Emerging new clinical patterns in the presentation of celiac disease

OBJECTIVE

To evaluate changes in the clinical presentation of celiac disease in southeastern Wisconsin.

DESIGN

Retrospective medical record review.

SETTING

Clinical specialty practice in pediatric gastroenterology. Patients The medical records of all patients diagnosed with celiac disease at the Children's Hospital of Wisconsin between 1986 and 2003 were reviewed. Data extracted from the medical records included year of diagnosis, demographics, indications for endoscopy and biopsy, signs, symptoms, and laboratory data. Biopsy specimens were read by the pediatric pathologist and graded according to the Marsh criteria. Main Exposure Date of initial diagnosis of celiac disease.

MAIN OUTCOME MEASURES

Presenting symptoms of patients with newly diagnosed celiac disease.

RESULTS

One hundred forty-three patients were diagnosed with celiac disease. The number of patients diagnosed with celiac disease increased from 1 in 1986 to 93 in 2003. The mean age at diagnosis increased from 5.32 years for patients diagnosed before 1995 to 8.70 years for patients diagnosed after 1995. Gastrointestinal symptoms dominated in children younger than 3 years, whereas in children older than 3 years, the majority presented with non-gastrointestinal indications. The percentage of patients presenting with gastrointestinal symptoms alone decreased during the study period; 11.2% of patients diagnosed with celiac disease were overweight (body mass index > 90).

CONCLUSIONS

Our study provides a unique longitudinal follow-up of clinical practice over a 17-year period. Currently, patients with celiac disease usually do not present with classic symptoms; they are more likely to be asymptomatic school-aged children who belong to a high-risk group.

Society of pediatric liver transplantation: Current registry status 2011-2018

BACKGROUND

SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies.

OBJECTIVE

To report the outcomes of the SPLIT registry from 2011 to 2018.

METHODS

This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period.

RESULTS

A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.

The Consensus from the Mycobacterium avium ssp. paratuberculosis (MAP) Conference 2017

On March 24 and 25, 2017 researchers and clinicians from around the world met at Temple University in Philadelphia to discuss the current knowledge of Mycobacterium avium ssp. paratuberculosis (MAP) and its relationship to human disease. The conference was held because of shared concern that MAP is a zoonotic bacterium that poses a threat not only to animal health but also human health. In order to further study this problem, the conferees discussed ways to improve MAP diagnostic tests and discussed potential future anti-MAP clinical trials. The conference proceedings may be viewed on the www.Humanpara.org website. A summary of the salient work in this field is followed by recommendations from a majority of the conferees.

Childhood obesity: knowledge, attitudes, and practices of European pediatric care providers

OBJECTIVE

To determine and compare attitudes, skills, and practices in childhood obesity management in 4 European countries with different obesity prevalence, health care systems, and economic situations.

METHODS

A cross-sectional survey was distributed to primary health care providers from France, Italy, Poland, and Ukraine. The questionnaire was returned by 1119 participants with a response rate of 32.4%.

RESULTS

The study revealed that most of the primary health care providers were convinced of their critical role in obesity management but did not feel sufficiently competent to perform effectively. The adherence to recommended practices such as routine weight and height measurements, BMI calculation, and plotting growth parameters on recommended growth charts was poor. Most primary health care providers recognized the need for continuing professional education in obesity management, stressing the importance of appropriate dietary counseling.

CONCLUSIONS

The study underlines insufficient implementation of national guidelines for management of obesity regardless of the country and its health system. It also makes clear that the critical problem is not elaboration of guidelines but rather creating support systems for implementation of the medical standards among the primary care practitioners.

New approaches to the autosomal recessive polycystic kidney disease patient with dual kidney-liver complications

