Pediatric Irritable Bowel Syndrome Patient and Parental Characteristics Differ by Care Management Type.

OBJECTIVES: This study evaluates whether certain patient or parental characteristics are associated with gastroenterology (GI) referral versus primary pediatrics care for pediatric irritable bowel syndrome (IBS). METHODS: A retrospective clinical trial sample of patients meeting pediatric Rome III IBS criteria was assembled from a single metropolitan health care system. Baseline socioeconomic status (SES) and clinical symptom measures were gathered. Various instruments measured participant and parental psychosocial traits. Study outcomes were stratified by GI referral versus primary pediatrics care. Two separate analyses of SES measures and GI clinical symptoms and psychosocial measures identified key factors by univariate and multiple logistic regression analyses. For each analysis, identified factors were placed in unadjusted and adjusted multivariate logistic regression models to assess their impact in predicting GI referral. RESULTS: Of the 239 participants, 152 were referred to pediatric GI, and 87 were managed in primary pediatrics care. Of the SES and clinical symptom factors, child self-assessment of abdominal pain duration and lower percentage of people living in poverty were the strongest predictors of GI referral. Among the psychosocial measures, parental assessment of their child's functional disability was the sole predictor of GI referral. In multivariate logistic regression models, all selected factors continued to predict GI referral in each model. CONCLUSIONS: Socioeconomic environment, clinical symptoms, and functional disability are associated with GI referral. Future interventions designed to ameliorate the effect of these identified factors could reduce unnecessary specialty consultations and health care overutilization for IBS.

Efficacy of a low-cost bubble CPAP system in treatment of respiratory distress in a neonatal ward in Malawi.

BACKGROUND: Respiratory failure is a leading cause of neonatal mortality in the developing world. Bubble continuous positive airway pressure (bCPAP) is a safe, effective intervention for infants with respiratory distress and is widely used in developed countries. Because of its high cost, bCPAP is not widely utilized in low-resource settings. We evaluated the performance of a new bCPAP system to treat severe respiratory distress in a low resource setting, comparing it to nasal oxygen therapy, the current standard of care. METHODS: We conducted a non-randomized convenience sample study to test the efficacy of a low-cost bCPAP system treating newborns with severe respiratory distress in the neonatal ward of Queen Elizabeth Central Hospital, in Blantyre, Malawi. Neonates weighing >1,000 g and presenting with severe respiratory distress who fulfilled inclusion criteria received nasal bCPAP if a device was available; if not, they received standard care. Clinical assessments were made during treatment and outcomes compared for the two groups. FINDINGS: 87 neonates (62 bCPAP, 25 controls) were recruited. Survival rate for neonates receiving bCPAP was 71.0% (44/62) compared with 44.0% (11/25) for controls. 65.5% (19/29) of very low birth weight neonates receiving bCPAP survived to discharge compared to 15.4% (1/13) of controls. 64.6% (31/48) of neonates with respiratory distress syndrome (RDS) receiving bCPAP survived to discharge, compared to 23.5% (4/17) of controls. 61.5% (16/26) of neonates with sepsis receiving bCPAP survived to discharge, while none of the seven neonates with sepsis in the control group survived. INTERPRETATION: Use of a low-cost bCPAP system to treat neonatal respiratory distress resulted in 27% absolute improvement in survival. The beneficial effect was greater for neonates with very low birth weight, RDS, or sepsis. Implementing appropriate bCPAP devices could reduce neonatal mortality in developing countries.

Inflammatory bowel disease characteristics in Hispanic children in Texas.

