Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: A handful of clinics in the U.S. routinely offer patients audio or video recordings of their clinic visits. While interest in the practice of clinic visit recording has increased, to date there is no data on the prevalence of recording in clinical practice in the U.S. Objective: Our objectives were to 1) determine the prevalence of sharing audio-recorded clinic visits for patients’ personal use in the U.S., 2) assess the attitudes of clinicians and the public toward recording, and 3) identify whether or not policies exist to guide recording practices in 49 of the largest health systems in the U.S. Methods: Two parallel cross-sectional surveys were administered in July 2017 to Internet Panels of U.S. based clinicians (SERMO Panel) and the U.S. public (Qualtrics Panel). To ensure a diverse range of perspectives, we set quotas to capture clinicians from eight specialties. Quotas were also applied to the public survey based on U.S. Census data (gender, race, ethnicity and language other than English spoken at home) to approximate views among U.S. adults. Forty-nine of the largest health systems (by clinician number) in the U.S. were contacted by email and telephone to determine the existence, or absence, of policies to guide audio-recordings of clinic visits for patients’ personal use. Multiple logistic regression models were used to determine factors associated with recording. Results: A total of 456 clinicians and 524 public respondents completed surveys. Approximately 28% of clinicians reported that they had recorded a clinic visit for patients’ personal use, while 18% of the public reported doing so, including 3% who recorded visits without the clinician’s permission. Of the 327 clinicians who had not recorded a clinic visit, 50% would be willing to do so in the future, while 66% of the public would be willing to record in the future. Clinician specialty was associated with prior recording: oncology, OR=5.1 (95% CI 1.9 to 14.9; P=0.002) and physical rehabilitation OR=3.9 (95% CI 1.4 to 11.6; P=0.01). Public respondents who were male, OR=2.11 (95% CI 1.26 to 3.61; P=0.005), younger age, OR=0.73 for a 10-year increase in age (95% CI 0.60 to 0.89; P=0.002); or spoke a language other than English at home, OR=1.99 (95% CI 1.09 to 3.59; P=0.02) were more likely to have recorded a clinic visit. None of the large health systems we contacted reported a dedicated policy, however 2 of the 49 health systems did report an existing policy that would cover the recording of clinic visits for patient use. Perceived benefits of recording included improved patient understanding and recall. Privacy and medico-legal concerns were raised. Conclusions: U.S. clinicians and public are taking the lead on recording clinic visits, while health systems seem to be lagging. Policy guidance from health systems and further examination of the impact of recordings, positive or negative, on the delivery of care and patients’ behavioral and health-related outcomes is urgently required.

INTRODUCTION: There are limited data characterizing eating habits among pediatric patients with eosinophilic esophagitis (EoE). We compared eating behaviors in pediatric patients with EoE with healthy controls and assessed the degree of correlation with symptomatology, endoscopic and histologic findings, and esophageal distensibility. METHODS: We conducted a prospective, observational study where subjects consumed 4 food textures (puree, soft solid, chewable, and hard solid) and were scored for eating behaviors including number of chews per bite, sips of fluid per food, and consumption time. Symptomatic, endoscopic, histologic, and esophageal distensibility data were collected for case subjects. RESULTS: Twenty-seven case subjects and 25 healthy controls were enrolled in our study (mean age 11.0 years, 63.5% male). Compared with healthy controls, pediatric patients with EoE demonstrated more chews per bite with soft solid (13.6 vs 9.1, P = 0.031), chewable (14.7 vs 10.7, P = 0.047), and hard solid foods (19.0 vs 12.8, P = 0.037). Patients with EoE also demonstrated increased consumption time with soft solid (94.7 vs 58.3 seconds, P = 0.002), chewable (90.0 vs 65.1 seconds, P = 0.005), and hard solid foods (114.1 vs 76.4 seconds, P = 0.034) when compared with healthy controls. Subgroup analysis based on disease status showed no statistically significant differences in eating behaviors between active and inactive EoE. Total endoscopic reference score positively correlated with consumption time (r = 0.53, P = 0.008) and number of chews (r = 0.45, P = 0.027) for chewable foods and with number of chews (r = 0.44, P = 0.043) for hard solid foods. Increased consumption time correlated with increased eosinophil count (r = 0.42, P = 0.050) and decreased esophageal distensibility (r = −0.82, P < 0.0001). DISCUSSION: Altered eating behaviors including increased chewing and increased consumption time can be seen in pediatric patients with EoE, can persist despite histologic remission, and may be driven by changes in esophageal distensibility.

We present the first case of a dupilumab-induced hyperinflammatory state in the setting of underlying eosinophilic esophagitis characterized by multisystem granulomatous inflammation. Although clinical trial data and subsequent real-world experience support dupilumab as a highly effective therapy for eosinophilic esophagitis, close monitoring for development of adverse symptoms following initiation remains paramount.

In homeostatic conditions, the basal progenitor cells of the esophagus differentiate into a stratified squamous epithelium. However, in the setting of acid exposure or inflammation, there is a marked failure of basal cell differentiation, leading to basal cell hyperplasia. We have previously shown that lysyl oxidase (LOX), a collagen crosslinking enzyme, is upregulated in the setting of allergic inflammation of the esophagus; however, its role beyond collagen crosslinking is unknown. Herein, we propose a non-canonical epithelial-specific role of LOX in the maintenance of epithelial homeostasis using 3D organoid and murine models. We performed quantitative reverse transcriptase PCR, Western blot, histologic analysis, and RNA sequencing on immortalized non-transformed human esophageal epithelial cells (EPC2-hTERT) with short-hairpin RNA (shRNA) targeting LOX mRNA in both monolayer and 3D organoid culture. A novel murine model with a tamoxifen-induced Lox knockout specific to the stratified epithelium (K5CreER; Lox^fl/fl) was utilized to further define the role of epithelial LOX in vivo. We found that LOX knockdown decreased the proliferative capacity of the esophageal epithelial cells in monolayer culture, and dramatically reduced the organoid formation rate (OFR) in the shLOX organoids. LOX knockdown was associated with decreased expression of the differentiation markers filaggrin, loricrin, and involucrin, with RNA sequencing analysis revealing 1224 differentially expressed genes demonstrating downregulation of pathways involved in cell differentiation and epithelial development. Mice with Lox knockout in their stratified epithelium demonstrated increased basaloid content of their esophageal epithelium and decreased Ki-67 staining compared to the vehicle-treated mice, suggesting reduced differentiation and proliferation in the Lox-deficient epithelium in vivo. Our results demonstrate, both in vivo and in vitro, that LOX may regulate epithelial homeostasis in the esophagus through the modulation of epithelial proliferation and differentiation. Understanding the mechanisms of perturbation in epithelial proliferation and differentiation in an inflamed esophagus could lead to the development of novel treatments that could promote epithelial healing and restore homeostasis.