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Discepolo V, Kelly CP, Koning F, Schuppan D. How Future Pharmacologic Therapies for Celiac Disease Will Complement the Gluten-Free Diet. Gastroenterology 2024:S0016-5085(24)00416-5. [PMID: 38604542 DOI: 10.1053/j.gastro.2024.02.050] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/13/2024]
Abstract
The only proven treatment for celiac disease is adherence to a strict, lifelong, gluten-free diet. However, complete dietary gluten avoidance is challenging and a substantial number of patients do not respond fully, clinically, or histologically, despite their best efforts. As celiac disease is common and its central pathophysiology is well elucidated, it has become attractive for drug development to address the limitations of dietary treatment. Most efforts address nonresponsive celiac disease, defined as continued symptoms and/or signs of disease activity despite a gluten-free diet, including the more severe forms of refractory celiac disease, types I and II. An increasing spectrum of therapeutic approaches target defined mechanisms in celiac disease pathogenesis and some have advanced to current phase 2 and 3 clinical studies. We discuss these approaches in terms of potential efficiency, practicability, safety, and need, as defined by patients, regulatory authorities, health care providers, and payors.
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Affiliation(s)
- Valentina Discepolo
- Department of Translational Medical Science and European Laboratory for the Investigation of Food Induced Diseases, University of Naples Federico II, Naples, Italy.
| | - Ciarán P Kelly
- Celiac Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Frits Koning
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Detlef Schuppan
- Celiac Center, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Institute of Translational Immunology and Research Center for Immunotherapy, Center for Celiac Disease and Autoimmunity, Johannes-Gutenberg University, Mainz, Germany.
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2
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Villafuerte Gálvez JA, Kelly CP. Editorial: An anti-inflammatory approach to drug repurposing for Clostridioides difficile infection. J Infect Dis 2024:jiae022. [PMID: 38243873 DOI: 10.1093/infdis/jiae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/17/2024] [Indexed: 01/22/2024] Open
Affiliation(s)
- Javier A Villafuerte Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School. Boston, MA
| | - Ciarán P Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School. Boston, MA
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3
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Rubio-Tapia A, Hill ID, Semrad C, Kelly CP, Greer KB, Limketkai BN, Lebwohl B. Response to Fahey et al. Am J Gastroenterol 2023; 118:2095-2096. [PMID: 37916753 DOI: 10.14309/ajg.0000000000002464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ivor D Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children Hospital, Columbus, Ohio, USA
| | - Carol Semrad
- Division of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Katarina B Greer
- Department of Medicine, Section of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | - Benjamin Lebwohl
- Division of Gastroenterology and Hepatology, Columbia University, New York, USA
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Ke S, Xiao Y, Weiss ST, Chen X, Kelly CP, Liu YY. A computational method to dissect colonization resistance of the gut microbiota against pathogens. Cell Rep Methods 2023; 3:100576. [PMID: 37751698 PMCID: PMC10545914 DOI: 10.1016/j.crmeth.2023.100576] [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] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/09/2023] [Accepted: 08/08/2023] [Indexed: 09/28/2023]
Abstract
The mammalian gut microbiome protects the host through colonization resistance (CR) against the incursion of exogenous and often harmful microorganisms, but identifying the exact microbes responsible for the gut microbiota-mediated CR against a particular pathogen remains a challenge. To address this limitation, we developed a computational method: generalized microbe-phenotype triangulation (GMPT). We first systematically validated GMPT using a classical population dynamics model in community ecology and demonstrated its superiority over baseline methods. We then tested GMPT on simulated data generated from the ecological network inferred from a real community (GnotoComplex microflora) and real microbiome data on two mouse studies on Clostridioides difficile infection. We demonstrated GMPT's ability to streamline the discovery of microbes that are potentially responsible for microbiota-mediated CR against pathogens. GMPT holds promise to advance our understanding of CR mechanisms and facilitate the rational design of microbiome-based therapies for preventing and treating enteric infections.
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Affiliation(s)
- Shanlin Ke
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Yandong Xiao
- College of System Engineering, National University of Defense Technology, Changsha, Hunan 410073, China
| | - Scott T Weiss
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Yang-Yu Liu
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA; Center for Artificial Intelligence and Modeling, The Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Champaign, IL, USA.
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5
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Sandora TJ, Kociolek LK, Williams DN, Daugherty K, Geer C, Cuddemi C, Chen X, Xu H, Savage TJ, Banz A, Garey KW, Gonzales-Luna AJ, Kelly CP, Pollock NR. Baseline stool toxin concentration is associated with risk of recurrence in children with Clostridioides difficile infection. Infect Control Hosp Epidemiol 2023; 44:1403-1409. [PMID: 36624698 PMCID: PMC10330943 DOI: 10.1017/ice.2022.310] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND In adults with Clostridioides difficile infection (CDI), higher stool concentrations of toxins A and B are associated with severe baseline disease, CDI-attributable severe outcomes, and recurrence. We evaluated whether toxin concentration predicts these presentations in children with CDI. METHODS We conducted a prospective cohort study of inpatients aged 2-17 years with CDI who received treatment. Patients were followed for 40 days after diagnosis for severe outcomes (intensive care unit admission, colectomy, or death, categorized as CDI primarily attributable, CDI contributed, or CDI not contributing) and recurrence. Baseline stool toxin A and B concentrations were measured using ultrasensitive single-molecule array assay, and 12 plasma cytokines were measured when blood was available. RESULTS We enrolled 187 pediatric patients (median age, 9.6 years). Patients with severe baseline disease by IDSA-SHEA criteria (n = 34) had nonsignificantly higher median stool toxin A+B concentration than those without severe disease (n = 122; 3,217.2 vs 473.3 pg/mL; P = .08). Median toxin A+B concentration was nonsignificantly higher in children with a primarily attributed severe outcome (n = 4) versus no severe outcome (n = 148; 19,472.6 vs 429.1 pg/mL; P = .301). Recurrence occurred in 17 (9.4%) of 180 patients. Baseline toxin A+B concentration was significantly higher in patients with versus without recurrence: 4,398.8 versus 280.8 pg/mL (P = .024). Plasma granulocyte colony-stimulating factor concentration was significantly higher in CDI patients versus non-CDI diarrhea controls: 165.5 versus 28.5 pg/mL (P < .001). CONCLUSIONS Higher baseline stool toxin concentrations are present in children with CDI recurrence. Toxin quantification should be included in CDI treatment trials to evaluate its use in severity assessment and outcome prediction.
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Affiliation(s)
- Thomas J. Sandora
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Larry K. Kociolek
- Division of Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - David N. Williams
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, 02115, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology (K.D., C.G., C.C., C.K) and Division of Infectious Diseases (N.R.P.), Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Christine Geer
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, 02115, USA
- Division of Gastroenterology (K.D., C.G., C.C., C.K) and Division of Infectious Diseases (N.R.P.), Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Christine Cuddemi
- Division of Gastroenterology (K.D., C.G., C.C., C.K) and Division of Infectious Diseases (N.R.P.), Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Xinhua Chen
- Division of Gastroenterology (K.D., C.G., C.C., C.K) and Division of Infectious Diseases (N.R.P.), Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Hua Xu
- Division of Gastroenterology (K.D., C.G., C.C., C.K) and Division of Infectious Diseases (N.R.P.), Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Timothy J. Savage
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, MA, 02115, USA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, 02120, USA
| | - Alice Banz
- bioMerieux, Marcy L’Etoile, 69280, France
| | - Kevin W. Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - Anne J. Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, 77204, USA
| | - Ciarán P. Kelly
- Division of Gastroenterology (K.D., C.G., C.C., C.K) and Division of Infectious Diseases (N.R.P.), Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
| | - Nira R. Pollock
- Division of Gastroenterology (K.D., C.G., C.C., C.K) and Division of Infectious Diseases (N.R.P.), Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02115, USA
- Department of Laboratory Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, 02115, USA
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6
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Rubio-Tapia A, Greer KB, Limketkai B, Hill ID, Semrad C, Kelly CP, Lebwohl B. Response to Catassi et al. Am J Gastroenterol 2023; 118:1703. [PMID: 37646453 DOI: 10.14309/ajg.0000000000002369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katarina B Greer
- Department of Medicine, Section of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Berkeley Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | - Ivor D Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children Hospital, Columbus, Ohio, USA
| | - Carol Semrad
- Division of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Benjamin Lebwohl
- Division of Gastroenterology and Hepatology, Columbia University, New York, USA
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7
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Rubio-Tapia A, Greer KB, Limketkai BN, Hill ID, Semrad C, Kelly CP, Lebwohl B. Response to Rettally and Husby and Murray. Am J Gastroenterol 2023; 118:1102-1103. [PMID: 37260136 DOI: 10.14309/ajg.0000000000002242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Katarina B Greer
- Department of Medicine, Section of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | - Ivor D Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children Hospital, Columbus, Ohio, USA
| | - Carol Semrad
- Division of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Benjamin Lebwohl
- Division of Gastroenterology and Hepatology, Columbia University, New York, New York, USA
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8
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Banegas M, Villafuerte-Gálvez J, Paredes R, Sprague R, Barrett C, Gonzales-Luna AJ, Daugherty K, Garey KW, Xu H, Lin Q, Wang L, Chen X, Pollock NR, Kelly CP, Alonso CD. Preservation of the Innate Immune Response to Clostridioides difficile Infection in Hospitalized Immunocompromised Patients. Open Forum Infect Dis 2023; 10:ofad090. [PMID: 36949876 PMCID: PMC10026545 DOI: 10.1093/ofid/ofad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/15/2023] [Indexed: 02/20/2023] Open
Abstract
Background Clostridioides difficile infection (CDI) immune response is influenced by the innate and adaptive (humoral) immune systems. Our prior research found attenuated humoral responses to C difficile in immunocompromised hosts (ICHs) with CDI. We sought to evaluate whether the innate immune response to CDI was influenced by ICH status. Methods We conducted a prospective study of hospitalized adults with CDI (acute diarrhea, positive C difficile stool nucleic acid amplification testing [NAAT], and decision to treat), with and without immunosuppression and measured a panel of cytokines (granulocyte colony-stimulating factor [G-CSF], interleukin [IL]-10, IL-15, IL-1β, IL-4, IL-6, IL-8, and tumor necrosis factor-α) in blood and stool at CDI diagnosis. Results were compared with measurements from a cohort of asymptomatic carrier patients (ASCs) (NAAT positive, without diarrhea) with and without immunocompromise. Results One hundred twenty-three subjects (42 ICHs, 50 non-ICHs, 31 ASCs) were included. Median values for blood and stool cytokines were similar in ICH versus non-ICH CDI subjects. In blood, G-CSF, IL-10, IL-15, IL-6, and IL-8 were higher in both groups of CDI subjects versus the ASC cohort (P < .05). In stool, IL-1β and IL-8 were higher in both groups of CDI subjects versus the ASC cohort (P < .05). Median stool concentrations of IL-1β demonstrated significant differences between the groups (ICHs, 10.97 pg/mL; non-ICHs, 9.71 pg/mL; and ASCs, 0.56 pg/mL) (P < .0001). Conclusions In this small exploratory analysis, ICH status did not significantly impact blood and fecal patterns of cytokines in humans at the diagnosis of CDI, suggesting that the innate immune response to C difficile may be conserved in immunocompromised patients.
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Affiliation(s)
- Marcela Banegas
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Javier Villafuerte-Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rodrigo Paredes
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rebecca Sprague
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Caitlin Barrett
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Qianyun Lin
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lamei Wang
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- College of Animal Science and Technology, Northwest A&F University, Yangling, Shaanxi Province, China
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nira R Pollock
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Carolyn D Alonso
- Correspondence: Carolyn D. Alonso, MD, FIDSA, Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, 110 Francis St, Suite GB, Boston, MA 02215 ()
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9
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Rubio-Tapia A, Hill ID, Semrad C, Kelly CP, Greer KB, Limketkai BN, Lebwohl B. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol 2023; 118:59-76. [PMID: 36602836 DOI: 10.14309/ajg.0000000000002075] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [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: 04/13/2022] [Accepted: 08/23/2022] [Indexed: 01/06/2023]
Abstract
This guideline presents an update to the 2013 American College of Gastroenterology Guideline on the Diagnosis and Management of Celiac Disease with updated recommendations for the evaluation and management of patients with celiac disease (CD). CD is defined as a permanent immune-mediated response to gluten present in wheat, barley, and rye. CD has a wide spectrum of clinical manifestations that resemble a multisystemic disorder rather than an isolated intestinal disease, and is characterized by small bowel injury and the presence of specific antibodies. Detection of CD-specific antibodies (e.g., tissue transglutaminase) in the serum is very helpful for the initial screening of patients with suspicion of CD. Intestinal biopsy is required in most patients to confirm the diagnosis. A nonbiopsy strategy for the diagnosis of CD in selected children is suggested and discussed in detail. Current treatment for CD requires strict adherence to a gluten-free diet (GFD) and lifelong medical follow-up. Most patients have excellent clinical response to a GFD. Nonresponsive CD is defined by persistent or recurrent symptoms despite being on a GFD. These patients require a systematic workup to rule out specific conditions that may cause persistent or recurrent symptoms, especially unintentional gluten contamination. Refractory CD is a rare cause of nonresponsive CD often associated with poor prognosis.
