1
|
Power BD, Kandane-Rathnayake R, Tiller G, Renton WD, Cox A, Johnstone L, Hoi A, Gowdie P. Enrolment of the first paediatric cohort into the Australian lupus registry and biobank: A single-centre experience. Lupus 2024; 33:749-758. [PMID: 38587355 DOI: 10.1177/09612033241244879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
INTRODUCTION We aim to report on the feasibility of establishment of the first paediatric cohort as part of the longitudinal database of the Australian Lupus Registry and Biobank (ALRB) and to describe the enrolment data with a focus on clinical characteristics, serological data, treatment strategies and patient/parent-reported outcome measures. METHODS All patients under the age of 18 years with a diagnosis of systemic lupus erythematosus (SLE) attending the paediatric rheumatology service of a single, tertiary hospital were identified. Patients were enrolled in the ALRB if they met ≥4/11 of the American College of Rheumatology (ACR) 1997 SLE classification criteria or the Systemic Lupus International Collaborating Clinics (SLICC) 2012 classification criteria. Enrolment data including demographics, clinical characteristics, serological profiles, disease activity and damage assessments were recorded. Peds-QL Rheumatology and General Modules were used to assess patient and parent-reported outcomes. RESULTS Twenty-seven patients were eligible for inclusion, with 26 patients (96%) consenting for enrolment. Twenty-five patients (92%) consented for biobanking. Twenty patients (77%) were female. The median age at enrolment was 16 years (interquartile range (IQR) 13.7, 17.4). The median disease duration from diagnosis was 3.2 years (IQR 1.4, 5.3). Sixteen patients (62%) had synovitis, 16 (62%) had cutaneous involvement, 4 (15%) had serositis, 17 (65%) had haematological involvement and 7 (27%) had renal involvement at enrolment. Nineteen patients (73%) were prescribed at least two disease-modifying anti-rheumatic medications (DMARDs). Hydroxychloroquine (n = 22, 85%) and mycophenolate mofetil (n = 9, 35%) were the most commonly prescribed DMARDs. The median SLEDAI-2K score was 2 (IQR 2, 4). Six patients (23%) had active disease (SLEDAI-2K ≥6) at enrolment. Three patients (11.5%) had reported damage using the SLICC/ACR Damage Index. Twenty-three children (88%) and eighteen parents (69%) completed the Paediatric Quality of Life Inventory. Quality of life scores reported across domains of physical, emotional, social and school functioning at enrolment were comparable to previously studied paediatric cohorts with SLE and other chronic diseases. CONCLUSION We have established our centre as the first paediatric participating site of the ALRB, providing contemporary data on the clinical characteristics, serological profile and health-related quality of life outcomes of Australian children with SLE. Paediatric involvement with this national registry will provide a unique perspective for future clinical and scientific research. Collection of Australian-specific paediatric longitudinal data will also enable a broader understanding of SLE within a multicultural Australian population.
