Gastrointestinal Pathologies in Pediatric Patients With Cystic Fibrosis Undergoing Endoscopy: A Single-Center Retrospective Review Over 15 Years.

Introduction Previous studies have demonstrated an increased incidence of gastrointestinal (GI) pathologies, specifically celiac disease (CD) and eosinophilic esophagitis (EoE), in patients with cystic fibrosis (CF). However, there is minimal data available regarding endoscopic findings in pediatric patients with CF and GI mucosal disease.  Methods A retrospective chart review was performed on patients with CF under 18 years of age who underwent esophagogastroduodenoscopy (EGD) or colonoscopy with biopsy over a 15-year period at our institution. Patient characteristics including assigned sex at birth, CF genetic mutations (if identified), and cystic fibrosis transmembrane conductance regulator (CFTR) modulator use were recorded. Data obtained at the time of biopsy included body mass index (BMI), indication for the procedure, exocrine pancreatic status, visual endoscopic findings, and histologic findings. Results A total of 72 patients with CF were included in the study. 24% (n=17) were found to have abnormal endoscopic biopsy results. EoE (13% of all patients, n=9) and CD (6% of all patients, n=4) were the most common GI diagnoses present on endoscopic biopsy. All 3 patients taking CFTR modulator medications at the time of endoscopy had normal biopsy results. Of the 17 patients found to have abnormal pathology results, 14 (82%) were taking proton-pump inhibitor (PPI) medication at the time of endoscopy. Conclusion This study highlights the probable increased frequency of GI disease in the pediatric CF population. These findings underscore the importance of maintaining a broad differential diagnosis while considering utilization of endoscopy with biopsy in pediatric patients with CF who have GI symptoms.

Recurrent Epistaxis Throughout the Lifespan: A Clinical Review.

Epistaxis is a common otolaryngologic complaint experienced by 60 percent of the U.S. population and can be the result of either local or systemic disturbance. Most nosebleeds arise from an anastomotic region along the anterior nasal septum known as Kiesselbach's plexus. However, roughly ten percent of nosebleeds originate posteriorly from the sphenopalatine branch of the maxillary artery. Posterior nosebleeds can be more difficult to control and are frequently associated with systemic derangement. Patients presenting with a nosebleed should first be assessed for airway patency and hemodynamic stability. Once the patient is confirmed to be acutely stable, pre-existing clots should be cleared from the nasal cavity and the nasal alae should be compressed against the septum for ten to fifteen minutes. Application of a topical vasoconstricting agent can also be considered at this time. If the nosebleed persists and the location of the bleed can be visualized, chemical or electrical cautery can be used. If the site of the bleed cannot be identified, nasal packing materials in the form of lubricant-impregnated ribbon gauze or readymade nasal packing devices can be placed to tamponade the bleed. Following failure of these conservative treatment modalities, otolaryngologist consultation should be sought. Next steps in management may include arterial ligation or embolization.

Simulation-Based Interprofessional ICU Bedside Rounding Course.

INTRODUCTION: Medical schools are beginning to implement courses in interprofessional education (IPE) to prepare students for the interprofessional team-based patient care model which is becoming the standard of practice in many healthcare facilities. Students often have little exposure to multidisciplinary rounds prior to residency, and fast-paced low-capacity healthcare environments such as operating rooms and intensive care units (ICUs) necessitate providers be competent and efficient in working within interprofessional teams. METHODS: The University of South Dakota Sanford School of Medicine has developed an innovative, simulationbased ICU bedside rounding course that uses a custom-designed simulated electronic health record system that is a hybrid desktop/web-based application. After they have had the opportunity to review the simulated patient's health records on their own, healthcare students of different backgrounds complete the simulated ICU rounding with a standardized patient at the Parry Simulation Center. This activity includes students from nursing, pharmacy, respiratory therapy, physical therapy, and occupational therapy alongside medical students. Students educate one another about their scope of practice, roles and responsibilities, strengths and limitations, as well as treatment goals and associated challenges. Students receive a formative assessment based on the clinical aspects of the curriculum. In addition, their IPE skills are assessed with the use of a 360-degree assessment instrument designed to measure core IPE competencies: (1) information sharing, (2) team support, (3) learning, (4) teaching, and (5) role clarity. The course consists of two-hour sessions that include a simulation-based encounter followed by a post-activity debriefing. RESULTS: Average medical student IPE competency score varied significantly based upon grader, with standardized patients grading more harshly. Several common clinical pitfalls were also identified, including indwelling line status and code status. Satisfaction surveys from students showed high satisfaction and requests for including more specialties. CONCLUSIONS: A simulation-based IPE course implemented at an appropriate time in a healthcare curriculum, with applied principles in effective teamwork and communication, will better prepare health professional students to work within the dynamic interprofessional healthcare environment.

