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Lee D, Braly K, Nuding M, Braly I, Hopp C, Twible H, Pope C, Hayden HS, Hoffman L, Zheng H, Wahbeh G, Suskind DL. Reverse-engineered exclusive enteral nutrition in pediatric Crohn's disease: A pilot trial. J Pediatr Gastroenterol Nutr 2024; 78:1135-1142. [PMID: 38558411 DOI: 10.1002/jpn3.12196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/18/2024] [Accepted: 03/02/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND In pediatric Crohn's disease (CD), commercial formulas used as exclusive enteral nutrition (EEN) are effective at inducing remission. This study aims to assess the impact of a whole-food blended smoothie as EEN on CD activity and the intestinal microbiome. METHODS A 4-week prospective trial assessed the impact of EEN with a whole-food smoothie on newly diagnosed mild-to-moderate active pediatric CD. The smoothie with a multivitamin were developed to meet age-appropriate nutritional requirements. Assessment over 4 weeks included Pediatric Crohn's Disease Activity Index (PCDAI), serum laboratories, fecal calprotectin (FCP), and stool collection for metagenomic shotgun sequencing and microbiota composition analysis. Clinical remission was defined as PCDAI ≤ 10 at week 4. RESULTS Ten participants were enrolled with median age 14.5 years, and 8 completed the trial. Baseline mean PCDAI was 26.3 ± 9.1 and mean FCP 1149 ± 718 µg/g. At week 4, 80% of participants achieved clinical remission. FCP decreased by over half in 60% of participants, with FCP below 250 µg/g in 60% and below 100 µg/g in 40%. Microbiome analysis showed a significant increase in species richness over 4 weeks (p = 0.01). Compared to baseline, the relative abundance at week 2 and at week 4 was significantly increased for Bifidobacterium and Streptococcus and decreased for Blautia (p < 0.05 for all). CONCLUSION A whole-food blended smoothie was effective for inducing clinical remission and decreasing FCP in pediatric CD similar to commercial EEN formulas. Further research may give insight into data-driven whole-food dietary approaches for CD management. CLINICALTRIALS gov NCT03508193.
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Affiliation(s)
- Dale Lee
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kim Braly
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Mason Nuding
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ian Braly
- Department of Chemical Engineering, University of Washington, Seattle, Washington, USA
| | - Courtney Hopp
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Heather Twible
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Christopher Pope
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Hillary S Hayden
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Luke Hoffman
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Department of Microbiology, University of Washington, Seattle, Washington
| | - Hengqi Zheng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Ghassan Wahbeh
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - David L Suskind
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Inflammatory Bowel Disease Center, Seattle Children's Hospital, Seattle, Washington, USA
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Johnson-Martínez JP, Diener C, Levine AE, Wilmanski T, Suskind DL, Ralevski A, Hadlock J, Magis AT, Hood L, Rappaport N, Gibbons SM. Generally-healthy individuals with aberrant bowel movement frequencies show enrichment for microbially-derived blood metabolites associated with reduced kidney function. bioRxiv 2024:2023.03.04.531100. [PMID: 36945445 PMCID: PMC10028848 DOI: 10.1101/2023.03.04.531100] [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] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Bowel movement frequency (BMF) has been linked to changes in the composition of the human gut microbiome and to many chronic conditions, like metabolic disorders, neurodegenerative diseases, chronic kidney disease (CKD), and other intestinal pathologies like irritable bowel syndrome and inflammatory bowel disease. Lower BMF (constipation) can lead to compromised intestinal barrier integrity and a switch from saccharolytic to proteolytic fermentation within the microbiota, giving rise to microbially-derived toxins that may make their way into circulation and cause damage to organ systems. However, the connections between BMF, gut microbial metabolism, and the early-stage development and progression of chronic disease remain underexplored. Here, we examined the phenotypic impact of BMF variation in a cohort of generally-healthy, community dwelling adults with detailed clinical, lifestyle, and multi-omic data. We showed significant differences in microbially-derived blood plasma metabolites, gut bacterial genera, clinical chemistries, and lifestyle factors across BMF groups that have been linked to inflammation, cardiometabolic health, liver function, and CKD severity and progression. We found that the higher plasma levels of 3-indoxyl sulfate (3-IS), a microbially-derived metabolite associated with constipation, was in turn negatively associated with estimated glomerular filtration rate (eGFR), a measure of kidney function. Causal mediation analysis revealed that the effect of BMF on eGFR was significantly mediated by 3-IS. Finally, we identify self-reported diet, lifestyle, and psychological factors associated with BMF variation, which indicate several common-sense strategies for mitigating constipation and diarrhea. Overall, we suggest that aberrant BMF is an underappreciated risk factor in the development of chronic diseases, even in otherwise healthy populations.
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Affiliation(s)
- Johannes P. Johnson-Martínez
- Institute for Systems Biology, Seattle, WA 98109, USA
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
| | | | - Anne E. Levine
- Institute for Systems Biology, Seattle, WA 98109, USA
- Seattle Children’s Hospital, Seattle, WA 98105, USA
| | | | | | | | | | | | - Leroy Hood
- Institute for Systems Biology, Seattle, WA 98109, USA
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
- Phenome Health, Seattle, WA 98109
- Department of Immunology, University of Washington, Seattle, WA 98195, USA
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, WA 98195, USA
| | - Noa Rappaport
- Institute for Systems Biology, Seattle, WA 98109, USA
| | - Sean M. Gibbons
- Institute for Systems Biology, Seattle, WA 98109, USA
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
- Department of Genome Sciences, University of Washington, Seattle, WA 98195, USA
- eScience Institute, University of Washington, Seattle, WA 98195, USA
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Kaenkumchorn TK, Mark D, Niedner K, Paratore PD, Carlin K, Merkouris R, Musburger B, Suskind DL, Zheng HB. Association between iron deficit repletion with ferric carboxymaltose relative to iron sucrose in children with inflammatory bowel disease: a retrospective cohort study. JPEN J Parenter Enteral Nutr 2023. [PMID: 37199058 DOI: 10.1002/jpen.2515] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Iron deficiency and iron deficiency anemia are common in pediatric inflammatory bowel disease and often require supplementation with iron. There is a paucity of literature regarding optimal iron formulation. The aim of this study is to compare outcomes in pediatric patients with inflammatory bowel disease receiving either iron sucrose or ferric carboxymaltose during inpatient hospitalizations. METHODS This was a single-center retrospective study of pediatric patients with inflammatory bowel disease admitted for newly diagnosed disease or flare who received either iron sucrose or ferric carboxymaltose. Linear regression was used to assess differences in iron repletion. Longitudinal linear mixed-effects models and generalized estimating equations compared hematologic and iron outcomes six months post iron repletion. RESULTS Thirty patients received ferric carboxymaltose. Sixty-nine patients received iron sucrose. Baseline hemoglobin and iron deficits were similar in both groups. A larger percentage of iron deficit was repleted in the ferric carboxymaltose group (81.4%) compared to iron sucrose (25.9%) (p<0.001) with fewer infusions. Cumulative doses of ferric carboxymaltose administered (18.7 mg/kg) were higher than iron sucrose (6.1 mg/kg) (p<0.001). Hemoglobin increased more quickly with ferric carboxymaltose compared to iron sucrose (p=0.04 and p=0.02, respectively). Total iron binding capacity and red cell distribution width levels decreased more over time with ferric carboxymaltose versus iron sucrose (p<0.01 and p=0.01, respectively). No adverse effects were seen. CONCLUSIONS Hematologic and iron parameters responded more quickly with fewer infusions in patients who received ferric carboxymaltose versus iron sucrose. Patients who received ferric carboxymaltose achieved a higher percentage of iron deficit repleted. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tanyaporn K Kaenkumchorn
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dominique Mark
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington
| | - Kara Niedner
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington
| | - Paul D Paratore
- Department of Pharmacy, Pediatrics Division, Denver Health Medical Center, Denver, Colorado
| | - Kristen Carlin
- Biostatistics, Epidemiology, and Analytics in Research, Seattle Children's Research Institute, Seattle, Washington
| | - Robert Merkouris
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Brooke Musburger
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - David L Suskind
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Hengqi B Zheng
- Division of Pediatric Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
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Reznikov EA, Suskind DL. Current Nutritional Therapies in Inflammatory Bowel Disease: Improving Clinical Remission Rates and Sustainability of Long-Term Dietary Therapies. Nutrients 2023; 15:nu15030668. [PMID: 36771373 PMCID: PMC9920576 DOI: 10.3390/nu15030668] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 01/31/2023] Open
Abstract
Inflammatory Bowel Disease (IBD) includes a spectrum of chronic immune-mediated intestinal diseases thought to be related to the complex interaction between the host immune system and the intestinal microbiome. Research supports the use of nutritional therapy in IBD; however, it is not routinely used in clinical practice. This literature review seeks to advance the understanding of diet and its effect in IBD with a focus on both Crohn's Disease (CD) and Ulcerative Colitis (UC). The contribution of diet to the development and treatment of IBD cannot be overstated. In both pediatric as well as adult IBD, nutritional interventions have been shown to improve clinical symptoms as well as inflammatory burden. The impact of dietary intervention is best exemplified through the use of Exclusive Enteral Nutrition (EEN) in CD. EEN and clinical research on exclusionary whole food diets-Crohn's Disease Exclusion Diet (CDED), Specific Carbohydrate Diet (SCD), low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet, and Mediterranean Diet-are discussed within this review. Current clinical literature supports the elimination of detrimental components and the incorporation of low processed whole foods in the diet. Additional prospective and longitudinal dietary studies on sustainable and long-term dietary options, along with a deeper understanding of the mechanism, are needed to further advance the role of nutritional interventions in IBD.
