bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinicopathological and Immunohistochemical Study of 14 Cases of Morbihan Disease: An Insight Into Its Pathogenesis
Authors: Ramirez-Bellver Jose L. , Pérez-González Yosmar C. , Chen Ko R. , Díaz-Recuero Jose L. , Requena Luis , Carlson John A. , Llamas-Velasco Mar
Published: September 2019

Introduction:

Morbihan disease (MORD) is rare with only 45 clear-cut cases previously reported. Histopathologic findings are supposed to be nonspecific. We report 14 patients and review the previous cases.

Objectives:

To characterize the clinicopathologic findings, outcomes, and immunophenotype of MORD.

Material and Methods:

Inclusion criteria were a clinical picture of persistent, nonpitting edema affecting the mid and or upper third of the face and histopathological findings fitting previous reports and exclusion of other entities.

Results:

The majority of our patients were males (71.5%) with a male/female ratio of 10/4. The mean age when diagnosed was 58.8 years. Eyelids and forehead were the most frequently involved areas. Two of the patients presented previous rosacea. Most constant histopathological findings were lymphatic vessel dilatations in the upper dermis and the presence of mast cells (7.5 in 10 high-power field as a mean). Mild edema was also present in most of the cases. Granulomas were found in 7 of the cases, and immunostaining with CD68 and CD14 only revealed an additional case.

Conclusions:

MORD occurs more in middle-aged males, not associated with rosacea and mostly affects eyelids and forehead. Granulomas are not mandatory for the diagnosis. Histopathology of MORD fits within the spectrum of localized lymphedema.
Joint and independent neurotoxic effects of early life exposures to a chemical mixture
Authors: Oulhote Youssef , Coull Brent , Bind Marie-Abele , Debes Frodi , Nielsen Flemming , Tamayo Ibon , Weihe Pal , Grandjean Philippe
Published: September 2019

Background:

Exposure to mercury (Hg) is associated with adverse developmental effects. However, Hg occurs with a multitude of chemicals. We assessed the associations of developmental exposure to multiple pollutants with children’s neurodevelopment using a novel approach.

Methods:

Hg, polychlorinated biphenyls (PCBs), and perfluoroalkyl substances (PFASs) were measured in maternal and children’s blood at 5 years (n = 449 and 419). At 7 years, children were administered Boston Naming Test (BNT) and the Strengths and Difficulties Questionnaire (SDQ). We used the G-formula combined with SuperLearner to estimate independent and joint effects of chemicals at both ages. We constructed flexible exposure-response relationships and assessed interactions.

Results:

Most chemicals showed negative relationships with BNT scores. An interquartile range (IQR) increase in maternal Hg and perfluorooctanoic acid (PFOA) was associated with 0.15 standard deviation (SD) (95% confidence interval [CI] = –0.29, –0.03) and 0.14 SD (95% CI = –0.26, –0.05) lower scores in BNT, whereas a joint IQR increase in the mixture of chemicals was associated with 0.48 SD (95% CI = –0.69, –0.25) lower scores in BNT. An IQR increase in PFOA was associated with 0.11 SD (95% CI = 0.02, 0.26) higher total SDQ difficulties scores. Maternal ∑PCBs concentrations were associated with lower SDQ scores (β = –0.09 SD; 95% CI = –0.19, 0), whereas 5 years ∑PCBs showed a negative association (β = –0.09 SD; 95% CI = –0.21, 0). Finally, a joint IQR increase in the mixture was associated with 0.22 SD (95% CI = 0.04, 0.4) higher SDQ scores.

Conclusions:

Using a novel statistical approach, we confirmed associations between prenatal mercury exposure and lower cognitive function. The potential developmental effects of PFASs need additional attention.
Air pollution, neighborhood deprivation, and autism spectrum disorder in the Study to Explore Early Development
Authors: McGuinn Laura A. , Windham Gayle C. , Messer Lynne C. , Di Qian , Schwartz Joel , Croen Lisa A. , Moody Eric J. , Rappold Ana G. , Richardson David B. , Neas Lucas M. , Gammon Marilie D. , Schieve Laura A. , Daniels Julie L.
Published: September 2019

Background:

To examine whether neighborhood deprivation modifies the association between early life air pollution exposure and autism spectrum disorder (ASD), we used resources from a multisite case–control study, the Study to Explore Early Development.

Methods:

Cases were 674 children with confirmed ASD born in 2003–2006; controls were 855 randomly sampled children born during the same time period and residents of the same geographic areas as cases. Air pollution was assessed by roadway proximity and particulate matter <2.5 µm (PM2.5) exposure during pregnancy and first year of life. To characterize neighborhood deprivation, an index was created based on eight census tract-level socioeconomic status-related parameters. The continuous index was categorized into tertiles, representing low, moderate, and high deprivation. Logistic regression was used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs).

Results:

Neighborhood deprivation modified (P
for interaction = 0.08) the association between PM2.5 exposure during the first year of life and ASD, with a stronger association for those living in high (OR = 2.42, 95% CI = 1.20, 4.86) rather than moderate (OR=1.21, 95% CI = 0.67, 2.17) or low (OR=1.46, 95% CI = 0.80, 2.65) deprivation neighborhoods. Departure from additivity or multiplicativity was not observed for roadway proximity or exposures during pregnancy.

