The Impact of Thyroid Autoimmunity on Thyroid Function in 12-year-old Children With Celiac Disease

ABSTRACTObjectives:Celiac disease (CD) is associated with thyroid autoimmunity and other autoimmune diseases. However, data are lacking regarding the relationship between thyroid autoimmunity and thyroid function, especially in regard to CD. Our aim was to investigate the impact of thyroid autoimmunity on thyroid function in 12-year-old children with CD compared to their healthy peers.Methods:A case-referent study was conducted as part of a CD screening of 12-year-olds. Our study included 335 children with CD and 1,695 randomly selected referents. Thyroid autoimmunity was assessed with antibodies against thyroid peroxidase (TPOAb). Thyroid function was assessed with thyroid stimulating hormone and free thyroxine.Results:TPOAb positivity significantly increased the risk of developing hypothyroidism in all children. The odds ratios (with 95% confidence intervals) were: 5.3 (2.7–11) in healthy 12-year-olds, 10 (3.2–32) in screening-detected CD cases, 19 (2.6–135) in previously diagnosed CD cases, and 12 (4.4–32) in all CD cases together. Among children with TPOAb positivity, hypothyroidism was significantly more common (odds ratio 3.1; 95% CI 1.03–9.6) in children with CD (10/19) than in children without CD (12/46).Conclusions:The risk of thyroid dysfunction due to thyroid autoimmunity is larger for those with CD than their healthy peers. Our study indicate that a gluten-free diet does not reduce the risk of thyroid dysfunction. Further studies are required for improved understanding of the role of the gluten-free diet for the risk of autoimmune diseases in children with CD. Objectives: Celiac disease (CD) is associated with thyroid autoimmunity and other autoimmune diseases. However, data are lacking regarding the relationship between thyroid autoimmunity and thyroid function, especially in regard to CD. Our aim was to investigate the impact of thyroid autoimmunity on thyroid function in 12-year-old children with CD compared to their healthy peers. Methods: A case-referent study was conducted as part of a CD screening of 12-year-olds. Our study included 335 children with CD and 1,695 randomly selected referents. Thyroid autoimmunity was assessed with antibodies against thyroid peroxidase (TPOAb). Thyroid function was assessed with thyroid stimulating hormone and free thyroxine. Results: TPOAb positivity significantly increased the risk of developing hypothyroidism in all children. The odds ratios (with 95% confidence intervals) were: 5.3 (2.7–11) in healthy 12-year-olds, 10 (3.2–32) in screening-detected CD cases, 19 (2.6–135) in previously diagnosed CD cases, and 12 (4.4–32) in all CD cases together. Among children with TPOAb positivity, hypothyroidism was significantly more common (odds ratio 3.1; 95% CI 1.03–9.6) in children with CD (10/19) than in children without CD (12/46). Conclusions: The risk of thyroid dysfunction due to thyroid autoimmunity is larger for those with CD than their healthy peers. Our study indicate that a gluten-free diet does not reduce the risk of thyroid dysfunction. Further studies are required for improved understanding of the role of the gluten-free diet for the risk of autoimmune diseases in children with CD. Address correspondence and reprint requests to Fredrik Norström, PhD, Department of Public Health and Clinical Medicine Epidemiology and Global Health Umeå University SE-901 87 Umeå (e-mail: fredrik.norstrom@umu.se). Received 23 September, 2017 Accepted 11 January, 2018 Sources of support: The study was funded by the Swedish Research Council (grants 521-2004-7093 and 521-2007-2953), the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning (grants 222-2004-1918 and 222-2007-1394), and the Swedish Council for Working Life and Social Research (grants 2005-0802). In addition, a contribution was made by Skåne County Council. The study was part of the European Union-supported project FP6-2005-FOOD-4B-36383-PREVENTCD. Phadia (Freiburg, Germany) and Eurospital SpA (Trieste, Italy) contributed analyses of coded serum samples. Conflicts of interest: The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