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Schwartz NRM, McNichol SR, Devine B, Phipps AI, Roth JA, Suskind DL. Assessing Barriers to use of the Specific Carbohydrate Diet in Pediatric Inflammatory Bowel Disease: A Qualitative Study. JPGN Rep 2022; 3:e239. [PMID: 37168638 PMCID: PMC10158296 DOI: 10.1097/pg9.0000000000000239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/03/2022] [Indexed: 05/13/2023]
Abstract
Because of the high cost and associated toxicities of pharmacotherapy treatment for inflammatory bowel disease (IBD), there has been growing interest in dietary therapy. The objective of this study is to assess barriers to initiating or maintaining the specific carbohydrate diet (SCD) to inform strategies for improving access and adherence to the diet. Methods We conducted semistructured interviews with parents of 10 children with IBD receiving care at a single academic treatment center. Parents were eligible if their child with IBD was either currently on the SCD, previously on the SCD, or opted not to initiate the SCD. Core questions were developed in conjunction with IBD clinical experts. Interviews were transcribed and analyzed using an inductive approach. Results Parents of children diagnosed with IBD primarily chose to try the SCD because of concerns about medication safety. Three major barriers to utilizing the SCD emerged: cost, time commitment, and psychosocial impact. Many parents also expressed that following the SCD got easier over time and some parents experienced spillover effects of improved personal health and understanding of nutrition. All parents were strong proponents of the importance of diet in managing IBD and expressed desire for more research into the SCD and other forms of dietary therapy. Conclusions These findings provide important insight into factors affecting utilization of the SCD in pediatric IBD. Further research is needed to develop interventions or strategies to diminish these barriers and enable more patients to benefit from the SCD.
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Affiliation(s)
- Naomi R M Schwartz
- From the CHOICE Institute, Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA
| | | | - Beth Devine
- From the CHOICE Institute, Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA
| | - Amanda I Phipps
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | | | - David L Suskind
- Department of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle WA
- Division of Gastroenterology, Department of Pediatrics, University of Washington, Seattle, WA
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Nicholson MR, Alexander E, Ballal S, Davidovics Z, Docktor M, Dole M, Gisser JM, Goyal A, Hourigan SK, Jensen MK, Kaplan JL, Kellermayer R, Kelsen JR, Kennedy MA, Khanna S, Knackstedt ED, Lentine J, Lewis JD, Michail S, Mitchell PD, Oliva-Hemker M, Patton T, Queliza K, Sidhu S, Solomon AB, Suskind DL, Weatherly M, Werlin S, de Zoeten EF, Kahn SA. Efficacy and Outcomes of Faecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection in Children with Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:768-777. [PMID: 34788420 PMCID: PMC9228903 DOI: 10.1093/ecco-jcc/jjab202] [Citation(s) in RCA: 10] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Children with inflammatory bowel disease [IBD] are disproportionally affected by recurrent Clostridioides difficile infection [rCDI]. Although faecal microbiota transplantation [FMT] has been used with good efficacy in adults with IBD, little is known about outcomes associated with FMT in paediatric IBD. METHODS We performed a retrospective review of FMT at 20 paediatric centres in the USA from March 2012 to March 2020. Children with and without IBD were compared with determined differences in the efficacy of FMT for rCDI. In addition, children with IBD with and without a successful outcome were compared with determined predictors of success. Safety data and IBD-specific outcomes were obtained. RESULTS A total of 396 paediatric patients, including 148 with IBD, were included. Children with IBD were no less likely to have a successful first FMT then the non-IBD affected cohort [76% vs 81%, p = 0.17]. Among children with IBD, patients were more likely to have a successful FMT if they received FMT with fresh stool [p = 0.03], were without diarrhoea prior to FMT [p = 0.03], or had a shorter time from rCDI diagnosis until FMT [p = 0.04]. Children with a failed FMT were more likely to have clinically active IBD post-FMT [p = 0.002] and 19 [13%] patients had an IBD-related hospitalisation in the 3-month follow-up. CONCLUSIONS Based on the findings from this large US multicentre cohort, the efficacy of FMT for the treatment of rCDI did not differ in children with IBD. Failed FMT among children with IBD was possibly related to the presence of clinically active IBD.
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Affiliation(s)
- Maribeth R Nicholson
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin Alexander
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Sonia Ballal
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Zev Davidovics
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Michael Docktor
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Michael Dole
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan M Gisser
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alka Goyal
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Suchitra K Hourigan
- Department of Pediatrics, Pediatric Specialists of Virginia, Fairfax, VA, USA
| | - M Kyle Jensen
- Department of Pediatrics, University of Utah Department of Pediatrics, Salt Lake City, UT, USA
| | - Jess L Kaplan
- Department of Pediatrics, MassGeneral Hospital for Children, Boston, MA, USA
| | - Richard Kellermayer
- Baylor College of Medicine, Texas Children's Hospital, USDA Children's Nutrition and Research Center, Houston, TX, USA
| | - Judith R Kelsen
- Department of Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa A Kennedy
- Department of Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sahil Khanna
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth D Knackstedt
- Department of Pediatrics, University of Utah Department of Pediatrics, Salt Lake City, UT, USA
| | - Jennifer Lentine
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Jeffery D Lewis
- Children's Center for Digestive Healthcare at Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sonia Michail
- Department of Pediatrics, University of Southern California Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Paul D Mitchell
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Maria Oliva-Hemker
- Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Tiffany Patton
- Department of Pediatrics, University of Chicago, Comer Children's Hospital, Chicago, IL, USA
| | - Karen Queliza
- Baylor College of Medicine, Texas Children's Hospital, USDA Children's Nutrition and Research Center, Houston, TX, USA
| | - Sarah Sidhu
- Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Aliza B Solomon
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - David L Suskind
- Department of Pediatrics, Seattle Children's Hospital and the University of Washington, Seattle, WA, USA
| | - Madison Weatherly
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Steven Werlin
- Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Edwin F de Zoeten
- Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA
| | - Stacy A Kahn
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Kaenkumchorn T, Suskind DL, Lee D, Singh N, Ford M, Skeen K, Macris PC, Yeung C, Summers C, Carpenter PA, Zheng HB. Adjunctive Dietary Therapy Is Associated With Improved Gastrointestinal Symptoms in Steroid-Refractory Gastrointestinal Graft-Versus-Host Disease: A Case Series. JPGN Rep 2022; 3:e203. [PMID: 37168898 PMCID: PMC10158262 DOI: 10.1097/pg9.0000000000000203] [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] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 01/09/2022] [Indexed: 05/13/2023]
Abstract
Acute gastrointestinal graft-versus-host disease (GI GVHD) is a complication after hematopoietic stem cell transplant with high morbidity and mortality. In particular, steroid-refractory GI GVHD can be difficult to treat. Recent investigations have revealed that patients after transplant can experience intestinal dysbiosis contributing to the progression of GVHD. Modulation of the gut microbiome through dietary intake could potentially improve the intestinal dysbiosis in GI GVHD. In this case series, we present 3 patients where dietary therapy was used in conjunction with immunosuppression to achieve clinical remission of GI GVHD.