Conclusion:

These results provide suggestive evidence of interaction between neighborhood deprivation and PM2.5 exposure during the first year of life in association with ASD.
Injectable contraception: emerging evidence on subcutaneous self-administration
Authors: Lerma Klaira , Goldthwaite Lisa M.
Published: September 2019

Purpose of review

Injectable contraception is a widely available and popular family planning method globally. It has evolved to allow for subcutaneous self-injection (DMPA-SC, Depo medroxyprogesterone acetate-subcutaneous). In this review, we will focus on research evaluating DMPA-SC, with specific regard to continuation rates, safety, and satisfaction among users.

Recent findings

Emerging evidence from the United States, Malawi, Uganda, and Senegal has established safety and higher continuation rates among self-inject users, compared with provider-inject users. Continuation is 10–28% higher among DMPA-SC self-inject users. Self-inject users across studies were highly satisfied and reported DMPA-SC was easy to use. Studies indicate continuation is likely to be attributable to self-administration and user autonomy, rather than inherent properties of the DMPA-SC injection.

DMPA-SC should be made available in high-resource and low-resource settings. Future efforts should be focused on implementation and evaluating how to best add DMPA-SC to the method mix. Cost–benefit analyses will need to evaluate the up-front costs of DMPA-SC for clients, facilities, and health systems compared with the higher continuation rates and saved opportunity-costs over time. Task-shifting strategies and development of mobile phone technologies to assist users in adherence should be considered in future service scale-up.
Antepartum and intrapartum risk factors for neonatal hypoxic–ischemic encephalopathy: a systematic review with meta-analysis
Authors: Rossi A. Cristina , Prefumo Federico
Published: September 2019

Purpose of review

To review literature about risk factors of neonatal hypoxic–ischemic encephalopathy (HIE).

Recent findings

Search in PubMed, MEDLINE, Embase, Clinicaltrials.gov and reference lists from 1999 to 2018. Inclusion criteria: study population composed of neonates who manifested HIE within 28 days from delivery, data reported as proportional rate. Studies were excluded if they included preterm pregnancies, postnatal conditions leading to HIE and/or fetal malformations, focused on a single risk factor, were not in English language. PRISMA guidelines were followed. Interstudies heterogeneity was assessed and a random/fixed models were generated as appropriate. Comparison between neonates with HIE vs. controls was performed by calculating odds ratio–95% confidence interval (OR–95% CI). Differences were significant if 95% CI did not encompass 1. Twelve articles were included. Fetuses with growth restriction (OR: 2.87; 95% CI: 1.77–4.67), nonreassuring cardiotocography (OR: 6.38; 95% CI: 2.56–15.93), emergency cesarean section (OR: 3.69; 95% CI: 2.75–4.96), meconium (OR: 3.76; 95% CI: 2.58–5.46) and chorioamnionitis (OR: 3.46: 95% CI: 2.07–5.79) were at higher risk of developing HIE. Nulliparity, gestational diabetes, hypertension, oligohydramnios, polyhydramnios, male sex, induction of labor, labor augmentation, premature rupture of membrane, and vacuum delivery were not significantly different.

Neonatal HIE has multifactorial origin and its cause is often undetermined and not preventable.

PROSPERO (Registration number: CRD42018106563).
The efficacy of using acupuncture in managing polycystic ovarian syndrome
Authors: Chen Hui , Lim Chi Eung Danforn
Published: September 2019

Purpose of review

Polycystic ovarian syndrome (PCOS) is a common reproductive disorder, which significantly impairs the fertility of 3–10% of women at reproductive age. It is getting very popular for women with PCOS to seek alternative therapies to treat PCOS, for example, acupuncture. This review examines the currently available evidence from the randomized controlled trial to guide future recommendation on using acupuncture to assist the treatment of PCOS.

Recent findings

PCOS is manifested by oligo-amenorrhoea, infertility, and hirsutism. The standard treatment of PCOS includes oral pharmacological agents, lifestyle changes, and surgical modalities. Pharmacologically based therapies are only effective in 60% of the patients, which are also associated with different side-effects. As such, acupuncture offered an alternative option. Acupuncture can affect β-endorphin production, which may, in turn, affect gonadotropin-releasing hormone secretion and affecting ovulation and menstrual cycle. Therefore, it is postulated that acupuncture may induce ovulation and restore menstrual cycle via increasing β-endorphin production.

Although modern medical science has discovered the action mechanisms underlying how acupuncture may manage the symptoms of PCOS, majority of the trials are small in sample size and lack of consistency in the choice of acupoints. Larger scale trials are needed to provide standardized protocols.
The Effect of Progressive Relaxation Exercises on Pain, Fatigue, and Quality of Life in Dialysis Patients
Authors: Kaplan Serin Emine , Ovayolu Nimet , Ovayolu Özlem
Published: September 2019

