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Tal N, Tzivinikos C, Gasparetto M, Serban DE, Zifman E, Hojsak I, Ledder O, Yerushalmy Feler A, Rolandsdotter H, Aloi M, Bramuzzo M, Buderus S, Lionetti P, Norsa L, Norden C, Urlep D, Romano C, Shaoul R, Martinez-Vinson C, Karoliny A, De Greef E, Kang B, VIčková E, Alvisi P, Kori M, Tavares M, Weiss B, Hussey S, Qamhawi ME, Palomino Pérez LM, Henderson P, Parmar R, Miele E, Rinawi F, Lozano-Ruf A, Zamvar V, Kolho KL, Shouval DS. Clinical Features and Natural History of Paediatric Patients with Ulcerative Proctitis: A Multicentre Study from the Paediatric IBD Porto Group of ESPGHAN. J Crohns Colitis 2023; 17:1939-1948. [PMID: 37392064 DOI: 10.1093/ecco-jcc/jjad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND AND AIMS Ulcerative proctitis [UP] is an uncommon presentation in paediatric patients with ulcerative colitis. We aimed to characterize the clinical features and natural history of UP in children, and to identify predictors of poor outcomes. METHODS This was a retrospective study involving 37 sites affiliated with the IBD Porto Group of ESPGHAN. Data were collected from patients aged <18 years diagnosed with UP between January 1, 2016 and December 31, 2020. RESULTS We identified 196 patients with UP (median age at diagnosis 14.6 years [interquartile range, IQR 12.5-16.0]), with a median follow-up of 2.7 years [IQR 1.7-3.8]. The most common presenting symptoms were bloody stools [95%], abdominal pain [61%] and diarrhoea [47%]. At diagnosis, the median paediatric ulcerative colitis activity index [PUCAI] score was 25 [IQR 20-35], but most patients exhibited moderate-severe endoscopic inflammation. By the end of induction, 5-aminosalicylic acid administration orally, topically or both resulted in clinical remission rates of 48%, 48%, and 73%, respectively. The rates of treatment escalation to biologics at 1, 3, and 5 years were 10%, 22%, and 43%, respectively. In multivariate analysis, the PUCAI score at diagnosis was significantly associated with initiation of systemic steroids, or biologics, and subsequent acute severe colitis events and inflammatory bowel disease-associated admission, with a score ≥35 providing an increased risk for poor outcomes. By the end of follow-up, 3.1% of patients underwent colectomy. Patients with UP that experienced proximal disease progression during follow-up [48%] had significantly higher rates of a caecal patch at diagnosis and higher PUCAI score by the end of induction, compared to those without progression. CONCLUSION Paediatric patients with UP exhibit high rates of treatment escalation and proximal disease extension.
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Affiliation(s)
- Noa Tal
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Marco Gasparetto
- Barts Health NHS Trust, The Royal London Children's Hospital, Department of Paediatric Gastroenterology, Queen Mary University of London, Centre for Immunobiology, Blizard Institute, London, UK
| | - Daniela E Serban
- 2nd Clinic of Pediatrics, 'Iuliu Hatieganu' University of Medicine and Pharmacy, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Eyal Zifman
- Pediatric Gastroenterology Unit, Meir Medical Center, Kfar-Saba, Israel
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia
| | - Oren Ledder
- The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Anat Yerushalmy Feler
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Gastroenterology Institute, 'Dana-Dwek' Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Helena Rolandsdotter
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Department of Gastroenterology, Södersjukhuset, Stockholm, Sweden
| | - Marina Aloi
- Pediatric Gastroenterology, Hepatology and Nutrition Institute, Sapienza University of Rome, Rome, Italy
| | - Matteo Bramuzzo
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste, Italy
| | | | - Paolo Lionetti
- Department NEUROFARBA, University of Florence, Meyer Children's Hospital, Florence, Italy
| | - Lorenzo Norsa
- Pediatric Hepatology, Gastroenterology and Transplantation Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Christoph Norden
- Department of Pediatrics, Hvidovre University Hospital, Copenhagen, Hvidovre, Denmark
| | - Darja Urlep
- Pediatric Gastroenterology and Liver Unit, University Children's Hospital of the University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood 'G. Barresi', University of Messina, Messina, Italy
| | - Ron Shaoul
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Christine Martinez-Vinson
- Service de Gastroentérologie et Nutrition Pédiatriques, Hôpital Universitaire Robert-Debré, Paris, France
| | - Anna Karoliny
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Elisabeth De Greef
- Department of Paediatric Gastroenterology and Nutrition, Kidz Health Castle UZ Brussels, Free University Brussels, Brussels, Belgium
| | - Ben Kang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eva VIčková
- Department of Pediatrics, 2nd Medical Faculty, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Michal Kori
- Pdiatric Gastroenterology, Kaplan Medical Centre, Rehovot and the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Marta Tavares
- Department of Pediatric Gastroenterology, Centro Materno Infantil do Norte, Centro Hospitalar e Universitário de Porto, Porto, Portugal
| | - Batia Weiss
- Division of Pediatric Gastroenterology and Nutrition, Edmond and Lily Safra Children's Hospital, Ramat Gan, Israel
| | - Seamus Hussey
- Children's Health Ireland, UCD and RCSI, Dublin, Ireland
| | - Maria E Qamhawi
- Department of Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital, StockholmSweden
| | - Laura M Palomino Pérez
- Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Raj Parmar
- Department of Pediatric Gastroenterology, Great North Children's Hospital, Newcastle, UK
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II', Naples, Italy
| | - Firas Rinawi
- Pediatric Gastroenterology Unit, Emek Medical Center, Afula, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ana Lozano-Ruf
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Veena Zamvar
- Department of Paediatric Gastroenterology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kaija-Leena Kolho
- Children's Hospital, University of Helsinki, Helsinki, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Dror S Shouval
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abu Hanna F, Atia O, Yerushalmy Feler A, Shouval D, Weiss B, Mresat H, Magen-Rimon R, Zifman E, Turner D, Rinawi F. Thiopurines Maintenance Therapy in Children With Ulcerative Colitis: A Multicenter Retrospective Study. J Pediatr Gastroenterol Nutr 2023; 77:505-511. [PMID: 37491713 DOI: 10.1097/mpg.0000000000003899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND AND AIMS Thiopurines are an established treatment for pediatric ulcerative colitis (UC). However, data regarding safety and efficacy are lacking. We aimed to determine short and long-term outcome following thiopurines use in children with UC. METHODS We conducted a retrospective review of children (2-18 years) with UC treated with thiopurines between January 2008 and January 2019 at 7 medical centers in Israel. The primary outcome was corticosteroid (CS)-free clinical remission at week 52 following thiopurines initiation without the need for rescue therapy (infliximab, calcineurin inhibitors, or colectomy). RESULTS A total of 133 children were included [median age at diagnosis of 12.4 (interquartile range 11.0-15.8) years, 30 (23%) left-sided colitis, 113 (85%) with moderate or severe disease at diagnosis]. At diagnosis 58 patients (44%) were treated with 5-aminosalicylates and 72 (54%) with CS. Sixty patients (45%) received thiopurines as 1st line maintenance therapy. Seventy-four patients (56%) had CS-free clinical remission at week 52 without rescue therapy. Predictors of clinical remission were not identified. In a sub-analysis among patients with steroid-responsive moderate to severe UC, 59 (55%) patients achieved this outcome. The likelihood of remaining free of rescue therapy among thiopurines-treated patients was 83%, 62%, 45%, and 37% at 1, 2, 3, and 4 years, respectively. CONCLUSION More than half of children with UC starting thiopurines without previous or concomitant biologic therapy have CS-free clinical remission at 52 weeks later without the need for rescue therapy. Thiopurines are effective in pediatric UC and could be considered prior to biologics.
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Affiliation(s)
- Firas Abu Hanna
- From the Pediatric Gastroenterology Unit, Emek Medical Centre, Afula, Israel
| | - Ohad Atia
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Anat Yerushalmy Feler
- Pediatric Gastroenterology Institute, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Shouval
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Batia Weiss
- the Pediatric Gastroenterology and Nutrition Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Hadeel Mresat
- From the Pediatric Gastroenterology Unit, Emek Medical Centre, Afula, Israel
| | - Ramit Magen-Rimon
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Faculty of Medicine, Technion, Haifa, Israel
| | - Eyal Zifman
- the Pediatric Gastroenterology Unit, Meir Medical Center, Kfar-Saba, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Dan Turner
- The Juliet Keiden Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Firas Rinawi
- From the Pediatric Gastroenterology Unit, Emek Medical Centre, Afula, Israel
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Wang Y, Huang X, Zhou G, Han J, Xie Z, Zhang M, Li X, Wu QR, Li L, Ye Z, Chen M, Qiu Y, Zhang S. A Novel Nomogram Combining Mucus Barrier Index for Predicting Treatment Failures in Ulcerative Colitis. J Inflamm Res 2023; 16:1879-1894. [PMID: 37152865 PMCID: PMC10162100 DOI: 10.2147/jir.s410057] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/21/2023] [Indexed: 05/09/2023] Open
Abstract
Background Treatment failures (TFs) generally exist in the course of ulcerative colitis (UC), while early reliable predictors of TFs are still lacking. We aimed to generate nomograms for the prediction of TFs. Methods In this retrospective case-control study, the endpoint was the occurrence of TFs, which included medically associated treatment failures and surgery-associated treatment failures (colectomy). Clinical features and mucus integrity evident by goblet cells (GCs) number, expression levels of MUC2 and SLC26A3 were enrolled in the univariate analysis. Nomogram performance was evaluated by discrimination and calibration. Results We identified 256 UC patients at our center from January 2010 to June 2022. Fourteen variables for TFs and 9 for colectomy were identified by univariate analysis. Five baseline indices were incorporated into the nomogram for the prediction of TFs: area of GCs, age at diagnosis, disease duration, hemoglobin, and Mayo score. The model was presented with decent discrimination (C index of 0.822) and well calibration. In addition, the colectomy predictive nomogram was built using MUC2 intensity, age at onset, and Mayo score with a good discrimination (C index of 0.92). Conclusion Nomograms based on comprehensive factors including mucus barrier function were developed to predict TFs in UC patients with great discrimination, which may serve as practical tools aiming to identify high-risk subgroups warrant timely intervention.
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Affiliation(s)
- Ying Wang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Xuanzhi Huang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Gaoshi Zhou
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Jing Han
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Zhuo Xie
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Mudan Zhang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Xiaoling Li
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Qi-rui Wu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Li Li
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Ziyin Ye
- Department of Pathology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Minhu Chen
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Yun Qiu
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
| | - Shenghong Zhang
- Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China
- Correspondence: Shenghong Zhang; Yun Qiu, Department of Gastroenterology, First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou Province, 510080, People’s Republic of China, Tel/Fax +86-20-87332916, Email ;
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Lee WS, Arai K, Alex G, Treepongkaruna S, Kim KM, Choong CL, Mercado KC, Darma A, Srivastava A, Aw MM. Management and monitoring of pediatric inflammatory bowel disease in the Asia-Pacific region: A position paper by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group: Surgical management, disease monitoring, and special considerations. J Gastroenterol Hepatol 2022; 38:510-522. [PMID: 36508314 DOI: 10.1111/jgh.16084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/11/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023]
Abstract
Disease phenotype of pediatric inflammatory bowel disease (PIBD) in children from the Asia-Pacific region differs from that of children from the West. Many parts of Asia are endemic for tuberculosis, making diagnosis and management of pediatric Crohn's disease a challenge. Current available guidelines, mainly from Europe and North America, may not be completely applicable to clinicians caring for children with PIBD in Asia due to differences in disease characteristics and regional resource constraints. This position paper is an initiative from the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN) that aims to provide an up-to-date, evidence-based approach to PIBD in the Asia-Pacific region. A group of pediatric gastroenterologists with a special interest in PIBD performed an extensive literature search covering epidemiology, disease characteristics and natural history, management, and monitoring. Attention was paid to publications from the region with special consideration to a resource-limited setting. This current position paper deals with surgical management, disease monitoring, immunization, bone health, and nutritional issues of PIBD in Asia. A special section on differentiating pediatric Crohn's disease from tuberculosis in children is included. This position paper provides a useful guide to clinicians in the surgical management, disease monitoring, and various health issues in children with IBD in Asia-Pacific region.
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Affiliation(s)
- Way Seah Lee
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.,Department of Population Medicine, Faculty of Medicine and Health Sciences, University Tunku Abdul Rahman, 59100, Kajang, Selangor, Malaysia
| | - Katsuhiro Arai
- Center for Pediatric Inflammatory Bowel Disease, National Center for Child Health and Development, Tokyo, Japan
| | - George Alex
- Department of Gastroenterology and Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chee Liang Choong
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Karen Calixto Mercado
- Makati Medical Center and The Medical City, Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition, Manila, Philippines
| | - Andy Darma
- Department of Child Health, Dr. Soetomo General Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Anshu Srivastava
- Department of Paediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Marion M Aw
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Girard C, Dirks M, Deslandres C. Tofacitinib to Treat Severe Acute Refractory Colitis in a Teenager: Case Report and Review of the Literature. JPGN REPORTS 2022; 3:e241. [PMID: 37168636 PMCID: PMC10158282 DOI: 10.1097/pg9.0000000000000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 06/18/2022] [Indexed: 05/13/2023]
Abstract
Acute severe colitis (ASC) may occur within 3 months of ulcerative colitis diagnosis in 9%-15% of children and the rate of colectomy is up to 40%-50% within 5 years after an ASC. The aim of this publication is to present recent and relevant data on the success of medical treatment with tofacitinib in ASC. Methods We report a challenging case of a teenage boy with ASC at diagnosis and conduct a discussion after a review of the literature regarding the use of tofacitinib in inflammatory bowel disease, especially in pediatric patients and in ASC. Results The patient was hospitalized for 10 weeks and was refractory to conventional therapies: intravenous corticosteroids, infliximab, methotrexate, and vedolizumab. He received 7 blood transfusions and also presented with a severe malnutrition requiring a total parenteral nutrition. Tofacitinib was considered as a medical last resort before colectomy and was started at week 8. Thirteen days after starting tofacitinib, he was asymptomatic and was discharged on tofacitinib as sole treatment. By week 9 of tofacitinib, a colonoscopy showed both endoscopic and histological remission. He has remained in clinical remission at 6-month follow-up. Conclusions Tofacitinib may be an alternative medical treatment to avoid colectomy in ASC. It is a small molecule with a rapid onset and few severe adverse events. It has been used for ASC in adult patients, allowing to avoid colectomy in more than 60%. To our knowledge, this is one of the few pediatric patients with refractory ASC at initial diagnosis who responded to tofacitinib.
