2018, Vol 14, No 4
The role of atorvastatin and ezetimibe in contemporary lipid-lowering therapy – time for combination treatment
Pediatr Med Rodz 2018, 14 (4), p. 361–368
DOI: 10.15557/PiMR.2018.0045

Hypercholesterolaemia is the most common cardiovascular risk factor in Poland. The benefits of intensive cholesterol lowering in both primary and secondary prevention have been clearly demonstrated in many clinical trials. Statins are drugs of choice and should be used in the highest recommended or tolerated dose in order to achieve therapeutic goals. Unfortunately, the success rates in achieving therapeutic goals in dyslipidaemia are still low in Poland, which, according to experts, is associated with low statin doses, the choice of drugs with low lipid-lowering activity, short treatment duration, unjustified treatment cessation, and the limited use of combination therapy. Numerous studies have shown that combining ezetimibe with any statin is associated with greater reduction of LDL cholesterol and more frequent achievement of lipid targets compared to statin monotherapy. Ezetimibe monotherapy should be used in patients with statin intolerance or contraindications to its use. Therapy with statin and ezetimibe should also be considered in patients at increased risk of adverse effects of statins (e.g. the elderly, patients with impaired liver or kidney function, with previous side effects of statins or with possibility of interactions). This paper presents the potential position of atorvastatin and ezetimibe in contemporary lipid-lowering therapy, with particular emphasis on the effectiveness and safety of its use.

Keywords: dyslipidaemia, atorvastatin, ezetimibe, combination therapy
Old and new face of aspirin
Pediatr Med Rodz 2018, 14 (4), p. 369–375
DOI: 10.15557/PiMR.2018.0046

Salicylic acid has been known as a therapeutic substance since antiquity. Since its inception, acetylsalicylic acid, i.e. its original acetylated derivative, has become one of the most popular analgesic substances. Over the years, it has gained the recognition of cardiologists, and its potential antineoplastic effects have been recently studied. By inhibiting cyclooxygenase 2 (COX-2), the drug reduces the formation of prostaglandins, which relieves inflammation, eases swelling and lowers fever. Moreover, aspirin has an anticoagulant effect owing to its inhibition of cyclooxygenase 1 (COX-1). The prophylactic outcome of acetylsalicylic acid in patients with cardiovascular diseases is undeniable, but its benefits in individuals without cardiac disease are controversial. However, research is ongoing to identify the group of beneficiaries of primary prevention precisely, and the results are expected in the near future. Another field of action of acetylsalicylic acid which is currently under investigation is related to the potential antineoplastic effect of the drug. Nowadays, most of the data indicate its positive effects in patients with a positive history of colorectal proliferative diseases. The antineoplastic activity of the drug is based on the inhibition of COX-2, an enzyme stimulating cell divisions. Therefore, the effect of the medicine may be visible in tumours characterised by an overexpression of this enzyme. A positive response to aspirin also depends on the human genome and specific mutations in cancer cells. By acting on platelet COX-1, aspirin reduces the metastatic potential of cancer, as platelet-derived substances promote the formation of metastases. To sum up, only a selected group of patients exhibit sensitivity to the anticancer effects of the drug. Nevertheless, the use of aspirin could turn out to be dangerous in people with a high risk of complications, so each patient should be treated individually.

Keywords: acetylsalicylic acid, colorectal cancer, cardiovascular disease, prevention
Severe atopic dermatitis in children: therapeutic dilemmas
Pediatr Med Rodz 2018, 14 (4), p. 376–380
DOI: 10.15557/PiMR.2018.0047