Collapse
Affiliation(s)
- Bronwyn D Power
- Department of Paediatric Rheumatology, Monash Children's Hospital, Clayton, VIC, Australia
| | | | - Georgina Tiller
- Department of Paediatric Rheumatology, Monash Children's Hospital, Clayton, VIC, Australia
- Rheumatology Team, Department of General Medicine, The Royal Children's Hospital, Parkville, VIC, Australia
| | - William D Renton
- Department of Paediatric Rheumatology, Monash Children's Hospital, Clayton, VIC, Australia
- Rheumatology Team, Department of General Medicine, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Angela Cox
- Department of Paediatric Rheumatology, Monash Children's Hospital, Clayton, VIC, Australia
- Rheumatology Team, Department of General Medicine, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Lilian Johnstone
- Monash University, Clayton, VIC, Australia
- Department of Paediatric Nephrology, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Alberta Hoi
- Monash University, Clayton, VIC, Australia
- Department of Rheumatology, Monash Health, Clayton, VIC, Australia
| | - Peter Gowdie
- Department of Paediatric Rheumatology, Monash Children's Hospital, Clayton, VIC, Australia
- Monash University, Clayton, VIC, Australia
- Rheumatology Team, Department of General Medicine, The Royal Children's Hospital, Parkville, VIC, Australia
| |
Collapse
|
2
|
Wang L, Li J, Jiang M, Luo Y, Xu X, Li J, Pan Y, Zhang H, Xiao ZXJ, Wang Y. SIRT1 Stabilizes β-TrCP1 to Inhibit Snail1 Expression in Maintaining Intestinal Epithelial Integrity to Alleviate Colitis. Cell Mol Gastroenterol Hepatol 2024; 18:101354. [PMID: 38729522 DOI: 10.1016/j.jcmgh.2024.05.002] [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: 10/30/2023] [Revised: 05/03/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND & AIMS Dysfunction of the intestinal epithelial barrier comprising the junctional complex of tight junctions and adherent junctions leads to increased intestinal permeability, which is a major cause of uncontrolled inflammation related to inflammatory bowel disease (IBD). The NAD+-dependent deacetylase SIRT1 is implicated in inflammation and the pathologic process of IBD. We aimed to elucidate the protective role and underlying mechanism of SIRT1 in cell-cell junction and intestinal epithelial integrity. METHODS The correlation of SIRT1 expression and human IBD was analyzed by GEO or immunohistochemical analyses. BK5.mSIRT1 transgenic mice and wild-type mice were given dextran sodium sulfate (DSS) and the manifestation of colitis-related phenotypes was analyzed. Intestinal permeability was measured by FITC-dextran and cytokines expression was analyzed by quantitative polymerase chain reaction. The expression of the cell junction-related proteins in DSS-treated or SIRT1-knockdown Caco2 or HCT116 cells was analyzed by Western blotting. The effects of nicotinamide mononucleotide in DSS-induced mice colitis were investigated. Correlations of the SIRT1-β-TrCP1-Snail1-Occludin/Claudin-1/E-cadherin pathway with human IBD samples were analyzed. RESULTS Reduced SIRT1 expression is associated with human IBD specimens. SIRT1 transgenic mice exhibit much-reduced manifestations of DSS-induced colitis. The activation of SIRT1 by nicotinamide mononucleotide bolsters intestinal epithelial barrier function and ameliorates DSS-induced colitis in mice. Mechanistically, DSS downregulates SiRT1 expression, leading to destabilization of β-TrCP1 and upregulation of Snail1, accompanied by reduced expression of E-cadherin, Occludin, and Claudin-1, consequently resulting in increased epithelial permeability and inflammation. The deregulated SIRT1-β-TrCP1-Snail1-Occludin/Claudin-1/E-cadherin pathway correlates with human IBD. CONCLUSIONS SIRT1 is pivotal in maintaining the intestinal epithelial barrier integrity via modulation of the β-TrCP1-Snail1-E-cadhein/Occludin/Claudin-1 pathway.
Collapse
Affiliation(s)
- Liang Wang
- Institute of Basic Medicine and Forensic Medicine, North Sichuan Medical College, Nanchong, China; Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China
| | - Jinsong Li
- Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China
| | - Mingshan Jiang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Yue Luo
- Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China
| | - Xiaoke Xu
- Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China
| | - Juan Li
- Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China
| | - Yang Pan
- Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China
| | - Hu Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China.
| | - Zhi-Xiong Jim Xiao
- Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China.
| | - Yang Wang
- Center of Growth, Metabolism and Aging, Key Laboratory of Bio-Resource and Eco-Environment, Ministry of Education, College of Life Sciences, Sichuan University, Chengdu, China.
