Positive Schemas, Coping, and Quality of Life in Pediatric Recurrent Abdominal Pain.

Pediatric recurrent abdominal pain is commonly associated with negative impacts on quality of life (QOL). Positive schemas (core beliefs about the self with subthemes of self-efficacy, optimism, trust, success, and worthiness) are a resilience factor that has not yet been examined within a pediatric recurrent pain context. This cross-sectional study examined (a) associations between positive schemas, pain coping, and youth QOL, and (b) exploratory analyses to investigate whether specific positive schema subthemes predicted QOL outcomes in youth with recurrent abdominal pain. Participants were 98 youth with recurrent abdominal pain (i.e., pain related to a disorder of gut-brain interaction [DGBI] or organic cause) who completed measures on positive schemas, QOL, and pain coping. Age and diagnostic status were controlled for in analyses. Positive schemas were significantly positively correlated with emotional, social, school, and overall QOL, as well as with approach and problem-focused avoidant coping, and significantly negatively correlated with emotion-focused coping. Worthiness was the strongest and only significant predictor of youth social functioning. Positive schemas may be an important cognitive resilience factor to consider within interventions for pediatric recurrent pain.

Hyoscine butylbromide versus acetaminophen for nonspecific colicky abdominal pain in children: a randomized controlled trial.

BACKGROUND: Less than two-thirds of children with abdominal pain in the emergency department receive analgesia. We sought to determine whether hyoscine butylbromide was superior to acetaminophen for children with nonspecific colicky abdominal pain. METHODS: We randomly allocated children aged 8-17 years with nonspecific colicky abdominal pain who presented to the pediatric emergency department of London Health Sciences Centre, London, Ontario to receive hyoscine butylbromide, 10 mg given orally, or acetaminophen, 15 mg/kg given orally (maximum 975 mg). We considered the minimal clinically important difference for the primary outcome (self-reported pain at 80 min) to be 13 mm on a 100 mm visual analogue scale. Secondary outcomes included administration of rescue analgesia, adverse effects and pain score less than 30 mm at 80 minutes. RESULTS: A total of 236 participants (120 in the hyoscine butylbromide group and 116 in the acetaminophen group) were included in the trial. The mean visual analogue scale scores at 80 minutes were 29 mm (standard deviation [SD] 26 mm) and 30 mm (SD 29 mm) with hyoscine butylbromide and acetaminophen, respectively (adjusted difference 1, 95% confidence interval -7 to 7). Rescue analgesia was administered to 4 participants (3.3%) in the hyoscine butylbromide group and 1 participant (0.9%) in the acetaminophen groups (p = 0.2). We found no significant differences in rates of adverse effects between hyoscine butylbromide (32/116 [27.6%]) and acetaminophen (28/115 [24.3]) (p = 0.5); no serious adverse effects were observed. The proportion with a pain score less than 30 mm at 80 minutes was 66 (55.0%) with hyoscine butylbromide and 63 (54.3%) with acetaminophen (p = 0.9). INTERPRETATION: Hyoscine butylbromide was not superior to acetaminophen in this setting. Both agents were associated with clinically important pain reduction, and either can be considered for children presenting to the emergency department with nonspecific colicky abdominal pain. Trial registration: Clinicaltrials.gov, no. NCT02582307.

An Unexpected Finding of Hepatosplenomegaly in a Pediatric Patient.

Gaucher disease (GD) is a rare autosomal recessive metabolic disorder. It is characterized by a deficiency of lysosomal glucocerebrosidase, which results in the accumulation of glycosphingolipid substrates, primarily glucosylceramide, in the phagocyte system. In GD Type 1, the liver, spleen, and bone marrow are typically affected. We report the case of a 7-year-old female with GD Type 1 who presented with hepatosplenomegaly detected incidentally following a motor vehicle accident. She was found to have concomitant thrombocytopenia and Erlenmeyer flask deformities of her lower limbs. Diagnosis was made on the basis of very low leukocyte ß-glucocerebrosidase activity and elevated plasma chitotriosidase. DNA mutation studies revealed both c.1226A>G and c.116_1505 deletion (exons 3-11). The patient is currently managed with biweekly intravenous imiglucerase (Cerezyme) replacement therapy. She demonstrated resolution of thrombocytopenia and hepatosplenomegaly at 2-year follow-up. Physicians must consider this rare diagnosis in children presenting with hepatosplenomegaly to prompt timely management.

