A Population-Based Cross-Sectional Study of Paediatric Coeliac Disease in Catalonia Showed a Downward Trend in Prevalence Compared to the Previous Decade.

(1) Background: Previous studies showed an increased prevalence and incidence of coeliac disease (CD) over time. The objective is to ascertain whether the CD prevalence in Catalonia (a region of Southern Europe) among children aged 1-5 is as high as previously found in 2004-2009; (2) Methods: From 2013 to 2019, 3659 subjects aged 1-5 years were recruited following the previously used methodology. Factors with a potential impact on CD prevalence were investigated; (3) Results: In 2013-2019, 43/3659 subjects had positive serology, giving a standardised seroprevalence of 12.55/1000 (95% CI: 8.92; 17.40), compared to 23.62 (13.21; 39.40) in 2004-2007. The biopsy-proven crude prevalence was 7.92/1000 (95% CI: 5.50; 11.30), and the crude prevalence based on ESPGHAN criteria was 8.74/1000 (95% CI: 6.20-12.30). In contrast to 2004-2009, we did not find differences in the seroprevalence rates between 1 and 2 years vs. 3 and 4 years of age (age percentage of change -7.0 (-29.5; 22.8) vs. -45.3 (-67.5; -8.0)). Rotavirus vaccination was the most remarkable potential protective factor (48% vs. 9% in 2004-2009; p < 0.0001), but not the time of gluten introduction. (4) Conclusion: The present study did not confirm a worldwide CD prevalence increase and emphasizes the need to perform prevalence studies over time using the same methodology in the same geographical areas.

Proton Pump Inhibitor Therapy in Pediatric Eosinophilic Esophagitis: Predictive Factors and Long-Term Step-Down Efficacy.

OBJECTIVES: To assess the short- and long-term efficacy of proton pump inhibitor (PPI) therapy for pediatric eosinophilic esophagitis (EoE) in real-world practice with a step-down strategy, and to evaluate factors predictive of PPI responsiveness. METHODS: We collected data regarding the efficacy of PPIs during this cross-sectional analysis of the prospective nationwide RENESE registry. Children with EoE treated with PPI monotherapy were included. Histological remission was defined as a peak eosinophilic count of <15 eosinophils (eos)/high-power field (hpf). Factors associated with PPI responsiveness were identified using multivariate logistic regression analysis. RESULTS: After induction therapy, histological and clinico-histological remission were observed in 51.4% (n = 346) and 46.5% of children, respectively. Normal endoscopic appearance of the esophagus was associated with a higher possibility [odds ratio (OR), 9.20; 95% confidence interval (CI), 2.10-40.16], and fibrostenotic phenotype was associated with a lower possibility (OR, 0.36; 95% CI, 0.18-0.74) of histological remission. Long-term therapy with a step-down strategy effectively maintained histological remission in 68.5% and 85.3% of children at 7 months (n = 108) and 16 months (n = 34), respectively. Complete initial histological remission (≤5 eos/hpf) was associated with a higher possibility of sustained histological remission (OR, 5.08; 95% CI, 1.75-14.68). Adverse events were infrequent and mild. CONCLUSIONS: We confirmed the efficacy of PPIs for a large cohort of children with EoE with sustained histological remission using a step-down strategy. Children with fibrostenotic phenotypes are less likely to respond to induction therapy. Furthermore, patients with complete initial histological remission are more likely to experience long-term histological remission.

Angina de Ludwig / Angina de Ludwig / Ludwig Angina

Introducció. L’angina de Ludwig és un procés infecciós ràpidament progressiu a l’espai submandibular relacionatamb infeccions odontogèniques preexistents. La tomografiacomputada (TC) és útil per definir-ne la localització i l’extensió. Un diagnòstic i un maneig precoços són importantsper evitar complicacions potencialment greus com l’obstrucció de la via aèria.Cas clínic. Adolescent de 14 anys que consulta per odontàlgia amb tumefacció submandibular dolorosa, sialorrea,trisme i disfàgia de 48 hores d’evolució, sense febre associada. Presenta càries en peces dentàries 46-48 i tumescència submandibular dreta, dura i dolorosa al tacte, quesobrepassa la línia mitjana, amb eritema, edema i calor. Alcap de 24 hores d’iniciar l’antibioteràpia, davant l’augmentde la tumefacció i l’empitjorament analític, es fa una TCcervical en què s’objectiva una col·lecció compatible ambabscés al terra de la boca. Es modifica el tractament antibiòtic, s’hi afegeix corticoteràpia i es deriva a cirurgia maxil·lofacial per a tractament quirúrgic.Comentaris. L’angina de Ludwig és una infecció greu delterra de la boca que cal considerar en el diagnòstic diferencial d’una infecció periodontal amb tumefacció submandibular. És de vital importància conèixer-ne les manifestacions locals i sistèmiques per actuar precoçment. (AU)