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Affiliation(s)
- Tanyaporn Kaenkumchorn
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA
| | - David L. Suskind
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA
| | - Dale Lee
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA
| | - Namita Singh
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA
| | - Madeline Ford
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA
| | - Kristina Skeen
- Clinical Nutrition, Seattle Children’s Hospital, Seattle, WA
| | - Paula C. Macris
- Medical Nutrition Therapy Services, Seattle Cancer Care Alliance, Seattle, WA
| | - Cecilia Yeung
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Corinne Summers
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Paul A. Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Hengqi B. Zheng
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA
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Levine AE, Zheng HB, Suskind DL. Linking Genetic Diagnosis to Therapeutic Approach in Very Early Onset Inflammatory Bowel Disease: Pharmacologic Considerations. Paediatr Drugs 2022; 24:207-216. [PMID: 35467244 DOI: 10.1007/s40272-022-00503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
Very early onset inflammatory bowel disease (VEO-IBD) is diagnosed in children < 6 years of age, and in rare cases may be due to an identifiable monogenic cause. Recent advances in genetic testing have allowed for more accurate diagnosis, with as many as 100 genes now known to be associated with monogenic inflammatory bowel disease. These genes are involved in many immune pathways and thus may represent potential avenues for targeted precision medicine with pharmacologic treatments aimed at these. This review describes the broad classifications of monogenic disorders known to cause VEO-IBD, as well as empiric and disease-specific medical therapies. These include immune-modulating or immunosuppressant medications, nutritional therapy, surgery, and hematopoietic stem cell transplantation. We aim to provide an overview of the current state of targeted therapy for VEO-IBD.
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Affiliation(s)
- Anne E Levine
- Division of Gastroenterology, Seattle Children's Hospital Inflammatory Bowel Disease Center, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Hengqi B Zheng
- Division of Gastroenterology, Seattle Children's Hospital Inflammatory Bowel Disease Center, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - David L Suskind
- Division of Gastroenterology, Seattle Children's Hospital Inflammatory Bowel Disease Center, Seattle, WA, USA.
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
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Arjomand A, Suskind DL. Clinical and Histologic Remission in an Adult Crohn’s Disease Patient Following the Specific Carbohydrate Diet and Its Impact on Healthcare Costs. Cureus 2022; 14:e22032. [PMID: 35340483 PMCID: PMC8913515 DOI: 10.7759/cureus.22032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/05/2022] Open
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10
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Morrison A, Braly K, Singh N, Suskind DL, Lee D. Differences in Nutrient Intake with Homemade versus Chef-Prepared Specific Carbohydrate Diet Therapy in Inflammatory Bowel Disease: Insights into Dietary Research. Pediatr Gastroenterol Hepatol Nutr 2021; 24:432-442. [PMID: 34557396 PMCID: PMC8443856 DOI: 10.5223/pghn.2021.24.5.432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the nutrient content consumed by children and adolescents on home-prepared versus chef-prepared specific carbohydrate diets (SCD) as therapy for inflammatory bowel disease (IBD). METHODS Dietary intake of two cohorts with active IBD initiating the SCD over 12 weeks was assessed. The home-prepared cohort received detailed guidance from dietitians on implementation of the SCD. The chef in the other cohort was knowledgeable in the SCD and prepared meals from a fixed set of recipes. Data from 3-day diet diaries at 4 different time points were collected. US Recommended Daily Allowances (RDA) were calculated for macronutrients, vitamins, and minerals. RESULTS Eight participants on the homemade SCD and 5 participants on the chef-prepared SCD were included in analysis. Mean % RDA for energy intake was 115% and 87% for homemade and chef-prepared groups (p<0.01). Mean % RDA for protein intake was 337% for homemade SCD and 216% for chef-prepared SCD (p<0.01). The homemade SCD group had higher mean % RDA values for vitamin A and iron, while the chef-prepared SCD group had higher intake of vitamins B1, B2, D, phosphorus and zinc (p<0.01 for all). CONCLUSION The SCD implemented homemade versus chef-prepared can result in significantly different intake of nutrients and this may influence efficacy of this dietary therapy. Meal preparation dynamics and the motivation of families who pursue dietary treatment may play an important role on the foods consumed and the outcomes on dietary therapy with the SCD.
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Affiliation(s)
- Alex Morrison
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Kimberly Braly
- Division of Gastroenterology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Namita Singh
- Division of Gastroenterology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - David L Suskind
- Division of Gastroenterology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Dale Lee
- Division of Gastroenterology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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Zheng HB, de la Morena MT, Suskind DL. The Growing Need to Understand Very Early Onset Inflammatory Bowel Disease. Front Immunol 2021; 12:675186. [PMID: 34122435 PMCID: PMC8187749 DOI: 10.3389/fimmu.2021.675186] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 03/02/2021] [Accepted: 05/04/2021] [Indexed: 11/24/2022] Open
Abstract
Very Early Onset Inflammatory Bowel Disease (VEO-IBD) represents a cohort of inflammatory bowel disease (IBD) patients diagnosed before 6 years of age. Unlike IBD diagnosed at older ages, VEO-IBD can be associated with underlying primary immunodeficiencies. VEO-IBD has been linked to monogenic variations in over 70 genes involved in multiple pathways of immunity. As sequencing technologies and platforms evolve and become readily available, an increasing number of genes linked to VEO-IBD have emerged. Although monogenic defects are rare in VEO-IBD, diagnosis of these variants can often dictate specific treatment. In this mini-review, we set out to describe monogenic variants previously characterized in multiple patients in the literature that contribute to VEO-IBD, diagnostic tools, unique treatment modalities for specific genetic diagnoses, and future directions in the field of VEO-IBD. Although this mini-review is by no means comprehensive of all the novel monogenic variants linked to VEO-IBD, we hope to provide relevant information that is readily accessible to clinicians and educators.
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Affiliation(s)
- Hengqi B Zheng
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - M Teresa de la Morena
- Department of Pediatrics, University of Washington, Seattle, WA, United States.,Division of Immunology, Seattle Children's Hospital, Seattle, WA, United States
| | - David L Suskind
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
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12
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Suskind DL, Lee D, Kim YM, Wahbeh G, Singh N, Braly K, Nuding M, Nicora CD, Purvine SO, Lipton MS, Jansson JK, Nelson WC. The Specific Carbohydrate Diet and Diet Modification as Induction Therapy for Pediatric Crohn's Disease: A Randomized Diet Controlled Trial. Nutrients 2020; 12:nu12123749. [PMID: 33291229 PMCID: PMC7762109 DOI: 10.3390/nu12123749] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Crohn’s disease (CD) is a chronic inflammatory intestinal disorder associated with intestinal dysbiosis. Diet modulates the intestinal microbiome and therefore has a therapeutic potential. The aim of this study is to determine the potential efficacy of three versions of the specific carbohydrate diet (SCD) in active Crohn’s Disease. Methods: 18 patients with mild/moderate CD (PCDAI 15–45) aged 7 to 18 years were enrolled. Patients were randomized to either SCD, modified SCD(MSCD) or whole foods (WF) diet. Patients were evaluated at baseline, 2, 4, 8 and 12 weeks. PCDAI, inflammatory labs and multi-omics evaluations were assessed. Results: Mean age was 14.3 ± 2.9 years. At week 12, all participants (n = 10) who completed the study achieved clinical remission. The C-reactive protein decreased from 1.3 ± 0.7 at enrollment to 0.9 ± 0.5 at 12 weeks in the SCD group. In the MSCD group, the CRP decreased from 1.6 ± 1.1 at enrollment to 0.7 ± 0.1 at 12 weeks. In the WF group, the CRP decreased from 3.9 ± 4.3 at enrollment to 1.6 ± 1.3 at 12 weeks. In addition, the microbiome composition shifted in all patients across the study period. While the nature of the changes was largely patient specific, the predicted metabolic mode of the organisms increasing and decreasing in activity was consistent across patients. Conclusions: This study emphasizes the impact of diet in CD. Each diet had a positive effect on symptoms and inflammatory burden; the more exclusionary diets were associated with a better resolution of inflammation.
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Affiliation(s)
- David L. Suskind
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA 98105, USA; (D.L.); (G.W.); (N.S.); (K.B.); (M.N.)
- Correspondence: ; Tel.: +1-206-987-2521; Fax: +1-206-987-2721
| | - Dale Lee
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA 98105, USA; (D.L.); (G.W.); (N.S.); (K.B.); (M.N.)
| | - Young-Mo Kim
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA 99354, USA; (Y.-M.K.); (C.D.N.); (J.K.J.); (W.C.N.)
| | - Ghassan Wahbeh
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA 98105, USA; (D.L.); (G.W.); (N.S.); (K.B.); (M.N.)
| | - Namita Singh
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA 98105, USA; (D.L.); (G.W.); (N.S.); (K.B.); (M.N.)
| | - Kimberly Braly
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA 98105, USA; (D.L.); (G.W.); (N.S.); (K.B.); (M.N.)
| | - Mason Nuding
- Department of Pediatrics, Division of Gastroenterology, Seattle Children’s Hospital and University of Washington, Seattle, WA 98105, USA; (D.L.); (G.W.); (N.S.); (K.B.); (M.N.)
| | - Carrie D. Nicora
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA 99354, USA; (Y.-M.K.); (C.D.N.); (J.K.J.); (W.C.N.)
| | - Samuel O. Purvine
- Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, WA 99354, USA; (S.O.P.); (M.S.L.)
| | - Mary S. Lipton
- Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, WA 99354, USA; (S.O.P.); (M.S.L.)
| | - Janet K. Jansson
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA 99354, USA; (Y.-M.K.); (C.D.N.); (J.K.J.); (W.C.N.)
| | - William C. Nelson
- Biological Sciences Division, Pacific Northwest National Laboratory, Richland, WA 99354, USA; (Y.-M.K.); (C.D.N.); (J.K.J.); (W.C.N.)
