Aliza Solomon

Positive Association between Helicobacter pylori and Gastroesophageal Reflux Disease in Children

Objectives:The role of Helicobacter pylori (H pylori) in gastroesophageal reflux disease (GERD) remains controversial, particularly in children, because there are limited published data. Adult studies suggested that H pylori infection may protect against GERD by causing atrophic gastritis, which leads to reduced gastric acid secretion. The objective of our study was to determine the role of H pylori infection in the development of GERD in a pediatric population. Patients and Methods:A retrospective analysis of 420 patients (M:F = 214:206) who underwent esophagogastroduodenoscopy (EGD) with biopsies between January 2000 and April 2006 was conducted. Patient demographics, clinical indications for EGD and the prevalence of reflux esophagitis (RE), the biomarker for GERD, in 2 groups, H pylori positive and H pylori negative, were reviewed. The prevalence of RE in the H pylori–positive and H pylori–negative groups was further analyzed on the basis of sex and age (<1 year, 1–10 years, >10 years). The mean age of the study population was 8.2 years (range 0–20 years). The clinical indications for EGD were as follows: recurrent abdominal pain (n = 186, 44%), malabsorption (n = 80, 19%), persistent vomiting (n = 80, 19%), suspected eosinophilic gastrointestinal disorders (n = 63, 15%), and others such as upper gastrointestinal bleeding or inflammatory bowel disease surveillance (n = 11, 3%). Statistical analysis was performed by using χ2 test, Fisher exact test, and multivariate logistical regression analysis. Results:Among the 420 patients, 16 patients (3.8%) were positive for H pylori and 167 patients (39.8%) were found to have RE. Thirteen patients with H pylori were found to have histologic evidence of RE. The prevalence of RE in the H pylori–positive population was 81.3% compared with 38.1% in the H pylori–negative population (P ≤ 0.05). There were no patients with H pylori in the youngest age group. In the second age group (1–10 years), 100% of the H pylori–positive patients had RE, whereas 44.6% of the H pylori–negative patients had RE (P ≤ 0.05). Both male and female patients with H pylori had a higher prevalence of RE, 77.8% and 85.7%, respectively. On a multivariate logistical regression, for the overall study cohort, H pylori–positive patients had an odds ratio of 5.79 of developing RE compared with H pylori–negative patients (P ≤ 0.05). Conclusions:Our study results indicate that there is a significantly higher prevalence of RE in an H pylori–infected cohort independent of age or sex. The findings suggest that H pylori infection in children is positively associated with RE.

Correlation Between Aeroallergen Levels and New Diagnosis of Eosinophilic Esophagitis in New York City.

Objective: The relation between food allergies and eosinophilic esophagitis (EoE) is well established. Aeroallergens may also contribute to the development of EoE; however, there are limited data to support or refute this hypothesis. The objectives of this pilot study were to determine whether there is a seasonal variation in the onset of symptoms and/or diagnosis of EoE and whether these variations correlate with a specific pollen concentration within New York City. Methods: We performed a retrospective chart review to identify all pediatric patients at New York Presbyterian Weill Cornell Medical Center diagnosed with EoE between 2002 and 2012. Sixty-six patients were identified and 28 were excluded. Cases were classified by both date of initial symptoms and date of histologic diagnosis. Pollen counts from a certified New York City counting station and the percentage of EoE cases were collated monthly and seasonally and compared. Results: There was a seasonal variation in onset of symptoms and diagnosis of EoE, with the highest number of patients reporting onset of symptoms of EoE in July to September, and those being diagnosed with EoE in October to December. There was a seasonal correlation between peak levels of grass pollen and peak onset of EoE symptoms, which were both highest in July to September. The diagnosis of EoE peaked one season later. Conclusions: The study findings suggest that there is a correlation between specific aeroallergens and both the onset of symptoms and time of diagnosis of patients with EoE.

Magnetic resonance enterography and wireless capsule endoscopy in the evaluation of patients with inflammatory bowel disease.

BACKGROUND Magnetic resonance enterography (MRE) is increasingly used in children due to growing concerns of radiation. OBJECTIVE To determine the performance of MRE, imaging findings were compared to wireless capsule endoscopy (WCE) and histology results in children with/or suspected inflammatory bowel disease (IBD). MATERIALS AND METHODS Pathology and WCE reports were retrospectively reviewed in 23 patients who had MRE. RESULTS The sensitivity of MRE was 75.0% while the sensitivity of WCE was 77.8%. CONCLUSION MRE and WCE are complementary techniques in evaluation of the small bowel in IBD.

Non-invasive assessment of endothelial function in children with obesity and lipid disorders.

