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Horgan C, Bitetti S, Newbould M, Sethuraman C, Fagbemi A, Kala A, Williams N, Wynn R. Non-Graft-versus-Host Disease Enterocolitis Following Cord Blood Transplantation is Real, with Poorly Understood Pathophysiology, and Requires Distinct Management, with Eventual Resolution without Immune Suppression. Transplant Cell Ther 2024; 30:440.e1-440.e9. [PMID: 38052367 DOI: 10.1016/j.jtct.2023.11.023] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 12/07/2023]
Abstract
Enterocolitis is common after cord blood transplantation (CBT) and a specific, non-graft-versus-host disease (GVHD) entity with specific histopathologic features ("cord colitis") has been described in some cases in selected series. Immune suppression is not without risk, and we have used it only when biopsy features are consistent with classical GVHD. In the absence of biopsy features of classical GVHD, our management of intestinal failure has been supportive, and we have withdrawn immune suppression to allow immune reconstitution and better prevent relapse of malignant disease and reduce infectious complications. We evaluated our approach over an 11-year period in a retrospective study of all patients at our large pediatric CBT center who experienced intestinal failure necessitating endoscopy and biopsy in the post-CBT period. We conducted a blinded histopathologic review of gastrointestinal (GI) biopsy specimens from all patients who had undergone GI endoscopy for intestinal failure in the post-CBT period. Patient records were evaluated to determine clinical HSCT course and outcome data, including mortality, relapse, and infection, as well as the duration of immune suppression and parenteral nutrition. Out of 144 patients who underwent CBT during the study period, 25 (17%) experienced intestinal failure requiring endoscopy. Thirteen patients were diagnosed with acute GVHD after blinded review of biopsy specimens, and 12 patients had non-GVHD enterocolitis. Management in the absence of GVHD on GI biopsy is supportive, with withdrawal of immune suppression in patients with malignant disease and continuing in accordance with institutional practice in those with nonmalignant disease. Compared with the GVHD cohort, the non-GVHD enterocolitis cohort had superior overall survival (91% versus 41%; P = .04) and a shorter duration of immune suppression (mean, 112 days versus 180 days; P = .049), reflecting these different management approaches. These results demonstrate that different histopathologic findings in those with intestinal failure after CBT likely indicates a different etiology from GVHD and mandates a different clinical management strategy to achieve optimal clinical outcomes.
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Affiliation(s)
- Claire Horgan
- Department of Paediatric Bone Marrow Transplant and Cellular Therapy, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Stefania Bitetti
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Melanie Newbould
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Chitra Sethuraman
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Andrew Fagbemi
- Department of Paediatric Gastroenterology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Adnan Kala
- Department of Paediatric Gastroenterology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Nicola Williams
- Department of Paediatric Bone Marrow Transplant and Cellular Therapy, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Robert Wynn
- Department of Paediatric Bone Marrow Transplant and Cellular Therapy, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
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Chatzidaki V, Wood R, Alegakis A, Lawson M, Fagbemi A. Parenteral support and micronutrient deficiencies in children with short bowel syndrome: A comprehensive retrospective study. Clin Nutr ESPEN 2023; 58:270-276. [PMID: 38057017 DOI: 10.1016/j.clnesp.2023.10.008] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND & AIMS Short bowel syndrome (SBS) is the leading cause of chronic intestinal failure. The duration of parenteral support (PS) and the long-term micronutrient needs in children with SBS vary, based on their clinical and anatomical characteristics. Our study aimed to review the clinical course and identify high risk patient groups for prolonged PS and long-term micronutrient supplementation. METHODS A retrospective review was conducted on electronic medical records of children with SBS and chronic intestinal failure who were enrolled in the multidisciplinary intestinal rehabilitation program at Manchester Children's Hospital, UK. Children were included in the review if they required PN for more than 60 days out of 74 consecutive days and had at least 3 years of follow-up. Statistical analysis was performed using IBM SPSS Statistics 24.0. RESULTS 40 children with SBS achieved enteral autonomy (EA) and 14 remained dependent on PS after 36 months of follow up. Necrotizing enterocolitis was the most common cause for intestinal resection (38.9%) followed by gastroschisis (22.2%), malrotation with volvulus (20.4%), segmental volvulus (9.3%) and long segment Hirschsprung disease (1.9%). Those who achieved EA had significantly longer intestinal length 27.5% (15.0-39.3) than those who remained on PS 6.0% (1.5-12.5) (p < 0.001). Type I SBS was only found in the PS cohort. Median PN dependence was 10.82 months [IQR 5.73-20.78]. Congenital diagnosis was associated with longer PN dependence (21.0 ± 20.0) than acquired (8.7 ± 7.8 months), (p = 0.02). The need for micronutrient supplementation was assessed after the transition to EA; 87.5% children had at least one micronutrient depletion, most commonly Vitamin D (64.1%), followed by iron (48.7%), Vitamin B12 (34.2%), and vitamin E (28.6%). Iron deficiency and vitamin A depletion were correlated with longer PS after multivariate analysis (OR: 1.103, 1.006-1.210, p = 0.037 and OR: 1.048, 0.998-1.102, p = 0.062 respectively). CONCLUSION In our cohort, small bowel length was the main predictor for EA. Children on longer PS, had more often a congenital cause of resection and were at risk for micronutrient deficiencies in EA.
