Increased Risk of Celiac Disease in Patients with Uveitis

PURPOSE

To examine whether patients with non-infectious uveitis (NIU) are at increased risk for celiac disease (CeD).

METHODS

Celiac antibody testing was completed in 112 patients. The control group included patients who had undergone upper endoscopy for suspicion of CeD.

RESULTS

2/112 (1.79%) of patients with NIU had positive anti-tTG serology and CeD was confirmed in both patients. When compared to the expected risk of CeD in the general Israeli population of 0.31%, this corresponded to an odds ratio of 5.77 (95% CI 1.4118 to 23.4737, P = 0.049). Three additional patients had positive serology for CeD but the diagnosis was not confirmed.

CONCLUSIONS

An increased risk of CeD was detected in patients with NIU. We therefore recommend screening for CeD in NIU patients. Larger prospective studies are required to further validate these results.

Sleep disorders in children with celiac disease: a prospective study

STUDY OBJECTIVES

Celiac disease (CD), an immune-mediated enteropathy, has a clinical spectrum that is remarkably wide and includes neuropsychiatric manifestations. While studies of adults have shown sleep disturbances, there is limited data in children. Our objectives were to assess the association between sleep disturbances and CD in children, and the effect of a gluten-free diet.

METHODS

Parents of children 3-12 years old referred for endoscopy completed the Sleep Disturbance Scale for Children and modified Epworth Sleepiness Scale. Children with CD were compared with healthy controls and children with abdominal pain but no definitive findings on investigation. Parents of children with CD and abdominal pain were contacted after 6 months for follow-up.

RESULTS

We enrolled 101 patients, mean age 6.5 (2.8), 51% female, 38 with CD, 18 abdominal pain, and 45 healthy. Sleep Disturbance Scale for Children scores were 37.4 (8.7), 41.3 (11.3), and 45.4 (13.7) in healthy controls, CD, and abdominal pain, respectively (P = .024). There was a significant difference in the disorders of arousal domain (P = .044). There were no significant differences on the modified Epworth Sleepiness Scale. A trend toward improvement in Sleep Disturbance Scale for Children scores was seen in children with CD presenting with abdominal pain after 6 months on a gluten-free diet (P = .07).

CONCLUSIONS

In this first prospective study of sleep disturbances in children with CD, we show high rates of disturbed sleep compared with healthy children. Sleep disturbances did not improve on a gluten-free diet and may be driven by abdominal pain.

CITATION

Reiter J, Abuelhija H, Slae M, et al. Sleep disorders in children with celiac disease: a prospective study. J Clin Sleep Med. 2023;19(3):591-594.

Endoscopic versus fluoroscopic esophageal dilatations in children with esophageal strictures: 10-year experience

Esophageal strictures in children may cause dysphagia, choking during feeds, and failure to thrive. They can be treated by balloon dilatations, either under endoscopic or fluoroscopic guidance; there is no literature comparing the methods. Retrospective review of the medical records of children (0-18 years) who were treated with balloon dilatations between 2010 and 2020. The primary outcome was the number of dilatation sessions required until clinical success after 3 months. Secondary outcomes were long-term success at 12 months, and complications of bleeding and perforation. Forty-six patients underwent 174 dilatation sessions. Success rates in the endoscopy and fluoroscopy groups were similar: 62% versus 67% (p = 0.454) at 3 months and 57% versus 67% (p = 0.721) at 12 months. Complication rate was lower in the endoscopy group (0% vs. 15%, p < 0.001). Both endoscopic and radiologic-guided balloon dilatations were shown to be equally effective, but endoscopic guidance had fewer complications.

Tumor necrosis factor-α inhibitor-induced follicular psoriasiform eruption

Tumor necrosis factor-α inhibitor-associated adverse cutaneous reactions are common in patients with inflammatory bowel disease. Infection-related dermatoses and psoriasiform eruptions are seen most frequently. We describe a follicular psoriasiform eruption that appeared during treatment with infliximab in two adolescents with Crohn's disease.

Efficacy and Outcomes of Faecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection in Children with Inflammatory Bowel Disease

BACKGROUND

Children with inflammatory bowel disease [IBD] are disproportionally affected by recurrent Clostridioides difficile infection [rCDI]. Although faecal microbiota transplantation [FMT] has been used with good efficacy in adults with IBD, little is known about outcomes associated with FMT in paediatric IBD.

METHODS

We performed a retrospective review of FMT at 20 paediatric centres in the USA from March 2012 to March 2020. Children with and without IBD were compared with determined differences in the efficacy of FMT for rCDI. In addition, children with IBD with and without a successful outcome were compared with determined predictors of success. Safety data and IBD-specific outcomes were obtained.

RESULTS

A total of 396 paediatric patients, including 148 with IBD, were included. Children with IBD were no less likely to have a successful first FMT then the non-IBD affected cohort [76% vs 81%, p = 0.17]. Among children with IBD, patients were more likely to have a successful FMT if they received FMT with fresh stool [p = 0.03], were without diarrhoea prior to FMT [p = 0.03], or had a shorter time from rCDI diagnosis until FMT [p = 0.04]. Children with a failed FMT were more likely to have clinically active IBD post-FMT [p = 0.002] and 19 [13%] patients had an IBD-related hospitalisation in the 3-month follow-up.