Atopic dermatitis is the most common skin disorder diagnosed in early childhood. Some children do not experience a relief of symptoms as they get older, and severe atopic dermatitis may develop, with manifestations including widespread skin lesions and unremitting itching. The disease is both physically and emotionally disabling, and significantly compromises the patient’s quality of life. Indications to intensify therapy include resistance to topical treatment and multidrug resistance. However, in many cases non-adherence to the treatment regimen, including inadequate skin care techniques, contribute to the development of severe or refractory atopic dermatitis. Persistent eczematous lesions may be a result of exacerbating environmental factors, secondary infection, and hypersensitivity reactions to topical treatments or other allergens. Wet-wrap treatment with topical corticosteroids, narrow-band UVB phototherapy and systemic immunosuppressive drugs, such as cyclosporine A, methotrexate, mycophenolate mofetil and azathioprine, are recommended for the treatment of severe atopic dermatitis in children. However, there are no evidence-based guidelines for using these agents. Systemic corticosteroids should be avoided, but they can be used for a short period of time for the immediate relief of acute flares before introducing other therapies. Patients need a holistic approach including education and modern biopsychosocial techniques. Paediatric studies are currently under way to test the safety and tolerability of dupilumab which was approved by the US Food and Drug Administration in 2017 for the treatment of adults with moderate-to-severe atopic dermatitis.

Keywords: atopic dermatitis, adherence, therapy, immunosuppressive drugs
Erythema nodosum – one symptom, many causes?
Pediatr Med Rodz 2018, 14 (4), p. 381–385
DOI: 10.15557/PiMR.2018.0048

Erythema nodosum is a skin lesion most often located on the anterior surface of the lower extremities. It initially appears as rounded nodules with a vivid red or purplish colour. Erythema nodosum may often be a predictive sign of systemic infectious or autoimmune diseases. Group A streptococcal infections, virological infections (cytomegalovirus and Epstein–Barr virus) and sarcoidosis are the most common aetiological factors of erythema nodosum. Certain drugs also may be the cause, whereas erythema nodosum is often idiopathic in clinical practice. It is more common in women. Erythema nodosum rarely affects children, but with equal prevalence in both sexes. It is important to note that basic diagnostic process should be performed in all cases of erythema nodosum. The diagnosis involves laboratory tests (complete blood count with differential, C-reactive protein levels, presence of rheumatoid factor, hepatic enzyme level) and medical imaging (chest radiograph, abdominal and thyroid ultrasound). Depending on the suspected etiological factor, the diagnostic process should be extended to include other, additional laboratory investigations. Erythema nodosum is caused by type IV delayed hypersensitivity reaction to a wide variety of possible stimuli. Additionally, circulating immune complexes cause complement activation in patients with erythema nodosum. The histopathological picture of skin lesions shows septal panniculitis (inflammation of subcutaneous fat tissue) with associated Miescher’s radial granulomas – aggregates of small histiocytes arranged around a central cleft. The most important therapeutic approach in erythema nodosum is the treatment of underlying disorders, if identified. If this is not possible, less potent topical corticosteroids and heparinoid ointments are used.

Keywords: erythema nodosum, skin lesions, sarcoidosis, medications, bacterial infections
Dental problems in obese patients
Pediatr Med Rodz 2018, 14 (4), p. 386–391
DOI: 10.15557/PiMR.2018.0049

The partial aetiological overlap between overweight/obesity and oral diseases has aroused interest in the medical environment. Studies to investigate the causal relationship between these two diseases are underway. However, most of the available literature reports fail to confirm the direct positive correlation between obesity and dental caries. On the other hand, overweight and obesity are considered risk factors for periodontal diseases. The proinflammatory mediators secreted by adipocytes in obese individuals may impair immune functions, thereby modifying host responses to dental plaque antigens and contributing to blocked defence functions in periodontal diseases. Gingivitis observed in overweight and obese patients is a result of metabolic disorders, inflammatory factors and improper oral hygiene habits. The latter ones are associated with frequent consumption of sweetened, pulpy and highly processed food products and sweetened carbonated beverages, which is a risk factor for overweight, particularly in children and adolescents. Undoubtedly, overweight and obesity affect salivary secretion and properties, including changes in the microbiological composition of saliva. Obese patients are at increased risk of adverse affects of dental treatment, dental surgeries in particular. Overweight and obese individuals require permanent preventive and medical dental care addressing their periodontal preventive and therapeutic needs. Dentists should actively participate in the prevention of overweight and obesity, especially in children and adolescents, taking advantage of frequent contact with this group of patients. Obese individuals may participate in integrated therapeutic management by means of dental treatment limiting food intake.

