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Siegal AR, Paul M, Malhotra NR, Miller E, Ho P, Masseaux J, Baldisserotto EM, Quiros JA, Ferrer FA. Does KUB play a role in the diagnosis of bladder bowel dysfunction? J Pediatr Urol 2024; 20:223.e1-223.e6. [PMID: 37968162 DOI: 10.1016/j.jpurol.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/30/2023] [Accepted: 11/02/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Kidney ureter bladder radiography (KUB) is widely used for the evaluation of constipation in children with bladder and bowel dysfunction (BBD); however, there is varying evidence to support its routine diagnostic use. One drawback to KUB is radiation exposure. The dangers of radiation in children are well-documented, and per As Low As Reasonably Achievable, non-beneficial radiation should be avoided. This risk is especially high in children who undergo repeated imaging in the follow up of constipation treatment. OBJECTIVE We sought to assess the utility of KUB in diagnosing children with BBD by comparing it to four diagnostic tests and/or validated instruments: the Dysfunctional Voiding Symptom Score (DVSS), Rome IV criteria, rectal diameter on ultrasound (RD), and the Bristol Stool Form Score (BSFS). STUDY DESIGN We prospectively enrolled a cohort of patients presenting to an academic pediatric urology practice with symptoms of BBD. Severity of stool burden on KUB (mild, moderate, or severe), RD on ultrasound (≥3.4 cm), DVSS, Rome IV, and BSFS were obtained for each patient. All imaging was interpreted by a pediatric radiologist and pediatric urologist. Primary outcomes were the association between the four diagnostic tests and KUB stool burden. Bivariate analysis of all individual variables versus KUB was performed, as well as multivariate regressions to determine if multiple measures were predictive of KUB stool burden when combined. RESULTS Between October 2020 and May 2022, 50 patients were enrolled. All children were under the age of 18, with a median age of 8 years (IQR 3-13). 38 % were male. Median BMI-for-age-percentile was 80.8 (IQR 50.3-98.3). When comparing individual variables to KUB in bivariate analyses, it was found that RD on ultrasound is predictive of significant stool burden on KUB (p = 0.03). No other individual variables were predictive. In the multivariate analyses, no combination of tests was found to be predictive of KUB. DISCUSSION We compared the effectiveness of four commonly used diagnostic tests in children with BBD to validate the use of KUB. In conclusion, our results support the use of RD on ultrasound as a non-radiating alternative to KUB to assess stool burden. Data also suggest that KUB for fecal load does not correlate with urinary (DVSS) or bowel (Rome IV, BSFS) symptoms in BBD, and that symptoms scores should still be used independently for diagnosis and monitoring of treatment response. CONCLUSION In conclusion, KUB has a limited role in the diagnosis of BBD.
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Affiliation(s)
- Alexandra R Siegal
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Megan Paul
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Neha R Malhotra
- Department of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Erin Miller
- Department of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Patrick Ho
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joy Masseaux
- Department of Pediatric Radiology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Eva M Baldisserotto
- Department of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - J Antonio Quiros
- Department of Pediatric Gastroenterology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
| | - Fernando A Ferrer
- Department of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, NY, USA
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Gupta R, Khalaf RT, Morrison J, Amankwah E, Ruan W, Fishman DS, Barth BA, Liu QY, Giefer M, Kim KM, Martinez M, Dall'oglio L, Torroni F, De Angelis P, Faraci S, Bitton S, Dua K, Werlin S, Gugig R, Huang C, Mamula P, Quiros JA, Zheng Y, Piester T, Grover A, Fox VL, Wilsey M, Troendle DM. Impact of Trainee Involvement on Pediatric ERCP Procedures: Results From the Pediatric ERCP Initiative. J Pediatr Gastroenterol Nutr 2023; 77:126-130. [PMID: 36976177 DOI: 10.1097/mpg.0000000000003782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
This study examines the role of trainee involvement with pediatric endoscopic retrograde cholangiopancreatography (ERCP) and whether it affects the procedure's success, post-procedural adverse outcomes, and duration. A secondary analysis of the Pediatric ERCP Database Initiative, an international database, was performed. Consecutive ERCPs on children <19 years of age from 18 centers were entered prospectively into the database. In total 1124 ERCPs were entered into the database, of which 320 (28%) were performed by trainees. The results showed that the presence of trainees did not impact technical success ( P = 0.65) or adverse events rates ( P = 0.43). Rates of post-ERCP pancreatitis, pain, and bleeding were similar between groups ( P > 0.05). Fewer cases involving trainees were in the top quartile (>58 minutes) of procedural time (19% vs 26%; P = 0.02). Overall, our findings indicate trainee involvement in pediatric ERCP is safe.
