Tissue Transglutaminase Levels Are Not Sufficient to Diagnose Celiac Disease in North American Practices Without Intestinal Biopsies.

BACKGROUND: Celiac serology is crucial for the diagnosis of celiac disease in children. The American guideline for celiac disease in children suggested that positive serology should be followed by confirmatory intestinal histology. The relationship between high tissue transglutaminase titers and celiac disease in children has not been well investigated in children from North America. AIMS: In the present study, we investigated whether different tissue transglutaminase titers in symptomatic children could predict celiac disease without the confirmation of intestinal histology. METHODS: Data from biopsy confirmed celiac children were collected from four different clinics in North America. Clinical, serological, histological, and follow-up data were collected. The accuracy rates of various tissue transglutaminase titers to predict celiac disease in children were calculated. RESULTS: The data from 240 children were calculated. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rate of tissue transglutaminase titers at ≥10× upper limit of normal were 75.4, 48.8, 87.7, 29.0, and 70.8 %, respectively. Similar data were noted in the other tissue transglutaminase titers (≥3× upper limit of normal, >100 U/ml, or >100 U/ml and >10× upper limit of normal). CONCLUSIONS: The positive predictive value of tissue transglutaminase titers at ≥3× upper limit of normal or higher was too low to predict celiac disease in children. Our data suggested that in routine clinical practice, high titers of tissue transglutaminase are not sufficient to diagnose celiac disease in North American children without intestinal biopsies.

Rate of celiac disease in children: view from the endoscopy suite.

OBJECTIVES: The low rate of celiac disease diagnosed in children from the United States may be limited by the practice of "serology-led" diagnosis. The frequency of seronegative celiac disease is unknown, but is underestimated in children and may result in misdiagnosis of celiac disease. The aim of the present study was to investigate the rate of celiac disease after upper endoscopy (esophagogastroduodenescopy [EGD]) with no prior positive celiac serology compared with the rate of celiac disease followed by positive serology. METHODS: Charts of all of the first diagnostic EGDs in children (2009-2013) were retrospectively reviewed. Patients with confirmed celiac disease were divided into 4 groups: group A, positive EGD/positive serology (histology-led diagnosis); group B, positive serology/positive histology (serology-led diagnosis); group C, positive histology followed by negative serology (control 1); and group D, positive serology followed by negative histology (control 2). RESULTS: A total of 761 upper endoscopic charts were reviewed. Of these, 15 children were confirmed with celiac disease (1.97%). There was no significant difference in the demographic data or clinical symptoms between group A and group B. No significant difference was observed in the rate of celiac disease between histology-led celiac diagnosis (group A) and serology-led celiac diagnosis (group B) (1.18% vs 0.79%, P = 0.273). CONCLUSIONS: The rate of celiac disease in endoscopy-led diagnosis was comparable to that in the serology-led diagnosis, suggesting that to increase the detection of celiac disease in children, an adequate number of intestinal biopsies should be performed in every diagnostic upper endoscopic procedure.

Modulation of intestinal TLR4 expression in infants with neonatal opioid withdrawal syndrome.

OBJECTIVE: Neonatal Opioid Withdrawal Syndrome (NOWS) has been associated with the development of necrotizing enterocolitis (NEC) in term and late-preterm neonates. In this study, we used stool gene expression to determine if an increase in baseline inflammation in the intestine of infants with NOWS is associated with these findings. STUDY DESIGN: Stool samples were prospectively collected between days 1-3 and days 4-9 after delivery for opioid-exposed ( n = 9) or non-exposed neonates (n = 8). Stool gene expression for TLR4 and HMGB1 was determined via real-time PCR. RESULTS: TLR4 expression was higher in the stool of the non-exposed group in both time periods, between days 1-3 (P < 0.0001) and days 4-9 (P < 0.05) after delivery. No significant difference in HMGB1 expression was found at either time point (P > 0.05). CONCLUSION: These findings point to an important interplay between opioid exposure and/or NOWS and the inflammatory milieu of the neonatal intestine.

Examination of cord blood at birth in women with SARS-CoV-2 exposure and/or vaccination during pregnancy and relationship to fetal complete blood count, cortisol, ferritin, vitamin D, and CRP.

