Publications by authors named "Devendra Mehta"

33 Publications

Efficacy of Short Course of Preksha Dhyana for Functional Abdominal Pain Disorder in a Busy Pediatric Clinic.

Front Pediatr 2021 25;9:646686. Epub 2021 May 25.

Department of Pediatric Gastroenterology and Nutrition, Orlando Health-Arnold Palmer Hospital for Children, Orlando, FL, United States.

Mind body techniques such as meditation improve symptoms in children and adults with IBS. Typical courses, however, are lengthy and difficult to administer. We report our experience with a short course of (PD), a child-friendly focused meditation with yoga. Physicians deliver focused meditation while medical assistants taught yoga. Three sessions were administered biweekly with recommendations for daily practice. Pain severity Likert scores were compared with a treatment as usual (TAU) historical control. Anxiety scores were compared from baseline in the PD group. Thirty PD patients aged 9-17 (20 female) and 52 consecutive TAU group aged 5-17 (33 female) were reviewed. The biweekly sessions had high (71%) completion rates. Utilization rates of PD were similar to TAU despite added sessions. The PD group had an average time of follow-up of 8.9 ± 9.4 vs. 6.0 ± 3.9 months in the TAU group ( = 0.522). Changes in pain scores from baseline showed improvement in the PD group, 0.67 ± 0.13 vs. TAU 1.39 ± 0.11 ( = 0.0003). In the PD group, anxiety scores improved significantly from baseline (0.5 vs. 1, < 0.001). Pain improved in 93% (28/30) and resolved in 47% (14/30). A short course of PD was successfully embedded in a busy pediatric office without additional staffing. The approach proved cost-effective without increasing overall healthcare utilization and showed significant benefits over TAU. Pending RCT confirmation, this offers a cost-effective method to incorporate mind-body techniques into a pediatric office practice.
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http://dx.doi.org/10.3389/fped.2021.646686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185299PMC
May 2021

Effects of Combining Meditation Techniques on Short-Term Memory, Attention, and Affect in Healthy College Students.

Front Psychol 2021 5;12:607573. Epub 2021 Mar 5.

Gastrointestinal Translational Laboratory, Arnold Palmer Hospital for Children, Orlando, FL, United States.

Meditation refers to a family of self-regulation practices that focuses on training attention and awareness to foster psycho-emotional well-being and to develop specific capacities such as calmness, clarity, and concentration. We report a prospective convenience-controlled study in which we analyzed the effect of two components of - buzzing bee sound meditation () and color meditation () on healthy college students. and are two practices that are based on sound and green color, respectively. The study population represents a suitable target as college students experience different stress factors during the school year. This study measures the individual and combined effects of two techniques (one focusing on sound and one focusing on color), on short-term memory, attention, and affect, in novice meditators. We used a battery of cognitive, performance, and compared results with baseline and control values. We found improved cognition, especially attention, short-term memory, and affect in terms of positivity and reduced negativity. Overall, the two techniques produced variable benefits and subjects showed improved scores over baseline for short-term memory, cognitive function, and overall wellbeing. Further studies are required to understand underlying mechanisms for the observed differences between the two techniques and to elucidate mechanisms underlying the more pronounced and global benefits observed with the combined techniques. These results underscore a need to examine individual components of meditation practices in order to individualize treatment approaches for attention disorders in young adults. ClinicalTrials.gov Identifier: NCT03779269.
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http://dx.doi.org/10.3389/fpsyg.2021.607573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973112PMC
March 2021

Pulmonary Microbiome of Patients Receiving Mechanical Ventilation: Changes Over Time.

Am J Crit Care 2021 03;30(2):128-132

Devendra Mehta is a pediatric gastroenterologist, Pediatric Specialty Diagnostic Laboratory, Arnold Palmer Hospital, Orlando, Florida.

Background: Interest in the pulmonary microbiome is growing, particularly in patients undergoing mechanical ventilation.

Objectives: To explore the pulmonary microbiome over time in patients undergoing prolonged mechanical ventilation and to evaluate the effect of an oral suctioning intervention on the microbiome.

Methods: This descriptive subanalysis from a clinical trial involved a random sample of 16 participants (7 intervention, 9 control) who received mechanical ventilation for at least 5 days. Five paired oral and tracheal specimens were evaluated for each participant over time. Bacterial DNA from the paired specimens was evaluated using 16S rRNA gene sequencing. Bacterial taxonomy composition, α-diversity (Shannon index), and β-diversity (Morisita-Horn index) were calculated and compared within and between participants.

Results: Participants were predominantly male (69%) and White (63%), with a mean age of 58 years, and underwent mechanical ventilation for a mean of 9.36 days. Abundant bacterial taxa included Prevotella, Staphylococcus, Streptococcus, Stenotrophomonas, and Veillonella. Mean tracheal α-diversity decreased over time for the total group (P = .002) and the control group (P = .02). β-Diversity was lower (P = .04) in the control group (1.905) than in the intervention group (2.607).

Conclusions: Prolonged mechanical ventilation was associated with changes in the pulmonary microbiome, with the control group having less diversity. The oral suctioning intervention may have reduced oral-tracheal bacterial transmission.
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http://dx.doi.org/10.4037/ajcc2021194DOI Listing
March 2021

Impact of Atrial Fibrillation on Acute Coronary Syndrome-Analysis of In-Hospital Outcomes and 30-Day Readmissions.

Curr Probl Cardiol 2021 Apr 13;46(4):100764. Epub 2020 Dec 13.