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Affiliation(s)
- Rekha Gupta
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Racha T Khalaf
- the Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL
| | - John Morrison
- Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | | | - Wenly Ruan
- Baylor College of Medicine Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Bradley A Barth
- the UT Southwestern Medical Center; Children's Health, Children's Medical Center, Dallas, TX
| | - Quin Y Liu
- the Cedars-Sinai Medical Center, Los Angeles, CA
| | - Matthew Giefer
- The University of Queensland, AU-Oschsner Health, New Orleans, LA
| | - Kyung Mo Kim
- University of Ulsan College of Medicine; Asan Medical Center Children's Hospital, Seoul, Republic of Korea
| | - Mercedes Martinez
- Columbia University New York Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | | | | | | | | | - Sam Bitton
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Kulwinder Dua
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Steven Werlin
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Roberto Gugig
- Stanford Children's Health; Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | | | - Petar Mamula
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Yuhua Zheng
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Travis Piester
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Amit Grover
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Victor L Fox
- From the Department of Pediatrics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - Michael Wilsey
- Johns Hopkins All Children's Hospital, Saint Petersburg, FL
| | - David M Troendle
- the UT Southwestern Medical Center; Children's Health, Children's Medical Center, Dallas, TX
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Trocchia C, Khalaf R, Amankwah E, Ruan W, Fishman DS, Barth BA, Liu QY, Giefer M, Kim KM, Martinez M, Dall'oglio L, Torroni F, De Angelis P, Faraci S, Bitton S, Werlin SL, Dua K, Gugig R, Huang C, Mamula P, Quiros JA, Zheng Y, Piester T, Grover A, Fox VL, Wilsey M, Troendle DM. Pediatric ERCP in the Setting of Acute Pancreatitis: A Secondary Analysis of an International Multicenter Cohort Study. J Pediatr Gastroenterol Nutr 2023; 76:817-821. [PMID: 36913706 PMCID: PMC10198832 DOI: 10.1097/mpg.0000000000003762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Previous studies have demonstrated the safety of performing endoscopic retrograde cholangiopancreatography (ERCP) in the pediatric population; however, few have addressed the outcomes of children undergoing ERCP during acute pancreatitis (AP). We hypothesize that ERCP performed in the setting of AP can be executed with similar technical success and adverse event profiles to those in pediatric patients without pancreatitis. Using the Pediatric ERCP Database Initiative, a multi-national and multi-institutional prospectively collected dataset, we analyzed 1124 ERCPs. One hundred and ninety-four (17%) of these procedures were performed in the setting of AP. There were no difference in the procedure success rate, procedure time, cannulation time, fluoroscopy time, or American Society of Anesthesiology class despite patients with AP having higher American Society of Gastrointestinal Endoscopy grading difficulty scores. This study suggests that ERCP can be safely and efficiently performed in pediatric patients with AP when appropriately indicated.
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Affiliation(s)
| | - Racha Khalaf
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Ernest Amankwah
- From Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Wenly Ruan
- Baylor College of Medicine; Texas Children's Hospital, Houston, TX
| | | | - Bradley A Barth
- the UT Southwestern Medical Center; Children's Health Children's Medical Center, Dallas, TX
| | - Quin Y Liu
- the Cedars-Sinai Medical Center, Los Angeles, CA
| | - Matthew Giefer
- The University of Queensland, AU-Oschsner Health, New Orleans, LA
| | - Kyung Mo Kim
- University of Ulsan College of Medicine; Asan Medical Center Children's Hospital, Seoul, The Republic of Korea
| | - Mercedes Martinez
- Columbia University; New York Presbyterian Morgan Stanley Children's Hospital of New York, New York, NY
| | | | | | | | | | - Sam Bitton
- Zucker School of Medicine at Hofstra/Northwell; Cohen Children's Medical Center, Lake Success, NY
| | - Steven L Werlin
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Kulwinder Dua
- Medical College of Wisconsin; Children's Wisconsin, Milwaukee, WI
| | - Roberto Gugig
- Stanford Children's Health, Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | | | - Petar Mamula
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Yuhua Zheng
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Travis Piester
- University of Southern California; Children's Hospital of Los Angeles, Los Angeles, CA
| | - Amit Grover
- Harvard Medical School; Boston Children's Hospital, Boston, MA
| | - Victor L Fox
- Harvard Medical School; Boston Children's Hospital, Boston, MA
| | - Michael Wilsey
- From Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - David M Troendle
- the UT Southwestern Medical Center; Children's Health Children's Medical Center, Dallas, TX
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Nathan JD, Ellery K, Balakrishnan K, Bhatt H, Ganoza A, Husain SZ, Kumar R, Morinville VD, Quiros JA, Schwarzenberg SJ, Sellers ZM, Uc A, Abu-El-Haija M. The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2022; 74:706-719. [PMID: 35258494 PMCID: PMC10286947 DOI: 10.1097/mpg.0000000000003439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Chronic pancreatitis (CP) is rare in childhood but impactful because of its high disease burden. There is limited literature regarding the management of CP in children, specifically about the various surgical approaches. Herein, we summarize the current pediatric and adult literature and provide recommendations for the surgical management of CP in children. METHODS The literature review was performed to include the scope of the problem, indications for operation, conventional surgical options as well as total pancreatectomy with islet autotransplantation, and outcomes following operations for CP. RESULTS Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions. Surgical management must be tailored to the patient's unique needs, considering the anatomy and morphology of their disease. A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass. Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease. The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation. CONCLUSIONS The morphology of disease and the presence of genetic risk factors must be considered while determining the optimal surgical approach for children with CP. Surgical outcomes for CP are variable and depend on the type of intervention. A multidisciplinary team approach is needed to assure that the best possible operation is selected for each patient, their recovery is optimized, and their immediate and long-term postoperative needs are well-met.