Background: SARS-CoV-2 is known to manifest a robust innate immune response. However, little is known about inflammatory influences from maternal SARS-CoV-2 infection or maternal mRNA vaccination upon the fetus. In addition, it is unknown if Vitamin D deficiency influences fetal homeostasis or if an anti-inflammatory mechanism to the development of possible innate cytokines or acute phase reactants by the maternal/fetal dyad, in the form of cortisol elevations, occur. In addition, effects on Complete Blood Count (CBC) are not known. Objective: To evaluate the neonatal acute phase reactants and anti-inflammatory responses after maternal SARS-CoV-2 disease or mRNA vaccination. Methods: Samples and medical records reviews from mother/baby dyads (n = 97) were collected consecutively, and were categorized into 4 groups; no SARS-CoV-2 or vaccination exposure (Control), Vaccinated mothers, maternal SARS-CoV-2 disease positive/IgG titer positive fetal blood, and maternal SARS-CoV-2 positive/IgG titer negative fetal blood. SARS-CoV-2 IgG/IgM/IgA titers, CBC, CRP, ferritin, cortisol, and Vitamin D were obtained to examine the possible development of an innate immune response and possible anti-inflammatory response. Student's t-test, Wilcoxon rank-sum, and Chi-squared with Bonferroni corrections were used to compare groups. Multiple imputations were performed for missing data. Results: Cortisol was higher in babies of both mothers who were vaccinated (p = 0.001) and SARS-CoV-2 positive/IgG positive (p = 0.009) as compared to the control group suggesting an attempt to maintain homeostasis in these groups. Measurements of ferritin, CRP, and vitamin D did not reach statistical significance. CBC showed no variation, except for the mean platelet volume (MPV), which was elevated in babies whose mothers were vaccinated (p = 0.003) and SARS-CoV-2 positive/IgG positive (p = 0.007) as compared to the control group. Conclusion: Acute phase reactant elevations were not noted in our neonates. Vitamin D levels were unchanged from homeostatic levels. Cord blood at birth, showed Cortisol and MPV higher in vaccinated and SARS-CoV-2 IgG positive mother/baby dyads as compared to the Control group, indicating that possible anti-inflammatory response was generated. The implication of possible inflammatory events and subsequent cortisol and/or MPV elevation effects upon the fetus after SARS-CoV-2 disease or vaccination is unknown and merits further investigation.

Better Outcomes for Hospitalized Children through Safe Transitions: A Quality Improvement Project.

This project's goal was to implement an already validated pediatric discharge toolkit to enhance the effectiveness of transition from hospital to home, thus reducing 30-day readmission rates. METHODS: This quality improvement study involved implementing a pediatric discharge planning toolkit to improve upon predetermined outcome measures. Critical elements in the toolkit included: (1) comprehensive patient risk assessment on admission; (2) teach-back curriculum; (3) fax or phone call to the primary care physician; (4) 72-hour follow-up calls; and (5) follow-up appointments, scheduled before discharge, within 2 weeks from discharge from hospital. We used the toolkit to gather data on pediatric patients as they were admitted and then prepare them for discharge from December 2016 until March 2017. The primary outcome measure was the 30-day readmissions to the hospital, and the secondary outcome measure was patient satisfaction scores. Our balancing metrics included follow-up appointments made and length of stay. These measures were compared with preintervention hospital pediatric administrative data collected from December 2015 through March 2016. RESULTS: Data collected during the study period (n = 91) compared to preintervention hospital administrative data collected the year prior (n = 132) showed a 31% reduction in readmissions, 4.8% and 7%, respectively (95% confidence interval 0.68-3.8), P = 0.004. Patient satisfaction scores showed no statistical significance. All patients (100%) in both groups had follow-up appointments made before discharge, and the length of stay showed no statistical difference. CONCLUSIONS: This pediatric discharge toolkit improved the efficacy of transition from hospital to home by reducing 30-day readmissions. Patient satisfaction scores were not reduced by utilizing the toolkit.

Diabetes alters vascular mechanotransduction: pressure-induced regulation of mitogen activated protein kinases in the rat inferior vena cava.