Keywords: obesity, oral cavity, children and adolescents, adults
Pediatr Med Rodz 2018, 14 (4), p. 392–395
DOI: 10.15557/PiMR.2018.0050

Hirsutism is defined as excessive hair growth in androgen-dependent areas and it affects about 5–10% of the female population. The majority of cases are either idiopathic or due to polycystic ovary syndrome. Other causes include adrenal glands disorders, congenital adrenal hyperplasia as well as adrenal and ovarian tumours and some medications. The Ferriman–Gallwey score is used to diagnose hirsutism. However, it should be noted that the assessment of the severity of hirsutism using this score is subjective. A thoroughly collected medical history and a detailed physical examination supplemented with laboratory and imaging diagnosis plays an important role in the diagnostic process. It is important to differentiate hirsutism from hypertrichosis, which is not associated with hyperandrogenaemia. Increased androgen levels can also cause other complications in women, such as masculinisation of the external genital organs, male-pattern hair loss, deepening of voice. The treatment uses pharmacotherapy and mechanical methods for excess hair removal. It should be noted that excessive hair in women may also have psychosocial consequences.

Keywords: hirsutism, polycystic ovary syndrome, idiopathic hirsutism, congenital adrenal hyperplasia, Ferriman–Gallwey score
An assessment of phenotype and haplotype in patients with coeliac disease hospitalised in the Department of Paediatrics, Immunology and Nephrology of the Polish Mother’s Memorial Hospital – Research Institute in Łódź between 2012 and 2018
Pediatr Med Rodz 2018, 14 (4), p. 396–401
DOI: 10.15557/PiMR.2018.0051

Introduction: Coeliac disease is a genetically determined intolerance to gluten found in European cereal grains (wheat, rye, barley). Four clinical forms of coeliac disease have been distinguished: classical, non-classical, subclinical and potential. According to the ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition) 2012 criteria, coeliac disease is diagnosed in a patient with clinical manifestations indicative of coeliac disease, tissue-transglutaminase antibody titers with levels >10 times the upper limit of normal, who is tested positive for endomysial antibodies and HLA-DQ2 and/or HLA-DQ8 haplotype. Inclusion of and compliance with a gluten-free diet is the only appropriate treatment for patients diagnosed with coeliac disease. Aim: The aim of the study was to perform a haplotype and phenotype analysis in children diagnosed for coeliac disease in the Department of Paediatrics, Immunology and Nephrology of the Polish Mother’s Memorial Hospital – Research Institute in Łódź in the years 2012–2018. Material and methods: A total of 40 patients aged between 12 months and 17 years and 3 months (mean age 7 years and 1 month), including 24 girls and 16 boys, hospitalised in the Department due to suspected coeliac disease were included in the study. The presented findings were part of standard diagnostic management following a child’s admission to hospital. Results: Two cases of classical and 38 cases of non-classical coeliac disease were diagnosed in the study group of 40 patients. A total of 31 children presented with HLA-DQ2, 5 with HLA-DQ8, and 4 with DQ2/DQ8. Conclusions: The non-classical form of coeliac disease and HLA-DQ2 genotype were the most common findings in patients with coeliac disease.

Keywords: coeliac disease, HLA-DQ2, HLA-DQ8, tissue transglutaminase
Effects of vegetarian diet on gastrointestinal symptoms
Pediatr Med Rodz 2018, 14 (4), p. 402–406
DOI: 10.15557/PiMR.2018.0052