CONCLUSIONS

Based on the findings from this large US multicentre cohort, the efficacy of FMT for the treatment of rCDI did not differ in children with IBD. Failed FMT among children with IBD was possibly related to the presence of clinically active IBD.

Evaluation of gastrointestinal symptoms in pediatric patients post hematopoietic stem cell transplantation: Ileo-colonoscopy versus sigmoidoscopy. A single-center experience and review of literature

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a curative therapy used to treat high-risk hematological malignant disorders and other life-threatening nonmalignant diseases. Gastrointestinal (GI) symptoms post-HSCT might be due to GI graft-versus-host disease (GVHD) or GI infections or both. GI endoscopy with biopsies is safe and beneficial in guiding the management of GI symptoms in children after HSCT, justifying the therapeutic management and contributing to improved outcomes.

METHODS

A retrospective cohort study including 16 children with malignant and nonmalignant diseases that underwent allogeneic HSCT who had 24 ileo-colonoscopies performed for GI symptoms. To facilitate an evidence-based approach to the endoscopic evaluation of GI symptoms in pediatric patients post HSCT, we examined whether a full ileo-colonoscopy, which includes right colon and terminal ileum (TI), as opposed to a limited sigmoidoscopy, was more accurate in the evaluation of GI symptoms in pediatric patients post HSCT.

RESULTS

Specific findings on the right colon/TI were found in nine out of 24 ileo-colonoscopies (38%, CI = 19%-59%). The macroscopic findings on ileo-colonoscopy were compared with the histopathologic findings. When macroscopic findings were present, there were matching histopathologic findings in 100% of cases. However, even in the absence of any macroscopic findings on ileo-colonoscopy, there were histopathological findings in 29% of the cases (p-value = .016).

CONCLUSIONS

This cohort favors ileo-colonoscopy over sigmoidoscopy, with systematic biopsy sampling, in evaluating GI symptoms in pediatric patients post HSCT.

The Relationship Between Self-Compassion, Concern for Others, and Parental Burnout in Child's Chronic Care Management

Objectives

Parental burnout is a construct that reflects the exhaustion and emotional distancing of parents from their children due to the growing demands of caring for them. Research has pointed to a heightened risk for parental burnout among parents of children with special needs. Additional research has indicated that parents' personality traits and relational dynamics serve as resiliency factors regarding parental burnout.

Methods

In the present study, 91 primary parental caregivers of children receiving ongoing treatment at a pediatric ambulatory care unit were recruited. A theoretical model proposing the specific ways in which self-compassion and concern for others complement each other in predicting parental burnout was examined. In this model, the relationships between self-compassion, concern for others, and burnout respectively are mediated by different basic psychological needs, detailed in self-determination theory. Participants completed various questionnaires measuring these constructs. Regression and mediation analyses were used to examine our hypotheses.

Results

Results indicated that self-compassion and concern for others predicted levels of parental burnout. The covariance between concern for others and burnout was mediated by the psychological need of relatedness.

Conclusions

The findings support the extension of a three-layered conceptual model of (a) self-compassion and concern for others, (b) psychological needs, and (c) burnout. The present study highlights self-compassion and concern for others as potential resilience factors regarding the risk of burnout in parental caregiving. These findings point to promising avenues for burnout prevention and preemptive facilitation of parental caregiving.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-021-01752-z.

Chronic demodicosis in patients with immune dysregulation: An unexpected infectious manifestation of Signal transducer and activator of transcription (STAT)1 gain-of-function

Signal transducer and activator of transcription (STAT)1 heterozygous gain-of-function (GOF) mutations are known to induce immune dysregulation and chronic mucocutaneous candidiasis (CMCC). Previous reports suggest an association between demodicosis and STAT1 GOF. However, immune characterization of these patients is lacking. Here, we present a retrospective analysis of patients with immune dysregulation and STAT1 GOF who presented with facial and ocular demodicosis. In-depth immune phenotyping and functional studies were used to characterize the patients. We identified five patients (three males) from two non-consanguineous Jewish families. The mean age at presentation was 11.11 (range = 0.58-24) years. Clinical presentation included CMCC, chronic demodicosis and immune dysregulation in all patients. Whole-exome and Sanger sequencing revealed a novel heterozygous c.1386C>A; p.S462R STAT1 GOF mutation in four of the five patients. Immunophenotyping demonstrated increased phosphorylated signal transducer and activator of transcription in response to interferon-α stimuli in all patients. The patients also exhibited decreased T cell proliferation capacity and low counts of interleukin-17-producing T cells, as well as low forkhead box protein 3⁺ regulatory T cells. Specific antibody deficiency was noted in one patient. Treatment for demodicosis included topical ivermectin and metronidazole. Demodicosis may indicate an underlying primary immune deficiency and can be found in patients with STAT1 GOF. Thus, the management of patients with chronic demodicosis should include an immunogenetic evaluation.

Hijab Pin Ingestions

OBJECTIVES

To characterize the clinical manifestations, outcomes, and complications of hijab pin ingestion in adolescents and to identify risk factors for a need for intervention.

