Publications by authors named "Timothy R Shope"

46 Publications

Child Care in the Time of Coronavirus Disease-19: A Period of Challenge and Opportunity.

J Pediatr 2020 Oct 17;225:239-245. Epub 2020 Jul 17.

Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.

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http://dx.doi.org/10.1016/j.jpeds.2020.07.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366077PMC
October 2020

Corticosteroids to prevent kidney scarring in children with a febrile urinary tract infection: a randomized trial.

Pediatr Nephrol 2020 11 15;35(11):2113-2120. Epub 2020 Jun 15.

University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Background: To evaluate the efficacy of adjuvant systemic corticosteroids in reducing kidney scarring. A previous study suggested that use of adjuvant systemic corticosteroids reduces kidney scarring in children radiologically confirmed to have extensive pyelonephritis. Efficacy of corticosteroids for children with febrile urinary tract infection (UTI) has not been studied.

Methods: Children aged 2 months to 6 years with their first febrile UTI were randomized to corticosteroids or placebo for 3 days (both arms received antimicrobial therapy); kidney scarring was assessed using Tc-dimercaptosuccinic acid kidney scan 5-24 months after the initial UTI.

Results: We randomized 546 children of which 385 had a UTI and 254 had outcome kidney scans (instead of the 320 planned). Rates of kidney scarring were 9.8% (12/123) and 16.8% (22/131) in the corticosteroid and placebo groups, respectively (p = 0.16), corresponding to an absolute risk reduction of 5.9% (95% confidence interval: - 2.2, 14.1).

Conclusion: While children randomized to adjuvant corticosteroids tended to develop fewer kidney scars than children who were randomized to receive placebo, a statistically significant difference was not achieved. However, the study was limited by not reaching its intended sample size.

Clinical Trial Registration: Clinicaltrials.gov , NCT01391793, Registered 7/12/2011 Graphical abstract.
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http://dx.doi.org/10.1007/s00467-020-04622-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529851PMC
November 2020

Laparoscopic Vertical Sleeve Gastrectomy as a Treatment Option for Adults with Diabetes Mellitus.

Adv Exp Med Biol 2021 ;1307:299-320

Center for Advanced Laparoscopic General & Bariatric Surgery, MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC, USA.

Obesity is a major factor in the worldwide rise in the prevalence of type 2 diabetes mellitus. The obesity "epidemic" will require novel, effective interventions to permit both the prevention and treatment of diabetes caused by obesity. Laparoscopic vertical sleeve gastrectomy is a newer bariatric surgical procedure with a lower risk of complications (compared to Roux-en-Y gastric bypass surgery). Based in part on restriction of daily caloric intake, sleeve gastrectomy has a major role in inducing significant weight loss and weight loss is maintained for at least 10 years. Prior studies have supported the utility of the vertical sleeve gastrectomy for the treatment and management of subgroups of individuals with diabetes mellitus. There are reports of 11% to 76.9% of obese individuals discontinuing use of diabetic medications in studies lasting up to 8 years after vertical sleeve gastrectomy. Major ongoing issues include the preoperative determination of the suitability of diabetic patients to undergo this bariatric surgical procedure. Understanding how this surgical procedure is performed and the resulting anatomy is important when vertical sleeve gastrectomy is being considered as a treatment option for diabetes. In the postoperative periods, specific macronutrient goals and micronutrient supplements are important for successful and safer clinical results. An understanding of immediate- and long term- potential complications is important for reducing the potential risks of vertical sleeve gastrectomy. This includes the recognition and treatment of postoperative nutritional deficiencies and disorders. Vertical sleeve gastrectomy is a component of a long term, organized program directed at treating diabetes related to obesity. This approach may result in improved patient outcomes when vertical sleeve gastrectomy is performed to treat type 2 diabetes in obese individuals.
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http://dx.doi.org/10.1007/5584_2020_487DOI Listing
January 2021

Influenza Vaccine Requirements in United States Child Care Centers.

J Pediatric Infect Dis Soc 2020 Nov;9(5):566-572

Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Background: Influenza vaccine is the most effective means to prevent influenza for the high-risk population of child care attendees. This national survey assessed child care center directors' reports of seasonal influenza vaccine requirements for children and adult caregivers.

Methods: This was a 2016 telephone-based survey of child care center directors randomly selected from a national database of licensed United States child care centers and queried about influenza vaccine requirements. Conceptually related items were grouped into 4 indexes: general infection control, use of health consultants, quality of child care, and pandemic influenza preparedness. These indexes, along with other center and director characteristics, were used to predict director-reported influenza vaccine requirements.