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Affiliation(s)
- Chloé Girard
- From the Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada
| | - Martha Dirks
- From the Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada
| | - Colette Deslandres
- From the Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Québec, Canada
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada
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Sagami S, Kobayashi T, Aihara K, Umeda M, Odajima K, Morikubo H, Asonuma K, Miyatani Y, Fukuda T, Matsubayashi M, Kiyohara H, Nakano M, Hibi T. Early improvement in bowel wall thickness on transperineal ultrasonography predicts treatment success in active ulcerative colitis. Aliment Pharmacol Ther 2022; 55:1320-1329. [PMID: 35218038 DOI: 10.1111/apt.16817] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/13/2021] [Accepted: 01/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Bowel ultrasonography is a non-invasive imaging tool that can repeatedly monitor ulcerative colitis (UC) activity. AIM This study aimed to determine whether early transabdominal or transperineal ultrasonography changes can predict subsequent clinical response to induction therapy in patients with UC. METHODS This single-centre prospective study explored ultrasonographic predictors for clinical remission (patient-reported outcome-2 ≤ 1 with no rectal bleeding subscore) at week 8 in patients with active UC who underwent induction therapy, in comparison with faecal calprotectin and C-reactive protein (measured at baseline, week 1 and week 8). Predictive factors were assessed using multivariable regression models and receiver-operating-characteristic curve analysis. RESULTS A total of 100 patients were analysed, of which 54 achieved remission at week 8. Baseline biomarker and ultrasonographic-parameter values were not predictive of remission. Contrastingly, change from baseline to week 1 in rectal bowel wall thickness measured using transperineal ultrasonography was an independent predictor of remission by week 8 (adjusted odds ratio is associated with a 1-mm decrease: 1.90 [95% confidence interval, 1.22-2.95]). In a subgroup analysis of the patients who did not achieve remission in 1 week, the predictive value of change in rectal bowel wall thickness remained high (AUC = 0.77 [95% confidence interval, 0.61-0.88]). CONCLUSION Improvement in rectal bowel wall thickness measured using transperineal ultrasonography at week 1 predicts treatment success and potentially facilitates decision making during the early course of induction therapy in UC.
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Affiliation(s)
- Shintaro Sagami
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kanako Aihara
- Department of Clinical Laboratory, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Misaki Umeda
- Department of Clinical Laboratory, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kazuhiro Odajima
- Department of Clinical Laboratory, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Hiromu Morikubo
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kunio Asonuma
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Yusuke Miyatani
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Tomohiro Fukuda
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Mao Matsubayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Hiroki Kiyohara
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Masaru Nakano
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
- Department of Gastroenterology and Hepatology, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Song EM, Oh EH, Hwang SW, Park SH, Yang DH, Byeon JS, Myung SJ, Yang SK, Ye BD. Comparison of outcomes of cyclosporine A and infliximab for steroid-refractory acute severe ulcerative colitis. J Gastroenterol Hepatol 2021; 36:2463-2470. [PMID: 33783045 DOI: 10.1111/jgh.15508] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 03/11/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Data comparing the outcomes of cyclosporin A (CsA) and infliximab (IFX) as rescue therapy for steroid-refractory acute severe ulcerative colitis (SR-ASUC) among Asians are scarce. METHODS In this single-center study, we retrospectively reviewed 121 patients with SR-ASUC according to the Truelove and Witts' criteria who received CsA or IFX as rescue therapy between 1995 and 2015. The cumulative rates of treatment failure and colectomy at 3 months were compared. Treatment failure was defined as colectomy, switch to other medications, acute flare-up events requiring steroid treatment, or adverse events leading to drug interruption. RESULTS Among 121 patients with SR-ASUC (male, 55.6%; median disease duration, 47.1 months; extensive colitis, 61.2%), 23 received CsA as rescue therapy. Baseline characteristics (e.g. age at diagnosis, sex, disease duration, disease extent at rescue therapy, and Mayo score at treatment initiation) were comparable between the two groups. During follow-up (median, 45 months; interquartile range 29.3-61.8), 84 patients (69.4%) experienced treatment failure, and 25 patients (20.7%) underwent colectomy. The CsA group and the IFX group did not show significant differences in the cumulative rates of treatment failure (39.1% vs 34.7%, P = 0.714) and colectomy (26.1% vs 13.3%, P = 0.198) at 3 months. Previous use of azathioprine (odds ratio [OR] = 2.309, 95% confidence interval [CI] = 1.076-4.951, P = 0.032) was associated with treatment failure at 3 months. Mayo score > 10 at the time of rescue therapy was significantly associated with colectomy at 3 months (OR = 8.444, 95% CI = 2.592-27.506, P < 0.001). CONCLUSION Among Korean patients with SR-ASUC, the rates of treatment failure and colectomy at 3 months were not significantly different between the CSA and the IFX treatment groups.
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Affiliation(s)
- Eun Mi Song
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Eun Hye Oh
- Division of Gastroenterology, Department of Internal Medicine, Inje University School of Medicine, Haeundae Paik Hospital, Busan, South Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.,Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.,Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.,Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Byong Duk Ye
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.,Inflammatory Bowel Disease Center, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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8
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Giachero F, Jenke A, Zilbauer M. Improving prediction of disease outcome for inflammatory bowel disease: progress through systems medicine. Expert Rev Clin Immunol 2021; 17:871-881. [PMID: 34142929 PMCID: PMC8903817 DOI: 10.1080/1744666x.2021.1945442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/08/2021] [Indexed: 11/30/2022]
Abstract
Introduction: Inflammatory bowel diseases (IBDs) are lifelong conditions causing relapsing inflammation of the intestine. In the absence of a cure, clinical management of IBDs is extremely challenging since they present with a wide range of phenotypes and disease behaviors. Hence, there is an urgent need for markers that could guide physicians in making the right choice of the rapidly growing treatment options toward a personalized care that could improve the overall outcome.Areas covered: In this review, the authors summarize existing biomarkers in IBD, discuss the challenges with the development of prognostic biomarkers and propose alternative options such as focusing on the prediction of the response to individual treatments, i.e. predictive biomarkers. The problems related to developing disease prognostic and predictive biomarkers in the field of IBDs are discussed including the difficulties in dealing with phenotypic heterogeneity particularly when performing studies in a real-life setting. The authors reviewed literature from PubMed.Expert opinion: Systems biology provides potential solutions to this problem by offering an unbiased, holistic approach to adjusting for variation in larger datasets thereby increasing the chances of identifying true associations between molecular profiles and clinical phenotypes.
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Affiliation(s)
- Federica Giachero
- Witten/Herdecke University, Faculty of Health, Department of Medicine, Clinical Molecular Genetics and Epigenetics, Centre for Biomedical Education & Research (ZBAF), Germany
| | - Andreas Jenke
- Witten/Herdecke University, Faculty of Health, Department of Medicine, Clinical Molecular Genetics and Epigenetics, Centre for Biomedical Education & Research (ZBAF), Germany
- Children´s Hospital Kassel, Department of Neonatology and Paediatric Gastroenterology, Klinikum Kassel, Mönchenbergstr, Kassel, Germany
| | - Matthias Zilbauer
- Witten/Herdecke University, Faculty of Health, Department of Medicine, Clinical Molecular Genetics and Epigenetics, Centre for Biomedical Education & Research (ZBAF), Germany
- Department of Paediatrics, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge, University Hospitals, Addenbrooke’s, Cambridge, UK
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9
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Colman RJ, Dhaliwal J, Rosen MJ. Predicting Therapeutic Response in Pediatric Ulcerative Colitis-A Journey Towards Precision Medicine. Front Pediatr 2021; 9:634739. [PMID: 33681110 PMCID: PMC7925616 DOI: 10.3389/fped.2021.634739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022] Open
Abstract
Ulcerative colitis (UC) is a disabling disease, characterized by chronic inflammation of the colon, with a rising prevalence worldwide in the pediatric age group. Although UC presents in children with varying severity, disease extent, and comorbidities, initial treatment is essentially uniform, consisting of 5-aminosalicylate drugs with corticosteroid induction for those with moderately to severely active disease. With the advent of anti-tumor necrosis factor (TNF) biologic therapy and several new biologics and small-molecule drugs for UC, precision medicine approaches to treatment are needed to more rapidly achieve sustained remission, restore quality of life, normalize development, and limit exposure to toxic corticosteroids in children with UC. Here, we review available data on clinical, biochemical, histopathologic, and molecular predictors of treatment response in UC. We also address known predictors and special treatment considerations in specific relevant scenarios such as very-early-onset UC, acute severe UC, ileal pouch anal anastomosis, and UC with concomitant primary sclerosing cholangitis. The review concludes with a prediction of how machine learning will integrate multimodal patient data to bring precision medicine to the bedside of children with UC in the future.
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Affiliation(s)
- Ruben J Colman
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Jasbir Dhaliwal
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Michael J Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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10
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Stallard L, Hussey S. Endoscopic and Histologic Predictors of Outcomes in Pediatric Ulcerative Colitis- Caveat Emptor. Front Pediatr 2021; 9:678132. [PMID: 34249815 PMCID: PMC8260952 DOI: 10.3389/fped.2021.678132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
The impact of endoscopic and histological mucosal healing on outcomes in adult settings is impressive. Despite many clinical parallels, pediatric ulcerative colitis (UC) is set apart from adult disease in several respects. Many frequently used indices are not fully validated, especially in pediatric settings, and consensus on precise definitions in clinical settings are lacking. Endoscopic mucosal healing is an acceptable long-term treatment goal in pediatrics, but not histologic normalization. Early prediction of disease course in UC may allow treatment stratification of patients according to risks of relapse, acute severe colitis, and colectomy. Putative endoscopic and histologic predictors of poor clinical outcomes in adults have not held true in pediatric settings, including baseline endoscopic extent, endoscopic severity, and specific histologic characteristics which are less prevalent in pediatrics at diagnosis. In this mini-review we appraise predictive endoscopic and histologic factors in pediatric UC with reference to relapse, severe colitis, and colectomy risks. We recommend that clinicians routinely use endoscopic and histologic sores to improve the quality of clinical and research practice. The review summarizes differences between adult and pediatric prediction data, advises special consideration of those with primary sclerosing cholangitis, and suggests areas for future study in this field.
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Affiliation(s)
- Lorraine Stallard
- National Centre for Paediatric Gastroenterology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Séamus Hussey
- National Centre for Paediatric Gastroenterology, Children's Health Ireland at Crumlin, Dublin, Ireland.,Department of Paediatrics, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland.,DOCHAS Study, National Children's Research Centre, Dublin, Ireland
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11
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Orlanski-Meyer E, Aardoom M, Ricciuto A, Navon D, Carman N, Aloi M, Bronsky J, Däbritz J, Dubinsky M, Hussey S, Lewindon P, Martin De Carpi J, Navas-López VM, Orsi M, Ruemmele FM, Russell RK, Veres G, Walters TD, Wilson DC, Kaiser T, de Ridder L, Griffiths A, Turner D. Predicting Outcomes in Pediatric Ulcerative Colitis for Management Optimization: Systematic Review and Consensus Statements From the Pediatric Inflammatory Bowel Disease-Ahead Program. Gastroenterology 2021; 160:378-402.e22. [PMID: 32976826 DOI: 10.1053/j.gastro.2020.07.066] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS A better understanding of prognostic factors in ulcerative colitis (UC) could improve patient management and reduce complications. We aimed to identify evidence-based predictors for outcomes in pediatric UC, which may be used to optimize treatment algorithms. METHODS Potential outcomes worthy of prediction in UC were determined by surveying 202 experts in pediatric UC. A systematic review of the literature, with selected meta-analysis, was performed to identify studies that investigated predictors for these outcomes. Multiple national and international meetings were held to reach consensus on evidence-based statements. RESULTS Consensus was reached on 31 statements regarding predictors of colectomy, acute severe colitis (ASC), chronically active pediatric UC, cancer and mortality. At diagnosis, disease extent (6 studies, N = 627; P = .035), Pediatric Ulcerative Colitis Activity Index score (4 studies, n = 318; P < .001), hemoglobin, hematocrit, and albumin may predict colectomy. In addition, family history of UC (2 studies, n = 557; P = .0004), extraintestinal manifestations (4 studies, n = 526; P = .048), and disease extension over time may predict colectomy, whereas primary sclerosing cholangitis (PSC) may be protective. Acute severe colitis may be predicted by disease severity at onset and hypoalbuminemia. Higher Pediatric Ulcerative Colitis Activity Index score and C-reactive protein on days 3 and 5 of hospital admission predict failure of intravenous steroids. Risk factors for malignancy included concomitant diagnosis of primary sclerosing cholangitis, longstanding colitis (>10 years), male sex, and younger age at diagnosis. CONCLUSIONS These evidence-based consensus statements offer predictions to be considered for a personalized medicine approach in treating pediatric UC.