With an aging population and significant overlap of risk factors, the cohort of patients with acute coronary syndrome (ACS) and concomitant atrial fibrillation (AF) is a sizable and growing one, with implications on cardiac reserve, anticoagulation and antiplatelet therapies, and related complications. The present study uses a large national database to analyze the impact of AF on patients admitted with an ACS. We queried the 2012 to 2014 National Readmissions Database to identify patients admitted with an ACS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) codes. These patients were then subcategorized based on the presence or absence of AF. Analysis of their initial hospitalization, 30-day readmissions and healthcare utilization and the economic burden was performed. Among 1,558,205 patients with ACS, 270,966 (17.4%) were noted to have concomitant AF. At baseline, these patients were older and more likely female, with a significantly higher burden of comorbidities. Patients with AF had longer and more complicated index hospitalizations with significantly higher mortality rates (8.6% vs 4.6%). Coronary artery bypass graft was the preferred method of revascularization in patients with AF as compared to percutaneous coronary intervention. The 30-day readmissions were higher in the AF group (15.6 vs 10.8%), largely driven by noncardiac causes. This was associated with higher healthcare utilization with longer hospitalizations during index admission. Patients admitted with ACS and concomitant AF is a high-risk population with increased in-hospital complications and mortality, as well as short term readmissions. Coronary artery bypass graft appears favored over percutaneous coronary intervention for revascularization in patients with AF.
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http://dx.doi.org/10.1016/j.cpcardiol.2020.100764DOI Listing
April 2021

Using Eosinophil Biomarkers From Rectal Epithelial Samples to Diagnose Food Protein-induced Proctocolitis: A Pilot Study.

J Pediatr Gastroenterol Nutr 2020 10;71(4):e109-e112

Pediatric Gastroenterology, Center for Digestive Health and Nutrition.

Objectives: The gold standard diagnostic procedure for food protein-induced proctocolitis (FPIP) requires flexible sigmoidoscopy (FS). To date there is no validated, noninvasive test to confirm FPIP diagnosis. Eosinophil-derived neurotoxin (EDN), a product of eosinophil (EOS) degranulation, has been shown to correlate with eosinophil infiltration in other tissues. Our objective was to compare EDN concentrations in rectal epithelial samples from infants with FPIP with those from a control population.

Methods: Children who underwent routine FS at Arnold Palmer Hospital for Children were enrolled in an IRB-approved, prospective, open-label pilot study between July 2017 and May 2019. We obtained rectal epithelial samples via: rectal swab, cytology brushing through FS, and rectal biopsy through FS. We then measured EDN levels in the samples and compared levels found in infants with FPIP against levels found in the control group. FPIP was defined as more than 60 EOS per 10 high-power fields (HPF) in rectal epithelial tissue obtained via rectosigmoid biopsy.

Results: Twenty-four patients were enrolled. The control group (n = 13) included patients with normal histopathology (84% boys, mean age 19 months, SD 6 months) and the FPIP group (n = 11) included patients with FPIP confirmed via biopsy (45% boys, mean age 6.9 months, SD 9 months). EDN concentration was significantly higher in the FPIP group than in the control group, for 2 sampling methods: rectal biopsy (183.6 ± 114.6 vs 76.6 ± 71.0 μg/mL; P = 0.010) and rectal swab (66.2 ± 64.8 vs 20.4 ± 22.2 μg/mL; P = 0.025).

Conclusions: EDN concentrations measured from rectal swab and rectal biopsy samples is elevated and may be a useful tool to screen for FPIP in children.
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http://dx.doi.org/10.1097/MPG.0000000000002812DOI Listing
October 2020

Intubation Setting, Aspiration, and Ventilator-Associated Conditions.

Am J Crit Care 2020 09;29(5):371-378

Mary Lou Sole is dean, Orlando Health Endowed Chair in Nursing, and University of Central Florida Pegasus Professor, University of Central Florida College of Nursing.

Background: Patients experience endotracheal intubation in various settings with wide-ranging risks for postintubation complications such as aspiration and ventilator-associated conditions.

Objectives: To evaluate associations between intubation setting, presence of aspiration biomarkers, and clinical outcomes.

Methods: This study is a subanalysis of data from the NO-ASPIRATE single-blinded randomized clinical trial. Data were prospectively collected for 513 adult patients intubated within 24 hours of enrollment. Patients with documented aspiration events at intubation were excluded. In the NO-ASPIRATE trial, intervention patients received enhanced oropharyngeal suctioning every 4 hours and control patients received sham suctioning. Tracheal specimens for α-amylase and pepsin tests were collected upon enrollment. Primary outcomes were ventilator hours, lengths of stay, and rates of ventilator-associated conditions.

Results: Of the baseline tracheal specimens, 76.4% were positive for α-amylase and 33.1% were positive for pepsin. Proportions of positive tracheal α-amylase and pepsin tests did not differ significantly between intubation locations (study hospital, transfer from other hospital, or field intubation). No differences were found for ventilator hours or lengths of stay. Patients intubated at another hospital and transferred had significantly higher ventilator-associated condition rates than did those intubated at the study hospital (P = .02). Ventilator-associated condition rates did not differ significantly between patients intubated in the field and patients in other groups.

Conclusions: Higher ventilator-associated condition rates associated with interhospital transfer may be related to movement from bed, vehicle loading and unloading, and transport vehicle vibrations. Airway assessment and care may also be suboptimal in the transport environment.
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http://dx.doi.org/10.4037/ajcc2020129DOI Listing
September 2020

Is α-Amylase an Important Biomarker to Detect Aspiration of Oral Secretions in Ventilated Patients?

Crit Care Explor 2020 Jul 15;2(7):e0159. Epub 2020 Jul 15.

Pediatric Specialty Diagnostic Laboratory, Arnold Palmer Hospital, Orlando, FL.

Alpha-amylase has emerged as a biomarker of interest in detecting aspiration of oral secretions. In several studies, most ventilated patients have α-amylase values detected in pulmonary secretions. Values of α-amylase are high (as expected) in oral secretions and lowest in bronchoalveolar lavage samples. Around 5-7% of oral α-amylase is detectable in tracheal secretions. Once secretions are aspirated, the duration of detection of α-amylase in pulmonary secretions is unknown. Evidence varies on the relationship between α-amylase and clinical outcomes. Although detection of α-amylase in pulmonary secretions is useful to identify that aspiration has occurred, the lack of standardized reference values, the lack of knowledge regarding duration of detection following aspiration, and mixed findings related to clinical outcomes, limit its usefulness as a measurement tool. If α-amylase is to be used in research and/or clinical practice, additional data are needed to assist in interpretation and application of findings.
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http://dx.doi.org/10.1097/CCE.0000000000000159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365705PMC
July 2020

Sucrase-isomaltase Gene Variants in Patients With Abnormal Sucrase Activity and Functional Gastrointestinal Disorders.