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Affiliation(s)
- Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ivor D Hill
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children Hospital, Columbus, Ohio, USA
| | - Carol Semrad
- Division of Gastroenterology, University of Chicago, Chicago, Illinois, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Katarina B Greer
- Department of Medicine, Section of Gastroenterology and Hepatology, Louis Stokes VA Medical Center, Cleveland, Ohio, USA
| | - Berkeley N Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, California, USA
| | - Benjamin Lebwohl
- Division of Gastroenterology and Hepatology, Columbia University, New York, USA
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10
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Alonso CD, Pollock NR, Garey KW, Gonzales-Luna AJ, Williams DN, Daugherty K, Cuddemi C, Villafuerte-Gálvez J, White NC, Chen X, Xu H, Sprague R, Barrett C, Miller M, Foussadier A, Lantz A, Banz A, Kelly CP. Higher In Vivo Fecal Concentrations of Clostridioides difficile Toxins A and B in Patients With North American Pulsed-Field Gel Electrophoresis Type 1/Ribotype 027 Strain Infection. Clin Infect Dis 2022; 75:2019-2022. [PMID: 35607815 DOI: 10.1093/cid/ciac406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/14/2022] [Indexed: 01/17/2023] Open
Abstract
Ultrasensitive, quantitative Clostridioides difficile stool toxin measurement demonstrated significantly higher concentrations of toxins A and B in patients infected with the North American pulsed-field gel electrophoresis type 1/ribotype 027 (NAP-1/027) strain compared with other strains, providing in vivo confirmation of the in vitro association between NAP-1/027 and elevated toxin production.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nira R Pollock
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - David N Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Cuddemi
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Javier Villafuerte-Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nicole C White
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rebecca Sprague
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Caitlin Barrett
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | | | | - Ciarán P Kelly
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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11
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Cao Y, Wang L, Ke S, Kelly CP, Pollock NR, Villafuerte Gálvez JA, Daugherty K, Xu H, Yao J, Chen Y, Liu YY, Chen X. Analysis of Intestinal Mycobiota of Patients with Clostridioides difficile Infection among a Prospective Inpatient Cohort. Microbiol Spectr 2022; 10:e0136222. [PMID: 35867408 PMCID: PMC9430669 DOI: 10.1128/spectrum.01362-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/23/2022] [Indexed: 11/20/2022] Open
Abstract
Clostridioides difficile infection (CDI) is a burden to health care systems worldwide. Gut microbiota dysbiosis associated with CDI has been well accepted. However, contribution of fungal mycobiota to CDI has recently gained research interest. Here, we report the gut mycobiota composition of 149 uniquely well characterized participants from a prospective clinical cohort and evaluate the discriminating ability of gut mycobiota to classify CDI and non-CDI patients. Fecal samples were divided into two groups: (i) CDI (inpatients who had clinically significant diarrhea and positive nucleic acid amplification testing [NAAT] and received subsequent CDI therapy, n = 58) and (ii) non-CDI, which can be further divided into three subgroups: (a) carrier (inpatients with positive stool NAAT but without diarrhea; n = 28); (b) diarrhea (inpatients with negative stool NAAT; n = 31); and (c) control (inpatients with negative stool NAAT and without diarrhea; n = 32). Fecal mycobiota composition was analyzed by internal transcribed spacer 2 (ITS2) sequencing. In comparison to non-CDI patients, CDI patients tend to have gut mycobiota with lower biodiversity, weaker fungi correlations, and weaker correlations between fungi and host immune factors. Notably, 11 genera (Saccharomyces, Penicillium, Aspergillus, Cystobasidium, Cladosporium, and so on) were significantly enriched in non-CDI patients, and Pichia and Suhomyces were enriched in patients with CDI, while 1 two genera, Cystobasidium and Exophiala, had higher abundance in patients with diarrhea compared with CDI (linear discriminant analysis [LDA] > 3.0; P < 0.05). Ascomycota and Basidiomycota (or Candida and Saccharomyces) exhibited a strong negative correlation (r ≤ -0.714 or r ≤ -0.387; P < 0.05), and the ratios of Ascomycota to Basidiomycota or genera Candida to Saccharomyces were dramatically higher in CDI patients than in non-CDI patients (P < 0.05). A disease-specific pattern with much weaker fungal abundance correlations was observed in the CDI group compared to that in the non-CDI and diarrhea groups, suggesting that these correlations may contribute to the development of CDI. Our findings provided specific markers of stool fungi that distinguish CDI from all non-CDI hospitalized patients. This study's potential clinical utility for better CDI diagnosis warrants further investigation. IMPORTANCE Clostridioides difficile is an opportunistic bacterial pathogen that causes a serious and potentially life-threatening infection of the human gut. It remains an existing challenge to distinguish active infection of CDI from diarrhea with non-CDI causes. A few large prospective studies from recent years suggest that there is no single optimal test for the diagnosis of CDI. Previous research has concentrated on the relationship between bacteria and CDI, while the roles of fungi, as a significant proportion of the gut microbial ecosystem, remain understudied. In this study, we report a series of fungal markers that may add diagnostic values for the development of a more systematic approach to accurate CDI diagnosis. These results help open the door for better understanding of the relationship between host immune factors and the fungal community in the context of CDI pathogenesis.
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Affiliation(s)
- Yangchun Cao
- College of Animal Science and Technology, Northwest A&F University, Yangling, Shaanxi Province, China
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lamei Wang
- College of Animal Science and Technology, Northwest A&F University, Yangling, Shaanxi Province, China
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Shanlin Ke
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ciarán P. Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nira R. Pollock
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Department of Laboratory Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Javier A. Villafuerte Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Junhu Yao
- College of Animal Science and Technology, Northwest A&F University, Yangling, Shaanxi Province, China
| | - Yulin Chen
- College of Animal Science and Technology, Northwest A&F University, Yangling, Shaanxi Province, China
| | - Yang-Yu Liu
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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12
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Sandora TJ, Williams DN, Daugherty K, Geer C, Cuddemi C, Kociolek LK, Chen X, Xu H, Savage TJ, Banz A, Garey KW, Gonzales-Luna AJ, Kelly CP, Pollock NR. Stool Toxin Concentration Does Not Distinguish Clostridioides difficile Infection from Colonization in Children Less Than 3 Years of Age. J Pediatric Infect Dis Soc 2022; 11:454-458. [PMID: 35801632 PMCID: PMC9595052 DOI: 10.1093/jpids/piac059] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 06/10/2022] [Indexed: 11/14/2022]
Abstract
In a prospective cohort study, stools from children <3 years with and without diarrhea who were Clostridioides difficile nucleic acid amplification test-positive underwent ultrasensitive and quantitative toxin measurement. Among 37 cases and 46 controls, toxin concentration distributions overlapped substantially. Toxin concentration alone does not distinguish C. difficile infection from colonization in young children.
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Affiliation(s)
- Thomas J Sandora
- Corresponding Author: Thomas J. Sandora, MD MPH, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. E-mail:
| | - David N Williams
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Geer
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts, USA,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Cuddemi
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Larry K Kociolek
- Division of Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy J Savage
- Division of Infectious Diseases, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nira R Pollock
- Department of Laboratory Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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13
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Osman M, Budree S, Kelly CR, Panchal P, Allegretti JR, Kassam Z, Ramakrishna B, Dubois N, O'Brien K, Fischer M, Stollman N, Hays RA, Kelly CP, Amaratunga K, Qazi T, Crothers JW, Abend A, Bougas M, Burns L, Decaille-Hodge I, Dickens M, Edelstein C, Gabdrakhmanova D, Landry R, Ling K, Martin D, Medina G, Mendolia G, Muñoz R, Rao S, Seng M, Smith M, Stehler L, Yoder K, Zellmer C. Effectiveness and Safety of Fecal Microbiota Transplantation for Clostridioides Difficile Infection: Results From a 5344-Patient Cohort Study. Gastroenterology 2022; 163:319-322. [PMID: 35398345 DOI: 10.1053/j.gastro.2022.03.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/24/2022] [Indexed: 12/17/2022]
Affiliation(s)
| | - Shrish Budree
- Department of Pediatrics, University of Cape Town, Cape Town, South Africa; Finch Therapeutics, Somerville, Massachusetts
| | - Colleen R Kelly
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Jessica R Allegretti
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Zain Kassam
- Finch Therapeutics, Somerville, Massachusetts
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14
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Ke S, Pollock NR, Wang XW, Chen X, Daugherty K, Lin Q, Xu H, Garey KW, Gonzales-Luna AJ, Kelly CP, Liu YY. Integrating gut microbiome and host immune markers to understand the pathogenesis of Clostridioides difficile infection. Gut Microbes 2021; 13:1-18. [PMID: 34132169 PMCID: PMC8210874 DOI: 10.1080/19490976.2021.1935186] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Clostridioides difficile (C.difficile) infection is the most common cause of healthcare-associated infection and an important cause of morbidity and mortality among hospitalized patients. A comprehensive understanding of C.difficile infection (CDI) pathogenesis is crucial for disease diagnosis, treatment, and prevention. Here, we characterized gut microbial compositions and a broad panel of innate and adaptive immunological markers in 243 well-characterized human subjects (including 187 subjects with both microbiota and immune marker data), who were divided into four phenotype groups: CDI, Asymptomatic Carriage, Non-CDI Diarrhea, and Control. We found that the interactions between gut microbiota and host immune markers are very sensitive to the status of C.difficile colonization and infection. We demonstrated that incorporating both gut microbiome and host immune marker data into classification models can better distinguish CDI from other groups than can either type of data alone. Our classification models display robust diagnostic performance to differentiate CDI from Asymptomatic carriage (AUC~0.916), Non-CDI Diarrhea (AUC~0.917), or Non-CDI that combines all other three groups (AUC~0.929). Finally, we performed symbolic classification using selected features to derive simple mathematic formulas that explicitly quantify the interactions between the gut microbiome and host immune markers. These findings support the potential roles of gut microbiota and host immune markers in the pathogenesis of CDI. Our study provides new insights for a microbiome-immune marker-derived signature to diagnose CDI and design therapeutic strategies for CDI.
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Affiliation(s)
- Shanlin Ke
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MassachusettsUSA,School of Animal Science and Technology, State Key Laboratory of Pig Genetic Improvement and Production Technology, Jiangxi Agricultural University 330045, China
| | - Nira R. Pollock
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA,Department of Laboratory Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Xu-Wen Wang
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MassachusettsUSA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Qianyun Lin
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kevin W. Garey
- Department of Pharmacy Practice and Translation Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Anne J. Gonzales-Luna
- Department of Pharmacy Practice and Translation Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Ciarán P. Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA,Ciarán P. Kelly Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MassachusettsUSA
| | - Yang-Yu Liu
- Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MassachusettsUSA,CONTACT Yang-Yu Liu Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MassachusettsUSA
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15
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Zhou WY, Liu XY, Wang MM, Liang LP, Liu L, Zheng DK, Silvester JA, Ma WJ, Wu W, Ji GY, Xu YJ, Xu XJ, Kelly CP, Chen Y. Prevalence of celiac disease in China: Meta-analysis and serological survey in high-risk populations. J Dig Dis 2021; 22:645-655. [PMID: 34482631 DOI: 10.1111/1751-2980.13049] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To summarize data from a serological survey of high-risk populations in Guangdong Province, China, and to perform a meta-analysis to investigate the prevalence and seroprevalence of celiac disease (CD) in the Chinese general and high-risk populations. METHODS We collected data from the serological survey of high-risk population of CD in Guangdong Province, China (N = 1390) by testing their serum tissue transglutaminase immunoglobulin A (tTG-IgA), deamidated gliadin peptides immunoglobulin A (DGP-IgA) and deamidated gliadin peptides immunoglobulin G (DGP-IgG). Additionally, a literature search was performed on PubMed, EMBASE, Cochrane Library and three Chinese databases for articles published up to 20 December 2020 to estimate the pooled prevalence and seroprevalence of CD in China. RESULTS In the serological survey, 0.94% (13/1390) of individuals were positive for CD antibodies. In a meta-analysis of 18 studies, the seroprevalence of CD in the general Chinese population was 0.27% (95% confidence interval [CI] 0.02%-0.71%). While that in the high-risk population was 8.34% (95% CI 4.90%-12.54%) (odds ratio 7.27, 95% CI 4.06-13.04). The prevalence of biopsy-confirmed CD in high-risk Chinese populations was 4.44% (95% CI 1.53%-8.58%). The seroprevalence of CD varied with patients' geographical origin, being higher in northern China than in southern China. CONCLUSIONS Early diagnosis of CD by serological screening in high-risk population and generous serological testing in those with vague symptoms, especially in northern China, are recommended.