Patients receiving hemodialysis treatment may experience several symptoms at the same time, such as fatigue and pain. Progressive relaxation exercises (PRE) have been reported to have positive effect on the control of these symptoms. In this study, a randomized, controlled, and experimental study was conducted to examine the effect of PRE on pain, fatigue, and quality of life in hemodialysis patients; the study was carried out with 48 intervention and 48 control patients receiving treatment in the hemodialysis units of 2 hospitals. Data were collected by a questionnaire prepared by the researcher, which included questions about sociodemographic variables and the disease; Piper Fatigue Scale; Visual Analog Scale that measures pain severity; and SF-36 Quality of Life Scale. The results of study revealed that mean total fatigue score and mean pain score decreased in the intervention group after the application of PRE; whereas no change was observed in the control group (P < .05). It was also found that quality of life physical component mean score and mental component mean score increased in the intervention group after the application of PRE (P < .05).
The Effect of Auricular Acupressure and Positive Group Psychotherapy With Motivational Interviewing for Smoking Cessation in Korean Adults
Authors: Lee Eun Jin
Published: September 2019

The aim of this study was to investigate the effects of positive group psychotherapy with auricular acupressure on tobacco withdrawal symptoms and smoking cessation. This study used a randomized controlled trial design. Participants were randomly assigned to 1 of 3 groups: group 1 (counseling and auricular acupressure), group 2 (counseling and placebo acupressure), and the control group (self-help for smoking cessation). Positive group psychotherapy and auricular acupressure were performed once a week for 6 weeks. The smoking cessation rates for 1 year in groups 1 and 2 were higher than that in the control group (9.5%, 15.6%, and 0%, respectively; odd ratio: 7.98,P= .019, n = 109). There was a significant difference of tobacco withdrawal symptoms among the 3 groups over 4 weeks (F= 2.9,P= .04). The mean differences between week 1 and week 4 among the 3 groups were statistically significant (4.7 ± 6.96, 5.18 ± 7.9, and 0.14 ± 7.15,F= 4.25,P= .018).
Effect of Inhalation Aromatherapy on Pain, Anxiety, Comfort, and Cortisol Levels During Trigger Point Injection
Authors: Kasar Kadriye Sayin , Yildirim Yasemin , Senuzun Aykar Fisun , Uyar Meltem , Sagin Ferhan Girgin , Atay Sevcan
Published: September 2019

The objective of this study was to examine the effects of inhaler aromatherapy on the level of pain, comfort, anxiety, and cortisol during trigger point injection in individuals with myofascial pain syndrome. Lavender oil inhalation was found to reduce pain and anxiety during trigger point injection and to improve patient comfort, but it did not affect the saliva cortisol level.
Practices of Exemplary Leaders in Clinical Education: A Qualitative Study of Director and Site Coordinator of Clinical Education Perspectives
Authors: Silberman Nicki , LaFay Vicki , Zeigler Stacey
Published: September 2019

Introduction.

Frequent turnover in director of clinical education (DCE) and site coordinator of clinical education (SCCE) positions may affect excellence in physical therapist (PT) clinical education (CE). Recognized CE leaders have demonstrated longevity and success in these roles. Understanding excellence in CE leadership may enhance delivery of PT CE. The purposes of this qualitative study were to explore characteristics of recognized PT CE leaders and identify the behaviors, thoughts, and actions of successful DCEs and SCCEs with demonstrated longevity.

Methods.

Purposeful sampling was used to identify PTs who have been either a DCE or a SCCE for at least 10 years and were recognized by their peers as a leader in PT CE. An interpretive phenomenological inquiry was conducted to explore the lived experience of CE leaders. Cognitive mapping and unstructured interviews were used to elicit perspectives on the factors that contributed to longevity and success. Using an inductive approach, DCE and SCCE data were analyzed separately. Due to substantial overlap in themes, the DCE and SCCE data were combined. Member checks and a peer review were conducted.

Results.

Seven DCEs and 6 SCCEs from the Northeast United States, with 8–26 (average 17) years in their position, completed the study. Five themes identifying their role success were the following: (1) Professional identity as a bridge between academic and clinical practices, (2) strong work ethic for excellence, (3) build meaningful relationships, (4) “bring-it-on” attitude, and (5) influence.

Discussion and Conclusion.

The participants shared common characteristics as exemplary leaders in CE. The main themes were in remarkable alignment with The 5 Practices of Exemplary Leaders, a well-established leadership model. These findings provide a framework to identify and develop the leadership qualities needed to fulfill these positions. These exemplary practices should be incorporated into leadership training for DCEs and SCCEs.
Begin With the End in Mind: Implementing a Series of Integrated Clinical Experience Courses
Authors: Colgrove Yvonne M. , Rucker Jason
Published: September 2019

Background and Purpose.

The evolving nature of clinical education requires program evaluation to inform intentional curriculum development. However, descriptions of the application of curriculum development frameworks in physical therapy are sparse. We used the context/input/process/product (CIPP) model to guide a didactic and clinical education curriculum reorganization that included the creation of a series of five integrated clinical experience (ICE) courses threaded throughout the first two years of a Doctor of Physical Therapy (DPT) program.

Method/Model Description and Evaluation.

The CIPP model guided comprehensive program evaluation. Context evaluation summarized strengths, weaknesses, opportunities, and threats. Input evaluation of information from multiple stakeholders and external influences, including accreditation standards, practices at other academic institutions, and published literature, was used to guide changes in the clinical education curriculum. Goals, objectives, and themes were developed for intentional alignment of didactic and clinical education curricula, alongside clinical site development and logistical planning. Process evaluation monitored the implementation of the new clinical education program to identify and address problems. The program is currently in the process of detailed product evaluation.