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Affiliation(s)
- V Chatzidaki
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK.
| | - R Wood
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Alegakis
- Laboratory of Toxicology, University of Crete, Greece
| | - M Lawson
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
| | - A Fagbemi
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, NHS Foundation Trust, UK
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Tridimas A, Padidela R, Bassett J, Wood R, Lawson M, Fagbemi A, Morris TJ. Reducing Metabolic Bone Disease Burden in Intestinal Failure Children on Home Parenteral Nutrition. JPGN Rep 2023; 4:e368. [PMID: 38034429 PMCID: PMC10684215 DOI: 10.1097/pg9.0000000000000368] [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: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 12/02/2023]
Abstract
Objective To determine the prevalence of secondary hyperparathyroidism in a cohort of pediatric patients receiving home parenteral nutrition. Methods For a service review, a population-based cohort of 37 pediatric intestinal failure patients receiving long-term parenteral nutrition that underwent serial biochemical monitoring during a study period of approximately 4 years were examined. Following the production of an algorithm, a follow-up audit was carried out (n = 33) after approximately 6 months. Results Of the 37 patients examined in the initial service review, 22 (59%) were found to have an elevated parathyroid hormone (PTH) during the period of monitoring and 5 (14%) had a persistently elevated PTH. In the follow-up audit following the implementation of an algorithm, the number with elevated PTH reduced to 6 (18%) and no patients had persistently high levels. Conclusion Elevated PTH is a common biochemical finding in pediatric intestinal failure patients receiving home parenteral nutrition and its presence should alert clinicians to the need to optimize nutritional parameters such as calcium to phosphate molar ratio and vitamin D status; failure to do so may increase the future burden of metabolic bone disease in such patients. We propose that an algorithm may help in this endeavor.
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Affiliation(s)
- Andreas Tridimas
- From the Directorate of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester, UK
- Clinical Biochemistry Department, Countess of Chester Hospital, Chester, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
- Faculty of Biology Medicine and Health, University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
| | - John Bassett
- From the Directorate of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rachel Wood
- Department of Therapy and Dietetics, Royal Manchester Children’s Hospital, Manchester, UK
| | - Maureen Lawson
- Department of Paediatric Gastroenterology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Andrew Fagbemi
- Department of Paediatric Gastroenterology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Timothy J. Morris
- From the Directorate of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Chiba M, Masumoto K, Kaji T, Matsuura T, Morii M, Fagbemi A, Hill S, Pakarinen MP, Protheroe S, Urs A, Chen ST, Sakui S, Udagawa E, Wada M. Efficacy and Safety of Teduglutide in Infants and Children With Short Bowel Syndrome Dependent on Parenteral Support. J Pediatr Gastroenterol Nutr 2023; 77:339-346. [PMID: 37364133 PMCID: PMC10412081 DOI: 10.1097/mpg.0000000000003867] [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: 10/04/2022] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal failure (SBS-IF). METHODS Two open-label phase 3 studies and 1 extension study investigated the short- and long-term safety and efficacy of teduglutide (0.05 mg/kg/day) in infants and children with SBS-IF: NCT03571516, 24-week study of infants who were randomized to receive teduglutide or standard of care (SoC); NCT02980666, 24-week study of infants and children who all received teduglutide; and NCT03268811, 24-week extension study of patients who completed NCT02980666 (patients could receive up to 48 weeks of total treatment). RESULTS Twelve infants and 8 children enrolled in the core studies, and 2 infants and 7 children in the extension study. After 24 weeks of treatment, parenteral support (PS) requirements reduced by ≥20% from baseline for 4 infants (57.1%) and 4 children (66.7%) receiving teduglutide and for 2 infants receiving SoC (50.0%). One infant (50.0%) and 4 children (80.0%) receiving teduglutide maintained the ≥20% reduction in PS at 48 weeks of treatment. Two children receiving teduglutide achieved enteral autonomy, after 12 weeks and 28 weeks of treatment, respectively. All adverse events (AEs) were in line with known impacts of SBS-IF and adverse reactions to teduglutide. Only one serious AE (abdominal pain) was considered related to teduglutide. CONCLUSIONS Short- and long-term treatment with teduglutide resulted in clinically meaningful reductions in PS requirements for infants and children with SBS-IF. Teduglutide was well tolerated, and efficacy improved with longer-term treatment.
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Affiliation(s)
- Masahiro Chiba
- From the Division of Pediatric Surgery, Department of Surgery, Showa University, Tokyo, Japan
| | - Kouji Masumoto
- the Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tatsuru Kaji
- the Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshiharu Matsuura
- the Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mayako Morii
- the Department of Pediatric Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Andrew Fagbemi
- the Department of Paediatric Gastroenterology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, NHS Foundation Trust and UCL Institute of Child Health, London, UK
| | - Mikko P. Pakarinen
- the Pediatric Research Center, Children’s Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Susan Protheroe
- the Department of Gastroenterology and Nutrition, Birmingham Women and Children’s Hospital, Birmingham, UK
| | - Arun Urs
- the Department of Paediatric Gastroenterology, Sheffield Children’s Hospital, Sheffield, UK
| | - Szu-Ta Chen
- Takeda Development Center Americas, Inc., Boston, MA, USA
| | - Sho Sakui
- Statistical and Quantitative Sciences, Data Sciences Institute, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Eri Udagawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Motoshi Wada
- the Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- the Division of Pediatric Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan
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Chukwuocha IK, Oguntiloye O, Fagbemi A, Olalusi O, Onyenokwe V. CLAUDE SYNDROME: A CASE REPORT. Ann Ib Postgrad Med 2023; 21:94-97. [PMID: 38298336 PMCID: PMC10811700] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 02/02/2024] Open
Abstract
Introduction Detailed description of infarction of the midbrain is sparse likely due to the complex arterial supply of this region of the brain. Among the ventral midbrain syndromes reported is Claude syndrome. This syndrome caused majorly by a vascular insult to the ventromedial midbrain, characteristically presents with ipsilateral third cranial nerve palsy and contralateral hemiataxia. It is a rare syndrome and only a few cases have been reported since 1912 when it was first described by Henri Claude. Case presentation 45-year-old male, who developed sudden onset dysarthria, right third cranial nerve palsy and left sided ataxia. An infarct in the right ventromedial midbrain was revealed on magnetic resonance imaging of the brain. Conclusion We describe a case report of a middle-aged man with minimal vascular risk factors (ASCVD = 1.3%) for stroke, who presented with features suggestive of Claude syndrome.
