Effect of Caffeine on Colonic Manometry in Children.

OBJECTIVES: Coffee and caffeinated products have been widely consumed for many centuries. Previous adult studies have suggested that both coffee and decaffeinated beverages induce colonic motility. However, no study has been conducted in pediatrics, and the role of caffeine alone in pediatric colonic motility needs to be explored. METHODS: A prospective study of pediatric patients undergoing standard colonic motility testing that were able to consume caffeinated coffee, decaffeinated coffee, and caffeine tablet during colonic manometry. Patients who had a gastrocolonic reflex and high amplitude propagated contractions (HAPCs) in response to intraluminal administration of bisacodyl in the colon were included in the final analyses. RESULTS: Thirty-eight patients were recruited, 22 of which were excluded, 11 due to abnormal studies (no HAPC seen in response to intraluminal response to bisacodyl), and 11 due to inability to consume all study agents or complete the study. Sixteen patients met criteria for final analyses. Intracolonic bisacodyl produced a larger area under the curve (AUC) compared to all other agents. Caffeinated coffee resulted in a higher AUC, motility index (MI), and time to HAPC compared with decaffeinated coffee ( P < 0.05). There was no significant difference between caffeinated coffee and caffeine tablet, or caffeine tablet and decaffeinated coffee. CONCLUSIONS: Caffeine is indeed a colonic stimulant; however, other components of caffeinated and non-caffeinated beverages likely induce colonic response and require further evaluation for possible use as a colonic stimulant.

Identifying Mast Cells in Gastrointestinal Biopsies in Pediatric Irritable Bowel Patients.

OBJECTIVES: Mast cells (MCs) have been proposed to be involved in the pathophysiology of irritable bowel syndrome (IBS). Nonetheless, the quantity and distribution of MCs in the gastrointestinal tract of pediatric patients with IBS are not well defined. This study aimed to compare the number of MCs in children with and without IBS and to establish histopathological reference values in pediatrics. METHODS: Forty-nine participants with IBS were prospectively enrolled and classified into IBS with atopy (n = 29) and IBS without atopy (n = 20). As our retrospective control group, we selected 42 individuals with a history of polyposis syndrome or gastroesophageal reflux disease with normal histopathology. Retrospective selection of the control cohort was performed in a manner similar to previously published adult and pediatric studies. MCs were prospectively stained immunohistochemically on specimens from the stomach, duodenum, terminal ileum, and descending colon of both groups. RESULTS: The IBS group showed significantly more MCs per high-power field (MCs/HPF) in the stomach, duodenum, terminal ileum, and descending colon ( P < 0.001), irrespective of their atopic status. Optimal MC cutoff values for IBS are ≥20.5 MCs/HPF in the stomach (area under the curve [AUC] = 0.84); ≥23.0 MCs/HPF in the duodenum (AUC = 0.79); ≥33.5 MCs/HPF in the terminal ileum (AUC = 0.82); and ≥22.5 MCs/HPF in the descending colon (AUC = 0.86). CONCLUSIONS: Pediatric patients with IBS showed increased numbers of MCs in the stomach, duodenum, terminal ileum, and descending colon when compared with controls. Further trials are needed to explain the role of MCs in pediatric IBS, which might facilitate the development of targeted therapeutic interventions.

Esophageal epithelial immunoglobulin G is an important marker for the diagnosis and management of pediatric eosinophilic esophagitis.

Background and Aim: Our primary aim was to describe the prevalence of immunoglobulin G (IgG) and its subclass IgG4 in immunohistochemistry staining in esophageal biopsy specimens of children with eosinophilic esophagitis (EoE) compared with that of specimens from children with gastroesophageal reflux disease (GERD). Methods: Esophageal biopsy specimens from children with EoE or GERD were stained prospectively for IgG and IgG4 antibodies. Subjects with EoE were divided into cohorts with either active EoE or EoE in remission. Active EoE cases were further divided into proton pump inhibitor responsive (PPI-r) and PPI-nonresponsive (PPI-nr) subgroups. Demographic, clinical, and histologic data were compared among groups, including quantified IgG and IgG4 staining, peak eosinophil count, eosinophil-derived neurotoxin levels, and EoE endoscopic reference score. Results: Seventy-nine children (aged 10.6 ± 5.6 years; 68% male) were enrolled. IgG-positive cell counts were significantly elevated in those with active EoE (n = 29, 3 [interquartile range, IQR: 2-6]/high-powered field [HPF]), compared with those having EoE remission (n = 25, 1 [IQR: 0-2]/HPF; P = 0.002) and those with GERD (n = 25, 0 [IQR: 0-0.25]/HPF, P = <0.0001). IgG-positive cell counts were significantly higher in the PPI-r (n = 15, 5 [IQR: 2.5-11]/HPF) subgroup, compared with the PPI-nr subgroup (n = 11, 3 [IQR: 1.5-3.5]/HPF; P = 0.041) at baseline endoscopy. Conclusion: Initial esophageal tissue biopsy specimens from pediatric subjects with active EoE showed a significant increase in IgG-positive staining compared with tissue from subjects in EoE remission or with GERD. There was higher positivity of IgG-stained cells in the PPI-r subgroup compared with the PPI-nr subgroup.