This document serves as an update of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2009 clinical guidelines for the diagnosis and management of gastroesophageal reflux disease (GERD) in infants and children and is intended to be applied in daily practice and as a basis for clinical trials. Eight clinical questions addressing diagnostic, therapeutic and prognostic topics were formulated. A systematic literature search was performed from October 1, 2008 (if the question was addressed by 2009 guidelines) or from inception to June 1, 2015 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Clinical Trials. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to define and prioritize outcomes. For therapeutic questions, the quality of evidence was also assessed using GRADE. Grading the quality of evidence for other questions was performed according to the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS) and Quality in Prognostic Studies (QUIPS) tools. During a three-day consensus meeting, all recommendations were discussed and finalized. In cases where no randomized controlled trials (RCT; therapeutic questions) or diagnostic accuracy studies were available to support the recommendations, expert opinion was used. The group members voted on each recommendation, using the nominal voting technique. With this approach, recommendations regarding evaluation and management of infants and children with GERD to standardize and improve quality of care were formulated. Additionally, two algorithms were developed, one for infants 

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Psychological Factors and Outcomes in the Surgical Treatment of Pediatric Patients With Median Arcuate Ligament Syndrome

ABSTRACTObjective:Median Arcuate Ligament Syndrome (MALS) is a frequently overlooked cause of chronic abdominal pain (CAP), and results in many symptoms that mimic other gastrointestinal conditions that result in CAP. A small, but growing body of literature indicates that surgery improves quality of life (QOL) in patients with MALS. The purpose of the current study was to examine the psychological characteristics of pediatric patients with MALS to determine their prevalence and impact on surgical outcomes.Methods:Thirty-two pediatric patients completed psychological assessments prior to surgery, and 6-months post-surgical intervention. Descriptive analyses and t-tests were conducted to characterize the sample and compare psychosocial and QOL items. To explore possible associations between coping and ultimate changes in QOL, exploratory multiple regressions were conducted.Results:Comorbid psychological conditions were common, occurring in about half the sample before and after surgery. Current pain significantly improved, as well as patient and parent-reported QOL constructs (ps 

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Esophageal Squamous Cell Papillomatosis Arising in Focal Dermal Hypoplasia in a Three-year-old Girl

No abstract available

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Stroop Test Validation to Screen for Minimal Hepatic Encephalopathy in Pediatric Extrahepatic Portal Venous Obstruction

ABSTRACTObjectives:Minimal Hepatic encephalopathy (MHE) has been reported in children with extra hepatic portal vein obstruction (EHPVO). MHE assessment is restricted to research situations as neuropsychiatric tests are time-intensive. Computerised Stroop Test (CST) has been used in cirrhotic adults for MHE screening. The study aims to assess MHE frequency in young Indian children with EHPVO and validate CST for MHE screening in pediatric EHPVOMethods:37 children with EHPVO between 7–12 years of age and 37 age and gender matched controls were enrolled. Fasting plasma ammonia was measured. MHE was diagnosed by Revised Amsterdamse Kinder Intelligentie Test (RAKIT). The performance of a Tamil language version of CST in MHE screening was assessed.Results:MHE was diagnosed in 18.9% (7/37) of EHPVO (EHPVO-MHE). Plasma ammonia levels were higher in EHPVO-MHE compared to EHPVO without MHE (EHPVO-No-MHE) but abnormal plasma ammonia levels are unsuitable for MHE screening. CST was administered in 35 EHPVO and 37 controls. EHPVO-MHE, compared to EHPVO-No-MHE, had longer "on time", "off time", "(on+off) time" and "(on-off) time". For MHE diagnosis, specificity and sensitivity of '(on+off) time' were 100% and 89.6% for a cut-off of >180.4 s (AUROC=0.97).Conclusions:In the absence of other risk factors for neurological insult or patent surgical shunts, MHE frequency in young Indian children with EHPVO, determined by RAKIT, was lesser than in earlier studies. CST is suitable for MHE screening in clinical practice to select patients for neuropsychiatric evaluation. Objectives: Minimal Hepatic encephalopathy (MHE) has been reported in children with extra hepatic portal vein obstruction (EHPVO). MHE assessment is restricted to research situations as neuropsychiatric tests are time-intensive. Computerised Stroop Test (CST) has been used in cirrhotic adults for MHE screening. The study aims to assess MHE frequency in young Indian children with EHPVO and validate CST for MHE screening in pediatric EHPVO Methods: 37 children with EHPVO between 7–12 years of age and 37 age and gender matched controls were enrolled. Fasting plasma ammonia was measured. MHE was diagnosed by Revised Amsterdamse Kinder Intelligentie Test (RAKIT). The performance of a Tamil language version of CST in MHE screening was assessed. Results: MHE was diagnosed in 18.9% (7/37) of EHPVO (EHPVO-MHE). Plasma ammonia levels were higher in EHPVO-MHE compared to EHPVO without MHE (EHPVO-No-MHE) but abnormal plasma ammonia levels are unsuitable for MHE screening. CST was administered in 35 EHPVO and 37 controls. EHPVO-MHE, compared to EHPVO-No-MHE, had longer "on time", "off time", "(on+off) time" and "(on-off) time". For MHE diagnosis, specificity and sensitivity of '(on+off) time' were 100% and 89.6% for a cut-off of >180.4 s (AUROC=0.97). Conclusions: In the absence of other risk factors for neurological insult or patent surgical shunts, MHE frequency in young Indian children with EHPVO, determined by RAKIT, was lesser than in earlier studies. CST is suitable for MHE screening in clinical practice to select patients for neuropsychiatric evaluation. Address correspondence and reprint requests to Barath Jagadisan, Associate Professor, Pediatric gastroenterology, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry – 605006, India (e-mail: barathjag@yahoo.com). Received 15 November, 2017 Accepted 11 January, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Financial Disclosure and funding: The authors have no financial relationships relevant to this article to disclose. No conflict of interests. The study was funded by an intramural grant from the institute (JIP/Res/Intra-MD-MS/1/2015-16). Ethical clearance: The study had been approved by the institute ethic committee that complies with international standards and is registered with the government of India (JIP/IEC/2015/15/577). Trial registration: Not applicable. This article has not been published elsewhere in any language and it is not currently under consideration for publication elsewhere. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Yield and Costs of Evaluating Children with Cyclic Vomiting Syndrome