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Affiliation(s)
- Wan Yan Zhou
- Department of Gastroenterology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Xiu Ying Liu
- Department of Gastroenterology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Ming Ming Wang
- Department of Gastroenterology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Li Ping Liang
- Department of Gastroenterology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Le Liu
- Department of Gastroenterology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - De Kai Zheng
- Department of Gastroenterology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Jocelyn A Silvester
- Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Wen Jun Ma
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China
| | - Wei Wu
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China
| | - Gui Yuan Ji
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China
| | - Yan Jun Xu
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China
| | - Xiao Jun Xu
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, Guangdong Province, China
| | - Ciarán P Kelly
- Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts, USA.,Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ye Chen
- Department of Gastroenterology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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16
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Alonso CD, Kelly CP, Garey KW, Gonzales-Luna AJ, Williams D, Daugherty K, Cuddemi C, Villafuerte-Gálvez J, White NC, Chen X, Xu H, Sprague R, Barrett C, Miller M, Foussadier A, Lantz A, Banz A, Pollock NR. Ultrasensitive and quantitative toxin measurement correlates with baseline severity, severe outcomes, and recurrence among hospitalized patients with Clostridioides difficile infection. Clin Infect Dis 2021; 74:2142-2149. [PMID: 34537841 DOI: 10.1093/cid/ciab826] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 06/24/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Stool toxin concentrations may impact Clostridioides difficile infection (CDI) severity and outcomes. We correlated fecal C. difficile toxin concentrations, measured by an ultrasensitive and quantitative assay, with CDI baseline severity, attributable outcomes, and recurrence. METHODS We enrolled 615 hospitalized adults (≥ 18y) with CDI (acute diarrhea, positive stool NAAT, and decision to treat). Baseline stool toxin A and B concentrations were measured by Single Molecule Array. Subjects were classified by baseline CDI severity (four scoring methods) and outcomes within 40 days (death, ICU stay, colectomy, and recurrence). RESULTS Among 615 patients (median 68.0 years), in all scoring systems, subjects with severe baseline disease had higher stool toxin A+B concentrations than those without (P<0.01). Nineteen subjects (3.1%) had a severe outcome primarily-attributed to CDI (group 1). This group had higher median toxin A+B [14,303 pg/mL (IQR 416.0, 141,967)] than subjects in whom CDI only contributed to the outcome [group 2, 163.2 pg/mL(0.0, 8423.3)], subjects with severe outcome unrelated to CDI [group 3, 158.6 pg/mL (0.0, 1795.2)], or no severe outcome [group 4, 209.5 pg/mL (0.0, 8566.3)](P=0.003). Group 1 was more likely to have detectable toxin (94.7%) than groups 2-4 (60.5-66.1%)(P=0.02). Individuals with recurrence had higher toxin A+B [2266.8 pg/mL(188.8, 29411)] than those without [154.0 pg/mL(0.0, 5864.3)](P<0.001) and higher rates of detectable toxin (85.7% versus 64.0%, P=0.004). CONCLUSIONS In CDI patients, ultrasensitive stool toxin detection and concentration correlated with severe baseline disease, severe CDI-attributable outcomes, and recurrence, confirming the contribution of toxin quantity to disease presentation and clinical course.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ciarán P Kelly
- Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College, of Pharmacy, Houston, TX, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College, of Pharmacy, Houston, TX, USA
| | - David Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Christine Cuddemi
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Javier Villafuerte-Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nicole C White
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rebecca Sprague
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Caitlin Barrett
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Nira R Pollock
- Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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17
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Kelly CP, Murray JA, Leffler DA, Getts DR, Bledsoe AC, Smithson G, First MR, Morris A, Boyne M, Elhofy A, Wu TT, Podojil JR, Miller SD. TAK-101 Nanoparticles Induce Gluten-Specific Tolerance in Celiac Disease: A Randomized, Double-Blind, Placebo-Controlled Study. Gastroenterology 2021; 161:66-80.e8. [PMID: 33722583 PMCID: PMC9053078 DOI: 10.1053/j.gastro.2021.03.014] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [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: 11/16/2020] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS In celiac disease (CeD), gluten induces immune activation, leading to enteropathy. TAK-101, gluten protein (gliadin) encapsulated in negatively charged poly(dl-lactide-co-glycolic acid) nanoparticles, is designed to induce gluten-specific tolerance. METHODS TAK-101 was evaluated in phase 1 dose escalation safety and phase 2a double-blind, randomized, placebo-controlled studies. Primary endpoints included pharmacokinetics, safety, and tolerability of TAK-101 (phase 1) and change from baseline in circulating gliadin-specific interferon-γ-producing cells at day 6 of gluten challenge, in patients with CeD (phase 2a). Secondary endpoints in the phase 2a study included changes from baseline in enteropathy (villus height to crypt depth ratio [Vh:Cd]), and frequency of intestinal intraepithelial lymphocytes and peripheral gut-homing T cells. RESULTS In phase 2a, 33 randomized patients completed the 14-day gluten challenge. TAK-101 induced an 88% reduction in change from baseline in interferon-γ spot-forming units vs placebo (2.01 vs 17.58, P = .006). Vh:Cd deteriorated in the placebo group (-0.63, P = .002), but not in the TAK-101 group (-0.18, P = .110), although the intergroup change from baseline was not significant (P = .08). Intraepithelial lymphocyte numbers remained equal. TAK-101 reduced changes in circulating α4β7+CD4+ (0.26 vs 1.05, P = .032), αEβ7+CD8+ (0.69 vs 3.64, P = .003), and γδ (0.15 vs 1.59, P = .010) effector memory T cells. TAK-101 (up to 8 mg/kg) induced no clinically meaningful changes in vital signs or routine clinical laboratory evaluations. No serious adverse events occurred. CONCLUSIONS TAK-101 was well tolerated and prevented gluten-induced immune activation in CeD. The findings from the present clinical trial suggest that antigen-specific tolerance was induced and represent a novel approach translatable to other immune-mediated diseases. ClinicalTrials.gov identifiers: NCT03486990 and NCT03738475.
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Affiliation(s)
- Ciarán P. Kelly
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Daniel A. Leffler
- Beth Israel Deaconess Medical Center, Harvard Medical School Celiac Research Program, Boston, Massachusetts;,Takeda Pharmaceuticals International Co., Cambridge, Massachusetts
| | - Daniel R. Getts
- COUR Pharmaceuticals Development Co, Inc, Northbrook, Illinois;,Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Adam C. Bledsoe
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Glennda Smithson
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts
| | - M. Roy First
- COUR Pharmaceuticals Development Co, Inc, Northbrook, Illinois
| | - Amy Morris
- COUR Pharmaceuticals Development Co, Inc, Northbrook, Illinois
| | - Michael Boyne
- COUR Pharmaceuticals Development Co, Inc, Northbrook, Illinois
| | - Adam Elhofy
- COUR Pharmaceuticals Development Co, Inc, Northbrook, Illinois
| | - Tsung-Teh Wu
- Department of Pathology, Mayo Clinic, Rochester, Minnesota
| | - Joseph R. Podojil
- COUR Pharmaceuticals Development Co, Inc, Northbrook, Illinois;,Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stephen D. Miller
- Department of Microbiology-Immunology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois;,Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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18
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Alonso CD, Papamichael K, Sprague R, Barrett C, Gonzales-Luna AJ, Daugherty K, Garey KW, Villafuerte-Gálvez J, Xu H, Lin Q, Wang L, Chen X, Pollock NR, Kelly CP. Humoral Immune Response to Clostridioides difficile Toxins A and B in Hospitalized Immunocompromised Patients With C difficile Infection. Open Forum Infect Dis 2021; 8:ofab286. [PMID: 34258317 PMCID: PMC8271131 DOI: 10.1093/ofid/ofab286] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/26/2021] [Indexed: 11/14/2022] Open
Abstract
Background The humoral immune response to Clostridioides difficile toxins in C difficile infection (CDI) is incompletely characterized in immunocompromised hosts (ICHs). Methods We conducted a prospective study of hospitalized adults with CDI, with and without immunosuppression (hematologic malignancy, active solid tumor, solid organ or stem cell transplant, inflammatory bowel disease, autoimmune disease, congenital or acquired immunodeficiency, asplenia, chronic receipt of high-dose steroids, or receipt of immunosuppressing medications within 12 months). Serum and stool antibody concentrations of immunoglobulin (Ig)M, IgG, and IgA to C difficile toxins A and B at treatment days 0, 3, and 10–14 were compared. Results Ninety-eight subjects (47 ICH; 51 non-ICH) were enrolled. Baseline serum antitoxin A and B antibody levels were similar. At day 3, ICHs demonstrated lower serum levels of antitoxin A IgG, antitoxin A IgA, and antitoxin B IgA (all P < .05). At day 10–14, lower antitoxin A IgG concentrations were observed in ICHs (ICH, 21 enzyme-linked immunosorbent assay [ELISA] units; interquartile range [IQR], 16.4–44.6) compared with non-ICH subjects (49.0 ELISA units; IQR, 21.5–103; P = .045). In stool, we observed lower concentrations of antitoxin B IgA antibodies at baseline and at day 3 for ICH subjects, with a notable difference in concentrations of antitoxin B IgA at day 3 (ICH, 6.7 ELISA units [IQR, 1.9–13.9] compared with non-ICH, 18.1 ELISA units [IQR, 4.9–31.7]; P = .003). Conclusions The ICHs with CDI demonstrated lower levels of C difficile antitoxin antibodies in serum and stool during early CDI therapy compared with non-ICHs. These data provide insight into the humoral response to CDI in ICHs.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Konstantinos Papamichael
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rebecca Sprague
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Caitlin Barrett
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Kaitlyn Daugherty
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kevin W Garey
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Javier Villafuerte-Gálvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hua Xu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Qianyun Lin
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lamei Wang
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,College of Animal Science and Technology, Northwest A&F University, Yangling, Shaanxi Province, China
| | - Xinhua Chen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nira R Pollock
- Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Laboratory Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ciarán P Kelly
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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19
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Kelly CP, Poxton IR, Shen J, Wilcox MH, Gerding DN, Zhao X, Laterza OF, Railkar R, Guris D, Dorr MB. Effect of Endogenous Clostridioides difficile Toxin Antibodies on Recurrence of C. difficile Infection. Clin Infect Dis 2021; 71:81-86. [PMID: 31628838 DOI: 10.1093/cid/ciz809] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 03/13/2019] [Accepted: 09/30/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Endogenous antibodies (eAbs) against Clostridioides (Clostridium) difficile toxins may protect against recurrence of C. difficile infection (rCDI). This hypothesis was tested using placebo group data from MODIFY (Monoclonal Antibodies for C. difficile Therapy) I and II (NCT01241552 and NCT01513239, respectively), global, randomized phase 3 trials that assessed the efficacy and safety of the antitoxin monoclonal antibodies bezlotoxumab and actoxumab in participants receiving antibiotic therapy for CDI. METHODS A placebo infusion (normal saline) was administered on study day 1. Serum samples were collected on day 1, week 4, and week 12, and eAb-A and eAb-B titers were measured by 2 validated electrochemiluminescence immunoassays. Rates of initial clinical cure and rCDI were summarized by eAb titer category (low, medium, high) at each time point. RESULTS Serum eAb titers were available from a total of 773 participants. The proportion of participants with high eAb-A and eAb-B titers increased over time. Rates of initial clinical cure were similar across eAb titer categories. There was no correlation between eAb-A titers and rCDI rate at any time point. However, there was a negative correlation between rCDI and eAb-B titer on day 1 and week 4. rCDI occurred in 22% of participants with high eAb-B titers at baseline compared with 35% with low or medium titers (P = .015). CONCLUSIONS Higher eAb titers against toxin B, but not toxin A, were associated with protection against rCDI. These data are consistent with the observed efficacy of bezlotoxumab, and lack of efficacy of actoxumab, in the MODIFY trials. CLINICAL TRIALS REGISTRATION NCT01241552 and NCT01513239.
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Affiliation(s)
- Ciarán P Kelly
- Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ian R Poxton
- University of Edinburgh, Edinburgh, United Kingdom
| | | | - Mark H Wilcox
- Leeds Teaching Hospitals and University of Leeds, United Kingdom
| | - Dale N Gerding
- Loyola University Chicago Stritch School of Medicine, Maywood.,Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois
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20
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Leonard MM, Silvester JA, Leffler D, Fasano A, Kelly CP, Lewis SK, Goldsmith JD, Greenblatt E, Kwok WW, McAuliffe WJ, Galinsky K, Siegelman J, Chow IT, Wagner JA, Sapone A, Smithson G. Evaluating Responses to Gluten Challenge: A Randomized, Double-Blind, 2-Dose Gluten Challenge Trial. Gastroenterology 2021; 160:720-733.e8. [PMID: 33130104 PMCID: PMC7878429 DOI: 10.1053/j.gastro.2020.10.040] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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] [Received: 05/07/2020] [Revised: 10/15/2020] [Accepted: 10/25/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Gluten challenge is used to diagnose celiac disease (CeD) and for clinical research. Sustained gluten exposure reliably induces histologic changes but is burdensome. We investigated the relative abilities of multiple biomarkers to assess disease activity induced by 2 gluten doses, and aimed to identify biomarkers to supplement or replace histology. METHODS In this randomized, double-blind, 2-dose gluten-challenge trial conducted in 2 US centers (Boston, MA), 14 adults with biopsy-proven CeD were randomized to 3 g or 10 g gluten/d for 14 days. The study was powered to detect changes in villous height to crypt depth, and stopped at planned interim analysis on reaching this end point. Additional end points included gluten-specific cluster of differentiation (CD)4 T-cell analysis with HLA-DQ2-gluten tetramers and enzyme-linked immune absorbent spot, gut-homing CD8 T cells, interleukin-2, symptoms, video capsule endoscopy, intraepithelial leukocytes, and tissue multiplex immunofluorescence. RESULTS All assessments showed changes with gluten challenge. However, time to maximal change, change magnitude, and gluten dose-response relationship varied. Villous height to crypt depth, video capsule endoscopy enteropathy score, enzyme-linked immune absorbent spot, gut-homing CD8 T cells, intraepithelial leukocyte counts, and HLA-DQ2-restricted gluten-specific CD4 T cells showed significant changes from baseline at 10 g gluten only; symptoms were significant at 3 g. Symptoms and plasma interleukin-2 levels increased significantly or near significantly at both doses. Interleukin-2 appeared to be the earliest, most sensitive marker of acute gluten exposure. CONCLUSIONS Modern biomarkers are sensitive and responsive to gluten exposure, potentially allowing less invasive, lower-dose, shorter-duration gluten ingestion. This work provides a preliminary framework for rational design of gluten challenge for CeD research. ClinicalTrials.gov number, NCT03409796.