Results: Of 518 child care center directors, only 24.5% and 13.1% reported an influenza vaccine requirement for children and adult caregivers, respectively. Center and director characteristics and the indexes were not associated with a director-reported influenza vaccine requirement. After adjusting for covariates, only having a state influenza vaccine law for children and an adult influenza vaccine requirement predicted having a child influenza vaccine requirement. Only having a child influenza vaccine requirement predicted having an adult vaccine requirement.

Conclusions: Director-reported influenza vaccine requirements for children and adult caregivers were influenced primarily by state influenza vaccine laws. Given the high risk of children in child care and low director-reported influenza vaccine requirements, more states should pass laws requiring influenza vaccine for children and adult caregivers at child care programs.
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http://dx.doi.org/10.1093/jpids/piz078DOI Listing
November 2020

Biomarkers that differentiate false positive urinalyses from true urinary tract infection.

Pediatr Nephrol 2020 02 22;35(2):321-329. Epub 2019 Nov 22.

Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA.

Background: The specificity of the leukocyte esterase test (87%) is suboptimal. The objective of this study was to identify more specific screening tests that could reduce the number of children who unnecessarily receive antimicrobials to treat a presumed urinary tract infection (UTI).

Methods: Prospective cross-sectional study to compare inflammatory proteins in blood and urine samples collected at the time of a presumptive diagnosis of UTI. We also evaluated serum RNA expression in a subset.

Results: We enrolled 200 children; of these, 89 were later demonstrated not to have a UTI based on the results of the urine culture obtained. Urinary proteins that best discriminated between children with UTI and no UTI were involved in T cell response proliferation (IL-9, IL-2), chemoattractants (CXCL12, CXCL1, CXCL8), the cytokine/interferon pathway (IL-13, IL-2, INFγ), or involved in innate immunity (NGAL). The predictive power (as measured by the area under the curve) of a combination of four urinary markers (IL-2, IL-9, IL-8, and NGAL) was 0.94. Genes in the pathways related to inflammation were also upregulated in serum of children with UTI.

Conclusions: Urinary proteins involved in the inflammatory response may be useful in identifying children with false positive results with current screening tests for UTI; this may reduce unnecessary treatment.
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http://dx.doi.org/10.1007/s00467-019-04403-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942213PMC
February 2020

Bariatric surgery among vulnerable populations: The effect of the Affordable Care Act's Medicaid expansion.

Surgery 2019 11 9;166(5):820-828. Epub 2019 Aug 9.

MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Georgetown University, Washington, DC; Integrated Surgical Services of MedStar Washington Region, Washington, DC. Electronic address:

Background: Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated. We sought to determine the impact of the Affordable Care Act's Medicaid expansion on disparate utilization rates of bariatric surgery.

Methods: A total of 47,974 nonelderly adult bariatric surgical patients (ages 18-64 years) were identified in 2 Medicaid-expansion states (Kentucky and Maryland) versus 2 nonexpansion control states (Florida and North Carolina) between 2012 and 2015 using the Healthcare Cost and Utilization Project's State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery by insurance (Medicaid/uninsured versus privately insured), income (high income versus low income), and race (African American versus white). The difference in the counts of bariatric surgery were then calculated to measure the gap in bariatric surgery rates.

Results: The adjusted incidence rate of bariatric surgery among Medicaid or uninsured and low-income patients increased by 15.8% and 5.1% per quarter, respectively, after the Affordable Care Act in expansion states (P < .001). No marginal change was seen in privately insured and high-income patients in expansion states. The adjusted incidence rates increased among African American and white patients, but these rates did not change significantly before and after the Affordable Care Act in expansion states.

Conclusion: The gap in bariatric surgery rates by insurance and income was reduced after the Affordable Care Act's Medicaid expansion, but racial disparities persisted. Future research should track these trends and identify factors to reduce racial disparity in bariatric surgery.
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http://dx.doi.org/10.1016/j.surg.2019.05.005DOI Listing
November 2019

Randomized Trial of Irrigation and Curetting for Cerumen Removal in Young Children.

Front Pediatr 2019 6;7:216. Epub 2019 Jun 6.

Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.

