2015, Vol 11, No 4
Immunostimulation using bacterial antigens – mechanism of action and clinical practice in viral respiratory tract infections
Pediatr Med Rodz 2015, 11 (4), p. 358–364
DOI: 10.15557/PiMR.2015.0033

Recurrent respiratory tract infections constitute a significant problem in the practice of a general practitioner and paediatrician. Antibiotic resistance of bacterial strains, which has been growing for years, prompts the search for alternative ways of combating pathogens. One of them is the usage of preparations based on cell lysis of various bacterial strains. Bacterial lysates have been available in Europe for many years. In preclinical trials, they are characterised by the capability of reducing infections caused by bacteria and viruses that are not the components of the preparations. A range of clinical trials have demonstrated their usefulness in reducing the frequency of seasonal respiratory tract infections and antibiotic use. Moreover, patients with chronic obstructive pulmonary disease gain an additional advantage in the form of the reduction of the risk of hospitalization due to disease exacerbations and a positive influence on the survival curve. The action of bacterial lysates is based on oral immunostimulation of gut-associated lymphoid tissue, which results in increased antibody production. Moreover, they activate a range of mucosal mechanisms of non-specific immunity, mainly by enhancing the activity of TLR-dependent mechanisms. The efficacy of this group of drugs has been confirmed in a range of clinical trials, systematic reviews and meta-analyses. Recent studies also indicate their immunoregulatory potential, suggesting that they might be used in the future in preventing allergies, asthma and autoimmune diseases. To conclude, physicians (paediatricians, laryngologists, pulmonologists) should consider reducing the use of antibiotics in their daily practice. Instead, they should offer preparations that promote the immune system, thus controlling infections in a better way.

Keywords: respiratory tract infections, bacterial lysates, OM-85, toll-like receptors
Immunostimulation as a method limiting unnecessary antibiotic therapy
Pediatr Med Rodz 2015, 11 (4), p. 365–373
DOI: 10.15557/PiMR.2015.0034

Recurring respiratory tract infections are typical of childhood. This results from the fact that children are exposed to pathogens, usually in groups of people, and from the immaturity of the immune system. Most upper and lower respiratory tract infections are caused by viruses. Nevertheless, antibiotics, which target bacteria, are often prescribed. Antibiotic overuse leads to increased microbial resistance to these drugs, resulting in their inefficacy. Improper treatment of respiratory infections with antibiotics ultimately leads to treatment failure. An increase in antibiotic resistance of many bacterial strains is becoming a serious global problem and makes treatment much more difficult. It is a responsibility of each physician to use antibiotics properly and implement adequate prevention of recurring respiratory tract infections. For many years, it has been attempted to find effective agents that improve immunity in children. The pharmaceutical market offers various preparations advertised as immunostimulants, such as bacterial lysates, vitamins, dietary supplements, probiotics or herbal, animal and homeopathic products. The role of immunomodulatory substances is to promote the immune system to fight pathogens, reduce the frequency of infections and decrease the demand for antibiotics. Unfortunately, most immunomodulators do not have sufficiently reliable clinical trials that would confirm their efficacy.

Keywords: immunostimulation, bacterial lysates, antibiotic therapy, respiratory tract infections
Pleiotropic effects of vitamins D and K
Pediatr Med Rodz 2015, 11 (4), p. 374–381
DOI: 10.15557/PiMR.2015.0035

Recent studies have shed new light on the functions of vitamins K and D. It has also been suggested that these vitamins have synergistic effects on certain metabolic processes (e.g. the formation of bone tissue). The serum levels of vitamin D are positively correlated with the degree of bone mineralisation and negatively correlated with serum parathyroid hormone levels. The mechanism underlying the effects of vitamin K on the skeletal system is associated with increased bone mineralization (carboxylation of Gla-protein osteocalcin) and decreased bone resorption due to the inhibition of osteoclast activity. Recently published studies have shown a relationship between the development of central nervous system diseases and low levels of vitamins K and D. It has been shown that deficiency of these vitamins may influence the development of dementia. Vitamin K has been shown to be involved in regulating the activity of sulfotransferases and Gas6 protein responsible for the accelerated growth of Schwann cells. There is a negative correlation between vitamin K intake and the risk of vascular calcification and mortality due to cardiovascular diseases. A close relationship was demonstrated between the activity of vitamin D and the presence of calcifications in the blood vessels in the course of a number of diseases such as atherosclerosis, osteoporosis and chronic kidney disease. It was also shown that a concomitant administration of vitamins K and C results in the induction of oxidative stress, leading to an anticancer effect without the use of chemotherapeutics. Squamous tumour cell line was most susceptible compared to endometrial and breast cancer cells. Antitumor effects of vitamin D are related to the mechanisms underlying the inhibition of proliferation, the activation of apoptosis and the inhibition of angiogenesis. The presence of an active, non-mutated vitamin D receptor is essential for an effective action of vitamin D. Increased vitamin D receptor expression is observed in the basal cell carcinoma of the skin and cervical cancer compared with healthy tissue.