Outcomes.

ICE courses were initially implemented at eight clinical sites. Course assessments were selected and administered at established intervals. Program outcome measures were identified and administered to 2 control cohorts from the original DPT curriculum, and the first cohort in the new DPT curriculum.

Discussion and Conclusion.

The process used a structured approach to curriculum development. It emphasized the necessity of engaging multiple stakeholders, developing strong clinical partnerships, and intentional design and placement of courses within the overall curriculum to ensure the quality of ICE courses.
Massive pulmonary embolism: embolectomy or extracorporeal membrane oxygenation?
Authors: Tahir Usman A. , Carroll Brett , Pinto Duane S.
Published: September 2019

Purpose of review

To highlight updates on the use of extracorporeal membrane oxygenation (ECMO) and surgical embolectomy in the treatment of massive pulmonary embolism.

Recent findings

Outcomes for surgical embolectomy for massive pulmonary embolism have improved in the recent past. More contemporary therapeutic options include catheter embolectomy, which although offer less invasive means of treating this condition, need further study. The use of ECMO as either a bridge or mainstay of treatment in patients with contraindications to fibrinolysis and surgical embolectomy, or have failed initial fibrinolysis, has increased, with data suggesting improved outcomes with earlier implementation in selected patients.

Although surgical embolectomy continues to be the initial treatment of choice in massive pulmonary embolism with contraindications or failed fibrinolysis, the use of ECMO in these high-risk patients provides an important tool in managing this often fatal condition.
Initial management of severe burn injury
Authors: Tejiram Shawn , Romanowski Kathleen S. , Palmieri Tina L.
Published: September 2019

Purpose of review

Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury.

Recent findings

Burn patients have long, complex ICU stays with accompanying multiorgan dysfunction. Recent advances in burn intensive care have focused on acute respiratory distress syndrome from inhalation injury, acute kidney injury (AKI), and transfusion, resulting in new strategies for organ failure, including renal replacement therapy and extracorporeal life support.

Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.
Vitamin C in surgical sepsis
Authors: Anand Tanya , Roller Lauren K. , Jurkovich Gregory J.
Published: September 2019

Purpose of review

The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock.

Recent findings

The antioxidant properties of vitamin C are touted to be useful in modulating the inflammatory response, decreasing vasopressor requirements, and improving resuscitation. Current resuscitation practices are focused on addressing the hemodynamic instability and ensuring adequate oxygen delivery to tissues. The conceptual framework of the use of vitamin C during a resuscitation is to modulate in a beneficial fashion the inflammatory response to sepsis while concomitantly resuscitating and treating the infection. While there is promising animal and burn-related data on improved fluid resuscitation with the use of vitamin C as an adjunct, the most recent meta-analyses of the available data fail to show a survival benefit in sepsis, and concerns regarding nephrotoxicity remain.

Although there are large number of animal studies, only a few small prospective and retrospective studies in humans address the use of vitamin C to treat sepsis. Further research in a controlled and randomized fashion is needed to determine if vitamin C is effective in this role. While there is a promise of ascorbate's addition to the sepsis bundle as an adjunct to resuscitation, the evidence is not conclusive.
Failure to rescue in the surgical patient: a review
Authors: Lafonte Marc , Cai Jenny , Lissauer Matthew E.
Published: September 2019

Purpose of review

Evaluating patient outcomes is essential in a healthcare environment focused on quality. Mortality after surgery has been considered a useful quality metric. More important than mortality rate, failure to rescue (FTR) has emerged as a metric that is important and may be improveable. The purpose of this review is to define FTR, describe patient and hospital level factors that lead to FTR, and highlight possible solutions to this problem.

Recent findings

FTR is defined as a death following a complication. Depending on the patient population, FTR rates vary from less than 1% to over 40%. Numerous patient factors including frailty, congestive heart failure (CHF), renal failure, serum albumin <3.5, COPD, cirrhosis, and higher ASA class may predispose patients to FTR. Hospital factors including technology, teaching status, increased nurse-to-patient ratios, and closed ICUs may help reduce FTR. More difficult to measure variables, such as hospital culture and teamwork may also influence FTR rates. Early warning systems may allow earlier identification of the deteriorating patient.

FTR is a major clinical concern and efforts aimed at optimizing patient and hospital factors, culture and communication, as well as early identification of the deteriorating patient may improve FTR rate.
Acute respiratory failure: nonintubation assist methods for the acutely deteriorating patient
Authors: Frat Jean-Pierre , Marie Damien , Thille Arnaud W.
Published: September 2019

Purpose of review

Noninvasive ventilation is strongly recommended in acute hypercapnic respiratory failure, whereas high-flow nasal oxygen therapy could be an alternative in de novo respiratory failure.