To gather preliminary data on the effectiveness and feasibility of cerumen removal using three irrigation methods and a metal curette in young children. Pilot study conducted as a randomized clinical trial of well and ill children age 6 months to 6 years with ≥25% cerumen occlusion in at least one ear. Children were stratified by age and randomized to one of four methods of cerumen removal: syringe with attached angiocath tubing, Elephant Ear Washer Bottle System, OtoClear Spray Wash Kit, or metal curette. Clinicians, blinded from treatment assignment, assessed the degree of cerumen occlusion before and after the procedure. Outcomes included reduction in cerumen occlusion, successful removal, time until completion and parental satisfaction. Rules for stopping procedures were established . Thirty-eight children underwent procedures (59 ears). There were no significant differences in reduction in cerumen and successful removal among the methods. Overall, 36 (61%) of 59 of procedures were successful. The syringe with angiocath tubing took the most time ( = 0.04) and resulted in the most stopped procedures ( < 0.01). Parental satisfaction scores were not significantly different. Irrigation methods performed comparably to cerumen removal with curette; the SA method had drawbacks. Irrigation can be performed by non-clinicians, which is potentially a significant advantage. (Clinical trial registration: http://www.isrctn.com/ISRCTN74402562).
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http://dx.doi.org/10.3389/fped.2019.00216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563688PMC
June 2019

Host and Bacterial Markers that Differ in Children with Cystitis and Pyelonephritis.

J Pediatr 2019 06 21;209:146-153.e1. Epub 2019 Mar 21.

Department of Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, PA.

Objective: To determine whether treatment for urinary tract infections in children could be individualized using biomarkers for acute pyelonephritis.

Study Design: We enrolled 61 children with febrile urinary tract infections, collected blood and urine samples, and performed a renal scan within 2 weeks of diagnosis to identify those with pyelonephritis. Renal scans were interpreted centrally by 2 experts. We measured inflammatory proteins in blood and urine using LUMINEX or an enzyme-linked immunosorbent assay. We evaluated serum RNA expression using RNA sequencing in a subset of children. Finally, for children with Escherichia coli isolated from urine cultures, we performed a polymerase chain reaction for 4 previously identified virulence genes.

Results: Urinary markers that best differentiated pyelonephritis from cystitis included chemokine (C-X-C motif) ligand (CXCL)1, CXCL9, CXCL12, C-C motif chemokine ligand 2, INF γ, and IL-15. Serum procalcitonin was the best serum marker for pyelonephritis. Genes in the interferon-γ pathway were upregulated in serum of children with pyelonephritis. The presence of E coli virulence genes did not correlate with pyelonephritis.

Conclusions: Immune response to pyelonephritis and cystitis differs quantitatively and qualitatively; this may be useful in differentiating these 2 conditions.
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http://dx.doi.org/10.1016/j.jpeds.2019.01.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535366PMC
June 2019

Bowel symptoms are associated with hypovitaminosis D in individuals with medically complicated obesity.

Nutr Res 2019 03 8;63:70-75. Epub 2018 Dec 8.

Center for Advanced Laparoscopic General & Bariatric Surgery, MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010. Electronic address:

We reported that 30% of individuals with medically complicated obesity have bowel symptoms, suggesting irritable bowel syndrome, but this prevalence of bowel symptoms is not related to body mass index or diabetes mellitus. Hypovitaminosis D is common in individuals with obesity and type 2 diabetes mellitus and is associated with depressive symptoms. Because antidepressants improve global symptoms in individuals with bowel symptoms, we hypothesize that the high prevalence of bowel symptoms in medically complicated obesity is associated with hypovitaminosis D. This is a single-institution, retrospective cohort study performed in a large, urban community teaching hospital. Over 2 years, individuals considering bariatric surgery completed a Manning symptom questionnaire to quantify bowel symptoms. Serum 25-hydroxy vitamin D was ordered, and the results were recorded for all individuals. Among 271 subjects, 229 subjects (80% women, 20% men; 67% black, 31% white; age range: 23-73 years; body mass index range: 35-91 kg/m) completed 25-hydroxy vitamin D testing. Sixty-seven subjects (29%) have 3 to 6 Manning bowel symptoms, suggesting irritable bowel syndrome; 84 (37%) have type 2 diabetes; and 180 (79%) had vitamin D insufficiency. There are significant negative associations between Manning bowel symptoms and vitamin D concentrations in subjects with obesity (P = .01) and with type 2 diabetes mellitus and obesity (P = .007). The results support our hypothesis that the high prevalence of bowel symptoms in people with medically complicated obesity is associated with hypovitaminosis D. A prospective study is required to evaluate vitamin D supplementation and relief of bowel symptoms in people with medically complicated obesity.
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http://dx.doi.org/10.1016/j.nutres.2018.12.002DOI Listing
March 2019

Current and future impact of clinical gastrointestinal research on patient care in diabetes mellitus.

World J Diabetes 2018 Nov;9(11):180-189

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States.