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Affiliation(s)
- Maureen M Leonard
- Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, Massachusetts; Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts
| | - Jocelyn A Silvester
- Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts; Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel Leffler
- Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts; Takeda Pharmaceuticals Inc Co, Cambridge, Massachusetts
| | - Alessio Fasano
- Center for Celiac Research and Treatment, Massachusetts General Hospital, Boston, Massachusetts; Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts
| | - Ciarán P Kelly
- Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts; Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Suzanne K Lewis
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jeffrey D Goldsmith
- Celiac Disease Research Program, Harvard Medical School, Boston, Massachusetts; Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | | | - William W Kwok
- Benaroya Research Institute at Virginia Mason, Seattle, Washington
| | | | | | | | - I-Ting Chow
- Benaroya Research Institute at Virginia Mason, Seattle, Washington
| | - John A Wagner
- Takeda Pharmaceuticals Inc Co, Cambridge, Massachusetts
| | - Anna Sapone
- Takeda Pharmaceuticals Inc Co, Cambridge, Massachusetts
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21
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Jordan RW, Kelly CP, Pap G, Joudet T, Nyffeler RW, Reuther F, Irlenbusch U. Mid-term results of a stemless ceramic on polyethylene shoulder prosthesis - A prospective multicentre study. Shoulder Elbow 2021; 13:67-77. [PMID: 33717220 PMCID: PMC7905519 DOI: 10.1177/1758573219866431] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/09/2019] [Accepted: 07/05/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Early reports of stemless shoulder arthroplasty have shown promising clinical and radiological outcomes. The purpose of this study was to report on the mid-term results of an implant that utilises a ceramic humeral head. METHODS A prospective, consecutive, multicentre study of stemless shoulder prosthesis with a minimum of four years of follow-up was conducted between August 2009 and May 2012. The adjusted Constant-Murley Score (CMS), revision rate and presence of radiolucent lines were recorded at intervals. RESULTS A total of 207 patients were eligible for study inclusion; 62.8% were female and mean age was 64.8 years (range 30-86). Mean follow-up was 70.7 months (range 48-100), 73% underwent TSA and 27% hemiarthroplasty. The mean CMS improvement was 42.6 (p < 0.0001) at 48 months. Radiolucencies were present in 2.7% of humeral zones and 14% of glenoid zones at 48-month follow-up. The revision rate was 6.3% with rotator cuff failure (2.9%) the most common indication. CONCLUSIONS Mid-term results demonstrate that the studied stemless implant with a ceramic humeral head had clinical and radiological outcomes that are comparable to other reported studies.
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Affiliation(s)
- RW Jordan
- Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry, England,RW Jordan, Robert Jones & Agnes Hunt Orthopaedic Hospital Gobowen, Oswestry SY10 7AG, England.
| | - CP Kelly
- Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry, England
| | - G Pap
- Helios Park-Hospital Leipzig, Leipzig, Germany
| | - T Joudet
- Clinique du Libournais, Libourne, France
| | | | - F Reuther
- DRK Clinic Berlin Koepenick, Berlin, Germany
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22
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Chen X, Yang X, de Anda J, Huang J, Li D, Xu H, Shields KS, Džunková M, Hansen J, Patel IJ, Yee EU, Golenbock DT, Grant MA, Wong GCL, Kelly CP. Clostridioides difficile Toxin A Remodels Membranes and Mediates DNA Entry Into Cells to Activate Toll-Like Receptor 9 Signaling. Gastroenterology 2020; 159:2181-2192.e1. [PMID: 32841647 PMCID: PMC8720510 DOI: 10.1053/j.gastro.2020.08.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 04/22/2020] [Revised: 07/31/2020] [Accepted: 08/18/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Clostridioides difficile toxin A (TcdA) activates the innate immune response. TcdA co-purifies with DNA. Toll-like receptor 9 (TLR9) recognizes bacterial DNA to initiate inflammation. We investigated whether DNA bound to TcdA activates an inflammatory response in murine models of C difficile infection via activation of TLR9. METHODS We performed studies with human colonocytes and monocytes and macrophages from wild-type and TLR9 knockout mice incubated with TcdA or its antagonist (ODN TTAGGG) or transduced with vectors encoding TLR9 or small-interfering RNAs. Cytokine production was measured with enzyme-linked immunosorbent assay. We studied a transduction domain of TcdA (TcdA57-80), which was predicted by machine learning to have cell-penetrating activity and confirmed by synchrotron small-angle X-ray scattering. Intestines of CD1 mice, C57BL6J mice, and mice that express a form of TLR9 that is not activated by CpG DNA were injected with TcdA, TLR9 antagonist, or both. Enterotoxicity was estimated based on loop weight to length ratios. A TLR9 antagonist was tested in mice infected with C difficile. We incubated human colon explants with an antagonist of TLR9 and measured TcdA-induced production of cytokines. RESULTS The TcdA57-80 protein transduction domain had membrane remodeling activity that allowed TcdA to enter endosomes. TcdA-bound DNA entered human colonocytes. TLR9 was required for production of cytokines by cultured cells and in human colon explants incubated with TcdA. TLR9 was required in TcdA-induced mice intestinal secretions and in the survival of mice infected by C difficile. Even in a protease-rich environment, in which only fragments of TcdA exist, the TcdA57-80 domain organized DNA into a geometrically ordered structure that activated TLR9. CONCLUSIONS TcdA from C difficile can bind and organize bacterial DNA to activate TLR9. TcdA and TcdA fragments remodel membranes, which allows them to access endosomes and present bacterial DNA to and activate TLR9. Rather than inactivating the ability of DNA to bind TLR9, TcdA appears to chaperone and organize DNA into an inflammatory, spatially periodic structure.
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Affiliation(s)
- Xinhua Chen
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Xiaotong Yang
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA,Institute of Microbiology and Immunology, College of Life Sciences, Shanghai Normal University, Shanghai, China
| | - Jaime de Anda
- Department of Bioengineering, Department of Chemistry and Biochemistry, California Nano Systems Institute, University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Jun Huang
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA,Department of Colorectal Surgery, the 6th Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dan Li
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hua Xu
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kelsey S. Shields
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mária Džunková
- DOE Joint Genome Institute, Lawrence Berkeley National Laboratory, Berkeley, California, USA
| | - Joshua Hansen
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Eric U. Yee
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Douglas T. Golenbock
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marianne A. Grant
- Division of Molecular and Vascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gerard C. L. Wong
- Department of Bioengineering, Department of Chemistry and Biochemistry, California Nano Systems Institute, University of California, Los Angeles, Los Angeles, CA 90095, USA,Corresponding Authors: Xinhua Chen, PhD, , or Gerard C. L. Wong, PhD,
| | - Ciarán P. Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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23
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Dubberke ER, Gerding DN, Kelly CP, Garey KW, Rahav G, Mosley A, Tipping R, Dorr MB. Efficacy of Bezlotoxumab in Participants Receiving Metronidazole, Vancomycin, or Fidaxomicin for Treatment of Clostridioides ( Clostridium) difficile Infection. Open Forum Infect Dis 2020; 7:ofaa157. [PMID: 32523972 PMCID: PMC7264839 DOI: 10.1093/ofid/ofaa157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/15/2020] [Indexed: 01/05/2023] Open
Abstract
Background In phase 3 MODIFY I/II trials, bezlotoxumab significantly reduced recurrence of Clostridioides (Clostridium) difficile infection (rCDI) over 12 weeks. Choice of CDI antibacterial treatment may affect CDI-related outcomes; therefore, this prespecified analysis assessed if the magnitude of bezlotoxumab-induced rCDI reduction was influenced by the antibiotic administered. Methods In MODIFY I/II (NCT01241552/NCT01513239), participants received a single infusion of bezlotoxumab (10 mg/kg) or placebo during anti-CDI treatment. Using pooled data from MODIFY I/II, initial clinical cure (ICC) and rCDI were assessed in metronidazole-, vancomycin-, and fidaxomicin-treated subgroups. Results Of 1554 participants in MODIFY I/II, 753 (48.5%) received metronidazole, 745 (47.9%) vancomycin, and 56 (3.6%) fidaxomicin. Fewer participants receiving metronidazole had a prior CDI episode in the previous 6 months (12.9%) or ≥1 risk factor for rCDI (66.0%) vs participants receiving vancomycin (41.2% and 83.6%, respectively) and fidaxomicin (55.4% and 89.3%, respectively). ICC rates were similar in the bezlotoxumab (metronidazole, 81.0%; vancomycin, 78.5%; fidaxomicin, 86.7%) and placebo groups (metronidazole, 81.3%; vancomycin, 79.6%; fidaxomicin, 76.9%). In placebo-treated participants, the rCDI was lower in the metronidazole subgroup vs the vancomycin and fidaxomicin subgroups (metronidazole, 28.0%; vancomycin, 38.4%; fidaxomicin, 35.0%). When analyzed by subsets based on history of CDI, rCDI rates were similar in the metronidazole and vancomycin groups. rCDI rates were lower in all antibiotic subgroups for bezlotoxumab vs placebo (metronidazole: rate difference [RD], –9.7%; 95% confidence interval [CI], –16.4% to –3.1%; vancomycin: RD, –15.4%; 95% CI, –22.7% to –8.0%; fidaxomicin: RD, –11.9%; 95% CI, –38.1% to 14.3%). Conclusion Bezlotoxumab reduces rCDI vs placebo in participants receiving metronidazole and vancomycin, with a similar effect size in participants receiving fidaxomicin.
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Affiliation(s)
- Erik R Dubberke
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Ciarán P Kelly
- BIDMC & Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, Texas, USA
| | - Galia Rahav
- Sheba Medical Center and The Sackler Faculty of Medicine, Tel Hashomer, Israel
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24
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Silvester JA, Comino I, Kelly CP, Sousa C, Duerksen DR. Most Patients With Celiac Disease on Gluten-Free Diets Consume Measurable Amounts of Gluten. Gastroenterology 2020; 158:1497-1499.e1. [PMID: 31866245 PMCID: PMC7103503 DOI: 10.1053/j.gastro.2019.12.016] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/09/2019] [Accepted: 12/15/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Jocelyn A Silvester
- Harvard Medical School Celiac Research Program, Boston, Massachusetts; Boston Children's Hospital, Boston, Massachusetts; Beth Israel Deaconess Medical Center, Boston, Massachusetts; Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Isabel Comino
- Department Microbiology y Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Ciarán P Kelly
- Harvard Medical School Celiac Research Program, Boston, USA,Beth Israel Deaconess Medical Center, Boston, USA
| | - Carolina Sousa
- Department Microbiology y Parasitology, Faculty of Pharmacy, University of Seville, Seville, Spain
| | - Donald R Duerksen
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada,St Boniface Hospital, Winnipeg, Manitoba, Winnipeg, Canada
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25
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Kassam Z, Dubois N, Ramakrishna B, Ling K, Qazi T, Smith M, Kelly CR, Fischer M, Allegretti JR, Budree S, Panchal P, Kelly CP, Osman M. Donor Screening for Fecal Microbiota Transplantation. N Engl J Med 2019; 381:2070-2072. [PMID: 31665572 DOI: 10.1056/nejmc1913670] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [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: 11/19/2022]
Affiliation(s)
| | | | | | | | | | | | - Colleen R Kelly
- Warren Alpert Medical School of Brown University, Providence, RI
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26
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Madoff SE, Urquiaga M, Alonso CD, Kelly CP. Prevention of recurrent Clostridioides difficile infection: A systematic review of randomized controlled trials. Anaerobe 2019; 61:102098. [PMID: 31493500 DOI: 10.1016/j.anaerobe.2019.102098] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [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: 02/04/2019] [Revised: 08/28/2019] [Accepted: 09/03/2019] [Indexed: 02/06/2023]
Abstract
Recurrent Clostridioides (formerly Clostridium) difficile infection (rCDI) is common, and patients who have had one recurrence are more likely to have multiple recurrences. Frequent recurrences have been associated with increased morbidity and mortality, high healthcare costs, and lower quality of life. In this review, we compare the efficacy of interventions designed to prevent rCDI. We performed a systematic review of the English literature, including randomized controlled trials (RCTs) that evaluated rCDI as an outcome. Studies were included irrespective of patient demographics, disease severity, type of intervention, comparator used, or time-point of outcome evaluation. We performed a comprehensive literature search with the assistance of a research librarian. Two reviewers independently extracted data and assessed risk of bias. Our search yielded 38 RCTs (8,102 participants). Nineteen RCTs (3,743 subjects) evaluated antibiotics, eight fecal microbiota transplantation (FMT) (582 subjects), three monoclonal antibodies (MAbs) (2,805 subjects), and eight probiotics, prebiotics, or non-antibiotic polymers (972 subjects). The antibiotic and FMT therapies that demonstrated efficacy in rCDI prevention included: fidaxomicin (when compared to a ten-day vancomycin course) and FMT administered by nasogastric tube (when compared to a fourteen-day vancomycin course and a fourteen-day vancomycin course plus bowel lavage). Actoxumab (MAb against C. difficile toxin A; CDA1) plus bezlotoxumab (MAb against C. difficile toxin B; CDB1) in combination or bezlotoxumab alone appeared to be more effective in preventing rCDI compared to actoxumab alone. Of the prebiotics, probiotics, and nonantibiotic polymers, oligofructose, Saccharomyces boulardii, and the nontoxigenic C. difficile strain M3 were the most efficacious for rCDI prevention. Thirty-eight RCTs (>8,000 participants) evaluating treatment modalities for CDI were examined for efficacy in prevention of rCDI. Several CDI-specific antibiotics, FMT modalities, monoclonal antibodies, and various prebiotics and probiotics demonstrated a reduction in risk of rCDI with the greatest risk reduction observed with FMT and monoclonal antibody therapy. It is notable that the comparators in these studies were very different from one another and the relative risk reduction of rCDI may not be directly comparable from one study to the next.