Introduction: More than million Polish people and 420 million individuals around the world have a vegetarian diet. Aim of the study: To evaluate the effects of vegetarian and vegan diets on gastrointestinal symptoms. Material and methods: The study included 1,209 individuals (886 from Poland and 323 from the United States of America). In the study population, 702 individuals declared following a vegetarian diet and 365 a vegan subtype of this diet. The control group included 142 individuals who had no dietary restrictions. All subjects completed a questionnaire composed of 31 questions. It was available online and was posted on vegetarian internet forums. Results: Before diet change, 60% of future vegans and 52% of future vegetarians experienced bloating and a sense of fullness; 32% and 25%, respectively, suffered from heartburn, nausea or vomiting; 44% and 35% had a tendency for constipation; 11% of subjects in both groups had a poor appetite and 3% of vegans and 2% of vegetarians had skin problems. After diet transition 84% of vegans and 74% of vegetarians reported health improvement (p = 0.002). Bloating and a sense of fullness decreased to 13% in vegans and 12% in vegetarians (p < 0.001), heartburn, nausea and vomiting to 2% and 4%, respectively (p < 0.001), poor appetite to 2% and 3% (p = 0.001), and bowel movement problems to 8% and 4% (p = 0.001). The rate of skin problems rose to 10% in vegans and 16% in vegetarians (p = 0.001). Conclusions: After the introduction of a vegetarian or vegan diet in the lives of the subjects a significant decrease in gastrointestinal complaints was observed; however, this was accompanied by an increase in the rate of skin problems.

Keywords: vegetarianism, veganism, gastrointestinal problems
Antibiotic therapy in children with pneumonia treated in hospital
Pediatr Med Rodz 2018, 14 (4), p. 407–411
DOI: 10.15557/PiMR.2018.0053

Introduction: Pneumonia is one of the most common causes of paediatric hospitalisations. Aim of the study: To analyse antibacterial treatment of pneumonia in children hospitalised in 2017 at the Department of Paediatrics, Paediatric Nephrology and Allergology of the Military Institute of Medicine in Warsaw. Material and methods: Medical documentation data of 360 children with clinical diagnosis of pneumonia was subjected to a retrospective analysis. Age, gender, antibiotics used before and during hospitalisation and time of treatment were considered. Results: Of all the children hospitalised at the Department (2,207), 360 pneumonias were reported (16.3% of all hospitalisations). The mean total time of antibiotic therapy was 10.76 ± 3.57 days. Out of 176 children (48.9% of all pneumonias) who reported to a general practitioner 91 (51.7%) received symptomatic treatment and 85 (48.3%) – antibiotic. On admission to hospital the type of antibiotic treatment was modified for 63/85 children (74.1%) and the form of antibiotic delivery was changed from oral to intravenous for 74/85 (87.1%). Antibacterial treatment in general practice was compliant with recommendations in 18/85 children (21.2%) and during hospitalisation – in 69/360 patients (19.2%). Conclusions: The most common infectious cause of paediatric hospitalisations was pneumonia. In general practice a significant problem is to diagnose community-acquired pneumonia with bacterial aetiology because of an uncharacteristic onset of symptoms. There is significant discrepancy between the everyday practice and recent guidelines on antibiotic use.

Keywords: pneumonia, hospitalisation, child, antibiotic therapy, primary health care
The use of synbiotic preparation in complex therapy of community-acquired pneumonia in preschool children
Pediatr Med Rodz 2018, 14 (4), p. 412–415
DOI: 10.15557/PiMR.2018.0054

The article discusses the effect of synbiotic therapy on the qualitative and quantitative changes in colonic microbiota in preschool children with community-acquired pneumonia. A total of 33 children aged from 1 to 3 years were included in the study. All patients were divided into two groups. The first group consisted of 17 children who received standard therapy. The second group consisted of 16 patients, whose treatment was supplemented with a synbiotic preparation at a dose of one sachet per day. The assessment of colonic microbiota was conducted in 33 patients with community-acquired pneumonia before treatment and on treatment days 12–14. The control group consisted of 20 healthy age and sex-matched children. Bacteriological study of gut microflora was conducted using the Epshtein-Lytvak method. The evaluation of the microflora composition changes in children suffering from community-acquired pneumonia showed an intensification of gut microflora imbalance after standard therapy. When studying the effectiveness of the synbiotic preparation in patients with community-acquired pneumonia, it was found that the state of colon microbiocenosis in patients who received complex therapy with synbiotic drug significantly improved compared to children treated with standard regimen. Thus, of the use of synbiotic therapy in patients with community-acquired pneumonia improves or fully restores gut microflora in some cases. This preparation can serve as a safe and convenient way to restore gut microflora balance and prevent the development of gastrointestinal pathologies.