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Affiliation(s)
- Esther Orlanski-Meyer
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Martine Aardoom
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Navon
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel
| | - Nicholas Carman
- Children's Hospital of Eastern Ontario, IBD Centre, University of Ottawa, Ottawa, Canada
| | - Marina Aloi
- Pediatric Gastroenterology Unit, Sapienza University of Rome, Umberto I Hospital, Rome, Italy
| | - Jiri Bronsky
- Department of Pediatrics, University Hospital Motol, Prague, Czech Republic
| | - Jan Däbritz
- University Medical Center Rostock, Department of Pediatrics, Rostock, Germany; Queen Mary University of London, The Barts and the London School of Medicine and Dentistry, Blizard Institute, Center for Immunobiology, London, United Kingdom
| | - Marla Dubinsky
- Pediatric Gastroenterology and Nutrition, Mount Sinai Kravis Children's Hospital; Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine, Mount Sinai, New York
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Javier Martin De Carpi
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Marina Orsi
- Pediatric Gastroenterology, Hepatology and Transplant Unit, Hospital Italiano de Buenos Aires, Argentina
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité; Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Service de Gastroentérologie Pédiatrique; Institute IMAGINE Inserm U1163, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Gabor Veres
- Pediatric Institute-Clinic, University of Debrecen, Hungary
| | - Thomas D Walters
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, Scotland, United Kingdom
| | - Thomas Kaiser
- Department of General Pediatrics, University Hospital Münster, Germany
| | - Lissy de Ridder
- Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Anne Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, the Hospital for Sick Children, Toronto, Canada
| | - Dan Turner
- Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Israel.
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12
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Grover Z, Alex G. Management of inflammatory bowel disease in children: It is time for an individualised approach. J Paediatr Child Health 2020; 56:1677-1684. [PMID: 31613039 DOI: 10.1111/jpc.14652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/16/2019] [Accepted: 09/02/2019] [Indexed: 12/22/2022]
Abstract
Paediatric-onset inflammatory bowel disease (PO-IBD) is associated with greater morbidity compared to adult-onset IBD. However, as not all children with PO-IBD will have poor outcome and the best management decisions involve weighing risks versus benefit and wishes of patient's and family, we review risk factors of IBD progression in children and summarise rapidly expanding treatment choices, potential drug-related adverse events and risk minimisation strategies, ending with new treatment paradigms focusing on long-term goal of intestinal healing. For the purpose of this article, we have outlined the conventional approach, including medications currently licenced and available for use in Australia for paediatric IBD through the Pharmaceutical Benefit Scheme and briefly discuss other promising therapies that are shown to be effective in adults but are undergoing paediatric clinical trials.
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Affiliation(s)
- Zubin Grover
- Department of Gastroenterology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - George Alex
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia
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13
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D'Arcangelo G, Aloi M. Treat-to-Target in Pediatric Inflammatory Bowel Disease: What Does the Evidence Say? Paediatr Drugs 2020; 22:463-472. [PMID: 32572841 DOI: 10.1007/s40272-020-00406-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The traditional management of inflammatory bowel disease, based on treatment intensification guided by clinical activity alone, has been revised in the last 10 years and a treat-to-target approach has been proposed and is currently under evaluation as a disease-modifying strategy. Treat-to-target focuses on objective and scheduled measures to monitor intestinal damage, with consequent therapeutic adjustments in case of failure to achieve pre-defined targets. Identification of targets has been set out by the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) committee in 2015. Mucosal healing is universally accepted as the main target both in Crohn's disease and ulcerative colitis, given its proven association with better long-term outcomes than clinical remission alone. Equally important is to ensure patients' clinical remission and improve patient-reported outcomes. Transmural healing (for Crohn's disease) and histological remission (for ulcerative colitis), listed as adjunctive targets, are likely to become primary targets in the near future. The ultimate goal of this approach is to modify the natural history of inflammatory bowel diseases by trying to block bowel damage progression, with interventions in the pre-clinical stage. In this review, we will discuss the current recommended therapeutic targets, as well as those that are considered adjunctive targets, with a focus on the limited pediatric literature available. Prospective long-term trials are warranted in order to identify the most appropriate target for the pediatric population and its specific issues. Identification of reliable predictors of disease course, outcome, and response to treatment will help to individually adapt each step of this monitoring algorithm and consequent therapeutic decision.
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Affiliation(s)
- Giulia D'Arcangelo
- Department of Women's and Children's Health, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Marina Aloi
- Department of Women's and Children's Health, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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14
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Green N, Lee D, Wahbeh G, Pacheco MC. Do Histologic Features Help Predict Colectomy in Pediatric Patients Presenting With Acute Severe Colitis? Pediatr Dev Pathol 2020; 23:380-386. [PMID: 32511053 DOI: 10.1177/1093526620929477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Multiple prior studies have looked at clinical and laboratory parameters in ulcerative colitis to predict prognosis, but individual histologic features of inflammation and their prognostic significance have not been well studied. The purpose of our study was to determine whether histologic features at presentation with acute severe colitis predict colectomy in pediatric patients. METHODS Patients were identified retrospectively through the gastroenterology and pathology databases. Demographic information, duration of disease, laboratory data, endoscopic appearance at scope, and histologic features of inflammation were reviewed along with medical therapies. Patients who underwent surgery within 90 days of hospitalization were compared to those who did not. RESULTS Fifty patients with acute severe colitis, defined as Pediatric Ulcerative Colitis Activity Index ≥65, were included. Sixteen patients had colectomies performed within 90 days of presentation. No statistically significant difference was found between the surgery and no-surgery groups for patient age, albumin, hemoglobin, or C-reactive protein, though hemoglobin trended toward significance, P = .05. The endoscopic Mayo score and histologic features of inflammation (architectural changes, chronic inflammation, eosinophils, neutrophils within the lamina propria, neutrophils in epithelium, crypt destruction, and ulceration) were similar between groups. CONCLUSION In pediatric patients presenting for hospitalization with acute severe colitis, no histologic features of inflammation predicted colectomy within 90 days.
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Affiliation(s)
- Nicole Green
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Dale Lee
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ghassan Wahbeh
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
| | - M Cristina Pacheco
- Department of Laboratories, Seattle Children's Hospital, Seattle, Washington.,Department of Pathology, University of Washington, Seattle, Washington
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15
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Rockowitz S, LeCompte N, Carmack M, Quitadamo A, Wang L, Park M, Knight D, Sexton E, Smith L, Sheidley B, Field M, Holm IA, Brownstein CA, Agrawal PB, Kornetsky S, Poduri A, Snapper SB, Beggs AH, Yu TW, Williams DA, Sliz P. Children's rare disease cohorts: an integrative research and clinical genomics initiative. NPJ Genom Med 2020; 5:29. [PMID: 32655885 PMCID: PMC7338382 DOI: 10.1038/s41525-020-0137-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 06/03/2020] [Indexed: 12/16/2022] Open
Abstract
While genomic data is frequently collected under distinct research protocols and disparate clinical and research regimes, there is a benefit in streamlining sequencing strategies to create harmonized databases, particularly in the area of pediatric rare disease. Research hospitals seeking to implement unified genomics workflows for research and clinical practice face numerous challenges, as they need to address the unique requirements and goals of the distinct environments and many stakeholders, including clinicians, researchers and sequencing providers. Here, we present outcomes of the first phase of the Children’s Rare Disease Cohorts initiative (CRDC) that was completed at Boston Children’s Hospital (BCH). We have developed a broadly sharable database of 2441 exomes from 15 pediatric rare disease cohorts, with major contributions from early onset epilepsy and early onset inflammatory bowel disease. All sequencing data is integrated and combined with phenotypic and research data in a genomics learning system (GLS). Phenotypes were both manually annotated and pulled automatically from patient medical records. Deployment of a genomically-ordered relational database allowed us to provide a modular and robust platform for centralized storage and analysis of research and clinical data, currently totaling 8516 exomes and 112 genomes. The GLS integrates analytical systems, including machine learning algorithms for automated variant classification and prioritization, as well as phenotype extraction via natural language processing (NLP) of clinical notes. This GLS is extensible to additional analytic systems and growing research and clinical collections of genomic and other types of data.
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Affiliation(s)
- Shira Rockowitz
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115 USA.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA
| | - Nicholas LeCompte
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115 USA.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA
| | - Mary Carmack
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115 USA.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA
| | - Andrew Quitadamo
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115 USA.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA
| | - Lily Wang
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115 USA.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA
| | - Meredith Park
- Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA 02115 USA.,Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Boston Children's Hospital, Boston, MA 02115 USA
| | - Devon Knight
- Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA 02115 USA.,Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Boston Children's Hospital, Boston, MA 02115 USA
| | - Emma Sexton
- Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA 02115 USA.,Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Boston Children's Hospital, Boston, MA 02115 USA
| | - Lacey Smith
- Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA 02115 USA.,Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Boston Children's Hospital, Boston, MA 02115 USA
| | - Beth Sheidley
- Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA 02115 USA.,Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Boston Children's Hospital, Boston, MA 02115 USA
| | - Michael Field
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115 USA
| | - Ingrid A Holm
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA.,Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115 USA
| | - Catherine A Brownstein
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA.,Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115 USA
| | - Pankaj B Agrawal
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA.,Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115 USA.,Division of Newborn Medicine, Boston Children's Hospital, Boston, MA 02115 USA
| | - Susan Kornetsky
- Research Administration, Boston Children's Hospital, Boston, MA 02115 USA
| | - Annapurna Poduri
- Harvard Medical School, Boston, MA 02115 USA.,Department of Neurology, F.M. Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA 02115 USA.,Division of Epilepsy and Clinical Neurophysiology and Epilepsy Genetics Program, Boston Children's Hospital, Boston, MA 02115 USA
| | - Scott B Snapper
- Harvard Medical School, Boston, MA 02115 USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115 USA
| | - Alan H Beggs
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA.,Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115 USA
| | - Timothy W Yu
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA.,Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA 02115 USA
| | - David A Williams
- Harvard Medical School, Boston, MA 02115 USA.,Division of Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA 02115 USA
| | - Piotr Sliz
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115 USA.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA 02115 USA.,Harvard Medical School, Boston, MA 02115 USA
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16
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Aardoom MA, Kemos P, Tindemans I, Aloi M, Koletzko S, Levine A, Turner D, Veereman G, Neyt M, Russell RK, Walters TD, Ruemmele FM, Samsom JN, Croft NM, de Ridder L. International prospective observational study investigating the disease course and heterogeneity of paediatric-onset inflammatory bowel disease: the protocol of the PIBD-SETQuality inception cohort study. BMJ Open 2020; 10:e035538. [PMID: 32611739 PMCID: PMC7332186 DOI: 10.1136/bmjopen-2019-035538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Patients with paediatric-onset inflammatory bowel disease (PIBD) may develop a complicated disease course, including growth failure, bowel resection at young age and treatment-related adverse events, all of which can have significant and lasting effects on the patient's development and quality of life. Unfortunately, we are still not able to fully explain the heterogeneity between patients and their disease course and predict which patients will respond to certain therapies or are most at risk of developing a more complicated disease course. To investigate this, large prospective studies with long-term follow-up are needed. Currently, no such European or Asian international cohorts exist. In this international cohort, we aim to evaluate disease course and which patients are most at risk of therapy non-response or development of complicated disease based on patient and disease characteristics, immune pathology and environmental and socioeconomic factors. METHODS AND ANALYSIS In this international prospective observational study, which is part of the PIBD Network for Safety, Efficacy, Treatment and Quality improvement of care (PIBD-SETQuality), children diagnosed with inflammatory bowel disease <18 years are included at diagnosis. The follow-up schedule is in line with standard PIBD care and is intended to continue up to 20 years. Patient and disease characteristics, as well as results of investigations, are collected at baseline and during follow-up. In addition, environmental factors are being assessed (eg, parent's smoking behaviour, dietary factors and antibiotic use). In specific centres with the ability to perform extensive immunological analyses, blood samples and intestinal biopsies are being collected and analysed (flow cytometry, plasma proteomics, mRNA expression and immunohistochemistry) in therapy-naïve patients and during follow-up. ETHICS AND DISSEMINATION Medical ethical approval has been obtained prior to patient recruitment for all sites. The results will be disseminated through peer-reviewed scientific publications. TRIAL REGISTRATION NUMBER NCT03571373.
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Affiliation(s)
- Martine A Aardoom
- Department of Paediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Polychronis Kemos
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Irma Tindemans
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marina Aloi
- Paediatric Gastroenterology and Liver Unit, Department of Paediatrics, Sapienza University of Rome, Rome, Italy
| | - Sibylle Koletzko
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Arie Levine
- Paediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Tel Aviv University, Holon, Israel
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gigi Veereman
- Department of Paediatric Gastroenterology and Nutrition, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mattias Neyt
- ME-TA Medical Evaluation and Technology Assessment, Merendree, Belgium
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Thomas D Walters
- IBD Centre, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frank M Ruemmele
- Department of Pediatric Gastroenterology, Université Paris Descartes, Sorbonne Paris Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants Malades, Paris, Île-de-France, France
| | - Janneke N Samsom
- Laboratory of Pediatrics, Division of Gastroenterology and Nutrition, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nicholas M Croft
- Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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17
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Colombel JF, D’haens G, Lee WJ, Petersson J, Panaccione R. Outcomes and Strategies to Support a Treat-to-target Approach in Inflammatory Bowel Disease: A Systematic Review. J Crohns Colitis 2020; 14:254-266. [PMID: 31403666 PMCID: PMC7008150 DOI: 10.1093/ecco-jcc/jjz131] [Citation(s) in RCA: 167] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Management of Crohn's disease and ulcerative colitis has typically relied upon treatment intensification driven by symptoms alone. However, a 'treat-to-target' management approach may help to address underlying inflammation, minimise disease activity at early stages of inflammatory bowel disease, limit progression, and improve long-term outcomes. METHODS A systematic literature review was conducted to identify data relevant to a treat-to-target approach in inflammatory bowel disease, published between January 1, 2007 and May 15, 2017. RESULTS Consistent with recommendations of the Selecting Therapeutic Targets in Inflammatory Bowel Disease [STRIDE] working group, studies have investigated factors influencing the achievement of both endoscopic and histological mucosal healing and patient-level outcomes in inflammatory bowel disease [IBD]. Histological healing and biomarker levels have also been shown to be modifiable outcomes. Although there is a lack of prospectively derived evidence validating mucosal healing as a treatment target, data are emerging to suggest that targeting mucosal healing or inflammation rather than symptoms may be cost-effective in some settings. The review highlighted several strategies that may support the implementation of a treat-to-target approach in IBD. The prospective randomised CALM study demonstrated how tight control [whereby treatment decisions are based on close monitoring of inflammatory biomarkers] leads to improvements in endoscopic and clinical outcomes. The review also considered the influence of coordinated care from a multidisciplinary team and patient engagement with improved adherence, as well as the role of therapeutic drug monitoring in inflammatory bowel disease management. CONCLUSIONS A treat-to-target strategy may impact on disease progression and improve outcomes in inflammatory bowel disease. Prospective studies including long-term data are required to ensure that the most appropriate targets and strategies are identified.