J Pediatr Gastroenterol Nutr 2021 01;72(1):29-35

Gastroenterology Translational Research Division, Arnold Palmer Hospital Specialty Diagnostic Laboratory.

Objectives: The aim of the study was to determine prevalence and characterize sucrase-isomaltase (SI) gene variants of congenital sucrase-isomaltase deficiency in non-Hispanic white pediatric and young adult patients with functional gastrointestinal disorders (FGIDs), and abnormal sucrase activity on histologically normal duodenal biopsy.

Methods: Clinical symptoms and disaccharidase activities data were collected for an abnormal (low) sucrase (≤25.8 U, n = 125) activity group, and 2 normal sucrase activity groups with moderate (≥25.8-≤55 U, n = 250) and high (>55 U, n = 250) sucrase activities. SI gene variants were detected by next-generation sequencing of DNA from formalin-fixed paraffin-embedded tissues of these patients. FGIDs symptoms based on Rome IV criteria and subsequent clinical management of abnormal sucrase activity cases with pathogenic SI gene variants were analyzed.

Results: Thirteen SI gene variants were found to be significantly higher in abnormal sucrase cases with FGIDs symptoms (36/125, 29%; 71% did not have a pathogenic variant) compared to moderate normal (16/250, 6.4%, P < 0.001) or high normal (5/250, 2.0%, P < 0.001) sucrase groups. Clinical management data were available in 26 of abnormal sucrase cases, and only 10 (38%) were correctly diagnosed and managed by the clinicians. Concomitant lactase deficiency (24%; 23/97) and pan-disaccharidase deficiency (25%; 13/51) were found in the abnormal sucrase group.

Conclusions: Heterozygous and compound heterozygous mutations in the SI gene were more prevalent in cases with abnormal sucrase activity presenting with FGIDs, and normal histopathology. This suggests heterozygous pathogenic variants of congenital sucrase-isomaltase deficiency may present as FGIDs. Concomitant lactase or pan-disaccharidase deficiencies were common in abnormal sucrase cases with SI gene variants.
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http://dx.doi.org/10.1097/MPG.0000000000002852DOI Listing
January 2021

Hypomorphic SI genetic variants are associated with childhood chronic loose stools.

PLoS One 2020 20;15(5):e0231891. Epub 2020 May 20.

Department of Pediatrics, The Ohio State University, Columbus, OH, United States of America.

Objective: The SI gene encodes the sucrase-isomaltase enzyme, a disaccharidase expressed in the intestinal brush border. Hypomorphic SI variants cause recessive congenital sucrase-isomaltase deficiency (CSID) and related gastrointestinal (GI) symptoms. Among children presenting with chronic, idiopathic loose stools, we assessed the prevalence of CSID-associated SI variants relative to the general population and the relative GI symptom burden associated with SI genotype within the study population.

Methods: A prospective study conducted at 18 centers enrolled 308 non-Hispanic white children ≤18 years old who were experiencing chronic, idiopathic, loose stools at least once per week for >4 weeks. Data on demographics, GI symptoms, and genotyping for 37 SI hypomorphic variants were collected. Race/ethnicity-matched SI data from the Exome Aggregation Consortium (ExAC) database was used as the general population reference.

Results: Compared with the general population, the cumulative prevalence of hypomorphic SI variants was significantly higher in the study population (4.5% vs. 1.3%, P < .01; OR = 3.5 [95% CI: 6.1, 2.0]). Within the study population, children with a hypomorphic SI variant had a more severe GI symptom burden than those without, including: more frequent episodes of loose stools (P < .01), higher overall stool frequency (P < .01), looser stool form (P = .01) and increased flatulence (P = .02).

Conclusion: Non-Hispanic white children with chronic idiopathic loose stools have a higher prevalence of CSID-associated hypomorphic SI variants than the general population. The GI symptom burden was greater among the study subjects with a hypomorphic SI variant than those without hypomorphic SI variants.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231891PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239456PMC
July 2020

Report on the Short Endoscopic Exocrine Pancreatic Function Test in Children and Young Adults.

Pancreas 2020 May/Jun;49(5):642-649

From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL.

Objectives: Endoscopic pancreatic function test (ePFT) has been in use for exocrine function testing since the 1990s. In patients, short ePFT assesses acinar function, unlike the longer version for ductal function in adults. The present study summarizes characteristics of 1913 short ePFTs (S-ePFT) performed at 2 centers since 2001.

Methods: The main indications in patients presenting at ages infancy to 24.3 years, for the S-ePFT were failure to thrive, weight loss, diarrhea, and abdominal pain with bloating. Secretin was administered as bolus, and 4 aliquots of fluid were collected between 4 and 10 minutes after administration. Amylase, lipase, trypsin, and chymotrypsin activities were measured in the laboratory.

Results: The pH of consecutive samples increased by 0.3 to 0.7. Overall, 36.7% had abnormal S-ePFT with selective amylase deficiency (9.5%) and generalized enzyme deficiency (8.9%) being the most frequent. Retest reproducibility, repeatability, and clinical validity were high. By adding S-ePFT to endoscopy for the suspicion of malabsorption, the abnormal findings increased by 36.9%.

Conclusions: Short ePFT assesses pancreatic acinar function in a reliable and clinically meaningful way in patients. Diagnostic yield of endoscopy increased substantially albeit with increased sedation time. By S-ePFT ductal function, cytokines and proteomics can also be assessed.
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http://dx.doi.org/10.1097/MPA.0000000000001540DOI Listing
May 2021

Impact of deep oropharyngeal suctioning on microaspiration, ventilator events, and clinical outcomes: A randomized clinical trial.

J Adv Nurs 2019 Nov 7;75(11):3045-3057. Epub 2019 Aug 7.

Pediatric Specialty Diagnostic Laboratory, Arnold Palmer Hospital, Orlando Health, Orlando, Florida.