Introducción. La angina de Ludwig es un proceso infeccioso rápidamente progresivo en el espacio submandibular relacionado coninfecciones odontogénicas preexistentes. La tomografía computarizada (TC) es útil para definir su localización y extensión. Undiagnóstico y manejo precoces son importantes para evitar complicaciones potencialmente graves, como la obstrucción de la víaaérea.Caso clínico. Adolescente de 14 años que consulta por odontalgiacon tumefacción submandibular dolorosa, sialorrea, trismo y disfagia de 48 horas de evolución, sin fiebre asociada. Presenta cariesen piezas dentales 46-48 y tumescencia submandibular derecha, dura y dolorosa al tacto, que sobrepasa la línea media, con eritema, edema y calor. A las 24 horas de iniciar antibioterapia, dadoel aumento de la tumefacción y empeoramiento analítico, se realiza una TC cervical donde se objetiva una colección compatiblecon absceso en el suelo de la boca. Se modifica el tratamientoantibiótico, se añade corticoterapia y se deriva a cirugía maxilofacial para tratamiento quirúrgico. (AU)

Introduction. Ludwig angina is a rapidly progressive infectious process of the submandibular space related to pre-existing odontogenic infections. Computed tomography (CT) is useful to define thelocation and extent. Early diagnosis and management are important to avoid potentially serious complications such as airway obstruction.Case report. A 14-year-old girl presented to the emergency roomwith a 48-hour history of toothache and submandibular swelling,sialorrhea, trismus and dysphagia without associated fever. Physical examination showed caries in teeth number 46-48 and rightsubmandibular tumescence, hard and painful to the touch, whichcrossed the midline, with erythema, edema and heat. Twenty-fourhours after starting antibiotic therapy, given the worsening clinicalcondition and laboratory findings, a cervical CT scan was performed, which showed a collection compatible with abscess in thefloor of the mouth. The antibiotic therapy was changed, corticoidswere added, and the patient was referred to maxillofacial surgeryfor surgical treatment.Comments. Ludwig angina is a serious infection of the floor of themouth that should be considered in the differential diagnosis ofperiodontal infection with submandibular swelling. It is very important to know its local and systemic manifestations for an earlyintervention. (AU)

Intraepithelial Lymphocyte Cytometric Pattern Is a Useful Diagnostic Tool for Coeliac Disease Diagnosis Irrespective of Degree of Mucosal Damage and Age-A Validation Cohort.

INTRODUCTION: The study of intraepithelial lymphocytes (IEL) by flow cytometry is a useful tool in the diagnosis of coeliac disease (CD). Previous data showed that an increase in %TCRγδ+ and decrease of %CD3- IEL constitute a typical CD cytometric pattern with a specificity of 100%. However, there are no data regarding whether there are differences in the %TCRγδ+ related to sex, age, titers of serology, and degree of histological lesion. STUDY AIMS: To confirm the high diagnostic accuracy of the coeliac cytometric patterns. To determine if there are differences between sex, age, serology titers, and histological lesion grade. RESULTS: We selected all patients who fulfilled "4 of 5" rule for CD diagnosis (n = 169). There were no differences in %TCRγδ+ between sexes (p = 0.909), age groups (p = 0.986), serology titers (p = 0.53) and histological lesion grades (p = 0.41). The diagnostic accuracy of complete CD cytometric pattern was: specificity 100%, sensitivity 82%, PPV 100%, NPV 47%. CONCLUSION: We confirmed, in a validation cohort, the high diagnostic accuracy of complete CD pattern irrespective of sex, age, serology titers, and grade of mucosal lesion.

Ús de la PCR de bacteris atípics en el maneig ambulatori de pacients amb pneumònia adquirida a la comunitat que acudeixen a urgències / Uso de la PCR de bacterias atípicas en el manejo ambulatorio de pacientes con neumonía adquirida en la comunidad que acuden a urgencias / Use of PCR for atypical bacteria in the ambulatory management of patients with community-acquired pneumonia seen in the emergency departament

FONAMENT: Mycoplasma pneumoniae I Chlamydophila pneu-moniae són agents causals freqüents de la pneumònia adquirida a la comunitat (PAC) en pediatria, I les tècniques com la reacció en cadena de la polimerasa (PCR) poden facilitar-ne el diagnòstic etiològic precoç, adequant l'antibioteràpia emprada. OBJECTIU: Descriure l'ús d'aquesta tècnica en el maneig ambulatori dels pacients pediàtrics amb PAC que acudeixen a urgències. MÈTODE: Estudi observacional, retrospectiu I descriptiu de pacients pediàtrics diagnosticats de PAC a urgències amb maneig ambulatori. RESULTATS: De 67 pacients, el 32,8% va obtenir un resultat positiu per a bacteris atípics. El percentatge de resultats positius en <4 anys va ser del 10,0% I en ≥4 anys del 42,6% (p = 0,021). Van rebre antibiòtic empíric a l'alta 49 pacients dels 67 (73,1%): 31 macròlids, 12 betalactàmics I 6 ambdós. Amb el resultat de la PCR, per resultat negatiu es van retirar els macròlids a 25 dels 37 als quals se'ls havia pautat (67,6%) I es va pautar a 10 dels 22 casos positius que no els estaven rebent (45,5%). CONCLUSIONS: La PCR de bacteris atípics facilita el diagnòstic microbiològic ràpid I l'adequació de l'antibioteràpia, i, sobretot, evita l'excés de tractament amb macròlids a les urgències pediàtriques