The worldwide rise in the prevalence of obesity supports the need for an increased interaction between ongoing clinical research in the allied fields of gastrointestinal medicine/surgery and diabetes mellitus. There have been a number of clinically-relevant advances in diabetes, obesity, and metabolic syndrome emanating from gastroenterological research. Gastric emptying is a significant factor in the development of upper gastrointestinal symptoms. However, it is not the only mechanism whereby such symptoms occur in patients with diabetes. Disorders of intrinsic pacing are involved in the control of stomach motility in patients with gastroparesis; on the other hand, there is limited impact of glycemic control on gastric emptying in patients with established diabetic gastroparesis. Upper gastrointestinal functions related to emptying and satiations are significantly associated with weight gain in obesity. Medications used in the treatment of diabetes or metabolic syndrome, particularly those related to pancreatic hormones and incretins affect upper gastrointestinal tract function and reduce hyperglycemia and facilitate weight loss. The degree of gastric emptying delay is significantly correlated with the weight loss in response to liraglutide, a glucagon-like peptide-1 analog. Network meta-analysis shows that liraglutide is one of the two most efficacious medical treatments of obesity, the other being the combination treatment phentermine-topiramate. Interventional therapies for the joint management of obesity and diabetes mellitus include newer endoscopic procedures, which require long-term follow-up and bariatric surgical procedure for which long-term follow up shows advantages for individuals with diabetes. Newer bariatric procedures are presently undergoing clinical evaluation. On the horizon, combination therapies, in part directed at gastrointestinal functions, appear promising for these indications. Ongoing and future gastroenterological research when translated to care of individuals with diabetes mellitus should provide additional options to improve their clinical outcomes.
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http://dx.doi.org/10.4239/wjd.v9.i11.180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6242723PMC
November 2018

Comment on: Laparoscopic sleeve gastrectomy in patients with heart failure and left ventricular assist devices as a bridge to transplant.

Authors:
Timothy R Shope

Surg Obes Relat Dis 2018 09 17;14(9):1274-1275. Epub 2018 May 17.

Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, D.C.

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http://dx.doi.org/10.1016/j.soard.2018.05.005DOI Listing
September 2018

Specialty Article: so You Think You Got a Bypass? A Case Series of Adventures in Bariatric Surgery.

Obes Surg 2018 05;28(5):1429-1432

Department of Surgery, MedStar Washington Hospital Center, 106 Irving Street NW, Physicians Office Building South Tower Suite 301, Washington, DC, 20010, USA.

To raise awareness for surgeons encountering bariatric patients with anatomy that deviates from the standard Roux-en-Y gastric bypass (RYGB). This is a single-institution retrospective case series over 12 years (2003-2014) involving patients who believed they received RYGBs, but actually did not. Data was obtained reviewing physician encounters, imaging, and operative reports. There were six cases with confusing clinical pictures, found to have aberrant RYGB anatomy: (1) gastric bypass with jejuno-jejunostomy only without gastrojejunostomy, (2) distal partial vertical gastrectomy without expected prosthetic band, (3) inverse vertical banded gastroplasty, (4) non-divided gastric bypass with no gastrojejunostomy, (5) 20-cm Roux limb, with gastro-gastric fistula, and (6) 200-cm bilio-pancreatic limb similar to the traditional Scopinaro procedure. There are cases of "Roux-en-Y gastric bypasses" that have no resemblance to the named procedure at all. Adjunctive upper gastrointestinal studies and upper endoscopies help surgeons make diagnoses that are incongruent with the surgical history. It is important to keep in mind that there could be anatomic or surgical variations which were born out of necessity or based on other surgeons' creativities.
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http://dx.doi.org/10.1007/s11695-018-3149-4DOI Listing
May 2018

Organization of future training in bariatric gastroenterology.

World J Gastroenterol 2017 Sep;23(35):6371-6378

Professor Emeritus, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States.

A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the long-term impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a long-term approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees' prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicated obesity.
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http://dx.doi.org/10.3748/wjg.v23.i35.6371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5643262PMC
September 2017

Pandemic Influenza Preparedness Among Child Care Center Directors in 2008 and 2016.

Pediatrics 2017 Jun 15;139(6). Epub 2017 May 15.

Division of General Academic Pediatrics, Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.

Background: Children in child care centers represent an important population to consider in attempts to mitigate the spread of an influenza pandemic. This national survey, conducted in 2008 and 2016, assessed directors' reports of their child care centers' pandemic influenza preparation before and after the 2009 H1N1 novel influenza pandemic.

Methods: This was a telephone-based survey of child care center directors randomly selected from a national database of licensed US child care centers who were queried about their preparedness for pandemic influenza. We grouped conceptually related items in 6 domains into indexes: general infection control, communication, seasonal influenza control, use of health consultants, quality of child care, and perceived barriers. These indexes, along with other center and director characteristics, were used to predict pandemic influenza preparedness.