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Affiliation(s)
- Jean-Frédéric Colombel
- Inflammatory Bowel Disease Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Geert D’haens
- Amsterdam University Medical Centers – Inflammatory Bowel Disease Unit, University of Amsterdam, Amsterdam, The Netherlands
| | - Wan-Ju Lee
- Global Gastroenterology, AbbVie, North Chicago, IL, USA
| | | | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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18
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Li X, Lee EJ, Gawel DR, Lilja S, Schäfer S, Zhang H, Benson M. Meta-Analysis of Expression Profiling Data Indicates Need for Combinatorial Biomarkers in Pediatric Ulcerative Colitis. J Immunol Res 2020; 2020:8279619. [PMID: 32411805 PMCID: PMC7204128 DOI: 10.1155/2020/8279619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/02/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Unbiased studies using different genome-wide methods have identified a great number of candidate biomarkers for diagnosis and treatment response in pediatric ulcerative colitis (UC). However, clinical translation has been proven difficult. Here, we hypothesized that one reason could be differences between inflammatory responses in an inflamed gut and in peripheral blood cells. METHODS We performed meta-analysis of gene expression microarray data from intestinal biopsies and whole blood cells (WBC) from pediatric patients with UC and healthy controls in order to identify overlapping pathways, predicted upstream regulators, and potential biomarkers. RESULTS Analyses of profiling datasets from colonic biopsies showed good agreement between different studies regarding pathways and predicted upstream regulators. The most activated predicted upstream regulators included TNF, which is known to have a key pathogenic and therapeutic role in pediatric UC. Despite this, the expression levels of TNF were increased in neither colonic biopsies nor WBC. A potential explanation was increased expression of TNFR2, one of the membrane-bound receptors of TNF in the inflamed colon. Further analyses showed a similar pattern of complex relations between the expression levels of the regulators and their receptors. We also found limited overlap between pathways and predicted upstream regulators in colonic biopsies and WBC. An extended search including all differentially expressed genes that overlapped between colonic biopsies and WBC only resulted in identification of three potential biomarkers involved in the regulation of intestinal inflammation. However, two had been previously proposed in adult inflammatory bowel diseases (IBD), namely, MMP9 and PROK2. CONCLUSIONS Our findings indicate that biomarker identification in pediatric UC is complicated by the involvement of multiple pathways, each of which includes many different types of genes in the blood or inflamed intestine. Therefore, further studies for identification of combinatorial biomarkers are warranted. Our study may provide candidate biomarkers for such studies.
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Affiliation(s)
- Xinxiu Li
- Centre for Personalized Medicine, Linköping University, Linköping, Sweden
| | - Eun Jung Lee
- Centre for Personalized Medicine, Linköping University, Linköping, Sweden
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Danuta R. Gawel
- Centre for Personalized Medicine, Linköping University, Linköping, Sweden
| | - Sandra Lilja
- Centre for Personalized Medicine, Linköping University, Linköping, Sweden
| | - Samuel Schäfer
- Centre for Personalized Medicine, Linköping University, Linköping, Sweden
| | - Huan Zhang
- Centre for Personalized Medicine, Linköping University, Linköping, Sweden
- Crown Princess Victoria Children's Hospital, Linköping University Hospital, Sweden
| | - Mikael Benson
- Centre for Personalized Medicine, Linköping University, Linköping, Sweden
- Crown Princess Victoria Children's Hospital, Linköping University Hospital, Sweden
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19
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Levine A, Chanchlani N, Hussey S, Ziv-Baran T, Escher JC, Amil Dias J, Veres G, Koletzko S, Turner D, Kolho KL, Paerregaard A, Staiano A, Lionetti P, Nuti F, Sladek M, Shaoul R, Lazowska-Prezeorek I, Martin de Carpi J, Sigall Boneh R, Pfeffer Gik T, Cohen-Dolev N, Russell RK. Complicated Disease and Response to Initial Therapy Predicts Early Surgery in Paediatric Crohn's Disease: Results From the Porto Group GROWTH Study. J Crohns Colitis 2020; 14:71-78. [PMID: 31162532 DOI: 10.1093/ecco-jcc/jjz111] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The ability to predict risk for poor outcomes in Crohn's disease [CD] would enable early treatment intensification. We aimed to identify children with CD with complications at baseline and throughout the study period who are at risk for surgery 2 years from diagnosis. METHODS Newly diagnosed children with CD were enrolled into a prospective, multicentre inception cohort. Disease characteristics and serological markers were obtained at baseline and week 12 thereafter. Outcome data including disease activity, therapies, complications and need for surgery were collected until the end of 104 weeks. A chi-square automatic interaction detection [CHAID] algorithm was used to develop a prediction model for early surgery. RESULTS Of 285 children enrolled, 31 [10.9%] required surgery within 2 years. Multivariate analysis identified stricturing disease at baseline (odds ratio [OR] 5.26, 95% confidence interval [CI] 2.02-13.67 [p = 0.001]), and Paediatric Crohn's Disease Activity Index [PCDAI] >10 at week 12 (OR 1.06, 95% CI 1.02-1.10 [p = 0.005]) as key predictors for early surgery. CHAID demonstrated that absence of strictures at diagnosis [7.6%], corticosteroid-free remission at week 12 [4.1%] and early immunomodulator therapy [0.8%] were associated with the lowest risk of surgery, while stricturing disease at diagnosis [27.1%, p < 0.001] or elevated PCDAI at week 12 [16.7%, p = 0.014] had an increased risk of surgery at follow-up. Anti-OmpC status further stratified high-risk patients. DISCUSSION A risk algorithm using clinical and serological variables at diagnosis and week 12 can categorize patients into high- and low-risk groups from diagnosis.
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Affiliation(s)
- Arie Levine
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, Holon, Israel
| | - Neil Chanchlani
- Exeter IBD Pharmacogenetics, RILD building, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Seamus Hussey
- National Children's Research Centre, Crumlin; Department of Paediatrics, UCD and RCSI, Dublin, Ireland
| | - Tomer Ziv-Baran
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Johanna C Escher
- Erasmus MC-Sophia Children's Hospital, Pediatric Gastroenterology, Rotterdam, Netherlands
| | - Jorge Amil Dias
- Pediatric Gastroenterology Unit, Centro Hospitalar de São João, Porto, Portugal
| | - Gabor Veres
- Pediatric Institute, University of Debrecen, Hungary
| | - Sibylle Koletzko
- Ludwig Maximilians-Universität München, Dr. von Hauner Children's Hospital, Munich, Germany
| | - Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Kaija-Leena Kolho
- University of Tampere, Tampere, Finland and Children's Hospital, Helsinki, Finland
| | | | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples 'Federico II' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Federica Nuti
- Intermediate Pediatric Care Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Pediatric Gastroenterology and Hepatology Unit, Sapienza University Rome, Italy
| | | | | | | | - Javier Martin de Carpi
- Department of Pediatric Gastroenterology, Hepatology and Nutritiom, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Rotem Sigall Boneh
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, Holon, Israel
| | - Tamar Pfeffer Gik
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, Holon, Israel
| | - Noa Cohen-Dolev
- Paediatric Gastroenterology and Nutrition Unit, Tel Aviv University, Edith Wolfson Medical Center, Holon, Israel
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
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20
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Krauthammer A, Tzivinikos C, Assa A, Miele E, Strisciuglio C, Urlep D, Serban ED, Singh A, Winter HS, Russell RK, Hojsak I, Malham M, Navas-López VM, Croft NM, Lee HM, Ledder O, Shamasneh I, Hussey S, Huynh HQ, Wine E, Shah N, Sladek M, de Meij TG, Romano C, Dipasquale V, Lionetti P, Afzal NA, Aloi M, Lee K, Martín-de-Carpi J, Yerushalmy-Feler A, Subramanian S, Weiss B, Shouval DS. Long-term Outcomes of Paediatric Patients Admitted With Acute Severe Colitis- A Multicentre Study From the Paediatric IBD Porto Group of ESPGHAN. J Crohns Colitis 2019; 13:1518-1526. [PMID: 31120524 DOI: 10.1093/ecco-jcc/jjz092] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Acute severe colitis [ASC] is associated with significant morbidity in paediatric patients with ulcerative colitis [UC]. Most outcome studies in ASC since tumour necrosis factor alpha [TNFα] antagonists became available have focused on the first year after admission. The aim of this study was to characterise the longer-term outcomes of paediatric patients admitted with ASC. METHODS This retrospective study was conducted in 25 centres across Europe and North America. Data on patients with UC aged <18 years, admitted with ASC (defined as paediatric ulcerative colitis activity index [PUCAI] score ≥65) between 2009 and 2011, were collected at discharge and 1, 3 and 5 years after admission. The primary outcome was colectomy-free rates at each time point. RESULTS Of the 141 patients admitted with ASC, 137 [97.1%] were treated with intravenous corticosteroids. Thirty-one [22.6%] patients were escalated to second-line therapy, mainly to infliximab. Sixteen patients [11.3%] underwent colectomy before discharge. Long-term follow-up showed colectomy-free rates were 71.3%, 66.4% and 63.6% at 1, 3 and 5 years after initial ASC admission, respectively, and were similar across different age groups. Sub-analysis of colectomy rates in patients with new-onset disease [42.5% of the cohort] yielded similar results. In a multivariate analysis, use of oral steroids in the 3 months before admission, erythrocyte sedimentation rate >70 mm/h, and albumin <2.5 g/dL, were significantly associated with 5-year colectomy risk. CONCLUSIONS High colectomy rates were demonstrated in paediatric UC patients admitted with ASC. Additional studies are required to determine whether intensification of anti-TNFα treatment, close therapeutic drug monitoring, and use of new drugs alter this outcome.
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Affiliation(s)
- Alex Krauthammer
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Centre, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christos Tzivinikos
- Department of Paediatric Gastroenterology, Alder Hey Children's Hospital, Liverpool, UK
| | - Amit Assa
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Centre of Israel, Petah Tiqwa, Israel
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II", Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania, "Luigi Vanvitelli"Naples, Italy
| | - Darja Urlep
- Department of Gastroenterology, Hepatology and Nutrition, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Elena Daniela Serban
- Second Department of Paediatrics, "Iuliu Hatieganu" University of Medicine and Pharmacy, Emergency Clinical Hospital for Children, Cluj-Napoca, Romania
| | - Avantika Singh
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, MassGeneral Hospital for Children and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Harland S Winter
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, MassGeneral Hospital for Children and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Mikkel Malham
- Paediatric Department, Hvidovre University Hospital, Hvidovre, Denmark
| | | | - Nicholas M Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
- Department of Paediatric Gastroenterology, Royal London Children's Hospital, Barts Health NHS Trust, London, UK
| | - Huey Miin Lee
- Department of Paediatric Gastroenterology, Royal London Children's Hospital, Barts Health NHS Trust, London, UK
| | - Oren Ledder
- Juliet Keidan Instutute of Pediatric Gastroenterology, Shaare Zedek Medical Centre, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ibrahim Shamasneh
- Juliet Keidan Instutute of Pediatric Gastroenterology, Shaare Zedek Medical Centre, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Seamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Hien Q Huynh
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Eytan Wine
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Neil Shah
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital London, London, UK
| | - Margaret Sladek
- Department of Pediatrics, Gastroenterology and Nutrition, Jagiellonian University Medical College, Cracow, Poland
| | - Tim G de Meij
- Department of Paediatric Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Paolo Lionetti
- Gastroenterology Unit, University of Florence, Department of "NEUROFARBA": Section of Child's Health, "Anna Meyer" Children's Hospital, Florence, Italy
| | - Nadeem A Afzal
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK
| | - Marina Aloi
- Sapienza University of Rome, Pediatric Gastroenterology and Liver Unit, Department of Pediatrics, Rome, Italy
| | - Kwangyang Lee
- Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol, UK
| | - Javier Martín-de-Carpi
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Anat Yerushalmy-Feler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Gastroenterology, Dana Dwek Children's Hospital, Tel Aviv, Israel
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool University Hospital and University of Liverpool, Liverpool, UK
| | - Batia Weiss
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Centre, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror S Shouval
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Centre, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
The incidence of paediatric Crohn's disease (CD) and ulcerative colitis (UC) is increasing. Surgical intervention is required during childhood in approximately 25% of children diagnosed with CD, and for 10% of those diagnosed with UC. Although there is evidence that the rate of surgical intervention undertaken in children is decreasing since the introduction of biologic therapy, this may only represent a delay rather than true reversal of the risk of surgery. Surgery for CD is not curative and limited resection is the key principle thus preserving bowel length. For UC, subtotal colectomy is relatively curative; ileo-anal pouch anastomosis can be performed to restore bowel continuity.
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Affiliation(s)
- Arun Kelay
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Lucinda Tullie
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
| | - Michael Stanton
- Department of Paediatric Surgery, University Hospital Southampton, Southampton, UK
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22
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Jerger L, Hyams JS. Special considerations for biologic medications in pediatric ulcerative colitis. Expert Opin Biol Ther 2019; 20:429-435. [PMID: 31652087 DOI: 10.1080/14712598.2020.1685492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: More extensive disease, high rates of corticosteroid refractory and dependent disease, and the potential impact of disease on growth and development differentiate inflammatory bowel disease in children from adults. This is particularly evident in ulcerative colitis where pancolitis predominates, success of mesalamine alone in achieving remission is less than 50%, and there is a high need for immunomodulator or biologic therapies.Areas Covered: This review describes the use of infliximab, adalimumab, golimumab, and vedolizumab in the treatment of children with ulcerative colitis but is limited in scope due to the paucity of controlled clinical trials. A search of existing literature with keywords of these specific biological therapies as well as 'pediatric', 'ulcerative colitis,' and 'inflammatory bowel disease' was used to complete this review.Expert Opinion: Therapeutic drug monitoring has become standard of care when assessing dosing and changes in therapy and will play a role in future treatment planning.