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Affiliation(s)
- Jaimie D. Nathan
- Nationwide Children’s Hospital, Department of Abdominal Transplant and Hepatopancreatobiliary Surgery, The Ohio State University College of Medicine, Department of Surgery, Columbus, Ohio, United States
| | - Kate Ellery
- University of Pittsburgh Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh, Pennsylvania, United States
| | - Keshawadhana Balakrishnan
- Texas Children’s Hospital, Section of Pediatric Gastroenterology, Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States
| | - Heli Bhatt
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Armando Ganoza
- University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, Pittsburgh, Pennsylvania, United States
| | - Sohail Z. Husain
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Rakesh Kumar
- Promedica Russell J. Ebeid Children’s Hospital, Toledo, Ohio, United States
| | - Veronique D. Morinville
- McGill University Health Center, Montreal Children’s Hospital, Division of Pediatric Gastroenterology and Nutrition, Montreal, Quebec, Canada
| | - J. Antonio Quiros
- Icahn School of Medicine, Mount Sinai Kravis Children’s Hospital, New York, New York, United States
| | - Sarah J. Schwarzenberg
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Zachary M. Sellers
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Aliye Uc
- University of Iowa, Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, Iowa, United States
| | - Maisam Abu-El-Haija
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, United States
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McSorley B, Cina RA, Jump C, Palmadottir J, Quiros JA. Endoscopic balloon dilation for management of stricturing Crohn’s disease in children. World J Gastrointest Endosc 2021; 13:382-390. [PMID: 34630888 PMCID: PMC8474695 DOI: 10.4253/wjge.v13.i9.382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/15/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Crohn’s disease (CD) has a multitude of complications including intestinal strictures from fibrostenotic disease. Fibrostenotic disease has been reported in 10%-17% of children at presentation and leads to surgery in 20%-50% of cases within ten years of diagnosis. When symptoms develop from these strictures, the treatment in children has primarily been surgical resection. Endoscopic balloon dilation (EBD) has been shown to be a safe and efficacious alternative to surgery in adults, but evidence is poor in the literature regarding its safety and efficacy in children.
AIM To evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.
METHODS In a single-center retrospective study, we looked at pediatric patients (ages 0-18) who carry the diagnosis of CD, who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1, 2012 through May 1, 2019. We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype. The type of intervention for patients’ strictures was then identified through procedural and surgical billing codes. We evaluated their demographics, clinical variables, whether they underwent EBD vs surgery or both, and their clinical outcomes.
RESULTS Of the 139 patients with CD, 25 (18%) developed strictures. The initial intervention for a stricture was surgical resection in 12 patients (48%) and EBD in 13 patients (52%). However, 4 (33%) patients whom initially had surgical resection required follow up EBD, and thus 17 total patients (68%) underwent EBD at some point in their treatment process. For those 8 patients who underwent successful surgical resection alone, 4 of these patients (50%) had a fistula present near the stricture site and 4 (50%) had strictures greater than 5 cm in length. All patients who underwent EBD had no procedural complications, such as a perforation. Twenty-two (88%) of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.
CONCLUSION EBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.
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Affiliation(s)
- Brianna McSorley
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Robert A Cina
- Department of Surgery, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Candi Jump
- Department of Pediatric Gastroenterology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Johanna Palmadottir
- Department of Pediatric Gastroenterology, MUSC Children's Hospital, Charleston, SC 29425, United States
| | - J Antonio Quiros
- Department of Pediatric Gastroenterology and Nutrition, Mount Sinai Kravis Children's Hospital, New York, NY 10029, United States
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Quiros JA, Saps M. The Coming Storm: Cannabis Hyperemesis Syndrome in Adolescents. J Adolesc Health 2021; 68:223-224. [PMID: 33541594 DOI: 10.1016/j.jadohealth.2020.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/28/2020] [Indexed: 11/18/2022]
Affiliation(s)
- J Antonio Quiros
- Pediatric Therapeutic Endoscopy Program, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Mount Sinai Kravis Children's Hospital, New York, New York
| | - Miguel Saps
- Chief of Division of Pediatric Gastroenterology, Miller School of Medicine, Hepatology and Nutrition, University of Miami, Miami, Florida
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Shahein AR, Quiros JA, Arbizu RA, Jump C, Lauzon SD, Baker SS. Impact of Clinical, Laboratory and Fluid Therapy Variables on Hospital Length of Stay for Children with Acute Pancreatitis. Pediatr Gastroenterol Hepatol Nutr 2020; 23:356-365. [PMID: 32704496 PMCID: PMC7354873 DOI: 10.5223/pghn.2020.23.4.356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/15/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE There have been many efforts to develop generalizable severity markers in children with acute pancreatitis (AP). Expert opinion panels have developed consensus guidelines on management but it is unclear if these are sufficient or valid. Our study aims to assess the effect of clinical and laboratory variables, in addition to treatment modality on hospital length of stay (LOS) as a proxy variable for severity in pediatric patients admitted with AP. METHODS We conducted a retrospective chart review of patients between ages of 0-18 years, who were admitted with AP at 2 institutions between 2013-2018, John R. Oishei Children's Hospital (Buffalo, NY, USA) and Medical University of South Carolina Children's Hospital (Charleston, SC, USA). We constructed three linear regression models to analyze the effect of clinical signs of organ dysfunction, laboratory markers and fluid intake on hospital LOS. RESULTS Ninety-two patients were included in the study. The mean age was 12 years (range, 7.6-17.4 years), 55% were females, and median LOS was 3 days. The most frequent cause of AP was idiopathic. Our study showed that elevated blood urea nitrogen (BUN) on admission (p<0.005), tachycardia that lasted for ≥48 hours (p<0.001) and need for fluid resuscitation were associated with increase LOS. Total daily fluid intake above maintenance did not have a significant effect on the primary outcome (p=0.49). CONCLUSION Elevated serum BUN on admission, persistent tachycardia and need for fluid resuscitation were associated with increase LOS in pediatric AP. Daily total fluid intake above recommended maintenance did not reduce LOS.
