Markers of Bile Acid Metabolism in Pediatric Diarrhea Predominant Irritable Bowel Syndrome and Healthy Controls.

OBJECTIVES: Excessive fecal bile acids in adults have been associated with diarrhea-predominant irritable bowel syndrome (IBS-D), but their role in pediatric IBS-D is unknown. Serum markers including 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor-19 (FGF-19) were validated in adults to detect bile acid diarrhea (BAD) compared to 48-hour fecal bile acid collection (48FBA). Our aims were to assess fasting serum C4 and FGF-19 and 48FBA in a pediatric population, to compare measurements in IBS-D patients and healthy controls (HC), and to determine the prevalence of BAD among children with IBS-D. METHODS: Using a cross-sectional design, 26 patients with IBS-D and 56 HC were recruited in two pediatric tertiary care centers. Fasting serum C4 and FGF-19 and 48FBA were obtained. Participants completed a 7-day bowel diary coinciding with stool collection. Associations were analyzed using Spearman correlations. RESULTS: Mean age was 14.7 ±â€Š2.5 years (42.3% female) in IBS-D and 12.6 ±â€Š2.4 years (39.3% female) in HC. There was a significant correlation of C4 with 48FBA (r = 0.48, P < 0.05) and an inverse association with FGF-19 (r = -0.43, P < 0.05). No significant differences were noted in C4 (P = 0.32), FGF-19 (P = 0.1), or 48FBA (P = 0.5) between IBS-D and HC groups; however, 20% of IBS-D patients had elevated C4 and 28% had low FGF-19 values.Fecal primary BA was significantly correlated with stool frequency (r = 0.45, P < 0.002). CONCLUSIONS: Correlations of C4 with 48FBA and FGF-19 are confirmed in a pediatric population. Twenty percent of pediatric patients with IBS-D had abnormal fasting serum C4. This serum test could be applied to identify BAD in pediatric IBS-D.

Multidisciplinary Treatment Reduces Pain and Increases Function in Children With Functional Gastrointestinal Disorders.

Functional gastrointestinal disorders (FGIDs) are common in children and adolescents, frequently resulting in extensive testing, school absenteeism, disability, and poor quality of life.1-3 FGIDs result from a complex interplay between genetic predisposition, biological triggers, and psychosocial triggers, and are best explained by the biopsychosocial model.1 Although this implies the necessity of multidisciplinary treatment, studies showing the efficacy of such an intervention are lacking. We describe the outcome of children with severe FGIDs treated in a multidisciplinary program.

Health Outcomes and Quality of Life Indices of Children Receiving Blenderized Feeds via Enteral Tube.

OBJECTIVE: To determine whether clinical and patient-reported outcomes differ in children receiving blenderized diets compared with conventional formula. STUDY DESIGN: We conducted a prospective cohort study of 70 children aged 1-18 years receiving blenderized diets vs conventional formula via feeding tube. We assessed rates of hospitalization and visits to the emergency department (ED) at Boston Children's Hospital in 2017 and Likert scale addressing satisfaction with feeding regimen; Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire; Pediatric Quality of Life Inventory; and Pediatric Quality of Life Inventory Gastrointestinal Symptoms Scale. RESULTS: Participants receiving blenderized diets (n = 42, 60%) did not differ in demographics or comorbid diagnoses from those receiving conventional formula (n = 28, 40%). Rates of total visits to the ED (0.8 ± 1.5 vs 1.4 ± 2.7, P = .05), total admissions (0.8 ± 1.2 vs 1.7 ± 2.3, P = .01), and respiratory-related admissions (0.2 ± 0.5 vs 0.6 ± 0.8, P = .04) per year were significantly lower in participants receiving blenderized diets, and respiratory-related visits to the ED trended toward significance (0.1 ± 0.4 vs 0.4 ± 0.8, P = .08). Compared with those receiving conventional formula, participants on blenderized diets reported greater satisfaction ratings (Likert scale 4.3 ± 1.0 vs 3.3 ± 1.2, P = .001), lower symptom (0.7 ± 0.8 vs 1.2 ± 1.1, P = .03), and total (0.8 ± 0.8 vs 1.2 ± 1.0, P = .02) scores on Pediatric Gastroesophageal Reflux Disease Symptom and Quality of Life Questionnaire and greater scores on the Pediatric Quality of Life Inventory Gastrointestinal Symptoms Scale, indicating less nausea and vomiting (64.0 ± 22.6 vs 49.0 ± 37.9, P = .02), abdominal pain (65.0 ± 26.8 vs 56.4 ± 33.9, P = .04), diarrhea (87.9 ± 15.5 vs 73.6 ± 26.3, P = .004), and fewer total symptoms (70.2 ± 16.3 vs 62.3 ± 19.6, P = .03). CONCLUSIONS: Blenderized diets are associated with decreased healthcare use, improved symptom scores, and increased patient satisfaction compared with conventional formulas.

Attitudes Toward Acupuncture Among Pain Fellowship Directors.

