A Quantitative Assessment of Mucosal Eosinophils in the Gastrointestinal Tract of Children Without Detectable Organic Disease

Background Accurate measurements of mucosal eosinophil concentrations in gastrointestinal tracts of healthy children are necessary to differentiate health and disease states in general, and better define eosinophilic gastrointestinal diseases. Study We retrospectively reviewed gastrointestinal biopsies from children with macroscopically normal endoscopies, who, after a minimal follow-up of one year, were not diagnosed with any organic disease. Peak eosinophil concentrations and distributions were assessed from each segment of the gastrointestinal tract. Results Three centers (Italy, United Kingdom, and Israel) contributed 202 patients (median age 13 years IQR 9.5–15.5, range 1–18 years). Median (IQR, range) eosinophil concentrations (eos/mm2) were: esophagus 0 (0–0, 0–84), stomach 0 (0–4, 0–84), duodenal bulb 20 (13–30, 7–67), second part of duodenum 20 (13–29, 0–105), terminal ileum 29 (14–51, 0–247), cecum 53 (37–89, 10–232), ascending colon 55 (25–84, 0–236), transverse colon 38 (21–67, 4–181), descending colon 29 (17–59, 0–114), sigmoid colon 25 (13–40, 0–215) and rectum 13 (4–28, 0–152). Significant geographical variance was present, however, no differences in eosinophil concentrations were identified between children with resolving symptoms vs. those with functional diagnoses, nor across age groups. Conclusions Standardized eosinophil concentrations from the gastrointestinal tracts of children without organic disease will serve to better define both health and disease states. No differences were found between resolved symptoms vs. functional diagnoses nor between age groups in this pediatric cohort.

Abdominal Pain

Key Points Functional abdominal pain disorders are the most common causes of recurrent abdominal pain in pediatrics.The Rome IV criteria in 2016 for functional abdominal pain have eliminated the requirement of "no evidence for organic disease"; it now is defined as > 2 months of pain, ≥ 4 times per month, and after appropriate medical evaluation the symptoms cannot be attributed to another medical condition.History and physical examination are the only evaluations required most of the time in a child with abdominal pain.

Prenatal electrocardiogram testing and postpartum depression: A population-based cohort study

Background Cardiovascular symptoms in pregnancy may be a clue to psychological distress. We examined whether electrocardiogram testing in pregnant women is associated with an increased risk of subsequent postpartum depression. Methods We conducted a population-based cohort study of pregnant women who delivered in Ontario, Canada comparing women who received a prenatal ECG to women who did not. Results In total, 3,238,218 women gave birth during the 25-year study period of whom 157,352 (5%) received an electrocardiogram during prenatal care. Receiving an electrocardiogram test was associated with a one-third relative increase in the odds of postpartum depression (odds ratio 1.34; 95% confidence interval 1.29–1.39, p < 0.001). Conclusion The association between prenatal electrocardiogram testing and postpartum depression suggests a possible link of organic disease with mental illness, and emphasizes that cardiovascular symptoms may be a clinical clue to the presence of an underlying mood disorder.

Symptomatic Treatment of Pain-Related Pediatric Functional Gastrointestinal Disorders in a Biopsychosocial Construct, and a Validity Study of Rome III Criteria

Our study aims to assess improvement with symptomatic treatment of pain-related functional gastrointestinal disorders (FGIDs) in a biopsychosocial construct and evaluate validity of Rome III criteria. Children with chronic abdominal pain diagnosed with an FGID or organic disease were followed for 1 year: 256/334 were diagnosed with an FGID and 78/334 were diagnosed with a possible organic disease due to alarm signs or not meeting Rome III criteria. After 1 year, 251 had true FGID and 46 had organic diseases. Ninety percent of FGID patients improved with symptomatic treatment over an average of 5.4 months. With a 95% confidence interval, Rome criteria predicted FGIDs with sensitivity 0.89, specificity 0.90, positive predictive value 0.98, and negative predictive value 0.59. We conclude that symptomatic treatment of pain-related FGIDs results in clinical improvement and could reduce invasive/expensive testing. Rome III criteria’s high specificity and positive predictive value suggest they can rule in a diagnosis of FGID.

Endometrial biopsy is an important diagnostic tool for the evaluation of abnormal uterine bleeding

In this study 100 biopsies were taken from the endometrium of childbearing women (18-50 yrs. of age) suffering from abnormal vaginal bleeding from Jan 2019-Dec 2019. Endometrial Biopsy (EB) is safe, an outpatient procedure, low cost, carries out without general anesthesia & the incidence of hemorrhage, infection & uterine perforation are less common than with D&C. EB is an alternative to dilatation & curette (D&C) for the evaluation of infertile & abnormal vaginal bleeding or dysmenorrheic patients. There are two main groups of causes to irregular vaginal bleeding. 1. Organic disease (74% of the cases), in this group there are obvious lesion such as, endometrial polyp, endometrial hyperplasia & chronic endometritis. The most common cause was endometrial hyperplasia 48%, it is commonly seen during the perimenopausal period (40-50yr). Less common causes include chronic endometritis 8%, hydatidiform mole 7%, and endometrial polyp 7%. 2. non-organic disease comprises 19% of all cases, anovulatory period 13% or Luteal phase insufficiency 6%. They are commonly seen from age of 18-40yrs. 6% of the cases found to have normal endometrium. 5 endometrial biopsies were inadequate & unsatisfactory for histopathological interpretation. The aim of this study is to evaluate the usefulness & disadvantages of EB & to compare it with the traditional method of endometrial curette.

Graves’ disease presenting with hypomania and paranoia to the acute psychiatry service

This manuscript describes the case of a young woman, with no prior psychiatric history, who developed hypomania and paranoia as the principal presenting features of Graves’ disease. After starting treatment with carbimazole and propranolol, symptoms resolved without the use of antipsychotic drugs. Close liaison between psychiatry and endocrinology services was essential. This demonstrates that treating underlying thyrotoxicosis in patients presenting with psychiatric symptoms may lead to recovery without the use of antipsychotic medication. While agitation, irritability and mood lability are well-recognised thyrotoxic symptoms, psychosis is a rare presenting feature of Graves’ disease. All patients with agitation, delirium or psychiatric symptoms should have thyroid function checked as part of initial tests screening for organic disease. In new or relapsing psychiatric conditions, it is important to ask patients, their carers or relatives about symptoms of hypothyroidism or thyrotoxicosis.

Chronic Refractory Constipation in Children: Think Beyond Stools

Chronic refractory constipation (CRC) is defined as children who are unable to pass stools in spite of being on maximum laxative therapy and require daily rectal stimulation in the form of enemas or suppositories to pass stools for >3 months. Children are often referred for treatment of refractory constipation that may result from uncontrolled underlying disease or ineffective treatment. Constipated children can be managed by a variety of medical therapeutic options that yield satisfying results in most cases. However, a subset of constipated children fails to benefit from conventional treatments. On treatment failure or on suspicion of organic disease the patient should be referred for further evaluation. Treatment options for treatment-resistant patients are presented. Pharmalogical and non-pharmalogical treatment modalities are reviewed and an algorithm for refractory constipation in children are presented.