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Affiliation(s)
- Abdul R Shahein
- Division of Pediatric Gastroenterology and Nutrition, Children's Hospital of Arkansas, Little Rock, AR, USA
| | - J Antonio Quiros
- Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Ricardo A Arbizu
- Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Candi Jump
- Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Steven D Lauzon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Susan S Baker
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
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Lin HC, Kasi N, Quiros JA. Alpha1-Antitrypsin Deficiency: Transition of Care for the Child With AAT Deficiency into Adulthood. Curr Pediatr Rev 2019; 15:53-61. [PMID: 30421678 PMCID: PMC6696823 DOI: 10.2174/1573396314666181113094517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 10/02/2018] [Accepted: 11/06/2018] [Indexed: 11/22/2022]
Abstract
IMPORTANCE Alpha1-antitrypsin (AAT) deficiency is a common, but an underdiagnosed genetic condition, affecting 1 in 1500 individuals. It can present insidiously with liver disease in children. Although clinical practice guidelines exist for the management of AAT deficiency, especially with regards to pulmonary involvement, there are no published recommendations that specifically relate to the management of the liver disease and monitoring for lung disease associated with this condition, particularly in children. OBJECTIVE To review the literature on the management of AAT deficiency-associated liver disease in adults and children. EVIDENCE REVIEW A systematic search for articles indexed in PubMed and published was undertaken. Some earlier selected landmark references were included in the review. Search terms included: "alpha1-antitrypsin deficiency"; "liver disease"; "end-stage liver disease"; "liver transplantation" and "preventative management". Recommendations for the management of children with suspected or confirmed AAT deficiency were made according to the Strength of Recommendation Taxonomy scale. FINDINGS Liver complications arising from AAT deficiency result from the accumulation of mutated AAT protein within hepatocytes. Liver disease occurs in 10% of children, manifested by cholestasis, pruritus, poor feeding, hepatomegaly, and splenomegaly, but the presentation is highly variable. A diagnostic test for AAT deficiency is recommended for these children. Baseline liver function tests should be obtained to assess for liver involvement; however, the only curative treatment for AAT deficiency-associated liver disease is organ transplantation. Conclusion and Relevance: There should be a greater vigilance for AAT deficiency testing among pediatricians. Diagnosis should prompt assessment of liver involvement. Children with AATdeficiency- associated liver disease should be referred to a liver specialist and monitored throughout their lifetimes for the symptoms of AAT-deficiency-related pulmonary involvement.
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Affiliation(s)
- Henry C Lin
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, United States
| | - Nagraj Kasi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition MUSC Children's Hospital, South Carolina, SC, United States
| | - J Antonio Quiros
- Division of Pediatric Gastroenterology, Hepatology and Nutrition MUSC Children's Hospital, South Carolina, SC, United States
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Jensen ET, Huang KZ, Chen HX, Landes LE, McConnell KA, Almond MA, Safta A, Johnston DT, Durban R, Jobe L, Frost C, Donnelly S, Antonio B, Quiros JA, Markowitz JE, Dellon ES. Longitudinal Growth Outcomes Following First-line Treatment for Pediatric Patients With Eosinophilic Esophagitis. J Pediatr Gastroenterol Nutr 2019; 68:50-55. [PMID: 30074576 PMCID: PMC6449848 DOI: 10.1097/mpg.0000000000002114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES No formal comparative effectiveness studies have been conducted to evaluate the effect of eosinophilic esophagitis (EoE) treatment choice on long-term growth in pediatric patients. Long-term studies of inhaled corticoid steroids in asthma, however, suggest possible effects on linear growth. The aim of this study was to compare longitudinal, anthropometric growth in children with EoE according to treatment approach. METHODS We conducted a retrospective, multicenter cohort study of anthropometric growth (height and body mass index [BMI] z scores) in pediatric (<18 years of age) patients newly diagnosed with EoE across 5 clinical sites between 2005 and 2014. We compared differences in growth according to treatment approach over a 12-month period. Modification by sex and age was examined and sensitivity analyses were conducted to assess robustness of results given study assumptions. RESULTS In the 409 patients identified, the mean age and proportion male differed by treatment (P = < 0.01 and P = 0.04, respectively). Baseline growth measures were associated with slight impairment of height at diagnosis (median baseline height z score of -0.1 [interquartile range -0.9, 0.8]). In general, treatment approach was not associated with any significant increase or decrease in expected growth over a 12-month period. Subtle decrease in linear growth was observed with treatment using a combined elemental and topical steroid (Δ height z score [adjusted]: -0.04; 95% confidence interval [CI]: -0.08, -0.01). Differences in linear growth differed by sex (P for interaction <0.01). For elemental formula in combination with topical steroids, only girls exhibited a significant decline in linear growth (Δ height z score [adjusted]: -0.24; 95% CI: -0.32, -0.17). A slight reduction in BMI was observed for patients treated with a combination of elemental diet and dietary elimination (Δ BMI z score [adjusted]: -0.07; 95% CI: -0.13, -0.01). CONCLUSIONS Treatment of EoE, in general, is not associated with major anthropometric growth changes in most pediatric patients. Slight linear growth impairment was observed for topical steroid treatment, and sex differences in growth by treatment approach were observed. Future prospective studies should evaluate the effect of treatment on optimal growth and development and over a longer period of follow-up.