Improved neonatal medical care and renal replacement technology have improved the long-term survival of patients with ARPKD. Ten-yr survival of those surviving the first year of life is reported to be 82% and is continuing to improve further. However, despite increases in overall survival and improved treatment of systemic hypertension and other complications of their renal disease, nearly 50% of survivors will develop ESRD within the first decade of life. In addition to renal pathology, patients with ARPKD develop ductal plate malformations with cystic dilation of intra- and extrahepatic bile ducts resulting in CHF and Caroli syndrome. Many patients with CHF will develop portal hypertension with resulting esophageal varices, splenomegaly, hypersplenism, protein losing enteropathy, and gastrointestinal bleeding. Management of portal hypertension may require EBL of esophageal varices or porto-systemic shunting. Complications of hepatic involvement can include ascending cholangitis, cholestasis with malabsorption of fat-soluble vitamins, and rarely benign or malignant liver tumors. Patients with ARPKD who eventually reach ESRD, and ultimately require kidney transplantation, present a unique set of complications related to their underlying hepato-biliary disease. In this review, we focus on new approaches to these challenging patients, including the indications for liver transplantation in ARPKD patients with severe chronic kidney disease awaiting kidney transplant. While survival in patients with ARPKD and isolated kidney transplant is comparable to that of age-matched pediatric patients who have received kidney transplants due to other primary renal diseases, 64-80% of the mortality occurring in ARPKD kidney transplant patients is attributed to cholangitis/sepsis, which is related to their hepato-biliary disease. Recent data demonstrate that surgical mortality among pediatric liver transplant recipients is decreased to <10% at one yr. The immunosuppressive regimen used for kidney transplant recipients is adequate for most liver transplant recipients. We therefore suggest that in a select group of ARPKD patients with recurrent cholangitis or complications of portal hypertension, combined liver-kidney transplant is a viable option. Although further study is necessary to confirm our approach, we believe that combined liver-kidney transplantation can potentially decrease overall mortality and morbidity in carefully selected ARPKD patients with ESRD and clinically significant CHF.

Identifying youth nonadherence in clinical settings: data-based recommendations for children and adolescents with inflammatory bowel disease

BACKGROUND

To examine the validity of patient self-report of thiopurine adherence in pediatric inflammatory bowel disease (IBD) against an objective electronic monitoring adherence measure, and to investigate the role of youth and maternal involvement in remembering to take daily medications as predictors of medication adherence.

METHODS

Fifty-one youths with IBD, ages 11-18 years, participated. Youths completed questionnaire assessments of their own and their maternal caregiver's involvement in remembering to take daily medications at baseline, completed monthly interviews assessing thiopurine adherence over the past week for a period of 6 months, and utilized a Medication Events Monitoring System (MEMS) electronic monitor for their thiopurine medication for 6 months. Participants were grouped into adherent (at least 80% of doses taken based on objective MEMS caps) or nonadherent for analyses.

RESULTS

Youths who were nonadherent based on electronic monitoring overestimated their adherence by 23%, whereas adherent youths overestimated their adherence by only 2%, and as such patient self-report offered little utility in identifying youths who were nonadherent. Youths who reported high levels of involvement in remembering to take their medications were nearly eight times less likely to be nonadherent.

CONCLUSIONS

The current findings provide evidence that clinicians who work with children and adolescents with IBD may benefit from modifying their approach to nonadherence screening. Asking about youth involvement in remembering daily medications may be more informative than asking them to recall their medication-taking behavior over the last week in identifying those at highest risk for nonadherence.

Resolution of Crohn's disease and complex regional pain syndrome following treatment of paratuberculosis

A cohort of family members with various chronic diseases including Crohn's disease, asthma, complex regional pain syndrome, hypothyroidism, type 1 diabetes mellitus, and lymphangiomatosis and/or evidence of infection by Mycobacterium avium subsp. paratuberculosis (MAP) are described in this series of case reports. MAP was cultured from the blood of three members affected by the first five diseases and there was accompanying elevated anti-MAP IgG in two members. The patient affected by the sixth disease has a markedly elevated anti-MAP titer. The two patients affected by the first four diseases have been treated with a combination of anti-MAP antibiotics and ultraviolet blood irradiation therapy with resolution of the disease symptomatology and inability to culture MAP in post treatment blood samples. These case reports of patients with MAP infections provide supportive evidence of a pathogenic role of MAP in humans.

Ten-year secular trend of overweight and obesity in school children in south-eastern Poland

OBJECTIVE

To examine the trend in prevalence of overweight and obesity in schoolchildren from south-eastern Poland over a 10-year period.

MATERIALS AND METHOD

A cross-sectional study was conducted in randomly selected primary schools. In total, 4,248 children (2,182 boys and 2,066 girls), mean age 10.5±2.4 years, were examined in 1998, and 2,412 children (1,184 boys and 1,228 girls), mean age 10.5±2.3 years in 2008. In each school the entire population was studied.

RESULTS

In 2008, the prevalence of overweight in girls was 13.3% and obesity 7.7%, compared to 12.0% and 10.1% in 1998. The decrease in obesity prevalence was statistically significant. In boys, the prevalence of overweight in 2008 was 14.2% and obesity 6.4%, compared to 10.5% and 6.8% in 1998. The increase in overweight prevalence among boys was statistically significant.

CONCLUSIONS

A trend toward stabilization of the prevalence of overweight and obesity was noted in school children from south-eastern Poland between 1998-2008. The declining prevalence of obesity in girls and increased prevalence of overweight in boys demonstrates that in this age group of children the secular trend is gender dependent.