Results: Among 1500 and 518 child care center directors surveyed in 2008 and 2016, respectively, preparation for pandemic influenza was low and did not improve. Only 7% of directors had taken concrete actions to prepare their centers. Having served as a center director during the 2009 influenza pandemic did not influence preparedness. After adjusting for covariates, child care health consultation and years of director's experience were positively associated with pandemic influenza preparation, whereas experiencing perceived barriers such as lack of knowing what to do in the event of pandemic influenza, was negatively associated with pandemic influenza preparedness.

Conclusions: Pandemic influenza preparedness of child care center's directors needs to improve. Child care health consultants are likely to be important collaborators in addressing this problem.
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http://dx.doi.org/10.1542/peds.2016-3690DOI Listing
June 2017

Reduced-Concentration Clavulanate for Young Children with Acute Otitis Media.

Antimicrob Agents Chemother 2017 07 27;61(7). Epub 2017 Jun 27.

Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA.

Amoxicillin-clavulanate (A/C) is currently the most effective oral antimicrobial in treating children with acute otitis media (AOM), but the standard dosage of 90 mg amoxicillin/6.4 mg clavulanate/kg of body weight/day commonly causes diarrhea. We examined whether an A/C formulation containing lower concentrations of clavulanate would result in less diarrhea while maintaining plasma levels of amoxicillin and clavulanate adequate to eradicate middle-ear pathogens and to achieve clinical success. We conducted an open-label study in children with AOM who were 6 to 23 months of age. In phase 1, we treated 40 children with a reduced-clavulanate A/C formulation providing 90 mg amoxicillin/3.2 mg clavulanate/kg/day for 10 days. In phase 2, we treated 72 children with the same formulation at a dosage of 80 mg amoxicillin/2.85 mg clavulanate/kg/day for 10 days. We compared the rates of protocol-defined diarrhea (PDD), diaper dermatitis, and AOM clinical response in these children with rates we had reported in children who received the standard A/C regimen, and we obtained plasma levels of amoxicillin and clavulanate at various time points. Outcomes in phase 1 children and in children who had received the standard regimen did not differ significantly. Rates of PDD in children receiving phase 2 and standard regimens were 17% and 26%, respectively ( = 0.10). The corresponding rates of diaper dermatitis were 21% and 33% ( = 0.04) and of AOM treatment failure were 12% and 16% ( = 0.44). Symptomatic responses did not differ significantly between regimens; both gave clavulanate levels sufficient to inhibit β-lactamase activity. In young children with AOM, clavulanate dosages lower than those currently used may be associated with fewer side effects without reducing clinical efficacy. (This study has been registered at ClinicalTrials.gov under registration no. NCT02630992.).
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http://dx.doi.org/10.1128/AAC.00238-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487636PMC
July 2017

Prevalence of clinical thiamine deficiency in individuals with medically complicated obesity.

Nutr Res 2017 Jan 1;37:29-36. Epub 2016 Dec 1.

Center for Advanced Laparoscopic General & Bariatric Surgery, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, USA. Electronic address:

Thiamine is a vitamin whose deficient can result in multiorgan symptoms. We described an 18% prevalence of clinical thiamine deficiency after gastric bypass surgery. Our hypotheses are that individuals with medically complicated obesity frequently have clinical thiamine deficiency and that diabetes mellitus is a mechanism for development of clinical thiamine deficiency. This is a single institution, retrospective observational study of consecutive patients with a body mass index of at least 35 kg/m who were evaluated in preoperative gastrointestinal bariatric clinic from 2013 to 2015. Each patient underwent a symptom survey. Clinical thiamine deficiency is defined by both (1) consistent clinical symptom and (2) either a low whole-blood thiamine concentration or significant improvement of or resolution of consistent clinical symptoms after receiving thiamine supplementation. After excluding 101 individuals with prior bariatric surgery or heavy alcohol consumption, 400 patients were included in the study. Sixty-six patients (16.5% of 400) fulfill a diagnosis of clinical thiamine deficiency, with 9 (14% of 66) having consistent gastrointestinal manifestations, 46 (70% of 66) having cardiac manifestations, 39 (59% of 66) having peripheral neurologic manifestations, and 3 (5% of 66) having neuropsychiatric manifestations. Diabetes mellitus is not a risk factor (P=.59). Higher body mass index is a significant risk for clinical thiamine deficiency (P=.007). Clinical thiamine deficiency is common in these individuals and a higher body mass index is an identified risk factor. Mechanisms explaining development of thiamine deficiency in obese individuals remain unclear.
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http://dx.doi.org/10.1016/j.nutres.2016.11.012DOI Listing
January 2017

Dysphagia after vertical sleeve gastrectomy: Evaluation of risk factors and assessment of endoscopic intervention.