Recent findings

High-flow nasal oxygen may improve the outcome of patients de novo respiratory failure as compared with standard oxygen. Its success within 2 h after initiation is well predicted by a ROX index (ratio of SpO2/FiO2 to respiratory rate) greater than 4.88, as failure when less than 3.85 at 12 h after initiation. However, the superiority of high-flow nasal oxygen to standard oxygen has not been confirmed in immunocompromised patients. Although noninvasive ventilation may be deleterious through barotrauma in patients with de novo respiratory failure, its use seems to be an optimal strategy for preoxygenation before intubation in preventing severe hypoxemia in most hypoxemic patients. In mild hypoxemic patient, high-flow nasal oxygen may be more efficient than bag-valve mask in preventing severe adverse events. After anesthetic induction further positive-pressure ventilation can better secure intubation procedure than absence of ventilation.

Despite the growing use of high-flow nasal oxygen, new studies are needed to confirm its superiority to standard oxygen in de novo respiratory failure and others causes of acute respiratory failure in place of standard oxygen.
Emergency bedside ultrasound-benefits as well as caution: Part 2: Echocardiography
Authors: Godement Mathieu , Malbrain Manu L.N.G. , Vieillard-Baron Antoine
Published: September 2019

Purpose of review

Critical care echocardiography (CCE) has become an important component of general critical care ultrasonography, and a current review of its performance is presented.

Recent findings

Basic CCE should be performed as a goal-directed examination to better identify specific signs and to answer important clinical questions concerning acute hemodynamic concerns. It has evolved in the ICU and also in the emergency department not only for improved diagnostic capability but also as an effective part of the triage process. It remains an efficacious procedure even in patients with respiratory failure when combined with lung ultrasonography. Numerous acronyms were proposed, but in all cases, CCE responds to the same rules as fundamental echocardiography. Basic CCE requires accessible and comprehensive training for physicians and is mandatory for all intensivists. Development of pocket echo devices may increase the use of basic CCE as has miniaturization of other medical technologies. Performance should be managed by guidelines, and the CCE training program should be standardized worldwide. More trials are welcome to evaluate its impact on patient outcomes.

Thanks to its ability to quickly obtain a diagnostic orientation at the bedside and to implement targeted therapy, basic CCE over the past decade has become an essential tool for hemodynamic assessment of the cardiopulmonary unstable patient. Its more recent incorporation into the education of trainees in medical school and residencies/fellowships has reinforced its perceived importance in critical care management, despite the relative paucity as yet of rigorous scientific evidence demonstrating positive outcome modification from its use.
Medications and the larynx
Authors: Harounian Jonathan , Postevka Eugene , Jamal Nausheen
Published: September 2019

Purpose of review

The larynx is a complex organ that houses some of the most intricate structures of the human body. Owing to its delicate nature, the larynx is affected by different medications to varying degrees. Many of these effects manifest in subjective complaints in one's voice or swallow. This review article invokes the present available literature to describe the effects different medical agents have on the functionality of the laryngeal structures.

Recent findings

Multiple available studies explore the effects of inhaled corticosteroids on the larynx. While laryngeal candidiasis is a well known complication of chronic steroid use, other rarer fungal infections have also demonstrated themselves as risks. Among anesthetics, the literature suggests that sevoflurane in standard and high doses does not appear to significantly reduce the risk of laryngospasm. The use of topical and intravenous lidocaine appear to have conflicting evidence regarding their use in laryngospasm prevention, whereas postoperative sore throat, hoarseness, and cough may be prevented with preinduction nebulization of ketamine and magnesium sulfate or budesonide.

Further study is warranted to explore the effects that these and other classes of agents, such as antibiotics, have on the structure and function of the larynx.
Gastric inlet patches: symptomatic or silent?
Authors: Cock Charles , Hamarneh Zaki
Published: September 2019

Purpose of review

The purpose of this review is to assess recent literature on the clinical relevance of the gastric inlet patch with particular focus on endoscopic diagnosis and treatment, the relationship of the inlet patch to laryngopharyngeal reflux disease and the association of proximal esophageal adenocarcinoma with inlet patch.

Recent findings

Recent studies suggest endoscopic diagnosis of inlet patch increases with endoscopist awareness (up to 10-fold) and when using enhanced imaging techniques such as narrow band imaging (up to three-fold). The literature remains mixed on the association of inlet patch with laryngopharyngeal symptoms or globus sensation. Studies of endoscopic ablation, using argon plasma coagulation or radiofrequency ablation have shown improved laryngopharyngeal reflux symptom scores posttreatment. Proximal esophageal adenocarcinomas are rare but often associated with inlet patch when they occur. Case studies have described endoscopic resection of malignant lesions related to inlet patch, using endoscopic mucosal resection or submucosal dissection.

Prospective, multicenter studies of symptom association with inlet patch using validated symptom questionnaires and blinded sham-controlled treatments are needed to further clarify the role of such treatments, which to date are limited to a small numbers of centers with a special interest.
Safety of in-office laryngology procedures
Authors: Marinone Lares Silvia G. , Allen Jacqueline E.
Published: September 2019

Purpose of review

A wide range of diagnostic and therapeutic laryngology procedures are currently performed in an office setting. In-office laryngology procedures (IOLP) are increasingly seen as standard-of-care, and while generally considered safe, high-quality evidence supporting the latter statement is lacking. This review aims to summarize recent literature regarding the safety of IOLP.

