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Turner A, Huth K, Luff D, Zendejas B, Newman LR, Leichtner AM. Lack of standardization and faculty development in pediatric colonoscopy: A qualitative study. J Pediatr Gastroenterol Nutr 2024; 78:948-956. [PMID: 38591669 DOI: 10.1002/jpn3.12100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 04/10/2024]
Abstract
A standard curriculum for pediatric colonoscopy training has neither been required nor universally implemented in North American fellowship programs. This qualitative study assessed the needs of colonoscopy training in pediatric gastroenterology to determine the standardized components of procedural teaching. Focus groups with pediatric gastroenterology attendings, fellows, procedural nurses, and interviews with advanced endoscopists, all practicing at a single institution, were conducted between March and June 2018. Data were analyzed using thematic analysis principles. Four themes emerged: (1) lack of standardization of colonoscopy performance, (2) lack of professional development of procedure teaching skills, (3) need for teaching behaviors that promote learner's performance, and (4) barriers to effective teaching and learning. A conceptual framework was created for developing a standardized "train-the-trainer" curriculum. Our needs assessment supports expansion of efforts to make this comprehensive training available to all pediatric gastroenterologists involved in procedure teaching.
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Affiliation(s)
- Amy Turner
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Huth
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Luff
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital Simulator Program, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Zendejas
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lori R Newman
- Department of Education, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alan M Leichtner
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Winn AS, Huth K, Leichtner AM, Newman LR. Beyond the Workshop: Results From a Longitudinal, Interprofessional Teaching Certificate Program. J Med Educ Curric Dev 2023; 10:23821205231205433. [PMID: 37799299 PMCID: PMC10548803 DOI: 10.1177/23821205231205433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/18/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES While most hospital-based, healthcare professionals are expected to teach and supervise, few receive training in education. We designed, implemented, and evaluated an interprofessional, hospital-based teaching certificate program based on experiential learning and reflective practice for healthcare professionals with little or no formal training in education. METHODS Participants attended educational seminars; incorporated new concepts, skills, and behaviors in their teaching; and submitted written reflections. Participants also met with an education coach, received feedback from a trained observer, and observed a "master teacher." We used descriptive statistics to analyze a survey distributed to the 2017-2019 cohort. We also analyzed written reflections to determine whether participants described a new teaching skill, concept, or behavior, and how they applied these to their teaching. RESULTS Survey completion rate was 15/20 (75%). Participants described feeling connected to an educator community, establishing educational alliances with senior educators, and learning teaching strategies from other certificate members outside their own profession. Participants indicated they are more likely to pursue educational innovation, leadership, and scholarship. In the reflections, 88% described incorporating a new concept in their teaching. CONCLUSION Participants in an interprofessional teaching certificate program engaged in a curriculum of professional development in education. Graduates of the program reported knowledge gain, behavior change, and establishment of educational alliances and a community of practice.
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Affiliation(s)
- Ariel S Winn
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Kathleen Huth
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Alan M Leichtner
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Education, Boston Children's Hospital, Boston, MA, USA
| | - Lori R Newman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Education, Boston Children's Hospital, Boston, MA, USA
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Ward VL, Tennermann NW, Chuersanga G, Melvin P, Milstein ME, Finkelstein JA, Garvin MM, Wood LJ, Rauscher NA, Laussen PC, Leichtner AM, Emans SJ, Churchwell KB. Creating a health equity and inclusion office in an academic pediatric medical center: priorities addressed and lessons learned. Pediatr Radiol 2022; 52:1776-1785. [PMID: 35229182 PMCID: PMC8885314 DOI: 10.1007/s00247-022-05283-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 11/21/2021] [Accepted: 01/10/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Over the last two decades, medical schools and academic health centers have acknowledged the persistence of health disparities in their patients and the lack of diversity in their faculty, leaders and extended workforce. We established an Office of Health Equity and Inclusion (OHEI) at our pediatric academic medical center after a thorough evaluation of prior diversity initiatives and review of faculty development data. OBJECTIVE To describe the lessons learned at a pediatric academic medical center in prioritizing and implementing health equity, diversity and inclusion (EDI) initiatives in creating the OHEI. MATERIALS AND METHODS We reviewed internal administrative data and faculty development data, including data related to faculty who are underrepresented in medicine, to understand the role of our EDI initiatives in the strategic priorities addressed and lessons learned in the creation of the OHEI. RESULTS The intentional steps taken in our medical center's strategic approach in the creation of this office led to four important lessons to improve pediatric health equity: (1) board, senior executive and institutional prioritization of EDI initiatives; (2) multi-specialty and interprofessional collaboration; (3) academic approach to EDI programmatic development; and (4) intentionality with accountability in all EDI initiatives. CONCLUSION The key lessons learned during the creation of an Office of Health Equity and Inclusion can provide guidance to other academic health centers committed to implementing institutional priorities that focus their EDI initiatives on the improvement of pediatric health equity.
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Affiliation(s)
- Valerie L Ward
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA.
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Nicole W Tennermann
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
| | - Geeranan Chuersanga
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
| | - Patrice Melvin
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA, USA
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, MA, USA
| | - Maxine E Milstein
- Office of Faculty Development, Boston Children's Hospital, Boston, MA, USA
| | - Jonathan A Finkelstein
- Harvard Medical School, Boston, MA, USA
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Michele M Garvin
- Office of General Counsel, Boston Children's Hospital, Boston, MA, USA
| | - Laura J Wood
- Nursing and Patient Care Operations, Boston Children's Hospital, Boston, MA, USA
| | - Nina A Rauscher
- Department of Health Affairs, Boston Children's Hospital, Boston, MA, USA
| | - Peter C Laussen
- Harvard Medical School, Boston, MA, USA
- Department of Health Affairs, Boston Children's Hospital, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Alan M Leichtner
- Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Division of Gastroenterology, Boston Children's Hospital, Boston, MA, USA
- Department of Education, Boston Children's Hospital, Boston, MA, USA
| | - S Jean Emans
- Harvard Medical School, Boston, MA, USA
- Office of Faculty Development, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Kevin B Churchwell
- Harvard Medical School, Boston, MA, USA
- Office of the CEO and President, Boston Children's Hospital, Boston, MA, USA
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4
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Veeraraghavan G, Therrien A, Degroote M, McKeown A, Mitchell PD, Silvester JA, Leffler DA, Leichtner AM, Kelly CP, Weir DC. Non-responsive celiac disease in children on a gluten free diet. World J Gastroenterol 2021; 27:1311-1320. [PMID: 33833484 PMCID: PMC8015304 DOI: 10.3748/wjg.v27.i13.1311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/04/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Non-responsive celiac disease (NRCD) is defined as the persistence of symptoms in individuals with celiac disease (CeD) despite being on a gluten-free diet (GFD). There is scant literature about NRCD in the pediatric population.
AIM To determine the incidence, clinical characteristics and underlying causes of NRCD in children.
METHODS Retrospective cohort study performed at Boston Children’s Hospital (BCH). Children < 18 years diagnosed with CeD by positive serology and duodenal biopsies compatible with Marsh III histology between 2008 and 2012 were identified in the BCH’s Celiac Disease Program database. Medical records were longitudinally reviewed from the time of diagnosis through September 2015. NRCD was defined as persistent symptoms at 6 mo after the initiation of a GFD and causes of NRCD as well as symptom evolution were detailed. The children without symptoms at 6 mo (responders) were compared with the NRCD group. Additionally, presenting signs and symptoms at the time of diagnosis of CeD among the responders and NRCD patients were collected and compared to identify any potential predictors for NRCD at 6 mo of GFD therapy.
RESULTS Six hundred and sixteen children were included. Ninety-one (15%) met criteria for NRCD. Most were female (77%). Abdominal pain [odds ratio (OR) 1.8 95% confidence interval (CI) 1.1-2.9], constipation (OR 3.1 95%CI 1.9-4.9) and absence of abdominal distension (OR for abdominal distension 0.4 95%CI 0.1-0.98) at diagnosis were associated with NRCD. NRCD was attributed to a wide variety of diagnoses with gluten exposure (30%) and constipation (20%) being the most common causes. Other causes for NRCD included lactose intolerance (9%), gastroesophageal reflux (8%), functional abdominal pain (7%), irritable bowel syndrome (3%), depression/anxiety (3%), eosinophilic esophagitis (2%), food allergy (1%), eating disorder (1%), gastric ulcer with Helicobacter pylori (1%), lymphocytic colitis (1%), aerophagia (1%) and undetermined (13%). 64% of children with NRCD improved on follow-up.
CONCLUSION NRCD after ≥ 6 mo GFD is frequent among children, especially females, and is associated with initial presenting symptoms of constipation and/or abdominal pain. Gluten exposure is the most frequent cause.