World J Gastroenterol 2016 Dec;22(47):10371-10379

Anand Nath, Department of Medicine, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, United States.

Aim: To evaluate the risks of medical conditions, evaluate gastric sleeve narrowing, and assess hydrostatic balloon dilatation to treat dysphagia after vertical sleeve gastrectomy (VSG).

Methods: VSG is being performed more frequently worldwide as a treatment for medically-complicated obesity, and dysphagia is common post-operatively. We hypothesize that post-operative dysphagia is related to underlying medical conditions or narrowing of the gastric sleeve. This is a retrospective, single institution study of consecutive patients who underwent sleeve gastrectomy from 2013 to 2015. Patients with previous bariatric procedures were excluded. Narrowing of a gastric sleeve includes: inability to pass a 9.6 mm gastroscope due to stenosis or sharp angulation or spiral hindering its passage.

Results: Of 400 consecutive patients, 352 are included; the prevalence of dysphagia is 22.7%; 33 patients (9.3%) have narrowing of the sleeve with 25 (7.1%) having sharp angulation or a spiral while 8 (2.3%) have a stenosis. All 33 patients underwent balloon dilatation of the gastric sleeve and dysphagia resolved in 13 patients (39%); 10 patients (30%) noted resolution of dysphagia after two additional dilatations. In a multivariate model, medical conditions associated with post-operative dysphagia include diabetes mellitus, symptoms of esophageal reflux, a low whole blood thiamine level, hypothyroidism, use of non-steroidal anti-inflammatory drugs, and use of opioids.

Conclusion: Narrowing of the gastric sleeve and gastric sleeve stenosis are common after VSG. Endoscopic balloon dilatations of the gastric sleeve resolves dysphagia in 69% of patients.
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http://dx.doi.org/10.3748/wjg.v22.i47.10371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5175249PMC
December 2016

Shortened Antimicrobial Treatment for Acute Otitis Media in Young Children.

N Engl J Med 2016 12;375(25):2446-2456

From the Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC) (A.H., J.L.P., D.H.K., S.B., T.R.S., J.M.M., M.K.-L., S.J.C., D.K.C., M.H., M.A.P., J.P.N., M.D.G., N.S.), the Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh (H.E.R.), and Children's Community Pediatrics (J.J.L., T.G.L., N.L.C.) - all in Pittsburgh; and Kentucky Pediatric and Adult Research, Bardstown (S.L.B.).

Background: Limiting the duration of antimicrobial treatment constitutes a potential strategy to reduce the risk of antimicrobial resistance among children with acute otitis media.

Methods: We assigned 520 children, 6 to 23 months of age, with acute otitis media to receive amoxicillin-clavulanate either for a standard duration of 10 days or for a reduced duration of 5 days followed by placebo for 5 days. We measured rates of clinical response (in a systematic fashion, on the basis of signs and symptomatic response), recurrence, and nasopharyngeal colonization, and we analyzed episode outcomes using a noninferiority approach. Symptom scores ranged from 0 to 14, with higher numbers indicating more severe symptoms.

Results: Children who were treated with amoxicillin-clavulanate for 5 days were more likely than those who were treated for 10 days to have clinical failure (77 of 229 children [34%] vs. 39 of 238 [16%]; difference, 17 percentage points [based on unrounded data]; 95% confidence interval, 9 to 25). The mean symptom scores over the period from day 6 to day 14 were 1.61 in the 5-day group and 1.34 in the 10-day group (P=0.07); the mean scores at the day-12-to-14 assessment were 1.89 versus 1.20 (P=0.001). The percentage of children whose symptom scores decreased more than 50% (indicating less severe symptoms) from baseline to the end of treatment was lower in the 5-day group than in the 10-day group (181 of 227 children [80%] vs. 211 of 233 [91%], P=0.003). We found no significant between-group differences in rates of recurrence, adverse events, or nasopharyngeal colonization with penicillin-nonsusceptible pathogens. Clinical-failure rates were greater among children who had been exposed to three or more children for 10 or more hours per week than among those with less exposure (P=0.02) and were also greater among children with infection in both ears than among those with infection in one ear (P<0.001).