Recent findings

There is a paucity of guidelines and standardized protocols for IOLP. To date, there is one available safety protocol specific to in-office laser procedures. Haemodynamic changes during IOLP have been documented and the significance of these changes continues to be unclear. Therefore, monitoring of vital signs is recommended. Continuing antithrombotic therapy during IOLP also appears safe, and this decision may be left to surgeon discretion. A protocol for management of antithrombotic therapy prior to in-office laser procedures is available. Actual serum lidocaine levels following topical application of mixed lidocaine preparations falls well below reported toxic levels but persists for longer than previously reported.

IOLP are safer that suspension laryngoscopy under general anaesthetic. Although complication rates of IOLP are low, patient characteristics and potential complications of both the procedure and of topical anaesthetic use must be considered. One must be prepared and equipped to deal with these potential complications.
Diagnosis of primary immunodeficiency diseases in the developing world: the need for education and networking with the developed world
Authors: Villavicencio Maria Fernanda , Pedroza Luis Alberto
Published: September 2019

Purpose of review

Even with the evident improvement in knowledge about clinical and molecular aspects and the technology used to diagnose primary immunodeficiency diseases (PIDs), there is still a significant delay in recognition of these diseases in the developing world, specifically in Latin America. In this review, the goal is to outline the challenges that need to overcome for the diagnosis of PIDs and the optimization of resources available based on our experience.

Recent findings

We describe the advances achieved in the past decade in Latin America in terms of recognition of PIDs, as well as the need for improvement. We outline the need for continued medical education, the lack of resources for laboratory testing, and how genetic testing through next-generation sequencing (that is becoming a day-to-day tool) can be achieved in the developing world.

We aim to gather information about the limitations and challenges for the diagnosis of PIDs in a low-resource environment and the opportunities to benefit from the available advanced tools for diagnosis.
Microbiota and Body Composition During the Period of Complementary Feeding
Authors: Smith‐Brown Paula , Morrison Mark , Krause Lutz , Davies Peter S.W.
Published: September 2019

Objectives:

This study aimed to explore the associations between food group intake, faecal microbiota profile, and body composition during the period of complementary feeding.

Methods:

Diet was assessed using a quantitative food frequency questionnaire, faecal microbiota profile was assessed using 16S rRNA gene sequencing, and body composition was assessed using bioelectrical impedance analysis and dual energy x‐ray absorptiometry, in a cohort of 50 infants aged 6 to 24 months of age.

Results:

During this critical period of microbiota development, age was the strongest predictor of microbiota composition with network analysis revealing a cluster of genera positively associated with age. A separate cluster comprised genera associated with fat mass index with Bifidobacterium showing the strongest correlation with fat mass index (rho = 0.55, P = 0.001, false discovery rate [FDR] = 0.018). Dairy intake was both negatively correlated with Bacteroides (rho = −0.49, P < 0.001, FDR = 0.024) and positively correlated with lean mass index (rho = 0.44, P = 0.007, FDR = 0.024). Antibiotics use in the first month of life had the most striking influence on body composition and was associated with an increase in mean body mass index z score of 1.17 (P = 0.001) and body fat of 3.5% (P = 0.001).

Conclusions:

Our results suggested that antibiotics use in the first month of life had the most striking influence on body composition in this cohort of infants aged 6 to 24 months, whereas dairy intake interacted with both microbiota and body composition in early life.
European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for Diagnosing Coeliac Disease 2020
Authors: Husby Steffen , Koletzko Sibylle , Korponay‐Szabó Ilma , Kurppa Kalle , Mearin Maria Luisa , Ribes‐Koninckx Carmen , Shamir Raanan , Troncone Riccardo , Auricchio Renata , Castillejo Gemma , Christensen Robin , Dolinsek Jernej , Gillett Peter , Hróbjartsson Asbjørn , Koltai Tunde , Maki Markku , Nielsen Sabrina Mai , Popp Alina , Størdal Ketil , Werkstetter Katharina , Wessels Margreet
Published: September 2019

Objectives:

The ESPGHAN 2012 coeliac disease (CD) diagnostic guidelines aimed to guide physicians in accurately diagnosing CD and permit omission of duodenal biopsies in selected cases. Here, an updated and expanded evidence‐based guideline is presented.

Methods:

Literature databases and other sources of information were searched for studies that could inform on 10 formulated questions on symptoms, serology, human leukocyte antigen genetics, and histopathology. Eligible articles were assessed using QUADAS2. GRADE provided a basis for statements and recommendations.

Results:

Various symptoms are suggested for case finding, with limited contribution to diagnostic accuracy. If CD is suspected, measurement of total serum IgA and IgA‐antibodies against transglutaminase 2 (TGA‐IgA) is superior to other combinations. We recommend against deamidated gliadin peptide antibodies (DGP‐IgG/IgA) for initial testing. Only if total IgA is low/undetectable, an IgG‐based test is indicated. Patients with positive results should be referred to a paediatric gastroenterologist/specialist. If TGA‐IgA is ≥10 times the upper limit of normal (10× ULN) and the family agrees, the no‐biopsy diagnosis may be applied, provided endomysial antibodies (EMA‐IgA) will test positive in a second blood sample. Human leukocyte antigen DQ2‐/DQ8 determination and symptoms are not obligatory criteria. In children with positive TGA‐IgA <10× ULN at least 4 biopsies from the distal duodenum and at least 1 from the bulb should be taken. Discordant results between TGA‐IgA and histopathology may require re‐evaluation of biopsies. Patients with no/mild histological changes (Marsh 0/I) but confirmed autoimmunity (TGA‐IgA/EMA‐IgA+) should be followed closely.