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Affiliation(s)
- Gopal Veeraraghavan
- Division of Gastro-enterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, United States
- The Celiac Center, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, United States
| | - Amelie Therrien
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, United States
- The Celiac Center, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, United States
| | - Maya Degroote
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, United States
| | - Allison McKeown
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, United States
| | - Paul D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA 02115, United States
| | - Jocelyn A Silvester
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, United States
- The Celiac Center, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, United States
| | - Daniel A Leffler
- The Celiac Center, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, United States
- Gastrointestinal Therapeutics, Takeda Pharmaceutical International Co, Cambridge, MA 02139, United States
| | - Alan M Leichtner
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, United States
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, United States
| | - Ciaran P Kelly
- The Celiac Center, Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, United States
| | - Dascha C Weir
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA 02115, United States
- Celiac Research Program, Harvard Medical School, Boston, MA 02115, United States
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Newman LR, Truog RD, Armstrong EG, Hatem CJ, Leichtner AM. Use of Nazi torture device image in digital scholarship article . Med Teach 2020; 42:717-718. [PMID: 32286107 DOI: 10.1080/0142159x.2020.1749251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Blansky BA, Hintze ZJ, Alhassan E, Leichtner AM, Weir DC, Silvester JA. Lack of Follow-up of Pediatric Patients With Celiac Disease. Clin Gastroenterol Hepatol 2019; 17:2603-2604. [PMID: 30597204 PMCID: PMC6599537 DOI: 10.1016/j.cgh.2018.12.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/13/2018] [Accepted: 12/18/2018] [Indexed: 02/07/2023]
Abstract
Celiac disease (CD) is often diagnosed in childhood, and the treatment is a lifelong gluten-free diet (GFD).1,2 It may take several years to gain competence in the skills required to follow a GFD successfully. Inadequately treated CD is associated with bone fractures, nutritional deficiencies, and lymphoma.3,4 Healthcare providers are key resources for patients with CD. Consultation with a dietitian with GFD expertise at diagnosis and annual disease-specific follow-up care are recommended.2,5 The primary objective of this study was to evaluate adherence to guidelines for dietitian consultation and follow-up for children with CD. A secondary objective was to identify factors associated with loss to follow-up.
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Affiliation(s)
- Bradley A. Blansky
- Harvard Celiac Disease Program, Boston, MA,Boston Children’s Hospital, Harvard Medical School, Boston, MA,Boston University, Boston, MA
| | - Zackary J. Hintze
- Harvard Celiac Disease Program, Boston, MA,Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Eaman Alhassan
- Harvard Celiac Disease Program, Boston, MA,Department of Medicine, West Virginia University, Morgantown, WV,Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alan M. Leichtner
- Harvard Celiac Disease Program, Boston, MA,Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Dascha C. Weir
- Harvard Celiac Disease Program, Boston, MA,Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Jocelyn A. Silvester
- Harvard Celiac Disease Program, Boston, MA,Boston Children’s Hospital, Harvard Medical School, Boston, MA,Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA,Rady College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB
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Kazmerski TM, Nelson EB, Newman LR, Haviland MJ, Luff D, Leichtner AM, Hayes MM, Miller E, Emans SJ, Sawicki GS. Interprofessional provider educational needs and preferences regarding the provision of sexual and reproductive health care in cystic fibrosis. J Cyst Fibros 2019; 18:671-676. [PMID: 30795973 DOI: 10.1016/j.jcf.2019.01.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sexual and reproductive health (SRH) is an important disease-specific concern for adolescent and young adult (AYA) women that is not consistently addressed in cystic fibrosis (CF) centers. This study identifies educational needs and preferences of interprofessional CF providers regarding SRH in AYA women with CF. METHODS Interprofessional CF providers participated in an anonymous survey regarding general and CF-specific SRH knowledge and skills, factors for optimizing SRH care, and preferred approaches for SRH training. We calculated descriptive statistics for all respondents and stratified by provider type. RESULTS A total of 523 providers completed the survey (39% physicians/advanced practice providers, 19% nurses, 20% social workers, and 22% other disciplines). Half reported comfort responding to female AYA SRH concerns; however, only one-third were comfortable asking appropriate questions and confident taking a sexual history. Only 29% were comfortable with their current CF-specific SRH knowledge. Respondents' preferred SRH topics for further training included: pregnancy/parenthood planning, sexual functioning, urinary incontinence, intimate partner violence, and taking a sexual history. Nearly two-thirds felt having connection to women's health specialists familiar with CF would facilitate SRH care. Approximately one-third desired SRH educational materials for providers to view at point-of-care or through online case-based learning; <10% were interested in role playing SRH skills. CONCLUSION Many interprofessional CF providers lack comfort and skills in addressing SRH with AYA women with CF. Provider training needs and approaches identified in this study can be used to develop tailored educational interventions to improve comprehensive CF care.
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Affiliation(s)
- Traci M Kazmerski
- Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; Center for Women's Health Research and Innovation (CWHRI), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.
| | - Eliza B Nelson
- Division of Respiratory Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America
| | - Lori R Newman
- Department of Medical Education, Boston Children's Hospital, Boston, MA, United States of America
| | - Miriam J Haviland
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Donna Luff
- Department of Medical Education, Boston Children's Hospital, Boston, MA, United States of America
| | - Alan M Leichtner
- Department of Medical Education, Boston Children's Hospital, Boston, MA, United States of America
| | - Margaret M Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America; Center for Women's Health Research and Innovation (CWHRI), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - S Jean Emans
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America
| | - Gregory S Sawicki
- Division of Respiratory Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States of America
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Silvester JA, Faucher EA, McCarty CE, Kalansky A, Hintze ZJ, Mitchell PD, Goldsmith JD, Weir DC, Leichtner AM. Red Spot Lesions in the Duodenal Bulb Are a Highly Specific Endoscopic Sign of Celiac Disease: A Prospective Study. J Pediatr Gastroenterol Nutr 2019; 68:251-255. [PMID: 30247425 PMCID: PMC6344298 DOI: 10.1097/mpg.0000000000002158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We have recognized red spot lesions (RSLs) in the duodenal bulb in children with celiac disease (CD) and believe they may represent an underappreciated and distinct endoscopic sign of CD. A total of 171 pediatric patients undergoing esophagogastroduodenoscopy with duodenal biopsy for symptoms consistent with CD were prospectively recruited. There were 75 patients who met criteria for CD and the remaining 96 patients served as symptomatic controls. As compared to endoscopic markers frequently mentioned in literature, RSLs had comparable sensitivity, specificity, positive predictive value, and negative predictive value of 31%, 94%, 80%, and 64%, respectively. If RSLs are noted during endoscopy in a patient with gastrointestinal symptoms that might be the result of CD, then sufficient duodenal biopsies to make the diagnosis of CD should be obtained.
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Affiliation(s)
- Jocelyn A. Silvester
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
- University of Manitoba, Winnipeg MB, CA
| | | | | | - Adie Kalansky
- Department of Internal Medicine; The Jewish Hospital of Cincinnati, Cincinnati, OH
| | - Zackary J. Hintze
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Paul D. Mitchell
- Institutional Centers for Clinical and Translational Research; Boston Children’s Hospital, Boston, MA
| | | | - Dascha C. Weir
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Alan M. Leichtner
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Boston, MA
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Gooding HC, McCarty C, Millson R, Jiang H, Armstrong E, Leichtner AM. The Boston Children's Hospital Academy: Development and Initial Assessment of a Hospital-Based Teaching Academy. Acad Med 2016; 91:1651-1654. [PMID: 26760057 DOI: 10.1097/acm.0000000000001095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PROBLEM Medical education academies play an important role in the recognition and career advancement of educators. However, hospital-based clinical faculty have unique professional development needs that may not be met by medical-school-based academies. APPROACH The Boston Children's Hospital Academy was founded in 2008 to serve the needs of its clinician-educators. It was open to junior faculty scholars and to senior faculty scholars and mentors, including interprofessional educators. To maintain membership, individuals must propose and work toward an education project or serve as a project mentor. In 2012, a survey was sent to all members, and annual project reports were reviewed to assess the academy's impact. OUTCOMES Sixty-five members completed the survey. The majority agreed that the academy created a community of educators, provided opportunities for networking and scholarship, contributed to their personal identity as an educator, and led to recognition by their chief. Projects addressed curriculum development, faculty development, learner assessment, program assessment, and resource development. They largely focused on graduate medical education and on patient safety and quality. During their tenure in the academy (mean length of membership = 2.4 years), members produced an average of 4.4 education presentations and 1.9 education publications, and 11 members were promoted. NEXT STEPS A hospital-based academy provides opportunities for interprofessional faculty development. Next steps include increasing interprofessional membership, wider dissemination of members' successes, better integration with the hospital's mission, specifically regarding graduate medical education and patient safety, and additional evaluation of the academy's impact on project completion and members' accomplishments.