BACKGROUND: Inflammatory bowel disease (IBD) has a wide spectrum and variability among different ethnic groups. We aimed to evaluate disease characteristics in the pediatric Hispanic population, which has not been well studied. METHODS: We identified patients <18 years old seen at Texas Children's Hospital (TCH) and diagnosed with IBD between 2004 and 2009. We compared them with their White, African American, and "other" counterparts with regard to their demographics, disease characteristics, and initial therapy. RESULTS: There were a total of 399 patients with IBD: 211 (52.9%) White, 67 (16.8%) African American, 53 (13.3%) Hispanic, and 68 (17%) "other." Crohn's disease (CD) was the most common IBD type among all groups; however, Hispanics had the highest proportion of patients with ulcerative colitis (UC) and IBD-unclassified (IBD-U). There was male predominance in all groups except African Americans. Hispanics had the highest percentage of Medicaid coverage (P < 0.01) and none of the Hispanics had a first-degree relative with IBD. They had a younger age at diagnosis but a similar duration of symptoms prior to diagnosis. Hispanics had less failure to thrive and a higher body mass index (BMI) Z-score. Hispanics with CD more often received systemic steroids while those with UC and IBD-U were more often treated with local steroids (P < 0.01), oral 5-aminosalicylate (P < 0.01), and less often received immunomodulators or biologics (P = 0.05). CONCLUSIONS: We demonstrate differences in disease characteristics between Hispanics and other ethnicities with IBD. Further epidemiologic studies are needed, including longer-term follow-up, to better define the burden of illness in Hispanics.

Assessment of DNA methylation at the interferon regulatory factor 5 (IRF5) promoter region in inflammatory bowel diseases.

BACKGROUND AND AIMS: A 5-bp insertion-deletion (indel) polymorphism in the promoter of interferon regulatory factor 5 (IRF5) has been associated with inflammatory bowel diseases (IBD). This polymorphism generates an additional binding site for the transcription factor SP1 and has been shown to augment the expression of IRF5. Additionally, it affects a CpG dinucleotide-dense genomic region. These features of the indel suggested that it may influence the epigenetic regulation of IRF5. The aim of this study was to investigate the potential effect of the 5-bp indel on the methylation pattern of four CpG sites upstream of the polymorphism. Possible CpG site methylation differences in this region between healthy persons and individuals suffering from IBD were also tested. METHODS: Genotype was determined by 4% polyacrylamide gel electrophoresis in 33 peripheral blood leukocyte (PBL) DNA samples. DNA methylation correlates of the genotypes were measured by bisulfite pyrosequencing. IRF5 promoter methylation in association to disease state was assessed in 87 proband (49 healthy, 18 Crohn's disease, 20 ulcerative colitis) PBL samples. RESULTS: The polymorphism did not affect the methylation pattern of the IRF5 promoter nor could we detect significant differences in the average, low methylation of the locus between healthy persons and individuals with IBD. CONCLUSIONS: These results implicate that epigenetic dysregulation of the IRF5 promoter is unlikely to be associated with IBD.

Assessment of the Cylex ImmuKnow cell function assay in pediatric heart transplant patients.

BACKGROUND: The Cylex ImmuKnow (Cylex, Columbia, MD) cell function assay (CICFA) is a commercially available test of immune response that purportedly identifies solid organ transplant patients at risk for either acute rejection (AR) or infection. Data on the utility of this test in pediatric heart transplant patients are very limited. This study tested the hypothesis that CICFA is a clinically useful test in this transplant population. METHODS: All children undergoing heart transplantation at the study center (1989-2006) for whom CICFA levels were obtained were reviewed. The association of CICFA levels with episodes of AR and significant infections was determined. RESULTS: Among 83 patients (34 girls, 41%), 367 CICFA levels were obtained (median, 4.0; interquartile range [IQR], 2.0-6.0 per patient). There were 26 episodes of AR in 17 patients (20%) and 38 infections in 34 patients (41%). CICFA levels were similar among patients with AR at the time of the CICFA measurement (median, 325 [IQR, 163-480] adenosine triphosphate [ATP] ng/ml) vs patients without AR (median, 330 [IQR, 227-441] ATP ng/ml; p = 0.36). CICFA levels were similar among patients with infections within 1 month of CICFA measurement (median, 295 [IQR, 216-366] ATP ng/ml) and those without infections (median, 330 [IQR, 226-453] ATP ng/ml; p = 0.24). CONCLUSIONS: The CICFA is not predictive of AR or significant infections in pediatric heart transplant patients. On the basis of the available evidence, this assay cannot be recommended as part of the routine management of pediatric heart transplant patients.

Reverse transport of children from a tertiary pediatric hospital.

