The COVID-19 (coronavirus disease 2019) pandemic brought rapid expansion of pediatric telehealth to maintain patient access to care while decreasing COVID-19 community spread. We designed a retrospective, serial, cross-sectional study to investigate if telehealth implementation at an academic pediatric practice led to disparities in health care access. Significant differences were found in pre-COVID-19 versus during COVID-19 patient demographics. Patients seen during COVID-19 were more likely to be younger, White/Caucasian or Asian, English speaking, and have private insurance. They were less likely to be Black/African American or Latinx and request interpreters. Age was the only significant difference in patient demographics between in-person and telehealth visits during COVID-19. A multivariate regression showed older age as a significant positive predictor of having a video visit and public insurance as a significant negative predictor. Our study demonstrates telehealth disparities based on insurance existed at our clinic as did inequities in who was seen before versus during COVID-19.
Alcohol-associated hepatitis (AH) refers to liver injury from alcoholic intake that usually occurs after years of heavy alcohol abuse. Frequent, heavy alcohol consumption causes hepatic inflammation, fibrosis, and cirrhosis. Some patients develop severe AH, which carries high short-term mortality and is the second most common reason for adult liver transplants (LTs) worldwide. We present one of the first cases of a teenager diagnosed with severe AH that led to LT evaluation. Our patient was a 15-year-old male who presented with epistaxis and 1 month of jaundice after 3 years of heavy daily alcohol abuse. In collaboration with our adult transplant hepatologist colleagues, we initiated a management plan that consisted of treating acute alcohol withdrawal, steroid utilization, mental health support, and LT evaluation.
A previously healthy 18-month-old male presented to the emergency department for rectal prolapse. Parents endorsed 2 months of intermittent, worsening rectal bulging. History is notable for the daily consumption of 32 ounces of milk. The patient was stooling daily, eating and drinking well, and gaining weight appropriately. The successful manual reduction was administered in the ED. The patient was discharged on daily polyethylene glycol (PEG) 4.25 g daily. Prolapse improved on daily PEG. However, after PEG discontinuation, prolapse returned, significantly larger and more difficult to reduce (Figs. 1 and 2). Given the worsening prolapse, pediatric surgery performed a repeat manual reduction under sedation with flexible sigmoidoscopy. The procedure was effective, and no polyps or lead points were visualized. No biopsies were obtained during the procedure. After this manual reduction under anesthesia, the patient was adherent to a regimen of 17 g of PEG daily. No further prolapse recurrences occurred.Figure 1.: Large rectal prolapse before manual reduction.Figure 2.: Lateral view of rectal prolapse.Rectal prolapse is classified as partial/mucosal or complete prolapse (1). Our patient had the latter, which involves full-thickness rectal wall extrusion. Predisposing conditions include chronic constipation (most common), increased bowel motility, celiac disease, and cystic fibrosis (1–3). Additionally, there are case reports highlighting the relationship between cow’s milk protein allergy and chronic constipation, which may warrant further consideration for the reduction and/or elimination of cow’s milk in the diet (4). Since our patient’s prolapse was most likely secondary to constipation with excessive milk intake, an additional workup was not performed. In general, management for rectal prolapse involves (1) immediate manual reduction if instantaneous spontaneous reduction does not occur and (2) constipation bowel regimens. For most children, rectal prolapse resolves with a bowel regimen alone. There are no definitive indications for surgery, but it can be considered if prolapse persists despite conservative therapy or if there is difficulty in manual reduction (1–3,5). ACKNOWLEDGMENTS All attempts have been exhausted in trying to contact the parents or guardian for the purpose of attaining their consent to publish the Image.