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Affiliation(s)
- Holly C Gooding
- H.C. Gooding is assistant professor of pediatrics and medicine, Harvard Medical School, and Boston Children's Hospital, Boston, Massachusetts. C. McCarty is clinical research associate, Massachusetts General Hospital Cancer Center, Boston, Massachusetts. R. Millson is senior administrative associate, Boston Children's Hospital, Boston, Massachusetts. H. Jiang is principal biostatistician, Boston Children's Hospital Clinical Research Center, Boston, Massachusetts. E. Armstrong is clinical professor of pediatrics, Harvard Medical School, Boston, Massachusetts. A.M. Leichtner is associate professor of pediatrics, Harvard Medical School, and Boston Children's Hospital, Boston, Massachusetts
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Mallon D, Vernacchio L, Leichtner AM, Kerfoot BP. 'Constipation Challenge' game improves guideline knowledge and implementation. Med Educ 2016; 50:589-590. [PMID: 27072479 DOI: 10.1111/medu.13035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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11
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Zeissig S, Petersen BS, Tomczak M, Melum E, Huc-Claustre E, Dougan SK, Laerdahl JK, Stade B, Forster M, Schreiber S, Weir D, Leichtner AM, Franke A, Blumberg RS. Early-onset Crohn's disease and autoimmunity associated with a variant in CTLA-4. Gut 2015; 64:1889-97. [PMID: 25367873 PMCID: PMC4512923 DOI: 10.1136/gutjnl-2014-308541] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/09/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE IBD is a group of complex, systemic disorders associated with intestinal inflammation and extraintestinal manifestations. Recent studies revealed Mendelian forms of IBD, which contributed significantly to our understanding of disease pathogenesis and the heritability of IBD. DESIGN We performed exome sequencing in a family with Crohn's disease (CD) and severe autoimmunity, analysed immune cell phenotype and function in affected and non-affected individuals, and performed in silico and in vitro analyses of cytotoxic T lymphocyte-associated protein 4 (CTLA-4) structure and function. RESULTS A novel missense variant was identified in CTLA4 encoding CTLA-4, a coinhibitory protein expressed by T cells and required for regulation of T cell activation. The residue affected by the mutation, CTLA-4 Tyr60, is evolutionarily highly conserved, and the identified Y60C variant is predicted to affect protein folding and structural stability and demonstrated to cause impaired CTLA-4 dimerisation and CD80 binding. Intestinal inflammation and autoimmunity in carriers of CTLA-4 Y60C exhibit incomplete penetrance with a spectrum of clinical presentations ranging from asymptomatic carrier status to fatal autoimmunity and intestinal inflammation. In a clinically affected CTLA-4 Y60C carrier, T cell proliferation was increased in vitro and associated with an increased ratio of memory to naive T cells in vivo, consistent with impaired regulation of T cell activation. CONCLUSIONS Our results support the concept that variants in CTLA4 provide the basis for a novel Mendelian form of early-onset CD associated with systemic autoimmunity. Incomplete penetrance of autoimmunity further indicates the presence of other genetic and/or environmental modifiers.
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Affiliation(s)
- Sebastian Zeissig
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Kiel, Kiel, Germany,Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Britt-Sabina Petersen
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Michal Tomczak
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Espen Melum
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Norwegian PSC Research Center, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,K.G. Jebsen Inflammation Research Centre, Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Emilie Huc-Claustre
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Kiel, Kiel, Germany
| | - Stephanie K Dougan
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon K Laerdahl
- Department of Microbiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Bioinformatics Core Facility, Department of Informatics, University of Oslo, Oslo, Norway
| | - Björn Stade
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Michael Forster
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Stefan Schreiber
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Kiel, Kiel, Germany,Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Dascha Weir
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Alan M Leichtner
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Richard S Blumberg
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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Mallon D, Vernacchio L, Trudell E, Antonelli R, Nurko S, Leichtner AM, Lightdale JR. Shared care: a quality improvement initiative to optimize primary care management of constipation. Pediatrics 2015; 135:e1300-7. [PMID: 25896837 PMCID: PMC4411778 DOI: 10.1542/peds.2014-1962] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children's Hospital and the Pediatric Physician's Organization at Children's (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. METHODS We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children's Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. RESULTS Fewer active patients in the sample were referred after implementation (61/27,365 [0.22%] vs 90/27,792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals. CONCLUSIONS A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration.
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Affiliation(s)
- Daniel Mallon
- Divisions of Gastroenterology, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
| | - Louis Vernacchio
- General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Pediatric Physicians’ Organization at Children’s, Brookline, Massachusetts; and
| | - Emily Trudell
- Pediatric Physicians’ Organization at Children’s, Brookline, Massachusetts; and
| | - Richard Antonelli
- General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Samuel Nurko
- Divisions of Gastroenterology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alan M. Leichtner
- Divisions of Gastroenterology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jenifer R. Lightdale
- Divisions of Gastroenterology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Division of Pediatric Gastroenterology, University of Massachusetts Memorial Children’s Medical Center, Worcester, Massachusetts
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13
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Tanpowpong P, Obuch JC, Jiang H, McCarty CE, Katz AJ, Leffler DA, Kelly CP, Weir DC, Leichtner AM, Camargo CA. Multicenter study on season of birth and celiac disease: evidence for a new theoretical model of pathogenesis. J Pediatr 2013; 162:501-4. [PMID: 23084709 DOI: 10.1016/j.jpeds.2012.08.056] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 07/12/2012] [Accepted: 08/31/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate whether season of birth is associated with celiac disease (CD). STUDY DESIGN We performed a medical record review of 1964 patients with biopsy-proven CD at 3 teaching hospitals (2 pediatric centers and 1 adult center) between 2000 and 2010. The first positive small intestinal biopsy result defined age of diagnosis. The observed proportions of births in each season (spring [March-May], summer [June-August], fall [September-November], and winter [December-February]) were compared with the expected proportions using binomial probability tests. RESULTS The mean age at diagnosis was 9.8 ± 5.0 years in the 2 pediatric centers and 43.6 ± 15.8 years in the adult center. The cohort was predominately female (69%). Overall, more patients were born in spring (27%) than in any other season: summer (25%), fall (25%), and winter (23%). In patients diagnosed before age 15 years, the spring birth excess was present in boys (33%; P = .0005), but not in girls (26%; P = .43). The sex difference in season of birth was less striking in patients with CD diagnosed at age ≥15 years. CONCLUSION Season of birth is an environmental risk factor for CD, particularly in boys diagnosed before age 15 years. The results are consistent with a new theoretical model that integrates potential environmental factors (eg, gluten introduction, ultraviolet-B exposure, vitamin D status) and acute viral gastrointestinal infections in early childhood.
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Affiliation(s)
- Pornthep Tanpowpong
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital for Children, Boston, MA 02114, USA
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14
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Leichtner AM, Gillis LA, Gupta S, Heubi J, Kay M, Narkewicz MR, Rider EA, Rufo PA, Sferra TJ, Teitelbaum J. NASPGHAN guidelines for training in pediatric gastroenterology. J Pediatr Gastroenterol Nutr 2013; 56 Suppl 1:S1-8. [PMID: 23263531 DOI: 10.1097/mpg.0b013e31827a78d6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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15
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Najarian RM, Hait EJ, Leichtner AM, Glickman JN, Antonioli DA, Goldsmith JD. Clinical significance of colonic intraepithelial lymphocytosis in a pediatric population. Mod Pathol 2009; 22:13-20. [PMID: 19116628 DOI: 10.1038/modpathol.2008.139] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The significance of colonic intraepithelial lymphocytosis has been well described in adults, and is associated with lymphocytic colitis, untreated celiac disease, and medications, among others. Little is known about the meaning of colonic intraepithelial lymphocytosis in the pediatric population; this study examines this finding in a cohort of children. Twenty patients in whom colonic intraepithelial lymphocytosis was a prominent feature were identified from 1999 to 2005. Colonic intraepithelial lymphocytosis was defined as 20 or more intraepithelial lymphocytes per 100 colonocytes present in at least one colonic mucosal biopsy. Each biopsy was examined for numbers of intraepithelial lymphocytes per 100 surface and crypt colonocytes; various architectural, inflammatory, and metaplastic changes were also noted. When available, concurrent duodenal and/or ileal biopsies were examined. Studied clinical parameters included indications for biopsy, clinical follow-up, final diagnosis, comorbidities, autoimmune serologies, and medications. A total of 121 colonic mucosal biopsies were examined in 20 patients who ranged from 1 to 17 years (mean 10.2 years; 40% male). Common indications for endoscopy included diarrhea and abdominal pain. A mean of 29 (+/-22) intraepithelial lymphocytes per 100 enterocytes were seen. Seven patients had colonic intraepithelial lymphocytosis as the only histologic finding. The remaining 13 patients had additional architectural, inflammatory, and metaplastic changes. The mean follow-up period was 14 months (range 1-48 months). Inflammatory bowel disease was diagnosed in 4 of 20 patients and was seen chiefly in biopsies in which colonic intraepithelial lymphocytosis was associated with architectural or inflammatory changes. Common disease associations include celiac disease, lymphocytic colitis, and autoimmune enteropathy. Pediatric colonic intraepithelial lymphocytosis, in the absence of other histologic findings, is associated with various diseases, including celiac disease, lymphocytic colitis, and autoimmune enteropathy. Colonic intraepithelial lymphocytosis in the presence of other inflammatory changes indicates the possibility of idiopathic inflammatory bowel disease. These findings are similar to those seen in adults, with the exception of autoimmune enteropathy.
