Current evidence suggests that additional pathogenetic factors could play a role in the development of chronic lung disease of prematurity, other than mechanical ventilation and free radical injury. The introduction of the concept of "fetal inflammatory response syndrome" offers a new perspective on the pathogenesis of chronic lung disease of prematurity. New statistical approaches could be useful tools in evaluating causal relationships in the development of chronic morbidity in preterm infants. The aim of this study was to test a new statistical framework incorporating path analysis to evaluate causality between exposure to chorioamnionitis and fetal inflammatory response syndrome and the development of chronic lung disease of prematurity. We designed a prospective cohort study that included consecutively born premature infants less than 32 weeks of gestation whose placentas were collected for histological analysis. Histological chorioamnionitis, clinical data, and neonatal outcomes were related to chronic lung disease. Along with standard statistical methods, a path analysis was performed to test the relationship between histological chorioamnionitis, gestational age, mechanical ventilation, and development of chronic lung disease of prematurity. Among the newborns enrolled in the study, 69/189 (36%) had histological chorioamnionitis. Of those with histological chorioamnionitis, 28/69 (37%) were classified as having fetal inflammatory response syndrome, according to the presence of severe chorioamnionitis and funisitis. Histological chorioamnionitis was associated with a lower birth weight, shorter gestation, higher frequency of patent ductus arteriosus, greater use of surfactant, and higher frequency of chronic lung disease of prematurity. Severe chorioamnionitis and funisitis were significantly associated with lower birth weight, lower gestational age, lower Apgar score at 5 minutes, more frequent use of mechanical ventilatory support and surfactant, as well as higher frequency of patent ductus arteriosus and chronic lung disease. The results of the path analysis showed that fetal inflammatory response syndrome has a significant direct (0.66), indirect (0.11), and overall (0.77) effect on chronic lung disease. This study demonstrated a strong positive correlation between exposure of the fetus to a severe inflammatory response and the development of chronic lung disease of prematurity.
Sažetak. Cilj: prikaz 15-godišnjeg pacijenta upućenog u našu Kliniku radi kroničnog kašlja i ezofagitisa. Prikaz slučaja: petnaestogodišnji mladić patio je od dugotrajnog kašlja uz koji su se javljale i poteškoće gutanja. Dijagnostičkom obradom postavljena je dijagnoza gastroezofagealne refluksne bolesti (engl. gastroesophageal reflux disease, GERD) i patohistološki dokazanog ezofagitisa koji se na provedeno liječenje značajno smanjuju, ali kašalj ostaje nepromijenjen. Pulmološkom i psihijatrijskom obradom postavljena je dijagnoza psihogenog kašlja te je započeto psihoterapijsko liječenje, nakon čega dolazi do smanjenja mladićevih tegoba. Zaključak: GERD se prezentira širokim spektrom ezofagealnih i ekstraezofagealnih simptoma, od kojih je značajan i kronični kašalj, no kašalj druge etiologije poput psihogenog kašlja može biti i uzrok GERD-u, što diferencijalnodijagnostički moramo razmotriti kod pacijenata u kojih medikamentozna terapija nije dovela do poboljšanja.Ključne riječi: ezofagitis; GERD; psihogeni kašalj; psihoterapija Abstract. Aim: To present a 15-year-old patient admitted to our Clinic because of chronic cough and esophagitis. Case report: A 15-year-old boy suffered from chronic cough along with swallowing difficulties. Diagnostic workup was performed and a diagnosis of gastroesophageal reflux disease (GERD) with pathohistologically proven esophagitis was made with significant improvement after completion of therapy, but cough remained unchanged. The boy was examined by a pulmologist and psychiatrist and they made a diagnosis of habitual cough; psychotherapy was started and resulted in improvement of symptoms. Conclusion: GERD presents with a broad spectrum of esophageal and extraeosphageal symptoms with chronic cough as an important one. Nevertheless, a cough from different origin, such as habitual cough, may cause GERD which must be included in differential diagnosis of patients to whom pharmacological treatment failed to help.
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