We are responding to Hildreth and Schwimmer's letter regarding our case report, "A Case of Pediatric Alcohol-Associated Hepatitis Evaluated for Liver Transplant Listing."1, 2 The letter makes the excellent point that, based on our patient's body mass index and diabetes mellitus type 2 (DM2) diagnosis at age 12, he may have had underlying metabolic associated steatotic liver disease (MASLD), increasing his risk for accelerated liver disease with alcohol consumption.2, 3 Individuals meet criteria for MASLD with steatotic liver disease (on imaging or biopsy) and one of five cardiometabolic criteria outlined elsewhere.3 We appreciate the commentary and agree that patient likely had MASLD.3 His labs from endocrinology clinic at age 12 suggest underlying hepatic disease and metabolic abnormalities (Table 1).3, 4 Metabolic alcohol-associated liver disease (MetALD) best encompasses this patient's condition at time of decompensation given his MASLD and >210 g/week of alcohol.3 Based on our concern for MetALD, after discharge, we focused on lifestyle improvements that resulted in 16 kg of weight loss, which, in addition to sobriety, likely contributed to liver enzyme improvement. We would like to stress that MASLD is just one underlying liver disease that can be comorbid with alcohol-associated liver disease (ALD). Any adolescent with baseline liver disease who binges alcohol is at increased risk of ALD. Our case highlights the rarity of fulminant ALD in adolescents and discusses the treatments we utilized to successfully help our patient avoid a liver transplant. We welcomed the opportunity to delve more thoroughly into this case and continue the discourse on pediatric MetALD. This publication was made possible by a National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) funded T32 (1T32DK127977-01A1) fellowship to Rachel B. Schenker. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIDDK. The authors declare no conflict of interest.
Abstract Objectives Metabolic dysfunction‐associated steatotic liver disease (MASLD) is the most common pediatric liver disease and can progress to liver fibrosis. Latino adolescents have increased MASLD and fibrosis risk. While fibrosis is diagnosed by biopsy or imaging, more accessible, noninvasive, and economical screening methods are needed. We aimed to use plasma metabolomics/lipidomics to identify potential fibrosis biomarkers in Latino adolescents with obesity. Methods Liver stiffness (LS) was measured in 93 Latino adolescents with obesity using magnetic resonance elastography. Metabolites and lipids were extracted from plasma and identified on Compound Discoverer. Associations between metabolites/lipids and fibrosis (LS > 2.73 kPa) were determined using linear regression models after covariate adjustment. False discovery rate (FDR) adjusted Pearson's correlations were performed. Analytes yielding significant FDR‐adjusted correlations were examined further by receiver operator curve analysis. Results Mean (±standard deviation) alanine transaminase (ALT) was 45.7(±65.2) IU/L, hepatic fat fraction was 12.7(±9.1)%, and LS was 2.4(±0.3) kPa. We identified 795 metabolites and 413 lipids in plasma, but only one single metabolite, dihydroxyacetone phosphate (DHAP), a marker of triglyceride synthesis, was significantly associated with fibrosis after FDR adjustment ( p < 0.05). In terms of predicting fibrosis, ALT had an area under the curve (AUC) of 0.79, and DHAP had an AUC of 0.79. When combined, ALT + DHAP had an AUC of 0.89. Conclusions The combination of ALT + DHAP may have the potential as an accurate, noninvasive test for liver fibrosis. Our data is limited to Latino children with obesity, and a larger cohort should be examined to further validate this novel biomarker.
Transgender and gender nonconforming (TGNC) individuals have a different gender identity than the sex they were assigned at birth. Despite an increase in provider awareness of TGNC health over the past decade, no original research or societal guidelines exist on TGNC patients with inflammatory bowel disease (IBD). We review TGNC IBD cases in the University of California, San Francisco (UCSF) Pediatric IBD Program and in the literature. We then provide some recommendations for the provision of high-quality care to the TGNC IBD population, divided into 3 categories: medications, anatomy, and mental health.
Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common paediatric liver disease. Latinos have high MASLD risk due to 50% prevalence of GG genotype of PNPLA3. Our primary aim was to evaluate associations between dietary carbohydrates/sugars and liver stiffness in Latino adolescents with obesity. Our secondary aim was to examine effect modification by (a) PNPLA3 genotype or (b) liver disease severity. Data were obtained from 114 Latino adolescents with obesity involved in two prior studies. No associations were seen between dietary carbohydrates/sugars and liver stiffness in the group as a whole. In subjects with GG genotype of PNPLA3, total sugar, fructose, sucrose, and glucose were associated with liver stiffness. Positive relationships between carbohydrate, total sugar, and sucrose and liver stiffness were stronger in those with MASLD and fibrosis compared to those with healthy livers and MASLD without fibrosis.