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Affiliation(s)
- I K Chukwuocha
- Department of Neurology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - O Oguntiloye
- Department of Neurology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - A Fagbemi
- Department of Neurology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - O Olalusi
- Department of Neurology, University College Hospital, Ibadan, Oyo State, Nigeria
| | - V Onyenokwe
- Department of Neurology, University College Hospital, Ibadan, Oyo State, Nigeria
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Copley S, Price J, Lawson M, Jago L, Kala A, Fagbemi A. N4 Compliance with gluten free diet and TTG values in children with coeliac disease diagnosed on serology compared to duodenal biopsy: a single centre experience. Nutrition 2022. [DOI: 10.1136/flgastro-2022-bspghan.76] [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] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ashton JJ, Narula P, Kiparissi F, Spray C, Wilson DC, Tayler R, Howarth L, Torrente F, Deb P, Cameron FL, Muhammed R, Paul T, Epstein J, Lawson M, Maginnis J, Zamvar V, Fagbemi A, Devadason D, Bhavsar HS, Kammermeier J, Beattie RM. Transition Services for Paediatric Inflammatory Bowel Disease: A Multicentre Study of Practice in the United Kingdom. J Pediatr Gastroenterol Nutr 2021; 73:251-258. [PMID: 33853108 DOI: 10.1097/mpg.0000000000003148] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Patients with paediatric inflammatory bowel disease (IBD) constitute one of the largest cohorts requiring transition from paediatric to adult services. Standardised transition care improves short and long-term patient outcomes. This study aimed to detail the current state of transition services for IBD in the United Kingdom (UK). METHODS We performed a nationwide study to ascertain current practice, facilities and resources for children and young people with IBD. Specialist paediatric IBD centres were invited to contribute data on: timing of transition/transfer of care; transition resources available including clinics, staff and patient information; planning for future improvement. RESULTS Twenty of 21 (95%) of invited centres responded. Over 90% of centres began the transition process below 16 years of age and all had completed transfer to adult care at 18 years of age. The proportion of patients in the transition process at individual centres varied from 10% to 50%.Joint clinics were held in every centre, with a mean of 12.9 clinics per year. Adult and paediatric gastroenterologists attended at all sites. Availability of additional team members was patchy across the UK, with dietetic, psychological and surgical attendance available in <50% centres. A structured transition tool was used in 75% of centres. Sexual health, contraception and pregnancy were discussed by <60% of teams. CONCLUSIONS This study provides real-world clinical data on UK-wide transition services. These data can be used to develop a national strategy to complement current transition guidelines, focused on standardising services whilst allowing for local implementation.
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Affiliation(s)
- James J Ashton
- Department of Paediatric Gastroenterology, Southampton Children's Hospital
- Human Genetics and Genomic Medicine, University of Southampton, Southampton
| | - Priya Narula
- Department of Paediatric Gastroenterology, Sheffield Children's NHS Foundation Trust, Sheffield
| | - Fevronia Kiparissi
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital, London
| | - Christine Spray
- Department of Paediatric Gastroenterology, Bristol Royal Hospital for Children, Bristol
| | - David C Wilson
- Department of Paediatric Gastroenterology, The Royal Hospital for Sick Children, Edinburgh
| | - Rachel Tayler
- Department of Paediatric Gastroenterology, Royal Hospital for Children Glasgow, Glasgow
| | - Lucy Howarth
- Department of Paediatric Gastroenterology, Oxford University Hospitals, Oxford
| | - Franco Torrente
- Department of Paediatric Gastroenterology, Addenbrooke's Hospital, Cambridge
| | - Protima Deb
- Department of Paediatric Gastroenterology, The Royal London Hospital, Barts Health NHS Trust, London
| | - Fiona L Cameron
- Department of Paediatric Gastroenterology, Alderhey Children's Hospital NHS Foundation Trust, West Derby, Liverpool
| | - Rafeeq Muhammed
- Department of Paediatric Gastroenterology, Birmingham Children's Hospital, Birmingham
| | - Thankam Paul
- Department of Paediatric Gastroenterology, St. Georges University Hospital NHS Foundation Trust
| | - Jenny Epstein
- Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital, London
| | - Maureen Lawson
- Department of Paediatric Gastroenterology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle
| | - Janis Maginnis
- Department of Paediatric Gastroenterology, University Hospitals of North Staffordshire NHS Trust, Stoke-On-Trent
| | - Veena Zamvar
- Department of Paediatric Gastroenterology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Andrew Fagbemi
- Department of Paediatric Gastroenterology, Royal Manchester Children's Hospital, Manchester, UK
| | - David Devadason
- Department of Paediatric Gastroenterology, Nottingham Children's Hospital, Queens Medical Centre, Nottingham
| | - Hemant S Bhavsar
- Department of Paediatric Gastroenterology, University Hospitals of Leicester NHS Trust, Leicester
| | - Jochen Kammermeier
- Department of Paediatric Gastroenterology, Evelina London Children's Hospital, UK
| | - Robert M Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital
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Goenka A, Doherty JA, Al-Farsi T, Jagger C, Banka S, Cheesman E, Fagbemi A, Hughes SM, Wynn RF, Hussell T, Arkwright PD. Neutrophil dysfunction triggers inflammatory bowel disease in G6PC3 deficiency. J Leukoc Biol 2020; 109:1147-1154. [PMID: 32930428 DOI: 10.1002/jlb.5ab1219-699rr] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 12/09/2019] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 11/06/2022] Open
Abstract
The glucose-6-phosphatase catalytic subunit 3 (G6PC3) encodes a ubiquitously expressed enzyme that regulates cytoplasmic glucose availability. Loss-of-function biallelic G6PC3 mutations cause severe congenital neutropenia and a diverse spectrum of extra-hematological manifestations, among which inflammatory bowel disease (IBD) has been anecdotally reported. Neutrophil function and clinical response to granulocyte colony-stimulating factor (G-CSF) and hematopoietic stem cell transplantation (HSCT) were investigated in 4 children with G6PC3 deficiency-associated IBD. G6PC3 deficiency was associated with early-onset IBD refractory to treatment with steroids and infliximab. The symptoms of IBD progressed despite G-CSF treatment. In vitro studies on the patients' blood showed that neutrophils displayed higher levels of activation markers (CD11b, CD66b, and CD14), excessive IL-8 and reactive oxygen species, and increased apoptosis and secondary necrosis. Secondary necrosis was exaggerated after stimulation with Escherichia coli and could be partially rescued with supplemental exogenous glucose. HSCT led to normalization of neutrophil function and remission of gastrointestinal symptoms. We conclude that neutrophils in G6PC3 deficiency release pro-inflammatory mediators when exposed to gut bacteria, associated with intestinal inflammation, despite treatment with G-CSF. HSCT is an effective therapeutic option in patients with G6PC3 deficiency-associated IBD refractory to immune suppressants.