INTRODUCTION: The purpose of this study was to determine the epidemiology and resources used and to study the potential savings of pediatric reverse transport patients. METHODS: A case control study was performed with patients undergoing a reverse or outbound transport from a large, pediatric hospital. Twenty-five children undergoing reverse transport were compared with matched controls. Lengths of stay and costs were compared between the reverse transport and matched control patients. RESULTS: Fifty-two percent of the reverse transport patients returned home, whereas 32% went home for end-of-life care and 16% went to other facilities. The average reverse transport was more than 400 miles and cost $6,064. The reverse transport of these patients did not save pediatric intensive care unit (PICU) days but did result in a shorter hospital stay compared with the matched controls (10 vs. 19 days, P = .03). Decreased utilization of bed days came from less use of intermediate care unit resources. CONCLUSIONS: Pediatric patients undergo reverse transports for a variety of reasons, often for end-of-life care. The ability to reverse transport pediatric patients may not save PICU bed days but may offer pediatric tertiary care hospitals a means to provide more intermediate care bed availability.

The changing face of pleural empyemas in children: epidemiology and management.

OBJECTIVE: Empyema remains a significant cause of morbidity in children. This study evaluates the changes that have affected the outcome in children with pleural empyema, including the emergence of resistant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video-assisted thoracoscopy (VATS). METHODS: A retrospective chart review was performed on all patients who were discharged with a diagnosis of empyema and community-acquired pneumonia over a 10-year period (1993-2002) at Texas Children's Hospital in Houston, Texas. Data collected included demographic information, clinical presentation, radiographic studies, laboratory data including culture results, and hospital course. RESULTS: A total of 230 charts were available for review. The mean age of the patients was 4.0 +/- 3.6 years. Of the pleural fluid cultures performed, 32% (69 of 219) were positive. An additional 27 patients had a cause identified by blood culture. The first penicillin-nonsusceptible Streptococcus pneumoniae was identified in 1995, and the first methicillin-resistant Staphylococcus aureus was identified in 1998. After the universal use of the pneumococcal conjugate vaccine, 3 major changes have occurred (1999-2000 vs 2001-2002): 1) the number of patients admitted with empyema (per 10 000 admissions) has decreased from 23 to 12.6; 2) the prevalence of S pneumoniae has decreased from 66% (29 of 44) to 27% (4 of 15); and 3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant. The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization (11.49 +/- 6.56 days vs 15.18 +/- 8.62 days). CONCLUSIONS: The microbiologic cause of empyema has changed with an increasing incidence of S aureus, particularly methicillin-resistant S aureus. The use of VATS for initial therapy of empyema results in decreased duration of fever and length of hospitalization.

Long-term assessment of T-cell populations in DiGeorge syndrome.

BACKGROUND: Patients with DiGeorge syndrome present with a broad range of T-cell deficiency. Partial DiGeorge syndrome (pDGS) is a preferred designation for patients with detectable T-cell function. Among immunology experts, there is no uniform opinion on the necessity of T-cell precautions for pDGS patients. Few studies have addressed the natural course of their immune function over time. OBJECTIVE: The objective of this study was to describe the natural history of immune parameters in pDGS. METHODS: We reviewed the medical records of 45 pDGS patients. Peripheral blood T-cell subsets counts and percentages were recorded at 1, 6, 12, 18, 24, 30, 48, 60, 72, 96, and 120 months of age, and the rates of change of T-cell measurements over the follow-up period (slopes) were calculated for each individual. Humoral immunity was evaluated by quantification of immunoglobulins and by testing antibody titers to recall antigens. RESULTS: T-cell subsets counts from pDGS patients were generally lower than those of age-matched normal populations but were not severely depressed (ie, CD4+ T-cell percentage less than 15%). The median of the slopes for CD3+, CD4+, and CD8+ T-cell percentages were -0.7%, -0.8%, and -0.1%/month, respectively, in the first year of age and 0.1%/month for each subpopulation from 12 to 120 months of age. Lymphoproliferative responses to phytohemagglutinin were adequate at all ages. Immunoglobulin deficiencies or inadequate production of specific antibodies were not detected. CONCLUSIONS: In our pDGS patient cohort, a significant deterioration of T-cell number or function did not occur over time. Clinical implications of this finding include the possibility of discontinuing T-cell deficiency precautions and frequency of reevaluations of pDGS patients with stable and adequate immune function.