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Affiliation(s)
- Sarah E Madoff
- Tufts University School of Medicine, Boston, MA, USA; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Mariana Urquiaga
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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27
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Kelly CP, Wilcox MH, Glerup H, Aboo N, Ellison MC, Eves K, Dorr MB. Bezlotoxumab for Clostridium difficile Infection Complicating Inflammatory Bowel Disease. Gastroenterology 2018; 155:1270-1271. [PMID: 30227108 DOI: 10.1053/j.gastro.2018.06.080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/18/2018] [Indexed: 12/02/2022]
Affiliation(s)
| | - Mark H Wilcox
- Leeds Teaching Hospitals and University of Leeds, Leeds, UK
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Jaiswal A, Malhotra A, Hay S, Kelly CP. Revision shoulder arthroplasty for failed surface replacement hemiarthroplasty. Musculoskelet Surg 2018; 103:69-75. [PMID: 29744735 DOI: 10.1007/s12306-018-0541-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 07/28/2017] [Accepted: 05/01/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE The aim of this study was to assess the reasons of failure of shoulder surface replacement hemiarthroplasty (SRH) and to evaluate the outcome of revision surgery. METHOD The study group included 25 patients (26 shoulders) with failed SRHs. The mean time to revision surgery was 3.6 years. Their functional outcome was evaluated using adjusted Constant-Murley score at mean follow-up of 5.2 years (range 2-16 years). RESULT Most common cause of failure was glenoid erosion (42%) and progressive failure of rotator cuff (31%). Median adjusted Constant-Murley score at mean follow-up of 5.2 years was 51.6. Median adjusted Constant-Murley score in patients who had primary diagnosis of osteoarthritis and had revision performed to anatomic TSA (14 shoulders) was 85 (range 40-100) at mean follow-up of 5 years compared to 36.3 (range 20-66.3) in the remaining patients at 5.4 years, p = 0.00008. CONCLUSION Revision surgery for failed SRH can be technically challenging with variable results. Most common mode of failure was glenoid erosion. Functional outcomes are better in those with revision performed to anatomic TSA.
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Affiliation(s)
- A Jaiswal
- Upper Limb Unit, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK.
| | - A Malhotra
- Upper Limb Unit, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - S Hay
- Upper Limb Unit, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - C P Kelly
- Upper Limb Unit, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
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Syage JA, Kelly CP, Dickason MA, Ramirez AC, Leon F, Dominguez R, Sealey-Voyksner JA. Determination of gluten consumption in celiac disease patients on a gluten-free diet. Am J Clin Nutr 2018; 107:201-207. [PMID: 29529159 DOI: 10.1093/ajcn/nqx049] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/29/2017] [Indexed: 12/11/2022] Open
Abstract
Background Celiac disease (CD) patients adhering to a gluten-free diet (GFD) are exposed frequently to low levels of gluten that contribute to symptoms and persistent intestinal histologic damage. Objective We analyzed prior clinical data to determine how much gluten is accidentally consumed while on a GFD. The aim was to understand the range of gluten consumption for a wide distribution of CD patients. Design A meta-analysis was conducted on data from 2 different clinical programs: 1) measurements of gluten in stool and urine in CD and non-CD populations; and 2) analysis of data from trials for the investigational therapeutic latiglutenase. The stool and urine studies included controlled gluten challenges. A calibration factor was applied that allowed normal ingestion of gluten to be computed from the urine and stool measurements. From the latiglutenase trial data, a determination of gluten consumption was made by estimating how much gluten was eliminated from patients' diets due to a trial effect that led to improved histology even in the placebo group. Results The average inadvertent exposure to gluten by CD individuals on a GFD was estimated to be ∼150-400 (mean) and ∼100-150 (median) mg/d using the stool test and ∼300-400 (mean) and ∼150 (median) mg/d using the urine test. The analyses of the latiglutenase data for CD individuals with moderate to severe symptoms indicate that patients ingested significantly >200 mg/d of gluten. Conclusions These surrogate biomarkers of gluten ingestion indicate that many individuals following a GFD regularly consume sufficient gluten to trigger symptoms and perpetuate intestinal histologic damage.
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Affiliation(s)
| | - Ciarán P Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
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Silvester JA, Kurada S, Szwajcer A, Kelly CP, Leffler DA, Duerksen DR. Tests for Serum Transglutaminase and Endomysial Antibodies Do Not Detect Most Patients With Celiac Disease and Persistent Villous Atrophy on Gluten-free Diets: a Meta-analysis. Gastroenterology 2017; 153:689-701.e1. [PMID: 28545781 PMCID: PMC5738024 DOI: 10.1053/j.gastro.2017.05.015] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [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: 01/08/2017] [Revised: 05/09/2017] [Accepted: 05/15/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Tests to measure serum endomysial antibodies (EMA) and antibodies to tissue transglutaminase (tTG) were developed to screen for celiac disease in patients consuming gluten. However, they are commonly used to monitor patients on a gluten-free diet (GFD). We conducted a meta-analysis to assess the sensitivity and specificity of tTG IgA and EMA IgA assays in identifying patients with celiac disease who have persistent villous atrophy despite a GFD. METHODS We searched PUBMED, EMBASE, BIOSIS, SCOPUS, clinicaltrials.gov, Science Citation Index, and Cochrane Library databases through November 2016. Inclusion criteria were studies of subjects with biopsy-confirmed celiac disease, follow-up biopsies, and measurement of serum antibodies on a GFD, biopsy performed on subjects regardless of symptoms, or antibody test results. Our analysis excluded subjects with refractory celiac disease, undergoing gluten challenge, or consuming a prescribed oats-containing GFD. Tests were considered to have positive or negative findings based on manufacturer cut-off values. Villous atrophy was defined as a Marsh 3 lesion or villous height:crypt depth ratio below 3.0. We constructed forest plots to determine the sensitivity and specificity of detection for individual studies. For the meta-analysis, a bivariate random effects model was used to jointly model sensitivity and specificity. RESULTS Our search identified 5408 unique citations. Following review of abstracts, 442 articles were reviewed in detail. Only 26 studies (6 of tTG assays, 15 of EMA assays, and 5 of tTG and EMA assays) met our inclusion criteria. The most common reason studies were excluded from our analysis was inability to cross-tabulate histologic and serologic findings. The serum assays identified patients with persistent villous atrophy with high levels of specificity: 0.83 for the tTG IgA assay (95% CI, 0.79-0.87) and 0.91 for the EMA IgA assay (95% CI, 0.87-0.94). However, they detected villous atrophy with low levels of sensitivity: 0.50 for the tTG IgA assay (95% CI, 0.41-0.60) and 0.45 for the EMA IgA assay (95% CI, 0.34-0.57). The tests had similar levels of performance in pediatric and adult patients. CONCLUSIONS In a meta-analysis of patients with biopsy-confirmed celiac disease undergoing follow-up biopsy on a GFD, we found that tests for serum tTG IgA and EMA IgA levels had low sensitivity (below 50%) in detection of persistent villous atrophy. We need more-accurate non-invasive markers of mucosal damage in children and adults with celiac disease who are following a GFD.
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Affiliation(s)
- Jocelyn A Silvester
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 3P5,Celiac Research Program, Harvard Medical School,Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
| | - Satya Kurada
- Celiac Research Program, Harvard Medical School,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
| | - Andrea Szwajcer
- University of Manitoba Health Sciences Libraries, Winnipeg, MB, Canada
| | - Ciarán P Kelly
- Celiac Research Program, Harvard Medical School,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
| | - Daniel A Leffler
- Celiac Research Program, Harvard Medical School,Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215
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Alonso CD, Braun DA, Patel I, Akbari M, Oh DJ, Jun T, McMasters M, Hammond SP, Glotzbecker B, Cutler C, Leffler DA, Ballen KK, Kelly CP. A multicenter, retrospective, case-cohort study of the epidemiology and risk factors for Clostridium difficile infection among cord blood transplant recipients. Transpl Infect Dis 2017; 19. [PMID: 28544102 DOI: 10.1111/tid.12728] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 02/02/2017] [Accepted: 03/18/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is the leading cause of health-care associated infectious diarrhea. The aim of this study was to evaluate the epidemiology and risk factors for CDI in the 100 days following umbilical cord blood transplantation (UCBT) at three Boston hospitals. METHODS We performed a multicenter, retrospective, case-cohort study of 226 UCBT recipients at Beth Israel Deaconess Medical Center, Massachusetts General Hospital, and Dana Farber/Brigham and Women's Cancer Center from 2003 to 2012. CDI was defined as diarrhea (≥3 unformed bowel movements for at least 2 days) plus a positive stool test for toxinogenic C. difficile and not attributed to any other cause. RESULTS Among 226 UCBT recipients, 22 patients (9.7%) developed CDI within the first 100 days of transplant (corresponding to an infection rate of 10.8 cases per 10 000 person-days). The 100-day and 1-year rates were stable across the time period and between institutions. UCBT recipients with CDI were more likely than non-CDI patients to be older, with higher body mass indices, and to have received an antipseudomonal penicillin agent. In a time-dependent case-cohort analysis of the risk factors associated with CDI in the first 100 days after UCBT, bacterial infection after UCBT was the strongest risk factor for CDI (hazard ratio 2.8; 95% confidence interval 1.08-7.24; P=.03), after adjustment for transplant variables including antibiotic exposure. CONCLUSION This study verifies the previously reported risk factors for CDI including older age and antibiotic exposure and identifies a novel association between bacterial infections and risk for CDI.
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Affiliation(s)
- Carolyn D Alonso
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David A Braun
- Dana-Farber/Partners CancerCare Program, Boston, MA, USA
| | - Ishan Patel
- Department of Medicine, Icahn School of Medicine, Elmhurst Program, New York, NY, USA
| | - Mona Akbari
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel Jungmyung Oh
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tomi Jun
- Stanford Health Care, Stanford, CA, USA
| | - Malgorzata McMasters
- Section of Hematological Malignancies and Bone Marrow Transplantation, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah P Hammond
- Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA
| | - Brett Glotzbecker
- Dana Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA, USA
| | - Corey Cutler
- Dana Farber Cancer Institute/Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Karen K Ballen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Ciarán P Kelly
- Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Abstract
Clostridium difficile infection (CDI) is the most common nosocomial infection in the U.S. 25% of CDI patients go on to develop recurrent CDI (rCDI) following current standard of care (SOC) therapy, leading to morbidity, mortality and economic loss. The first passive immunotherapy drug targeting C.difficile toxin B (bezlotoxumab) has been approved recently by the FDA and EMA for prevention of rCDI. Areas covered: A body of key studies was selected and reviewed by the authors. The unmet needs in CDI care were ascertained with emphasis in rCDI, including the epidemiology, pathophysiology and current management. The current knowledge about the immune response to C. difficile toxins and how this knowledge led to the development and the clinical use of bezlotoxumab is described. Current and potential future competitors to the drug were examined. Expert commentary: A single 10 mg/kg intravenous infusion of bezlotoxumab has been shown to decrease rCDI by ~40% (absolute reduction ~10%) in patients being treated for primary CDI or rCDI with SOC antibiotics. Targeting C.difficile toxins by passive immunotherapy is a novel mechanism for prevention of C.difficile infection. Bezlotoxumab will be a valuable adjunctive therapy to reduce the burden of CDI.
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Affiliation(s)
- Javier A Villafuerte Gálvez
- a Department of Medicine , Harvard Medical School , Boston , MA
- b Department of Medicine - Division of Hematology and Oncology , Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Ciarán P Kelly
- a Department of Medicine , Harvard Medical School , Boston , MA
- c Department of Medicine - Division of Gastroenterology , Beth Israel Deaconess Medical Center , Boston , MA , USA
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Mahadev S, Murray JA, Wu TT, Chandan VS, Torbenson MS, Kelly CP, Maki M, Green PHR, Adelman D, Lebwohl B. Factors associated with villus atrophy in symptomatic coeliac disease patients on a gluten-free diet. Aliment Pharmacol Ther 2017; 45:1084-1093. [PMID: 28220520 DOI: 10.1111/apt.13988] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [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: 10/13/2016] [Revised: 10/25/2016] [Accepted: 01/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Duodenal injury persists in some coeliac disease patients despite gluten-free diet, and is associated with adverse outcomes. AIM To determine the prevalence and clinical risk factors for persistent villus atrophy among symptomatic coeliac disease patients. METHODS A nested cross-sectional analysis was performed on coeliac disease patients with self-reported moderate or severe symptoms while following a gluten-free diet, who underwent protocol-mandated duodenal biopsy upon enrolment in the CeliAction clinical trial. Demographic factors, symptom type, medication use, and serology were examined to determine predictors of persistent villus atrophy. RESULTS Of 1345 symptomatic patients, 511 (38%, 95% CI, 35-41%) were found to have active coeliac disease with persistent villus atrophy, defined as average villus height to crypt depth ratio ≤2.0. On multivariable analysis, older age (OR, 5.1 for ≥70 vs. 18-29 years, 95% CI, 2.5-10.4) was a risk factor while longer duration on gluten-free diet was protective (OR, 0.37, 95% CI, 0.24-0.55 for 4-5.9 vs. 1-1.9 years). Villus atrophy was associated with use of proton-pump inhibitors (PPIs; OR, 1.6, 95% CI, 1.1-2.3), non-steroidal anti-inflammatory drugs (NSAIDs; OR, 1.64, 95% CI, 1.2-2.2), and selective serotonin reuptake inhibitors (SSRIs; OR, 1.74, 95% CI, 1.2-2.5). Symptoms were not associated with villus atrophy after adjusting for covariates. Conclusions A majority of symptomatic coeliac disease patients did not have active disease on follow-up histology. Symptoms were poorly predictive of persistent mucosal injury. The impact of NSAIDs, PPIs, and SSRIs on mucosal healing in coeliac disease warrants further study.