Conclusions:

CD diagnosis can be accurately established with or without duodenal biopsies if given recommendations are followed.
Photoprotection But Not N‐acetylcysteine Improves Intestinal Blood Flow and Oxidation Status in Parenterally Fed Piglets
Authors: Huber Lee‐Anne , Lee Theresa , LeDrew Robyn L. , Dodge M. Elaine , Brunton Janet A. , Bertolo Robert F.
Published: September 2019

Objectives:

The purpose of the present study was to determine if protecting parenteral nutrition solutions from ambient light and supplementing with N‐acetylcysteine (NAC) improves mesenteric blood flow, gut morphology, and oxidative status of parenterally fed neonates.

Methods:

Neonatal Yucatan miniature piglets (n = 23, 7–11 days old) were surgically fitted with central venous catheters and an ultrasonic blood flow probe around the superior mesenteric artery. Piglets were fed continuously for 7 days either light‐protected (LP) or light‐exposed (LE) complete parenteral nutrition that was enriched with either NAC or alanine (ALA).

Results:

There were no differences in body weight or overall gut morphology among groups after 7 days. Plasma concentrations of NAC were greater and total homocysteine lower in NAC‐ versus ALA‐supplemented pigs on day 7 (N‐acetylcysteine: 94 vs 7 μmol/L; P < 0.001; homocysteine: 14 versus 21 μmol/L; P < 0.005); plasma total glutathione was not affected. Hepatic lipid peroxidation was reduced by 25% in piglets that received LP parenteral nutrition (P < 0.05). The mesenteric artery blood flow decreased in all pigs between days 2 and 6 (P < 0.001) because of parenteral feeding. Photoprotection alone (LP‐ALA) attenuated the decrease in mesenteric blood flow to 66% of baseline on day 6 compared with LE‐ALA (37%; P < 0.05) and LP‐NAC pigs (43%; P = 0.062); LE‐NAC piglets had intermediate reductions in blood flow (55%).

Conclusions:

Photoprotection of parenteral nutrition solutions is a simple, effective method to attenuate decline in blood flow to the gut and hepatic lipid peroxidation, which are both commonly associated with parenteral feeding.
Depression Screening in Pediatric Inflammatory Bowel Disease Clinics
Authors: Mackner Laura M. , Whitaker Brandi N. , Maddux Michele H. , Thompson Suzanne , Hughes‐Reid Cheyenne , Drovetta Megan , Reed Bonney
Published: September 2019

Objective: Rates of youth depression are increasing, and approximately 75% of adolescents with depression go unrecognized. Research in pediatric IBD documents increased depression risk, with rates up to 25%, as well as worse adherence and treatment outcomes associated with depressive symptoms. Evidence‐based psychological interventions improve the physical and emotional health of these patients, highlighting the importance of detection and treatment. Psychosocial screening has been shown to increase the accurate identification of psychosocial problems and facilitate timely psychosocial intervention. The objective of this article is to establish clinical guidelines for depression screening in youth diagnosed with IBD and to provide resources for implementation.

Methods: The psychosocial screening task force group constituted of psychologists and social workers in the ImproveCareNow (ICN) learning health system reviewed research and clinical guidelines in other fields, and consulted with physicians, nurses, other psychosocial professionals, patients with IBD, and parents of children with IBD in ICN.

Results/Conclusions: It is recommended that adolescents with IBD ages 12 and older be screened for depression annually. Additional practical recommendations for implementation, triage, and treatment within the pediatric gastroenterology clinic are also provided.
Neurocognitive Functioning in Early School‐age Children With Intestinal Failure
Authors: Gold Anna , Danguecan Ashley , Belza Christina , So Stephanie , de Silva Nicole , Avitzur Yaron , Wales Paul W.
Published: September 2019

Objectives:

Little is known about school‐age functioning in children with intestinal failure (IF). This study examines neurocognitive outcomes of children with IF at ages 4 to 8 years treated at a single centre, along with relevant medical and demographic variables.

Methods:

Between 2012 and 2016, neurocognitive assessments were administered to 28 children receiving treatment in our IF rehabilitation program, and included measures of intelligence, academics, learning/memory, language, visual‐motor integration, and fine‐motor dexterity. DSM‐IV/V criteria were used to diagnose Learning Disability, Intellectual Disability, and/or Attention Deficit/Hyperactivity Disorder.

Results:

Intellectual functioning ranged from extremely low to superior (Full Scale IQ range 53–123, mean = 89). Forty‐six percentage received a cognitive/learning DSM diagnosis. Total number of first‐year septic episodes correlated with poorer outcomes on the most cognitive measures. Adjusting for gestational age (61% were born <37 weeks), number of first‐year septic episodes negatively predicted working memory, visual‐motor integration, and visual memory scores. Additional factors correlating with poorer outcomes on ≥2 cognitive measures included length of first‐year admissions, necrotizing enterocolitis diagnosis, and first‐year sustained conjugated hyperbilirubinemia. Having ≥2 first‐year septic episodes increased the likelihood of poorer outcome. Having a sibling was a significant positive predictor of working memory, processing speed, reading, and verbal learning skills.