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13
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Gupta N, Liu C, King E, Sylvester F, Lee D, Boyle B, Trauernicht A, Chen S, Colletti R, Ali SA, Al-Nimr A, Ayers TD, Baron HI, Beasley GL, Benkov KJ, Cabrera JM, Cho-Dorado ME, Dancel LD, Di Palma JS, Dorsey JM, Gulati AS, Hellmann JA, Higuchi LM, Hoffenberg E, Israel EJ, Jester TW, Kiparissi F, Konikoff MR, Leibowitz I, Maheshwari A, Moulton DE, Moses J, Ogunmola NA, Palmadottir JG, Pandey A, Pappa HM, Pashankar DS, Pasternak BA, Patel AS, Quiros JA, Rountree CB, Samson CM, Sandberg KC, Schoen B, Steiner SJ, Stephens MC, Sudel B, Sullivan JS, Suskind DL, Tomer G, Tung J, Verstraete SG. Continued Statural Growth in Older Adolescents and Young Adults With Crohn's Disease and Ulcerative Colitis Beyond the Time of Expected Growth Plate Closure. Inflamm Bowel Dis 2020; 26:1880-1889. [PMID: 31968095 DOI: 10.1093/ibd/izz334] [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: 08/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cessation of statural growth occurs with radiographic closure of the growth plates, radiographically defined as bone age (BA) 15 years in females and 17 in males. METHODS We determined the frequency of continued growth and compared the total height gain beyond the time of expected growth plate closure and the chronological age at achievement of final adult height in Crohn's disease (CD) vs ulcerative colitis (UC) and described height velocity curves in inflammatory bowel disease (IBD) compared with children in the National Health and Nutrition Examination Survey (NHANES). We identified all females older than chronological age (CA) 15 years and males older than CA 17 years with CD or UC in the ImproveCareNow registry who had height documented at ≥3 visits ≥6 months apart. RESULTS Three thousand seven patients (48% female; 76% CD) qualified. Of these patients, 80% manifested continued growth, more commonly in CD (81%) than UC (75%; P = 0.0002) and in females with CD (83%) than males with CD (79%; P = 0.012). Median height gain was greater in males with CD (1.6 cm) than in males with UC (1.3 cm; P = 0.0004), and in females with CD (1.8 cm) than in females with UC (1.5 cm; P = 0.025). Height velocity curves were shifted to the right in patients with IBD vs NHANES. CONCLUSIONS Pediatric patients with IBD frequently continue to grow beyond the time of expected growth plate closure. Unexpectedly, a high proportion of patients with UC exhibited continued growth, indicating delayed BA is also common in UC. Growth, a dynamic marker of disease status, requires continued monitoring even after patients transition from pediatric to adult care.
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Affiliation(s)
- Neera Gupta
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eileen King
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Francisco Sylvester
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dale Lee
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Brendan Boyle
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Anna Trauernicht
- Division of Pediatric Gastroenterology, Boys Town National Research Hospital, Boys Town, NE, USA
| | - Shiran Chen
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Richard Colletti
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT, USA
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14
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Nicholson MR, Mitchell PD, Alexander E, Ballal S, Bartlett M, Becker P, Davidovics Z, Docktor M, Dole M, Felix G, Gisser J, Hourigan SK, Jensen MK, Kaplan JL, Kelsen J, Kennedy M, Khanna S, Knackstedt E, Leier M, Lewis J, Lodarek A, Michail S, Oliva-Hemker M, Patton T, Queliza K, Russell GH, Singh N, Solomon A, Suskind DL, Werlin S, Kellermayer R, Kahn SA. Efficacy of Fecal Microbiota Transplantation for Clostridium difficile Infection in Children. Clin Gastroenterol Hepatol 2020; 18:612-619.e1. [PMID: 31009795 PMCID: PMC7549313 DOI: 10.1016/j.cgh.2019.04.037] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [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: 09/05/2018] [Revised: 04/02/2019] [Accepted: 04/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Fecal microbiota transplantation (FMT) is commonly used to treat Clostridium difficile infection (CDI). CDI is an increasing cause of diarrheal illness in pediatric patients, but the effects of FMT have not been well studied in children. We performed a multi-center retrospective cohort study of pediatric and young adult patients to evaluate the efficacy, safety, and factors associated with a successful FMT for the treatment of CDI. METHODS We performed a retrospective study of 372 patients, 11 months to 23 years old, who underwent FMT at 18 pediatric centers, from February 1, 2004, to February 28, 2017; 2-month outcome data were available from 335 patients. Successful FMT was defined as no recurrence of CDI in the 2 months following FMT. We performed stepwise logistic regression to identify factors associated with successful FMT. RESULTS Of 335 patients who underwent FMT and were followed for 2 months or more, 271 (81%) had a successful outcome following a single FMT and 86.6% had a successful outcome following a first or repeated FMT. Patients who received FMT with fresh donor stool (odds ratio [OR], 2.66; 95% CI, 1.39-5.08), underwent FMT via colonoscopy (OR, 2.41; 95% CI, 1.26-4.61), did not have a feeding tube (OR, 2.08; 95% CI, 1.05-4.11), or had 1 less episode of CDI before FMT (OR, 1.20; 95% CI, 1.04-1.39) had increased odds for successful FMT. Seventeen patients (4.7%) had a severe adverse event during the 3-month follow-up period, including 10 hospitalizations. CONCLUSIONS Based on the findings from a large multi-center retrospective cohort, FMT is effective and safe for the treatment of CDI in children and young adults. Further studies are required to optimize the timing and method of FMT for pediatric patients-factors associated with success differ from those of adult patients.
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Affiliation(s)
| | | | | | - Sonia Ballal
- Boston Children’s Hospital, Boston, Massachusetts
| | | | - Penny Becker
- Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Zev Davidovics
- Connecticut Children’s Medical Center, Hartford, Connecticut
| | | | - Michael Dole
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Grace Felix
- Johns Hopkins Children’s Center, Baltimore, Maryland
| | | | - Suchitra K. Hourigan
- Johns Hopkins Children’s Center, Baltimore, Maryland;,Pediatric Specialists of Virginia, Fairfax, Virginia
| | - M. Kyle Jensen
- Primary Children’s Hospital at University of Utah, Salt Lake City, Utah
| | - Jess L. Kaplan
- MassGeneral Hospital for Children, Boston, Massachusetts
| | - Judith Kelsen
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa Kennedy
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | - Jeffery Lewis
- Children’s Center for Digestive Healthcare at Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Sonia Michail
- University of Southern California Children’s Hospital of Los Angeles, Los Angeles, California
| | | | | | - Karen Queliza
- Baylor College of Medicine, Texas Children’s Hospital, Children’s Nutrition and Research Center, Houston, Texas
| | | | - Namita Singh
- Cedars Sinai Medical Center, Los Angeles, California
| | | | - David L. Suskind
- Seattle Children’s Hospital and the University of Washington, Seattle, Washington
| | | | - Richard Kellermayer
- Baylor College of Medicine, Texas Children’s Hospital, Children’s Nutrition and Research Center, Houston, Texas
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15
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Schwartz NRM, Hutfless S, Herrinton LJ, Amsden LB, Fevrier HB, Giefer M, Lee D, Suskind DL, Delaney JAC, Phipps AI. Proton Pump Inhibitors, H 2 Blocker Use, and Risk of Inflammatory Bowel Disease in Children. J Pediatr Pharmacol Ther 2019; 24:489-496. [PMID: 31719810 DOI: 10.5863/1551-6776-24.6.489] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Evidence suggests use of proton pump inhibitors (PPIs) and H2 blockers may provoke disease flares in individuals with established inflammatory bowel disease (IBD); however, there are no studies investigating the relationship of these medications with risk of developing pediatric IBD. The hypothesis was that use of acid suppression therapy in children might be associated with development of pediatric IBD. METHODS This was a nested case-control study of 285 Kaiser Permanente Northern California members, age ≤21 years diagnosed with IBD from 1996 to 2016. Four controls without IBD were matched to each case on age, race, and membership status at the case's index date. Disease risk scores (DRS) were computed for each subject. Odds ratios and 95% confidence intervals were calculated by using conditional logistic regression models adjusted for DRS. RESULTS The children's mean age was 15.1 ± 2.6 years and 49.5% were female. Six cases (n = 3 Crohn's disease [CD], n = 3 ulcerative colitis [UC]) and 6 controls were prescribed PPIs and 10 cases (n = 7 CD, n = 3 UC) and 28 controls were prescribed H2 blockers. The OR for the association of at least 1 PPI or H2 blocker prescription with subsequent IBD was 3.6 (95% CI, 1.1-11.7) for PPIs and 1.6 (95% CI, 0.7-3.7) for H2 blockers. CONCLUSIONS Early-life PPI use appears to be associated with subsequent IBD risk. These findings have implications for clinical treatment of children with gastrointestinal symptoms and warrant further investigation in a larger cohort.