Aims: To evaluate a deep oropharyngeal suction intervention (NO-ASPIRATE) in intubated patients on microaspiration, ventilator-associated events and clinical outcomes.

Design: Prospective, two-group, single-blind, randomized clinical trial.

Methods: The study was conducted between 2014 - 2017 in 513 participants enroled within 24 hr of intubation and randomized into NO-ASPIRATE or usual care groups. Standard oral care was provided to all participants every 4 hr and deep oropharyngeal suctioning was added to the NO-ASPIRATE group. Oral and tracheal specimens were obtained to quantify α-amylase as an aspiration biomarker.

Results: Data were analysed for 410 study completers enrolled at least 36 hr: NO-ASPIRATE (N = 206) and usual care (N = 204). Percent of tracheal specimens positive for α-amylase, mean tracheal α-amylase levels over time and ventilator-associated events were not different between groups. The NO-ASPIRATE group had a shorter hospital length of stay and a subgroup with moderate aspiration at baseline had significantly lower α-amylase levels across time.

Conclusion: Hospital length of stay was shorter in the NO-ASPIRATE group and a subgroup of intervention participants had lower α-amylase across time. Delivery of standardized oral care to all participants may have been an intervention itself and possibly associated with the lack of significant findings for most outcomes.

Impact: This trial compared usual care to oral care with a deep suctioning intervention on microaspiration and ventilator-associated events, as this has not been systematically studied. Further research on the usefulness of α-amylase as an aspiration biomarker and the role of oral suctioning, especially for certain populations, is indicated.

Trial Registration Number: ClinicalTrials.gov: NCT02284178.
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http://dx.doi.org/10.1111/jan.14142DOI Listing
November 2019

Assessment of Exocrine Pancreatic Function During Endoscopy in Children.

J Pediatr Gastroenterol Nutr 2019 06;68(6):768-776

Division of Gastroenterology, Nationwide Children's Hospital, Columbus, OH.

This article will review briefly the physiology of pancreatic enzyme secretion and the role of stimulated endoscopic testing for assessing exocrine pancreatic function. Published studies in both the pediatric and adult literature are reviewed. The technique and utility of endoscopic pancreatic function testing as the method of choice in the differential diagnosis of pancreatic disorders in childhood is described. Finally, emerging, clinically useful markers that can be measured in the pancreatic fluid will be described.
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http://dx.doi.org/10.1097/MPG.0000000000002230DOI Listing
June 2019

Gastrointestinal Conditions in Children With Severe Feeding Difficulties.

Glob Pediatr Health 2019 16;6:2333794X19838536. Epub 2019 Apr 16.

Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL, USA.

Feeding aversion in children may progress to severe feeding difficulties. While oral-motor and sensory issues are usually the leading causes, organic etiologies should be considered. This study aimed to assess the prevalence of gastrointestinal conditions in children with severe feeding difficulties. We conducted a retrospective study of 93 children requiring an intensive feeding program. The medical records, radiologic and diagnostic tests, use of gastric tube feedings, preexisting medical conditions, and medications were reviewed. Fifty-two percent (52%) had esophagitis, 26.2% gastritis, and 40.7% lactase deficiency in upper endoscopy. In those who underwent an upper endoscopy, 26% of patients that were also tested for small intestinal bacterial overgrowth were found to be positive. Allergy testing was abnormal in 56.6% of those tested, while 27.5% and 75% had abnormal gastric emptying times and pH impedance results, respectively. Constipation was present in 76.3%. Thirteen of 32 were weaned off tube feedings. We conclude that gastrointestinal conditions are common in children with feeding disorders and should be investigated prior to feeding therapy.
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http://dx.doi.org/10.1177/2333794X19838536DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469270PMC
April 2019

Isolated Amylase Deficiency in Children and Its Clinical Implication.

J Pediatr Gastroenterol Nutr 2019 06;68(6):854-860

The Florida State University, Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL.

Objectives: Among the 3 lines of pancreatic enzymes, amylase secretion develops last and it is not detected in duodenal aspirates of infants in the first month after birth. The aim of this study was to assess the prevalence and symptoms of isolated amylase deficiency in children.

Methods: During a 6-year period, we performed endoscopic pancreatic function tests (ePFT) in 712 children. Isolated amylase deficiency was defined as activity that was below the third percentile of our referenced population with normal lipase and protease activities.

Results: Seventy-two children between age 0.21 and 15.7 years (boys, n = 35) had isolated amylase deficiency. The highest prevalence of isolated amylase deficiency was found in patients less than 6 months of age (52.9%). From 6 months to 1 year of age, the prevalence was 40%. The prevalence gradually decreased until 18 months. Failure to thrive, poor weight gain, diarrhea, and abdominal bloating were the most frequent indications for ePFT. Eleven children had repeat ePFT after initial diagnosis and 6 had normal enzyme activity, whereas 5 had remained amylase-deficient an average of 1.65 years later.

Conclusions: The prevalence of selective amylase deficiency was 10.1% in the 712 children who underwent ePFT with the suspicion of malabsorption. Low amylase activity is "physiologic" in infants <6 months of age, however, this study supports that it should be considered in the differential diagnosis in children older than 6 months of age.
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http://dx.doi.org/10.1097/MPG.0000000000002317DOI Listing
June 2019

Nursing oral suction intervention to reduce aspiration and ventilator events (NO-ASPIRATE): A randomized clinical trial.

J Adv Nurs 2019 May 23;75(5):1108-1118. Epub 2019 Jan 23.

University of Central Florida College of Nursing, Orlando, Florida.

Aim: The primary aim of this study is to compare an oropharyngeal suction intervention versus usual care on microaspiration in intubated patients. Secondary aims are to evaluate the intervention on ventilator-associated condition rates, time to occurrence and compare tracheal-oral α-amylase ratios between groups.

Design: Prospective randomized clinical trial.