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Affiliation(s)
- S Mahadev
- Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, USA
| | - J A Murray
- Division of Gastroenterology and Hepatology, The Mayo Clinic, Rochester, MN, USA
| | - T-T Wu
- Department of Laboratory Medicine and Pathology, The Mayo Clinic, Rochester, MN, USA
| | - V S Chandan
- Department of Laboratory Medicine and Pathology, The Mayo Clinic, Rochester, MN, USA
| | - M S Torbenson
- Department of Laboratory Medicine and Pathology, The Mayo Clinic, Rochester, MN, USA
| | - C P Kelly
- Celiac Center, Beth Israel Deaconess Medical Center and Celiac Research Program, Harvard Medical School, Boston, MA, USA
| | - M Maki
- Tampere Center for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Finland, Europe
| | - P H R Green
- Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, USA
| | - D Adelman
- Division of Allergy/Immunology, Department of Medicine, University of California, San Francisco, CA, USA
| | - B Lebwohl
- Celiac Disease Center, Columbia University College of Physicians and Surgeons, New York, USA
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Leffler DA, Acaster S, Gallop K, Dennis M, Kelly CP, Adelman DC. A Novel Patient-Derived Conceptual Model of the Impact of Celiac Disease in Adults: Implications for Patient-Reported Outcome and Health-Related Quality-of-Life Instrument Development. Value Health 2017; 20:637-643. [PMID: 28408006 DOI: 10.1016/j.jval.2016.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 12/02/2016] [Accepted: 12/21/2016] [Indexed: 06/07/2023]
Abstract
BACKGROUND Celiac disease is a chronic inflammatory condition with wide ranging effects on individual's lives caused by a combination of symptoms and the burden of adhering to a gluten-free diet (GFD). OBJECTIVES To further understand patients' experience of celiac disease, the impact it has on health-related quality of life (HRQOL), and to develop a conceptual model describing this impact. METHODS Adults with celiac disease on a GFD reporting symptoms within the previous 3 months were included; patients with refractory celiac disease and confounding medical conditions were excluded. A semistructured discussion guide was developed exploring celiac disease symptoms and impact on patients' HRQOL. An experienced interviewer conducted in-depth interviews. The data set was coded and analyzed using thematic analysis to identify concepts, themes, and the inter-relationships between them. Data saturation was monitored and concepts identified formed the basis of the conceptual model. RESULTS Twenty-one participants were recruited, and 32 distinct gluten-related symptoms were reported and data saturation was reached. Analysis identified several themes impacting patients' HRQOL: fears and anxiety, day-to-day management of celiac disease, physical functioning, sleep, daily activities, social activities, emotional functioning, and relationships. The conceptual model highlights the main areas of impact and the relationships between concepts. CONCLUSIONS Both symptoms and maintaining a GFD have a substantial impact on patient functioning and HRQOL in adults with celiac disease. The conceptual model derived from these data may help to design future patient-reported outcomes as well as interventions to improve the quality of life in an individual with celiac disease.
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Affiliation(s)
- Daniel A Leffler
- Celiac Center, Beth Israel Deaconess Medical Center, Boston, MA, USA; Celiac Research Program, Harvard Medical School, Boston, MA, USA.
| | | | | | - Melinda Dennis
- Celiac Center, Beth Israel Deaconess Medical Center, Boston, MA, USA; Celiac Research Program, Harvard Medical School, Boston, MA, USA
| | - Ciarán P Kelly
- Celiac Center, Beth Israel Deaconess Medical Center, Boston, MA, USA; Celiac Research Program, Harvard Medical School, Boston, MA, USA
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Murray JA, Kelly CP, Green PHR, Marcantonio A, Wu TT, Mäki M, Adelman DC. No Difference Between Latiglutenase and Placebo in Reducing Villous Atrophy or Improving Symptoms in Patients With Symptomatic Celiac Disease. Gastroenterology 2017; 152:787-798.e2. [PMID: 27864127 DOI: 10.1053/j.gastro.2016.11.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [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: 04/14/2016] [Revised: 11/04/2016] [Accepted: 11/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gluten ingestion leads to symptoms and small intestinal mucosal injury in patients with celiac disease. The only option is the strict lifelong exclusion of dietary gluten, which is difficult to accomplish. Many patients following a gluten-free diet continue to have symptoms and have small intestinal mucosal injury. Nondietary therapies are needed. We performed a phase 2 study of the ability of latiglutenase, an orally administered mixture of 2 recombinant gluten-targeting proteases, to reduce mucosal morphometric measures in biopsy specimens from patients with celiac disease. METHODS We performed a double-blind, placebo-controlled, dose-ranging study to assess the efficacy and safety of latiglutenase in 494 patients with celiac disease (with moderate or severe symptoms) in North America and Europe, from August 2013 until December 2014. Participants reported following a gluten-free diet for at least 1 year before the study began. Patients with documented moderate or severe symptoms and villous atrophy (villous height:crypt depth ratio of ≤2.0) were assigned randomly to groups given placebo or 100, 300, 450, 600, or 900 mg latiglutenase daily for 12 or 24 weeks. Subjects completed the Celiac Disease Symptom Diary each day for 28 days and underwent an upper gastrointestinal endoscopy with duodenal biopsy of the distal duodenum at baseline and at weeks 12 and 24. The primary end point was a change in the villous height:crypt depth ratio. Secondary end points included numbers of intraepithelial lymphocytes, serology test results (for levels of antibodies against tissue transglutaminase-2 and deamidated gliadin peptide), symptom frequencies, and safety. RESULTS In a modified intent-to-treat population, there were no differences between latiglutenase and placebo groups in change from baseline in villous height:crypt depth ratio, numbers of intraepithelial lymphocytes, or serologic markers of celiac disease. All groups had significant improvements in histologic and symptom scores. CONCLUSIONS In a phase 2 study of patients with symptomatic celiac disease and histologic evidence of significant duodenal mucosal injury, latiglutenase did not improve histologic and symptom scores when compared with placebo. There were no significant differences in change from baseline between groups. ClinicalTrials.gov no: NCT01917630.
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Affiliation(s)
- Joseph A Murray
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Ciarán P Kelly
- Celiac Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Peter H R Green
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | - Tsung-Teh Wu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Markku Mäki
- School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland
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Khanna S, Shin A, Kelly CP. Management of Clostridium difficile Infection in Inflammatory Bowel Disease: Expert Review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol 2017; 15:166-174. [PMID: 28093134 DOI: 10.1016/j.cgh.2016.10.024] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [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] [Received: 09/18/2016] [Revised: 10/02/2016] [Accepted: 10/13/2016] [Indexed: 02/07/2023]
Abstract
The purpose of this expert review is to synthesize the existing evidence on the management of Clostridium difficile infection in patients with underlying inflammatory bowel disease. The evidence reviewed in this article is a summation of relevant scientific publications, expert opinion statements, and current practice guidelines. This review is a summary of expert opinion in the field without a formal systematic review of evidence. Best Practice Advice 1: Clinicians should test patients who present with a flare of underlying inflammatory bowel disease for Clostridium difficile infection. Best Practice Advice 2: Clinicians should screen for recurrent C difficile infection if diarrhea or other symptoms of colitis persist or return after antibiotic treatment for C difficile infection. Best Practice Advice 3: Clinicians should consider treating C difficile infection in inflammatory bowel disease patients with vancomycin instead of metronidazole. Best Practice Advice 4: Clinicians strongly should consider hospitalization for close monitoring and aggressive management for inflammatory bowel disease patients with C difficile infection who have profuse diarrhea, severe abdominal pain, a markedly increased peripheral blood leukocyte count, or other evidence of sepsis. Best Practice Advice 5: Clinicians may postpone escalation of steroids and other immunosuppression agents during acute C difficile infection until therapy for C difficile infection has been initiated. However, the decision to withhold or continue immunosuppression in inflammatory bowel disease patients with C difficile infection should be individualized because there is insufficient existing robust literature on which to develop firm recommendations. Best Practice Advice 6: Clinicians should offer a referral for fecal microbiota transplantation to inflammatory bowel disease patients with recurrent C difficile infection.
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Affiliation(s)
- Sahil Khanna
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Andrea Shin
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Ciarán P Kelly
- Gastroenterology Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Patel I, Wungjiranirun M, Theethira T, Villafuerte-Galvez J, Castillo N, Akbari M, Alonso CD, Leffler DA, Kelly CP. Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality. J Antimicrob Chemother 2017; 72:574-581. [PMID: 28115504 PMCID: PMC6074846 DOI: 10.1093/jac/dkw423] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 05/13/2016] [Revised: 09/01/2016] [Accepted: 09/08/2016] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES The objective of this study was to determine our institution's compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes. METHODS We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality. RESULTS We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023). CONCLUSIONS Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.
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Affiliation(s)
- I Patel
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - M Wungjiranirun
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - T Theethira
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - J Villafuerte-Galvez
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - N Castillo
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - M Akbari
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - C D Alonso
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - D A Leffler
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - C P Kelly
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Kabbani TA, Pallav K, Dowd SE, Villafuerte-Galvez J, Vanga RR, Castillo NE, Hansen J, Dennis M, Leffler DA, Kelly CP. Prospective randomized controlled study on the effects of Saccharomyces boulardii CNCM I-745 and amoxicillin-clavulanate or the combination on the gut microbiota of healthy volunteers. Gut Microbes 2016; 8:17-32. [PMID: 27973989 PMCID: PMC5341914 DOI: 10.1080/19490976.2016.1267890] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Probiotics are believed to be beneficial in maintaining a healthy gut microbiota whereas antibiotics are known to induce dysbiosis. This study aimed to examine the effects of the probiotic Saccharomyces boulardii CNCM I-745 (SB), the antibiotic Amoxicillin-Clavulanate (AC) and the combination on the microbiota and symptoms of healthy humans. Healthy subjects were randomized to one of 4 study groups: SB for 14 days, AC for 7 days, SB plus AC, Control (no treatment). Participants gave stool samples and completed gastro-intestinal symptom questionnaires. Microbiota changes in stool specimens were analyzed using 16s rRNA gene pyrosequencing (bTEFAP). Only one subject withdrew prematurely due to adverse events. Subjects treated by S boulardii + AC had fewer adverse events and tolerated the study regimen better than those receiving the AC alone. Control subjects had a stable microbiota throughout the study period. Significant microbiota changes were noted in the AC alone group during antibiotic treatment. AC associated changes included reduced prevalence of the genus Roseburia and increases in Escherichia, Parabacteroides, and Enterobacter. Microbiota alterations reverted toward baseline, but were not yet completely restored 2 weeks after antibiotherapy. No significant shifts in bacterial genera were noted in the SB alone group. Adding SB to AC led to less pronounced microbiota shifts including less overgrowth of Escherichia and to a reduction in antibiotic-associated diarrhea scores. Antibiotic treatment is associated with marked microbiota changes with both reductions and increases in different genera. S. boulardii treatment can mitigate some antibiotic-induced microbiota changes (dysbiosis) and can also reduce antibiotic-associated diarrhea.
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Affiliation(s)
- Toufic A. Kabbani
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Kumar Pallav
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Javier Villafuerte-Galvez
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rohini R. Vanga
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Natalia E. Castillo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joshua Hansen
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Melinda Dennis
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel A. Leffler
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciarán P. Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Bailey CA, Kuiper JH, Kelly CP. Biomechanical Evaluation of a New Composite Bioresorbable Screw. ACTA ACUST UNITED AC 2016; 31:208-12. [PMID: 16361004 DOI: 10.1016/j.jhsb.2005.10.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Revised: 10/17/2005] [Accepted: 07/25/2005] [Indexed: 12/28/2022]
Abstract
A new bioresorbable composite cannulated screw has been developed for small bone fracture fixation. The LG (“Little Grafter”) screw is manufactured from Biosteon™, which is a composite of poly l-lactic acid and hydroxyapatite. This study aimed to compare interfragmentary compression generated by this new screw with conventional metal screws commonly used in scaphoid fracture fixation. Four small metallic screws were compared with the LG screw, using a bone model produced from rigid polyurethane foam. The screws included the Acutrak, Asnis III, Herbert and Herbert–Whipple screws. The mean maximum compression forces for the LG screw, the Asnis and the Acutrak were comparable (LG 32.3 N, Asnis 32.8 N, Acutrak 38.3 N), whereas those using the Herbert and the Herbert–Whipple screw were significantly lower (Herbert 21.8 N, Herbert–Whipple 19.9 N). The bioresorbable LG screw has been shown to have good compressive properties compared to commonly used small bone fragment compression screws.
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Affiliation(s)
- C A Bailey
- Hand and Upper Limb Unit, Robert Jones and Agnes Hunt Hospital, Oswestry, Shropshire, UK.
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Roy A, Mehra S, Kelly CP, Tariq S, Pallav K, Dennis M, Peer A, Lebwohl B, Green PHR, Leffler DA. The association between socioeconomic status and the symptoms at diagnosis of celiac disease: a retrospective cohort study. Therap Adv Gastroenterol 2016; 9:495-502. [PMID: 27366218 PMCID: PMC4913330 DOI: 10.1177/1756283x16637532] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There are little data on patient factors that impact diagnosis rates of celiac disease. This study aims to evaluate the association between patient socioeconomic status and the symptoms at diagnosis of celiac disease. METHODS A total of 872 patients with biopsy-proven celiac disease were categorized based on the presence or absence of (1) diarrhea and (2) any gastrointestinal symptoms at diagnosis. Univariate and multivariate analyses were used to assess the association between socioeconomic status and symptoms. RESULTS Patients without diarrhea at presentation had a higher mean per capita income (US$34,469 versus US$32,237, p = 0.02), and patients without any gastrointestinal symptoms had a higher mean per capita income (US$36,738 versus US$31,758, p < 0.01) compared with patients having such symptoms. On multivariable analysis adjusting for sex, age, autoimmune or psychiatric comorbidities, and income, per capita income remained a significant predictor of diagnosis without gastrointestinal symptoms (odds ratio: 1.71, 95% confidence interval: 1.17-2.50, p < 0.01), and it showed a trend towards significance in diagnosis without diarrhea (odds ratio: 1.40, 95% confidence interval: 0.98-2.02, p = 0.06). CONCLUSIONS Patients with nonclassical symptoms of celiac disease are less likely to be diagnosed if they are of lower socioeconomic status. Celiac disease may be under-recognized in this population due to socioeconomic factors that possibly include lower rates of health-seeking behavior and access to healthcare.