ABSTRACTBackground:Cyclic vomiting syndrome (CVS) clinical guidelines recommend an algorithm of basic testing for standard patients, and more targeted testing, including laboratory and imaging studies, in the presence of specific red flags. The cost effectiveness of this screening of children with suspected CVS is lacking.Objectives:To determine if screening studies in CVS patients results in diagnostic change, and to estimate their healthcare cost.Method:Charts of patients (1–18 years) with suspected CVS were retrospectively reviewed at a single center. Results and cost of laboratory and imaging studies were analyzed.Results:503 charts were reviewed from electronic medical records with the ICD9 code 536.2 or search terms "CVS, cyclic vomiting, persistent emesis/vomiting, hyperemesis, or intractable/ periodic vomiting". Of these, 165 (33%) had a diagnosis of CVS and 135 (82%) children (mean age 7.7 ± 4.3; 73 (54%) females) met CVS criteria based on NASPGHAN diagnostic criteria. Of those meeting CVS criteria, 6 (4%) had a change in management based on the CVS screening evaluation. The mean cost of screening per patient that met CVS criteria was $6,125.02 USD and the estimated total cost for all patients who met CVS criteria was $826,877.88 USD.Conclusion:The screening metabolic labs, pelvic ultrasound, MRI, and upper endoscopy resulted in a diagnosis change in few patients screened for CVS. Most children who met criteria for CVS did not benefit from screening evaluation as results did not change clinical diagnosis or management, and were associated with higher cost. Background: Cyclic vomiting syndrome (CVS) clinical guidelines recommend an algorithm of basic testing for standard patients, and more targeted testing, including laboratory and imaging studies, in the presence of specific red flags. The cost effectiveness of this screening of children with suspected CVS is lacking. Objectives: To determine if screening studies in CVS patients results in diagnostic change, and to estimate their healthcare cost. Method: Charts of patients (1–18 years) with suspected CVS were retrospectively reviewed at a single center. Results and cost of laboratory and imaging studies were analyzed. Results: 503 charts were reviewed from electronic medical records with the ICD9 code 536.2 or search terms "CVS, cyclic vomiting, persistent emesis/vomiting, hyperemesis, or intractable/ periodic vomiting". Of these, 165 (33%) had a diagnosis of CVS and 135 (82%) children (mean age 7.7 ± 4.3; 73 (54%) females) met CVS criteria based on NASPGHAN diagnostic criteria. Of those meeting CVS criteria, 6 (4%) had a change in management based on the CVS screening evaluation. The mean cost of screening per patient that met CVS criteria was $6,125.02 USD and the estimated total cost for all patients who met CVS criteria was $826,877.88 USD. Conclusion: The screening metabolic labs, pelvic ultrasound, MRI, and upper endoscopy resulted in a diagnosis change in few patients screened for CVS. Most children who met criteria for CVS did not benefit from screening evaluation as results did not change clinical diagnosis or management, and were associated with higher cost. Correspondence: Chantal Lucia-Casadonte, M.D, Assistant Professor of Pediatrics, The University of Kansas Medical Center, Division of Pediatric Gastroenterology, Hepatology and Nutrition, 3901 Rainbow Blvd, Mail Stop 4004, Kansas City, KS 66160 (e-mail: cluciacasadonte@kumc.edu). Received 22 December, 2016 Accepted 18 December, 2017 Conflicts of Interest and Sources of Funding: None of the authors have any conflicts of interest to disclose. This study was done without specific funding support. This article has been developed as a Journal CME Activity by NASPGHAN. Visit http://ift.tt/2ioSD8w to view instructions, documentation, and the complete necessary steps to receive CME credit for reading this article. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Residual Force Enhancement is Preserved for Conditions of Reduced Contractile Force