| |
Collapse
|
3
|
Östensson M, Björkqvist O, Guo A, Størdal K, Halfvarson J, Mårild K, Ludvigsson J. Epidemiology, validation, and clinical characteristics of inflammatory bowel disease: the ABIS birth cohort study. BMC Gastroenterol 2023; 23:199. [PMID: 37291531 DOI: 10.1186/s12876-023-02840-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Birth cohort studies with linked register-based data on inflammatory bowel disease (IBD) provide opportunities to prospectively study early-life determinants of the disease. However, register-based data often lack information on clinical characteristics and rely on diagnostic algorithms. Within the All Babies in Southeast Sweden (ABIS) cohort, we examined the validity of a register-based definition of IBD, its incidence, and clinical and therapeutic characteristics at diagnosis. METHODS We followed 16,223 children from birth (1997-1999) until the end of 2020 for the diagnosis of IBD as defined by a minimum of two diagnostic codes for IBD in the Swedish National Patient Register (NPR). We described the incidence and cumulative incidence of IBD. Through a medical record review of cases diagnosed by the end of 2017, we examined the positive predictive value (PPV) for IBD and described its clinical characteristics and treatment. RESULTS By 2020, at an average age of 22.2 years, 113 participants (0.74%, 95% confidence interval [CI] = 0.61-0.89) had a register-based diagnosis of IBD, corresponding to an incidence of 31.3 per 100,000 person-years of follow-up; the incidence for Crohn's disease (CD) was 11.1 per 100,000 person-years and 15.8 for ulcerative colitis (UC). Of 77 participants with a register-based definition of IBD by the end of 2017, medical records were identified for 61 participants, of whom 57 had true IBD (PPV = 93%; 95%CI = 0.87-1.00). While oral 5-aminosalicylic acid treatment was equally common in newly diagnosed CD and UC patients, biologics were more often used for newly diagnosed CD. The median faecal calprotectin levels were 1206 mg/kg at diagnosis and 93 mg/kg at the last follow-up (P < 0.001). CONCLUSIONS In this population-based sample of Swedish children and young adults the cumulative IBD incidence was 0.74. The validity of register-based definition of IBD was high and supports using such data to identify IBD patients in cohort studies.
Collapse
Affiliation(s)
- Malin Östensson
- Bioinformatics and Data Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olle Björkqvist
- Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Annie Guo
- Department of Paediatrics, Institute of Clinical Science, University of Gothenburg, Gothenburg, Sweden
| | - Ketil Størdal
- Department of Paediatric Research, Faculty of Medicine, University of Oslo, Oslo, Norway
- Children's Centre, Oslo University Hospital, Oslo, Norway
| | - Jonas Halfvarson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karl Mårild
- Department of Paediatrics, Institute of Clinical Science, University of Gothenburg, Gothenburg, Sweden.
- Department of Paediatrics, Queen Silvia Children's Hospital, 416 78, Gothenburg, Sweden.
| | - Johnny Ludvigsson
- Crown Princess Victoria Children's Hospital, Region Östergötland, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Division of Paediatrics, Linköping University, Linköping, Sweden
| |
Collapse
|
4
|
Oliveira CRD, Alvarenga P, Paixão C. Repercussões das Doenças Inflamatórias Intestinais no Desenvolvimento Socioemocional de Pacientes Pediátricos. REVISTA PSICOLOGIA E SAÚDE 2023. [DOI: 10.20435/pssa.v14i3.1803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Este estudo descreve as repercussões dos sintomas das doenças inflamatórias intestinais (DII) nas emoções, na vida escolar e nas interações sociais de pacientes pediátricos. Participaram 20 cuidadores de crianças e adolescentes com idades entre cinco e 17 anos e diagnosticados com alguma DII. Os cuidadores, que tinham entre 26 e 54 anos, forneceram informações clínicas e sociodemográficas e responderam a um questionário sobre as repercussões dos sintomas das DII na vida das crianças e dos adolescentes. A análise das frequências absolutas e relativas e o teste de aderência revelaram que os impactos dos sintomas foram significativamente maiores nas emoções quando comparados aos impactos na vida escolar e nas interações sociais (X² = 6,14; df= 2; p= 0,04). O tratamento das DII deve incluir a construção de planos terapêuticos sensíveis às necessidades psicossociais dos pacientes pediátricos.