Keywords: community-acquired pneumonia, preschool children, gut microflora
The attitudes of parents towards vaccination in the region of Upper Silesia in Poland
Pediatr Med Rodz 2018, 14 (4), p. 416–420
DOI: 10.15557/PiMR.2018.0055

Vaccination provides the best protection against infectious diseases. Getting to know parents’ beliefs and opinions about vaccination allows one to undertake actions aiming to increase their confidence about vaccination and maintain vaccination coverage at an acceptable level. Aim of the study: The aim of the study was to analyse the attitudes of parents towards vaccination in Upper Silesia, Poland, by investigating the parents’ awareness of safety, efficacy and the need for vaccination in children, and to establish educational needs of parents in the area of vaccination. Material and methods: Six hundred parents of children at the age of 0–6 years were included in the study. The study was conducted in randomly selected kindergartens in Bielsko-Biała, in the Paediatric Hospital in Bielsko-Biała and in the Department of Paediatrics of the Medical University of Silesia in Katowice. The research was conducted through a diagnostic survey, using a self-constructed questionnaire. Results: The implementation of mandatory vaccination of children in the investigated group is at a high level. Less than a half of the surveyed parents received information about adverse effects of vaccines from a doctor or a nurse. After vaccination, children experienced adverse reactions, which were mild. In the study group, most parents expressed a negative opinion about safety and effectiveness of vaccination, or had no opinion on the subject. The parents usually derived information about vaccination from a doctor and the Internet. The parents believed that vaccinations were necessary but not free from risks. Conclusions: The study reveals that it is significant to make health care professionals more involved in the education of parents about safety and efficacy of vaccination and to have them provide information about adverse effects of vaccination.

Keywords: vaccination, attitudes of parents, child
Impaired tear secretion as the first symptom of triple A syndrome in two siblings
Pediatr Med Rodz 2018, 14 (4), p. 421–424
DOI: 10.15557/PiMR.2018.0056

Triple A syndrome is a rare, autosomal recessive disease. It is characterised by a triad of symptoms: alacrima, adrenocortical insufficiency and oesophageal achalasia. Atrophy of the optic nerve and a number of neurological disorders also occur in patients with this syndrome. Only about one hundred cases have been described in the literature since the first description by Allgrove in 1978. This paper presents a case report of siblings diagnosed with triple A syndrome. A 6-year-old girl developed adrenocortical insufficiency, axonal-demyelinating polyneuropathy and oesophageal achalasia, while her 3-year-old brother showed an abnormal adrenal reserve. Both children presented with the lack of tears during crying.

Keywords: triple A syndrome, child, dry eye
A suspicious non-healing wound of the pinna
Pediatr Med Rodz 2018, 14 (4), p. 425–427
DOI: 10.15557/PiMR.2018.0057

Squamous cell carcinoma of the pinna occurs primarily in older males who are exposed to sunlight for a prolonged period. Most squamous cell carcinomas of the pinna are well differentiated and present as a painless mass or a sessile nodule. We describe an interesting case of an adult woman with a non-healing wound located on the right pinna which was treated conservatively, and was later diagnosed as squamous cell carcinoma.

Keywords: pinna, squamous cell carcinoma, wound
Attention to biotinidase deficiency in children! A case report
Pediatr Med Rodz 2018, 14 (4), p. 428–430
DOI: 10.15557/PiMR.2018.0058

Biotinidase deficiency is an autosomal recessive metabolic disease that causes biotin deficiency. The exact diagnosis of the lack of biotinidase is made by demonstrating the absence of enzyme activity in the serum. Biotinidase deficiency is treated with oral biotin taken for lifetime. Early diagnosis and treatment are very important and prevent a number of complications. In this case report, a newborn baby was referred for periodic healthcare assessments to a family medicine centre, where biotinidase deficiency was diagnosed. Screening performed as part of periodic health assessment in the primary care setting is important for the detection of certain diseases, as many disease-related disabilities can be prevented with early diagnosis. In family practice, “shared decision-making,” which represents one of the elements of the patient-centred clinical method, is very effective, provided that patients and their relatives adapt to preventive healthcare.