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16
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Pratt J, Jeffers D, King EC, Kappelman MD, Collins J, Margolis P, Baron H, Bass JA, Bassett MD, Beasley GL, Benkov KJ, Bornstein JA, Cabrera JM, Crandall W, Dancel LD, Garin-Laflam MP, Grunow JE, Hirsch BZ, Hoffenberg E, Israel E, Jester TW, Kiparissi F, Lakhole A, Lapsia SP, Minar P, Navarro FA, Neef H, Park KT, Pashankar DS, Patel AS, Pineiro VM, Samson CM, Sandberg KC, Steiner SJ, Strople JA, Sudel B, Sullivan JS, Suskind DL, Uppal V, Wali PD. Implementing a Novel Quality Improvement-Based Approach to Data Quality Monitoring and Enhancement in a Multipurpose Clinical Registry. EGEMS (Wash DC) 2019; 7:51. [PMID: 31646151 PMCID: PMC6777196 DOI: 10.5334/egems.262] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 09/10/2019] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To implement a quality improvement based system to measure and improve data quality in an observational clinical registry to support a Learning Healthcare System. DATA SOURCE ImproveCareNow Network registry, which as of September 2019 contained data from 314,250 visits of 43,305 pediatric Inflammatory Bowel Disease (IBD) patients at 109 participating care centers. STUDY DESIGN The impact of data quality improvement support to care centers was evaluated using statistical process control methodology. Data quality measures were defined, performance feedback of those measures using statistical process control charts was implemented, and reports that identified data items not following data quality checks were developed to enable centers to monitor and improve the quality of their data. PRINCIPAL FINDINGS There was a pattern of improvement across measures of data quality. The proportion of visits with complete critical data increased from 72 percent to 82 percent. The percent of registered patients improved from 59 percent to 83 percent. Of three additional measures of data consistency and timeliness, one improved performance from 42 percent to 63 percent. Performance declined on one measure due to changes in network documentation practices and maturation. There was variation among care centers in data quality. CONCLUSIONS A quality improvement based approach to data quality monitoring and improvement is feasible and effective.
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Affiliation(s)
| | | | - Eileen C. King
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, US
| | | | | | - Peter Margolis
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, US
| | - Howard Baron
- Pediatric Gastroenterology & Nutrition Associates, US
| | | | | | - Genie L. Beasley
- UF Health Pediatric Gastroenterology, Hepatology and Nutrition, US
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Phillip Minar
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati, US
| | | | - Haley Neef
- University of Michigan – C.S. Mott Children’s Hospital, US
| | | | | | | | | | | | | | | | | | | | | | | | - Vikas Uppal
- Nemours Children’s Health System – Wilmington, US
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17
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Little EM, Grevich S, Huber JL, Suskind DL, Bradford MC, Stevens AM, Zhao Y. Parental Perception of Dietary Intervention in Juvenile Idiopathic Arthritis. J Altern Complement Med 2019; 25:643-647. [DOI: 10.1089/acm.2018.0407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | - David L. Suskind
- Gastroenterology, Seattle Children's Hospital, Seattle, WA
- Centers for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Miranda C. Bradford
- Centers for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
| | - Anne M. Stevens
- Department of Pediatrics, University of Washington, Seattle, WA
- Centers for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Yongdong Zhao
- Department of Pediatrics, University of Washington, Seattle, WA
- Centers for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
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18
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Suskind DL, Lee D, Solan P, Wahbeh G, Hayden H, Brittnacher M, Nuding M, Miller S. Dietary therapy for clostridium difficile colonization: A case series. Anaerobe 2019; 57:1-3. [PMID: 30826445 DOI: 10.1016/j.anaerobe.2019.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/11/2019] [Accepted: 02/27/2019] [Indexed: 01/20/2023]
Abstract
Clostridium difficile (C. difficile) is an important nosocomial pathogen in adults and children. Roughly 4-5% of non hospitalized healthy adults carry the organism in their intestinal flora while adults in long term care facilities have asymptomatic carriage rates estimated at 20-50%. C. difficile colonization results in a spectrum of clinical conditions from asymptomatic carrier state to fulminant colitis. Changes in the fecal microbiome are central in the development of C. difficile colonization and disease pathogenesis. C. difficile infection has been shown to be associated with reduced biodiversity of the gut microbiome and intestinal dysbiosis. With the importance of the intestinal microbiota in development of CDI and with the known impact of diet on the intestinal microbiota, we report the first known case of C. difficile colonization/recurrence successful treated by dietary modification.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics, Division of Gastroenterology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA.
| | - Dale Lee
- Department of Pediatrics, Division of Gastroenterology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Peggy Solan
- Department of Nutrition, Seattle Children's Hospital, Seattle, WA, USA
| | - Ghassan Wahbeh
- Department of Pediatrics, Division of Gastroenterology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Hillary Hayden
- Department of Microbiology, University of Washington, Seattle, WA, 98195, USA
| | - Mitch Brittnacher
- Department of Microbiology, University of Washington, Seattle, WA, 98195, USA
| | - Mason Nuding
- Department of Pediatrics, Division of Gastroenterology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Samuel Miller
- Department of Microbiology, University of Washington, Seattle, WA, 98195, USA; Department of Laboratory Medicine, University of Washington, Seattle, WA, 98195, USA; Department of Medicine, University of Washington, Seattle, WA, 98195, USA; Department of Immunology, University of Washington, Seattle, WA, 98195, USA; Department of Genome Sciences, University of Washington, Seattle, WA, 98195, USA
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19
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Bluestone H, Kronman MP, Suskind DL. Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infections in Pediatric Hematopoietic Stem Cell Transplant Recipients. J Pediatric Infect Dis Soc 2018; 7:e6-e8. [PMID: 29040661 DOI: 10.1093/jpids/pix076] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 03/30/2017] [Indexed: 11/13/2022]
Affiliation(s)
- Hira Bluestone
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle
| | - Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle.,Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
| | - David L Suskind
- Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington.,Division of Gastroenterology, Department of Pediatrics, University of Washington, Seattle
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20
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Suskind DL, Kong D, Stevens A, Wahbeh G, Christie D, Baxter-Lowe LA, Muench MO. Maternal microchimerism in pediatric inflammatory bowel disease. Chimerism 2017; 2:50-4. [PMID: 21912719 DOI: 10.4161/chim.2.2.16556] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 06/05/2011] [Accepted: 06/05/2011] [Indexed: 01/08/2023]
Abstract
UNLABELLED Inflammatory bowel disease (IBD) shares many immunologic and clinical characteristics with graft versus host disease caused by allogeneic T lymphocytes after hematopoietic cell transplantation. Since maternal cells are known to enter the fetal circulation in a high proportion of pregnancies, we hypothesized that maternal engraftment in the fetus results in immune sequelae that can lead to IBD. METHOD The presence and extent of maternal microchimerism in tissues and blood samples from patients with Crohn's, Ulcerative colitis (UC), and control groups were determined using kinetic Polymerase Chain Reaction (kPCR) to detect maternal- and patient-specific HLA types. In addition, fluorescent in situ hybridization (FISH) was employed to detect maternal cells in biopsies from patients with IBD. RESULTS Using kPCR, maternal microchimerism was observed in 9 of the 16 (56%) patients with IBD and 6 out of 15 of the control group (40%) (P=NS). Five of 10 Crohn's patients had evidence of maternal microchimerism (50%) (P=NS). Four of six UC patients had evidence of maternal microchimerism in gut tissues (67%) (P=NS). There was no correlation between maternal michrochimerism and disease activity, disease location or granulomas in patients with IBD. Using FISH, five male Crohn's and five male UC patient's intestinal biopsies were analyzed for maternal microchimerism. No maternal cells were identified. CONCLUSION There is nothing in the data to suggest that patients with IBD differ from disease controls in their frequency of maternal microchimerism in either blood or gut mucosal tissues. These data suggest that maternal microchimerism in blood and biopsies is a relatively common phenomenon that has neither positive nor negative impact on IBD.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics; Seattle Children's Hospital; University of Washington; Seattle, WA USA
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21
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Miller TL, Lee D, Giefer M, Wahbeh G, Suskind DL. Nutritional Therapy in Very Early-Onset Inflammatory Bowel Disease: A Case Report. Dig Dis Sci 2017; 62:2196-2200. [PMID: 28551707 DOI: 10.1007/s10620-017-4616-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 03/20/2017] [Accepted: 05/12/2017] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal tract caused by a dysregulated immune response to the fecal microbiota. Very early-onset inflammatory bowel disease (VEO-IBD) refers to a subgroup of pediatric patients with IBD diagnosed before 6 years of age. This subgroup is often characterized by increased severity, aggressive progression, strong family history of IBD, and often poor response to conventional treatments. Nutritional therapies have been utilized to treat IBD, but their role in VEO-IBD is unclear. Disease behavior in VEO-IBD is often different from disease in adolescents and adults, as it is often restricted to the colon and refractory to standard medical therapies. Up to 25% of VEO-IBD patients have an identified underlying immunodeficiency, which may impact response to therapy. While specific mutations in interleukin 10 (IL-10), the IL-10 receptor (IL-10R), and mutations in NCF2, XIAP, LRBA, and TTC7 have been identified in VEO-IBD, polymorphisms in these genes are also associated with increased risk of developing IBD in adolescence or adulthood. We describe two cases in which infants presenting with VEO-IBD achieved clinical remission using exclusive enteral nutrition, a formula-based diet which has been shown to induce remission in older children with active Crohn's disease.