Keywords: vitamin D, vitamin K, synergism, vascular calcification, osteoporosis
Allergic cross-reactivity – a new challenge for allergists?
Pediatr Med Rodz 2015, 11 (4), p. 382–390
DOI: 10.15557/PiMR.2015.0036

Allergic cross-reactivity is an important epidemiological issue in all age groups. It is caused by a non-specific binding of both primary allergen as well as allergens causing secondary cross-reactivity by the same IgE antibodies. This phenomenon results from the similarity of the molecular structure of allergen epitopes and leads to a number of allergic cross-reactivity syndromes, such as pollen-food syndromes, pork-cat syndrome or latex-fruit syndrome. They are characterized by rich symptomatology and the possible occurrence of symptoms related to various systems, including life-threatening systemic reactions. In many cases, specific allergen groups responsible for certain cross-reactions, such as plant profilins, fish parvalbumins or invertebrate tropomyosins, have been identified. Also, some of the factors affecting the spatial conformation of allergens, and thus modifying their allergenic potential, have been identified. Despite all these achievements, the diagnostics of cross reactivity syndromes still remains difficult due to the limited available methods and the possible occurrence of overlapping phenomena such as co-sensitisation, asymptomatic cross-sensitisation or IgE-independent or nonimmunological adverse drug reactions. Therefore, careful management based on medical history as well as avoidance of unjustified treatment methods, e.g. diet therapy or immunotherapy, are necessary. This is of great importance as the incidence of food allergies is expected to increase mainly due to the progressive rise in the prevalence of inhalant allergies to pollens.

Keywords: cross-reactions, food hypersensitivity, pollen allergy, immunoglobulin E (IgE), respiratory hypersensitivity
Inhalatory delirium – the way out
Pediatr Med Rodz 2015, 11 (4), p. 391–401
DOI: 10.15557/PiMR.2015.0037

Inhalation therapy is one of the main therapeutic modalities in modern pulmonology. It allows for the use of smaller daily doses of various medications which exhibit potent local therapeutic effects and low systemic action. Moreover, adverse effects, particularly the general (systemic) ones are minimal. The use of medical aerosols enables the treatment of not only diseases of the airways, but also makes it possible to deliver medicinal products that have a systemic effect (insulin, hormones, pain relievers or vaccines). The deposition of therapeutic molecules depends on a variety of factors (such as breath frequency, intensity of breathing or tidal volume). The greater the intensity of breathing (short, abrupt inspiration or a series of rapid shallow breaths), the greater the filtration ability of the upper airways (nasopharynx, larynx). These effects of the respiratory physiology should be always kept in mind since they are of key importance for a deposited (therapeutic) dose. The most common aerosol generators are pressurized metered dose inhalers and dry powder inhalers as well as nebulisers (jet, ultrasonic and MESH). All of these devices differ from one another in producing aerosol clouds (different particle diameters, different way of particle generation). That is why they cannot be used in all patients. Inhaler selection is one of the most important decisions in inhalation therapy. Its course and success are determined by multiple factors (patient-generated air flow, skill and ability to use aerosol generators). Prior to making a decision concerning treatment, an algorithm proposed by Laube et al. should be used since it makes inhaler selection considerably easier.