Keywords: biotinidase deficiency, newborn screening, primary care
Self-introduction of urethral foreign bodies in adolescent boys: a rising problem
Pediatr Med Rodz 2018, 14 (4), p. 431–434
DOI: 10.15557/PiMR.2018.0059

There has been an increase in reports of self-introduced urethrovesical foreign bodies, but they are still considered to be rare in children. A special type of foreign bodies are magnetic bodies inserted into the lower urinary tract – a phenomenon which clearly corresponds with an increase in paediatric magnet-related foreign bodies insertion requiring emergency care. We present two adolescent boys with voiding difficulty as a leading symptom following self-introduction of numerous magnetic beads (in the first case) and eyebrow tweezers (in the second case) treated during the last 3 months. Magnetic beads had to be removed operatively, eyebrow tweezers were removed from urethra manually. Our observations confirm that in the differential diagnosis of lower urinary tract symptoms especially in adolescents, the presence of foreign bodies should be taken into consideration.

Keywords: foreign body, magnets, self-insertion, urinary tract, adolescents
Late diagnosis of cerebral palsy in a 16-year-old girl – a case report
Pediatr Med Rodz 2018, 14 (4), p. 435–438
DOI: 10.15557/PiMR.2018.0060

Cerebral palsy is the most common cause of motor disability in children. Cerebral palsy is a static encephalopathy with a variable clinical picture and multifactorial aetiology. Disorders arise from disturbances in the early development of the brain in the foetal, perinatal or postnatal period. The disease affects around 17 million people worldwide; its incidence is estimated to be 1.5–3 per 1,000 live births. A slight male predominance is observed. The disease has a multifactorial aetiology, with prematurity being the most important risk factor. There are four types of cerebral palsy: spastic (the most common – (70%), dystonic (10%), mixed (15%) and ataxic (5%). In addition to motor disability of varying severity, the majority of patients present with other accompanying deficits, such as mental retardation, epilepsy, dysphagia, impaired hearing and vision. The diagnosis of cerebral palsy should be based on detailed medical history, including pregnancy and childbirth as well as a regular assessment of the child’s development from the first months of life. In the case of clinical doubts, the diagnosis is extended to include magnetic resonance imaging, electroencephalography, metabolic and genetic tests. Children with cerebral palsy require a comprehensive, multidisciplinary care, including physical therapy and rehabilitation. Bobath and Vojta concepts are the most common rehabilitation approaches. Early diagnosis and regular rehabilitation are crucial to ensure adequate quality of life for a child with cerebral palsy. The paper presents a case of a 16-year-old girl with a long history of pain in the lower limbs, spine and temporomandibular joints. The symptoms were accompanied by chest pain as well as numbness and weakness of the left upper limb.

Keywords: cerebral palsy, aetiology, disability, prematurity, spasticity
Case reports of patients with significantly elevated CA 19-9 levels without confirmed malignancy
Pediatr Med Rodz 2018, 14 (4), p. 439–443
DOI: 10.15557/PiMR.2018.0061

The CA 19-9 antigen is a marker whose concentration is elevated usually in the presence of gastrointestinal cancer. CA 19-9 is considered to be characteristic for pancreatic and biliary cancer; however, an elevated level of this marker may also indicate a cancer with a different point of origin such as the colon or the stomach. CA 19-9 has limited application in diagnosis; however, the observation of its level makes it possible to monitor treatment progress and can help in the detection of cancer spread. CA 19-9 is a glycoprotein with a molecular mass of 210 kD, produced not only by cancer cells, but also by gastrointestinal and liver cells during foetal development, by salivary glands, mature pancreatic and biliary cells as well as the bronchi. This study presents the cases of patients who were diagnosed with significantly elevated CA 19-9 levels and in whom cancer was excluded in the course of further clinical follow-up. The authors indicate that a very high concentration of CA 19-9 can have a different cause than cancer: in the cases described in the present study it was usually cholestasis caused by benign biliary diseases that led to the elevation of this marker.

Keywords: CA 19-9, acute cholangitis, cholestasis