FUNDAMENTO: Mycoplasma pneumoniae y Chlamydophila pneumoniae son agentes causales frecuentes de la neumonía adquirida en la comunidad (NAC) en pediatría, y las técnicas como la reacción en cadena de la polimerasa (PCR) pueden facilitar su diagnóstico etiológico precoz, adecuando la antibioterapia utilizada. OBJETIVO: Describir el uso de esta técnica en el manejo ambulatorio de los pacientes pediátricos con NAC que acuden a urgencias. MÉTODO: Estudio observacional, retrospectivo y descriptivo de pacientes pediátricos diagnosticados de NAC en urgencias manejados ambulatoriamente. RESULTADOS: De 67 pacientes, el 32,8% obtuvo resultado positivo para bacterias atípicas. El porcentaje de resultados positivos en <4 años fue del 10,0% y en ≥4 años de 42,6% (p = 0,021). Recibieron antibiótico empírico 49 pacientes de los 67 (73,1%): 31 macrólidos, 12 betalactámicos y 6 ambos. Con el resultado de la PCR, por resultado negativo se retiraron los macrólidos a 25 de los 37 a los que se les había pautado (67,6%) y se pautó a 10 de los 22 casos positivos que no los estaban recibiendo (45,5%). CONCLUSIONES: La PCR de bacterias atípicas facilita el diagnóstico microbiológico rápido y la adecuación de la antibioterapia, evitando sobre todo el exceso de tratamiento con macrólidos en urgencias

BACKGROUND: Mycoplasma pneumoniae and Chlamydophila pneu-moniae are frequent causative agents of community-acquired pneumonia (CAP) in children. Techniques such as the polymerase chain reaction (PCR) can facilitate early diagnosis and adequacy of antibiotic therapy. OBJECTIVE: To describe the use of this test in the ambulatory management of children with CAP seen in the emergency room. METHOD: Observational, retrospective and descriptive study of children diagnosed with CAP in the emergency room and managed as outpatients. RESULTS: Sixty-seven patients were recruited and 22 (32.8%) had a positive PCR for atypical bacteria. The percentage of positive results in children <4 years was 10.0% and it was 42.6% in children ≥4 years (p = 0.021). Forty-nine (73.1%) patients received antibiotic treatment: 31 received macrolides, 12 beta-lactams and 6 both. The results of the PCR test resulted in discontinuation of macrolide treatment in 25 of 37 patients (67.6%) after a negative PCR test and in its prescription to 10 of the 22 (45.5%) positive cases that were not receiving it. CONCLUSIONS: The use of PCR for atypical bacteria in the emergency department facilitates rapid microbiological diagnosis and the adequacy of antibiotic therapy, avoiding over-treatment with macrolides

Recomendaciones para el diagnóstico y manejo práctico de la esofagitis eosinofílica pediátrica / Recommendations for the diagnosis and practical management of paediatric eosinophilic oesophagitis

La esofagitis eosinofílica es una enfermedad emergente, crónica, mediada por el sistema inmune y caracterizada por síntomas de disfunción esofágica e inflamación con infiltración eosinofílica aislada en el esófago. Es más frecuente en varones y en sujetos atópicos y los síntomas varían con la edad: en niños pequeños se manifiesta con vómitos, dolor abdominal y problemas con la alimentación y en niños mayores y adolescentes con disfagia e impactación alimentaria. El diagnóstico se basa en la presencia de síntomas e inflamación esofágica con ≥ 15 eosinófilos/campo de gran aumento, tras descartar otras causas de eosinofilia esofágica. Sin tratamiento, la enfermedad suele persistir y puede evolucionar a formas fibroestenóticas más frecuentes en el adulto. Las opciones terapéuticas incluyen inhibidores de la bomba de protones, dieta de eliminación empírica y corticoides deglutidos. Tras el tratamiento de inducción es aconsejable la terapia de mantenimiento. La dieta es el único tratamiento que se dirige a la causa de la enfermedad, al identificar los alimentos desencadenantes. La respuesta a los tratamientos requiere la evaluación histológica, por la escasa concordancia entre los síntomas y la inflamación esofágica. El manejo práctico de la esofagitis eosinofílica presenta desafíos debido, entre otras causas, a la falta de disponibilidad actual de fármacos específicos y a su abordaje con tratamientos dietéticos, en ocasiones, complejos. El presente documento, elaborado por el Grupo de Trabajo de Trastornos Gastrointestinales Eosinofílicos de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátricas, tiene como objetivo facilitar el abordaje diagnóstico y terapéutico de la esofagitis eosinofílica pediátrica, con base en las recientes guías de consenso basadas en la evidencia