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Affiliation(s)
- Logan Jerger
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, USA
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, USA
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23
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Tokarz R, Hyams JS, Mack DR, Boyle B, Griffiths AM, LeLeiko NS, Sauer CG, Shah S, Markowitz J, Baker SS, Rosh J, Baldassano RN, Kugathasan S, Walters T, Tagliafierro T, Sameroff S, Lee B, Che X, Oleynik A, Denson LA, Lipkin WI. Characterization of Stool Virome in Children Newly Diagnosed With Moderate to Severe Ulcerative Colitis. Inflamm Bowel Dis 2019; 25:1656-1662. [PMID: 31112614 PMCID: PMC7108593 DOI: 10.1093/ibd/izz099] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Viral infections have been suggested as possible triggers for the onset of ulcerative colitis (UC). METHODS We employed VirCapSeq-Vert, a high-throughput sequencing virus capture platform, to examine the stool virome of children with newly diagnosed moderate to severe UC. We surveyed fecal samples collected at presentation, after symptom remission, and from a control group diagnosed with irritable bowel syndrome. RESULTS Seventy subjects with UC (mean age 13 years, 45 had moderate symptoms, 25 had severe, 69 of 70 had a Mayo endoscopy subscore 2/3) were studied. We detected a wide range of animal viruses that were taxonomically classified into 12 viral families. A virus was present in 50% of fecal samples collected at presentation, 41% of samples collected after remission, and 40% of samples in our control group. The most frequently identified viruses were diet-based gyroviruses. The UC cohort had a significantly higher prevalence of anelloviruses compared with the control cohort. However, we did not identify a single virus that can be implicated in the onset of UC and did not find an association between UC disease severity and viral presence. CONCLUSION Presence of virus in stool was not associated with the onset of pediatric UC.
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Affiliation(s)
- Rafal Tokarz
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA,Address correspondence to: Rafal Tokarz, Center for Infection and Immunity, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 1701, New York, NY 10032, USA. E-mail:
| | | | - David R Mack
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | | | - Sapana Shah
- Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James Markowitz
- Cohen Children’s Medical Center of New York, New Hyde Park, NY, USA
| | - Susan S Baker
- Women & Children’s Hospital of Buffalo WCHOB, Buffalo, NY, USA
| | - Joel Rosh
- Goryeb Children’s Hospital, Atlantic Health, Morristown, NJ, USA
| | | | | | | | - Teresa Tagliafierro
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Stephen Sameroff
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Bohyun Lee
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Xiaoyu Che
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | - Alexandra Oleynik
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, NY, USA
| | | | - W Ian Lipkin
- Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
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24
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Deva Rajoo G, Tan L, Lopez A, Lewindon P, Grover Z. Early Response to Corticosteroid and Baseline C-Reactive Protein Predicts Outcomes in Children with Moderate to Severe Ulcerative Colitis. Dig Dis Sci 2019; 64:1929-1937. [PMID: 30734233 DOI: 10.1007/s10620-019-05486-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/22/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Initial response to corticosteroids (CS) is recognized as a strong predictor of outcomes in ulcerative colitis (UC). AIM To compare outcomes of early poor responders (PR) versus good responders (GR) to initial CS at 1, 2, and 3 years from diagnosis. METHODS In this retrospective study, we report longitudinal outcomes of children with moderate-severe UC, initiating oral/IV CS < 1 month of diagnosis and a minimum follow-up (FU) of 1 year. CS resistance (CSR) and CS dependency (CSD) were combined as PR, and those with CS-free remission (CSFR) at 6 months were GR. RESULTS Of 116 children with UC, 76 (33 males) fulfilled study criteria. Median age at diagnosis was 12 years (IQR 12-14), and a median FU was 48 months (IQR 27-65). Thirty-five (46%, CSR = 10, CSD = 25) were PR, and 41 (54%) were GR. Mean relapse (2.39 vs. 1.1, p = 0.0009), acute severe UC flare-up (40% vs. 9.7%, p = 0.002), and colectomy rates (34.2% vs. 2.4%) were greater in PR versus GR, despite frequent early (< 6 months) use of azathioprine (74% vs. 27%, p = 0.004) and anti-TNFs (43% vs. 2.4%, p = 0.0001). Cumulative colectomy at 3 years was lowest in those with GR versus CSD and CSR (2.4% vs. 28% and 50% p = 0.001). On univariate analysis, CRP > 20 mg/L at diagnosis, Mayo Clinical Score > 1 at 3 months, and PR predicted colectomy. On multivariate regression, only baseline CRP > 20 mg/L predicted colectomy (HR 4.9, p = 0.03). CONCLUSIONS Baseline CRP and poor response to initial CS are associated with unfavorable outcomes in children with UC.
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Affiliation(s)
- Gayetri Deva Rajoo
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia
| | - Lian Tan
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia
| | - Ainslie Lopez
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia
| | - Peter Lewindon
- Gastroenterology Department, Lady Cilento Hospital, Brisbane, 4101, Australia
| | - Zubin Grover
- Gastroenterology Department, Princess Margaret Hospital for Children, Roberts Road, Subiaco, Perth, WA, 6008, Australia.
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25
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Hyams JS, Davis Thomas S, Gotman N, Haberman Y, Karns R, Schirmer M, Mo A, Mack DR, Boyle B, Griffiths AM, LeLeiko NS, Sauer CG, Keljo DJ, Markowitz J, Baker SS, Rosh J, Baldassano RN, Patel A, Pfefferkorn M, Otley A, Heyman M, Noe J, Oliva-Hemker M, Rufo PA, Strople J, Ziring D, Guthery SL, Sudel B, Benkov K, Wali P, Moulton D, Evans J, Kappelman MD, Marquis MA, Sylvester FA, Collins MH, Venkateswaran S, Dubinsky M, Tangpricha V, Spada KL, Saul B, Wang J, Serrano J, Hommel K, Marigorta UM, Gibson G, Xavier RJ, Kugathasan S, Walters T, Denson LA. Clinical and biological predictors of response to standardised paediatric colitis therapy (PROTECT): a multicentre inception cohort study. Lancet 2019; 393:1708-1720. [PMID: 30935734 PMCID: PMC6501846 DOI: 10.1016/s0140-6736(18)32592-3] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Lack of evidence-based outcomes data leads to uncertainty in developing treatment regimens in children who are newly diagnosed with ulcerative colitis. We hypothesised that pretreatment clinical, transcriptomic, and microbial factors predict disease course. METHODS In this inception cohort study, we recruited paediatric patients aged 4-17 years with newly diagnosed ulcerative colitis from 29 centres in the USA and Canada. Patients initially received standardised mesalazine or corticosteroids, with pre-established criteria for escalation to immunomodulators (ie, thiopurines) or anti-tumor necrosis factor-α (TNFα) therapy. We used RNA sequencing to define rectal gene expression before treatment, and 16S sequencing to characterise rectal and faecal microbiota. The primary outcome was week 52 corticosteroid-free remission with no therapy beyond mesalazine. We assessed factors associated with the primary outcome using logistic regression models of the per-protocol population. This study is registered with ClinicalTrials.gov, number NCT01536535. FINDINGS Between July 10, 2012, and April 21, 2015, of 467 patients recruited, 428 started medical therapy, of whom 400 (93%) were evaluable at 52 weeks and 386 (90%) completed the study period with no protocol violations. 150 (38%) of 400 participants achieved week 52 corticosteroid-free remission, of whom 147 (98%) were taking mesalazine and three (2%) were taking no medication. 74 (19%) of 400 were escalated to immunomodulators alone, 123 (31%) anti-TNFα therapy, and 25 (6%) colectomy. Low baseline clinical severity, high baseline haemoglobin, and week 4 clinical remission were associated with achieving week 52 corticosteroid-free remission (n=386, logistic model area under the curve [AUC] 0·70, 95% CI 0·65-0·75; specificity 77%, 95% CI 71-82). Baseline severity and remission by week 4 were validated in an independent cohort of 274 paediatric patients with newly diagnosed ulcerative colitis. After adjusting for clinical predictors, an antimicrobial peptide gene signature (odds ratio [OR] 0·57, 95% CI 0·39-0·81; p=0·002) and abundance of Ruminococcaceae (OR 1·43, 1·02-2·00; p=0·04), and Sutterella (OR 0·81, 0·65-1·00; p=0·05) were independently associated with week 52 corticosteroid-free remission. INTERPRETATION Our findings support the utility of initial clinical activity and treatment response by 4 weeks to predict week 52 corticosteroid-free remission with mesalazine alone in children who are newly diagnosed with ulcerative colitis. The development of personalised clinical and biological signatures holds the promise of informing ulcerative colitis therapeutic decisions. FUNDING US National Institutes of Health.
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Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA.
| | - Sonia Davis Thomas
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA; Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA; RTI International, Research Triangle Park, NC, USA
| | - Nathan Gotman
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Yael Haberman
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA; Sheba Medical Center, affiliated with the Tel Aviv University, Tel Hashomer, Israel
| | - Rebekah Karns
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Melanie Schirmer
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Angela Mo
- Georgia Institute of Technology, Atlanta, GA, USA
| | - David R Mack
- School of Biological Sciences, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Brendan Boyle
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Anne M Griffiths
- Divisioin of Pediatric Gastroenterology, Hospital For Sick Children, Toronto, ON, Canada
| | - Neal S LeLeiko
- IBD Centre, Department of Paediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - Cary G Sauer
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - David J Keljo
- Division of Gastroenterology, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James Markowitz
- Division of Gastroenterology, Hepatology, and Nutrition, Cohen Children's Medical Center Of New York, New Hyde Park, NY, USA
| | - Susan S Baker
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Women & Children's Hospital of Buffalo WCHOB, Buffalo, NY, USA
| | - Joel Rosh
- Division of Gastroenterology, Hepatology, and Nutrition, Goryeb Children's Hospital, Atlantic Health, Morristown, NJ, USA
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashish Patel
- Division of Gastroenterology, Hepatology, and Nutrition, UT Southwestern, Dallas, TX, USA
| | - Marian Pfefferkorn
- Division of Gastroenterology, Hepatology, and Nutrition, Riley Children's Hospital Indiana, Indianapolis, IN, USA
| | - Anthony Otley
- Division of Gastroenterology, Hepatology, and Nutrition, IWK Health Centre, Halifax, NS, Canada
| | - Melvin Heyman
- Division of Gastroenterology, Hepatology, and Nutrition, University of California at San Francisco, San Francisco, CA, USA
| | - Joshua Noe
- Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maria Oliva-Hemker
- Division of Gastroenterology, Hepatology, and Nutrition, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Paul A Rufo
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Boston, Harvard Medical School Boston, MA, USA
| | - Jennifer Strople
- Division of Gastroenterology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Ziring
- Division of Gastroenterology, Hepatology, and Nutrition, UCLA Medical Center, Los Angeles, CA, USA
| | - Stephen L Guthery
- Division of Gastroenterology, Hepatology, and Nutrition, Primary Children's Hospital and the University of Utah, Salt Lake City, UT, USA
| | - Boris Sudel
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Keith Benkov
- Division of Gastroenterology, Hepatology, and Nutrition, Mt Sinai Hospital, New York City, NY, USA
| | - Prateek Wali
- Division of Gastroenterology, Hepatology, and Nutrition, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Dedrick Moulton
- Division of Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr Children's Hospital of Vanderbilt, Nashville, TN, USA
| | - Jonathan Evans
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Clinic, Jacksonville, FL, USA
| | - Michael D Kappelman
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - M Alison Marquis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Margaret H Collins
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Suresh Venkateswaran
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - Marla Dubinsky
- Division of Gastroenterology, Hepatology, and Nutrition, Mt Sinai Hospital, New York City, NY, USA
| | - Vin Tangpricha
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - Krista L Spada
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Bradley Saul
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jessie Wang
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jose Serrano
- National Institutes of Diabetes, Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Kevin Hommel
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Greg Gibson
- Georgia Institute of Technology, Atlanta, GA, USA
| | - Ramnik J Xavier
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Center for Computational and Integrative Biology, Gastrointestinal Unit, and Center for the Study of Inflammatory Bowel Disease, Massachusetts General Hospital, Boston, MA, USA; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Subra Kugathasan
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - Thomas Walters
- Divisioin of Pediatric Gastroenterology, Hospital For Sick Children, Toronto, ON, Canada
| | - Lee A Denson
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Abstract
Paediatric-onset inflammatory bowel disease (IBD) is associated with greater disease burden and morbidity compared to adult-onset IBD. Accurate risk prediction for a complicated disease course in childhood onset IBD is essential for making the best treatment choices. Complicating course in IBD is closely linked with choice of therapies and treatment targets. In this review article, we examine risk factors of complicated disease course in children with IBD in the era of increasing use of biologics and tighter treatment targets. We also discuss emerging paediatric data supporting an early intensive approach targeting deeper healing, aiming for remission beyond symptoms with repeat endoscopic examination to make treatment adjustments.