Hospital medicine team perception of diversity and inclusion at work.

BACKGROUND: : Diversity and Inclusion concepts are crucial in healthcare as the patient population we encounter as hospitalist medicine team is diverse. A diverse and inclusive environment for healthcare employees can lead to improved job satisfaction and high-quality medical care of patients. However, hospitalist perspectives on diversity and inclusion in their work environment are not well studied and noted in literature. Understanding hospitalist perspectives of diversity and inclusion is important in promoting organizational culture. METHODS: We conducted an online survey of a large hospitalist group at Mayo Clinic, Rochester, from October-December 2019, as part of Hospital Internal Medicine (HIM) Diversity Council (HIM-DC) inception, to understand the perceptions of its staff about diversity and inclusion at work and facilitate the next best steps for the team. The responses to the survey questions were graded on a likert scale. Descriptive statistics were used to analyze and interpret the data. RESULTS: : Of the 135 team members, 78 responded (58%). Of the respondents, more than 80% never witnessed or experienced discrimination from a colleague, while more than 50% did witness or experience discrimination from a patient/visitor. More than 70% did not report this discrimination. Nearly 90% felt that it was an inclusive environment at work, across different personal attributes. Most of the respondents requested additional cultural education and social events. CONCLUSION: Unfortunately, a higher percentage of discrimination is perceived from patients/visitors. This highlights the need for institutional policies about visitor conduct. A high proportion of HIM staff felt inclusive at workplace. Committees such as HIM-DC can augment cultural education and social events to improve team's perception.

Efficacy of Short Course of Preksha Dhyana for Functional Abdominal Pain Disorder in a Busy Pediatric Clinic.

Introduction: Mind body techniques such as meditation improve symptoms in children and adults with IBS. Typical courses, however, are lengthy and difficult to administer. We report our experience with a short course of Preksha Dhyana (PD), a child-friendly focused meditation with yoga. Method: Physicians deliver focused meditation while medical assistants taught yoga. Three sessions were administered biweekly with recommendations for daily practice. Pain severity Likert scores were compared with a treatment as usual (TAU) historical control. Anxiety scores were compared from baseline in the PD group. Results: Thirty PD patients aged 9-17 (20 female) and 52 consecutive TAU group aged 5-17 (33 female) were reviewed. The biweekly sessions had high (71%) completion rates. Utilization rates of PD were similar to TAU despite added sessions. The PD group had an average time of follow-up of 8.9 ± 9.4 vs. 6.0 ± 3.9 months in the TAU group (p = 0.522). Changes in pain scores from baseline showed improvement in the PD group, 0.67 ± 0.13 vs. TAU 1.39 ± 0.11 (p = 0.0003). In the PD group, anxiety scores improved significantly from baseline (0.5 vs. 1, P < 0.001). Pain improved in 93% (28/30) and resolved in 47% (14/30). Conclusion: A short course of PD was successfully embedded in a busy pediatric office without additional staffing. The approach proved cost-effective without increasing overall healthcare utilization and showed significant benefits over TAU. Pending RCT confirmation, this offers a cost-effective method to incorporate mind-body techniques into a pediatric office practice.

Nelarabine associated myotoxicity and rhabdomyolysis.

Nelarabine (ara-G; Arranon; compound 506U78) is an antineoplastic purine analog used for the treatment of refractory or relapsed T-cell acute lymphoblastic leukemia (T-ALL) and T-cell lymphoblastic lymphoma (T-LBL). The drug was granted accelerated approval in October 2005 by the US Food and Drug Administration (FDA) given the efficacy (induction of complete responses) noted in 2 single-arm trials (one in pediatric setting and one in adult patient population). The main spectra of toxicities that have been reported in these clinical trials and subsequent studies are hematological and neurological. Nelarabine induced rhabdomyolysis and increased creatinine phosphokinase (CK; CPK) levels apparently have been reported and this side effect has been added as an adverse reaction in the product monograph from the drug company during postmarketing surveillance. However, the true extent and incidence of the myotoxicity from the drug are unclear. In this paper we report a grade IV CK elevation and rhabdomyolysis in a patient with T-ALL treated with nelarabine. Given the reported finding, we examined the literature further for myotoxicity, increased CK, and/or rhabdomyolysis associated with the use of the nelarabine and report our findings.