Conclusions:

Our data provides preliminary evidence that children with IF are at risk of neurocognitive problems at early school age. Managing septic events during the first year is one strategy that may help reduce long‐term neurocognitive risks in this population.
Factors Associated With Frequent Opioid Use in Children With Acute Recurrent and Chronic Pancreatitis
Authors: Perito Emily R. , Palermo Tonya M. , Pohl John F. , Mascarenhas Maria , Abu‐El‐Haija Maisam , Barth Bradley , Bellin Melena D. , Fishman Douglas S. , Freedman Steven , Gariepy Cheryl , Giefer Matthew , Gonska Tanja , Heyman Melvin B. , Himes Ryan W. , Husain Sohail Z. , Lin Tom , Liu Quin , Maqbool Asim , McFerron Brian , Morinville Veronique D. , Nathan Jaime D. , Ooi Chee Y. , Rhee Sue , Schwarzenberg Sarah Jane , Shah Uzma , Troendle David M. , Werlin Steven , Wilschanski Michael , Zheng Yuhua , Zimmerman Miriam Bridget , Lowe Mark , Uc Aliye
Published: September 2019

Objectives:

The aim of the study was to understand the association of frequent opioid use with disease phenotype and pain pattern and burden in children and adolescents with acute recurrent (ARP) or chronic pancreatitis (CP).

Methods:

Cross‐sectional study of children <19 years with ARP or CP, at enrollment into the INSPPIRE cohort. We categorized patients as opioid “frequent use” (daily/weekly) or “nonfrequent use” (monthly or less, or no opioids), based on patient and parent self‐report.

Results:

Of 427 children with ARP or CP, 17% reported frequent opioid use. More children with CP (65%) reported frequent opioid use than with ARP (41%, P = 0.0002). In multivariate analysis, frequent opioid use was associated with older age at diagnosis (odds ratio [OR] 1.67 per 5 years, 95% confidence interval [CI] 1.13–2.47, P = 0.01), exocrine insufficiency (OR 2.44, 95% CI 1.13–5.24, P = 0.02), constant/severe pain (OR 4.14, 95% CI 2.06–8.34, P < 0.0001), and higher average pain impact score across all 6 functional domains (OR 1.62 per 1‐point increase, 95% CI 1.28–2.06, P < 0.0001). Children with frequent opioid use also reported more missed school days, hospitalizations, and emergency room visits in the past year than children with no frequent use (P < 0.0002 for each). Participants in the US West and Midwest accounted for 83% of frequent opioid users but only 56% of the total cohort.

Conclusions:

In children with CP or ARP, frequent opioid use is associated with constant pain, more healthcare use, and higher levels of pain interference with functioning. Longitudinal and prospective research is needed to identify risk factors for frequent opioid use and to evaluate nonopioid interventions for reducing pain and disability in these children.
Comparison of Tolerance and Complication Rates Between Early and Delayed Feeding After Percutaneous Endoscopic Gastrostomy Placement in Children
Authors: Peck Jacquelin , Mills Katie , Dey Aditi , Nguyen Anh Thy H. , Amankwah Ernest K. , Wilsey Alexander , Swan Emily , Son Sorany , Karjoo Sara , McClenathan Daniel , Wilsey Michael
Published: September 2019

Background:

Enteral nutrition is commonly initiated 24 hours after percutaneous endoscopic gastrostomy (PEG) in children. Adult studies report safe refeeding within 1 to 6 hours of PEG, and these findings have been cautiously applied to children. Comparative studies assessing early versus next‐day refeeding in children are currently lacking. This study evaluates feeding tolerance and complications following early versus next‐day refeeding in children.

Methods:

This is a single‐center, pre‐post study. In June 2015 our clinical practice changed to begin refeeding within 6 hours of PEG. Children receiving early refeeding from December 2015 to August 2017 were included. A retrospective cohort from February 2013 to April 2015 was used for comparison.

Results:

Forty‐six children received early refeeding after PEG and 37 received next‐day refeeding. Gender distribution was similar in the 2 groups. Early refeeding patients were slightly older (3.5 vs 2.2 years) and heavier (15.5 vs 11.5 kg) at PEG placement compared to next‐day refeeding patients. Early refeeding patients experienced greater postprocedural nausea and/or vomiting (19% vs 8%, P < 0.001) and leakage, irritation, and infection around the stoma (19% vs 0.0%, P < 0.001). Compared to early refeeders, next‐day refeeding patients experienced higher occurrence of fever (35% vs 13%, P = 0.021), longer nutritional disruption (24.6 vs 3.7 hours, P < 0.001), and longer length of stay (51 vs 27 hours; P < 0.001). One next‐day refeeding patient experienced peritonitis. One early refeeding patient experienced cellulitis requiring hospitalization and a second experienced gastrostomy tube migration into the peritoneal cavity requiring removal.

Conclusion:

Early refeeders experienced higher rates of postprocedural nausea or vomiting and irritation, leakage, or infection around the stoma; but experienced lower rates of postoperative fever. Early refeeding resulted in reduced nutritional interruption and hospital length of stay.