Eosinophilic oesophagitis is an emerging and chronic disorder mediated by the immune system, and is characterised by symptoms of oesophageal dysfunction and inflammation with isolated eosinophil infiltration in the oesophagus. It is more common in males and in atopic subjects, and the symptoms vary with age. In younger children, there is vomiting, abdominal pain and dietary problems, with dysphagia and food impaction in older children and adolescents. The diagnosis is based on the presence of symptoms and oesophageal inflammation with ≥ 15 eosinophils / high power field, and after ruling out other causes of oesophageal eosinophilia. Without treatment, the disease usually persists and can progress to fibrostenotic forms more common in adults. The treatment options included proton pump inhibitors, empirical elimination diets, and swallowed topical corticosteroids. Maintenance therapy is advisable after the induction treatment. Diet is the only treatment that is directed at the cause of the disease, on identifying the triggering food or foods. The response to the treatments requires a histological assessment due to the poor agreement between the symptoms and the oesophageal inflammation. The practical management of Eosinophilic oesophagitis presents with challenges, due to, among other causes, the current lack of availability of specific drugs, and to its approach with, occasionally complex, diet treatments. The present document, prepared by the Working Group on Eosinophilic Gastrointestinal Disorders of the Spanish Society of Paediatric Gastroenterology, Hepatology and Nutrition, has as its objective to help in the diagnostic and therapeutic approach to paediatric eosinophilic oesophagitis, based on the recent evidence-based consensus guidelines

[Recommendations for the diagnosis and practical management of paediatric eosinophilic oesophagitis]. / Recomendaciones para el diagnóstico y manejo práctico de la esofagitis eosinofílica pediátrica.

Eosinophilic oesophagitis is an emerging and chronic disorder mediated by the immune system, and is characterised by symptoms of oesophageal dysfunction and inflammation with isolated eosinophil infiltration in the oesophagus. It is more common in males and in atopic subjects, and the symptoms vary with age. In younger children, there is vomiting, abdominal pain and dietary problems, with dysphagia and food impaction in older children and adolescents. The diagnosis is based on the presence of symptoms and oesophageal inflammation with ≥ 15 eosinophils / high power field, and after ruling out other causes of oesophageal eosinophilia. Without treatment, the disease usually persists and can progress to fibrostenotic forms more common in adults. The treatment options included proton pump inhibitors, empirical elimination diets, and swallowed topical corticosteroids. Maintenance therapy is advisable after the induction treatment. Diet is the only treatment that is directed at the cause of the disease, on identifying the triggering food or foods. The response to the treatments requires a histological assessment due to the poor agreement between the symptoms and the oesophageal inflammation. The practical management of Eosinophilic oesophagitis presents with challenges, due to, among other causes, the current lack of availability of specific drugs, and to its approach with, occasionally complex, diet treatments. The present document, prepared by the Working Group on Eosinophilic Gastrointestinal Disorders of the Spanish Society of Paediatric Gastroenterology, Hepatology and Nutrition, has as its objective to help in the diagnostic and therapeutic approach to paediatric eosinophilic oesophagitis, based on the recent evidence-based consensus guidelines.

Differences in Management of Eosinophilic Esophagitis in Europe: An Assessment of Current Practice.

OBJECTIVES: The aim of the study was to assess differences in the diagnosis and management of eosinophilic esophagitis (EoE) by European pediatric (PG) and adult gastroenterologists (AG), and their self-reported adherence to guidelines. METHODS: A multiple-choice questionnaire gauged the diagnostic and management strategies of gastroenterologists treating children or adults in 14 European countries and the United Arab Emirates (UAE). RESULTS: Questionnaires were completed by 465 PG and 743 AG. PG were significantly more likely to take biopsies in patients with symptoms of esophageal dysfunction (86.2% PG vs 75.4% AG, P < 0.001) and to perform endoscopic follow-up (86.3% PG vs 80.6% AG, P < 0.001). After failure of proton-pump inhibitors (PPIs), topical steroids were the preferred second-line therapy; however, PG opted more frequently for elimination diets (47.5% PG vs 13.7% AG, P < 0.001). More PG than AG indicated having read recent guidelines (89.4% PG vs 58.2% AG, P < 0.001). Geographic differences in practice were reported, with respondents from the United Kingdom, Portugal, and Spain more often adhering to recommended biopsy protocols. Physicians in the UAE, France, Lithuania, and Poland tended to opt for steroid therapy or elimination diets as first-line therapy, in contrast to most other countries. CONCLUSIONS: Significant differences in general practice between PG and AG were demonstrated with notable divergence from consensus guidelines. International practice variations are also apparent. Among other strategies, educational activities to highlight current recommendations may help harmonize and optimize clinical practice.