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Affiliation(s)
- Robert M Najarian
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA
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16
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Dehlink E, Yen E, Leichtner AM, Hait EJ, Fiebiger E. First evidence of a possible association between gastric acid suppression during pregnancy and childhood asthma: a population-based register study. Clin Exp Allergy 2008; 39:246-53. [PMID: 19134022 DOI: 10.1111/j.1365-2222.2008.03125.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Recent data in mice suggest that acid suppression during pregnancy yields offspring with type 2 T helper-dominant immunity, suggesting a predisposition for allergy. OBJECTIVE To determine the association of in utero exposure to acid-suppressive medications and the subsequent development of allergic diseases in children. METHODS We studied a population-based observational cohort formed by linking data from three Swedish national healthcare registers: the Medical Birth Register, the Hospital Discharge Register, and the Swedish Prescribed Drug Register. Main outcome measures included a hospital discharge diagnosis of an allergic disease or prescription for asthma medications, epinephrine auto-injectors, antihistamines or steroid ointments in children. Data were analysed using the Mantel-Haenszel procedure. RESULTS Twenty-nine thousand four hundred and ninety (5.03%) children had a discharge diagnosis of allergy or prescriptions for allergy medications. Five thousand six hundred and forty-five (0.96%) children had been exposed to acid suppression therapy during pregnancy; of these, 405 (0.07%) were treated for allergic diseases. Exposure to acid-suppressive medications in utero was associated with an increased odds ratio (OR) for developing allergy (OR 1.43, 95% confidence interval (95% CI) 1.29-1.59). We observed this association irrespective of the type of drug, time of exposure during pregnancy, and maternal history of allergy. The use of maternal acid-suppressive medication was associated with an increased OR for the development of childhood asthma (3.7% in the population at large vs. 5.6% in exposed children, OR 1.51, 95% CI 1.35-1.69), but not for other allergic diseases. CONCLUSION These data provide first evidence of a significant association between in utero exposure to acid-suppressive drugs and the risk of developing childhood asthma.
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Affiliation(s)
- E Dehlink
- Division of Gastroenterology and Nutrition, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
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17
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Leichtner AM. Fellowship training in pediatric gastroenterology in the United States: where are we going? Does one size fit all? J Pediatr Gastroenterol Nutr 2008; 47:274-6. [PMID: 18728520 DOI: 10.1097/mpg.0b013e31816dd2a3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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18
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El-Hallak M, Binstadt BA, Leichtner AM, Bennett CM, Neufeld EJ, Fuhlbrigge RC, Zurakowski D, Sundel RP. Clinical effects and safety of rituximab for treatment of refractory pediatric autoimmune diseases. J Pediatr 2007; 150:376-82. [PMID: 17382113 DOI: 10.1016/j.jpeds.2006.10.067] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Revised: 08/19/2006] [Accepted: 10/19/2006] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the safety, tolerability, and clinical effects of rituximab, an anti-CD20 monoclonal antibody, in the treatment of severe pediatric autoimmune diseases. STUDY DESIGN We reviewed the records of 10 patients treated with rituximab for severe, refractory autoimmune diseases at a single tertiary care children's hospital. Adverse events as well as treatment effects were recorded. RESULTS All patients received 4 weekly doses of rituximab at 375 mg/m2 per dose. One patient died as the result of complications of her underlying systemic lupus erythematosus 7 weeks after rituximab therapy. Three patients had serious infections, all of which resolved with standard therapy. Rituximab led to transient or sustained improvement in clinical and laboratory parameters in nine subjects. At a median follow-up of 9 months, the median prednisone dose was reduced in the responders by 0.75 mg/kg per day (mean decrease of 63%), and four patients were able to discontinue corticosteroids entirely. With longer follow-up (median, 22 months), we found that 5 of 9 patients remained clinically stable after rituximab therapy, whereas 4 patients had recurrent or new features of their underlying autoimmune disorders requiring additional corticosteroids or other immunosuppressive medications. CONCLUSIONS Rituximab had an acceptable toxicity profile in this group of patients with severe, refractory autoimmune diseases, although there were three serious infections and one patient death. Rituximab appears to be beneficial for patients with refractory autoimmune diseases and may reduce corticosteroid exposure. Although rituximab therapy provided a durable clinical benefit for some patients in this population, other patients had reemergence of their underlying autoimmune disease.
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Affiliation(s)
- Moussa El-Hallak
- Department of Medicine, Children's Hospital Boston, Boston, Massachusetts 02115, USA
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19
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Abstract
Chilblains, or pernio, are cutaneous lesions that may accompany systemic illnesses including states of malnutrition and autoimmune diseases. We report an adolescent girl in whom chilblains were the chief presenting sign of celiac disease. A gluten-free diet led to weight gain and resolution of the chilblains. We speculate that in this patient, weight loss due to celiac disease contributed to the development of chilblains.
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20
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Szigethy E, Levy-Warren A, Whitton S, Bousvaros A, Gauvreau K, Leichtner AM, Beardslee WR. Depressive symptoms and inflammatory bowel disease in children and adolescents: a cross-sectional study. J Pediatr Gastroenterol Nutr 2004; 39:395-403. [PMID: 15448431 DOI: 10.1097/00005176-200410000-00017] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES This study assessed the rates of depressive symptoms in older children and adolescents with inflammatory bowel disease (IBD) and the associations between depressive symptoms and IBD disease characteristics. METHODS One hundred and two youths (aged 11-17 years) with IBD seen consecutively in a gastroenterology clinic were screened for depressive symptoms using the Children's Depression Inventory (CDI). Subjects with CDI scores > or = 12 were evaluated for current psychiatric diagnoses using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). Disease characteristics examined included IBD type, duration, current severity, course, age at diagnosis and steroid treatment. RESULTS Of the total sample, 25 (24.5%) had a CDI score > or = 12, consistent with clinically significant depressive symptoms. Nineteen of 25 qualified subjects participated in the K-SADS-PL semi-structured interview and 16 of 19 met criteria for major or minor depressive disorder. Mean CDI scores positively correlated with age at IBD diagnosis but not with IBD type, duration or course. Youths with moderate/severe current IBD-related symptoms had significantly higher mean CDI scores than those with inactive disease activity. Anhedonia, fatigue and decreased appetite were selectively correlated with IBD disease severity. Subjects on steroids were more likely to have CDI scores > or = 12, and those with such scores were on higher doses of steroids than subjects without clinically significant depressive symptoms (both P values < 0.05). CONCLUSIONS These findings support the recommendation that adolescents with IBD in outpatient medical care settings, particularly older adolescents and those on steroids, should be screened for depression.
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Affiliation(s)
- Eva Szigethy
- Department of Psychiatry, Children's Hospital, Boston, Massachusetts 02115, USA.
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21
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Glickman JN, Bousvaros A, Farraye FA, Zholudev A, Friedman S, Wang HH, Leichtner AM, Odze RD. Pediatric patients with untreated ulcerative colitis may present initially with unusual morphologic findings. Am J Surg Pathol 2004; 28:190-7. [PMID: 15043308 DOI: 10.1097/00000478-200402000-00006] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Anecdotal observations by the authors of this study, together with the results of a few previous smaller studies, suggest that children with new-onset (previously untreated) ulcerative colitis (UC) may occasionally present with discontinuous disease, relative or absolute rectal sparing, and may lack histologic features ofchronicity. Therefore, the objectives of this study were to determine the clinical and pathologic features of new-onset UC in children and to compare the initial presentation of UC in this group with a control group of adults. DESIGN Routinely processed rectal and colonic mucosal biopsies from 73 pediatric (male/female ratio 33/40, mean age 11.5 years, range 2.5-18 years) and 38 adult patients (male/female ratio 15/23, mean age 41.5 years, range 27-64 years) who presented with new-onset UC were evaluated for a variety of clinical and pathologic features, including duration of symptoms prior to presentation, crypt architectural (e.g., atrophy, branching) and nonarchitectural (e.g., basal plasmacytosis, Paneth cell metaplasia) features of chronicity, degree of active inflammation, and distribution and extent of disease. RESULTS A significant proportion of children with new-onset UC had patchiness of microscopic features of chronicity (21% of patients), relative (23%), or absolute (3%), rectal sparing, and had little or no crypt architectural distortion in their rectal biopsies (8%). These features were not observed in adult patients with UC. In addition, a higher proportion of children with UC initially presented with subtotal or with pancolitis compared with the adults (42% vs. 11%; P < 0.002). CONCLUSIONS A significant proportion of children with new-onset UC may show unusual patterns of disease. Pathologists should be aware of these findings since they have significant implications for the differential diagnosis of pediatric inflammatory bowel disease.
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Affiliation(s)
- Jonathan N Glickman
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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22
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Bousvaros A, Kirschner BS, Werlin SL, Parker-Hartigan L, Daum F, Freeman KB, Balint JP, Day AS, Griffiths AM, Zurakowski D, Ferry GD, Leichtner AM. Oral tacrolimus treatment of severe colitis in children. J Pediatr 2000; 137:794-9. [PMID: 11113835 DOI: 10.1067/mpd.2000.109193] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy of oral tacrolimus as an induction agent in steroid-refractory severe colitis. STUDY DESIGN Open-label, multicenter trial of oral tacrolimus in patients with severe colitis. Patients not responding to conventional therapy received tacrolimus, 0.1 mg/kg/dose given twice a day, and the dosage was adjusted to achieve blood levels between 10 and 15 ng/mL. Response was defined as improvement in a number of clinical parameters (including abdominal pain, diarrhea, rectal bleeding, and cessation of transfusions). Patients who responded by 14 days continued to receive tacrolimus, and 6-mercaptopurine or azathioprine was added as a steroid-sparing agent 4 to 6 weeks after the tacrolimus was instituted. RESULTS Fourteen patients were enrolled in the study. One patient elected to withdraw after 48 hours. Of the 13 remaining, 9 (69%) responded and were discharged. Tacrolimus was continued for 2 to 3 months in the responders, except for 1 patient who was given tacrolimus for 11 months. After 1 year of follow-up, only 5 (38%) patients were receiving maintenance therapy; the other 4 responders had undergone colectomy. CONCLUSION Although tacrolimus is effective induction therapy for severe ulcerative or Crohn's colitis, fewer than 50% of patients treated will successfully achieve a long-term remission.