Health-related quality of life in youth with abdominal pain: An examination of optimism and pain self-efficacy.

OBJECTIVES: Abdominal pain adversely impacts children with functional gastrointestinal disorders (FGIDs) or organic gastrointestinal disorders (OGIDs); findings are inconsistent regarding diagnosis and health-related quality of life (HRQoL). This study utilizes a positive psychology framework to understand the experience of youth with abdominal pain (i.e., do positive psychological factors, such as optimism and pain self-efficacy, relate to higher HRQoL?). Consistent with a protective factor model of resilience, in which personal assets may serve as buffers between risk factors and negative outcomes, optimism and pain self-efficacy were examined as they relate to HRQoL in youth with abdominal pain. Specifically, exploratory moderational analyses examined a) if optimism and pain self-efficacy moderate the relation between pain and HRQoL, and b) whether diagnostic status moderated the relation between optimism/pain self-efficacy and HRQoL. METHODS: In a cross-sectional, observational study, youth (n = 98; Mage = 13, SD = 3) experiencing abdominal pain related to FGIDs or OGIDs and one of their parents participated. Measures included pain intensity, optimism, pain self-efficacy, and HRQoL. Analyses controlled for diagnosis, age, and gender. RESULTS: Higher pain and age related to lower HRQoL. Higher levels of optimism and pain self-efficacy associated with HRQoL beyond demographics. Optimism and pain self-efficacy did not moderate the relation between pain and HRQoL. Diagnostic status did not moderate the relation between optimism or pain self-efficacy and HRQoL. DISCUSSION: Our results suggest positive relations between positive psychological factors (optimism, pain self-efficacy) and HRQoL in youth with abdominal pain. Such factors could be further examined in intervention studies.

Emergency case of spontaneous common bile duct (CBD) perforation.

Spontaneous or non-traumatic common bile duct (CBD) perforation in children is a rare condition leading to difficulty and delay in diagnosis and resulting in high mortality. Presentation can vary significantly. Patients usually present with sudden obstructive jaundice, acholic stools, and abdominal pain and distension. Treatment tends to be surgical, consisting of CBD exploration, and possibly, repair. We report the case of a 22-month-old female with spontaneous CBD perforation. She presented with a 1-month history of increasing abdominal distension, abdominal pain, and jaundice. On exploratory laparotomy, a large amount of bile-stained ascitic fluid was drained. She was managed conservatively with 3 weeks of external intra-abdominal drains. Follow-up at 6 months showed complete recovery. Due to the rarity of spontaneous bile duct perforation, delayed diagnosis and intervention is common. Physicians must consider this diagnosis in a child with abdominal pain in order to prompt timely surgical management for a successful outcome.

Is focal active colitis of greater clinical significance in pediatric patients? A retrospective review of 68 cases with clinical correlation.

Focal active colitis (FAC) is a histopathologic finding of uncertain clinical significance in individual patients. In adults, infection accounts for approximately 50%, Crohn's disease (CD) for 0-13%, and 20%-30% are idiopathic. One previous study of 29 cases of pediatric FAC showed a 28% rate of CD. This study reviewed a larger cohort of pediatric patients to determine what proportion had IBD, and whether an amount or pattern of inflammation could predict IBD. Sixty-eight patients aged ≤18years with FAC were identified and reviewed. Patients with a prior diagnosis of IBD or chronic colitis in the index biopsies were excluded. Slides were assessed for a number of inflammatory criteria. Clinical data and final diagnoses were recorded. Data were analyzed using Pearson correlations and Fisher's exact χ2 analyses. Sixteen patients (24%) had a final diagnosis of IBD. When cases with terminal ileal (TI) inflammation were excluded, 6 of 54 patients had a final diagnosis of IBD (11%). A final diagnosis of IBD was significantly associated with crypt abscesses and elevated serum inflammatory markers. IBD was significantly associated with TI inflammation. An amount or pattern of inflammation that could be used to predict IBD was not determined. This study demonstrated a 24% rate of IBD in pediatric patients with FAC; however, when patients with associated TI inflammation were excluded, the rate was 11%, similar to reported rates in adults. FAC in pediatric patients without terminal ileal inflammation does not appear to warrant more aggressive follow-up.