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Affiliation(s)
- Elizabeth T. Jensen
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kevin Z. Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Hannah X. Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lisa Englander Landes
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Kristen A McConnell
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - M. Angie Almond
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Anca Safta
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | | | - Laura Jobe
- University of South Carolina School of Medicine, Greenville, SC
- Greenvile Children’s Hospital; Greenville, SC
| | | | - Sarah Donnelly
- Pediatric Gastroenterology and Nutrition, MUSC Children’s Hospital, Charleston, SC
| | - Brady Antonio
- Pediatric Gastroenterology and Nutrition, MUSC Children’s Hospital, Charleston, SC
| | - J. Antonio Quiros
- Pediatric Gastroenterology and Nutrition, MUSC Children’s Hospital, Charleston, SC
| | - Jonathan E. Markowitz
- University of South Carolina School of Medicine, Greenville, SC
- Greenvile Children’s Hospital; Greenville, SC
| | - Evan S. Dellon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC
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10
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Huang KZ, Jensen ET, Chen HX, Landes LE, McConnell KA, Almond MA, Johnston DT, Durban R, Jobe L, Frost C, Donnelly S, Antonio B, Safta AM, Quiros JA, Markowitz JE, Dellon ES. Practice Pattern Variation in Pediatric Eosinophilic Esophagitis in the Carolinas EoE Collaborative: A Research Model in Community and Academic Practices. South Med J 2018; 111:328-332. [PMID: 29863219 DOI: 10.14423/smj.0000000000000817] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Differences in the initial management of pediatric eosinophilic esophagitis (EoE) by practice setting have not been well characterized. We aimed to characterize these differences for sites in the Carolinas EoE Collaborative (CEoEC), a multicenter network of academic and community practices. METHODS We performed a retrospective cohort study of pediatric EoE patients at five CEoEC sites: University of North Carolina (UNC) Hospital, Charlotte Asthma and Allergy Specialists, Greenville Health Systems, Wake Forest Baptist Medical Center, and the Medical University of South Carolina Hospital. Cases of EoE were defined by consensus guidelines. Data were extracted from electronic medical records. We tested for differences among sites and used a multinomial model (polytomous regression) to assess associations between treatment and site, adjusting on patient factors. RESULTS We identified 464 children with EoE across the CEoEC sites. The median age was highest at Wake Forest (11.4 years), the median eosinophil count was highest at UNC (69 eos/hpf), and UNC had the most male patients (82%). UNC used topical steroids for initial treatment in 86% of cases, compared with <1% in Greenville (P < 0.01). Greenville used dietary elimination more frequently than UNC (81% vs 2%, P < 0.01). Differences in treatment approach held after adjusting for potential baseline confounders. There was no significant association between patient factors and initial treatment approach. CONCLUSIONS Significant differences in EoE patient factors and treatment approaches were identified across CEoEC sites and were not explained by patient or practice factors. This suggests that institutional or provider preferences drive initial treatment approaches, and that more data are needed to drive best practice decisions.
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Affiliation(s)
- Kevin Z Huang
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Elizabeth T Jensen
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Hannah X Chen
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Lisa E Landes
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Kristen A McConnell
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - M Angie Almond
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Douglas T Johnston
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Raquel Durban
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Laura Jobe
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Carrie Frost
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Sarah Donnelly
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Brady Antonio
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Anca M Safta
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - J Antonio Quiros
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Jonathan E Markowitz
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
| | - Evan S Dellon
- From the Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, Asthma and Allergy Specialists, Charlotte, North Carolina, the University of South Carolina School of Medicine, Greenville, Greenville Children's Hospital, Greenville, South Carolina, and the Division of Pediatric Gastroenterology and Nutrition, Medical University of South Carolina Children's Hospital, Charleston, South Carolina
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11
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Lewis K, Butts R, Antonio Quiros J, Hudspeth M, Twombley K, Savage A, Self S, Burnette A, Sun S. Autoimmune enteropathy and hepatitis in pediatric heart transplant recipient. Pediatr Transplant 2017; 21. [PMID: 28097735 DOI: 10.1111/petr.12877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 01/09/2023]
Abstract
AIE is a rare disorder in children that presents with severe diarrhea and malabsorption, caused by immune-mediated damage to intestinal mucosa. AIE is often associated with various syndromes of immunodeficiency including IPEX syndrome (immune dysregulation, polyendocrinopathy and enteropathy, X-linked). Dysfunctional T regulatory cells are the source of pathology in both IPEX syndrome and AIE as they are essential in maintaining tolerance to self-antigens and eliminating autoreactive B cells. This case report describes a 10-year-old cardiac transplant and total thymectomy patient on chronic immunosuppression with tacrolimus that presented with AIE and extraintestinal manifestations of cyclical hepatitis. Transition from tacrolimus to sirolimus successfully increased T regulatory cells and resolved enteritis and hepatitis symptoms. Data support that thymectomy at <1 year of age increases risk of autoimmune disease due to abnormal immune maturation. Studies suggest that the sirolimus promotes the upregulation of the FoxP3 protein that is classically associated with Tregs. In turn, Tregs prevent the maturation of autoreactive B cells that lead to autoimmune reactions.
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Affiliation(s)
- Kimberly Lewis
- Medical University of South Carolina - MUSC, Charleston, SC, USA
| | - Ryan Butts
- Department of Pediatrics Cardiology, MUSC, Charleston, SC, USA
| | - J Antonio Quiros
- Department of Pediatric Gastroenterology, MUSC, Charleston, SC, USA
| | | | | | - Andrew Savage
- Department of Pediatrics Cardiology, MUSC, Charleston, SC, USA
| | - Sally Self
- Department of Pathology, MUSC, Charleston, SC, USA
| | - Ali Burnette
- Department of Pediatrics Cardiology, MUSC, Charleston, SC, USA
| | - Shaoli Sun
- Department of Pathology, MUSC, Charleston, SC, USA
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12
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Pall H, Zacur GM, Kramer RE, Lirio RA, Manfredi M, Shah M, Stephen TC, Tucker N, Gibbons TE, Sahn B, McOmber M, Friedlander J, Quiros JA, Fishman DS, Mamula P. Bowel preparation for pediatric colonoscopy: report of the NASPGHAN endoscopy and procedures committee. J Pediatr Gastroenterol Nutr 2014; 59:409-16. [PMID: 24897169 DOI: 10.1097/mpg.0000000000000447] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Pediatric bowel preparation protocols used before colonoscopy vary greatly, with no identified standard practice. The present clinical report reviews the evidence for several bowel preparations in children and reports on their use among North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition members. Publications in the pediatric literature for bowel preparation regimens are described, including mechanisms of action, efficacy and ease of use, and pediatric studies. A survey distributed to pediatric gastroenterology programs across the country reviews present national practice, and cleanout recommendations are provided. Finally, further areas for research are identified.