Biliary dyskinesia in pediatrics

Biliary dyskinesia is a potential cause for acalculous biliary colic in pediatric patients. A triad of symptoms and signs, consisting of abdominal pain (with or without associated nausea or fatty food intolerance), absence of gallstones, and an abnormally low cholecystokinin-stimulated gallbladder ejection fraction is used to diagnose the disorder. In several small pediatric case series, cholecystectomy resulted in symptomatic improvement in a majority of patients with biliary dyskinesia. However, the diagnosis of biliary dyskinesia and appropriate management remain controversial. This review discusses the purported pathophysiology of biliary dyskinesia and the data available regarding diagnosis and treatment of this entity in the pediatric population.

Prevalence of glucose intolerance in school age children. Population based cross-sectional study

AIM

The aim of the study was to determine the prevalence of glucose intolerance among school children in south-eastern Poland.

METHODS

Schools were randomly selected in the area and the entire school population was studied. We examined 1083 children (510 boys and 573 girls) in the mean age 14.49 years (age range: 7.9-19 years). Their weight and height were measured and body mass index (BMI) was calculated. Patients were classified as overweight or obese based on International Obesity Task Force (IOTF) criteria. We tested fasting glucose level in randomly selected children with normal weight (N=83) in all overweight and obese subjects (N=229). In children with fasting blood glucose level higher than 5.5 mmol/L (100 mg/dL) oral glucose tolerance test (OGTT) was performed.

RESULTS

About 17.8% of children were overweight and 4.6% obese. Fasting hyperglycemia was found in 16.7% obese children. The calculated prevalence of fasting hyperglycemia for entire population was 6.7/1000. Impaired glucose tolerance (IGT) was found only in obese children. The prevalence of glucose intolerance in obese children was 7.1%, in contrast the calculated prevalence of glucose intolerance for the entire population was 3.0/1000 (95% confidence interval: 0-8.4/1000).

CONCLUSION

Despite relatively high number of obese children, the prevalence of IGT among schoolchildren of south-eastern Poland remains low.

Liver failure and x-linked immunodeficiency type 47

Patients with defects in the ATP6AP1 gene have rarely been described. ATP6AP1-related disorders are a subtype of CDG, which result in enzyme deficiencies affecting multiple organ systems ranging from mild to life-threatening. Of the 13 patients described, all had hepatopathy, but this is the first case to be successfully transplanted. We describe two brothers who developed hyperbilirubinemia shortly after birth and progressed to liver failure, case 1 by 12 months of age, with successful transplant 2 years later, and case 2 by 4 months of age, who passed away while awaiting liver transplant. Both boys were found to have a new variant in the ATP6AP1 gene: c.932/p.Leu311Gln. Although the identified ATP6AP1 gene variant was classified as unknown significance at the time, both children's phenotypes fit with what has been described for ATP6AP1-related disorders. Therefore, this result appears to have been diagnostic for both boys. This rare type of CDG, X-linked immunodeficiency type 47 (OMIM #300972), particularly in patients who progress to liver failure requiring transplant, should be included on the differential of liver failure in infants and toddlers, and its gene should be added to the diagnostic workup for such cases.

Respiratory syncytial virus and pediatric liver transplant: one center's experience

Respiratory syncytial virus (RSV) is a ubiquitous virus responsible for acute infections of the respiratory tract in patients of all ages. RSV presents significant health risks to immunocompromised patients. Two patients, 1 before a liver transplant and 1 after a liver transplant, died of a severe RSV infection. Because of the high risk of death, we recommend expanding the criteria for palivizumab prophylaxis to 2 types of patients: (1) patients with chronic liver disease or who have received a liver transplant and are 24 months old or less and (2) transplant recipients with underlying pulmonary conditions who are less than 36 months old. Further research is indicated in pediatric solid-organ transplant centers to evaluate the effective management of RSV infection to prevent morbidity.

Allergic enterocolitis and protein-losing enteropathy as the presentations of manganese leak from an ingested disk battery: a case report

Introduction

Disk battery ingestions can lead to serious complications including airway or digestive tract perforation, blood vessel erosions, mediastinitis, and stricture formation.

Case presentation

We report a 20-month-old Caucasian child who developed eosinophilic enterocolitis and subsequent protein-losing enteropathy from manganese that leaked from a lithium disk battery. The disk battery was impacted in her esophagus for 10 days resulting in battery corrosion. We postulate that this patient's symptoms were due to a manganese leak from the 'retained' disk battery; this resulted in an allergic response in her gut and protein-losing enteropathy. Her symptoms improved gradually over the next 2 weeks with conservative management.