Conclusions: Among children 6 to 23 months of age with acute otitis media, reduced-duration antimicrobial treatment resulted in less favorable outcomes than standard-duration treatment; in addition, neither the rate of adverse events nor the rate of emergence of antimicrobial resistance was lower with the shorter regimen. (Funded by the National Institute of Allergy and Infectious Diseases and the National Center for Research Resources; ClinicalTrials.gov number, NCT01511107 .).
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http://dx.doi.org/10.1056/NEJMoa1606043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5319589PMC
December 2016

Association Between Uropathogen and Pyuria.

Pediatrics 2016 07 21;138(1). Epub 2016 Jun 21.

Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Objective: We sought to determine factors associated with the absence of pyuria in symptomatic children whose urine culture was positive for a known uropathogen.

Methods: We obtained data on children evaluated at the Children's Hospital of Pittsburgh emergency department between 2007 and 2013 with symptoms of urinary tract infection (UTI) who had paired urinalysis and urine cultures. We excluded children with an unknown or bag urine collection method, major genitourinary anomalies, immunocompromising conditions, or with multiple organisms on culture. We chose a single, randomly-selected urine specimen per child and limited the analysis to those with positive cultures.

Results: There were 46 158 visits during the study period; 1181 children diagnosed with UTI met all inclusion criteria and had a microscopic urinalysis for pyuria. Pyuria (≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter) was present in 1031 (87%) children and absent in 150 (13%). Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis. Results were similar when we restricted the analysis to children whose urine samples were collected by bladder catheterization.

Conclusions: We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over- and undertreatment of UTIs.
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http://dx.doi.org/10.1542/peds.2016-0087DOI Listing
July 2016

Diet and Activity Programs Are Ineffective in Nonalcoholic Steatohepatitis.

Mayo Clin Proc 2016 05;91(5):683-4

MedStar-Georgetown Transplant Institute and Georgetown University School of Medicine, Washington, DC.

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http://dx.doi.org/10.1016/j.mayocp.2016.02.021DOI Listing
May 2016

Breath Hydrogen as a Biomarker for Glucose Malabsorption after Roux-en-Y Gastric Bypass Surgery.

Dis Markers 2015 11;2015:102760. Epub 2015 Oct 11.

Department of Surgery and Center for Advanced Laparoscopic & Bariatric Surgery, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, USA.

Objective: Abdominal symptoms are common after bariatric surgery, and these individuals commonly have upper gut bacterial overgrowth, a known cause of malabsorption. Breath hydrogen determination after oral glucose is a safe and inexpensive test for malabsorption. This study is designed to investigate breath hydrogen levels after oral glucose in symptomatic individuals who had undergone Roux-en-Y gastric bypass surgery.

Methods: This is a retrospective study of individuals (n = 63; 60 females; 3 males; mean age 49 years) who had gastric bypass surgery and then glucose breath testing to evaluate abdominal symptoms.

Results: Among 63 postoperative individuals, 51 (81%) had a late rise (≥45 minutes) in breath hydrogen or methane, supporting glucose malabsorption; 46 (90%) of these 51 subjects also had an early rise (≤30 minutes) in breath hydrogen or methane supporting upper gut bacterial overgrowth. Glucose malabsorption was more frequent in subjects with upper gut bacterial overgrowth compared to subjects with no evidence for bacterial overgrowth (P < 0.001).

Conclusion: These data support the presence of intestinal glucose malabsorption associated with upper gut bacterial overgrowth in individuals with abdominal symptoms after gastric bypass surgery. Breath hydrogen testing after oral glucose should be considered to evaluate potential malabsorption in symptomatic, postoperative individuals.
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http://dx.doi.org/10.1155/2015/102760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4619887PMC
July 2016

Risk model for renal scarring: validation and implications still needed for primary care—reply.

JAMA Pediatr 2015 Feb;169(2):189-90

Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

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http://dx.doi.org/10.1001/jamapediatrics.2014.2902DOI Listing
February 2015

Development of minimally invasive techniques for management of medically-complicated obesity.

World J Gastroenterol 2014 Oct;20(37):13424-45

Farzin Rashti, Ekta Gupta, Suzan Ebrahimi, Timothy R Koch, Section of Gastroenterology and Hepatology, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, United States.

The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this complex disorder. The development of new laparoscopic and minimally invasive treatments for medically-complicated obesity has made it essential that gastrointestinal physicians obtain a thorough understanding of past developments and possible future directions in bariatrics. New laparoscopic advancements provide patients and practitioners with a variety of options that have an improved safety profile and better efficacy without open, invasive surgery. The mechanisms of weight loss after bariatric surgery are complex and may in part be related to altered release of regulatory peptide hormones from the gut. Endoscopic techniques designed to mimic the effects of bariatric surgery and endolumenal interventions performed entirely through the gastrointestinal tract offer potential advantages. Several of these new techniques have demonstrated promising, preliminary results. We outline herein historical and current trends in the development of bariatric surgery and its transition to safer and more minimally invasive procedures designed to induce weight loss.
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http://dx.doi.org/10.3748/wjg.v20.i37.13424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4188895PMC
October 2014

Infectious diseases in early education and child care programs.