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Affiliation(s)
- Zubin Grover
- Department of Gastroenterology, Perth Children's Hospital, Perth, Australia
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27
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Oliva S, Thomson M, de Ridder L, Martín-de-Carpi J, Van Biervliet S, Braegger C, Dias JA, Kolacek S, Miele E, Buderus S, Bronsky J, Winter H, Navas-López VM, Assa A, Chong SKF, Afzal NA, Smets F, Shaoul R, Hussey S, Turner D, Cucchiara S. Endoscopy in Pediatric Inflammatory Bowel Disease: A Position Paper on Behalf of the Porto IBD Group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:414-430. [PMID: 30130311 DOI: 10.1097/mpg.0000000000002092] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopy is a central tool for the evaluation and management of inflammatory bowel disease (IBD). In the last few decades, gastrointestinal (GI) endoscopy has undergone significant technological developments including availability of pediatric-size equipment, enabling comprehensive investigation of the GI tract in children. Simultaneously, professional organization of GI experts have developed guidelines and training programs in pediatric GI endoscopy. This prompted the Porto Group on Pediatric IBD of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition to develop updated guidelines on the role of GI endoscopy in pediatric IBD, specifically taking into considerations of recent advances in the diagnosis, disease stratification, and novel therapeutic targets in these patients.
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Affiliation(s)
- Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Sheffield, United Kingdom
| | - Lissy de Ridder
- Pediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Javier Martín-de-Carpi
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | | | - Christian Braegger
- Division of Gastroenterology and Nutrition, University Children's Hospital, Zurich, Switzerland
| | - Jorge Amil Dias
- Pediatric Gastroenterology Unit, Hospital Sao João, Porto, Portugal
| | - Sanja Kolacek
- Children's Hospital Zagreb, Faculty of Medicine, Zagreb, Croatia
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, "Federico II," University of Naples, Italy
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Harland Winter
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA
| | | | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, affiliated to the Sackler faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sonny K F Chong
- Queen Mary's Hospital for Children, Epsom & St Helier University Hospitals NHS Trust, Carshalton, Surrey
| | - Nadeem Ahmad Afzal
- Department of Paediatric Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Francoise Smets
- Pediatric Gastroenterology and Hepatology Unit, IREC, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Séamus Hussey
- National Children's Research Centre and Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Dan Turner
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Salvatore Cucchiara
- Pediatric Gastroenterology and Liver Unit, Sapienza-University of Rome, Italy
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28
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Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos KH, Croft N, Navas-López VM, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 2: Acute Severe Colitis-An Evidence-based Consensus Guideline From the European Crohn's and Colitis Organization and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:292-310. [PMID: 30044358 DOI: 10.1097/mpg.0000000000002036] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Acute severe colitis (ASC) is one of the few emergencies in pediatric gastroenterology. Tight monitoring and timely medical and surgical interventions may improve outcomes and minimize morbidity and mortality. We aimed to standardize daily treatment of ASC in children through detailed recommendations and practice points which are based on a systematic review of the literature and consensus of experts. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Fifteen predefined questions were addressed by working subgroups. An iterative consensus process, including 2 face-to-face meetings, was followed by voting of the national representatives of ECCO and all members of the Paediatric Inflammatory Bowel Disease (IBD) Porto group of ESPGHAN (43 voting experts). RESULTS A total of 24 recommendations and 43 practice points were endorsed with a consensus rate of at least 91% regarding diagnosis, monitoring, and management of ASC in children. A summary flowchart is presented based on daily scoring of the Paediatric Ulcerative Colitis Activity Index. Several topics have been altered since the previous 2011 guidelines and from those published in adults. DISCUSSION These guidelines standardize the management of ASC in children in an attempt to optimize outcomes of this intensive clinical scenario.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- Ist Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva (affiliated to the Sackler Faculty of Medicine), Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | | | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver BC, Canada
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29
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Gasparetto M, Wong-Spracklen V, Torrente F, Howell K, Brennan M, Noble-Jamieson G, Heuschkel R, Zilbauer M. Early Treatment Response Predicts Outcome in Paediatric Ulcerative Colitis: GASTROENTEROLOGY: INFLAMMATORY BOWEL DISEASE. J Pediatr Gastroenterol Nutr 2018; 67:217-220. [PMID: 30044356 DOI: 10.1097/mpg.0000000000001941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The disease course of children with ulcerative colitis (UC) varies substantially. Published data on predictors of disease outcomes in children remain scarce. We validate clinical predictors of outcomes in 93 children with UC in a single centre (age range: 2-18 years, minimum follow-up: 18 months). We stratified children into 3 groups according to their disease course, that is, 1 = mild (38/93, 40.9%), 2 = moderate (38/93, 40.9%), 3 = severe (17, 18.2%). Comparison of clinical and biochemical parameters was performed between groups using Chi-square, Mann-Whitney, and log-rank tests. Predictors of a severe disease course included pancolitis (P 0.01), low albumin (P 0.005), low haemoglobin at diagnosis (P 0.04), paediatric ulcerative colitis activity index (PUCAI) at 3 months, and nonresponse to steroids at 3 months (P 0.0001). In our cohort, failure to achieve remission at 3 months implied an 80% likelihood to require biologics or major surgery within 18 months. A specific 3-month review point is recommended to guide future management.
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Affiliation(s)
- Marco Gasparetto
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital.,Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge University Hospitals, Addenbrooke's, Cambridge, United Kingdom
| | - Vivien Wong-Spracklen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge University Hospitals, Addenbrooke's, Cambridge, United Kingdom
| | - Franco Torrente
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge University Hospitals, Addenbrooke's, Cambridge, United Kingdom
| | - Kate Howell
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital
| | - Mary Brennan
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge University Hospitals, Addenbrooke's, Cambridge, United Kingdom
| | - Gabriele Noble-Jamieson
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge University Hospitals, Addenbrooke's, Cambridge, United Kingdom
| | - Robert Heuschkel
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge University Hospitals, Addenbrooke's, Cambridge, United Kingdom
| | - Matthias Zilbauer
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital.,Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cambridge University Hospitals, Addenbrooke's, Cambridge, United Kingdom
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30
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Turner D, Ruemmele FM, Orlanski-Meyer E, Griffiths AM, de Carpi JM, Bronsky J, Veres G, Aloi M, Strisciuglio C, Braegger CP, Assa A, Romano C, Hussey S, Stanton M, Pakarinen M, de Ridder L, Katsanos K, Croft N, Navas-López V, Wilson DC, Lawrence S, Russell RK. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2018; 67:257-291. [PMID: 30044357 DOI: 10.1097/mpg.0000000000002035] [Citation(s) in RCA: 255] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. METHODS These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. RESULTS These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. CONCLUSIONS These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.
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Affiliation(s)
- Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Frank M Ruemmele
- Université Paris Descartes, Sorbonne Paris Cité, APHP, Hôpital Necker Enfants Malades, Paris, France
| | | | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Gabor Veres
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania "Luigi Vanvitelli," Napoli, Italy
| | | | - Amit Assa
- Schneider Children's Hospital, Petach Tikva, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Claudio Romano
- Pediatric Department, University of Messina, Messina, Italy
| | - Séamus Hussey
- National Children's Research Centre, Royal College of Surgeons of Ireland and University College Dublin, Dublin, Ireland
| | | | - Mikko Pakarinen
- Helsinki University Children's Hospital, Department of Pediatric Surgery, Helsinki, Finland
| | - Lissy de Ridder
- Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Nick Croft
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Victor Navas-López
- Pediatric Gastroenterology and Nutrition Unit. Hospital Materno, IBIMA, Málaga, Spain
| | - David C Wilson
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Sally Lawrence
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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31
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Abstract
OBJECTIVES The aims of this retrospective study were to describe ulcerative colitis (UC) phenotype at diagnosis and follow-up and to identify possible predictors of severe disease course. METHODS This was a retrospective, single-center study. We reviewed the charts of patients with UC diagnosed between 2 and 18 years at our referral center from January 2007 to January 2016. Laboratory and clinical features at diagnosis, such as disease extent, atypical phenotypes, extraintestinal manifestations, and therapies, and pattern changes during the follow-up, including relapse rate, disease extension, and the cumulative risk for colectomy were collected. RESULTS One hundred eleven patients were enrolled. Atypical phenotypes were identified at diagnosis in 55 out of 111 patients (49.5%). Extraintestinal manifestations were detected in 16 out of 111 (14.4%) at the diagnosis. During the follow-up 60 out of 111 (54%) patients needed to start azathioprine, 9 out of 111 (8.1%) patients started biologic therapy and 10 out of 111 (patients underwent surgery, resulting in a cumulative risk of 8% at 5 years and 16% at 10 years. Steroid refractoriness (hazard ratio: 13.9) and starting of biologic therapy (hazard ratio: 25.3) represented the best predictors for surgery. The cumulative probability of first relapse was 47% at 6 months and 63% at 1 year. Disease extension was reported in 21 out of 70 patients (30%). CONCLUSION Pediatric UC is associated with a severe phenotype and a high percentage of atypical features. Surgery rate seems to be decreased from early reports.
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32
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Rinawi F, Assa A, Hartman C, Mozer Glassberg Y, Nachmias Friedler V, Rosenbach Y, Silbermintz A, Zevit N, Shamir R. Long-term Extent Change of Pediatric-Onset Ulcerative Colitis. J Clin Gastroenterol 2018; 52:326-332. [PMID: 28067753 DOI: 10.1097/mcg.0000000000000741] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Data describing extent change (progression or regression) in pediatric-onset ulcerative colitis (UC) are scarce. GOAL We aimed to describe extent change in pediatric-onset UC during long-term follow-up and to assess predictors of extent change. STUDY Medical charts of pediatric-onset UC patients with at least 5-year follow-up were analyzed retrospectively. Disease extent was determined using the Paris classification. It was examined at diagnosis and during follow-up at different time points. The impact of possible predictors on extent change including age at diagnosis, gender, clinical manifestations, disease, severity indices, and different therapeutic regimens during disease course was assessed. RESULTS Patients (n=134, 55% males) were followed for a median duration of 13.1 (range, 5 to 28) years. Median age at diagnosis was 13.1 (range, 2 to 17.8) years. Of 134 patients, 40.5% had extensive or pancolitis, 33.5% left-sided colitis, and 26% had proctitis at diagnosis. On follow-up (n=117), 45% had unchanged disease extent, 35% experienced extent progression, whereas 20% experienced regression of disease extent. The multivariate Cox models demonstrated that among children with left-sided disease at diagnosis, presence of extraintestinal manifestations (hazard ratio, 5.19; P=0.022), and higher pediatric UC activity index (hazard ratio, 8.77; P=0.008) were associated with extent progression to extensive disease. Predictors of extent regression have not been identified. CONCLUSIONS Disease extent changes significantly over time in pediatric-onset UC. In our cohort, presence of extraintestinal manifestation and higher pediatric UC activity index score at diagnosis were associated with progression from limited to extensive disease during follow-up.
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Affiliation(s)
- Firas Rinawi
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Corina Hartman
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yael Mozer Glassberg
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Vered Nachmias Friedler
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Yoram Rosenbach
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Ari Silbermintz
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach-Tikva.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Assa A, Rinawi F, Shamir R. The Long-Term Predictive Properties of the Paris Classification in Paediatric Inflammatory Bowel Disease Patients. J Crohns Colitis 2018; 12:39-47. [PMID: 28961726 DOI: 10.1093/ecco-jcc/jjx125] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/06/2017] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The Paris modification of the Montreal classification for children with inflammatory bowel disease was accepted in 2011. We aimed to investigate the long-term clinical outcomes of patients diagnosed with IBD during childhood in a population-based cohort according to the Paris classification at diagnosis. METHODS The medical records of paediatric inflammatory bowel disease patients, diagnosed from 2000 to 2016, were reviewed retrospectively. Main outcome measures included time to first flare, hospitalisation, surgery, and biologic therapy. RESULTS In Crohn's disease patients [n = 301, median age 14.2 years], colonic location was associated with higher prevalence of extraintestinal manifestations, whereas ileal location and complicated behaviour were associated with anti-Saccharomyces cerevisiae antibody positivity. During a median follow-up of 9.1 years (interquartile range [IQR]of 4.7-12.3), complicated behaviour at diagnosis was associated with increased risk for surgery (hazard ratio[ HR] = 2.7, p < 0.001] and hospitalisation [HR = 1.5, p = 0.01] but not with the risk for flare or stepping-up to biologic therapy. Isolated colonic disease was associated with a decreased risk of surgery [HR = 0.25, p = 0.02]. During a median follow-up of 8.5 years [interquartile range of 5.1-12], in patients with ulcerative colitis [n = 126, median age 13.7 years], severe disease at diagnosis but not disease extent was associated with the risk for colectomy [HR = 3.5, p = 0.002], hospitalisation [HR = 3.3, p < 0.001], flare [HR = 2.4, p < 0.001] and biologic therapy [HR = 2.6, p = 0.001]. CONCLUSIONS The Paris classification for paediatric inflammatory bowel disease has clear predictive properties. Complicated disease and ileal location at diagnosis in Crohn's disease, and severity of disease but not its extension in ulcerative colitis, predict long-term worse outcomes.
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Affiliation(s)
- Amit Assa
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Firas Rinawi
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Abstract
The incidence of pediatric-onset ulcerative colitis (UC) is rising. Children often present with a more severe disease phenotype as compared to adults with over a third requiring hospitalization for the management of acute severe ulcerative colitis (ASUC). Further, in pediatric patients presenting with inflammatory bowel disease (IBD) limited to the colon, a definitive diagnosis of UC vs. Crohn's disease is often unclear. Here, we review the unique aspects of pediatric ASUC including the epidemiology, diagnosis, medical, and surgical management of this disease.
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Affiliation(s)
- Vei Shaun Siow
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Riha Bhatt
- Division of Gastroenterology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Division of Pediatric Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania.