Paromomycin is superior to metronidazole in Dientamoeba fragilis treatment.

Dientamoeba fragilis is a trichomonad parasite of the human intestine that is found worldwide. However, the biological cycle and transmission of this parasite have yet to be elucidated. Although its pathogenic capacity has been questioned, there is increasing evidence that clinical manifestations vary greatly. Different therapeutic options with antiparasitic drugs are currently available; however, very few studies have compared the effectiveness of these drugs. In the present longitudinal study, we evaluate 13,983 copro-parasitological studies using light microscopy of stools, during 2013-2015, in Terrassa, Barcelona (Spain). A total of 1150 (8.2%) presented D. fragilis. Of these, 739 episodes were finally analyzed: those that involved a follow-up parasitology test up to 3 months later, corresponding to 586 patients with gastrointestinal symptoms (53% under 15 years of age). Coinfection by Blastocystis hominis was present in 33.6% of the subjects. Our aim was to compare therapeutic responses to different antiparasitic drugs and the factors associated with the persistence of D. fragilis post-treatment. Gender, age, and other intestinal parasitic coinfections were not associated with parasite persistence following treatment. Metronidazole was the therapeutic option in most cases, followed by paromomycin: 65.4% and 17.5% respectively. Paromomycin was found to be more effective at eradicating parasitic infection than metronidazole (81.8% vs. 65.4%; p = 0.007), except in children under six years of age (p = 0.538). Although Dientamoeba fragilis mainly produces mild clinical manifestations, the high burden of infection means we require better understanding of its epidemiological cycle and pathogenicity, as well as adequate therapeutic guidelines in order to adapt medical care and policies to respond to this health problem.

A Scoring System for Identifying Patients Likely to Be Diagnosed with Low-Grade Coeliac Enteropathy.

BACKGROUND & AIMS: Determining whether patients with lymphocytic enteritis (LE) have coeliac disease is a challenge. We analysed the variables associated with a low-grade coeliac enteropathy diagnosis in patients with suspected coeliac disease but without villous atrophy, and developed a scoring system to identify them. METHODS: We collected data from 2010 through to 2016 on patients with lymphocytic enteritis and persistent symptoms compatible with the clinical spectrum of coeliac disease. One hundred and four patients starting on a gluten-free diet (GFD) were included. Duodenal biopsies were collected before the GFD and analysed for numbers of CD3+ T-cell receptor gamma delta+ (TCRγδ+), and CD3- intraepithelial lymphocytes. We performed a logistic regression analysis to identify factors associated with a low-grade coeliac enteropathy diagnosis. RESULTS: Sixty-two patients achieved clinical remission after the GFD. Fifty of these 62 patients were diagnosed with low-grade coeliac enteropathy. Multivariate analysis identified the presence of >25% intraepithelial lymphocytosis, HLA-DQ2.5, positive serology, and increased numbers of TCRγδ+ cells with a low-grade coeliac enteropathy diagnosis. We developed a scoring system that identified patients with an area under the ROC curve (AUC) of 0.91. Scores of >10 had 86% sensitivity and 85% specificity. CONCLUSION: We developed a scoring system that identifies patients likely to be diagnosed with low-grade coeliac enteropathy with an AUC value of 0.91.

Pediatric Eosinophilic Esophagitis: Results of the European Retrospective Pediatric Eosinophilic Esophagitis Registry (RetroPEER).

OBJECTIVES: Recommendations for diagnosing and treating eosinophilic esophagitis (EoE) are evolving; however, information on real world clinical practice is lacking. To assess the practices of pediatric gastroenterologists diagnosing and treating EoE and to identify the triggering allergens in European children. METHODS: Retrospective anonymized data were collected from 26 European pediatric gastroenterology centers in 13 countries. Inclusion criteria were: Patients diagnosis with EoE, completed investigations prescribed by the treating physician, and were on stable medical or dietary interventions. RESULTS: In total, 410 patients diagnosed between December 1999 and June 2016 were analyzed, 76.3% boys. The time from symptoms to diagnosis was 12 ±â€Š33.5 months and age at diagnosis was 8.9 ±â€Š4.75 years. The most frequent indications for endoscopy were: dysphagia (38%), gastroesophageal reflux (31.2%), bolus impaction (24.4%), and failure to thrive (10.5%). Approximately 70.3% had failed proton pump inhibitor treatment. The foods found to be causative of EoE by elimination and rechallenge were milk (42%), egg (21.5%), wheat/gluten (10.9%), and peanut (9.9%). Elimination diets were used exclusively in 154 of 410 (37.5%), topical steroids without elimination diets in 52 of 410 (12.6%), both diet and steroids in 183 of 410 (44.6%), systemic steroids in 22 of 410 (5.3%), and esophageal dilation in 7 of 410 (1.7%). Patient refusal, shortage of endoscopy time, and reluctance to perform multiple endoscopies per patient were noted as factors justifying deviation from guidelines. CONCLUSIONS: In this "real world" pediatric European cohort, milk and egg were the most common allergens triggering EoE. Although high-dose proton pump inhibitor trials have increased, attempted PPI treatment is not universal.

Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: The 2-4-6 study.

BACKGROUND: Numerous dietary restrictions and endoscopies limit the implementation of empiric elimination diets in patients with eosinophilic esophagitis (EoE). Milk and wheat/gluten are the most common food triggers. OBJECTIVE: We sought to assess the effectiveness of a step-up dietary strategy for EoE. METHODS: We performed a prospective study conducted in 14 centers. Patients underwent a 6-week 2-food-group elimination diet (TFGED; milk and gluten-containing cereals). Remission was defined by symptom improvement and less than 15 eosinophils/high-power field. Nonresponders were gradually offered a 4-food-group elimination diet (FFGED; TFGED plus egg and legumes) and a 6-food-group elimination diet (SFGED; FFGED plus nuts and fish/seafood). In responders eliminated food groups were reintroduced individually, followed by endoscopy. RESULTS: One hundred thirty patients (25 pediatric patients) were enrolled, with 97 completing all phases of the study. A TFGED achieved EoE remission in 56 (43%) patients, with no differences between ages. Food triggers in TFGED responders were milk (52%), gluten-containing grains (16%), and both (28%). EoE induced only by milk was present in 18% and 33% of adults and children, respectively. Remission rates with FFGEDs and SFGEDs were 60% and 79%, with increasing food triggers, especially after an SFGED. Overall, 55 (91.6%) of 60 of the TFGED/FFGED responders had 1 or 2 food triggers. Compared with the initial SFGED, a step-up strategy reduced endoscopic procedures and diagnostic process time by 20%. CONCLUSIONS: A TFGED diet achieves EoE remission in 43% of children and adults. A step-up approach results in early identification of a majority of responders to an empiric diet with few food triggers, avoiding unnecessary dietary restrictions, saving endoscopies, and shortening the diagnostic process.

Intestinal intraepithelial lymphocyte cytometric pattern is more accurate than subepithelial deposits of anti-tissue transglutaminase IgA for the diagnosis of celiac disease in lymphocytic enteritis.

BACKGROUND & AIMS: An increase in CD3+TCRγδ+ and a decrease in CD3- intraepithelial lymphocytes (IEL) is a characteristic flow cytometric pattern of celiac disease (CD) with atrophy. The aim was to evaluate the usefulness of both CD IEL cytometric pattern and anti-TG2 IgA subepithelial deposit analysis (CD IF pattern) for diagnosing lymphocytic enteritis due to CD. METHODS: Two-hundred and five patients (144 females) who underwent duodenal biopsy for clinical suspicion of CD and positive celiac genetics were prospectively included. Fifty had villous atrophy, 70 lymphocytic enteritis, and 85 normal histology. Eight patients with non-celiac atrophy and 15 with lymphocytic enteritis secondary to Helicobacter pylori acted as control group. Duodenal biopsies were obtained to assess both CD IEL flow cytometric (complete or incomplete) and IF patterns. RESULTS: Sensitivity of IF, and complete and incomplete cytometric patterns for CD diagnosis in patients with positive serology (Marsh 1+3) was 92%, 85 and 97% respectively, but only the complete cytometric pattern had 100% specificity. Twelve seropositive and 8 seronegative Marsh 1 patients had a CD diagnosis at inclusion or after gluten free-diet, respectively. CD cytometric pattern showed a better diagnostic performance than both IF pattern and serology for CD diagnosis in lymphocytic enteritis at baseline (95% vs 60% vs 60%, p = 0.039). CONCLUSIONS: Analysis of the IEL flow cytometric pattern is a fast, accurate method for identifying CD in the initial diagnostic biopsy of patients presenting with lymphocytic enteritis, even in seronegative patients, and seems to be better than anti-TG2 intestinal deposits.

Are positive serum-IgA-tissue-transglutaminase antibodies enough to diagnose coeliac disease without a small bowel biopsy? Post-test probability of coeliac disease.

BACKGROUND: It has been suggested that high titres of tTG are associated with elevated positive predictive values (PPV) for celiac disease. However, the PPV of a strongly positive tTG will depend on the celiac disease prevalence in the different risk groups of the disease AIMS: To assess the PPV of a strongly positive tTG for celiac disease. In addition, to calculate the post-test probability for celiac disease of a strongly positive tTG in a setting of routine clinical practice. METHODS: 145 consecutive celiac disease patients with positive tTG, and with a small bowel biopsy were included. The PPV for different cut-off points of tTG levels for the diagnosis of celiac disease was assessed. In addition, the cut-offs associated with higher PPV were used to calculate the positive likelihood ratio. A simulation in a setting of routine clinical practice was performed to calculate the post-test probability of celiac disease. RESULTS: No cut-off level was associated with a PPV of 100%. A cut-off of 80 U/mL (11.4×upper normal limit) was associated with the higher PPV value of 98.6%. In the most frequent clinical situations, which in general have a pre-test probability <10%, the post-test probability after having a strongly positive tTG was 90% or less. CONCLUSIONS: A strongly positive tTG should not be enough to diagnose celiac disease in the most frequent clinical situations, small bowel biopsy remaining as the gold standard in these cases.