BACKGROUND Digital tonometry is designed to non-invasively screen for endothelial dysfunction by the detection of impaired flow-induced reactive hyperaemia in the fingertip. We determined whether digital reactive hyperaemia correlated with risk factors for atherosclerosis in two groups of children at increased risk for endothelial dysfunction. METHODS A total of 15 obese children and 23 non-obese, dyslipidaemic children, 8-21 years of age, were enrolled, and their medical histories, anthropometric measurements, carotid wall thickness by means of ultrasonography, and fasting blood samples for cardiovascular risk factors were obtained. The standard endoPAT index of digital reactive hyperaemia was modified to reflect the true peak response or the integrated response of the entire post-occlusion period. In each group, age, sex, pubertal status, carotid wall thickness, and multiple cardiovascular risk factors were tested as predictors of endothelial dysfunction. RESULTS In the non-obese, dyslipidaemic group, but not in the obese group, both indices strongly correlated with height (r=0.55, p=0.007, by peak response) followed by weight, waist circumference, and age. In both groups, neither index of reactive hyperaemia significantly correlated with any other cardiovascular risk factor. CONCLUSIONS Contrary to the known age-related increase in atherosclerosis, digital reactive hyperaemia increased with age and its correlates in non-obese, dyslipidaemic children and was not related to other cardiovascular risk factors in either group. The reason for the lack of this relationship with age in obese children is unknown. The age-dependent physiology of digital microvascular reactivity and the endothelium-independent factors controlling the peak hyperaemic response need further study in children with a wide age range.

Using the Objective Structured Clinical Examination to Assess ACGME Competencies in Pediatric Gastroenterology Fellows

Background: The Accreditation Council for Graduate Medical Education has described 6 core competencies with which trainees should demonstrate proficiency. Using the Objective Structured Clinical Examination (OSCE), we aimed to assess 4 of these competencies among Pediatric Gastrointestinal (GI) fellows (PGs). Methods: Eight first-year PGs from 6 medical centers in the New York area participated in a 4-station OSCE with trained standardized patient (SP) actors. The cases included an emergency department (ED) consult, or “ED Consult” for lower gastrointestinal bleeding; “Breaking Bad News” focusing on CF nutritional complications; “Second Opinion” for abdominal pain; “Transition of Care” for inflammatory bowel disease. At each station, attending faculty observed the encounters behind a 1-way mirror. SPs and faculties provided immediate feedback to the examined fellows. Previously validated OSCE checklists were used to assess performance. On completion, fellows attended debriefing sessions and completed surveys about the educational value. Results: Median overall milestone competency scores were 6.9 (PC1), 4.8 (PC2), 5.9 (MK1), 5.7 (MK2), 6.4 (ICS1), 6.9 (Prof1), and 6.7 (Prof3). Overall, fellows score highest (7/9) on the inflammatory bowel disease “Transition of Care” case, found the “Breaking Bad News” Cystic Fibrosis OSCE to be the most challenging, and were most comfortable with the “ED Consult” OSCE, as a commonly encountered scenario. Overall, the fellows rated the educational value of the program highly. Conclusions: To our knowledge, although the OSCE has been validated in other medical fields, this is the first OSCE program developed for PGs fellows. These OSCEs have included Accreditation Council for Graduate Medical Education competencies, serving to assess fellows’ skills in these areas while exposing them to challenging medical and psychosocial cases that they may not frequently encounter.

An Adolescent Female With Chronic Musculoskeletal Pain

The patient was a 17-year-old athletic girl with a history of chronic musculoskeletal pain. The pain was described as “achy,” began in the left lower extremity in the Achilles tendon and calf and was 4/10 on the pain scale. The frequency of her symptoms was intermittent at first then progressed to daily. The pain subsequently spread to involve the bilateral shoulder girdle, bilateral upper extremities, and bilateral thighs and calves.

Sa1981 Pre-Operative Nutritional Status and Immunosuppression as Predictors of Post-Operative Events in Pediatric Ulcerative Colitis Patients

days) post-operative events occurred in two patients with recurrent perianal disease. Both had normal BMI: one was on IM and one on biologics peri-operatively. Long-term (30-180 days) post-operative events included repeat surgery (1/13, on steroids/biologics), and rectal bleeding requiring readmission (1/13, on biologis); both had normal BMI. One patient had an anastomotic stricture requiring repeat surgery, however this was at >2 years. Of note, 9/ 13 (69%) were seen by our practice as a second opinion. Conclusions: Immunosuppression is more common than malnutrition in pediatric patients with Crohns disease who have post-operative events. Pre-Operative Nutritional Status and Immunosuppression as Predictors of Post-Operative Events in Pediatric Crohns Disease Patients