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Abstract
OBJECTIVES Data describing the incidence and risk factors for colectomy in pediatric ulcerative colitis (UC) is inconsistent. Our aim was to describe the colectomy rate and to identify risk factors associated with colectomy in a large cohort of children with UC with long-term follow-up. MATERIALS AND METHODS We performed a retrospective chart review of pediatric UC cases that were diagnosed at Schneider Children's Medical Center of Israel between 1981 and 2013. Potential predictors for colectomy including age at diagnosis, sex, disease extent, severity indices, and different therapeutic regimens during disease course were assessed. RESULTS Of 188 patients with pediatric onset UC, 34 (18%) underwent colectomy. Median follow-up was 6.9 years (range, 1-30). Kaplan-Meier survival estimates of the cumulative probability for colectomy were 4% at 1 year and 17% at 10 years from diagnosis. Multivariate Cox models showed that male sex (hazard ratio 4.2, P = 0.001) and severe disease at diagnosis reflected by Pediatric Ulcerative Colitis Activity Index score ≥65 (hazard ratio 8.9, P < 0.001) were associated with increased risk for colectomy. Age, disease extent, ethnicity, family history of inflammatory bowel disease, early introduction of immunomodulators, or treatment with antitumor necrosis factor α agent did not affect the risk of colectomy. CONCLUSIONS Male sex and higher Pediatric Ulcerative Colitis Activity Index score at diagnosis are independent risk factors for colectomy.
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Hyams JS, Davis S, Mack DR, Boyle B, Griffiths AM, LeLeiko NS, Sauer CG, Keljo DJ, Markowitz J, Baker SS, Rosh J, Baldassano RN, Patel A, Pfefferkorn M, Otley A, Heyman M, Noe J, Oliva-Hemker M, Rufo P, Strople J, Ziring D, Guthery SL, Sudel B, Benkov K, Wali P, Moulton D, Evans J, Kappelman MD, Marquis A, Sylvester FA, Collins MH, Venkateswaran S, Dubinsky M, Tangpricha V, Spada KL, Britt A, Saul B, Gotman N, Wang J, Serrano J, Kugathasan S, Walters T, Denson LA. Factors associated with early outcomes following standardised therapy in children with ulcerative colitis (PROTECT): a multicentre inception cohort study. Lancet Gastroenterol Hepatol 2017; 2:855-868. [PMID: 28939374 PMCID: PMC5695708 DOI: 10.1016/s2468-1253(17)30252-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/25/2017] [Accepted: 07/28/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous retrospective studies of paediatric ulcerative colitis have had limited ability to describe disease progression and identify predictors of treatment response. In this study, we aimed to identify characteristics associated with outcomes following standardised therapy after initial diagnosis. METHODS The PROTECT multicentre inception cohort study was based at 29 centres in the USA and Canada and included paediatric patients aged 4-17 years who were newly diagnosed with ulcerative colitis. Guided by the Pediatric Ulcerative Colitis Activity Index (PUCAI), patients received initial standardised treatment with mesalazine (PUCAI 10-30) oral corticosteroids (PUCAI 35-60), or intravenous corticosteroids (PUCAI ≥65). The key outcomes for this analysis were week 12 corticosteroid-free remission, defined as PUCAI less than 10 and taking only mesalazine, and treatment escalation during the 12 study weeks to anti-tumour necrosis factor α (TNFα) agents, immunomodulators, or colectomy among those initially treated with intravenous corticosteroids. We identified independent predictors of outcome through multivariable logistic regression using a per-protocol approach. This study is registered with ClinicalTrials.gov, number NCT01536535. FINDINGS Patients were recruited between July 10, 2012, and April 21, 2015. 428 children initiated mesalazine (n=136), oral corticosteroids (n=144), or intravenous corticosteroids (n=148). Initial mean PUCAI was 31·1 (SD 13·3) in children initiating with mesalazine, 50·4 (13·8) in those initiating oral corticosteroids, and 66·9 (13·7) in those initiating intravenous corticosteroids (p<0·0001 for between-group comparison). Week 12 outcome data were available for 132 patients who initiated with mesalazine, 141 with oral corticosteroids, and 143 with intravenous corticosteroids. Corticosteroid-free remission with the patient receiving mesalazine treatment only at 12 weeks was achieved by 64 (48%) patients in the mesalazine group, 47 (33%) in the oral corticosteroid group, and 30 (21%) in the intravenous corticosteroid group (p<0·0001). Treatment escalation was required by nine (7%) patients in the mesalazine group, 21 (15%) in the oral corticosteroid group, and 52 (36%) in the intravenous corticosteroid group (p<0·0001). Eight patients, all of whom were initially treated with intravenous corticosteroids, underwent colectomy. Predictors of week 12 corticosteroid-free remission were baseline PUCAI less than 35 (odds ratio 2·44, 95% CI 1·41-4·22; p=0·0015), higher baseline albumin by 1 g/dL increments among children younger than 12 years (4·05, 1·90-8·64; p=0·00030), and week 4 remission (6·26, 3·79-10·35; p<0·0001). Predictors of treatment escalation by week 12 in patients initially treated with intravenous corticosteroids included baseline total Mayo score of 11 or higher (2·59, 0·93-7·21; p=0·068 [retained in model due to clinical relevance]), rectal biopsy eosinophil count less than or equal to 32 cells per high power field (4·55, 1·62-12·78; p=0·0040), rectal biopsy surface villiform changes (3·05, 1·09-8·56; p=0·034), and not achieving week 4 remission (30·28, 6·36-144·20; p<0·0001). INTERPRETATION Our findings provide guidelines to assess the response of children newly diagnosed with ulcerative colitis to standardised initial therapy and identify predictors of treatment response and failure. These data suggest that additional therapeutic interventions might be warranted to improve early outcomes, especially in patients presenting with severe disease and requiring intravenous corticosteroids. FUNDING National Institutes of Health.
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Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA.
| | - Sonia Davis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - David R Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of East Ontario, Ottawa, ON, Canada
| | - Brendan Boyle
- Gastroenterology & Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Anne M Griffiths
- Gastroenterology, Hepatology and Nutrition, Hospital For Sick Children, Toronto, ON, Canada
| | - Neal S LeLeiko
- Division of Pediatric Gastroenterology, Nutrition & Liver Diseases, Hasbro Children's Hospital, Providence, RI, USA
| | - Cary G Sauer
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - David J Keljo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James Markowitz
- Division of Pediatric Gastroenterology, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Susan S Baker
- Gastroenterology (Digestive Diseases and Nutrition), Women & Children's Hospital of Buffalo WCHOB, Buffalo, NY, USA
| | - Joel Rosh
- Pediatric Gastroenterology and Nutrition, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashish Patel
- Pediatric Gastroenterology, UT Southwestern, Dallas, TX, USA
| | - Marian Pfefferkorn
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Children's Hospital Indiana, Indianapolis, IN, USA
| | - Anthony Otley
- Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, NS, Canada
| | - Melvin Heyman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California at San Francisco, San Francisco, CA, USA
| | - Joshua Noe
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maria Oliva-Hemker
- Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Paul Rufo
- Gastroenterology, Hepatology and Nutrition, Harvard-Children's Hospital Boston, Boston, MA, USA
| | - Jennifer Strople
- Gastroenterology, Hepatology & Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Ziring
- Division of Digestive Diseases and Nutrition, UCLA Medical Center, Los Angeles, CA, USA
| | - Stephen L Guthery
- Pediatric Gastroenterology, Hepatology, Nutrition, Primary Children's Medical Center University of Utah, Salt Lake City, UT, USA
| | - Boris Sudel
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Keith Benkov
- Division of Pediatric Gastroenterology, Mt Sinai Hospital, New York City, NY, USA
| | - Prateek Wali
- Division of Pediatric Gastroenterology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Dedrick Moulton
- Division of Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr Children's Hospital of Vanderbilt, Nashville, TN, USA
| | - Jonathan Evans
- Division of Pediatric Gastroenterology and Nutrition Nemours Children's Clinic, Jacksonville, FL, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alison Marquis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Francisco A Sylvester
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margaret H Collins
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Marla Dubinsky
- Division of Pediatric Gastroenterology, Mt Sinai Hospital, New York City, NY, USA
| | - Vin Tangpricha
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - Krista L Spada
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Ashley Britt
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Bradley Saul
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Nathan Gotman
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jessie Wang
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jose Serrano
- National Institutes of Diabetes, Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - Thomas Walters
- Gastroenterology, Hepatology and Nutrition, Hospital For Sick Children, Toronto, ON, Canada
| | - Lee A Denson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Truffi M, Colombo M, Peñaranda-Avila J, Sorrentino L, Colombo F, Monieri M, Collico V, Zerbi P, Longhi E, Allevi R, Prosperi D, Corsi F. Nano-targeting of mucosal addressin cell adhesion molecule-1 identifies bowel inflammation foci in murine model. Nanomedicine (Lond) 2017. [PMID: 28621606 DOI: 10.2217/nnm-2017-0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIM We investigate MAdCAM-1 as a reliable target to detect active bowel inflammation for selective noninvasive nanodiagnostics. MATERIALS & METHODS We coupled anti-MAdCAM-1 antibodies to manganese oxide nanoparticles, and analyzed nanoconjugate biodistribution and safety in murine model of inflammatory bowel disease by imaging and histology. RESULTS Nanoparticles were stable and nontoxic. Upon administration in colitic mice, anti-MAdCAM-1 functionalized nanoparticles preferentially localized in the inflamed bowel, whereas untargeted nanoparticles were more rapidly washed out. Nanoparticles did not induce lesions in nontarget organs. CONCLUSION Anti-MAdCAM-1 functionalized nanoparticles detected active bowel inflammation foci, accurately following MAdCAM-1 expression pattern. These nanoconjugates could be a promising noninvasive imaging system for an early and accurate follow-up in patients affected by acute colitis.
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Affiliation(s)
- Marta Truffi
- Department of Biomedical & Clinical Sciences 'L. Sacco', University of Milan, via G. B. Grassi 74, 20157 Milan, Italy
| | - Miriam Colombo
- Department of Biotechnologies & Biosciences, NanoBioLab, University of Milano-Bicocca, Piazza della Scienza 2, 20126 Milan, Italy
| | - Jesus Peñaranda-Avila
- Department of Biotechnologies & Biosciences, NanoBioLab, University of Milano-Bicocca, Piazza della Scienza 2, 20126 Milan, Italy
| | - Luca Sorrentino
- Department of Biomedical & Clinical Sciences 'L. Sacco', University of Milan, via G. B. Grassi 74, 20157 Milan, Italy
| | - Francesco Colombo
- Surgery Department, IBD Unit, ASST Fatebenefratelli Sacco-Luigi Sacco University Hospital, via G. B. Grassi 74, 20157 Milan, Italy
| | - Matteo Monieri
- Department of Biomedical & Clinical Sciences 'L. Sacco', University of Milan, via G. B. Grassi 74, 20157 Milan, Italy
| | - Veronica Collico
- Department of Biotechnologies & Biosciences, NanoBioLab, University of Milano-Bicocca, Piazza della Scienza 2, 20126 Milan, Italy
| | - Pietro Zerbi
- Department of Biomedical & Clinical Sciences 'L. Sacco', University of Milan, via G. B. Grassi 74, 20157 Milan, Italy.,Pathology Department, ASST Fatebenefratelli Sacco-Luigi Sacco Hospital, via G. B. Grassi 74, 20157 Milan, Italy
| | - Erika Longhi
- Department of Biomedical & Clinical Sciences 'L. Sacco', University of Milan, via G. B. Grassi 74, 20157 Milan, Italy
| | - Raffaele Allevi
- Department of Biomedical & Clinical Sciences 'L. Sacco', University of Milan, via G. B. Grassi 74, 20157 Milan, Italy
| | - Davide Prosperi
- Department of Biotechnologies & Biosciences, NanoBioLab, University of Milano-Bicocca, Piazza della Scienza 2, 20126 Milan, Italy
| | - Fabio Corsi
- Department of Biomedical & Clinical Sciences 'L. Sacco', University of Milan, via G. B. Grassi 74, 20157 Milan, Italy.,Surgery Department, Breast Unit, ICS Maugeri S.p.A. SB, via S. Maugeri 10, 27100 Pavia, Italy
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Seeing Without Looking: Predicting Mucosal Healing Without Endoscopic Evaluation in Pediatric Ulcerative Colitis. J Pediatr Gastroenterol Nutr 2017; 64:848-849. [PMID: 28045775 DOI: 10.1097/mpg.0000000000001514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Turner D, Yerushalmi B, Kori M, Broide E, Mozer-Glassberg Y, Shaoul R, Kolho KL, Shteyer E, Shamaly H, Ledder O, Cohen S, Peleg S, On A, Levine A. Once- Versus Twice-daily Mesalazine to Induce Remission in Paediatric Ulcerative Colitis: A Randomised Controlled Trial. J Crohns Colitis 2017; 11:527-533. [PMID: 28453754 DOI: 10.1093/ecco-jcc/jjw180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/30/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Trials in adults suggested that, in ulcerative colitis [UC], once-daily [OD] dosing of 5-ASA [5-amino salicylic acid] may be as or more effective than twice-daily [BD] dosing. In this induction of remission, investigator-blinded, randomised controlled-trial, we aimed to compare effectiveness and safety of once- versus twice-daily mesalazine in paediatric UC. METHODS Children, aged 4-18 years with a PUCAI [Paediatric Ulcerative Colitis Activity Index] of 10-55 points at inclusion, were randomised in blocks of six with blinded allocation to OD or BD mesalazine, using a weight-based dosing table. The primary outcome was mean PUCAI score at Week 6. RESULTS A total of 83/86 randomised children were eligible and analysed: 43 in the OD group and 40 in the BD group (mean age 14 ± 2.7 years, 43 [52%] males, 51 [62%] extensive colitis). The groups did not differ with regard to disease activity or any other parameter at baseline. There was no difference in median PUCAI score between the OD group and BD group at Week 6: 15 ( interquartile range [IQR] 5-40) versus 10 [0-40]; p = 0.48]. Response was seen in 25 [60%] OD versus 25 [63%] BD dosing [p = 0.78]. Proportion of children in remission [PUCAI < 10] at Week 6 was 13 [30%] OD versus 16 [40%] BD; p = 0.35]. Most adverse events were related to disease aggravation; the rates of serious adverse events were similar [p > 0.2]. CONCLUSIONS In this first randomised controlled trial in children, no differences were found between OD and BD dosing for any clinical outcome. Remission was achieved in 35% of children treated with mesalazine for active UC.
