Effect of Severity of Esophageal Acidification on Sleep vs Wake Periods in Infants Presenting with Brief Resolved Unexplained Events.

OBJECTIVES: To describe the pattern of gastroesophageal reflux (GER) events in wake and sleep states with increasing acid reflux index (ARI) in neonates and to test the hypothesis that GER-related symptoms are frequent in ARI >7% in wake state. STUDY DESIGN: Infants underwent 24-hour pH-impedance studies with 6-hour concurrent video-polysomnography studies. Data were stratified based on the 24-hour ARI (% duration that esophageal pH is <4) into ARI < 3% (normal), ARI 3 ≥ to ≤7% (intermediate), and ARI >7% (abnormal). GER frequency, clearance mechanisms, and symptoms were distinguished during wake state and sleep state. RESULTS: Total wake and sleep duration was similar (P ≥ .2) in all ARI groups. Acidic events were frequent with increasing ARI in wake state vs sleep state (P ≤ .03). The symptom index increased with increasing ARI (P ≤ .02) in both wake state and sleep state. Acid clearance time increased with increasing ARI in wake state (P ≤ .02). In ARI > 7% vs ARI ≤ 7%, frequency of acidic GER events was higher (P ≤ .02) in wake state and sleep state; proximal migration of acid (P = .03) and acid clearance time were higher in wake state (P = .0005) only. Symptom index was higher in ARI >7% vs ARI ≤ 7% in wake state (P < .0001), comparable in normal vs intermediate (P = .4), and higher in abnormal vs intermediate (P = .0004) groups. CONCLUSIONS: Severe esophageal acid exposure (ARI >7%) is associated with increased reflux-associated symptoms in wake state. Sleep state appears to be protective regardless of ARI, likely because of greater chemosensory thresholds. Attention to posture and movements during wake state can be helpful. Scrutiny for non-GER etiologies should occur for infants presenting with life-threatening symptoms.

Autoimmune Hemolytic Anemia in Children: Mayo Clinic Experience.

We studied 35 pediatric patients with autoimmune hemolytic anemia seen at Mayo Clinic from 1994 to 2014. The median age was 10.0 years and 65.7% were males. Most had warm antibodies (80.0%) and some secondary to viral (14.3%) or autoimmune disorders (31.4%). Seven (20.0%) patients presented with Evans syndrome, 3 of whom also had common variable immunodeficiency. The median hemoglobin at diagnosis was 6.1 g/dL and 62.8% patients required red cell transfusions. The severity of anemia was worse among children below 10 years (median 5.5 vs. 7.0 g/dL, P=0.01). Steroid was the initial treatment for 88.5% patients, with overall response rate of 82.7% (68.5% complete, 14.2% partial) and median response duration of 10.7 months (range, 0.2 to 129.7+ mo). After median follow-up of 26.6 months, 8 (22.8%) patients relapsed. Salvage treatments included splenectomy, intravenous immunoglobulin, rituximab, and mycophenolate mofetil. Infectious complications occurred in 9 (25.7%) patients and 1 patient died of cytomegalovirus infection. Four patients had cold agglutinin disease and 3 (75.0%) responded to steroids. Autoimmune hemolytic anemia is a rare disorder in pediatric population and most respond well to steroids regardless of the type of antibody. Infectious complications are common and screening for immunodeficiency is recommended among those with Evans syndrome.

Patient Interest in Video Integration for After-Hours Telemedicine.

PURPOSE: To understand patient attitudes, access toward video calling to enhance efficiency of after-hours triage calls. METHODS: We surveyed patients aged 18 to 89 years. Questions included demographics, preferences, access to video calling devices, and perceived advantages and disadvantages of this technology. Answers were entered into Qualtrics database and analyzed using JMP 11 (SAS, Cary, NC). RESULTS: Two hundred ninety-eight patients agreed to participate. Mean age was 47.9 years; 71.6% were female; and 75.1% had access to video calling device. Device proficiency was inversely related to age and greatest in 18-to-32-years group (χ2 = 71.18, P < .0001). Seventy-one percent of patients enjoyed video communication, directly proportional to education (trend test Z = 2.78, P < .005). Adjusted for both age and education, respondents with college education or above were 3 times more likely to self identify as "good' with video (OR, 3.11; 95% CI, 1.48-6.64); those under age 48 had even higher proficiency (Odds ratio (OR), 13.9; 95% CI, 4.79-59.34). Patients with prior video experience were 3 times more likely to prefer video calling (Relative risk (RR) = 3.46; 95% CI, 1.95-6.11). Patients calling their doctor 5 or more times annually preferred video calling significantly more than calling by telephone (RR, 1.61; 95% CI, 1.31-1.97). Faster contact with the primary care provider (19.8%) was the most perceived advantage. Loss of in-person interaction with doctor (37.1%) was the greatest perceived disadvantage. CONCLUSIONS: Patients seem to have access and interest in video communication for after-hours calls. Further studies are needed to evaluate whether addition of video component to after-hours triage calls will help reduce unnecessary emergency department visits.