Evolución de las formas de presentación de la enfermedad celíaca en 429 niños a lo largo de veinte años. Estudio multicéntrico / Different clinical presentations of celiac disease over time. Multicentric study of a cohort of 429 children diagnosed over a 20-year period

Fundamento. La enfermedad celíaca es una enfermedadinducida genéticamente, en la que existe una intoleranciapermanente al gluten, y que provoca una lesión severade la mucosa intestinal. En la actualidad se sabe quesu expresividad clínica puede ser muy variada y que, ademásde la forma clásica (diarrea, pérdida de peso, distensiónabdominal, cambio de carácter, etc.), pueden existirformas atípicas, predominantemente extradigestivas, e inclusoformas asintomáticas o silentes.Objetivo. El objetivo de este estudio es conocer las formasde presentación de la enfermedad celíaca en la actualidady su evolución a lo largo de los últimos años.Método. Para ello se ha realizado un estudio multicéntricodescriptivo y retrospectivo, a través de la revisión delas historias clínicas de los pacientes diagnosticados de enfermedadcelíaca en las unidades de gastroenterología infantilde ocho centros hospitalarios, desde 1984 hasta2003, siendo requisito indispensable para la inclusión en elestudio la constatación de lesión de la mucosa intestinalsegún los criterios de Marsh.Resultados. La forma de presentación más frecuentefue la forma digestiva (60%), seguida de las atípicas(33.5%) (retraso de peso, dolor abdominal, distensión abdominal,estreñimiento, retraso de talla, alteraciones aisladasen la analítica sanguínea o vómitos) y las asintomáticaso silentes (6.5%).Se han establecido cuatro periodos de estudio (1984-1988, 1989-1993, 1994-1998 y 1999-2003), y se ha objetivadoun aumento progresivo de la edad media dediagnóstico a lo largo de los diferentes períodos, que secorresponde con un gradual aumento de las formasatípicas, en detrimento de las digestivas, así como unalenta progresión a lo largo del tiempo de las formas silentes diagnosticadas, pasando de un 81.8% de formas digestivasen el primer quinquenio, a un 55.3% en el último. Elanálisis del peso de los enfermos en el momento del diagnósticoen relación con el año en que se realizó éstedemuestra que ha ido mejorando progresivamente a lolargo de los años, lo que es un índice de menor afectacióngeneral en las formas atípicas.Conclusiones. Se concluye que la utilización de marcadoresserológicos para la detección de enfermedad celíacapermite sospechar el diagnóstico en muchos casos de formasatípicas de presentación anteriormente desconocidas,que posteriormente se confirman mediante biopsia intestinal.A medida que esos conocimientos se divulgan, se amplíael campo de investigación y consecuentemente aumentael número de casos diagnosticados