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Affiliation(s)
- Anu Goenka
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.,Department of Paediatric Allergy & Immunology, Royal Manchester Children's Hospital, Manchester, UK.,School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - John A Doherty
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Tariq Al-Farsi
- Department of Paediatric Allergy & Immunology, Royal Manchester Children's Hospital, Manchester, UK
| | - Christopher Jagger
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Siddharth Banka
- Division of Evolution and Genomic Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK.,Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester, UK
| | - Edmund Cheesman
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester, UK
| | - Andrew Fagbemi
- Department of Paediatric Gastroenterology, Royal Manchester Children's Hospital, Manchester, UK
| | - Stephen M Hughes
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.,Department of Paediatric Allergy & Immunology, Royal Manchester Children's Hospital, Manchester, UK
| | - Robert F Wynn
- Department of Paediatric Haematology Royal Manchester Children's Hospital, Manchester, UK
| | - Tracy Hussell
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Peter D Arkwright
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.,Department of Paediatric Allergy & Immunology, Royal Manchester Children's Hospital, Manchester, UK
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Fagbemi A, Newman WG, Tangye SG, Hughes SM, Cheesman E, Arkwright PD. Refractory very early-onset inflammatory bowel disease associated with cytosolic isoleucyl-tRNA synthetase deficiency: A case report. World J Gastroenterol 2020; 26:1841-1846. [PMID: 32351297 PMCID: PMC7183863 DOI: 10.3748/wjg.v26.i15.1841] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 01/06/2020] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Aminoacyl tRNA synthetases/ligases (ARSs) are highly conserved enzymes involved in attaching amino acids to tRNA promoting protein synthesis. Although deficiencies of ARSs localized to the mitochondria classically present with neuropathology, the clinical features of cytosolic ARS deficiencies are more variable. They have previously been associated with neonatal hepatitis, but never with early-onset inflammatory bowel disease.
CASE SUMMARY A nine-year-old Bangladeshi boy presented with neonatal liver failure and deranged clotting, transaminitis and cholestasis. His parents were first cousins. Two older brothers and a sister were well. The patient suffered from loose stools from early infancy which became more troublesome and persistent from five years old with ten bloody motions a day. Repeated endoscopies showed persistent pancolitis, which was refractory to mesalazine, corticosteroids, azathioprine, sirolimus and anti-TNF (adalimumab) therapy, but has improved recently with subcutaneous methotrexate.Whole Genome Sequencing revealed a novel pathogenic missense variant (c.290A > G) in the cytosolic isoleucyl-tRNA synthetase gene, leading to an amino acid substitution (p.Asp97Gly). Pathogenic variants in other genes associated with inflammatory bowel disease (IBD) (ADAM17, EGFR, FOXP3, IL10RA, IL10RB, IL21R, NCF4, STAT3) were excluded. Cytokine assays demonstrated markedly elevated IL-2, IL-5, IL-13, IL-9 and IL-10 by the patient’s CD4+ T-cells, while IL-17A, IL-17F, IFNβ were lower, and TNFα not significantly different when compared to healthy controls.
CONCLUSION This case report provides evidence that recessive mutations in cytosolic isoleucyl-tRNA synthetase are a novel monogenic cause of IBD, which should be considered, particularly in infants and children with a history of neonatal hepatitis and very early-onset IBD poorly responsive to treatment.