Methods: The study received funding from the National Institutes of Health in February 2014 and Institutional Review Board approval in July 2013. Over 4 years, a convenience sample of 600 orally intubated, ventilated adult patients will be enrolled within 24 hr of intubation. The target sample is 400 participants randomized to the two groups. The intervention involves enhanced suctioning of the mouth and oropharynx every 4 hr, while the usual care group receives a sham suctioning. The research team will deliver usual oral care to all patients every 4 hr and collect oral and tracheal specimens every 12 hr, to quantify α-amylase levels to detect aspiration of oral secretions. Study completers must be enrolled at least 36 hr (baseline and three paired samples). Outcomes include α-amylase levels, percent of positive specimens, ventilator-associated conditions, length of stay, ventilator hours, and discharge disposition.

Discussion: Enrolment has closed, and data analysis has begun. Subgroup analyses emerged, contributing to future research knowledge.

Impact: Standardized interventions have reduced but do not address all risk factors associated with ventilator-associated conditions. This study provides the potential to reduce microaspiration and associated sequelae in critically ill, intubated patients.
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http://dx.doi.org/10.1111/jan.13920DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6568323PMC
May 2019

ESPGHAN and NASPGHAN Report on the Assessment of Exocrine Pancreatic Function and Pancreatitis in Children.

J Pediatr Gastroenterol Nutr 2015 Jul;61(1):144-53

*Sheffield Children's Hospital, Sheffield, UK †St Christopher's Hospital for Children, Philadelphia, PA ‡Arnold Palmer Hospital for Children, Orlando, FL §Children's Hospital of Pittsburgh of UPMC and the University of Pittsburgh, Pittsburgh, PA ||Children's Hospital of Erlanger, Chattanooga, TN ¶Ghent University Hospital, Ghent, Belgium #Beatrix Children's Hospital, University Medical Center, University of Groningen, Groningen, The Netherlands **Hadassah-Hebrew University Medical Center, Jerusalem, Israel. ***Collaborators: Vandenplas Y, Gottrand F, Lionetti P, Papadopoulos A, Rümmele F, Tempia-Schäppi M, Thapar N, Orel R, Heuschkel R, Falconer J, and Karelis S.

The purpose of this clinical report is to discuss several recent advances in assessing exocrine pancreatic insufficiency (EPI) and pancreatitis in children, to review the array of pancreatic function tests, to provide an update on the inherited causes of EPI, with special emphasis on newly available genetic testing, and to review newer methods for evaluating pancreatitis.
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http://dx.doi.org/10.1097/MPG.0000000000000830DOI Listing
July 2015

Cough in asthma triggered by reflux episodes.

Del Med J 2014 May;86(5):143-8

With combined pH and impedance monitoring, non-acid, as well as acid reflux episodes, are more commonly detected immediately prior to cough in asthma in children. Gastroesophageal reflux should be evaluated as a trigger for cough in difficult childhood asthma.
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May 2014

Pepsin and amylase in oral and tracheal secretions: a pilot study.

Am J Crit Care 2014 Jul;23(4):334-8

Mary Lou Sole is Orlando Health Distinguished Professor, University of Central Florida, and a research scientist at Orlando Health, Orlando, Florida. Janet Conrad is a clinical scientist in the pediatric specialty diagnostic laboratory and Devendra Indulal Mehta is the director of the pediatric gastroenterology laboratory, Arnold Palmer Hospital for Children, Orlando, Florida. Melody Bennett is a member of the adjunct faculty, University of Central Florida, and a staff nurse at Orlando Health. Aurea Middleton is a staff nurse at Orlando Health. Katherine Hay is a staff nurse at University of Alabama at Birmingham, Birmingham, Alabama. Suzanne Ashworth is a clinical nurse specialist in neurological critical care, Orlando Regional Medical Center, Orlando, Florida.

Background: Endotracheal intubation increases the risk for microaspiration of secretions around the tube cuff. Pepsin has been used as a biomarker for gastric aspiration. Amylase is a newer proposed biomarker for aspiration of oral contents.

Objective: To assess the presence of pepsin and amylase in paired oral-tracheal secretions of adult patients treated with mechanical ventilation.

Methods: In this descriptive study, paired samples of oral and tracheal secretions were obtained from adult patients at baseline and again within 4 hours when a need for endotracheal suctioning was assessed. Assays of pepsin and amylase were processed in a specialty diagnostic laboratory.

Results: The sample consisted of 10 men and 3 women with a median age of 56 years. The majority were intubated with a subglottic suction endotracheal tube (9 patients, 69%), receiving synchronized intermittent mandatory ventilation (10 patients; 77%), and receiving enteral feedings (11 patients; 85%) through a tube distally placed in the stomach (8 patients; 67%). Pepsin was present in oral secretions of 9 patients (69%), and in tracheal specimens of 7 patients (54%) at one or both sampling times. Amylase was detected in all patients' oral secretions and in tracheal secretions of 5 patients (38%) at one or both sampling times.

Conclusions: Many patients had pepsin, amylase, or both in tracheal aspirates. Pepsin was more commonly detected than was amylase. Although the relationship of this finding to long-term outcomes was not assessed, findings indicate that microaspiration of oral and gastric secretions occurs frequently.
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http://dx.doi.org/10.4037/ajcc2014292DOI Listing
July 2014

Effectiveness of anti-TNFα for Crohn disease: research in a pediatric learning health system.

Pediatrics 2014 Jul 16;134(1):37-44. Epub 2014 Jun 16.

Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Objectives: ImproveCareNow (ICN) is the largest pediatric learning health system in the nation and started as a quality improvement collaborative. To test the feasibility and validity of using ICN data for clinical research, we evaluated the effectiveness of anti-tumor necrosis factor-α (anti-TNFα) agents in the management of pediatric Crohn disease (CD).

Methods: Data were collected in 35 pediatric gastroenterology practices (April 2007 to March 2012) and analyzed as a sequence of nonrandomized trials. Patients who had moderate to severe CD were classified as initiators or non-initiators of anti-TNFα therapy. Among 4130 patients who had pediatric CD, 603 were new users and 1211 were receiving anti-TNFα therapy on entry into ICN.