Loss of interleukin-10 receptor disrupts intestinal epithelial cell proliferation and skews differentiation towards the goblet cell fate.

Intestinal epithelial cells (IEC) are crucial for maintaining proper digestion and overall homeostasis of the gut mucosa. IEC proliferation and differentiation are tightly regulated by well described pathways, however, relatively little is known about how cytokines shape these processes. Given that the anti-inflammatory cytokine interleukin (IL)-10 promotes intestinal barrier function, and insufficient IL-10 signaling increases susceptibility to intestinal diseases like inflammatory bowel disease, we hypothesized that IL-10 signaling modulates processes underlying IEC proliferation and differentiation. This was tested using in vivo and in vitro IEC-specific IL-10 receptor 1 (IL-10R1) depletion under homeostatic conditions. Our findings revealed that loss of IL-10R1 drove lineage commitment toward a dominant goblet cell phenotype while decreasing absorptive cell-related features. Diminished IL-10 signaling also significantly elevated IEC proliferation with relatively minor changes to apoptosis. Characterization of signaling pathways upstream of proliferation demonstrated a significant reduction in the Wnt inhibitor, DKK1, increased nuclear localization of ß-catenin, and increased transcripts of the proliferation marker, OLFM4, with IL-10R1 depletion. Phosphorylated STAT3 was nearly completely absent in IL-10R1 knockdown cells and may provide a mechanistic link between our observations and the regulation of these cellular processes. Our results demonstrate a novel role for IL-10 signaling in intestinal mucosal homeostasis by regulating proper balance of proliferation and IEC lineage fate.

Interleukin 1α Is Critical for Resistance against Highly Virulent Aspergillus fumigatus Isolates.

Heterogeneity among Aspergillus fumigatus isolates results in unique virulence potential and inflammatory responses. How these isolates drive specific immune responses and how this affects fungally induced lung damage and disease outcome are unresolved. We demonstrate that the highly virulent CEA10 strain is able to rapidly germinate within the immunocompetent lung environment, inducing greater lung damage, vascular leakage, and interleukin 1α (IL-1α) release than the low-virulence Af293 strain, which germinates with a lower frequency in this environment. Importantly, the clearance of CEA10 was consequently dependent on IL-1α, in contrast to Af293. The release of IL-1α occurred by a caspase 1/11- and P2XR7-independent mechanism but was dependent on calpain activity. Our finding that early fungal conidium germination drives greater lung damage and IL-1α-dependent inflammation is supported by three independent experimental lines. First, pregermination of Af293 prior to in vivo challenge drives greater lung damage and an IL-1α-dependent neutrophil response. Second, the more virulent EVOL20 strain, derived from Af293, is able to germinate in the airways, leading to enhanced lung damage and IL-1α-dependent inflammation and fungal clearance. Third, primary environmental A. fumigatus isolates that rapidly germinate under airway conditions follow the same trend toward IL-1α dependency. Our data support the hypothesis that A. fumigatus phenotypic variation significantly contributes to disease outcomes.