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Affiliation(s)
- Andrew Fagbemi
- Department of Paediatric Gastroenterology, Royal Manchester Children’s Hospital, Manchester M199WL, United Kingdom
| | - William G Newman
- Department of Medical Genetics, Manchester University NHS Foundation Trust, Manchester M139WL, United Kingdom
- Evolution and Genomic Sciences, University of Manchester, Manchester M139WL, United Kingdom
| | - Stuart G Tangye
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia
- St Vincent’s Clinical School, Faculty of Medicine, UNSW Australia, Sydney, NSW 2010, Australia
| | - Stephen M Hughes
- Department of Paediatric Allergy and Immunology, Royal Manchester Children’s Hospital, Manchester M139WL, United Kingdom
| | - Edmund Cheesman
- Department of Paediatric Histopathology, St Mary’s Hospital, Manchester M139WL, United Kingdom
| | - Peter D Arkwright
- Department of Paediatric Allergy and Immunology, Royal Manchester Children’s Hospital, Manchester M139WL, United Kingdom
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester M139WL, United Kingdom
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10
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Chanchlani N, Mortier K, Williams LJ, Muhammed R, Auth MKH, Cosgrove M, Fagbemi A, Fell J, Chong S, Zamvar V, Hyer W, Bisset WM, Morris MA, Rodrigues A, Mitton SG, Bunn S, Beattie RM, Willmott A, Wilson DC, Russell RK. Use of Infliximab Biosimilar Versus Originator in a Pediatric United Kingdom Inflammatory Bowel Disease Induction Cohort. J Pediatr Gastroenterol Nutr 2018; 67:513-519. [PMID: 29697550 DOI: 10.1097/mpg.0000000000002011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [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: 02/06/2023]
Abstract
OBJECTIVES The aim of the study was to summarize short-term effectiveness, safety, and cost of using infliximab biosimilar (IFX-B) drugs, (Inflectra [Hospira] and Remsima [NAAP]) compared to originator infliximab (IFX-O) (Remicade [MSD]) in biologic naive pediatric inflammatory bowel disease in the United Kingdom. METHODS Prospective audit of patients starting anti-tumour necrosis factor (TNF) therapy. Disease severity, response to treatment, and remission rate was measured by Pediatric Crohn's Disease Activity Index (PCDAI) and/or Physician Global Assessment. RESULTS Between March 2015 and February 2016, 278 patients (175 IFX-O, 82 IFX-B, and 21 Adalimumab) were started on anti-TNF therapy. This was compared with collected data on 398 patients started on IFX-O from 2011 to 2015. At initiation, median PCDAI was 36 (20,48) (n = 42) in the IFX-O group and 28 (20,40) (n = 29) in the IFX-B group, (P = 0.08). Immunosuppression rates were similar: 150/175 (86%) for IFX-O and 65/82 (79%) for IFX-B (P > 0.05). Post induction, median PCDAI score was 5 (0,11) (n = 19) and 0 (0,8) (n = 15) in the IFX-O and IFX-B groups, respectively (P = 0.35). There was no difference in response to treatment using Physician Global Assessment 85% (n = 28) in IFX-O group and 86% (n = 19) in IFX-B group (P > 0.05). Adverse events at initiation and post induction were not different between both groups (P > 0.05). Using conservative calculations, £875,000 would have been saved for a 1-year period with universal adoption of biosimilars in patients who were instead treated with IFX-O. CONCLUSIONS IFX-B is likely as effective as IFX-O in treating IBD in comparable pediatric populations. Sites should adopt infliximab biosimilar for new starts due to cost reduction with no difference in other parameters.
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Affiliation(s)
| | | | - Linda J Williams
- Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh
| | - Rafeeq Muhammed
- Birmingham Children's Hospital, Birmingham, Birmingham Children's Hospital, Birmingham
| | - Marcus K H Auth
- Alder Hey Children's Hospital and University of Liverpool, Liverpool
| | - Mike Cosgrove
- Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Wales
- Children's Hospital for Wales, Heath Park, Cardiff
| | | | - John Fell
- Chelsea and Westminster Hospital, London
| | - Sonny Chong
- Queen Mary's Hospital for Children (Epsom and St Helier University Hospitals), Sutton, Carshalton
| | - Veena Zamvar
- Clarendon Wing, Leeds General Infirmary, Leeds, West Yorkshire
| | - Warren Hyer
- Northwick Park and St Mark's Hospital, Harrow, Middlesex
| | | | - Mary-Anne Morris
- Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital, Norwich
| | - Astor Rodrigues
- Children's Hospital, John Radcliffe Hospital, Headley Way, Oxford
| | | | - Su Bunn
- Great North Children's Hospital, Royal Victoria Infirmary, Newcastle upon Tyne
| | - R Mark Beattie
- Southampton Children's Hospital, Tremona Road, Southampton
| | - Anne Willmott
- Leicester Royal Infirmary, Infirmary Square, Leicester
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11
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Sheen PAJ, Zahid MSB, Fagbemi A, Fullwood C, Whitehead K. 'Holiday sickness'-reported exploratory outcome of over 500 United Kingdom holidaymakers with travellers' diarrhoea. J Travel Med 2017; 24:taw077. [PMID: 28077608 DOI: 10.1093/jtm/taw077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 09/02/2016] [Indexed: 11/14/2022]
Abstract
AIMS To ascertain any predictors of potential food poisoning pathogens and development of post-infective irritable bowel syndrome (IBS) in UK travellers. An analysis was undertaken on prospectively collected data on 527 patients reporting symptoms of suspected food poisoning between June 2012 and June 2015. MAIN OUTCOME MEASURES Positive stool sample indicative of food poisoning pathogens and diagnosis of post-infective IBS. RESULTS Data on 527 patients were examined. The large majority of patients did not provide a stool sample on return from holiday (n = 430, 81.6%) as few visited a Doctor locally or in the UK. Only 18 patients (18.6%, 95% confidence interval [CI] 11.4-27.7) who provided a stool sample were positive for microbiological food poisoning pathogens. Univariate analysis indicated a significant relationship between a positive stool sample and whether the individual sought any medical assistance at the resort (odds ratio [OR] 0.24, 95% CI 0.08-0.70) and whether they took any treatment (including self-medicated), (OR 0.21, 95% CI 0.06-0.67). Of the 527 patients only 30 (5.7%, 95% CI 3.9-8.1) experienced post-infective IBS. Univariate regression indicated a significant relationship between experiencing Per Rectal (PR) bleeding and a diagnosis of post-infective IBS (OR 3.64, 95% CI 1.00-10.49). Univariate regression also indicated an increase in the risk of developing post-infective IBS with increasing duration of symptoms (OR 1.04, 95% CI 1.02-1.05). No significant relationship was found between a positive stool sample and developing post-infective IBS (P = 0.307). CONCLUSIONS Very few patients provide a stool sample after experiencing holiday sickness abroad. Of those that do, only a small proportion have a positive stool sample indicative of a food poisoning microorganism. Around 6% of individuals were diagnosed with post-infective IBS. Those individuals with PR bleeding and symptoms persisting for longer durations were significantly more at risk of developing post-infective IBS, whilst medical aid and treatment abroad was found to reduce the odds of a positive stool sample.