Results: During a 26-week follow-up period, rate ratios obtained from Cox proportional hazards models, adjusting for patient and disease characteristics and concurrent medications, were 1.53 (95% confidence interval [CI], 1.20-1.96) for clinical remission and 1.74 (95% CI, 1.33-2.29) for corticosteroid-free remission. The rate ratio for corticosteroid-free remission was comparable to the estimate produced by the adult SONIC study, which was a randomized controlled trial on the efficacy of anti-TNFα therapy. The number needed to treat was 5.2 (95% CI, 3.4-11.1) for clinical remission and 5.0 (95% CI, 3.4-10.0) for corticosteroid-free remission.

Conclusions: In routine pediatric gastroenterology practice settings, anti-TNFα therapy was effective at achieving clinical and corticosteroid-free remission for patients who had Crohn disease. Using data from the ICN learning health system for the purpose of observational research is feasible and produces valuable new knowledge.
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http://dx.doi.org/10.1542/peds.2013-4103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531278PMC
July 2014

Peer-mediated multimodal intervention program for the treatment of children with ADHD in India: one-year followup.

ISRN Pediatr 2012 20;2012:419168. Epub 2012 Dec 20.

Trinity College of Arts and Sciences, Duke University, Durham, NC 27708, USA.

The objective was to assess the efficacy of a one-year, peer-mediated interventional program consisting of yoga, meditation and play therapy maintained by student volunteers in a school in India. The population consisted of 69 students between the ages of 6 and 11 years, previously identified as having attention deficit hyperactivity disorder (ADHD). A program, known as Climb-Up, was initially embedded in the school twice weekly. Local high school student volunteers were then trained to continue to implement the program weekly over the period of one year. Improvements in ADHD symptoms and academic performance were assessed using Vanderbilt questionnaires completed by both parents and teachers. The performance impairment scores for ADHD students assessed by teachers improved by 6 weeks and were sustained through 12 months in 46 (85%) of the enrolled students. The improvements in their Vanderbilt scores assessed by parents were also seen in 92% (P < 0.0001, Wilcoxon). The Climb-Up program resulted in remarkable improvements in the students' school performances that were sustained throughout the year. These results show promise for a cost-effective program that could easily be implemented in any school.
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http://dx.doi.org/10.5402/2012/419168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539379PMC
January 2013

Multimodal behavior program for ADHD incorporating yoga and implemented by high school volunteers: a pilot study.

ISRN Pediatr 2011 11;2011:780745. Epub 2011 Aug 11.

Columbia College, Columbia University, New York, NY 10027, USA.

A low-cost resource approach to ADHD therapy would be a practical approach to treating children in developing countries. Research has shown that ADHD is prevalent in all areas of the world, and yet treatment for children in more impoverished countries is still lacking. The approach taken was to combine yoga and meditation combined with multimodal behavioral therapy program for children ageing 6 to 11. The program was kept low cost by using trained high school volunteers and integrating the program within the public school. After 6 weeks of the program, 90.5% of children showed improvement as measured by their performance impairment score, a measurement of academic performance. Parent and Teacher evaluations of behavior also found improvement as 25 of the 64 children (39.1%) improved into the normal range as measured by the Vanderbilt questionnaire. Moreover, children could successfully learn both yoga and meditation from high school students irrespective of their age, ADHD type, or initial performance impairment. The results demonstrate efficacy of a multimodal behavioral program incorporating yoga and meditation. The use of high school volunteers from schools in the area demonstrates an effective low-cost and universally applicable approach.
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http://dx.doi.org/10.5402/2011/780745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263567PMC
August 2012

Bacterial overgrowth and methane production in children with encopresis.

J Pediatr 2010 May 29;156(5):766-70, 770.e1. Epub 2009 Dec 29.

Division of Pediatric Gastroenterology and Nutrition, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA.

Objectives: To assess the prevalence of small intestinal bacterial overgrowth (SIBO) and methane production in children with encopresis.

Study Design: Radiographic fecal impaction (FI) scores were assessed in children with secondary, retentive encopresis and compared with the breath test results. Breath tests with hypoosmotic lactulose solution were performed in both the study patients (n = 50) and gastrointestinal control subjects (n = 39) groups.

Results: The FI scores were significantly higher in the patients with encopresis who were methane producers (P < .01). SIBO was diagnosed in 21 of 50 (42%) patients with encopresis and 9 of 39 (23%) of control subjects (P = .06). Methane was produced in 56% of the patients with encopresis versus 23.1% of the control subjects in the gastrointestinal group (P < .01). Fasting methane level was elevated in 48% versus 10.3 %, respectively (P < .01).

Conclusions: Children with FI and encopresis had a higher prevalence of SIBO, elevated basal methane levels, and higher methane production. Methane production was associated with more severe colonic impaction. Further study is needed to determine whether methane production is a primary or secondary factor in the pathogenesis of SIBO and encopresis.
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http://dx.doi.org/10.1016/j.jpeds.2009.10.043DOI Listing
May 2010

Gastric pepsin in middle ear fluid of children with otitis media: clinical implications.

Curr Allergy Asthma Rep 2008 Nov;8(6):513-8

Division of Pediatric Otolaryngology, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.

Gastroesophageal reflux and extraesophageal reflux have been postulated to be involved in the pathogenesis of otitis media. This is supported by recent studies revealing the presence of gastric pepsin in the middle ear space of children with otitis media but not in control patients without otitis media. Reflux's role in otitis media appears to be most pronounced in younger children and those with purulent effusions.
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http://dx.doi.org/10.1007/s11882-008-0094-7DOI Listing
November 2008

The role of extraesophageal reflux in otitis media in infants and children.

Laryngoscope 2008 Jul;118(7 Part 2 Suppl 116):1-9

Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.