BACKGROUND: Diabetes mellitus is an important risk factor for increased vein graft failure after bypass surgery. However, the cellular and molecular mechanism(s) underlying vessel attrition in this population remain largely unexplored. Recent reports have suggested that the pathological remodeling of vein grafts may be mediated by mechanically-induced activation of the mitogen activated protein kinase (MAPK) signaling pathways and the MAPK-related induction of caspase-3 activity. On the basis of these findings, we hypothesized that diabetes may be associated with alterations in how veins "sense" and "respond" to altered mechanical loading. METHODS: Inferior venae cavae (IVC) from the non-diabetic lean (LNZ) and the diabetic obese (OSXZ) Zucker rats were isolated and incubated ex vivo under basal or pressurized conditions (120 mmHg). Protein expression, basal activation and the ability of increased pressure to activate MAPK pathways and apoptosis-related signaling was evaluated by immunoblot analysis. RESULTS: Immunoblot analyses revealed differential expression and activation of extracellular signal-regulated kinase (ERK1/2), p38 and c-Jun NH2-terminal kinase (JNK) MAPKs in the IVCs of diabetic rats as compared to non-diabetic rats. In particular, the expression and basal phosphorylation of p38beta- (52.3 +/- 11.8%; 45.8 +/- 18.2%), JNK 1- (21.5 +/- 9.3%; 19.4 +/- 11.6%) and JNK3-MAPK (16.8 +/- 3.3%; 29.5 +/- 17.6%) were significantly higher (P < 0.05) in the diabetic vena cava. An acute increase in IVC intraluminal pressure failed to increase the phosphorylation of ERK1-, JNK-2, or any of the p38-MAPKs in the diabetic obese Zucker rats. Also, IVC loading in the LNZ led to a 276.0 +/- 36.0% and 85.8 +/- 25.1% (P < 0.05) increase in the cleavage of caspase-3 and caspase-9, respectively, with no effect on these molecules in the OSXZ. No differences were found in the regulation of Bax and Bcl-2 between groups. However, basal expression levels of Akt, phospho-Akt, PTEN, phospho-PTEN and phospho-Bad were higher in the diabetic venae cavae (P < 0.05). CONCLUSION: These data suggest that diabetes is associated with significant alteration in the ability of the vena cava to activate MAPK- and apoptosis-related signaling. Whether these changes are associated with the increased vein graft attrition seen in the diabetic population will require further investigation.

Age-related dystrophin-glycoprotein complex structure and function in the rat extensor digitorum longus and soleus muscle.

This study tested the hypothesis that age-related changes in the dystrophin-glycoprotein complex (DGC) may precede age-associated alterations in muscle morphology and function. Compared to those in adult (6 month) rats, extensor digitorum longus (EDL) and soleus muscle mass was decreased in old (30 month) and very old (36 month) Fischer 344/NNiaHSD x Brown Norway/BiNia rats. The amount of dystrophin, beta-dystroglycan, and alpha-sarcoglycan increased with aging in the EDL and decreased with aging in the soleus. alpha-Dystroglycan levels were increased with aging in both muscles and displayed evidence of altered glycosylation. Immunostaining for the presence of antibody infiltration and dystrophin following increased muscle stretch suggested that the aging in the soleus was characterized by diminished membrane integrity. Together, these data suggest that aging is associated with alterations in EDL and soleus DGC protein content and localization. These results may implicate the DGC as playing a role in age-associated skeletal muscle remodeling.

Upper endoscopy in children: do symptoms predict positive findings?

Upper endoscopy (esophagogastroduodenoscopy or EGD) is an important diagnostic tool for many gastrointestinal symptoms. In recent years, the number of EGDs has increased dramatically. Unfortunately, the rate of negative (normal) EGD in children is high, approximating 50% of all procedures. To decrease the cost of EGD procedures, it is important to assess which clinical symptom would detect positive findings. This information may also be valuable in improving the referral practices of the primary care physicians for EGD. In a retrospective study, we investigated the pathological yield of the first EGD in children referred for various symptoms. Abdominal pain was the most common referral symptom and the best predictor of positive EGD, reaching an accuracy level of 79.9%. All other investigated symptoms had less than 50% accuracy. We concluded that most gastrointestinal symptoms in children have a poor predictive value for positive EGD. A cost-benefit analysis of EGD in children is needed.

Uniaxial stretch-induced regulation of mitogen-activated protein kinase, Akt and p70 S6 kinase in the ageing Fischer 344 x Brown Norway rat aorta.

The effects of ageing on the cardiovascular system contribute to substantial alterations in cellular morphology and function. The variables regulating these changes are unknown; however, one set of signalling molecules that may be of particular importance in mediating numerous cellular responses, including control of cell growth, differentiation and adaptation, are the proteins associated with the mitogen-activated protein kinase (MAPK) signalling systems. The MAPKs, in conjunction with the p70 S6k signalling cascade, have emerged as critical components for regulating numerous mechanotransduction-related cellular responses. Here we investigate the ability of uniaxial stretch to activate the MAPK and p70 S6k pathways in adult (6-month-old), aged (30-month-old) and very aged (36-month-old) Fischer 344/NNiaHSd x Brown Norway/BiNia (FBN) rats. Western blotting of the MAPK family proteins extracellular signal-regulated kinase (Erk) 1/2, p38- and c-Jun NH(2)-terminal kinase (Jnk)-MAPKs showed differential expression and activation between these proteins with age. An acute 15 min interval of 20% uniaxial stretch using an ex vivo aortic preparation demonstrated similar regulation of Erk1/2, p38- and Jnk-MAPK. However, ageing altered uniaxial induced p70 S6k pathway signalling. These observations confirm previous data demonstrating that MAPK proteins are mechanically regulated and also suggest that p70 S6k signalling expression and activation are controlled differently with ageing. Taken together, these data may help to explain, in part, the age-related changes in vascular morphology, function and response to injury.