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Affiliation(s)
- Prof Aali J Sheen
- Department of Surgery, Central Manchester NHS Foundation Trust, Oxford Road, Manchester, UK .,Department of Microbiology Research, School of Healthcare Sciences, Manchester Metropolitan University, Manchester, UK
| | - M Saad B Zahid
- Department of Surgery, Central Manchester NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Andrew Fagbemi
- Department of Paediatric Gastroenterology, Central Manchester NHS Foundation Trust, Oxford Road, Manchester, UK
| | - Catherine Fullwood
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Research & Innovation, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Kathryn Whitehead
- Department of Microbiology Research, School of Healthcare Sciences, Manchester Metropolitan University, Manchester, UK
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12
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Kyrana E, Beath S, Gabe S, Small M, Hill S, Basude D, Cosgrove M, Cunningham S, Davies I, Fagbemi A, Flynn D, Holden C, Koglmeier J, Naik S, MacDonald S, Puntis J, Protheroe S. Current practices and experience of transition of young people on long term home parenteral nutrition (PN) to adult services – A perspective from specialist centres. Clin Nutr ESPEN 2016; 14:9-13. [DOI: 10.1016/j.clnesp.2016.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/30/2016] [Accepted: 04/02/2016] [Indexed: 10/21/2022]
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Abstract
Neurological complications in paediatric patients with inflammatory bowel disease (IBD) are rare. Most previous reports involve cerebral venous thrombosis, central nervous system vasculitis, or peripheral nerve inflammation. We report a child with active inflammatory bowel disease complicated by acute disseminated encephalomyelitis (ADEM). The child presented with acute neurological deficits following an exacerbation of colitis with evidence of lesions in the central nervous system white matter on magnetic resonance imaging. Ancillary investigations did not provide evidence of systemic infection, coagulation disorders, or vasculitis. In our case the colitis improved with immunosuppressive therapy, with a similar improvement in the white matter lesions showing almost complete resolution of the MR scan changes and no evidence of infarction. This case suggests that ADEM may be another extra intestinal manifestation of inflammatory bowel disease, probably associated with an autoimmune pathogenic mechanism.
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Affiliation(s)
- Majid Aziz
- Department of Paediatric Neurology, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK.
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14
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Diacono D, Fagbemi A, Puleston J, Banerjee I. Bezafibrate to prevent relapsing pancreatitis in WAGR syndrome. Case Reports 2012; 2012:bcr-2012-006413. [DOI: 10.1136/bcr-2012-006413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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15
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Malik S, Ahmed SF, Wilson ML, Shah N, Loganathan S, Naik S, Bourke B, Thomas A, Akobeng AK, Fagbemi A, Wilson DC, Russell RK. The effects of anti-TNF-α treatment with adalimumab on growth in children with Crohn's disease (CD). J Crohns Colitis 2012; 6:337-44. [PMID: 22405171 DOI: 10.1016/j.crohns.2011.09.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [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: 08/18/2011] [Revised: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Adalimumab is used to treat children with Crohn's disease (CD), but the effects of adalimumab on growth in CD have not been studied. AIM To study growth and disease activity over 12 months (6 months prior to (T-6), baseline (T0) and for 6 months following (T+6) adalimumab). SUBJECTS AND METHODS Growth and treatment details of 36 children (M: 22) who started adalimumab at a median (10th, 90th) age of 14.7 years (11.3, 16.8) were reviewed. RESULTS Of 36 cases, 28 (78%) went into remission. Overall 42% of children showed catch up growth, which was more likely in: (i) those who achieved remission (median change in height SDS (ΔHtSDS) increased from -0.2 (-0.9, 1.0) at T0 to 0.2 (-0.6, 1.6) at T+6, (p=0.007)), (ii) in those who were on immunosuppression ΔHtSDS increased from -0.2 (-0.9, 1.0) at T0 to 0.1 (-0.8, 1.3) at T+6, (p=0.03) and (iii) in those whose indication for using adalimumab therapy was an allergic reaction to infliximab, median ΔHtSDS increased significantly from -0.3 (-0.9, 1.0) at T0 to 0.3 (-0.5, 1.6) at T+6, (p=0.02). Median ΔHtSDS also increased from -0.4 (-0.8, 0.7) at T0 to 0.0 (-0.6, 1.6) at T+6, (p=0.04) in 15 children who were on prednisolone therapy when starting adalimumab. CONCLUSION Clinical response to adalimumab therapy is associated with an improvement in linear growth in a proportion of children with CD. Improved growth is more likely in patients entering remission and on immunosuppression but is not solely due to a steroid sparing effect.