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Affiliation(s)
- Harpreet Pall
- *Section of Gastroenterology, Hepatology, and Nutrition, St Christopher's Hospital for Children, Philadelphia, Pennsylvania †Division of Pediatric Gastroenterology, University of Michigan Health System, Ann Arbor ‡Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, Aurora §Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center/Children's Medical Center, Omaha
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts ¶Division of Pediatric Gastroenterology, Loma Linda University, Loma Linda, California #Division of Pediatric Gastroenterology, University of Louisville, Louisville, Kentucky **Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Broward Health Medical Center, Fort Lauderdale, Florida ††Division of Pediatric Gastroenterology and Nutrition, Arkansas Children's Hospital, Little Rock ‡‡Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania §§Division of Gastroenterology, Phoenix Children's Hospital, Phoenix, Arizona
- Division of Pediatric Gastroenterology, Medical University of South Carolina, Charleston ¶¶Division of Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston
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13
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Affiliation(s)
- J Antonio Quiros
- Division of Pediatric Gastroenterology, California Pacific Medical Center, University of California-San Francisco, San Francisco, CA, USA.
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14
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Friedlander J, Quiros JA, Morgan T, Zhang Z, Tian W, Kehr E, Shackleton DV, Zigman A, Stenzel P. Diagnosis of autoimmune pancreatitis vs neoplasms in children with pancreatic mass and biliary obstruction. Clin Gastroenterol Hepatol 2012; 10:1051-5.e1. [PMID: 22732272 DOI: 10.1016/j.cgh.2012.06.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 06/05/2012] [Accepted: 06/06/2012] [Indexed: 02/07/2023]
Abstract
Autoimmune pancreatitis (AIP) is a rare autoimmune disorder that resembles pancreatic neoplasia and occurs primarily in adults. Management strategies and diagnostic criteria are being revised for adult patients; there are no clear diagnostic criteria for pediatric patients. We describe 3 cases of AIP in children, on the basis of clinical and pathology records. We also performed a literature review to determine the incidence of biliary obstruction in pediatric patients with pancreatic tumors. We found that children with AIP present with a variety of symptoms, and that diagnostic and therapeutic strategies also vary. Furthermore, on the basis of the many studies published on pediatric patients with pancreatic tumors, only a small percentage of the patients have biliary obstructions. Cytologic analysis of samples collected by fine-needle aspiration cytology does not accurately identify AIP in children. However, frozen section needle core biopsy samples can be used to distinguish children with AIP from those with neoplasia. Children with pancreatic mass and biliary obstruction are more likely to have AIP than neoplasms.
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Affiliation(s)
- Joel Friedlander
- Department of Pediatrics, University of Colorado Health Sciences Center, Aurora, Colorado 80045, USA.
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15
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Siegel CA, Siegel LS, Hyams JS, Kugathasan S, Markowitz J, Rosh JR, Leleiko N, Mack DR, Crandall W, Evans J, Keljo DJ, Otley AR, Oliva-Hemker M, Farrior S, Langton CR, Wrobel IT, Wahbeh G, Quiros JA, Silber G, Bahar RJ, Sands BE, Dubinsky MC. Real-time tool to display the predicted disease course and treatment response for children with Crohn's disease. Inflamm Bowel Dis 2011. [PMID: 20812335 DOI: 10.1002/ibd.21386]] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Immunomodulators and biologics are effective treatments for children with Crohn's disease (CD). The challenge of communicating the anticipated disease course with and without therapy to patients and parents is a barrier to the timely use of these agents. The aim of this project was to develop a tool to graphically display the predicted risks of CD and expected benefits of therapy. METHODS Using prospectively collected data from 796 pediatric CD patients we developed a model using system dynamics analysis (SDA). The primary model outcome is the probability of developing a CD-related complication. Input variables include patient and disease characteristics, magnitude of serologic immune responses expressed as the quartile sum score (QSS), and exposure to medical treatments. RESULTS Multivariate Cox proportional analyses show variables contributing a significant increase in the hazard ratio (HR) for a disease complication include female gender, older age at diagnosis, small bowel or perianal disease, and a higher QSS. As QSS increases, the HR for early use of corticosteroids increases, in contrast to a decreasing HR with early use of immunomodulators, early or late biologics, and early combination therapy. The concordance index for the model is 0.81. Using SDA, results of the Cox analyses are transformed into a simple graph displaying a real-time individualized probability of disease complication and treatment response. CONCLUSIONS We have developed a tool to predict and communicate individualized risks of CD complications and how this is modified by treatment. Once validated, it can be used at the bedside to facilitate patient decision making.
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Affiliation(s)
- Corey A Siegel
- Dartmouth-Hitchcock Inflammatory Bowel Disease Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
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16
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Siegel CA, Siegel LS, Hyams JS, Kugathasan S, Markowitz J, Rosh JR, Leleiko N, Mack DR, Crandall W, Evans J, Keljo DJ, Otley AR, Oliva-Hemker M, Farrior S, Langton CR, Wrobel IT, Wahbeh G, Quiros JA, Silber G, Bahar RJ, Sands BE, Dubinsky MC. Real-time tool to display the predicted disease course and treatment response for children with Crohn's disease. Inflamm Bowel Dis 2011; 17:30-8. [PMID: 20812335 PMCID: PMC2998586 DOI: 10.1002/ibd.21386] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 05/17/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immunomodulators and biologics are effective treatments for children with Crohn's disease (CD). The challenge of communicating the anticipated disease course with and without therapy to patients and parents is a barrier to the timely use of these agents. The aim of this project was to develop a tool to graphically display the predicted risks of CD and expected benefits of therapy. METHODS Using prospectively collected data from 796 pediatric CD patients we developed a model using system dynamics analysis (SDA). The primary model outcome is the probability of developing a CD-related complication. Input variables include patient and disease characteristics, magnitude of serologic immune responses expressed as the quartile sum score (QSS), and exposure to medical treatments. RESULTS Multivariate Cox proportional analyses show variables contributing a significant increase in the hazard ratio (HR) for a disease complication include female gender, older age at diagnosis, small bowel or perianal disease, and a higher QSS. As QSS increases, the HR for early use of corticosteroids increases, in contrast to a decreasing HR with early use of immunomodulators, early or late biologics, and early combination therapy. The concordance index for the model is 0.81. Using SDA, results of the Cox analyses are transformed into a simple graph displaying a real-time individualized probability of disease complication and treatment response. CONCLUSIONS We have developed a tool to predict and communicate individualized risks of CD complications and how this is modified by treatment. Once validated, it can be used at the bedside to facilitate patient decision making.