Keywords: inhalation therapy, inhalers, DPI, pMDI, nebulisation
The effects of an 8-month sports training on the levels of vascular endothelial growth factor in young athletes – the role of adaptive angiogenesis in the development of the aerobic capacity
Pediatr Med Rodz 2015, 11 (4), p. 402–409
DOI: 10.15557/PiMR.2015.0038

A long-term sports training induces morphological and functional changes in the cardiovascular system, with the activation of angiogenesis being one of the most significant ones. Aim: The aim of the study was to assess the impact of an 8-month sports training on the serum levels of vascular endothelial growth factor and the physical performance in young athletes. Material and methods: A total of 28 sports middle school students (athletics faculty) aged 13 years, including 14 boys and 14 girls, were included in the study. All participants underwent clinical assessment at each stage of the study. Electrocardiographic and echocardiographic examinations were performed. Furthermore, the levels of vascular endothelial growth factor were measured and a cardiac stress test was performed, the outcome of which was used to calculate the physical working capacity (PWC170). Results: There was a statistically significant decrease (274.3 ± 195.7 vs. 193.8 ± 153.8 ng/ml, p < 0.001) in the serum levels of vascular endothelial growth factor during the 8-month sports training. The levels were significantly lower in male athletes both at baseline (196.2 ± 157.3 vs. 352.4 ± 204.0 ng/ml, p = 0.02), and at the end of the observation period (139.6 ± 110.9 vs. 247.9 ± 174.6 ng/ml, p = 0.003). In the same period, the average PWC170 value increased throughout the study group (108.6 ± 28.1 vs. 119.0 ± 34.1 W, p = 0.02), and sex-related statistically significant changes occurred only on the male group of athletes. No statistically significant correlations were found between the relative changes in the levels of vascular endothelial growth factor and the PWC170 index (Spearman’s rank correlation coefficient – Rs 0.158, p > 0.05). Conclusions: Long-term sports training results in a decrease in the levels of vascular endothelial growth factor. At the same time, physical efficiency improvement is observed, which may suggest the involvement of adaptive, exerciseinduced angiogenesis in the skeletal muscles. However, the observed changes show distinct differences depending on the sex.

Keywords: angiogenesis, vascular endothelial growth factor, physical efficiency, athletes
Difficulties related to compliance with gluten-free diet by patients with coeliac disease living in Upper Silesia
Pediatr Med Rodz 2015, 11 (4), p. 410–418
DOI: 10.15557/PiMR.2015.0039

Compliance with gluten-free diet is the basic method for controlling coeliac disease in patients regardless of their age. It may be, however, challenging to follow in daily life. The prevalence of the disease (approx. 1% of European population is affected) makes it an important public health problem. Aim of the study: Investigating the difficulties and obstacles related to compliance with gluten-free diet by children and adult patients living in Upper Silesia region. Material and method: The study included 30 mothers of children with coeliac disease (Group I) and 30 adult coeliac disease patients (Group II). The patients kept a gluten-free diet. Data were obtained in an anonymous survey drawn up for the purpose of this study, conducted in 2010. Results: The respondents reported a very limited access to gluten-free meals in mass-catering establishments (76.7% of the participants in Group II, and 70% children at nurseries, kindergartens and schools), lack of adequate food product labelling (93% in both groups), difficulties experienced in social life (60% in Group II), difficulties experienced when travelling within Poland (76.7% in Group II) and abroad (83.3% in Group II), and no existing reimbursement plan for the high diet costs (16.7% in Group I vs. 26.7% in Group II). Conclusions: 1) The necessity of compliance with gluten-free diet causes a lot of difficulties in everyday life to patients with coeliac disease and parents of children suffering from coeliac disease. Proper treatment requires their identification by the attending physician. 2) Improved food labelling as regards gluten content as well as inclusion of gluten-free meals in the menu of food-serving establishments will contribute to improved quality of life of children and adults suffering from coeliac disease. 3) Associations of patients on a gluten-free diet should continue their efforts to have high costs of this diet refunded.

Keywords: coeliac disease, children, adults, gluten-free diet, difficulties
Complicated thromboembolic prophylaxis in the treatment of septic gonitis – case report
Pediatr Med Rodz 2015, 11 (4), p. 419–423
DOI: 10.15557/PiMR.2015.0040

In this paper the case of a patient subjected to orthopaedic treatment with a history of a number of internal comorbidities, cardiac ones in particular, has been reported. Cardiac comorbidities were related to the implantation of a VVI pacemaker. The patient was chronically administered acenocoumarol with a standard INR control. He developed infectious arthritis of the left knee joint. The condition was the indication for surgery. The surgical treatment was performed with the implementation of antithrombotic prophylaxis using low-molecular-weight heparin at a dose as prescribed by a cardiologist. The prescribed dosage of nadroparin – 100 mg – was higher than indicated in both Polish and international regimen standards. Higher dose was also maintained in next days that followed the surgery. Intra-articular haematoma occurred as a post-surgery complication, hence the revision of the knee joint was performed. The haematoma was diagnosed intraoperatively, then removed and pulsed lavage was performed. Garamycin sponge was applied to treat the inflammation. A targeted antibiotic therapy was continued. Surgical site drainage was performed for one day without the use of negative pressure. Thromboembolic prophylaxis was implemented in accordance with the applicable dosage regimen in Poland. In view of a vast majority of thrombosis risk factors, prolonged prophylaxis with heparin and return to acenocoumarol were indicated once the surgical would had healed. As a result, other early and late postoperative complications were avoided.