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Affiliation(s)
- S Malik
- Bone & Endocrine Research Group Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
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16
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Russell RK, Wilson ML, Loganathan S, Bourke B, Kiparissi F, Mahdi G, Torrente F, Rodrigues A, Davies I, Thomas A, Akobeng AK, Fagbemi A, Hyer W, Spray C, Vaish S, Rogers P, McGrogan P, Heuschkel RB, Ayub N, Fell JM, Afzal NA, Green M, Murphy MS, Rao P, Shah N, Ho GT, Naik S, Wilson DC. A British Society of Paediatric Gastroenterology, Hepatology and Nutrition survey of the effectiveness and safety of adalimumab in children with inflammatory bowel disease. Aliment Pharmacol Ther 2011; 33:946-53. [PMID: 21342211 DOI: 10.1111/j.1365-2036.2011.04603.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [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] [Indexed: 12/24/2022]
Abstract
BACKGROUND Adalimumab is efficacious therapy for adults with Crohn's disease (CD). AIM To summarise the United Kingdom and Republic of Ireland paediatric adalimumab experience. METHODS British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) members with Inflammatory Bowel Disease (IBD) patients <18 years old commencing adalimumab with at least 4 weeks follow-up. Patient demographics and details of treatment were then collected. Response and remission was assessed using the Paediatric Crohn's Disease Activity Index (PCDAI)/Physicians Global Assessment (PGA). RESULTS Seventy-two patients [70 CD, 1 ulcerative colitis (UC), 1 IBD unclassified (IBDU)] from 19 paediatric-centres received adalimumab at a median age of 14.8 (IQR 3.1, range 6.1-17.8) years; 66/70 CD (94%) had previously received infliximab. A dose of 80 mg then 40 mg was used for induction in 41(59%) and 40 mg fortnightly for maintenance in 61 (90%). Remission rates were 24%, 58% and 41% at 1, 6 and 12 months, respectively. Overall 43 (61%) went into remission at some point, with 24 (35%) requiring escalation of therapy. Remission rates were higher in those on concomitant immunosuppression cf. those not on immunosuppression [34/46 (74%) vs. 9/24 (37%), respectively, (χ(2) 8.8, P=0.003)]. There were 15 adverse events (21%) including four (6%) serious adverse events with two sepsis related deaths in patients who were also on immunosuppression and home parenteral nutrition (3% mortality rate). CONCLUSIONS Adalimumab is useful in treatment of refractory paediatric patients with a remission rate of 61%. This treatment benefit should be balanced against side effects, including in this study a 3% mortality rate.
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Gutman J, Fagbemi A, Alphonsus K, Eigege A, Miri ES, Richards FO. Missed treatment opportunities for schistosomiasis mansoni, in an active programme for the treatment of urinary schistosomiasis in Plateau and Nasarawa states, Nigeria. Ann Trop Med Parasitol 2008; 102:335-46. [PMID: 18510814 DOI: 10.1179/136485908x278810] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Both Schistosoma haematobium and S. mansoni are endemic in Nigeria. Since 1999 the ministries of health of Plateau and Nasarawa states, assisted by The Carter Center, have provided mass drug administrations with praziquantel to villages where >20% of the school-aged children tested with urine dipsticks have been found to have haematuria (presumed to be caused by S. haematobium). The current extent of S. mansoni in Nigeria remains relatively unknown because the tests needed to detect human infection with this parasite are difficult to perform in many endemic areas. In a cross-sectional survey involving 924 children, the prevalence of S. mansoni was determined in 30 villages (in four local government areas) that had been excluded from mass praziquantel administrations because the prevalence of haematuria in their school-aged children had been found to be <20%. Seventeen (57%) of the surveyed villages had sufficient S. mansoni (i.e. prevalences of at least 10%) to warrant treatment. The results indicated that, if both S. haematobium and S. mansoni are taken into account, 81% of the villages in the four local government areas studied require treatment, compared with 50% if only S. haematobium is considered. At the moment, the costs of the village-by-village diagnosis of S. haematobium and S. mansoni would be greater than those of the presumptive treatment of the school-aged children in all villages. Until improved and cheaper rapid diagnostic methods for S. mansoni become available, the cheapest approach to the overall problem of schistosomiasis in this part of Nigeria would therefore be wide-spread mass drug distributions, without screening for at-risk populations.
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Affiliation(s)
- J Gutman
- Department of Pediatric Infectious Disease, Emory University School of Medicine, Atlanta, GA 30322, USA.
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18
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Abstract
OBJECTIVE Recent evidence suggests that autistic children may have significant gastrointestinal symptoms. Although constipation occurs in 2% to 5% of healthy children, its clinical diagnosis is often difficult in children with behavioral disorders. We thus aimed to assess the prevalence of fecal loading in autistic children with gastrointestinal symptoms and to identify possible predictors of constipation. METHODS We studied abdominal radiographs of 103 autistic children (87 boys) who were referred for gastroenterological assessment, in comparison with 29 control radiographs from children who were referred to the emergency department, most with abdominal pain. Radiographs were scored independently, in blinded manner, by 4 pediatric gastroenterologists and a radiologist. The severity of constipation was determined using a validated index. Details of stool habit, abdominal pain, dietary history, and laxative use were obtained from case notes. RESULTS The incidence of constipation in the control subjects with abdominal pain was higher than reported for normal children. Despite this, moderate or severe constipation was more frequent in the autistic group than in the control subjects (36% vs 10%). Analysis of rectosigmoid loading showed more striking differences (54.4% of autistic children had moderate/severe loading or acquired megarectum compared with 24.1% of control subjects). Multivariate regression analysis showed consumption of milk to be the strongest predictor of constipation in the autistic group, whereas stool frequency, gluten consumption, soiling, and abdominal pain were not predictive of constipation. CONCLUSIONS Constipation is a frequent finding in children with gastrointestinal symptoms and autism, particularly in the rectosigmoid colon, often with acquired megarectum. The absence of any correlation between the clinical history and the degree of fecal impaction in autistic children confirms the importance of an abdominal radiograph in the assessment of their degree of constipation.