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Affiliation(s)
- A Bousvaros
- Combined Program in Pediatric Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts 02115, USA
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Abstract
Infiltration of esophageal epithelium by eosinophils is seen in reflux esophagitis and allergic gastroenteritis. This study was performed to identify differences between patients with acid reflux esophagitis and those with non-acid reflux, possibly allergic, esophagitis. Intraepithelial eosinophils were demonstrated in posttherapy esophageal biopsy specimens in 28 children treated for gastroesophageal reflux disease (GERD). These patients were divided into three groups based on their response to treatment and the results of esophageal pH probe monitoring. Eleven patients (Group A) had incomplete clinical response and normal pH probe monitoring results. Ten patients (Group B) had incomplete response but did not have pH probe monitoring. These two groups formed the index population. Seven patients (Group C) had clinical improvement with GERD therapy and abnormal pH probe monitoring characteristic of GERD; they constituted the control population. Clinical, laboratory, and pathologic features were evaluated to detect differences between index and control populations. Dysphagia, food impaction, failure to thrive, peripheral eosinophilia, and abnormal allergen skin test results were detected only in Group A and B patients. Biopsy specimens of the distal 9 cm of the esophagus, after GERD therapy, contained larger numbers of eosinophils in Groups A and B than in Group C as shown on high-power fields (HPF) (A: 31/HPF +/- 19.5; B: 28/HPF +/-23.7; versus C: 5/HPF +/-6.7; p = 0.009). Eosinophil aggregates were identified only in Groups A and B (p = 0.07). Eosinophils located preferentially in the superficial layers of the squamous epithelium were noted only in Groups A and B (p = 0.02). Group A and B patients demonstrated clinical improvement when given antiallergic therapy. The authors identified a group of pediatric patients characterized by an allergic history, lack of adequate response to GERD therapy, normal esophageal pH probe monitoring results, and large numbers of eosinophils in esophageal biopsy specimens obtained after GERD treatment. On the basis of these features, the authors propose that these patients represent examples of allergic esophagitis.
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Affiliation(s)
- S V Walsh
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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24
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Giannasca PJ, Giannasca KT, Leichtner AM, Neutra MR. Human intestinal M cells display the sialyl Lewis A antigen. Infect Immun 1999; 67:946-53. [PMID: 9916113 PMCID: PMC96409 DOI: 10.1128/iai.67.2.946-953.1999] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/1998] [Accepted: 11/24/1998] [Indexed: 02/05/2023] Open
Abstract
The biochemical features that distinguish human M cells from other intestinal epithelial cell types are important for understanding microbial pathogenesis and for targeting vaccines to the mucosal immune system. We applied a large panel of carbohydrate-specific monoclonal antibodies and lectins to Peyer's patch and cecum biopsy specimens from three normal individuals and a patient with inflammatory bowel disease. The results show that human M-cell glycosylation patterns are distinct from those of other species examined and that human M cells preferentially display the sialyl Lewis A antigen. This carbohydrate epitope is also present in a small subpopulation of enterocytes in the follicle-associated epithelium and in goblet cell mucins.
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Affiliation(s)
- P J Giannasca
- Department of Pediatrics, Harvard Medical School, and Department of Medicine and GI Cell Biology Research Laboratory, Children's Hospital, Boston, Massachusetts 02115, USA
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25
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Shamberger RC, Masek BJ, Leichtner AM, Winter HS, Lillehei CW. Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis. J Pediatr Surg 1999; 34:163-6. [PMID: 10022164 DOI: 10.1016/s0022-3468(99)90249-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE The ileoanal pull-through procedure (IAP) is gaining increasing favor and use in the surgical treatment of children with ulcerative colitis (UC) and familial adenomatous polyposis (FP). Although physiological studies have been performed to assess the outcome of these children, no long-term quality-of-life assessment after the procedure has been performed. METHODS Forty-three patients were identified who had an IAP at our institution in the last 10 years and were at least 6 months postsurgery. Thirty-four were contacted, and 32 agreed to participate in the survey, which was approved by the Human Studies Committee. Participants completed the standardized Medical Outcome Study Short Form-36 (SF-36), which has well-established normative values. Several supplemental questions were prepared in a similar format dealing with issues specific to the ileoanal pull-through procedure. RESULTS Of the 32 participants, 19 (59%) were girls and 26 (81%) had ulcerative colitis. Mean age at the time of survey was 18.1 years with 12 less than 18 years and 20 > or =18 years. Data from the latter group could be compared with national normative values for this age. The study group was not statistically different from age-appropriate US population normal values on all assessable scales of physical and mental health in the SF-36 survey including physical functioning, role limitations-physical, bodily pain, general health, vitality, social functioning, role limitations-emotional, and mental health (all P>.05 or mean difference SD units <0.8). The supplemental questionaire demonstrated little adverse effect of the surgery. There was limited consumption of medications to control bowel frequency and little restriction of activity because of the frequency of bowel movements or fear of incontinence. The surgical scar was the sole negative factor of significance. CONCLUSIONS The ileoanal pull-through procedure is an excellent surgical option for children with ulcerative colitis or familial adenomatous polyposis, and it produced minimal, if any, adverse effects on their long-term quality of life.
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Affiliation(s)
- R C Shamberger
- Department of Surgery, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Klein GL, Leichtner AM, Heyman MB. Aluminum in large and small volume parenterals used in total parenteral nutrition: response to the Food and Drug Administration notice of proposed rule by the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 1998; 27:457-60. [PMID: 9779979 DOI: 10.1097/00005176-199810000-00019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- G L Klein
- Patient Care Committee, North American Society for Pediatric Gastroenterology and Nutrition, San Francisco, CA 94143-0136, USA
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Fishman SJ, Burrows PE, Leichtner AM, Mulliken JB. Gastrointestinal manifestations of vascular anomalies in childhood: varied etiologies require multiple therapeutic modalities. J Pediatr Surg 1998; 33:1163-7. [PMID: 9694115 DOI: 10.1016/s0022-3468(98)90552-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND/PURPOSE Vascular anomalies, including hemangiomas and vascular malformations afford complex diagnostic and therapeutic challenges when gastrointestinal (GI) manifestations are present. METHODS Twenty-one patients evaluated or treated in our Vascular Anomalies Program from 1993 through 1997 were reviewed retrospectively with regard to presentation, treatment modalities, and outcome. RESULTS Four patients had hemangiomas, and 17 had various vascular malformations. GI symptoms began in infancy or early childhood in all patients. Manifestations included GI bleeding (n = 15), obstruction (n = 2), diarrhea (n = 2), ascites (n = 2), pain (n = 1), emesis (n = 1), ileo-ileal intussusception (n = 1), protein-losing enteropathy (n = 1), and hypersplenism (n = 1). Four patients had proven portal hypertension. Fourteen had associated musculoskeletal or cutaneous lesions. Congestive heart failure, partial anomalous pulmonary venous return, pulmonary edema, and pleural or pericardial effusion occurred in one patient each. Bleeding was the most common symptom of both hemangiomas and malformations. Of four patients with hemangiomas, three were treated with corticosteroids or interferon. Endoscopic banding and embolization of an associated arterioportal hepatic shunt were each used in one patient. One patient died. The malformations were treated with resection (n = 8), endoscopic banding or sclerosis (n = 7), percutaneous or intraoperative sclerosis (n = 5), embolization or device interruption (n = 3), and portosystemic shunt (n = 2). GI symptoms were ameliorated in 12 patients with malformation, improved in two, unchanged in two, and one died after prolonged palliation. CONCLUSIONS Vascular anomalies with gastrointestinal manifestations are heterogeneous in their presentation and type. Although bleeding is the most common symptom of both hemangiomas and vascular malformations, treatment differs. Pharmacological angiogenesis inhibition is the mainstay of hemangioma therapy. Resection, endoscopic or radiologic vascular obliteration, and portal decompression are important in treating vascular malformations. An individualized and interdisciplinary approach is often required to successfully diagnose and treat these complex lesions.
