Endoscopic and histologic utility of transnasal endoscopy in pediatric eosinophilic esophagitis.

Unsedated transnasal endoscopy (TNE) is an alternative method of examining the esophageal mucosa in pediatric patients with eosinophilic esophagitis (EoE), reducing cost, time, and risk associated with frequent surveillance esophagogastroduodenoscopies (EGD). Adequacy of transnasal esophageal biopsies for the evaluation of eosinophilic esophagitis histologic scoring system (EoEHSS) has not yet been evaluated. We compared procedure times, endoscopic findings, and EoEHSS scoring for EoE patients undergoing TNE versus standard EGD. Sixty-six TNE patients and 132 EGD controls matched for age (mean age 14.0 years) and disease status (29.3% active) were included. Compared to patients undergoing standard EGD, patients undergoing TNE spent 1.94 h less in the GI suite (p < 0.0001), with comparable occurrence rates of all visual endoscopic findings and most EoEHSS components. TNE serves as a useful tool for long-term disease surveillance, and consideration should be given to its use in clinical trials for EoE.

Race-specific characteristics in pediatric eosinophilic esophagitis in an urban inner-city clinic.

BACKGROUND: Manifestations of pediatric eosinophilic esophagitis (EoE) are varied and dictated by multiple factors. The influence of race is limited to small observational cohorts of dichotomized data (Whites vs non-Whites) or single-racial analysis. OBJECTIVE: To better understand phenotypic variability in the manifestation and atopic sensitization of pediatric EoE, from the perspective of race. METHODS: Retrospective observational cohort study performed at a tertiary referral center. Subjects were included if less than 21 years old, with suggestive clinical features and histopathologic (>15 eosinophils/high-power field [hpf]) confirmation of EoE. Statistical computation was performed using Stata/IC 11 on variables of interest. RESULTS: A total of 34 subjects were included in the analysis. The median (interquartile range [IQR]) age for initial atopy was 2 (1-5) years. The median (IQR) age for EoE diagnosis was 5 (3-8) years. Age of EoE diagnosis was higher for Black or African Americans than non-Black or African Americans (P = .01). Between the racial groups, there was no difference in the total number of food sensitizations (P = .13), yet environmental allergy testing revealed that Black or African Americans were more likely to be sensitized for weeds (P = .03), dog (P = .009), and mold (P = .006). On histopathologic analysis, Black or African American subjects were found to have more prominent midesophageal eosinophilia at median 50/hpf (20-80/hpf), whereas Hispanic or LatinXs have more prominent lower esophageal eosinophilia at median 40/hpf (IQR, 20-40/hpf), compared with the other races (P = .04 and P = .04, respectively). CONCLUSION: Black or African Americans are more likely to present at an older age, have aeroallergen sensitization, and have more prominent midesophageal eosinophilia.

Retrospective case series of increased oral propranolol dosage for infantile hemangiomas.

BACKGROUND: Infantile hemangiomas (IH) are the most common benign tumor of infancy. Although oral propranolol is currently first-line therapy, optimal dosing for treatment of IH remains debated. We sought to identify hemangioma characteristics associated with poor response to standard dosing (2 mg/kg/d) and to assess the therapeutic benefit of higher dosing. METHODS: Retrospective chart review was conducted of 559 patients with IH seen at Johns Hopkins between 2008 and 2018, of whom 245 (44%) were treated with propranolol. Baseline characteristics were compared between patients who received increased propranolol dosing (≥2.5 mg/kg/d) and those who remained on standard dose (2 mg/kg/d). Changes in the Hemangioma Activity Score (HAS) during the increased dosage period were scored by two trained, blinded pediatric dermatologists. RESULTS: Of 245 patients, 204 (83%) received standard 2 mg/kg/d propranolol dosing while 41 (17%) received a higher dose of ≥2.5 mg/kg/d. The most common location of IH in both groups was the face. In the increased dosage group, 85.4% of IH were of mixed or deep morphology with a mean greatest diameter of 4.6 cm. IH requiring increased dosing received longer courses of propranolol (mean of 389 vs. 282 days, P < .001) and underwent higher rates of excision by plastic surgery (26.8% vs. 5.9%, P < .001). Mean change in HAS over the period with dosage ≥2.5 mg/kg/d was minimal (-0.70; P < .001). CONCLUSIONS: Most recalcitrant IH were located on the face, larger in diameter, and of mixed or deep morphology. Patients had little improvement in HAS score with increased propranolol dosing implemented late in the treatment course with over one-fourth ultimately receiving surgical excision.

Fifteen-minute consultation: Polydipsia, polyuria or both.

Children can present with polydipsia and/or polyuria for a number of reasons. We will discuss polydipsia and polyuria, how a child may present and how to investigate further in order to establish the cause. We highlight the important areas to cover in the history and examination of a child presenting with polydipsia and/or polyuria.