Collapse
|
5
|
Lund K, Knudsen T, Kjeldsen J, Nielsen RG, Nørgård BM. Health-Related Quality of Life, Anxiety, and Self-Image in Young Patients With Crohn's Disease and Ulcerative Colitis. JPGN REPORTS 2023; 4:e287. [PMID: 37181920 PMCID: PMC10174745 DOI: 10.1097/pg9.0000000000000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/16/2022] [Indexed: 05/16/2023]
Abstract
We examined health-related quality of life, anxiety, and self-image in patients aged 10-20 years with Crohn's disease (CD) and ulcerative colitis (UC) in remission. These areas are key concerns in clinical care. We used the IMPACT-III for health-related quality of life and The Beck Youth Inventory-II for anxiety and self-image. Linear regression models were used to compare CD to UC. We included 67 patients, 44 (66%) with CD and 23 (34%) with UC. The mean score for IMPACT-III, anxiety, and self-image for CD versus UC was 78 (±SD: 13) versus 78 (±SD: 15), 44 (±SD: 9) versus 45 (±SD: 8), and 10 (±SD: 9) versus 9 (±SD: 6), respectively. We found no difference between CD and UC. Despite remission, we found an elevated score of anxiety and a low score of self-image. When evaluating mental health status, a varied approach may be beneficial for researchers.
Collapse
Affiliation(s)
- Ken Lund
- From the Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Torben Knudsen
- Department of Medicine, Hospital of Southwest Jutland, Esbjerg, Denmark
- Department of Regional Health Science, University of Southern Denmark, Esbjerg, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastroenterology S, Odense University Hospital, Odense, Denmark
- Research Unit of Medical Gastroenterology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rasmus Gaardskær Nielsen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Research Unit of Pediatrics, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- From the Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
6
|
Ahmed S, Alam S, Alsabri M. Health-Related Quality of Life in Pediatric Inflammatory Bowel Disease Patients: A Narrative Review. Cureus 2022; 14:e29282. [PMID: 36277571 PMCID: PMC9578282 DOI: 10.7759/cureus.29282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 12/02/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic autoimmune condition that can have a wide range of symptoms among pediatric patients. Although clinical symptoms like hematochezia, diarrhea, and abdominal pain are commonly addressed, health-related quality of life (HRQOL) is often overlooked in patients with IBD and pediatric patients with chronic disease in general. Examining HRQOL can help improve patient outcomes, but it has been studied sparingly. In this review, we aim to compare HRQOL between pediatric patients suffering from IBD and healthy children, as well as those suffering from other illnesses. We searched through peer-reviewed primary literature related to IBD and HRQOL and selected 10 articles from the PubMed database to be reviewed. Our inclusion criteria included articles published after the year 2000 in English, primary studies, and those that corresponded to the aim of this review. Case reports and secondary and tertiary articles were excluded from our review. We found that patients with IBD reported worse HRQOL in terms of overall health and in various subdomains, including physical health and fatigue, compared to their healthy counterparts. However, children with IBD demonstrated a comparable HRQOL with children suffering from functional abdominal pain (FAP) and obesity. Additionally, children with IBD displayed a greater HRQOL than pediatric patients with gastroesophageal reflux disease (GERD) and chronic constipation. In addressing the aim of this review, we found that children with IBD had a lower HRQOL when compared to healthy children, but a comparable or greater HRQOL than other sick children. Some factors associated with a reduced HRQOL include disease activity, age, fatigue, gender, psychological variables, and associated symptoms. Going forward, HRQOL should be considered by practitioners when caring for pediatric IBD patients in a clinical setting as it can help improve patient care. More studies need to be conducted to further explore HRQOL in pediatric patients. This can help implement early psychosocial interventions in children to reduce the disease burden.