Evaluation of Outcomes in Adolescent Inflammatory Bowel Disease Patients Following Transfer From Pediatric to Adult Health Care Services: Case for Transition.

PURPOSE: We aimed to evaluate the impact of a transition service on clinical and developmental outcomes in adolescent Inflammatory Bowel Disease (IBD) patients on transfer to adult health care services. METHODS: We reviewed the records of IBD patients diagnosed in pediatric care following their transfer/attendance to the adult IBD service. The data on patients who attended the transition service were compared with those who did not pass through the transition service. RESULTS: Seventy-two patients were included in the study 41M and 31F. Forty-four patients went through the transition system (Group A), and 28 had no formalized transition arrangement before transfer (Group B). A significantly higher number of Group B patients needed surgery within 2 years of transfer when compared with patients in Group A (46% vs. 25%, p = .01). Sixty-one percent of patients in Group B needed at least one admission within 2 years of transfer when compared with 29% of Group A patients (p = .002). Nonattendance at clinics was higher in Group B patients with 78% having at least one nonattendance, whereas 29% of Group A failed to attend at least one appointment (p = .001). In addition, drug compliance rates were higher in the transition group when compared with Group B (89% and 46%, respectively; p = .002). A higher proportion of transitioned patients achieved their estimated maximum growth potential when completing adolescence. There was a trend toward higher dependence on opiates and smoking in Group B patients. CONCLUSIONS: In adolescent IBD patients, transition care is associated with better disease specific and developmental outcomes. Prospective studies of different models of transition care in IBD are needed.

Change in hematologic indices over time in pediatric inflammatory bowel disease treated with azathioprine.

Azathioprine leads to changes in mean corpuscular volume (MCV) and white blood cell (WBC) indices reflecting efficacy or toxicity. Understanding the interactions between bone marrow stem cells and azathioprine could highlight abnormal response patterns as forerunners for hematologic malignancies. This study gives a statistical description of factors influencing the relationship between MCV and WBC in children with inflammatory bowel disease treated with azathioprine. We found that leukopenia preceded macrocytosis. Macrocytosis is therefore not a good predictor of leukopenia. Further studies will be necessary to determine the subgroup of patients at increased risk of malignancies based on bone marrow response.

Pediatric columnar lined esophagus vs Barrett's esophagus: is it the time for a consensus definition.

We describe the clinical, endoscopic, and histological features of all cases of Barrett's esophagus (BE) diagnosed at our institution between 2000 and 2007 following the criteria of the British Society of Gastroenterology. This society defines BE as a segment of columnar metaplasia (CLO) (whether intestinalized or not) of any length, visible endoscopically above the gastroesophageal junction and confirmed histologically. The diagnosis was challenged after immunostaining for Cdx2 (marker of intestinal differentiation). Information was collected with respect to age, symptoms, treatment, and endoscopic and histological features. Twelve children (10 males and 2 females) with a median age of 11.7 (2 to 17) years had been diagnosed with CLO-BE. Histology confirmed BE in 31 of 38 endoscopies. The initial diagnosis was reviewed according to Cdx2 results in 10 of 12 patients: Cdx2 strongly expressed in 4 cases with intestinal metaplasia (the diagnosis of BE was maintained); was negative in 4 other patients with "CLO" mucosa (reviewed diagnosis was that of expansion of the gastric cardia into the distal esophagus); and 2 patients had occasional Cdx2-positive cells showing cardia-type mucosa with goblet cells (early BE?). The estimated prevalence of CLO-BE in the pediatric population of South Yorkshire (United Kingdom) is 0.0024%, 0.8% in children referred for endoscopy and 5.5% in the children with reflux esophagitis. Characterization of the BE and confirmation of intestinal differentiation may have prognostic implications that can impact the surveillance program. Our results showed that intestinal differentiation as demonstrated with Cdx2 was only seen if goblet cells were present. A consensus definition and further studies to understand the molecular mechanisms involved in the development of BE at this age are needed.