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Affiliation(s)
- Talya L Miller
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.
| | - Dale Lee
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
| | - Mathew Giefer
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
| | - Ghassan Wahbeh
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
| | - David L Suskind
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
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Abstract
Inflammatory bowel disease is a heterogeneous group of chronic disorders that result from the interaction of the intestinal immune system with the gut microbiome. Until recently, most investigative efforts and therapeutic breakthroughs were centered on understanding and manipulating the altered mucosal immune response that characterizes these diseases. However, more recent studies have highlighted the important role of environmental factors, and in particular the microbiota, in disease onset and disease exacerbation. Advances in genomic sequencing technology and bioinformatics have facilitated an explosion of investigative inquiries into the composition and function of the intestinal microbiome in health and disease and have advanced our understanding of the interplay between the gut microbiota and the host immune system. The gut microbiome is dynamic and changes with age and in response to diet, antibiotics and other environmental factors, and these alterations in the microbiome contribute to disease onset and exacerbation. Strategies to manipulate the microbiome through diet, probiotics, antibiotics or fecal microbiota transplantation may potentially be used therapeutically to influence modulate disease activity. This review will characterize the factors involved in the development of the intestinal microbiome and will describe the typical alterations in the microbiota that are characteristic of inflammatory bowel disease. Additionally, this manuscript will summarize the early but promising literature on the role of the gut microbiota in the pathogenesis of inflammatory bowel disease with implications for utilizing this data for diagnostic or therapeutic application in the clinical management of patients with these diseases.
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Affiliation(s)
- Erin R Lane
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital
| | - Timothy L Zisman
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - David L Suskind
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital
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Suskind DL, Wahbeh G, Cohen SA, Damman CJ, Klein J, Braly K, Shaffer M, Lee D. Patients Perceive Clinical Benefit with the Specific Carbohydrate Diet for Inflammatory Bowel Disease. Dig Dis Sci 2016; 61:3255-3260. [PMID: 27638834 DOI: 10.1007/s10620-016-4307-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [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: 06/17/2016] [Accepted: 09/07/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Recent studies suggest that dietary therapy may be effective for patients with inflammatory bowel disease (IBD), but limited published data exist on the usage and efficacy of dietary therapy. AIM To evaluate the perspective of IBD patients using the specific carbohydrate diet (SCD). METHODS An anonymous online survey was conducted using REDCap, a Web-based survey tool. Survey links were sent to known Web sites as well as support groups in an attempt to characterize patient utilization of the SCD and perception of efficacy of the SCD. RESULTS There were 417 respondents of the online survey on the SCD with IBD. Mean age for individuals on the SCD was 34.9 ± 16.4 years. Seventy percent were female. Forty-seven percent had Crohn's disease, 43 % had ulcerative colitis, and 10 % had indeterminate colitis. Individuals perceived clinical improvement on the SCD. Four percent reported clinical remission prior to the SCD, while 33 % reported remission at 2 months after initiation of the SCD, and 42 % at both 6 and 12 months. For those reporting clinical remission, 13 % reported time to achieve remission of less than 2 weeks, 17 % reported 2 weeks to a month, 36 % reported 1-3 months, and 34 % reported greater than 3 months. For individuals who reported reaching remission, 47 % of individuals reported associated improvement in abnormal laboratory values. CONCLUSIONS The SCD is utilized by many patients as a primary and adjunct therapy for IBD. Most patients perceive clinical benefit to use of the SCD.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.
| | - Ghassan Wahbeh
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
| | - Stanley A Cohen
- Children's Center for Digestive Health Care, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Christopher J Damman
- Department of Medicine, Division of Gastroenterology, University of Washington Medical Center, Seattle, WA, USA
| | - Jani Klein
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
| | - Kim Braly
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
| | - Michele Shaffer
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Dale Lee
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA
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Brittnacher MJ, Heltshe SL, Hayden HS, Radey MC, Weiss EJ, Damman CJ, Zisman TL, Suskind DL, Miller SI. GUTSS: An Alignment-Free Sequence Comparison Method for Use in Human Intestinal Microbiome and Fecal Microbiota Transplantation Analysis. PLoS One 2016; 11:e0158897. [PMID: 27391011 PMCID: PMC4938407 DOI: 10.1371/journal.pone.0158897] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/23/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Comparative analysis of gut microbiomes in clinical studies of human diseases typically rely on identification and quantification of species or genes. In addition to exploring specific functional characteristics of the microbiome and potential significance of species diversity or expansion, microbiome similarity is also calculated to study change in response to therapies directed at altering the microbiome. Established ecological measures of similarity can be constructed from species abundances, however methods for calculating these commonly used ecological measures of similarity directly from whole genome shotgun (WGS) metagenomic sequence are lacking. RESULTS We present an alignment-free method for calculating similarity of WGS metagenomic sequences that is analogous to the Bray-Curtis index for species, implemented by the General Utility for Testing Sequence Similarity (GUTSS) software application. This method was applied to intestinal microbiomes of healthy young children to measure developmental changes toward an adult microbiome during the first 3 years of life. We also calculate similarity of donor and recipient microbiomes to measure establishment, or engraftment, of donor microbiota in fecal microbiota transplantation (FMT) studies focused on mild to moderate Crohn's disease. We show how a relative index of similarity to donor can be calculated as a measure of change in a patient's microbiome toward that of the donor in response to FMT. CONCLUSION Because clinical efficacy of the transplant procedure cannot be fully evaluated without analysis methods to quantify actual FMT engraftment, we developed a method for detecting change in the gut microbiome that is independent of species identification and database bias, sensitive to changes in relative abundance of the microbial constituents, and can be formulated as an index for correlating engraftment success with clinical measures of disease. More generally, this method may be applied to clinical evaluation of human microbiomes and provide potential diagnostic determination of individuals who may be candidates for specific therapies directed at alteration of the microbiome.
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Affiliation(s)
- Mitchell J. Brittnacher
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
| | - Sonya L. Heltshe
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Seattle Children's Research Institute, Seattle, Washington, United States of America
| | - Hillary S. Hayden
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
| | - Matthew C. Radey
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
| | - Eli J. Weiss
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
| | - Christopher J. Damman
- Division of Gastroenterology, University of Washington, Seattle, Washington, United States of America
| | - Timothy L. Zisman
- Division of Gastroenterology, University of Washington, Seattle, Washington, United States of America
| | - David L. Suskind
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Seattle Children’s Hospital, Seattle, Washington, United States of America
| | - Samuel I. Miller
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Immunology, University of Washington, Seattle, Washington, United States of America
- Department of Genome Sciences, University of Washington, Seattle, Washington, United States of America
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Vindigni SM, Zisman TL, Suskind DL, Damman CJ. The intestinal microbiome, barrier function, and immune system in inflammatory bowel disease: a tripartite pathophysiological circuit with implications for new therapeutic directions. Therap Adv Gastroenterol 2016; 9:606-25. [PMID: 27366227 PMCID: PMC4913337 DOI: 10.1177/1756283x16644242] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We discuss the tripartite pathophysiological circuit of inflammatory bowel disease (IBD), involving the intestinal microbiota, barrier function, and immune system. Dysfunction in each of these physiological components (dysbiosis, leaky gut, and inflammation) contributes in a mutually interdependent manner to IBD onset and exacerbation. Genetic and environmental risk factors lead to disruption of gut homeostasis: genetic risks predominantly affect the immune system, environmental risks predominantly affect the microbiota, and both affect barrier function. Multiple genetic and environmental 'hits' are likely necessary to establish and exacerbate disease. Most conventional IBD therapies currently target only one component of the pathophysiological circuit, inflammation; however, many patients with IBD do not respond to immune-modulating therapies. Hope lies in new classes of therapies that target the microbiota and barrier function.