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Affiliation(s)
- Nadeem Afzal
- Centre for Pediatric Gastroenterology, Royal Free Hospital, Hampstead, London, United Kingdom
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19
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Afzal NA, Addai S, Fagbemi A, Murch S, Thomson M, Heuschkel R. Refeeding syndrome with enteral nutrition in children: a case report, literature review and clinical guidelines. Clin Nutr 2002; 21:515-20. [PMID: 12468372 DOI: 10.1054/clnu.2002.0586] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.6] [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: 11/18/2022]
Abstract
Refeeding syndrome is a potentially fatal complication of the nutritional management of severely malnourished patients. The syndrome almost always develops during the early stages of refeeding. It can be associated with a severe derangement in electrolyte and fluid balance, and result in significant morbidity and mortality. It is most often reported in adults receiving total parenteral nutrition (TPN), although refeeding with enteral feeds can also precipitate this syndrome. We report what we believe to be the first case of refeeding syndrome in an adolescent with newly diagnosed Crohn's disease. This developed within a few days of starting exclusive polymeric enteral nutrition. A systematic literature review revealed 27 children who developed refeeding syndrome after oral/enteral feeding. Of these, nine died as a direct result of complications of this syndrome. We discuss the implications of this syndrome on clinical practice and propose evidence-based guidelines for its management.
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Affiliation(s)
- N A Afzal
- Centre for Paediatric Gastroenterology, Royal Free Hospital, Hampstead, London, UK
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20
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Calnan DP, Fagbemi A, Berlanga-Acosta J, Marchbank T, Sizer T, Lakhoo K, Edwards AD, Playford RJ. Potency and stability of C terminal truncated human epidermal growth factor. Gut 2000; 47:622-7. [PMID: 11034576 PMCID: PMC1728116 DOI: 10.1136/gut.47.5.622] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [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: 12/08/2022]
Abstract
INTRODUCTION Epidermal growth factor (EGF) is normally present as EGF(1-53). A variety of C terminal truncated forms have been used in preliminary trials for treating gastrointestinal injury but their relative potency and stability when used in a clinical setting are unclear. Therefore, we compared the biological activity of recombinant EGF(1-53), EGF(1-52), EGF(1-51), and the C terminal peptides EGF(44-53) and EGF(49-53). METHODS Purity of forms was confirmed by mass spectrometry. Bioactivity of the different EGF forms was determined using [methyl-(3)H] thymidine incorporation into primary rat hepatocytes and their ability to reduce indomethacin (20 mg/kg subcutaneously)/restraint induced gastric injury in rats. Stability of EGF peptides was determined by serial sampling from a syringe driver system containing EGF/4% albumin in saline. RESULTS Biological activity assays of EGF(1-53), EGF(1-52), and EGF(1-51) gave almost identical thymidine uptake dose-response curves (maximal responses increasing baseline uptake from 4400 (600) cpm (mean (SEM)) to about 22 000 (2000) cpm when EGF was added at 1. 6 nM). EGF(44-53) and EGF(49-53) did not stimulate (3)H thymidine uptake. Control rats had 47 (4) mm(2) damage/stomach, EGF(1-51), EGF(1-52), and EGF(1-53) at 0.16 and 0.80 nmol/kg/h each reduced gastric injury by about 50% and 80%, respectively (both doses p<0.01 compared with control but no significant difference between the different forms). EGF was stable at room temperature for seven days but biological activity decreased by 35% and 40% at two and three weeks, respectively (both p<0.01). Exposure to light did not affect bioactivity. CONCLUSION EGF(1-51) and EGF(1-52) are as biologically active as full length EGF(1-53) but the C terminal penta- and decapeptides are ineffective. Clinical trials of EGF can probably use infusion systems for at least 48 hours at room temperature and with exposure to light, without reducing biological efficacy.
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Affiliation(s)
- D P Calnan
- University Division of Gastroenterology, Leicester General Hospital, Leicester, UK
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21
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Maalouf EF, Fagbemi A, Duggan PJ, Jayanthi S, Counsell SJ, Lewis HJ, Fletcher AM, Lakhoo K, Edwards AD. Magnetic resonance imaging of intestinal necrosis in preterm infants. Pediatrics 2000; 105:510-4. [PMID: 10699101 DOI: 10.1542/peds.105.3.510] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [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] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Noninvasive diagnosis of intestinal necrosis is important in planning surgery in preterm infants with necrotizing enterocolitis (NEC). We aimed to assess the potential of magnetic resonance imaging (MRI) for the diagnosis of intestinal necrosis. STUDY PARTICIPANTS AND METHODS Abdominal MRI scans were performed in a group of preterm infants with suspected NEC and compared with surgical findings and to MRI results in a group of control infants. In addition, MRI was performed in 2 preterm infants with suspected NEC who did not require surgery. RESULTS Six infants with a median birth weight of 1220 g (range, 760-1770 g) and median gestational age at birth of 30 weeks (range, 28-34 weeks) were studied at a median postnatal age of 10 days (range, 4-19 days). Four infants had a bubble-like appearance in part of the intestinal wall, intramural gas, and an abnormal fluid level within bowel lumen. At surgery, NEC was found in 5 infants and sigmoid volvulus in 1. The site of the bubble-like appearance corresponded to the site of intestinal necrosis at surgery. Four control infants with a median birth weight of 1500 g (range, 730-2130 g) and a median gestational age of 31 weeks (range, 26-36 weeks) had abdominal MRI at a median postnatal age of 8 days (range, 4-70 days). None of the above findings were seen in any control infant. The bubble-like appearance was not seen in the 2 infants with suspected NEC who did not require surgery. CONCLUSION Abdominal MRI allows the noninvasive diagnosis of bowel necrosis. This may aid the timing of surgical intervention in preterm infants with a clinical diagnosis of NEC.gangrene, ischemia, MRI, necrotizing enterocolitis.
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Affiliation(s)
- E F Maalouf
- Department of Paediatrics, Imperial College School of Medicine, Hammersmith Hospital, London, England
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