Conclusion

This is the first case report to highlight the potential complication of allergic enterocolitis and protein-losing enteropathy secondary to ingested manganese. Clinicians should be vigilant about this rare complication in managing patients with disk battery ingestions.

Quality improvement project to improve vaccinations in the pediatric liver transplant population

OBJECTIVES

A quality improvement approach was used to increase pediatric liver transplant recipient live and inactive vaccination rates by assessing titers and recommending vaccinations.

METHODS

A new screening and immunization process for both live and inactive vaccines was discussed with families at their annual visit. Antibody titers for varicella, measles, mumps, rubella, Haemophilus influenzae type B, hepatitis A, and hepatitis B were obtained. Specific criteria were developed for live virus vaccination candidacy. Vaccines were recommended based on patient titers and vaccination candidacy criteria. Surveillance for adverse effects to live vaccines was performed. Repeat titers were obtained approximately 1-month post-vaccine administration.

RESULTS

After PDSA cycle 1, 99% (71/72) of pediatric liver transplant patients had titers obtained. Live vaccines were recommended for 32 patients and 16 (50%) were vaccinated. Inactive vaccines were recommended to 64 patients, and 31 (48%) were vaccinated. Eight of 13 (62%) patients with follow-up titers achieved immunity for inactive vaccines. Zero patients had an adverse reaction to any live vaccine. Ten of 12 (83%) patients with follow-up titers achieved immunity from live vaccines. The most common barriers to receive live vaccines included not scheduling appointment with primary care provider (n = 3) and "non-vaccinators" (n = 3).

CONCLUSIONS

Administering live and inactive vaccines to select pediatric liver transplant patients appears to be safe and effective in our studied population. For PDSA cycle 2, we will continue our current practice and consider offering vaccines in transplant clinic, since this was a barrier to vaccination identified during PDSA cycle 1.

Does High-Intensity Exercise Cause Acute Liver Injury in Patients with Fontan Circulation? A Prospective Pilot Study

The Fontan procedure results in chronic hepatic congestion and Fontan-associated liver disease (FALD) characterized by progressive liver fibrosis and cirrhosis. Exercise is recommended in this population, but may accelerate the progression of FALD from abrupt elevations in central venous pressure. The aim of this study was to assess if acute liver injury occurs after high-intensity exercise in patients with Fontan physiology. Ten patients were enrolled. Nine had normal systolic ventricular function and one had an ejection fraction < 40%. During cardiopulmonary exercise testing, patients had near-infrared spectroscopy (NIRS) to measure oxygen saturation of multiple organs, including the liver, and underwent pre- and post-exercise testing with liver elastography, laboratory markers, and cytokines to assess liver injury. The hepatic and renal NIRS showed a statistically significant decrease in oxygenation during exercise, and the hepatic NIRS had the slowest recovery compared to renal, cerebral, and peripheral muscle NIRS. A clinically significant increase in shear wave velocity occurred after exercise testing only in the one patient with systolic dysfunction. There was a statistically significant, albeit trivial, increase in ALT and GGT after exercise. Fibrogenic cytokines traditionally associated with FALD did not increase significantly in our cohort; however, pro-inflammatory cytokines that predispose to fibrogenesis did significantly rise during exercise. Although patients with Fontan circulation demonstrated a significant reduction in hepatic tissue oxygenation based on NIRS saturations during exercise, there was no clinical evidence of acute increase in liver congestion or acute liver injury following high-intensity exercise.

Risk factors for obesity development in school children from south-eastern Poland

The aim of the study was to determine socio-economic and parental factors affecting odds for development of obesity in school-age children from south-eastern Poland (SEP). 2,182 boys and 2,066 girls from randomly selected elementary schools in SEP were involved in this study. The mean age of the girls was 10.4 years (SD 2.4, range 6.7-14.9). The mean age of the boys was 10.5 years (SD 2.3, range 6.9-14.9). 167 boys (7.7 % , 95 % CI : 6.6-8.8 %) and 208 girls (10.1 % , 95 % CI : 8.8-11.4 %) were obese. The difference in prevalence of obesity between genders was statistically significant. Socioeconomic risk factors (RF) were different from those in Western Europe or the United States. A small number of siblings was RF for obesity. Intact family had a protective effect. No correlation was found between child's obesity and parental education, income per capita or mother working outside the home. Parental obesity was RF for the obesity in children. High BMI at birth was an RF for obesity. A distinct pattern of socio-economic RF underlines the importance of population specific epidemiological studies. Defining RF in a specific region provides information to design specific preventive strategies.