METHODS

A retrospective review of patients <25 years of age who presented to our emergency department because of hijab pin ingestion between 2007 and 2018. Comparison was performed between impaled and nonimpaled pins.

RESULTS

We reviewed 1558 foreign-body ingestion cases. Of these, 208 (13.3%) patients presented because of hijab pin ingestion, with a total of 225 ingested pins. The mean patient age was 14.7 ± 4.1 years, and 88% of patients were girls. Time from ingestion to presentation was 24 ± 49.5 hours. Most pins were located in the stomach (46.6%), and 18.6% of all pins were impaled. Location in the stomach (odds ratio = 4.3 [95% confidence interval: 1.9-9.2]; P < .001) and abdominal tenderness on examination (odds ratio = 2.7 [95% confidence interval: 1.3-5.6]; P = .007) were strong independent risk factors for an impaled pin. Time to intervention was 22.9 hours, and 41 endoscopies were performed. One patient required laparoscopic surgery. No complications were observed.

CONCLUSIONS

The hijab pin is an increasingly encountered foreign body in pediatric practice. Its specific clinical features distinguish it from other sharp objects. A delayed interventional approach in selected patients does not carry a higher risk of complications and results in significantly fewer interventions compared to existing guidelines. These findings will help guide pediatric specialists in this prevalent clinical scenario. Management recommendations are proposed.

Efficacy of Fecal Microbiota Transplantation for Clostridium difficile Infection in Children

BACKGROUND & AIMS

Fecal microbiota transplantation (FMT) is commonly used to treat Clostridium difficile infection (CDI). CDI is an increasing cause of diarrheal illness in pediatric patients, but the effects of FMT have not been well studied in children. We performed a multi-center retrospective cohort study of pediatric and young adult patients to evaluate the efficacy, safety, and factors associated with a successful FMT for the treatment of CDI.

METHODS

We performed a retrospective study of 372 patients, 11 months to 23 years old, who underwent FMT at 18 pediatric centers, from February 1, 2004, to February 28, 2017; 2-month outcome data were available from 335 patients. Successful FMT was defined as no recurrence of CDI in the 2 months following FMT. We performed stepwise logistic regression to identify factors associated with successful FMT.

RESULTS

Of 335 patients who underwent FMT and were followed for 2 months or more, 271 (81%) had a successful outcome following a single FMT and 86.6% had a successful outcome following a first or repeated FMT. Patients who received FMT with fresh donor stool (odds ratio [OR], 2.66; 95% CI, 1.39-5.08), underwent FMT via colonoscopy (OR, 2.41; 95% CI, 1.26-4.61), did not have a feeding tube (OR, 2.08; 95% CI, 1.05-4.11), or had 1 less episode of CDI before FMT (OR, 1.20; 95% CI, 1.04-1.39) had increased odds for successful FMT. Seventeen patients (4.7%) had a severe adverse event during the 3-month follow-up period, including 10 hospitalizations.

CONCLUSIONS

Based on the findings from a large multi-center retrospective cohort, FMT is effective and safe for the treatment of CDI in children and young adults. Further studies are required to optimize the timing and method of FMT for pediatric patients-factors associated with success differ from those of adult patients.

Moderate lead exposure elicits neurotrophic effects in cerebral cortical precursor cells in culture

Lead (Pb) persists as an environmental toxicant despite aggressive environmental and occupational regulation. Neurotoxicological effects of acute Pb poisoning range from subtle cognitive deficits, to clumsiness and ataxia, to coma and seizures. In adult neurotoxicity, reductions of blood Pb levels are often associated with reversal of clinical signs. In children, however, the effects are more likely to endure, with even low levels of chronic Pb exposure correlating with decreasing IQ. These persistent effects likely result from neurodevelopmental insults, such as altered cell survival or maturation, although the mechanisms have not been fully defined. In the present study we define the effects of moderate-level Pb exposure on mammalian neurogenesis using a well-characterized cortical precursor model. Gestational day 14.5 rat cerebral cortical precursor cells were cultured in defined media and cell number, precursor proliferation, apoptosis, and neuritic process outgrowth were assessed following exposure to a range of Pb acetate concentrations. Surprisingly, whereas a concentration of 30 microg/ml Pb acetate was acutely toxic to neurons, concentrations between 1 and 10 microg/ml Pb acetate (approximately 3 microM and 30 microM Pb, respectively) increased cell number: 10 times as many cells exposed to 10 microg/ml Pb were present on day 4 as compared to control. The increase in cell number was not a result of increased proliferation, however, as DNA synthesis did not increase. Rather, Pb exposure maintained the survival of cortical precursors, as the progressive apoptosis occurring under control conditions was markedly reduced by the metal. Additionally, neuritic process initiation and outgrowth increased in a concentration-dependent manner, with processes four times as abundant on day 1 and twice as long on day 2. These results suggest that brief exposure to lead during neurogenesis directly affects cell survival and process development, potentially altering cortical arrangement. Consequently, alterations in neural circuitry may underlie some of the neurological effects of Pb exposure during brain development.