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Affiliation(s)
- S J Fishman
- Department of Surgery, The Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
BACKGROUND Pediatric inflammatory bowel disease is often associated with growth failure and inadequate energy intake. Although several circulating cytokines are known to be elevated in inflammatory bowel disease, the mechanism for the related anorexia has not been described. Leptin is a newly recognized circulating protein that is an important regulator of appetite and energy metabolism; leptin levels are elevated in several animal models of inflammation. This study was conducted to determine whether serum leptin levels are elevated in young patients with inflammatory bowel disease. METHODS One hundred twelve children and young adults with Crohn's disease or ulcerative colitis were studied prospectively. Forty-two patients with other gastrointestinal illnesses were used as control subjects. Height, weight, erythrocyte sedimentation rate, serum albumin concentration, and clinical information were collected prospectively, and leptin was measured by radioimmunoassay of stored serum. RESULTS No significant differences in leptin levels were found among disease groups or control subjects. Body mass index and gender were the only independent predictors of serum leptin in all groups examined. Disease activity varied inversely with serum leptin in patients with Crohn's disease, but these differences were explained entirely by variations in body mass index. CONCLUSIONS The determinants of serum leptin were the same in young patients with inflammatory bowel disease as in normal populations, indicating that alterations in leptin levels are unlikely to mediate the anorexia and growth failure associated with this disease.
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Affiliation(s)
- A G Hoppin
- Combined Program in Pediatric Gastroenterology and Nutrition, Harvard Medical School, Massachusetts General Hospital, Boston 02114-2696, USA
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29
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Bousvaros A, Zurakowski D, Duggan C, Law T, Rifai N, Goldberg NE, Leichtner AM. Vitamins A and E serum levels in children and young adults with inflammatory bowel disease: effect of disease activity. J Pediatr Gastroenterol Nutr 1998; 26:129-35. [PMID: 9481625 DOI: 10.1097/00005176-199802000-00002] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypovitaminosis and fat-soluble vitamin deficiency have been reported in adults with inflammatory bowel disease (IBD). A prospective study was undertaken to determine the prevalence of low serum levels of vitamins A and E in children and young adults with IBD. METHODS Clinical information and serum for vitamin levels was gathered prospectively from 61 patients with Crohn's disease, 36 patients with ulcerative colitis, and 23 control subjects. Disease activity and disease location were determined for IBD patients. Serum retinol and alpha-tocopherol levels were determined by high-performance liquid chromatography. RESULTS The prevalence of hypovitaminosis A (defined as serum vitamin A < 20 micrograms/dl) or hypovitaminosis E (defined as serum vitamin E < 5 mg/l) was 16% in the pediatric IBD population studied. Low vitamin A levels were more common than low vitamin E levels. Serum retinol levels correlated significantly with alpha-tocopherol levels. Hypovitaminosis was significantly more prevalent in the Crohn's disease patients who had active disease, an erythrocyte sedimentation rate of more than 25 mm/hour, or a serum albumin level less than 3 mg/dl. CONCLUSIONS Children and young adults with active IBD frequently have low serum levels of vitamin A or vitamin E. The severity of disease activity is a better predictor of risk for hypovitaminosis than is nutritional status. Further work is necessary to determine whether the hypovitaminosis seen in children with IBD reflects true deficiency.
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Affiliation(s)
- A Bousvaros
- Combined Program in Gastroenterology and Nutrition, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
The course of Crohn's disease is quite variable in children. To assess the frequency and indications for surgery with current medical therapy, the authors reviewed the cases of 204 children (ages, 0.2 to 18.8 years at diagnosis, median, 12.8 years) who had Crohn's disease treated at a single institution from December 1968 to January 1994, with a median of 3.8 years of follow-up (range, 0.0 to 22.2 years). Ninety-four children (46%) required surgical resection for the following indications: (1) failure of medical therapy with persistent symptoms or growth retardation (n = 44, 47%), (2) intraabdominal abscess or perforation (n = 15, 16%), (3) fistula formation (n = 13, 14%), (4) obstruction (n = 15, 16%), (5) hemorrhage (n = 4, 4%), and (6) appendectomy at exploration for diagnosis (n = 3, 3%). The probability for surgery 3 years after diagnosis is 28.8% and by 5 years is 47.2%. Resections included ileocolectomy (71 children), colectomy (n = 16), small bowel resection (n = 4), and appendectomy (n = 3). Fourteen fistulas in 13 children required surgical intervention (7 enteroenteral, 3 enterovesical, 2 enterovaginal, and 2 enterocutaneous). The median duration from diagnosis to surgery for the fistulas was 2.6 years (range 0.1 to 9.8 years). Forty patients experienced recurring disease after resection during follow-up with a median of 1.8 years (range 0.4 to 18.1 years). The authors found that the course of the disease was unpredictable, with some children requiring early surgical intervention and others continuing with medical therapy for years.
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Affiliation(s)
- H I Patel
- Department of Surgery, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Bousvaros A, Zurakowski D, Fishman SJ, Keough K, Law T, Sun C, Leichtner AM. Serum basic fibroblast growth factor in pediatric Crohn's disease. Implications for wound healing. Dig Dis Sci 1997; 42:378-86. [PMID: 9052523 DOI: 10.1023/a:1018882322566] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Basic fibroblast growth factor is a heparin-binding protein known to stimulate angiogenesis and promote wound healing in tissues. Since Crohn's disease is characterized in part by submucosal vascular proliferation, we sought to determine whether serum basic fibroblast growth factor is elevated in children with Crohn's disease and whether serum levels reflect disease activity. Sera were obtained from 64 children with Crohn's disease, 44 children with ulcerative colitis, 20 children with functional abdominal pain, and 29 from children with documented inflammatory disease evaluated in our gastroenterology program. Disease activity indices and clinical data were gathered prospectively for the inflammatory bowel disease patients. Serum basic fibroblast growth factor levels were measured by enzyme-linked immunosorbent assay. Although the mean basic fibroblast growth factor level did not significantly differ between children with Crohn's disease and other conditions, there was a strong (r = 0.53, P < 0.001) correlation between basic fibroblast growth factor level and disease activity. The relationship of basic fibroblast growth factor with disease activity persisted even after adjusting for other covariates (including age, sex, hematocrit, albumin, and sedimentation rate) in a multivariate linear regression model. There was also a statistically significant, although less strong correlation (r = 0.33, P = 0.03) between basic fibroblast growth factor level and disease activity in ulcerative colitis. While basic fibroblast growth factor is not a specific marker for Crohn's disease, serum levels reflect disease activity. Therefore, basic fibroblast growth factor release may be important in mediating the angiogenesis and wound healing seen in Crohn's disease.
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Affiliation(s)
- A Bousvaros
- Combined Program in Gastroenterology and Nutrition, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Fox VL, Abel SD, Malas S, Duggan C, Leichtner AM. Complications following percutaneous endoscopic gastrostomy and subsequent catheter replacement in children and young adults. Gastrointest Endosc 1997; 45:64-71. [PMID: 9013172 DOI: 10.1016/s0016-5107(97)70304-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy has gained wide acceptance for patients who require prolonged tube feeding support. We sought to identify complications and associated risk factors of endoscopic gastrostomy and subsequent catheter replacement in pediatric patients. METHODS Medical records were reviewed for 137 patients. Odds ratios were calculated for complications related to patient age, weight, weight-for-age Z score, and principal diagnosis. RESULTS Seventeen patients (12.4%) developed significant complications after gastrostomy: cellulitis occurred in 10 patients (7.3%); other complications included gastrocolic fistula (2), duodenal hematoma (1), complicated pneumoperitoneum (1), necrotizing fasciitis (1), gastric perforation (1), and catheter migration (1). Patients with cancer had significantly greater odds for developing a wound infection, and patients with AIDS had significantly greater odds for total complications. A trend toward increased wound infection was observed in patients with cardiac disease. Age, weight, and weight-for-age Z score were not associated with adverse outcome. Two complications occurred in 85 patients (2.4%) after gastrostomy catheter replacement. CONCLUSIONS Pediatric patients with cancer and AIDS are at increased risk for complications after endoscopic gastrostomy regardless of age, weight, or nutritional status. Infrequent yet life-threatening complications may occur after replacement of initial gastrostomy catheter.
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Affiliation(s)
- V L Fox
- Combined Program in Pediatric Gastroenterology and Nutrition, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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33
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Affiliation(s)
- A Bousvaros
- Division of Immunology, Children's Hospital, Harvard University, Boston, Massachusetts, USA
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Bross DA, Leichtner AM, Zurakowski D, Law T, Bousvaros A. Elevation of serum interleukin-6 but not serum-soluble interleukin-2 receptor in children with Crohn's disease. J Pediatr Gastroenterol Nutr 1996; 23:164-71. [PMID: 8856584 DOI: 10.1097/00005176-199608000-00012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Previous studies have demonstrated elevated serum levels of interleukin-6 (IL-6) and the soluble interleukin-2 receptor (IL-2R, CD25) in individuals with inflammatory bowel disease (IBD). The aim of our study was to compare serum IL-6 and IL-2R levels to see if one marker better distinguished IBD from other intestinal disorders or better reflected disease activity. Blood samples were obtained from 41 pediatric patients with Crohn's disease, 22 with ulcerative colitis, 19 with other gastrointestinal inflammatory disorders, and 13 with functional abdominal pain. Disease activity and disease location were determined for patients with Crohn's disease and ulcerative colitis. Serum levels of IL-6 and IL-2R were determined by using an enzyme-linked immunosorbent assay. Mean serum levels of IL-6 were significantly elevated (p < 0.05) in patients with Crohn's disease when compared with individuals with ulcerative colitis, other gastrointestinal inflammatory disorders, or functional abdominal pain. By comparison, there was no significant difference in mean serum levels of IL-2R in individuals with Crohn's disease compared with these other groups. Patients with moderate/severe Crohn's disease had elevated mean serum levels of IL-6 and IL-2R when compared with those with mild and inactive disease (p < 0.05); however, neither marker distinguished between inactive and mild disease. IL-6 correlated better with the erythrocyte sedimentation rate (ESR; r = 0.57, p < 0.001) than did IL-2R (r = 0.28, p < 0.01). Our results suggest that elevated IL-6 levels a.e more likely to be seen in patients with Crohn's disease. Although IL-6 may be a better marker for Crohn's disease and active disease than IL-2R, it does not appear to offer any advantage over the ESR.