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Affiliation(s)
- Stephen M. Vindigni
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Timothy L. Zisman
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David L. Suskind
- Department of Pediatrics, Seattle Children’s Hospital and University of Washington, Seattle, WA, USA
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Obih C, Wahbeh G, Lee D, Braly K, Giefer M, Shaffer ML, Nielson H, Suskind DL. Specific carbohydrate diet for pediatric inflammatory bowel disease in clinical practice within an academic IBD center. Nutrition 2015; 32:418-25. [PMID: 26655069 DOI: 10.1016/j.nut.2015.08.025] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [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: 08/07/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Despite dietary factors being implicated in the pathogenesis of inflammatory bowel disease (IBD), nutritional therapy, outside of exclusive enteral nutrition (EEN), has not had a defined role within the treatment paradigm of pediatric IBD within IBD centers. Based on emerging data, Seattle Children's Hospital IBD Center has developed an integrated dietary program incorporating the specific carbohydrate diet (SCD) into its treatment paradigm. This treatment paradigm uses the SCD as primary therapy as well as adjunctive therapy for the treatment of IBD. The aim of this study was to evaluate the potential effects of the SCD on clinical outcomes and laboratory studies of pediatric patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS In this retrospective study, we reviewed the medical records of patients with IBD on SCD. RESULTS We analyzed 26 children on the SCD: 20 with CD and 6 with UC. Duration of the dietary therapy ranged from 3 to 48 mo. In patients with active CD (Pediatric Crohn's Disease activity index [PCDAI] >10), PCDAI dropped from 32.8 ± 13.2 at baseline to 20.8 ± 16.6 by 4 ± 2 wk, and to 8.8 ± 8.5 by 6 mo. The mean Pediatric Ulcerative Colitis Activity Index for patients with active UC decreased from a baseline of 28.3 ± 10.3 to 20.0 ± 17.3 at 4 ± 2 wk, to 18.3 ± 31.7 at 6 mo. CONCLUSION This retrospective review provides evidence that the SCD can be integrated into a tertiary care center and may improve clinical and laboratory parameters for pediatric patients with nonstructuring, nonpenetrating CD as well as UC. Further prospective studies are needed to fully assess the safety and efficacy of the SCD in pediatric patients with IBD.
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Affiliation(s)
- Chinonyelum Obih
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Ghassan Wahbeh
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Dale Lee
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Kim Braly
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Matthew Giefer
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Michele L Shaffer
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Heather Nielson
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - David L Suskind
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA.
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Abstract
Article first published online 29 April 2015.
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28
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Kelly CR, Ihunnah C, Fischer M, Khoruts A, Surawicz C, Afzali A, Aroniadis O, Barto A, Borody T, Giovanelli A, Gordon S, Gluck M, Hohmann EL, Kao D, Kao JY, McQuillen DP, Mellow M, Rank KM, Rao K, Ray A, Schwartz MA, Singh N, Stollman N, Suskind DL, Vindigni SM, Youngster I, Brandt L. Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients. Am J Gastroenterol 2014; 109:1065-71. [PMID: 24890442 PMCID: PMC5537742 DOI: 10.1038/ajg.2014.133] [Citation(s) in RCA: 478] [Impact Index Per Article: 47.8] [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: 01/06/2014] [Accepted: 04/21/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection (CDI), which has increased to epidemic proportions over the past decade. Fecal microbiota transplantation (FMT) appears effective for the treatment of CDI, although there is concern that IC patients may be at increased risk of having adverse events (AEs) related to FMT. This study describes the multicenter experience of FMT in IC patients. METHODS A multicenter retrospective series was performed on the use of FMT in IC patients with CDI that was recurrent, refractory, or severe. We aimed to describe rates of CDI cure after FMT as well as AEs experienced by IC patients after FMT. A 32-item questionnaire soliciting demographic and pre- and post-FMT data was completed for 99 patients at 16 centers, of whom 80 were eligible for inclusion. Outcomes included (i) rates of CDI cure after FMT, (ii) serious adverse events (SAEs) such as death or hospitalization within 12 weeks of FMT, (iii) infection within 12 weeks of FMT, and (iv) AEs (related and unrelated) to FMT. RESULTS Cases included adult (75) and pediatric (5) patients treated with FMT for recurrent (55%), refractory (11%), and severe and/or overlap of recurrent/refractory and severe CDI (34%). In all, 79% were outpatients at the time of FMT. The mean follow-up period between FMT and data collection was 11 months (range 3-46 months). Reasons for IC included: HIV/AIDS (3), solid organ transplant (19), oncologic condition (7), immunosuppressive therapy for inflammatory bowel disease (IBD; 36), and other medical conditions/medications (15). The CDI cure rate after a single FMT was 78%, with 62 patients suffering no recurrence at least 12 weeks post FMT. Twelve patients underwent repeat FMT, of whom eight had no further CDI. Thus, the overall cure rate was 89%. Twelve (15%) had any SAE within 12 weeks post FMT, of which 10 were hospitalizations. Two deaths occurred within 12 weeks of FMT, one of which was the result of aspiration during sedation for FMT administered via colonoscopy; the other was unrelated to FMT. None suffered infections definitely related to FMT, but two patients developed unrelated infections and five had self-limited diarrheal illness in which no causal organism was identified. One patient had a superficial mucosal tear caused by the colonoscopy performed for the FMT, and three patients reported mild, self-limited abdominal discomfort post FMT. Five (14% of IBD patients) experienced disease flare post FMT. Three ulcerative colitis (UC) patients underwent colectomy related to course of UC >100 days after FMT. CONCLUSIONS This series demonstrates the effective use of FMT for CDI in IC patients with few SAEs or related AEs. Importantly, there were no related infectious complications in these high-risk patients.
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Affiliation(s)
- Colleen R. Kelly
- Division of Gastroenterology, Brown Alpert Medical School, Women’s Medicine Collaborative, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Chioma Ihunnah
- Division of Gastroenterology, Brown Alpert Medical School, Women’s Medicine Collaborative, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Monika Fischer
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Anita Afzali
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Olga Aroniadis
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Amy Barto
- Lahey Clinic Hospital and Medical Center, Tufts University School of Medicine, Burlington, Massachusetts, USA
| | - Thomas Borody
- Centre for Digestive Diseases, Five Dock, Sydney, New South Wales, Australia
| | - Andrea Giovanelli
- Northern California Gastroenterology Consultants, Inc., Oakland, California, USA
| | - Shelley Gordon
- California Pacific Medical Center, San Francisco, California, USA
| | - Michael Gluck
- Virginia Mason Medical Center, Seattle, Washington, USA
| | - Elizabeth L. Hohmann
- Massachusetts General Hospital and Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dina Kao
- University of Alberta, Edmonton, Alberta, Canada
| | - John Y. Kao
- University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel P. McQuillen
- Lahey Clinic Hospital and Medical Center, Tufts University School of Medicine, Burlington, Massachusetts, USA
| | - Mark Mellow
- Integris Baptist Medical Center, Oklahoma, Oklahoma, USA
| | - Kevin M. Rank
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Krishna Rao
- University of Michigan, Ann Arbor, Michigan, USA
| | - Arnab Ray
- Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | | | - Namita Singh
- Seattle Children’s Hospital, Seattle, Washington, USA
| | - Neil Stollman
- Northern California Gastroenterology Consultants, Inc., Oakland, California, USA
| | | | | | - Ilan Youngster
- Massachusetts General Hospital and Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence Brandt
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Wahbeh GT, Suskind DL, Lee SD, Waldhausen JT, Murray KF. The pediatric pouch in inflammatory bowel disease: a primer for the gastroenterologist. Expert Rev Gastroenterol Hepatol 2013; 7:215-23. [PMID: 23445231 DOI: 10.1586/egh.12.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pediatric severe ulcerative colitis that is resistant to current medical treatment can successfully be managed surgically with a colectomy, ileal pouch creation and pouch-anal anastomosis. Key issues that should be considered and discussed before the pouch option can be offered include alternative surgical procedures, pouch function expectations, risk of surgical leak, pelvic sepsis, anastomotic strictures, acute and chronic pouch inflammation, Crohn's disease of the pouch and risk of reduced fertility for females. A long-term risk is malignancy of the residual colonic tissue. The decision to proceed with a pouch or not poses a substantial emotional burden to the child and family. Despite the risk of surgical complications and pouch inflammatory and functional challenges, the overwhelming majority of children and their families are satisfied with their pouch surgery outcomes. Further study is needed to assess preoperative risk predictors, prevention and treatment of complications.