OBJECTIVES: The purpose of this survey was to evaluate attitudes toward acupuncture among pain medicine fellowship directors. Additional goals were to assess the availability of acupuncture at academic medical centers and ascertain the inclusion of this modality in fellowship curricula. METHODS: Electronic and paper surveys were distributed to the 97 American College of Graduate Medical Education pain medicine fellowship directors during January and February, 2014. Directors were queried about their referral patterns to acupuncture, as well as their perceptions of the utility of acupuncture for common pain conditions. They were asked about the availability of acupuncture at their institution, and whether acupuncture was included in the fellowship curriculum. RESULTS: Sixty-seven percent of fellowship directors (65/97) completed the questionnaire. A majority of directors (83%) reported acupuncture is available to patients at their institution, and reported that acupuncture is a modality that they discuss with patients when creating a treatment plan for chronic pain (72%). The majority of programs include acupuncture as part of didactic (63%) and clinical (52%) education. Time constraints, lack of qualified teaching personnel, and cost to patients were cited as barriers to inclusion. The majority of fellowship directors considered acupuncture a safe and worthwhile option for common pain conditions. CONCLUSION: Results from this survey indicate that acupuncture is widely available to patients at academic medical centers, integrated into many pain fellowship curricula, and considered a useful modality by physician leaders in the field of pain medicine. This sentiment, paired with the flexibility of national guidelines for pain fellowship curricula, suggests a trend toward greater inclusion of this modality in academic medicine.

Perceptions of Pain Treatment in Pediatric Patients With Functional Gastrointestinal Disorders.

OBJECTIVES: Individual understanding of and expectations for chronic pain treatment can influence treatment adherence and thus success, but little is known about these critical factors in parents and children presenting with pain-predominant functional gastrointestinal disorders. The aim of this study was to identify parent and patient understanding of pain-predominant functional gastrointestinal disorders, expectations for treatment, and interventions utilized before presenting to a multidisciplinary clinic. MATERIALS AND METHODS: This was a prospective study of patients evaluated in a Multidisciplinary Functional Abdominal Pain Program. Before the clinic visit, parents and patients completed questionnaires regarding their understanding of chronic pain, perceptions of abdominal pain contributors, expectations regarding treatment, and identification of previous interventions utilized. RESULTS: Participants were knowledgeable regarding the biology of chronic pain. Perceptions of contributors to abdominal pain included a sensitive stomach, general stress, and nerves/worry. Most had attempted to treat their pain with medication, exercise or physical therapy, or a psychological treatment. Participants reported that receiving a definite diagnosis would be the most helpful intervention, followed by psychological treatment. DISCUSSION: Participants were knowledgeable regarding chronic pain, but still indicated that receiving a definite diagnosis would be the most helpful intervention. Most had tried multiple interventions and did not believe that further medication, testing, or surgery would solve their pain. Instead, parents presenting at this Functional Abdominal Pain Program appeared most hopeful about the benefits of multidisciplinary treatment approaches including psychological interventions, a focus on activity and functioning, and complementary and alternative medicine interventions.

Computer-assisted provision of hormonal contraception in acute care settings.

BACKGROUND: We evaluated whether computerized counseling about contraceptive options and screening for contraindications increased women's subsequent knowledge and use of hormonal contraception. METHODS: For the study 814 women aged 18-45 years were recruited from the waiting rooms of three emergency departments and an urgent care clinic staffed by non-gynecologists and asked to use a randomly selected computer module before seeing a clinician. RESULTS: Women in the intervention group were more likely to report receiving a contraceptive prescription when seeking acute care than women in the control group (16% vs. 1%, p=.001). Women who requested contraceptive refills were not less likely than women requesting new prescriptions to have potential contraindications to estrogen (75% of refills vs. 52% new, p=.23). Three months after visiting the clinic, women in the intervention group tended to be more likely to have used contraception at last intercourse (71% vs. 65%, p=.91) and to correctly answer questions about contraceptive effectiveness, but these differences were not statistically significant. CONCLUSION: Patient-facing computers appear to increase access to prescription contraception for women seeking acute care.

Unexpected interference of baby wash products with a cannabinoid (THC) immunoassay.

OBJECTIVES: The results of newborn drug screening have far-reaching impact not only in healthcare, but also in the legal domain. Therefore, the accuracy of these results cannot be undervalued. When false positive cannabinoid (THC) screening results for this population were suspected at our institution, a multidisciplinary approach was initiated to evaluate the screening process for any pre-analytical or analytical sources of error or interference. DESIGN AND METHODS: Mixtures of drug-free urine with various commercial products and materials that commonly contact newborns in our nursery were prepared and tested using the immunoassay screening methods in our laboratory. Additional commercial products were similarly tested; and when available, individual surfactants common to the interfering products were also evaluated. RESULTS: Addition of Head-to-Toe Baby Wash to drug-free urine produced a dose dependent measureable response in the THC immunoassay. Addition of other commercially available baby soaps gave similar results, and subsequent testing identified specific chemical surfactants that reacted with the THC immunoassay. CONCLUSION: We have identified commonly used soap and wash products used for newborn and infant care as potential causes of false positive THC screening results. Such results in this population can lead to involvement by social services or false child abuse allegations. Given these consequences, it is important for laboratories and providers to be aware of this potential source for false positive screening results and to consider confirmation before initiating interventions. Most importantly, we demonstrate the need for active involvement in the "total testing process," as sources of error are not confined to the laboratory walls.