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Affiliation(s)
- Dan Turner
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Baruch Yerushalmi
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | | | | | | | | | | | | | - Oren Ledder
- Institute of Paediatric Gastroenterology, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shlomi Cohen
- Tel Aviv Medical Center, Tel Aviv University, Israel
- Poriya Medical Center, Pediatric Gastroenterology; Bar-Ilan University, Faculty of Medicine in the Galilee, Ramat Gan, Israel
| | | | - Avi On
- Poriya Medical Center, Pediatric Gastroenterology; Bar-Ilan University, Faculty of Medicine in the Galilee, Ramat Gan, Israel
| | - Arie Levine
- Tel Aviv Univeristy and Edith Wolfson Medical Center, Paediatric Gastroenterology and Nutrition, Tel Aviv, Israel
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Cesarini M, Collins GS, Rönnblom A, Santos A, Wang LM, Sjöberg D, Parkes M, Keshav S, Travis SPL. Predicting the Individual Risk of Acute Severe Colitis at Diagnosis. J Crohns Colitis 2017; 11:335-341. [PMID: 27647858 PMCID: PMC5881607 DOI: 10.1093/ecco-jcc/jjw159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 09/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Acute severe colitis [ASC] is associated with major morbidity. We aimed to develop and externally validate an index that predicted ASC within 3 years of diagnosis. METHODS The development cohort included patients aged 16-89 years, diagnosed with ulcerative colitis [UC] in Oxford and followed for 3 years. Primary outcome was hospitalization for ASC, excluding patients admitted within 1 month of diagnosis. Multivariable logistic regression examined the adjusted association of seven risk factors with ASC. Backwards elimination produced a parsimonious model that was simplified to create an easy-to-use index. External validation occurred in separate cohorts from Cambridge, UK, and Uppsala, Sweden. RESULTS The development cohort [Oxford] included 34/111 patients who developed ASC within a median 14 months [range 1-29]. The final model applied the sum of 1 point each for extensive disease, C-reactive protein [CRP] > 10mg/l, or haemoglobin < 12g/dl F or < 14g/dl M at diagnosis, to give a score from 0/3 to 3/3. This predicted a 70% risk of developing ASC within 3 years [score 3/3]. Validation cohorts included different proportions with ASC [Cambridge = 25/96; Uppsala = 18/298]. Of those scoring 3/3 at diagnosis, 18/18 [Cambridge] and 12/13 [Uppsala] subsequently developed ASC. Discriminant ability [c-index, where 1.0 = perfect discrimination] was 0.81 [Oxford], 0.95 [Cambridge], 0.97 [Uppsala]. Internal validation using bootstrapping showed good calibration, with similar predicted risk across all cohorts. A nomogram predicted individual risk. CONCLUSIONS An index applied at diagnosis reliably predicts the risk of ASC within 3 years in different populations. Patients with a score 3/3 at diagnosis may merit early immunomodulator therapy.
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Affiliation(s)
- Monica Cesarini
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK,Dipartimento di Medicina Interna e Specialità Mediche, ‘Sapienza’, University of Rome, Rome, Italy
| | - Gary S. Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Anders Rönnblom
- Department of Medical Sciences, Gastroenterology, Uppsala University, Uppsala, Sweden
| | - Antonieta Santos
- Gastroenterology Unit, Cambridge University Hospitals, Cambridge, UK,Gastroenterology Unit, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Lai Mun Wang
- Department of Cellular Pathology, Oxford University Hospitals, Oxford, UK
| | - Daniel Sjöberg
- Department of Medical Sciences, Gastroenterology, Uppsala University, Uppsala, Sweden
| | - Miles Parkes
- Gastroenterology Unit, Cambridge University Hospitals, Cambridge, UK
| | - Satish Keshav
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
| | - Simon P. L. Travis
- Translational Gastroenterology Unit, Oxford University Hospitals, Oxford, UK
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Larsen MD, Baldal ME, Nielsen RG, Nielsen J, Lund K, Nørgård BM. The incidence of Crohn's disease and ulcerative colitis since 1995 in Danish children and adolescents <17 years - based on nationwide registry data. Scand J Gastroenterol 2016; 51:1100-5. [PMID: 27160395 DOI: 10.3109/00365521.2016.1172340] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Worldwide the incidence of pediatric Crohn's disease (CD) and ulcerative colitis (UC) is suspected to be increasing. Based on unselected nationwide register data the aim of this study is to examine the change in incidence of CD and UC in children and adolescents in Denmark. MATERIALS AND METHODS All children and adolescents <17 years with a diagnosis of CD or UC registered in the Danish National Patient Registry from 1 January 1995 to 31 December 2013 were included. Using a Poisson regression model we estimated the incidence rate ratio (IRR) for the annual change in the incidence adjusted for gender and age. The cumulative incidence was described using Kaplan-Meier survival analyses. RESULTS The IRR for CD was 1.052 (95% CI: 1.039-1.065), and for UC the IRR was 1.022 (95% CI: 1.011-1.033), adjusted for age and gender. The incidence rate of CD increased during the study period to 10.0 (95% CI: 7.5-13.2) per 100,000 person years for girls and 9.4 (95% CI: 7.0-13.2) for boys, in 2013. Similar, the incidence of UC increased to 7.2 (95% CI: 5.0-9.9) per 100,000 person years for girls and 6.2 (95% CI: 4.3-8.7) for boys. CONCLUSIONS In a period of 19 years from 1995 to 2013 we found an increasing incidence for pediatric UC and CD, especially pronounced for CD.
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Affiliation(s)
- Michael Due Larsen
- a Research Unit of Clinical Epidemiology , Institute of Clinical Research, University of Southern Denmark , Odense , Denmark ;,b Center for Clinical Epidemiology , Odense University Hospital , Odense , Denmark
| | - Mira Eggebrecht Baldal
- a Research Unit of Clinical Epidemiology , Institute of Clinical Research, University of Southern Denmark , Odense , Denmark
| | - Rasmus Gaardskær Nielsen
- c Hans Christian Andersen Children's Hospital, Odense University Hospital, and Research Unit of Pediatric , Institute of Clinical Research, University of Southern Denmark , Odense , Denmark
| | - Jan Nielsen
- a Research Unit of Clinical Epidemiology , Institute of Clinical Research, University of Southern Denmark , Odense , Denmark ;,b Center for Clinical Epidemiology , Odense University Hospital , Odense , Denmark
| | - Ken Lund
- b Center for Clinical Epidemiology , Odense University Hospital , Odense , Denmark
| | - Bente Mertz Nørgård
- a Research Unit of Clinical Epidemiology , Institute of Clinical Research, University of Southern Denmark , Odense , Denmark ;,b Center for Clinical Epidemiology , Odense University Hospital , Odense , Denmark
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Clinical Experience of Use of High-dose Intravenous Methylprednisolone in Children With Acute Moderate to Severe Colitis. J Pediatr Gastroenterol Nutr 2016; 63:51-7. [PMID: 26756873 DOI: 10.1097/mpg.0000000000001080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Treatment of acute severe colitis (ASC) has been associated with high morbidity and high colectomy rate in children. In the prebiologics era, our centre used short-term high-dose intravenous corticosteroids (IVCS) at 2 to 30 mg · kg · day. We conducted a retrospective review to compare efficacy of different dosing regimes of IVCS. METHODS Thirty-four children treated with IVCS for ASC were included over 8 years. Patients were studied as 2 groups with similar pretreatment patient characteristics. Group 1 (standard dose) received IVCS at 2 mg · kg · day and group 2 (high dose) received IVCS at 10 to 30 mg · kg · day. Safety, efficacy, and follow-up of the entire cohort for >1 year were studied. The median IVCS dose in the standard- and high-dose cohort was 1.5 mg · kg · day (maximum 60 mg · kg · day) and 24.8 mg · kg · day (maximum 1000 mg · kg · day), respectively. RESULTS Pediatric Ulcerative Colitis Activity Index scores at day 5 were significantly lower in high-dose (15, interquartile range 8.5-20) than in standard-dose IVCS (30, interquartile range 20-30). IVCS side effects were minor and reversible. Overall, medical salvage therapy was required in 5.8% (2 children) before discharge, and in 17% (6 children) at follow-up after 1 year. The colectomy rate of the entire cohort was remarkably low with 0% during admission and 11% (4 children) after 1 year, with a trend of less colectomies in high-dose (4.8%-1 child) than in standard-dose (23%-3 children). CONCLUSIONS Our data show that in paediatric ASC, the short-term use of high-dose IVCS is safe and effective. Prospective studies are needed to define the role of IVCS within salvage therapy protocols.
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Larsen MD, Qvist N, Nielsen J, Kjeldsen J, Nielsen RG, Nørgård BM. Use of Anti-TNFα Agents and Time to First-time Surgery in Paediatric Patients with Ulcerative Colitis and Crohn's Disease. J Crohns Colitis 2016; 10:650-6. [PMID: 26802081 DOI: 10.1093/ecco-jcc/jjw017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/18/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS It is debated whether the need for surgery has changed following introduction of anti-TNFα agents in the treatment of paediatric ulcerative colitis [UC] and Crohn's disease [CD]. We aimed to describe the implementation of anti-TNFα agents in paediatric patients, and the need of first-time surgery before and after introduction of anti-TNFα agents. METHODS In the Danish National Patient Registry, we identified incident paediatric patients diagnosed from 1998. We calculated the proportion of patients receiving anti-TNFα agents within 5 years from diagnosis, and the cumulative 5 year proportion of surgery, according to calendar periods of diagnosis. RESULTS At the end of our study period [2007 and 2008], 29-41% of CD children were treated with anti-TNFα agents within 5 years, and for UC children 17-19%. In 1278 CD patients, the 5 year cumulative proportions of surgery were 14.6-15.6% for children diagnosed in 1998-2008 and 9.7% (95% confidence interval [CI]: 6.7-13.7) for those diagnosed in 2009-2013. In 1468 UC patients, the cumulative proportion of surgery suggested a decline in patients diagnosed after mid 2005, and the hazard ratio of surgery was 0.64 [95% CI: 0.47-0.86] after the introduction of anti-TNFα agents compared with before. For UC patients diagnosed in 2009-2013, the 5 year cumulative proportion of surgery was 7.6% [95% CI: 5.2-11.2]. CONCLUSIONS This nationwide study showed an extensive use of anti-TNFα agents at the end of our study period. For UC children, our data suggest a decline in the proportion of surgery in the period of increasing use of anti-TNFα agents.
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Affiliation(s)
- Michael Due Larsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, DenmarkC
| | - Niels Qvist
- Department of Surgical Gastroenterology A, Odense University Hospital, and Research Unit of Surgery, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, DenmarkC
| | - Jens Kjeldsen
- Department of Medical Gastroenterology S, Odense University Hospital, and Research Unit of Medical Gastroenterology, Institute of Clinical Research, University of Southern Denmark, Odense Denmark
| | - Rasmus Gaardskær Nielsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, and Paediatric Research Unit, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, DenmarkC
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Sifuentes-Dominguez L, Patel AS. Genetics and Therapeutics in Pediatric Ulcerative Colitis: the Past, Present and Future. F1000Res 2016; 5. [PMID: 26973787 PMCID: PMC4776672 DOI: 10.12688/f1000research.7440.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2016] [Indexed: 12/19/2022] Open
Abstract
Ulcerative colitis (UC) is a relapsing and remitting disease with significant phenotypic and genotypic variability. Though more common in adults, UC is being increasingly diagnosed in childhood. The subsequent lifelong course of disease results in challenges for the patient and physician. Currently, there is no medical cure for UC. Even though surgical removal of the colon can be curative, complications including infertility in females make colectomy an option often considered only when the disease presents with life-threatening complications or when medical management fails. One of the greatest challenges the clinician faces in the care of patients with UC is the inability to predict at diagnosis which patient is going to respond to a specific therapy or will eventually require surgery. This therapeutic conundrum frames the discussion to follow, specifically the concept of individualized or personalized treatment strategies based on genetic risk factors. As we move to therapeutics, we will elucidate traditional approaches and discuss known and novel agents. As we look to the future, we can expect increasing integrated approaches using several scientific disciplines to inform how genetic interactions shape and mold the pathogenesis and therapeutics of UC.
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Affiliation(s)
| | - Ashish S Patel
- Children's Health, UT Southwestern Medical Center, Dallas, Texas, USA
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Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease that most often occurs in association with inflammatory bowel disease (IBD). We examined whether the activity or colonic distribution of IBD differed in pediatric patients with and without PSC. METHODS We compared colonic disease distribution, physician global assessment scores, Mayo endoscopic severity scores, IBD-related hospital admissions, and colonic resection surgery rate in a retrospective cohort of pediatric patients with IBD with and without PSC. RESULTS We identified 37 patients with PSC-IBD, and 137 non-PSC matched IBD controls. Pancolitis was seen in 89.7 versus 72.4% (P = 0.051) of patients with PSC-IBD and rectal sparing in 24.3 versus 21.6% (P = 0.721) of patients with IBD. Physician global assessment and Mayo scores at presentation and in follow-up were similar in PSC-IBD and IBD. Patients with PSC-IBD had 0.19 admissions per person-year compared with 0.25 in patients with IBD. The incidence rate ratio for admission was 0.75 (95% confidence interval (CI), 0.51-1.08). The 5-year probability of colonic surgery was 16.4% (95% CI, 7.0-36.0) in patients with PSC-IBD and 24.7% (95% CI, 17.7-33.8) in patients with IBD (P = 0.271). In a multivariate model, male sex (hazard ratio [HR] = 2.2 [95% CI, 1.1-4.3]) and the presence of a non-PSC immune-mediated comorbidity {HR = 3.9 (95% CI, 1.5-10.4), but not PSC (HR = 0.5 [95% CI, 0.2-1.3])} or Crohn's disease (HR = 0.5 [95% CI, 0.1-1.5]), were risk factors for colonic surgery in pediatric IBD. CONCLUSIONS Patients with IBD and PSC were more likely to present with pancolitis, but had similar rates of rectal sparing. Patients with IBD showed similar disease activity across a wide range of measures, at presentation and in follow-up, regardless of the presence of PSC.
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