Biomarkers for diagnosing and monitoring IBD and UC

Feng JR, et al. Diagnostic Value of Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio in Crohn’s Disease. Gastroenterol Res Pract. 2017;2017:3526460.

The aim of this study is to investigate the diagnostic efficacy of neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-monocyte ratio (NMR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) in patients with Crohn’s disease (CD) and non-CD controls. These ratios were all derived from complete blood counts. Two hundred and six participants including CD inpatients and non-CD controls were retrospectively enrolled. We found statistically higher NLR and PLR and lower LMR in CD patients than in non-CD controls (all P < 0.01). However, NMR was not different between the two groups (P = 0.18). In addition, NLR, PLR, and LMR were associated with CRP and ESR. Optimal cutoffs for NLR and PLR were 2.72 (sensitivity: 68.3%, specificity: 75.9%, and overall accuracy: 70.1%) and 132.88 (sensitivity: 76.7%, specificity: 84.8%, and overall accuracy: 80.8%), respectively. In conclusion, the NLR and PLR might be effective, readily available, and low-cost biomarkers for differentiating CD patients from non-CD controls.

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Cherfane CE, et al. Monocytosis and a Low Lymphocyte to Monocyte Ratio Are Effective Biomarkers of Ulcerative Colitis Disease Activity. Inflamm Bowel Dis. 2015 Aug;21(8):1769-75.

Monocytosis and a low L/M ratio might be effective, readily available, and low-cost biomarkers to identify disease activity in UC patients. N/L values were more effective in distinguishing active UC patients from patients without IBD and those with C. difficile infection.

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Diagnostic imaging for inflammatory bowel disease

Barber JL, et al. Early onset inflammatory bowel disease – What the radiologist needs to know. Eur J Radiol. 2018 Sep;106:173-182.

Approximately 25% of Inflammatory Bowel Disease (IBD) patients present before the age of 18 years; early-onset IBD is defined as disease presenting before 10 years of age. Although early-onset disease is rare, it presents a particular challenge both in terms of treatment and diagnosis. There is a strong genetic component to these diseases and it is now possible to identify specific genetic mutations associated with certain patterns of early-onset IBD. All of these children require specific clinical work-up that is often performed at specialist centres. Young children with IBD, present a particular challenge to the radiologist because conventional bowel imaging techniques such as MR Enterography require general anaesthetic and other techniques such as CT or fluoroscopy must be carefully considered given the increased susceptibility to radiation in this young patient population. In this paper, we present a review of the aetiology, clinical work-up, differential diagnosis, and latest theories on the genetics of early-onset and very-early onset (<6 years) IBD. We also present our experience in the imaging of these children with particular focus on the difficulties and nuances that this group present to the radiologist.

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Upcoming PCO Webinar on Clinical Practice Guideline: Maintenance Intravenous Fluids in Children

Clinical Practice Guideline: Maintenance Intravenous Fluids in Children
Wednesday, January 16, 2019
12:00 – 1:00 PM EST

We invite you to join us on when Drs Leonard G. Feld, Michael L. Moritz, and Matthew D. Garber, on behalf of the American Academy of Pediatrics (AAP) Subcommittee on Fluid and Electrolyte Therapy, discuss the new AAP guideline “Clinical Practice Guideline: Maintenance Intravenous Fluids in Children.”

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Pulmonary blastomycosis

Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. Gauthier, Gregory M.; Klein, Bruce S… Published December 31, 2018. “Chest radiograph of a right upper lobe infiltrate due to blastomycosis.”

 

 

Feigin and Cherry’s Textbook of Pediatric Infectious Diseases.
Gauthier, Gregory M.; Klein, Bruce S… Published December 31, 2018. “Computed tomography of the chest reveals consolidation and abscess formation in the right lower lobe of the lung.”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Click here for PubMed collection on pulmonary blastomycosis.

Lemierre syndrome

Allen BW, Bentley TP. Lemierre Syndrome. 2018 Oct 27. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.

Lemierre syndrome (LS) is named after the French physician, Andre Lemierre, who in 1936 reported 20 cases of anaerobic septicemia originating from oropharyngeal infections. It is a rare complication of bacterial pharyngitis/tonsillitis and involves an extension of the infection into the lateral pharyngeal spaces of the neck with subsequent septic thrombophlebitis of the internal jugular vein(s). It is associated with anaerobic septicemia and death in young, healthy patients. Due to the high frequency of benign oropharyngeal infections in this population, the diagnosis of LS is often elusive on initial presentation. This can result in treatment delays.

