pre‐mixed insulin regimen. All patients showed a tendency to high blood glucose at the time of commencing their fast. Those on twice daily insulin continued to have hyperglycaemia during the day whilst those on basal‐bolus insulin showed a steady fall in blood glucose towards normal by the time of breaking their fast. Although there was a greater tendency to hypoglycaemia in the basal‐bolus group, this could be successfully prevented by reducing the dose of basal insulin by 10–20%. We recommend that it is safe for adolescents with diabetes to fast during Ramadan as long as they reduce their basal insulin by this amount and continue to monitor their blood glucose regularly.     

Neonatology in developed and developing nations

Neonatal care has made tremendous improvements in developing countries. However there are number of challenges to be met and neonatal mortality remains unacceptably high. In contrast to this neonatal care in developed nations have moved ahead of a pre-occupation to reducing the neonatal mortality only. The main reasons for this gap are poor infrastructure, resource limitations and lack of systems developed by neonatal units in the developed nations. Though this communication we explore the possibilities of application of health policies in the Australian neonatal units n developing countries.     

Type-2 diabetes in childhood: incidence and prognosis

Type-2 diabetes is a global public health concern, and young people have not escaped the epidemic. However, there is a paucity of information – particularly population-based data – regarding the incidence, prevalence, and natural history of type-2 diabetes in young people, with a lack of uniformity in case definition, data collection, and follow-up. In some populations, type-2 diabetes accounts for more than 50% of incident cases of diabetes in 10–18-year-olds, with the highest rates found in ethnic minority groups. The rise in youth-onset type-2 diabetes has been attributed to environmental factors such as change in lifestyle, lack of exercise, and diet, and parallels the rise in childhood obesity. The risk of diabetes may begin in utero with fetal overgrowth and adiposity. Type-2 diabetes in young people is frequently complicated by other features of the metabolic syndrome, including hypertension and dyslipidaemia, and comorbidities such as microalbuminuria are more common than in type-1 diabetes. The increasing caseload of type-2 diabetes threatens to have a significant impact on morbidity and mortality in the current generation of overweight young people; there is an urgent need for the development of evidence-based strategies to intervene.     

Transitional care of biliary atresia

Worldwide native liver survival (NLS) for young adults (>20 years) with biliary atresia varies between 14% and 44% with the majority of patients developing complications in adulthood. Cholangitis and portal hypertension with variceal bleeding are the most common complications and development of these during adolescence associated with the need for liver transplantation during adulthood. Adult listing criteria, typically developed on the background of adult liver disease might not be applicable to this patient population and leads to longer waiting time and risk of deterioration of their medical condition.Current data on growth and puberty in young people with biliary atresia surviving with native liver are rare. Pregnancy has been associated with serious complications in particular for those patients with advanced liver disease and, close follow up by specialist teams recommended. The long-term effect of having a chronic liver disease such as biliary atresia on neuro-cognitive and pubertal development has not been sufficiently explored to date despite reports of a high prevalence of additional educational needs in this cohort. In addition, patients and parents report inferior health related quality of life compared to healthy peers and similar to that of children post liver transplantation.Moving on from paediatric to adult services is challenging for young people and their parents and adult health professionals might not be familiar with the condition and complications. Young people deserve to be looked after by specialist, multidisciplinary services who provide holistic care and address their psychosocial needs in addition to the medical needs.     

Use of continuous glucose monitoring in young children with type 1 diabetes: implications for behavioral research

Patton SR, Williams LB, Eder SJ, Crawford MJ, Dolan L, Powers SW. Use of continuous glucose monitoring in young children with type 1 diabetes: implications for behavioral research. Objective: This study presents data on the use of continuous glucose monitoring (CGM) in young children with type 1 diabetes mellitus (T1DM). CGM provides moment‐to‐moment tracking of glucose concentrations and measures of intra‐ and interday variability, which are particularly salient measures in young children with T1DM. Methods: Thirty‐one children (mean age = 5.0 yr ) with T1DM wore the Medtronic Minimed CGM for a mean of 66.8 h. The CGM was inserted in diabetes clinics, and parents were provided brief training. Results: Few difficulties were experienced and families cited the acceptability of CGM. Participants' CGM data are compared with self‐monitoring blood glucose (SMBG) data as well as data from older children with T1DM to illustrate differences in methodology and variability present in this population. CGM data are used to calculate glucose variability, which is found to be related to diabetes variables such as history of hypoglycemic seizures. Conclusions: CGM is an acceptable research tool for obtaining glucose data in young children with T1DM and has been used previously in older children and adults. CGM may be particularly useful in young children who often experience more glucose variability. Data obtained via CGM are richer and more detailed than traditional SMBG data and allow for analyses to link blood glucose with behavior.     

Improving drug use for children in the developing world.