Background. Celiac disease is a genetically-determinedillness characterized by permanent intolerance to gluten,resulting in a severe damage to the intestinal mucosa. It iswell known that celiac disease has a wide spectrum ofclinical presentations; in addition to the classic form, characterizedby diarrhea, weight loss, and abdominal distension,atypical forms with predominantly extraabdominaldisease, and even asymptomatic or silent forms, exist.Objective. The objective of this study is to describe thedifferent presentation forms diagnosed over time.Method. A multicentric retrospective descriptive studywas performed. The medical records of patients diagnosedwith celiac disease in eight gastroenterology units betweenthe years 1984 and 2003, were reviewed. Documentationof the typical intestinal mucosa changes using theMarsh criteria was required.Results. The digestive form was the most common(60%), followed by the atypical form (poor weight orheight gain, abdominal pain, constipation, abnormal laboratorytests, or vomiting) in 33.5%, and the asymptomaticor silent form in 6.5%.The patient population was divided in four periodsaccording to the date of diagnosis (1984-1988, 1989-1993,1994-1998, and 1999-2003). The median age at diagnosisincreased in successive periods, which correlated with agradual increase in the percentage of the atypical andsilent forms. During the first period, 81.8% of celiacdisease cases were digestive forms, compared with 55.3%during the last period. The weight at the time of diagnosisalso increased over time, as a reflection of the less clinicalseverity of the atypical forms.Conclusions. We conclude that the use of serologicalmarkers for the detection of celiac disease allows for thediagnosis of atypical and silent forms, later confirmed byintestinal biopsy. As this knowledge is disseminated, thefield of research is expanded, and the number of casesdiagnosed increasesBackground. Celiac disease is a genetically-determined illness characterized by permanent intolerance to gluten, resulting in a severe damage to the intestinal mucosa. It is well known that celiac disease has a wide spectrum of clinical presentations; in addition to the classic form, characterized by diarrhea, weight loss, and abdominal distension, atypical forms with predominantly extraabdominal disease, and even asymptomatic or silent forms, exist. Objective. The objective of this study is to describe the different presentation forms diagnosed over time. Method. A multicentric retrospective descriptive study was performed. The medical records of patients diagnosed with celiac disease in eight gastroenterology units between the years 1984 and 2003, were reviewed. Documentation of the typical intestinal mucosa changes using the Marsh criteria was required. Results. The digestive form was the most common (60%), followed by the atypical form (poor weight or height gain, abdominal pain, constipation, abnormal laboratory tests, or vomiting) in 33.5%, and the asymptomatic or silent form in 6.5%. The patient population was divided in four periods according to the date of diagnosis (1984-1988, 1989-1993, 1994-1998, and 1999-2003). The median age at diagnosis increased in successive periods, which correlated with a gradual increase in the percentage of the atypical and silent forms. During the first period, 81.8% of celiac disease cases were digestive forms, compared with 55.3% during the last period. The weight at the time of diagnosis also increased over time, as a reflection of the less clinical severity of the atypical forms. Conclusions. We conclude that the use of serological markers for the detection of celiac disease allows for the diagnosis of atypical and silent forms, later confirmed by intestinal biopsy. As this knowledge is disseminated, the field of research is expanded, and the number of cases diagnosed increasesBackground. Celiac disease is a genetically-determined illness characterized by permanent intolerance to gluten, resulting in a severe damage to the intestinal mucosa. It is well known that celiac disease has a wide spectrum of clinical presentations; in addition to the classic form, characterized by diarrhea, weight loss, and abdominal distension, atypical forms with predominantly extraabdominal disease, and even asymptomatic or silent forms, exist. Objective. The objective of this study is to describe the different presentation forms diagnosed over time. Method. A multicentric retrospective descriptive study was performed. The medical records of patients diagnosed with celiac disease in eight gastroenterology units between the years 1984 and 2003, were reviewed. Documentation of the typical intestinal mucosa changes using the Marsh criteria was required. Results. The digestive form was the most common (60%), followed by the atypical form (poor weight or height gain, abdominal pain, constipation, abnormal laboratory tests, or vomiting) in 33.5%, and the asymptomatic or silent form in 6.5%. The patient population was divided in four periods according to the date of diagnosis (1984-1988, 1989-1993, 1994-1998, and 1999-2003). The median age at diagnosis increased in successive periods, which correlated with a gradual increase in the percentage of the atypical and silent forms. During the first period, 81.8% of celiac disease cases were digestive forms, compared with 55.3% during the last period. The weight at the time of diagnosis also increased over time, as a reflection of the less clinical severity of the atypical forms. Conclusions. We conclude that the use of serological markers for the detection of celiac disease allows for the diagnosis of atypical and silent forms, later confirmed by intestinal biopsy. As this knowledge is disseminated, the field of research is expanded, and the number of cases diagnosed increases

Cursos de reanimación cardiopulmonar pediátrica básica para padres y educadores / Training in basic cardiopulmonary resuscitation for parents and educators

Fundamento. Las maniobras de reanimación cardiopulmonar (RCP) pediátrica son útiles cuando comienzan antes de los 4 minutos de haberse producido la parada cardiorespiratoria. Los adultos que normalmente cuidan a los niños (padres y maestros) tienen que conocer estas maniobras. Objetivo. Determinar las características de los alumnos que han realizado el curso de RCP, así como su grado de aceptación y el grado de eficacia, en una consulta privada de pediatría de Terrassa. Método. Entre noviembre de 1999 y junio del 2002 se realizaron 20 cursos de RCP básica dirigidos a padres y maestros de escuela, con 279 alumnos, con una media de 6,1 alumnos por sesión (rango 3-12). Todos los cursos siguieron las recomendaciones de Grupo Español de Reanimación Cardiopulmonar Pediátrica y Neonatal. Resultados. El 75.5 por ciento de los alumnos fueron mujeres. El 61.3 por ciento del total fueron maestros, el 31 por ciento madres y padres, el 5.8 por ciento canguros, el 1 por ciento abuelos y abuelas, y otro 1 por cientovariado. Hay diferencias estadísticamente significativas entre la evaluación teórica inicial y la final (5.3 v. 8.5; p < 0.001). La evaluación práctica refleja que la maniobra más dificultosa por parte del alumno es la apertura de la vía aérea. El 87 por ciento de los alumnos se consideran preparados para realizar una RCP básica al finalizar el curso. Discusión. La población femenina está más sensibilizada. La evaluación teórica y práctica sirve como indicador de la eficacia de los cursos. La encuesta de satisfacción es un buen método de control de calidad. Nuestra experiencia indica que los padres y los maestros aceptan su puesto dentro de la cadena de supervivencia (AU)