AbstractIntroductionThe isometric muscle force attained after active stretch is greater than that attained in a purely isometric contraction. This property is referred to as residual force enhancement (RFE). Since RFE is thought to be caused by a titin-based passive force, it should be preserved in reduced contractile force states. Therefore, we evaluated the magnitude of RFE in normal and reduced contractile force states.MethodsSkinned fibers of rabbit psoas and soleus (N = 60) were used in all experiments. Reduced contractile force states were induced by (i) using a low Ca2+ concentration (pCa6.0) (N = 30), (ii) by adding 20 mM butanedione monoxime (BDM) (N = 15), and (iii) by lowering the pH (pH6.0) level (N = 15). Force enhancement and reference isometric tests were conducted for each condition. In the force enhancement tests, fibers were actively stretched from an average sarcomere length of 2.4 μm to 3.0 μm. The isometric force attained 15s after the end of stretching was used for analysis. In the isometric reference tests, fibers were activated isometrically at an average sarcomere length of 3.0 μm, and the force at steady-state was used for analysis. The absolute and relative magnitudes of RFE were calculated.ResultsThe absolute RFE was the same for the normal and reduced contractile force states. Since the isometric reference force was smaller in the reduced contractile force states, the relative RFE was greater in the reduced contractile force than the normal states for all conditions.ConclusionRFE was preserved in the reduced contractile force states. Introduction The isometric muscle force attained after active stretch is greater than that attained in a purely isometric contraction. This property is referred to as residual force enhancement (RFE). Since RFE is thought to be caused by a titin-based passive force, it should be preserved in reduced contractile force states. Therefore, we evaluated the magnitude of RFE in normal and reduced contractile force states. Methods Skinned fibers of rabbit psoas and soleus (N = 60) were used in all experiments. Reduced contractile force states were induced by (i) using a low Ca2+ concentration (pCa6.0) (N = 30), (ii) by adding 20 mM butanedione monoxime (BDM) (N = 15), and (iii) by lowering the pH (pH6.0) level (N = 15). Force enhancement and reference isometric tests were conducted for each condition. In the force enhancement tests, fibers were actively stretched from an average sarcomere length of 2.4 μm to 3.0 μm. The isometric force attained 15s after the end of stretching was used for analysis. In the isometric reference tests, fibers were activated isometrically at an average sarcomere length of 3.0 μm, and the force at steady-state was used for analysis. The absolute and relative magnitudes of RFE were calculated. Results The absolute RFE was the same for the normal and reduced contractile force states. Since the isometric reference force was smaller in the reduced contractile force states, the relative RFE was greater in the reduced contractile force than the normal states for all conditions. Conclusion RFE was preserved in the reduced contractile force states. Corresponding Author: Atsuki FUKUTANI, Ph.D. Research Organization of Science and Technology, Ritsumeikan University, 1-1-1 Noji-higashi, Kusatsu, Shiga, 525–8577, Japan. E-mail address: atsukifukutani@gmail.com. Tel: +81 77 561 2791, Fax: +81 77 561 3761 This study was supported by the Grant-in-Aid for Challenging Exploratory Research (16K13009) and Postdoctoral Fellowship for Research Abroad (183), Nakatomi Foundation, CIHR Foundation Scheme Grant, NSERC of Canada Discovery Grant, The Canada Research Chair Programme, and the Killam Foundation. The results of the present study do not constitute endorsement by the American College of Sports Medicine. The authors declare that the results of the study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation. Conflicts of interest: None. Accepted for Publication: 19 January 2018 © 2018 American College of Sports Medicine

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