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Affiliation(s)
- Corey A. Siegel
- Dartmouth-Hitchcock Inflammatory Bowel Disease Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Jeffrey S. Hyams
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Subra Kugathasan
- Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | | | - Joel R. Rosh
- Department of Pediatrics, Morristown Memorial Hospital, Morristown, NJ, USA
| | - Neal Leleiko
- Department of Pediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - David R. Mack
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Wallace Crandall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jonathan Evans
- Department of Pediatrics, Nemours Children's Clinic, Jacksonville, FL, USA
| | - David J. Keljo
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anthony R. Otley
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | - Sharmayne Farrior
- Department of Pediatrics, IBD Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christine R. Langton
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Iwona T. Wrobel
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Ghassan Wahbeh
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Gary Silber
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Ron J. Bahar
- Department of Pediatrics, IBD Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bruce E. Sands
- Gastrointestinal Unit, MGH Crohn's and Colitis Center, Massachusetts General Hospital, Boston, MA, USA
| | - Marla C. Dubinsky
- Department of Pediatrics, IBD Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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17
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Abstract
The use of esophageal stents has been commonplace in adults for many years and for a variety of indications, including palliative care for malignant lesions involving the esophagus. The use of esophageal stents in the pediatric population, however, was limited by the inability to remove them and the implications this has for the growing child, especially for primarily benign esophageal lesions. With the advent of removable, covered stents, the potential uses for stents in children expanded to include treatment of a wide variety of congenital and acquired esophageal strictures. Stenting offers tremendous potential advantage over more traditional pneumatic or bougie dilation in its ability to provide continuous, radially oriented dilation pressure sustained over a period of time. This review examines the published pediatric literature on stents, discusses the indications for their use, outlines the types of stents available, offers technical guidance for proper placement, and reviews subsequent management and complications.
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Affiliation(s)
- Robert E Kramer
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, The Children's Hospital/University of Colorado Denver, 13123 East 16th Avenue, B-290, Aurora, CO, 80124, USA.
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18
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Gerich ME, Quiros JA, Marcin JP, Tennyson L, Henthorn M, Prindiville TP. A prospective evaluation of the impact of allopurinol in pediatric and adult IBD patients with preferential metabolism of 6-mercaptopurine to 6-methylmercaptopurine. J Crohns Colitis 2010; 4:546-52. [PMID: 21122558 DOI: 10.1016/j.crohns.2010.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Revised: 03/12/2010] [Accepted: 03/13/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND 6-mercaptopurine (6-MP) is used for the induction and maintenance of remission of inflammatory bowel disease (IBD). 6-MP is converted into 6-methylmercaptopurine (6-MMP) or 6-thioguanine nucleotides (6-TGN) intracellularly. Treatment response in IBD patients correlates with 6-TGN levels. This study prospectively evaluated the effect of allopurinol on 6-MP metabolites in adult and pediatric IBD patients. Additionally, we quantified the prevalence of preferential metabolism towards 6-MMP through a retrospective analysis of IBD patients. METHODS Twenty patients (10 adult; 10 pediatric) with evidence of preferential metabolism towards 6-MMP, (6-TGN<250 pmol/8×10⁸ RBCs and 6-MMP>5000 pmol/8×10⁸ RBCs) were prospectively treated with allopurinol 100 mg daily and up to 100 mg of 6-MP. 6-MP dose was adjusted after a 3-week metabolite measurement. RESULTS The median dose of 6-MP for adults decreased from 100mg daily (range: 37.5-150 mg) to 25mg daily (range: 12.5-50 mg). The median dose of 6-MP for pediatric patients decreased from 50 mg (range: 25-50 mg) to 10.7 mg (range: 10.7 to 21.4 mg). Mean 6-TGN levels in all subjects increased from 197.4 (± 59) to 284.8 (± 107) pmol/8×10⁸ RBCs (p=0.0005). Mean 6-MMP levels in all subjects decreased from a mean of 7719.8 (± 4716) to 404.8 (± 332) pmol/8×10⁸ RBCs (p=0.0004). There were no complications associated with allopurinol therapy. Eighty-eight (30.9%) of 285 IBD patients had evidence of preferential metabolism towards 6-MMP. The proportion of preferential metabolism was equal in adults and pediatric patients. CONCLUSION Our results indicate that the addition of allopurinol safely shifts metabolite production in both adult and pediatric IBD patients and that there is a high prevalence of preferential metabolism towards 6-MMP among IBD patients.