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Affiliation(s)
| | - Shilpa Mehra
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Ciarán P. Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sohaib Tariq
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kumar Pallav
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Melinda Dennis
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ann Peer
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Benjamin Lebwohl
- Department of Gastroenterology, Columbia University, New York, NY, USA
| | - Peter H. R. Green
- Department of Gastroenterology, Columbia University, New York, NY, USA
| | - Daniel A. Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Olsen MA, Young-Xu Y, Stwalley D, Kelly CP, Gerding DN, Saeed MJ, Mahé C, Dubberke ER. The burden of clostridium difficile infection: estimates of the incidence of CDI from U.S. Administrative databases. BMC Infect Dis 2016; 16:177. [PMID: 27102582 PMCID: PMC4840985 DOI: 10.1186/s12879-016-1501-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 04/09/2016] [Indexed: 12/22/2022] Open
Abstract
Background Many administrative data sources are available to study the epidemiology of infectious diseases, including Clostridium difficile infection (CDI), but few publications have compared CDI event rates across databases using similar methodology. We used comparable methods with multiple administrative databases to compare the incidence of CDI in older and younger persons in the United States. Methods We performed a retrospective study using three longitudinal data sources (Medicare, OptumInsight LabRx, and Healthcare Cost and Utilization Project State Inpatient Database (SID)), and two hospital encounter-level data sources (Nationwide Inpatient Sample (NIS) and Premier Perspective database) to identify CDI in adults aged 18 and older with calculation of CDI incidence rates/100,000 person-years of observation (pyo) and CDI categorization (onset and association). Results The incidence of CDI ranged from 66/100,000 in persons under 65 years (LabRx), 383/100,000 in elderly persons (SID), and 677/100,000 in elderly persons (Medicare). Ninety percent of CDI episodes in the LabRx population were characterized as community-onset compared to 41 % in the Medicare population. The majority of CDI episodes in the Medicare and LabRx databases were identified based on only a CDI diagnosis, whereas almost ¾ of encounters coded for CDI in the Premier hospital data were confirmed with a positive test result plus treatment with metronidazole or oral vancomycin. Using only the Medicare inpatient data to calculate encounter-level CDI events resulted in 553 CDI events/100,000 persons, virtually the same as the encounter proportion calculated using the NIS (544/100,000 persons). Conclusions We found that the incidence of CDI was 35 % higher in the Medicare data and fewer episodes were attributed to hospital acquisition when all medical claims were used to identify CDI, compared to only inpatient data lacking information on diagnosis and treatment in the outpatient setting. The incidence of CDI was 10-fold lower and the proportion of community-onset CDI was much higher in the privately insured younger LabRx population compared to the elderly Medicare population. The methods we developed to identify incident CDI can be used by other investigators to study the incidence of other infectious diseases and adverse events using large generalizable administrative datasets. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1501-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Margaret A Olsen
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 660 S. Euclid Ave, St. Louis, 63110, MO, USA. .,Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
| | - Yinong Young-Xu
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Dustin Stwalley
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 660 S. Euclid Ave, St. Louis, 63110, MO, USA
| | - Ciarán P Kelly
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Dale N Gerding
- Edward Hines Jr. Veterans Affairs Hospital, Hines, IL, USA and Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Mohammed J Saeed
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 660 S. Euclid Ave, St. Louis, 63110, MO, USA
| | | | - Erik R Dubberke
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 660 S. Euclid Ave, St. Louis, 63110, MO, USA
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Dubberke ER, Olsen MA, Stwalley D, Kelly CP, Gerding DN, Young-Xu Y, Mahé C. Identification of Medicare Recipients at Highest Risk for Clostridium difficile Infection in the US by Population Attributable Risk Analysis. PLoS One 2016; 11:e0146822. [PMID: 26859403 PMCID: PMC4747338 DOI: 10.1371/journal.pone.0146822] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/22/2015] [Indexed: 12/14/2022] Open
Abstract
Background Population attributable risk percent (PAR%) is an epidemiological tool that provides an estimate of the percent reduction in total disease burden if that disease could be entirely eliminated among a subpopulation. As such, PAR% is used to efficiently target prevention interventions. Due to significant limitations in current Clostridium difficile Infection (CDI) prevention practices and the development of new approaches to prevent CDI, such as vaccination, we determined the PAR% for CDI in various subpopulations in the Medicare 5% random sample. Methods This was a retrospective cohort study using the 2009 Medicare 5% random sample. Comorbidities, infections, and healthcare exposures during the 12 months prior to CDI were identified. CDI incidence and PAR% were calculated for each condition/exposure. Easy to identify subpopulations that could be targeted from prevention interventions were identified based on PAR%. Findings There were 1,465,927 Medicare beneficiaries with 9,401 CDI cases for an incidence of 677/100,000 persons. Subpopulations representing less than 15% of the entire population and with a PAR% ≥ 30% were identified. These included deficiency anemia (PAR% = 37.9%), congestive heart failure (PAR% = 30.2%), fluid and electrolyte disorders (PAR% = 29.6%), urinary tract infections (PAR% = 40.5%), pneumonia (PAR% = 35.2%), emergent hospitalization (PAR% = 48.5%) and invasive procedures (PAR% = 38.9%). Stratification by age and hospital exposures indicates hospital exposures are more strongly associated with CDI than age. Significance Small and identifiable subpopulations that account for relatively large proportions of CDI cases in the elderly were identified. These data can be used to target specific subpopulations for CDI prevention interventions.
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Affiliation(s)
- Erik R. Dubberke
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
| | - Margaret A. Olsen
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Dustin Stwalley
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Ciarán P. Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Dale N. Gerding
- Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, and Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, United States of America
| | - Yinong Young-Xu
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States of America
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Džunková M, D'Auria G, Xu H, Huang J, Duan Y, Moya A, Kelly CP, Chen X. The Monoclonal Antitoxin Antibodies (Actoxumab-Bezlotoxumab) Treatment Facilitates Normalization of the Gut Microbiota of Mice with Clostridium difficile Infection. Front Cell Infect Microbiol 2016; 6:119. [PMID: 27757389 PMCID: PMC5048712 DOI: 10.3389/fcimb.2016.00119] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/21/2016] [Indexed: 02/05/2023] Open
Abstract
Antibiotics have significant and long-lasting impacts on the intestinal microbiota and consequently reduce colonization resistance against Clostridium difficile infection (CDI). Standard therapy using antibiotics is associated with a high rate of disease recurrence, highlighting the need for novel treatment strategies that target toxins, the major virulence factors, rather than the organism itself. Human monoclonal antibodies MK-3415A (actoxumab-bezlotoxumab) to C. difficile toxin A and toxin B, as an emerging non-antibiotic approach, significantly reduced the recurrence of CDI in animal models and human clinical trials. Although the main mechanism of protection is through direct neutralization of the toxins, the impact of MK-3415A on gut microbiota and its restoration has not been examined. Using a CDI murine model, we compared the bacterial diversity of the gut microbiome of mice under different treatments including MK-3415A, vancomycin, or vancomycin combined with MK-3415A, sampled longitudinally. Here, we showed that C. difficile infection resulted in the prevalence of Enterobacter species. Sixty percent of mice in the vehicle group died after 2 days and their microbiome was almost exclusively formed by Enterobacter. MK-3415A treatment resulted in lower Enterobacter levels and restoration of Blautia, Akkermansia, and Lactobacillus which were the core components of the original microbiota. Vancomycin treatment led to significantly lower survival rate than the combo treatment of MK-3415A and vancomycin. Vancomycin treatment decreased bacterial diversity with predominant Enterobacter and Akkermansia, while Staphylococcus expanded after vancomycin treatment was terminated. In contrast, mice treated by vancomycin combined with MK-3415A also experienced decreased bacterial diversity during vancomycin treatment. However, these animals were able to recover their initial Blautia and Lactobacillus proportions, even though episodes of Staphylococcus overgrowth were detected by the end of the experiments. In conclusion, MK-3415A (actoxumab-bezlotoxumab) treatment facilitates normalization of the gut microbiota in CDI mice. It remains to be examined whether or not the prevention of recurrent CDI by the antitoxin antibodies observed in clinical trials occurs through modulation of microbiota.
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Affiliation(s)
- Mária Džunková
- Área de Genómica y Salud, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain
- Instituto Cavanilles de Biodiversidad y Biología Evolutiva, Universitat de ValènciaValencia, Spain
- Centro de Investigación Biomédica en Red en Epidemoioloía y Salud PúblicaMadrid, Spain
| | - Giuseppe D'Auria
- Área de Genómica y Salud, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain
- Instituto Cavanilles de Biodiversidad y Biología Evolutiva, Universitat de ValènciaValencia, Spain
- Centro de Investigación Biomédica en Red en Epidemoioloía y Salud PúblicaMadrid, Spain
| | - Hua Xu
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - Jun Huang
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - Yinghua Duan
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - Andrés Moya
- Área de Genómica y Salud, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad ValencianaValencia, Spain
- Instituto Cavanilles de Biodiversidad y Biología Evolutiva, Universitat de ValènciaValencia, Spain
- Centro de Investigación Biomédica en Red en Epidemoioloía y Salud PúblicaMadrid, Spain
| | - Ciarán P. Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - Xinhua Chen
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
- *Correspondence: Xinhua Chen
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Villafuerte-Galvez J, Vanga RR, Dennis M, Hansen J, Leffler DA, Kelly CP, Mukherjee R. Factors governing long-term adherence to a gluten-free diet in adult patients with coeliac disease. Aliment Pharmacol Ther 2015. [PMID: 26206401 DOI: 10.1111/apt.13319] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [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] [Indexed: 12/11/2022]
Abstract
BACKGROUND A strict gluten-free diet is the cornerstone of treatment for coeliac disease. Studies of gluten-free diet adherence have rarely used validated instruments. There is a paucity of data on long-term adherence to the gluten-free diet in the adult population. AIMS To determine the long-term adherence to the gluten-free diet and potential associated factors in a large coeliac disease referral centre population. METHODS We performed a mailed survey of adults with clinically, serologically and histologically confirmed coeliac disease diagnosed ≥5 years prior to survey. The previously validated Celiac Disease Adherence Test was used to determine adherence. Demographic, socio-economic and potentially associated factors were analysed with adherence as the outcome. RESULTS The response rate was 50.1% of 709 surveyed, the mean time on a gluten-free diet 9.9 ± 6.4 years. Adequate adherence (celiac disease adherence test score <13) was found in 75.5% of respondents. A higher level of education was associated with adequate adherence (P = 0.002) even after controlling for household income (P = 0.0220). Perceptions of cost, effectiveness of the gluten-free diet, knowledge of the gluten-free diet and self-effectiveness at following the gluten-free diet correlated with adherence scores (P < 0.001). CONCLUSIONS Long-term adherence to a gluten-free diet was adequate in >75% of respondents. Perceived cost remains a barrier to adherence. Perceptions of effectiveness of gluten-free diet as well as its knowledge, are potential areas for intervention.
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Affiliation(s)
- J Villafuerte-Galvez
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - R R Vanga
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - M Dennis
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - J Hansen
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - D A Leffler
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - C P Kelly
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - R Mukherjee
- Celiac Center, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Sartelli M, Malangoni MA, Abu-Zidan FM, Griffiths EA, Di Bella S, McFarland LV, Eltringham I, Shelat VG, Velmahos GC, Kelly CP, Khanna S, Abdelsattar ZM, Alrahmani L, Ansaloni L, Augustin G, Bala M, Barbut F, Ben-Ishay O, Bhangu A, Biffl WL, Brecher SM, Camacho-Ortiz A, Caínzos MA, Canterbury LA, Catena F, Chan S, Cherry-Bukowiec JR, Clanton J, Coccolini F, Cocuz ME, Coimbra R, Cook CH, Cui Y, Czepiel J, Das K, Demetrashvili Z, Di Carlo I, Di Saverio S, Dumitru IM, Eckert C, Eckmann C, Eiland EH, Enani MA, Faro M, Ferrada P, Forrester JD, Fraga GP, Frossard JL, Galeiras R, Ghnnam W, Gomes CA, Gorrepati V, Ahmed MH, Herzog T, Humphrey F, Kim JI, Isik A, Ivatury R, Lee YY, Juang P, Furuya-Kanamori L, Karamarkovic A, Kim PK, Kluger Y, Ko WC, LaBarbera FD, Lee JG, Leppaniemi A, Lohsiriwat V, Marwah S, Mazuski JE, Metan G, Moore EE, Moore FA, Nord CE, Ordoñez CA, Júnior GAP, Petrosillo N, Portela F, Puri BK, Ray A, Raza M, Rems M, Sakakushev BE, Sganga G, Spigaglia P, Stewart DB, Tattevin P, Timsit JF, To KB, Tranà C, Uhl W, Urbánek L, van Goor H, Vassallo A, Zahar JR, Caproli E, Viale P. WSES guidelines for management of Clostridium difficile infection in surgical patients. World J Emerg Surg 2015; 10:38. [PMID: 26300956 PMCID: PMC4545872 DOI: 10.1186/s13017-015-0033-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/12/2015] [Indexed: 02/08/2023] Open
Abstract
In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.