Keywords: low-molecular-weight heparin, gonitis, prophylaxis, haematoma
Atypical course of erysipelas and coexisting infections. Case study and literature review
Pediatr Med Rodz 2015, 11 (4), p. 424–429
DOI: 10.15557/PiMR.2015.0041

Erysipelas is an acute, erythematous, rapidly spreading skin infection, usually caused by beta-haemolytic group A Streptococcus bacteria. The disease is usually located on the legs and toes, less frequently on the face. One of the predisposing factors for the development of erysipelas are coexisting infections. The aim of the work was to attempt to determine whether there was any connection between the atypical course of erysipelas and Helicobacter pylori infection in a 47-year-old female patient. The patient had a history of treatment for chronic otitis media with effusion and recurring abdominal pain. The current disease started abruptly with fever, erythematous skin lesion located on the right cheek and severe pain in the right ear. After a few days, the facial erythema got worse, oedema appeared on the right side of the face and redness, oedema and pain in the auricle could be observed. After examinations by an ENT specialist and a dermatologist, erysipelas of the face, auricle and external auditory meatus was diagnosed. The diagnosis was confirmed by bacteriological examination. As a result of antibiotic therapy skin lesions subsided and the patient’s general condition improved. As the dyspeptic symptoms exacerbated, a diagnostic test was performed and a coexisting Helicobacter pylori infection was diagnosed. The overall clinical picture and data obtained from medical literature suggest that the coexisting Helicobacter pylori infection could have contributed to both the chronic otitis media with effusion and atypical course of erysipelas. According to medical literature, in the case of patients with dyspeptic symptoms, Helicobacter pylori bacteria can be transferred from the lining of the stomach upwards to the oral cavity, middle ear and paranasal sinuses. Kariya et al. in their review of original work suggested that Helicobacter pylori may contribute to the exacerbation of an existing inflammation in the middle ear, which is a microaerophilic environment required for this bacteria to grow. In conclusion, it seems that constant stimulation of the immune system by Helicobacter pylori could have caused the system to become dysregulated and weakened, which probably accounted for the atypical course of erysipelas in the patient described.

Keywords: erysipelas, Helicobacter pylori, otitis media with effusion
Suspicion of the battered child’s syndrome – a paediatrician’s nightmare?
Pediatr Med Rodz 2015, 11 (4), p. 431–438
DOI: 10.15557/PiMR.2015.0042

Child abuse may occur across all cultural, social and ethnic groups. Children may be abused by adults, adolescents, their own peers, and institutional workers alike. Whenever a suspicion arises concerning violence or other kind of abuse being possibly inflicted on a child, immediate thorough medical investigation is absolutely essential, and the child’s behaviour, appearance and development evaluated. Multispecialist diagnostics may be necessary, including the available imaging modalities. Abuse symptoms include abnormal patterns of child’s and parents’ behaviour, explanations concerning the injuries that are inconsistent with the actual clinical picture, delay in seeking medical attention, parents ignoring or downplaying the child’s injuries, seemingly strained relations between parents and the child. Parental attitudes that may be indicative of child abuse tend to be a result of alcohol dependence, drug addiction, or a deviation. At times, aggression or particular strictness towards the child may be observed. Whenever sexual or physical abuse is suspected, the child should immediately be referred to a hospital for further observation and accessory investigations. Relevant institutions should also be contacted and collaborated with. Child abuse seems to be on the rise, with more cases each year. Simultaneously, various social measures are undertaken aimed at ensuring assistance to the victims, and counteracting violence and abuse. It should be remembered that the treating doctor is obliged to report a suspicion of abuse taking place to the relevant authorities immediately upon taking its suspicion.

Keywords: battered child syndrome, general practitioner/family doctor, diagnostics