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Affiliation(s)
- D A Bross
- Combined Program in Gastroenterology and Nutrition, Children's Hospital, Harvard Medical School, Boston, Massachussetts 02115, USA
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35
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Abstract
Autoimmune enteropathy is characterized by chronic secretory diarrhea, villous atrophy, associated autoantibodies, and a partial response to immunosuppression. Currently available therapy (including steroids and cyclosporine) has resulted in remission only in a subset of patients. We evaluated the effects of tacrolimus (FK506) in patients with autoimmune enteropathy refractory to steroids and cyclosporine. Three patients with diagnosed autoimmune enteropathy who continued to have intractable diarrhea despite treatment with steroids and/or cyclosporine were treated with oral tacrolimus. Despite documented histological villous atrophy and poor absorption of oral cyclosporine, therapeutic tacrolimus levels were easily achieved in all 3 patients. All patients showed clinical improvement as documented by decreased stool output and ability to be weaned off parenteral nutrition; response time ranged from 1 to 4 months after tacrolimus was begun. Histological improvement was noted in all patients, and the small bowel biopsy specimens of 2 of the 3 patients showed a return to normal. All patients have been followed up for at least 6 months and are in clinical remission; 1 has received a bone marrow transplant for underlying immunodeficiency. Tacrolimus is a useful drug in the treatment of autoimmune enteropathy, even in patients who have not responded to steroids or cyclosporine. No long-term follow-up of patients with autoimmune enteropathy treated with tacrolimus is currently available.
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Affiliation(s)
- A Bousvaros
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts. USA
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36
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Shamberger RC, Leichtner AM, Jonas MM, LaQuaglia MP. Long-term hepatic regeneration and function in infants and children following liver resection. J Am Coll Surg 1996; 182:515-9. [PMID: 8646352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hepatic regeneration and function after resection has been evaluated in adults, but long-term quantitative assessment has not been performed in children. Semiquantitative short-term evaluations, including radioisotope scans, have suggested that hepatic regeneration occurs quickly in children, but the effect of chemotherapy on hepatic regeneration has not been evaluated. Treating hepatoblastoma in children increasingly includes chemotherapy before resection, hence evaluating regeneration is critical. STUDY DESIGN A retrospective evaluation was done of ten children older than one year following anatomic hepatic resection for benign or malignant tumors. Three components were evaluated. First, hepatic function was evaluated by a series of tests of synthetic function. Second, the metabolic function of the liver was evaluated by measuring the hepatic conversion of lidocaine to its breakdown product, monoethylglycinexylidide (MEGX). Third, hepatic volume was assessed by magnetic resonance imaging scan. RESULTS All children were clinically well at the time of evaluation. Results of tests of synthetic function were essentially normal in all patients. Serum ammonia levels were mildly elevated in six patients. Hepatocellular enzymes were mildly elevated in several children, and the alkaline phosphatase level was mildly elevated in three. A lidocaine infusion study demonstrated normal levels of MEGX in all of the children except one with positive hepatitis C serology. Studies demonstrated that hepatic volumes were below but near the expected levels in most children. Sequential studies in six children demonstrated progressive growth of the livers. No adverse effect on hepatic size was noted in the children who received chemotherapy. CONCLUSIONS The cohort of children had adequate regeneration and function of the liver following hepatic resection. No adverse effect of perioperative chemotherapy could be identified.
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Affiliation(s)
- R C Shamberger
- Department of Surgery, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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37
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Affiliation(s)
- A M Leichtner
- Combined Program in Pediatric Gastroenterology and Nutrition, Children's Hospital, Harvard Medical School, Boston, Massachusettes 02115-5737, USA
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38
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Abstract
We present the case of a 4-month-old infant with a prolonged illness due to an occult intestinal stricture. Diagnosis of the lesion escaped conventional radiologic and surgical methods and required intraoperative enteroscopy. Resection of the stricture lead to prompt clinical improvement. Our patient illustrates a primary diagnostic use of intraoperative enteroscopy in the detection of a partial intraluminal small bowel obstruction. As further experience accumulates with small bowel endoscopy, roles for therapeutic enteroscopy (such as polypectomy, photocoagulation, and perhaps balloon dilatation) will certainly arise. Such endeavors will depend on the continued productive collaboration between members of the surgical and gastroenterological teams.
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Affiliation(s)
- C Duggan
- Combined Program in Pediatric Gastroenterology and Nutrition, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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39
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Abstract
Seven consecutive patients presenting acutely with suspected variceal hemorrhage underwent endoscopic variceal ligation (EVL) of esophageal varices. Active bleeding had ceased by the time of the initial EVL session in all patients, although active variceal hemorrhage was controlled by EVL in one patient during a subsequent episode of bleeding. Treatment sessions were repeated at approximately monthly intervals until varices were reduced in size to grade 1 (< 4 mm diameter) or eradicated. All patients had portal hypertension secondary to intrahepatic disease. Patient age ranged from 2.4 to 14.5 years (mean, 8.5 years). One patient underwent successful liver transplantation 1 week after the initial treatment session. The remaining six patients required a mean (+/- SD) of 4.0 +/- 1.3 treatment sessions for elimination of varices. One episode of recurrent variceal hemorrhage and one episode of treatment-related hemorrhage occurred in two separate patients. Transient, mild dysphagia or odynophagia occurred in all patients. No other complications were reported during a mean (+/- SD) follow-up period of 13.8 +/- 4.6 months (range, 8-20 months). Recurrent varices were seen in three of four (75%) patients returning for follow-up endoscopy between 5 and 8 months from initial eradication. All underwent repeat EVL without complication. Endoscopic variceal ligation may be a suitable substitute for sclerotherapy in children with bleeding esophageal varices.
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Affiliation(s)
- V L Fox
- Combined Program in Pediatric Gastroenterology and Nutrition, Children's Hospital, Boston, MA 02115, USA
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40
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Affiliation(s)
- R D Odze
- Department of Pathology, Brigham and Women's Hospital, Boston, MA 02115
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41
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Shamberger RC, Hendren WH, Leichtner AM. Long-term nutritional and metabolic consequences of pancreaticoduodenectomy in children. Surgery 1994; 115:382-8. [PMID: 7907435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The long-term nutritional and metabolic consequences of pancreaticoduodenectomy in children are unknown. METHODS Five children were evaluated in a clinical research center 2.5 to 10 years after pancreaticoduodenectomy to assess their nutritional status based on patterns of growth and to assess their gastrointestinal function. Investigation included vitamin levels, a bentiromide study, and serum immunoreactive trypsinogen levels to evaluate pancreatic function and a d-xylose absorption and a radionuclide gastric emptying scan for intestinal absorption and motility. RESULTS Children were able to grow after pancreaticoduodenectomy. Three remained in low percentile groups for height/weight ratio, and two were near or above normal. Low normal levels of the fat-soluble vitamins were present. Very low levels of pancreatic function were found based on the bentiromide and trypsinogen studies, whereas intestinal absorption of d-xylose was normal except for one patient with extremely rapid gastric emptying. CONCLUSIONS After pancreaticoduodenectomy children can grow and develop normally if given adequate levels of oral pancreatic supplements to replace the severely decreased level of endogenous pancreatic enzymes after operation. Routine supplementation of the fat-soluble vitamins should be considered.
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Affiliation(s)
- R C Shamberger
- Department of Surgery, Children's Hospital, Boston, Mass. 02115
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Abstract
Allergic proctocolitis is a major cause of rectal bleeding in infants, but its clinical features and laboratory results are often nonspecific. Our previous retrospective study demonstrated that large numbers of eosinophils in colonic mucosal biopsy specimens were highly associated with cases of allergic proctocolitis. Therefore, we prospectively examined 60 colonic mucosal biopsy specimens from the same sites (4, 8, and 12 cm from the anal verge) in 20 infants with clinically confirmed allergic proctocolitis to validate this morphologic feature, to characterize its distribution, and to correlate these data with the clinical information. The patients (age range, 4 to 304 days) were fed breast milk or a variety of formulas and all presented with rectal bleeding. Sigmoidoscopic examination was abnormal in 19 cases, typically characterized by focal areas of mucosal erythema. The major histologic finding was a strikingly focal increase in the number of eosinophils in all mucosal compartments, with a predilection to aggregate in close association with lymphoid nodules. Eosinophilic infiltration varied not only between biopsies at different sites, but also within individual biopsy specimens. Only 12 of 20 patients (60%) had all three of their biopsy specimens categorized as abnormal; in the remainder, only one (four patients) or two (four patients) of the three biopsy specimens were abnormal. The average number of eosinophils per high-power field of lamina propria for all cases was 15.6. No significant correlation was identified between the number of eosinophils in the mucosa and the patient's age, length of illness, endoscopic appearance, or type of inciting formula. In summary, eosinophils appear to be an excellent marker for infantile allergic proctocolitis. Given the focal distribution of the eosinophils, multiple mucosal biopsy specimens should be obtained and several levels of each examined to confirm the diagnosis.