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Affiliation(s)
- Massimo Sartelli
- />Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62019 Macerata, Italy
| | | | - Fikri M. Abu-Zidan
- />Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Stefano Di Bella
- />2nd Infectious Diseases Division, National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | - Lynne V. McFarland
- />Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Washington, USA
| | - Ian Eltringham
- />Department of Medical Microbiology, King’s College Hospital, London, UK
| | - Vishal G. Shelat
- />Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - George C. Velmahos
- />Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA USA
| | - Ciarán P. Kelly
- />Gastroenterology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA USA
| | - Sahil Khanna
- />Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN USA
| | | | - Layan Alrahmani
- />Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI USA
| | - Luca Ansaloni
- />General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Goran Augustin
- />Department of Surgery, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Miklosh Bala
- />Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Frédéric Barbut
- />UHLIN (Unité d’Hygiène et de Lutte contre les Infections Nosocomiales) National Reference Laboratory for Clostridium difficile Groupe Hospitalier de l’Est Parisien (HUEP), Paris, France
| | - Offir Ben-Ishay
- />Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Aneel Bhangu
- />Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Walter L. Biffl
- />Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
| | - Stephen M. Brecher
- />Pathology and Laboratory Medicine, VA Boston Healthcare System, West Roxbury MA and BU School of Medicine, Boston, MA USA
| | - Adrián Camacho-Ortiz
- />Department of Internal Medicine, University Hospital, Dr.José E. González, Monterrey, Mexico
| | - Miguel A. Caínzos
- />Department of Surgery, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Laura A. Canterbury
- />Department of Pathology, University of Alberta Edmonton, Edmonton, AB Canada
| | - Fausto Catena
- />Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Shirley Chan
- />Department of General Surgery, Medway Maritime Hospital, Gillingham Kent, UK
| | - Jill R. Cherry-Bukowiec
- />Department of Surgery, Division of Acute Care Surgery, University of Michigan, Ann Arbor, MI USA
| | - Jesse Clanton
- />Department of Surgery, Northeast Ohio Medical University, Summa Akron City Hospital, Akron, OH USA
| | | | - Maria Elena Cocuz
- />Faculty of Medicine, Transilvania University, Infectious Diseases Hospital, Brasov, Romania
| | - Raul Coimbra
- />Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Science, San Diego, USA
| | - Charles H. Cook
- />Division of Acute Care Surgery, Trauma and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA USA
| | - Yunfeng Cui
- />Department of Surgery,Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Jacek Czepiel
- />Department of Infectious Diseases, Jagiellonian University, Medical College, Kraków, Poland
| | - Koray Das
- />Department of General Surgery, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Zaza Demetrashvili
- />Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | | | | | | | - Catherine Eckert
- />National Reference Laboratory for Clostridium difficile, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Christian Eckmann
- />Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Hospital of Medical University Hannover, Peine, Germany
| | | | - Mushira Abdulaziz Enani
- />Department of Medicine, Section of Infectious Diseases, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mario Faro
- />Department of General Surgery, Trauma and Emergency Surgery Division, ABC Medical School, Santo André, SP Brazil
| | - Paula Ferrada
- />Division of Trauma, Critical Care and Emergency Surgery, Virginia Commonwealth University, Richmond, VA USA
| | | | - Gustavo P. Fraga
- />Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Jean Louis Frossard
- />Service of Gastroenterology and Hepatology, Geneva University Hospital, Genève, Switzerland
| | - Rita Galeiras
- />Critical Care Unit, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, Universidade da Coruña (UDC), A Coruña, Spain
| | - Wagih Ghnnam
- />Department of Surgery Mansoura, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Carlos Augusto Gomes
- />Surgery Department, Hospital Universitario (HU) Terezinha de Jesus da Faculdade de Ciencias Medicas e da Saude de Juiz de Fora (SUPREMA), Hospital Universitario (HU) Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora, Brazil
| | - Venkata Gorrepati
- />Department of Internal Medicine, Pinnacle Health Hospital, Harrisburg, PA USA
| | - Mohamed Hassan Ahmed
- />Department of Medicine, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, Buckinghamshire UK
| | - Torsten Herzog
- />Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Felicia Humphrey
- />Department of Gastroenterology and Hepatology, Ochsner Clinic Foundation, New Orleans, LA USA
| | - Jae Il Kim
- />Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Arda Isik
- />General Surgery Department, Erzincan University Mengücek Gazi Training and Research Hospital, Erzincan, Turkey
| | - Rao Ivatury
- />Division of Trauma, Critical Care and Emergency Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Yeong Yeh Lee
- />School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan Malaysia
| | - Paul Juang
- />Department of Pharmacy Practice, St Louis College of Pharmacy, St Louis, MO USA
| | - Luis Furuya-Kanamori
- />Research School of Population Health, The Australian National University, Acton, ACT Australia
| | - Aleksandar Karamarkovic
- />Clinic For Emergency surgery, University Clinical Center of Serbia, Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Peter K Kim
- />General and Trauma Surgery, Albert Einstein College of Medicine, North Bronx Healthcare Network, Bronx, NY USA
| | - Yoram Kluger
- />Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Wen Chien Ko
- />Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | | | - Jae Gil Lee
- />Division of Critical Care & Trauma Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Ari Leppaniemi
- />Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland
| | - Varut Lohsiriwat
- />Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sanjay Marwah
- />Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - John E. Mazuski
- />Department of Surgery, Washington University School of Medicine, Saint Louis, USA
| | - Gokhan Metan
- />Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ernest E. Moore
- />Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
| | | | - Carl Erik Nord
- />Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Carlos A. Ordoñez
- />Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | | | - Nicola Petrosillo
- />2nd Infectious Diseases Division, National Institute for Infectious Diseases L. Spallanzani, Rome, Italy
| | - Francisco Portela
- />Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Basant K. Puri
- />Department of Medicine, Hammersmith Hospital and Imperial College London, London, UK
| | - Arnab Ray
- />Department of Gastroenterology and Hepatology, Ochsner Clinic Foundation, New Orleans, LA USA
| | - Mansoor Raza
- />Infectious Diseases and Microbiology Unit, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, Buckinghamshire UK
| | - Miran Rems
- />Department of Abdominal and General Surgery, General Hospital Jesenice, Jesenice, Slovenia
| | | | - Gabriele Sganga
- />Division of General Surgery and Organ Transplantation, Department of Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Patrizia Spigaglia
- />Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - David B. Stewart
- />Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA USA
| | - Pierre Tattevin
- />Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | | | - Kathleen B. To
- />Department of Surgery, Division of Acute Care Surgery, University of Michigan, Ann Arbor, MI USA
| | - Cristian Tranà
- />Emergency Medicine and Surgery, Macerata hospital, Macerata, Italy
| | - Waldemar Uhl
- />Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Libor Urbánek
- />1st Surgical Clinic, University Hospital of St. Ann Brno, Brno, Czech Republic
| | - Harry van Goor
- />Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Angela Vassallo
- />Infection Prevention/Epidemiology, Providence Saint John’s Health Center, Santa Monica, CA USA
| | - Jean Ralph Zahar
- />Infection Control Unit, Angers University, CHU d’Angers, Angers, France
| | - Emanuele Caproli
- />Department of Surgery, Ancona University Hospital, Ancona, Italy
| | - Pierluigi Viale
- />Clinic of Infectious Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
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Abstract
Celiac disease is an autoimmune disorder that is induced by dietary gluten in genetically predisposed individuals. It has a prevalence of approximately 1% in many populations worldwide. New diagnoses have increased substantially, owing to increased awareness, better diagnostic tools, and probable real increases in incidence. The breadth of recognized clinical presentations continues to expand, making the disorder highly relevant to all physicians. Newer diagnostic tools, including serologic tests for antibodies against tissue transglutaminase and deamidated gliadin peptide, greatly facilitate diagnosis. Tests for celiac-permissive HLA-DQ2 and HLA-DQ8 molecules are useful in defined clinical situations. Celiac disease is diagnosed by histopathologic examination of duodenal biopsy specimens. However, according to recent controversial guidelines, a diagnosis can be made without a biopsy in certain circumstances, especially in children. Symptoms, mortality, and risk for malignancy each can be reduced by adherence to a gluten-free diet. This treatment is a challenge, however, because the diet is expensive, socially isolating, and not always effective in controlling symptoms or intestinal damage. Hence, there is increasing interest in developing nondietary therapies.
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Affiliation(s)
- Ciarán P. Kelly
- Celiac Program, Harvard Medical School & Beth Israel Deaconess Medical Center, 330 Brookline Ave, Gastroenterology, Dana 601E, Boston, MA 02215-5400, United States, Phone: (617) 667-1272
| | - Julio C. Bai
- Hospital Gastroenterologia, Dr. Bonorino Udaondo, Av. Casero 2061, Buenos Aires, 1264, Argentina, Phone: +549114404-8022
| | - Edwin Liu
- Colorado Center for Celiac Disease, Digestive Health Institute, Children's Hospital Colorado and the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045. United States, Phone: (720) 777-6669
| | - Daniel A. Leffler
- Celiac Program, Harvard Medical School & Beth Israel Deaconess Medical Center, 330 Brookline Ave, Gastroenterology, Dana 501, Boston, MA 02215-5400, United States, Phone: (617) 667-1272
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Na X, Martin AJ, Sethi S, Kyne L, Garey KW, Flores SW, Hu M, Shah DN, Shields K, Leffler DA, Kelly CP. A Multi-Center Prospective Derivation and Validation of a Clinical Prediction Tool for Severe Clostridium difficile Infection. PLoS One 2015; 10:e0123405. [PMID: 25906284 PMCID: PMC4408056 DOI: 10.1371/journal.pone.0123405] [Citation(s) in RCA: 40] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/18/2015] [Indexed: 12/18/2022] Open
Abstract
Background and Aims Prediction of severe clinical outcomes in Clostridium difficile infection (CDI) is important to inform management decisions for optimum patient care. Currently, treatment recommendations for CDI vary based on disease severity but validated methods to predict severe disease are lacking. The aim of the study was to derive and validate a clinical prediction tool for severe outcomes in CDI. Methods A cohort totaling 638 patients with CDI was prospectively studied at three tertiary care clinical sites (Boston, Dublin and Houston). The clinical prediction rule (CPR) was developed by multivariate logistic regression analysis using the Boston cohort and the performance of this model was then evaluated in the combined Houston and Dublin cohorts. Results The CPR included the following three binary variables: age ≥ 65 years, peak serum creatinine ≥2 mg/dL and peak peripheral blood leukocyte count of ≥20,000 cells/μL. The Clostridium difficile severity score (CDSS) correctly classified 76.5% (95% CI: 70.87-81.31) and 72.5% (95% CI: 67.52-76.91) of patients in the derivation and validation cohorts, respectively. In the validation cohort, CDSS scores of 0, 1, 2 or 3 were associated with severe clinical outcomes of CDI in 4.7%, 13.8%, 33.3% and 40.0% of cases respectively. Conclusions We prospectively derived and validated a clinical prediction rule for severe CDI that is simple, reliable and accurate and can be used to identify high-risk patients most likely to benefit from measures to prevent complications of CDI.
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Affiliation(s)
- Xi Na
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alan J. Martin
- Department of Medicine for the Older Person, Mater Misericordiae University Hospital and University College Dublin, Dublin, Ireland
| | - Saurabh Sethi
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lorraine Kyne
- Department of Medicine for the Older Person, Mater Misericordiae University Hospital and University College Dublin, Dublin, Ireland
| | - Kevin W. Garey
- University of Houston College of Pharmacy, Houston, Texas, United States of America
| | - Sarah W. Flores
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Mary Hu
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Dhara N. Shah
- University of Houston College of Pharmacy, Houston, Texas, United States of America
| | - Kelsey Shields
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel A. Leffler
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ciarán P. Kelly
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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48
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Abstract
Clostridium difficile is a spore-forming anaerobic gram-positive organism that is the leading cause of antibiotic-associated nosocomial infectious diarrhea in the Western world. This article describes the evolving epidemiology of C difficile infection (CDI) in the twenty-first century, evaluates the importance of vaccines against the disease, and defines the roles of both innate and adaptive host immune responses in CDI. The effects of passive immunotherapy and active vaccination against CDI in both humans and animals are also discussed.
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Affiliation(s)
- Chandrabali Ghose
- Aaron Diamond AIDS Research Center, 455 First Avenue, 7th Floor, New York, NY 10016, USA.
| | - Ciarán P Kelly
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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49
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Affiliation(s)
- Daniel A Leffler
- Department of Medicine, Harvard Medical School and Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ciarán P Kelly
- Department of Medicine, Harvard Medical School and Celiac Center, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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50
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Pallav K, Dowd SE, Villafuerte J, Yang X, Kabbani T, Hansen J, Dennis M, Leffler DA, Newburg DS, Kelly CP. Effects of polysaccharopeptide from Trametes versicolor and amoxicillin on the gut microbiome of healthy volunteers: a randomized clinical trial. Gut Microbes 2014; 5:458-67. [PMID: 25006989 DOI: 10.4161/gmic.29558] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [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] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Interactions between the microbial flora of the intestine and the human host play a critical role inmaintaining intestinal health and in the pathophysiology of a wide variety of disorders such as antibiotic associated diarrhea, Clostridium difficile infection, and inflammatory bowel disease. Prebiotics can confer health benefits by beneficial effects on the intestinal microbiome, whereas antibiotics can disrupt the microbiome leading to diarrhea andother side effects. AIM To compare the effects of the prebiotic, polysaccharopeptide from Trametes versicolor, to those of the antibiotic,amoxicillin, on the human gut microbiome METHODS Twenty-four healthy volunteers were randomized to receive PSP, amoxicillin, or no treatment (control).Stool specimens were analyzed using bTEFAP microbial ecology methods on seven occasions over 8 weeks from each participant in the active treatment groups and on three occasions for the controls. RESULTS Twenty-two of 24 participants completed the protocol. PSP led to clear and consistent microbiome changes consistent with its activity as a prebiotic. Despite the diversity of the human microbiome we noted strong microbiome clustering among subjects. Baseline microbiomes tended to remain stable and to overshadow the treatment effects.Amoxicillin treatment caused substantial microbiome changes most notably an increase in Escherichia/Shigella. Antibiotic associated changes persisted to the end of the study, 42 days after antibiotic therapy ended. CONCLUSIONS The microbiomes of healthy individuals show substantial diversity but remain stable over time.The antibiotic amoxicillin alters the microbiome and recovery from this disruption can take several weeks. PSP from T. versicolor acts as a prebiotic to modulate human intestinal microbiome composition.
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Affiliation(s)
- Kumar Pallav
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
| | | | - Javier Villafuerte
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
| | - Xiaotong Yang
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
| | - Toufic Kabbani
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
| | - Joshua Hansen
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
| | - Melinda Dennis
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
| | - Daniel A Leffler
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
| | - David S Newburg
- Program in Glycobiology; Boston College; Chestnut Hill, MA USA
| | - Ciarán P Kelly
- The Celiac Center, Division of Gastroenterology; Beth Israel Deaconess Medical Center; Harvard Medical School; Boston, MA USA
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