Children differ significantly from adults in the way they absorb, metabolise, and excrete drugs. These parameters also vary as children grow from neonates through to adolescence. The practical implications and challenges that this presents are well know to anyone who is involved in the medical management of sick children. The importance of paediatric medication safety and efficacy has been gaining increasing attention in the developed world over the past decade. The United States has introduced a carrot and stick approach to increase research into medications for children with the "paediatric exclusivity provision" and the "paediatric rule". The European Union is also investigating ways of improving the availability of medications for children. Unfortunately, this increased focus on appropriate medicines for children, which has occurred in the developed world, has not been mirrored in developing nations. Currently more than 10 million children under the age of 5 years die each year, with only six countries accounting for 50% of these deaths. The majority of these deaths are from treatable or preventable diseases. The developed world has a moral and ethical obligation to share its gains with the children of the world.     

Improving drug use for children in the developing world

Children differ significantly from adults in the way they absorb, metabolise, and excrete drugs. These parameters also vary as children grow from neonates through to adolescence. The practical implications and challenges that this presents are well know to anyone who is involved in the medical management of sick children. The importance of paediatric medication safety and efficacy has been gaining increasing attention in the developed world over the past decade. The United States has introduced a carrot and stick approach to increase research into medications for children with the "paediatric exclusivity provision" and the "paediatric rule". The European Union is also investigating ways of improving the availability of medications for children. Unfortunately, this increased focus on appropriate medicines for children, which has occurred in the developed world, has not been mirrored in developing nations. Currently more than 10 million children under the age of 5 years die each year, with only six countries accounting for 50% of these deaths. The majority of these deaths are from treatable or preventable diseases. The developed world has a moral and ethical obligation to share its gains with the children of the world.     

Aberrant monocyte prostaglandin synthase 2 (PGS2) expression in type 1 diabetes before and after disease onset

Methods: We examined monocyte prostaglandin synthase 2 (PGS2/COX2) expression in individuals at risk for or with type 1 diabetes including: (i) 58 established type 1 and 2 diabetic patients; (ii) 34 autoantibody positive (AA+) children and adults; (iii) 164 infants and young children with insulin‐dependent diabetes mellitus (IDDM) susceptibility human leukocyte antigen (HLA) alleles; and (iv) 37 healthy control individuals, over a 5‐yr period. Results: Established type 1 diabetic patients (1 month to 30+ yr post‐disease onset) had significantly higher PGS2 expression than healthy controls; by contrast, insulin‐treated type 2 diabetic patients had significantly lower PGS2 expression than healthy controls. Longitudinal studies of AA+ subjects at risk for type 1 diabetes indicated that 73% (11/15) of individuals who developed this disease during the study period expressed high levels of PGS2 prior to or after onset. We also found high level PGS2 expression in genetically at‐risk infants and young children that correlated with having a first‐degree relative with type 1 diabetes, but not with age, gender, or HLA genotype. In this population, high level PGS2 expression coincided with or preceded autoantibody detection in 30% (3/10) of subjects. Conclusions: These findings suggest that high level monocyte PGS2 expression, although subject to fluctuation, is present in at‐risk subjects at an early age and is maintained during progression to and after type 1 diabetes onset.     

Effect of early protein intake on linear growth velocity and development of adiposity

Protein deficiency results in retarded growth, and many studies from developing countries have shown that animal protein has a growth-promoting effect in children getting a diet mainly based on vegetable products. To what degree this is caused by an improved protein quality, nutrients associated with animal protein such as zinc, or a growth-stimulating effect of certain amino acids or peptides is not known. In industrialized countries, it is not likely that either the amount of protein or the protein quality will be growth limiting in healthy children. However, there are data suggesting that the high protein intake in infants and young children seen in industrialized countries could have growth-modulating effects and that there could be long-term effects. The aim of this paper is to review data on the association between early protein intake and linear growth velocity and early protein intake and later development of obesity. The review will focus on term healthy infants and young children from industrialized countries. The review will also include data on differences in growth and development of obesity between breastfed and formula-fed infants as there are considerable differences in protein intake between these two groups and one of the suggested causes for these effects has been difference in protein intake.     

Nutrigenomics - perspectives of personalized nutrition

Currently used dietary recommendations and requirements are generalized. It applies to both healthy and ailing individuals. These recommendations are meant to avert leading chronic illnesses such as: type 2 diabetes mellitus, obesity, hyperlipidemia, cardiovascular diseases and hypertension. In the future it might be possible to give dietary advice tailored to every - sick and healthy - individual. Nutrigenomics and nutrigenetics are two fields derived from nutrition science and genetics. Their main goal is to elucidate the influence of interactions between genes and diet on individuals' health. This paper shows the examples of metabolic response changes according to diet and chosen gene polymorphisms. It will enable an effective prevention or management of chronic diseases by accurate diet and lifestyle matched to an individual's genetic makeup. It could be useful especially to define predisposition for type 2 diabetes mellitus in young children. It will be possible to change their diet and lifestyle so that they could avoid this chronic disease. There will also be a possibility to detect early the beginning of the illness and choose/select proper treatment. It is important because type 2 diabetes mellitus frequency is up to 90% of all cases of diabetes mellitus. It's often diagnosed too late and a lot of patients have already developed complications caused by this disease. Successful dietotherapy will also be available in such disease entities as dyslipidemias, hypertension and micro- , macronutrients and vitamins defficiences.