Objectives/hypothesis: Gastroesophageal reflux disease (GERD) is common in children, and extraesophageal reflux disease (EORD) has been implicated in the pathophysiology of otitis media (OM). We sought to 1) determine the incidence of pepsin/pepsinogen presence in the middle ear cleft of a large sample of pediatric patients undergoing myringotomy with tube placement for OM; 2) compare this with a control population of pediatric patients undergoing middle ear surgery (cochlear implantation) with no documented history of OM; 3) analyze potential risk factors for OM in children with EORD demonstrated by the presence of pepsin in the middle ear cleft; and 4) determine if pepsin positivity at the time of myringotomy with tube placement predisposes to posttympanostomy tube otorrhea.

Study Design And Methods:

Study Group: prospective samples of 509 pediatric patients (n = 893 ear samples) undergoing myringotomy with tube placement for recurrent acute OM and/or otitis media with effusion in a tertiary care pediatric hospital with longitudinal follow-up of posttympanostomy tube otorrhea.

Control Group: prospective samples of 64 pediatric patients (n = 74 ears) with negative history of OM undergoing cochlear implantation at one of the three tertiary care pediatric hospitals. A previously validated, highly sensitive and specific modified enzymatic assay was used to detect the presence of pepsin in the middle ear aspirates of study and control patients. Risk factors for OM and potentially associated conditions, including GERD, allergy, and asthma were analyzed for the study group through review of the electronic medical record and correlated topresence of pepsin in the middle ear space. Study patients were followed longitudinally postoperatively to determine the incidence of posttympanostomy tube otorrhea.

Results: The incidence of pepsin in the middle ear cleft of the study group was 20% of patients and 14% of ears, which is significantly higher than 1.4% of control patients and 1.5% of control ears (P < .05). Study patients younger than 1 year had a higher rate of purulent effusions and pepsin in the middle ear cleft (P < .05). Patients with pepsin in the middle ear cleft were more likely to have an effusion at the time of surgery than patients without pepsin in the middle ear cleft (P < .05). There was no statistical association found between the presence of pepsin and clinical history of GERD, allergy, asthma, or posttympanostomy tube otorrhea.

Conclusions: Pepsin is detectable in the middle ear cleft of 20% of pediatric patients with OM undergoing tympanostomy tube placement, compared with 1.4% of controls; recovery of pepsin in the middle ear space of pediatric patients with OM is an independent risk factor for OM. Patients under 1 year of age have a higher incidence of purulent effusions and pepsin-positive effusions. Clinical history of GERD, allergy, and asthma do not seem to correlate with evidence of EORD reaching the middle ear cleft. The presence of pepsin in the middle ear space at the time of tube placement does not seem to predispose to posttympanostomy tube otorrhea.
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http://dx.doi.org/10.1097/MLG.0b013e31817924a3DOI Listing
July 2008

Pepsin, a marker of gastric contents, is increased in tracheal aspirates from preterm infants who develop bronchopulmonary dysplasia.

Pediatrics 2008 Feb;121(2):e253-9

Division of Gastroenterology and Nutrition and Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.

Objective: The objective of this study was to study the association between pepsin in tracheal aspirate samples and the development of bronchopulmonary dysplasia in preterm infants.

Methods: Serial tracheal aspirate samples were collected during the first 28 days from mechanically ventilated preterm neonates. Bronchopulmonary dysplasia was defined as the need for supplemental oxygen at 36 weeks' postmenstrual age. An enzymatic assay with a fluorescent substrate was used to detect pepsin. Total protein was measured by the Bradford assay to correct for the dilution during lavage. Immunohistochemistry using antibody against human pepsinogen was performed in 10 lung tissue samples from preterm infants.

Results: A total of 256 tracheal aspirate samples were collected from 59 preterm neonates. Pepsin was detected in 234 (91.4%) of 256 of the tracheal aspirate samples. Twelve infants had no bronchopulmonary dysplasia, 31 infants developed bronchopulmonary dysplasia, and 16 infants died before 36 weeks' postmenstrual age. The mean pepsin concentration was significantly lower in infants with no bronchopulmonary dysplasia compared with those who developed bronchopulmonary dysplasia or developed bronchopulmonary dysplasia/died before 36 weeks' postmenstrual age. Moreover, the mean pepsin level was significantly higher in infants with severe bronchopulmonary dysplasia compared with moderate bronchopulmonary dysplasia. The mean pepsin level in tracheal aspirate samples from the first 7 days was also lower in infants with no bronchopulmonary dysplasia compared with those who developed bronchopulmonary dysplasia or developed bronchopulmonary dysplasia/died before 36 weeks' postmenstrual age. Pepsinogen was not localized in the lung tissues by immunohistochemistry.

Conclusion: The concentration of pepsin was increased in the tracheal aspirate of preterm infants who developed bronchopulmonary dysplasia or died before 36 weeks' postmenstrual age. Recovery of pepsin in tracheal aspirate samples is secondary to gastric aspiration, not by hematogenous spread or local synthesis in the lungs. Chronic aspiration of gastric contents may contribute in the pathogenesis of bronchopulmonary dysplasia.
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http://dx.doi.org/10.1542/peds.2007-0056DOI Listing
February 2008

Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children.

Acta Paediatr 2008 Jan 10;97(1):55-60. Epub 2007 Dec 10.

Gastroenterology, Levine Children's Hospital, Charlotte, NC, USA.

Aim: Mechanically ventilated patients are at risk for aspiration of gastric contents. The aim of this observational study was to determine the prevalence of micro-aspiration in children with cuffed and uncuffed endotracheal (ET) tubes and with tracheostomies and to assess the effect of feeding status on aspiration. Micro-aspiration was determined by measuring gastric pepsin in tracheal aspirates.

Methods: We studied 27 children on ventilators in paediatric intensive care unit (PICU) and 10 children undergoing elective surgeries for various indications. Tracheal aspirates were collected from children on ventilatory support in the intensive care unit during medically indicated suctioning and from the group of children undergoing elective surgery in the operation room. Pepsin was detected by enzymatic assay.

Results: Overall 70% of cases in PICU were positive for pepsin in at least one of the aspirates. Pepsin positivity was significantly lower in the cuffed group than in the uncuffed and tracheostomy groups. Tube feedings did not significantly influence the prevalence of pepsin positivity.