Authors:
Timothy R Shope

Pediatr Rev 2014 May;35(5):182-93

Department of Pediatrics, Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA.

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http://dx.doi.org/10.1542/pir.35-5-182DOI Listing
May 2014

Exclusion of mildly ill children from childcare.

Pediatr Ann 2012 May;41(5):204-8

University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. timothy.

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http://dx.doi.org/10.3928/00904481-20120426-11DOI Listing
May 2012

Nutritional deficiencies after bariatric surgery.

Nat Rev Endocrinol 2012 Sep 24;8(9):544-56. Epub 2012 Apr 24.

Department of Medicine, Washington Hospital Center, POB North, Suite 3400, 106 Irving Street Northwest, Washington, DC 20010, USA.

Lifestyle intervention programmes often produce insufficient weight loss and poor weight loss maintenance. As a result, an increasing number of patients with obesity and related comorbidities undergo bariatric surgery, which includes approaches such as the adjustable gastric band or the 'divided' Roux-en-Y gastric bypass (RYGB). This Review summarizes the current knowledge on nutrient deficiencies that can develop after bariatric surgery and highlights follow-up and treatment options for bariatric surgery patients who develop a micronutrient deficiency. The major macronutrient deficiency after bariatric surgery is protein malnutrition. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Other disorders, including small intestinal bacterial overgrowth, can promote micronutrient deficiencies, especially in patients with diabetes mellitus. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize long-term adverse effects. A major clinical concern is the relationship between vitamin D deficiency and the development of metabolic bone diseases, such as osteoporosis or osteomalacia; metabolic bone diseases may explain the increased risk of hip fracture in patients after RYGB. Further studies are required to determine the optimal levels of nutrient supplementation and whether postoperative laboratory monitoring effectively detects nutrient deficiencies. In the absence of such data, clinicians should inquire about and treat symptoms that suggest nutrient deficiencies.
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http://dx.doi.org/10.1038/nrendo.2012.48DOI Listing
September 2012

Prevalence and risk factor analysis for methicillin-resistant Staphylococcus aureus nasal colonization in children attending child care centers.

J Clin Microbiol 2011 Mar 29;49(3):1041-7. Epub 2010 Dec 29.

UNC School of Medicine, Department of Pathology and Laboratory Medicine, Campus Box 7525, Chapel Hill, NC 27599, USA.

Children attending child care centers (CCCs) are at increased risk for infections, including those caused by methicillin-resistant Staphylococcus aureus (MRSA). Nasal colonization often precedes infection, and MRSA colonization has been associated with increased infection risk. Community-associated MRSA (CA-MRSA) has caused increased MRSA infections in the general population, including children. Little is known about the frequency of MRSA nasal colonization in young children, particularly in those attending CCCs where disease transmission is common. We sampled the nares of 1,163 children in 200 classrooms from 24 CCCs in North Carolina and Virginia to assess S. aureus colonization. MRSA strains were molecularly analyzed for staphylococcal cassette chromosome mec (SCCmec) type, Panton-Valentine leukocidin status, and multilocus sequence type. A case-control study was performed to identify risk factors for MRSA colonization. We found that 18.1% children were colonized with S. aureus and 1.3% with MRSA. Molecular analysis of the MRSA strains identified 47% as CA-MRSA and 53% as health care-associated MRSA (HA-MRSA). Although two centers had multiple children colonized with MRSA, genotyping indicated that no transmission had occurred within classrooms. The case-control study did not detect statistically significant risk factors for MRSA colonization. However, MRSA-colonized children were more likely to be nonwhite and to have increased exposure to antibiotics and skin infections in the home. Both CA-MRSA and HA-MRSA strains were found colonizing the nares of children attending CCCs. The low frequency of colonization observed highlights the need for a large multicenter study to determine risk factors for MRSA colonization and subsequent infection in this highly susceptible population.
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http://dx.doi.org/10.1128/JCM.02235-10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3067749PMC
March 2011

Retroperitoneal diffuse large B-cell lymphoma presenting as pseudoachalasia.

J Clin Oncol 2010 Apr 15;28(12):e184-7. Epub 2010 Mar 15.

Department of Surgery, Pennsylvania State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA, USA.

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http://dx.doi.org/10.1200/JCO.2009.25.8715DOI Listing
April 2010