Collapse
|
7
|
Alhadab AA, AlMahamed SN, Hassan IE, Hammo AH. The impact of inflammatory bowel diseases on the quality of life of Saudi pediatric patients: A cross-sectional study. Saudi J Gastroenterol 2022; 28:448-455. [PMID: 35946259 PMCID: PMC9843516 DOI: 10.4103/sjg.sjg_162_22] [Citation(s) in RCA: 1] [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] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is a chronic gastrointestinal tract disorder characterized by periods of exacerbations and remissions that affect multiple aspects of a pediatric patient's quality of life. The purpose of this study is to describe the health-related quality of life of Saudi pediatric IBD patients and to determine the influencing factors which can affect it. METHODS This is a single center cross-sectional descriptive study, conducted between December 2019 and December 2021. Patients aged between 9 and 16 years diagnosed with IBD were included; IMPACT III quality of life questionnaire was used. RESULTS Thirty-eight patients participated in the study, 57.9 % being male, with a mean age of 12.48 ± 2.72 years, and 55.3 % of patients were diagnosed with Crohn's disease (CD). The most frequent medications were aminosalicylic acids derivatives, followed by immune-modulators and biologics. The IMPACT III quality of life questionnaire has shown lower scores in IBD patients in comparison to healthy control groups. Patients with active disease have lower total and sub-domain scores than patients with inactive disease. We found no correlation between health-related quality of life (HrQOL) and the number of medications used, disease duration, or gender. CONCLUSIONS Pediatric IBD patients have significantly lower HrQOL scores than healthy children. Disease activity was found to be a predictor for poor HrQOL outcome.
Collapse
Affiliation(s)
- Abdulhamid A. Alhadab
- Department of Pediatric, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Shaden N. AlMahamed
- Department of Pediatric, Section of Pediatric Gastroenterology, Burjeel Specialty Hospital, Sharjah, United Arab Emirates
| | - Ibrahim E. Hassan
- Department of Pediatric, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Abdelhai H. Hammo
- Department of Pediatric, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, King Fahad Specialist Hospital, Dammam, Saudi Arabia,Address for correspondence: Dr. Abdelhai H. Hammo, Department of Pediatric, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, King Fahad Specialist Hospital, Dammam, Saudi Arabia. E-mail:
| |
Collapse
|
8
|
Holbein CE, Plevinsky J, Patel T, Conrad MC, Kelsen JR. Pediatric Global Health in Children with Very Early-Onset Inflammatory Bowel Disease. J Pediatr Psychol 2021; 46:747-756. [PMID: 34313785 DOI: 10.1093/jpepsy/jsab035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Children with very early-onset inflammatory bowel disease (VEO-IBD) represent a distinct group of patients with IBD with unique phenotypic and genetic characteristics; however, they are frequently omitted from psychosocial research. This study used a novel, brief measure of pediatric global health to assess (1) overall health-related quality of life (HRQOL) in children with VEO-IBD, (2) HRQOL compared to healthy children, and (3) whether gastrointestinal symptoms account for the differences in HRQOL between these groups. METHODS Caregivers of 51 children with VEO-IBD (Mage = 4.26 years, 75% male) and 54 healthy children (Mage = 3.50 years, 54% male) completed the PROMIS Pediatric Global Health Scale (PGH-7) parent-proxy form to assess HRQOL and a questionnaire assessing gastrointestinal symptoms. Descriptive statistics, analysis of variance with covariates (ANCOVA), and meditation analyses with bootstrapping were conducted. RESULTS Caregivers of children with VEO-IBD rated their HRQOL as relatively positive, although children with greater disease yielded lower ratings on some PGH-7 items (e.g., fun with friends, physical health, sadness). Compared to healthy youth, children with VEO-IBD scored lower on the PGH-7, with significantly lower item-level scores on overall health, physical health, mental health, and quality of life. Gastrointestinal symptoms mediated the association between health status (i.e., VEO-IBD vs. healthy) and HRQOL, αβ = -2.84, 95% CI = -5.70, -0.34. CONCLUSIONS While some children with VEO-IBD are at risk for deficits in HRQOL, many are quite resilient. Psychosocial screening is necessary for providing appropriate referrals to behavioral health services and learning more about psychosocial adjustment in children with VEO-IBD.
Collapse
Affiliation(s)
- Christina E Holbein
- Department of Child & Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia
| | - Jill Plevinsky
- Department of Child & Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia.,Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Trusha Patel
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
| | - Maire C Conrad
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
| | - Judith R Kelsen
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania
| |
Collapse
|