Conclusions: Measurement of gastric pepsin in tracheobronchial fluid is a sensitive tool to detect aspirations in mechanically ventilated children and to assess the efficacy of preventive measures in PICU settings.
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http://dx.doi.org/10.1111/j.1651-2227.2007.00578.xDOI Listing
January 2008

An automated method for the determination of intestinal disaccharidase and glucoamylase activities.

J Autom Methods Manag Chem 2006 ;2006:93947

Nemours Biomedical Research Alfred I. duPont Hospital for Children Wilmington DE 19803 USA.

Determination of disaccharidase and glucoamylase activities is important for the diagnosis of intestinal diseases. We adapted a widely accepted manual method to an automated system that uses the same reagents reaction volumes, incubation times, and biopsy size as the manual method. A dye was added to the homogenates as the internal quality control to monitor the pipetting precision of the automated system. When the automated system was tested using human intestinal homogenates, the activities of all the routinely tested disaccharidases, including lactase, maltase, sucrase, and palatinase, as well as the activity of glucoamylase, showed perfect agreement with the manual method and were highly reproducible. The automated analyzer can perform the same routine assays of disaccharidases and glucoamylase with high consistency and accuracy and reduce testing costs by performing a larger sample size with the same number of staff. Additional developments, such as barcoding and built-in plate reading, would result in a completely automated system.
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http://dx.doi.org/10.1155/JAMMC/2006/93947DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1903450PMC
July 2011

Detection of gastric pepsin in middle ear fluid of children with otitis media.

Otolaryngol Head Neck Surg 2007 Jul;137(1):59-64

Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.

Objective: We sought to confirm the finding of pepsin/pepsinogen in the middle ear fluid of children with otitis media in a larger sample size using a sensitive and specific pepsin assay.

Study Design And Setting: We evaluated 152 children (225 ear samples) in a prospective study at a tertiary care children's hospital. The presence of pepsin in middle ear aspirates was determined using enzymatic assay.

Results: Of the patients, 14.4 percent (22 of 152) had detectable pepsin activity in one or both of the ear samples with no pepsin activity detected in control serum. Average pepsin concentration in the samples was 96.6 +/- 170.8 ng/ml, ranging from 13 to 687 ng/ml. Pepsin concentration in the middle ear of children younger than 1.0 year was significantly higher than in older age groups.

Conclusion And Significance: Results indicate that pepsin/pepsinogen is present in the middle ears of children with otitis media, although not at the high rate previously reported. Gastric reflux may be one causative factor in the pathogenesis of otitis media.
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http://dx.doi.org/10.1016/j.otohns.2007.02.002DOI Listing
July 2007

Pepsin, a reliable marker of gastric aspiration, is frequently detected in tracheal aspirates from premature ventilated neonates: relationship with feeding and methylxanthine therapy.

J Pediatr Gastroenterol Nutr 2006 Sep;43(3):336-41

Division of Gastroenterology and Nutrition, and Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.

Objectives: To determine the frequency of pepsin detection in tracheal aspirate (TA) samples of mechanically ventilated premature neonates and its association with feedings and methylxanthine therapy.

Patients And Methods: Serial TA samples (days 1, 3, 5, 7, 14, 21, 28 and >28 days) were collected from premature neonates receiving ventilatory support. An enzymatic assay with a fluorescent substrate was used to detect pepsin. Pepsin was also measured in 10 serum samples collected in conjunction with the TA samples from 8 neonates.

Results: A total of 239 TA samples was collected from 45 premature neonates (mean birth weight, 762 +/- 166 g; mean gestational age, 25.5 +/- 1.5 wk). Pepsin was detectable in 222 of 239 TA samples (92.8%) and in none of the serum samples. Pepsin was significantly lower on day 1 (mean, 170 +/- 216 ng/mL) when compared with all other time points (P < 0.05). Mean concentration of pepsin was significantly lower when infants were unfed (265 +/- 209 ng/mL) compared with levels during feeding (390 +/- 260 ng/mL, P = 0.02). The mean level of pepsin was significantly higher in infants during xanthine therapy (419 +/- 370 ng/mL) compared with no xanthine therapy (295 +/- 231 ng/mL, P = 0.037).

Conclusion: Pepsin, a marker of gastric contents, was detected in more than 92% of TA samples from premature infants on mechanical ventilation. The level of pepsin was higher in fed infants when compared with unfed infants. Xanthine therapy was also associated with increased pepsin in TA samples. Chronic aspiration of gastric contents may worsen lung disease in premature infants.
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http://dx.doi.org/10.1097/01.mpg.0000232015.56155.03DOI Listing
September 2006

Are there psychosocial differences in diagnostic subgroups of children with recurrent abdominal pain?

J Pediatr Gastroenterol Nutr 2005 Aug;41(2):216-20

Department of Psychology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, and the University of Delaware, Newark, Delaware, USA.

Objectives: To examine psychosocial differences in diagnostic subgroups of children with recurrent abdominal pain (RAP).

Methods: Children meeting Apley's 1975 definition of RAP were divided according to physician ratings into three subgroups, based on the Rome II diagnostic criteria of functional gastrointestinal disorders: functional dyspepsia (n=17), irritable bowel syndrome (n=18), and functional abdominal pain (n=27). Groups were compared using measures of (a) child psychopathology, (b) parent psychopathology, and (c) child pain, somatization, and functional disability.

Results: Multivariate results from a discriminant function analysis demonstrated that children classified according to these criteria could not be differentiated with respect to parent reported child psychopathology or child pain, somatization, and functional disability. There were significant univariate differences, however, between groups on parental psychopathology (F=4.39, P=0.02); parents of children with functional dyspepsia reported greater parental psychopathology symptoms than the other two groups.

Conclusions: This study provides a preliminary comparison of pain, somatization, functional impact, and psychopathology ratings in the Rome II diagnostic subclassifications of children with RAP. Further investigation utilizing larger sample sizes, pain measures specifying pain location, and parental modeling of somatic behavior is indicated to better understand potential similarities and differences between these subgroups.
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http://dx.doi.org/10.1097/01.mpg.0000170601.88263.50DOI Listing
August 2005
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