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The use of “critical samples” in diagnosing hypoglycemia

Box 6-2. Criteria for Diagnosing Hyperinsulinism Based on “Critical” Samples (Drawn at a Time of Fasting Hypoglycemia: Plasma Glucose < 50 mg/dL)

  1. Hyperinsulinemia (plasma insulin > 2 μU/mL) *
  2. Hypofattyacidemia (plasma FFA < 1.5 mmol/L)
  3. Hypoketonemia (plasma BOB < 2 mmol/L)
  4. Inappropriate glycemic response to glucagon, 1 mg IV (delta glucose > 30 mg/dL)

*Depends on sensitivity of insulin assay.

BOB, β-hydroxybutyrate; FFA, free fatty acids.

From: De León, Diva D, et al. Hypoglycemia in the newborn and infant. In: Pediatric Endocrinology, 4th ed. Published December 31, 2013.

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Lung ultrasonography to diagnose pneumonia in children

Balk DS, et al. Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: A meta-analysis. Pediatr Pulmonol. 2018 Aug;53(8):1130-1139.

In our meta-analysis, lung ultrasound had significantly better sensitivity with similar specificity when compared to chest x-ray for the diagnosis of pediatric community acquired pneumonia.

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Orso D, Ban A, Guglielmo N. Lung ultrasound in diagnosing pneumonia in childhood: a systematic review and meta-analysis. J Ultrasound. 2018 Jun 21.

LUS seems to be a promise tool for diagnosing pneumonia in children. However, the high heterogeneity found across the individual studies, and the absence of a reliable reference standard, make the finding questionable. More methodologically rigorous studies are needed.

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Ingestion of detergent pods

Vohra R, et al. Exposures to Single-Use Detergent Sacs Reported to a Statewide Poison Control System, 2013-2015. Pediatr Emerg Care. 2018 May 2. [Epub ahead of print]

“Nine (37%) of 24 patients who underwent endoscopy or bronchoscopy ingested Tide Pods, 5 (20%) ingested All Mighty Pacs pods, 5 (20%) ingested unknown SUDS, 1 (4%) each of Purex, Gain Flings and Grocery Store Generic. Of the 16 patients requiring intubation, 6 (37%) ingested Tide Pods; 4 (25%) ingested All Mighty Pacs pods, 2 (12%) ingested Purex pods, 1 each ingested Gain Flings and Grocery Store Generic pod, and 2 (12%) ingested an unknown SUDS.

Physical signs and symptoms related to airway injury or vulnerability were frequently correlated with invasive procedures. Lethargy was present in 9 (56%) of 16 cases requiring intubation, and 5 cases required either endoscopy or bronchoscopy. For comparison, the total number of cases with lethargy reported as a symptom was 32 (<1%) of 3504 exposures. Four (25%) of 16 cases requiring intubation had stridor as a presenting symptom, and 3 (19%) of 16 had wheezing. The total numbers of cases with either stridor or wheezing were 14 (<1%) and 31(<1%), respectively. Six of 16 cases that required endoscopy had drooling as a presenting symptom (37%), with 2 also requiring bronchoscopy (25% of all bronchoscopies). The total number of cases with drooling as one of the reported symptoms was 53 (1.5%) (Figs. 1 and 2).

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Article of interest: Community-acquired pneumonia requiring hospitalization among U.S. children.

Jain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015 Feb 26; 372(9):835-45.

“In conclusion, the burden of community-acquired pneumonia requiring hospitalization was highest among younger children, with respiratory viruses frequently detected. Effective anti-viral vaccines or treatments, particularly for RSV, could have an impact on pediatric pneumonia. The low prevalence of bacterial detections likely reflects both the effectiveness of bacterial conjugate vaccines and relatively insensitive diagnostics. The pediatric community-acquired pneumonia burden was associated with multiple different and co-detected pathogens, underscoring a need for the enhancement of sensitive, inexpensive, and rapid diagnostics to accurately identify pneumonia pathogens.”

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