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Affiliation(s)
- R D Odze
- Department of Pathology, Children's Beth Israel Hospital, Boston, MA
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43
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Abstract
Fifty pediatric patients suspected of having colonic disease were evaluated by antegrade barium study ("antegrade colonogram") and by colonoscopy with multiple biopsy specimens. Radiographic patterns of mucosal irregularity, nodularity, or ulceration, haustral asymmetry or edema, and narrowing of the colonic lumen were easily recognized. Correlation between colonographic patterns, biopsy findings, and gross appearance at colonoscopy showed the colonogram to have an overall accuracy of 77-88%. The antegrade colonogram is easily performed and often provides information regarding areas of the colon not seen by the endoscopist. In some cases it may also be useful in the evaluation of response to therapy for inflammatory bowel disease.
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Affiliation(s)
- B C Dangman
- Department of Radiology, Children's Hospital, Boston, MA
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Leichtner AM, Banta JV, Etienne N, Schwartz AN, Renshaw TS, Solari LD, Ascione J, Hyams JS. Pancreatitis following scoliosis surgery in children and young adults. J Pediatr Orthop 1991; 11:594-8. [PMID: 1717507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Forty-four patients undergoing single-stage surgery for scoliosis were monitored for biochemical and clinical evidence of pancreatitis. Six patients (14%) developed elevation of both serum amylase and lipase levels. Four of these had symptoms or signs suggestive of pancreatitis. Mean intraoperative blood loss was significantly higher in the group with pancreatitis. No significant differences were noted with regard to age, surgical technique, degree of initial or residual deformity, or length of surgery. The patients with pancreatitis required a longer average period of fasting time. Patients with prolonged ileus or abdominal pain after scoliosis surgery should be investigated for possible pancreatitis.
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45
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Hyams JS, Moore RE, Leichtner AM, Carey DE, Goldberg BD. Longitudinal assessment of type I procollagen in children with inflammatory bowel disease subjected to surgery. J Pediatr Gastroenterol Nutr 1989; 8:68-74. [PMID: 2732865 DOI: 10.1097/00005176-198901000-00013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Using radioimmunoassay we have measured the serum concentrations of the C-terminal propeptide of type I procollagen (pColl-I-C) in 12 Tanner I-II subjects (aged 9-16 years) with severe Crohn's disease (8 patients) or ulcerative colitis (4 patients) and markedly decreased growth velocity who were subjected to surgery and 50 similarly aged children with either ulcerative colitis (20 patients) or Crohn's disease (30 patients) and normal growth. Prior to operation, the mean growth velocity and pColl-I-C concentration in the former group of 12 children were 0.03 +/- 0.02 cm/month (normal greater than or equal to 0.5 cm/month) and 14.1 +/- 1.9 micrograms/dl, respectively. This pColl-I-C concentration is comparable with that previously reported for adults (5-17 micrograms/dl) and significantly lower than found in the 50 normally growing children with inflammatory bowel disease (IBD) (46.9 +/- 2.0 micrograms/dl) (p less than 0.001). All 12 children subjected to surgery had a marked increase in growth velocity and pColl-I-C concentration to 0.73 +/- 0.08 cm/month and 59.1 +/- 5.6 micrograms/dl, respectively (p less than 0.001 compared with preoperative values). Changes in pColl-I-C concentrations antedated measurable changes in linear growth. These data suggest that pColl-I-C concentrations can reflect growth velocity in children with IBD subjected to surgery and may provide a rapidly available measure of current "growth activity."
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Affiliation(s)
- J S Hyams
- Department of Pediatrics, Hartford Hospital, CT 06115-0729
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46
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Hyams JS, Etienne NL, Leichtner AM, Theuer RC. Carbohydrate malabsorption following fruit juice ingestion in young children. Pediatrics 1988; 82:64-8. [PMID: 3380601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
We performed breath hydrogen analyses in 13 healthy children (9 to 36 months of age) and seven children (14 to 27 months of age) with chronic nonspecific diarrhea after they had ingested pear, grape, and apple juices and a 2% sorbitol solution. Excess breath H2 excretion was found in virtually all study subjects following the ingestion of either pear juice (with approximately 2% sorbitol content) or the 2% sorbitol solution, in approximately 50% of those ingesting apple juice (0.5% sorbitol), and in 25% of those ingesting grape juice (no sorbitol) (P less than .001, analysis of variance). No differences were noted between the healthy children and those with chronic nonspecific diarrhea. Forty percent of all study subjects in whom excess breath hydrogen excretion occurred also had diarrhea and abdominal cramping. Carbohydrate malabsorption appears to be frequent following the ingestion of common fruit juices and in some children may be associated with nonspecific gastrointestinal symptoms.
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Affiliation(s)
- J S Hyams
- Department of Pediatrics, Hartford Hospital, Connecticut 06115
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47
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Abstract
We determined the serum concentration of the C-terminal propeptide of type I procollagen (pColl-I-C) in 60 children and adolescents (ages 4 to 17 years) with inflammatory bowel disease (24 ulcerative colitis, 36 Crohn disease) and in seven children (ages 2 to 15 years) with nongastrointestinal disease (asthma) during varying regimens of corticosteroid therapy. Patients with inflammatory bowel disease were grouped according to disease severity (mild, and moderate to severe). Significantly lower pColl-I-C concentrations and growth velocities were found in each severity group among those subjects receiving daily corticosteroid therapy compared with those receiving alternate-day or no corticosteroid therapy (P less than 0.01). When daily corticosteroid therapy was initiated and then maintained for 7 to 14 days in 11 patients with exacerbation of inflammatory bowel disease clinical improvement resulted, but mean procollagen concentrations decreased significantly (P less than 0.001). In seven children with asthma receiving methylprednisolone intravenously, significant decreases in pColl-I-C concentrations were noted within 24 to 48 hours of therapy (P less than 0.001). These data indicate that serum procollagen values decrease during both short- and long-term daily administration of corticosteroid therapy. Longitudinal assessment of procollagen concentrations may provide rapid assessment of the effects of different corticosteroid regimens on growth.
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Affiliation(s)
- J S Hyams
- Department of Pediatrics, Hartford Hospital, CT 06115-0729
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48
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Abstract
To develop clinical and laboratory criteria to identify young children with gastroesophageal reflux (GER) who are at particular risk for esophagitis and then to monitor their clinical course we have prospectively studied 40 subjects (ages 2-22 months, mean 8 months) with persistent symptoms of GER with 18 h intraesophageal pH monitoring, endoscopy, and grasp and suction esophageal biopsies. Esophagitis was found in 16 of 20 patients under 7 months, 12 of 14 between 7 and 12 months, and five of six between 12 and 24 months. Esophagitis was equally frequent in those patients with or without poor weight gain, wheezing, or irritability. Only 15% of patients with esophagitis had occult blood in their stool. No parameter of intraesophageal pH monitoring was both sensitive and specific in identifying patients who were ultimately found to have either mild or severe esophagitis. Follow-up data (37 patients) revealed that fundoplication was eventually required in four of eight patients with severe esophagitis, three of 22 with mild esophagitis, and none of seven without esophagitis. Currently used clinical and laboratory assessments of GER have limited value in identifying those children with either normal esophageal mucosa or at risk for varying degrees of esophagitis. Preliminary observations suggest that the presence of severe histologic esophagitis at the time of initial evaluation may have prognostic value in identifying those patients most likely to fail medical therapy and require fundoplication.
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Affiliation(s)
- J S Hyams
- Department of Pediatrics, Hartford Hospital, Connecticut 06115
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49
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Abstract
Obstructive uropathy with hydronephrosis is a well-known complication of Crohn's disease. The treatment for this condition is still controversial. This is the case study of a 14-year-old girl with documented right-sided obstructive uropathy secondary to Crohn's disease associated with renin-mediated hypertension secondary to her obstructive uropathy. The patient had complete resolution of her hypertension following surgery, which involved only resection of the involved bowel without ureterolysis.
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50
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Abstract
A 14-yr-old boy with a 5-yr history of autoimmune chronic active hepatitis refractory to corticosteroid therapy was given cyclosporin A (5 mg/kg X day). Before cyclosporine therapy, serum aminotransferase levels were 20 times normal and immunoglobulin G was 4 g/dl. Within 2 wk of starting cyclosporine therapy, aminotransferase levels decreased; by 2 mo they were almost normal, and at 1 yr into therapy they were normal. A decrease in cyclosporine dosage was associated with an increase in aminotransferase levels, which then again decreased as the dose was increased. Severe growth failure observed during previous corticosteroid therapy reversed during cyclosporine treatment and the patient displayed "catch-up" growth. No significant side effects were noted after 1 yr of cyclosporine therapy. Further evaluation of cyclosporine in the treatment of corticosteroid-unresponsive autoimmune chronic active hepatitis appears warranted.
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