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Affiliation(s)
- Mark E Gerich
- Department of Internal Medicine, Division of Gastroenterology, University of California Davis Health System, Sacramento, CA 95817, United States
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19
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Markowitz J, Kugathasan S, Dubinsky M, Mei L, Crandall W, LeLeiko N, Oliva-Hemker M, Rosh J, Evans J, Mack D, Otley A, Pfefferkorn M, Bahar R, Vasiliauskas E, Wahbeh G, Silber G, Quiros JA, Wrobel I, Nebel J, Landers C, Picornell Y, Targan S, Lerer T, Hyams J. Age of diagnosis influences serologic responses in children with Crohn's disease: a possible clue to etiology? Inflamm Bowel Dis 2009; 15:714-9. [PMID: 19107777 PMCID: PMC2726983 DOI: 10.1002/ibd.20831] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Crohn's disease (CD) is often associated with antibodies to microbial antigens. Differences in immune response may offer clues to the pathogenesis of the disease. The aim was to examine the influence of age at diagnosis on the serologic response in children with CD. METHODS Data were drawn from 3 North American multicenter pediatric inflammatory bowel disease (IBD) research consortia. At or shortly after diagnosis, pANCA, ASCA IgA, ASCA IgG, anti-ompC, and anti-CBir1 were assayed. The results were compared as a function of age at CD diagnosis (0-7 years versus 8-15 years). RESULTS In all, 705 children (79 <8 years of age at diagnosis, 626 >or=8 years) were studied. Small bowel CD was less frequent in the younger group (48.7% versus 72.6%; P < 0.0001), while colonic involvement was comparable (91.0% versus 86.5%). ASCA IgA and IgG were seen in <20% of those 0-7 years old compared to nearly 40% of those 8-15 years old (P < 0.001), while anti-CBir1 was more frequent in the younger children (66% versus 54%, P < 0.05). Anti-CBir1 detected a significant number of children in both age groups who otherwise were serologically negative. Both age at diagnosis and site of CD involvement were independently associated with expression of ASCA and anti-CBir1. CONCLUSIONS Compared to children 8-15 years of age at diagnosis, those 0-7 years are more likely to express anti-CBir1 but only half as likely to express ASCA. These age-associated differences in antimicrobial seropositivity suggest that there may be different, and as yet unrecognized, genetic, immunologic, and/or microbial factors leading to CD in the youngest children.
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Affiliation(s)
- James Markowitz
- Division of Pediatric Gastroenterology, North Shore - LIJ Health System, New Hyde Park, NY, USA, Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA
| | - Subra Kugathasan
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Wisconsin Pediatric IBD Research Group, Milwaukee, WI, USA, Emory University, Atlanta GA
| | - Marla Dubinsky
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ling Mei
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Wallace Crandall
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Nationwide Children’s Hospital, Columbus, OH
| | - Neal LeLeiko
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Hasbro Children’s Hospital, Providence, RI
| | - Maria Oliva-Hemker
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joel Rosh
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Morristown Memorial Hospital, Morristown, NJ
| | - Jonathan Evans
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Nemours Children’s Clinic, Jacksonville, FL
| | - David Mack
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Children’s Hospital of Eastern Ontario, Ottawa, Ontario
| | - Anthony Otley
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, IWK Grace Health Centre, Halifax, Nova Scotia
| | - Marian Pfefferkorn
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Riley Children’s Hospital, Indianapolis, IN
| | - Ron Bahar
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eric Vasiliauskas
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ghassan Wahbeh
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Seattle Children’s Hospital, Seattle, WA
| | - Gary Silber
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Phoenix Children’s Hospital, Phoenix, AZ
| | - J. Antonio Quiros
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, California Pacific Hospital, San Francisco, CA
| | - Iwona Wrobel
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Alberta Children’s Hospital, Calgary, Canada
| | - Justin Nebel
- Wisconsin Pediatric IBD Research Group, Milwaukee, WI, USA, Medical College of Wisconsin, Milwaukee, WI
| | - Carol Landers
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Yoanna Picornell
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephan Targan
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Trudy Lerer
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Connecticut Children’s Medical Center, Hartford, CT
| | - Jeffrey Hyams
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Connecticut Children’s Medical Center, Hartford, CT
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Antonio Quiros J, Van Dam J, Longacre T, Banerjee S. Gastric pyogenic granuloma. Gastroenterol Hepatol (N Y) 2007; 3:850-854. [PMID: 21960796 PMCID: PMC3104146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
| | | | - Teri Longacre
- Department of Pathology, Stanford University School of Medicine, Stanford, California
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Abstract
A 10-year-old patient with known coccidioidomycosis relapsed and had dysrrhythmias and a right atrial mass. Histopathology and culture after surgical removal revealed that this was a vegetative mass infected with Coccidioides spp. We believe that this is the first case of coccidioidal endocarditis to be reported.
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Affiliation(s)
- William V La Via
- Division of Infectious Diseases, Childrens Hospital at Los Angeles, Los Angeles, CA, USA
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Abstract
Liver disease is the second most common cause of death in patients with cystic fibrosis (CF). Improvement in surgical techniques, medical management, and imaging modalities has broadened the range of options for treatment of these patients. Medical management with ursodeoxycholic acid and nutritional support may help decelerate the progression of liver disease. A timely evaluation of CF patients with liver involvement for transplantation is important. Such evaluation should not be delayed until signs of hepatic decompensation occur. Combined lung-liver transplant can be considered for patients with advanced pulmonary disease. Pretransplant management of portal hypertension with a portosystemic shunt procedure is an option for patients with well-preserved synthetic liver function. Improvement in lung function after liver transplantation and no significant risk of pulmonary infection with immunosuppressive therapy have been reported. Review of individual center experiences have shown satisfactory survival and improved quality of life for CF patients undergoing liver transplant.
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Affiliation(s)
- Y S Genyk
- Division of Pediatric Gastroenterology and Pediatric Liver Transplant Program, Childrens Hospital Los Angeles, University of Southern California, Los Angeles, California 90027, USA.
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24
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Quiros JA. Managed care: our self-inflicted illness and how to eradicate it. Arch Intern Med 1998; 158:2067. [PMID: 9778209 DOI: 10.1001/archinte.158.18.2067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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