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Affiliation(s)
- Ghassan T Wahbeh
- Inflammatory Bowel Disease Program, Seattle Children's Hospital, University of Washington, W7830, Gastroenterology, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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Abstract
Nutrition interventions play a central role in the treatment and management of inflammatory bowel disease in children. Malnutrition is a common presenting symptom in both pediatric ulcerative colitis and Crohn's disease and is associated with increased morbidity. Providing macronutrients can improve growth; likewise, identifying and correcting micronutrient deficiencies can improve comorbid conditions like osteopenia and anemia. Although many patients manipulate their diets to help treat their inflammatory bowel disease, only parenteral nutrition with bowel rest and exclusive enteral nutrition therapy have been shown effective for the treatment of inflammatory bowel disease.
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Affiliation(s)
- Daniel P Mallon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
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Abstract
Biliary atresia is an idiopathic neonatal cholestatic disease characterized by the destruction of both the intra- and extra-hepatic biliary ducts. There are two clinical manifestations of the disease: an embryonal subtype, which often presents at birth and is associated with congenital malformations, and a 'perinatal' subtype, which is probably an acquired disease due to unknown etiology. Over the last two decades, researchers have focused on activation of the cell-mediated immunity as the mechanism for biliary epithelial cell destruction for the latter subtype. A proposed trigger of this immune response is an initial viral infection, inducing biliary epithelial cells to become antigen-presenting cells and thus instigating immune-mediated destruction of the biliary tract. However, putative viruses have never been confirmed. More recently, a novel hypothesis - that maternal microchimerism may initiate a host immunologic response towards the bile duct epithelia - has been proposed. This paper discusses the etiology of biliary atresia in the context of the current research.
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Affiliation(s)
- Toshihiro Muraji
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, 311-4145, Japan.
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Abstract
Nutritional deficiencies have always been a major consideration in pediatrics. Although the classic forms of many of the well-documented nutritional deficiencies are memorized during training as a physician, nutritional deficiencies that can occur in otherwise asymptomatic normally growing children are often overlooked. The two most common deficiencies seen in children who are growing normally are iron and vitamin D deficiencies. These deficiencies are surprisingly common and can have a significant impact on the overall health of a child. This article reviews these nutritional deficiencies and other less commonly seen deficiencies in children who are otherwise growing normally.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics, Division of Pediatric Gastroenterology Hepatology and Nutrition, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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Abstract
Alagille syndrome (AGS) is caused by heterozygous mutations in JAG1, and mutations have been previously reported in about 70% of patients who meet clinical diagnostic criteria. We studied a cohort of 247 clinically well-defined patients, and using an aggressive and sequential screening approach we identified JAG1 mutations in 94% of individuals. Mutations were found in 232 out of 247 patients studied and 83 of the mutations were novel. This increase in the mutation rate was accomplished by combining rigorous clinical phenotyping, with a combination of mutation detection techniques, including fluorescence in situ hybridization (FISH), genomic and cDNA sequencing, and quantitative PCR. This higher rate of mutation identification has implications for clinical practice, facilitating genetic counseling, prenatal diagnosis, and evaluation of living-related liver transplant donors. Our results suggest that more aggressive screening may similarly increase the rate of mutation detection in other dominant and recessive disorders.
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Affiliation(s)
- David L Suskind
- Division of Gastroenterology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
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Suskind DL, Finn L, Wahbeh G, Christie D, Horslen S. A child with Kabuki syndrome and primary sclerosing cholangitis successfully treated with ursodiol and cholestryamine. J Pediatr Gastroenterol Nutr 2006; 43:542-4. [PMID: 17033534 DOI: 10.1097/01.mpg.0000228114.06488.ef] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- David L Suskind
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital and Regional Medical Center, University of Washington, Seattle, WA 98105, USA.
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Muench MO, Ohkubo T, Smith CA, Suskind DL, Bárcena A. Maintenance of proliferative capacity and retroviral transduction efficiency of human fetal CD38(-)/CD34(++) stem cells. Stem Cells Dev 2006; 15:97-108. [PMID: 16522167 DOI: 10.1089/scd.2006.15.97] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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: 12/22/2022] Open
Abstract
Methods for the efficient transduction and expansion of fetal hematopoietic stem cells could lead to novel in utero therapies for blood cell disorders and enzymatic deficiencies. Here we describe a new assay to measure rapidly the effects of cytokines on the differentiation or expansion of primitive progenitors and stem cells found among CD38(-)CD34(++) lineage() cells isolated from human midgestation liver. Importantly, conditions that otherwise supported the expansion of clonogenic progenitors reduced their proliferative capacity. A combination of megakaryocyte growth and development factor and granulocyte-macrophage colony-stimulating factor maintained proliferative potential while also yielding an intermediate level of progenitor expansion. Retroviral transduction was achieved using Moloney murine leukemia virus-based vectors. Freshly isolated candidate stem cells could be transduced at almost 17% efficiency by a 1-h exposure to virus with centrifugation to aid transduction. This was increased to a mean 35.5% transduction efficiency after 1 day of culture. Additionally, the transduction efficiency of candidate stem cells isolated from fetal placental blood was 33.0%. These findings encourage further investigation into the feasibility of ex utero gene therapy whereby fetal cells are isolated from the circulation, transduced, and expanded ex utero before being returned to the fetus.
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Affiliation(s)
- Marcus O Muench
- Department of Laboratory Medicine, University of California, San Francisco, CA 94143, USA.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Seattle Children's Hospital and Regional Medical Center, University of Washington, Seattle, WA, USA
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Suskind DL, Murray K, Christie D. An unusual case of an ulcerative colitis flare resulting in disseminated intravascular coagulopathy and a bladder hematoma: a case report. BMC Gastroenterol 2004; 4:26. [PMID: 15471542 PMCID: PMC526371 DOI: 10.1186/1471-230x-4-26] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2004] [Accepted: 10/07/2004] [Indexed: 01/06/2023] Open
Abstract
Background Disorders of coagulation have long been associated with inflammatory bowel disease. Children, as well as adults, with both active and inactive ulcerative colitis have been found to have abnormal coagulation and fibrinolysis. Disseminated intravascular coagulation arises from an overwhelming of the haemostatic regulatory mechanisms leading to an excessive generation of thrombin and a failure of the normal inhibitory pathways to prevent systemic effects of this enzyme. Ulcerative colitis has been associated with disseminated intravascular coagulation in conjunction with septicemia, toxic megacolon and surgery. Case presentation A fourteen-year-old boy with a history of poorly controlled ulcerative colitis presented with nonbilious emesis, hematochezia, and hematuria. Laboratory workup revealed disseminated intravascular coagulation. He was placed on triple antibiotics therapy. An infectious workup came back negative. A computerized tomography (CT) scan of the abdomen revealed a marked thickening and irregularity of the bladder wall as well as wall thickening of the rectosigmoid, ascending, transverse, and descending colon. Patient's clinical status remained stable despite a worsening of laboratory values associated with disseminated intravascular coagulation. Patient was begun on high dose intravenous steroids with improvement of the disseminated intravascular coagulation laboratory values within 12 hours and resolution of disseminated intravascular coagulopathy within 4 days. A thorough infectious workup revealed no other causes to his disseminated intravascular coagulation. Conclusions The spectrum of hypercoagulable states associated with ulcerative colitis varies from mild to severe. Although disseminated intravascular coagulation associated with ulcerative colitis is usually related to septicemia, toxic megacolon or surgery, we present a case of an ulcerative colitis flare resulting in disseminated intravascular coagulation and a bladder hematoma.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics, Seattle Children's Hospital and Regional Medical Center, University of Washington, 4800 Sand Point Way NE, Seattle, Washington, USA
| | - Karen Murray
- Department of Pediatrics, Seattle Children's Hospital and Regional Medical Center, University of Washington, 4800 Sand Point Way NE, Seattle, Washington, USA
| | - Dennis Christie
- Department of Pediatrics, Seattle Children's Hospital and Regional Medical Center, University of Washington, 4800 Sand Point Way NE, Seattle, Washington, USA
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Suskind DL, Rosenthal P, Heyman MB, Kong D, Magrane G, Baxter-Lowe LA, Muench MO. Maternal microchimerism in the livers of patients with biliary atresia. BMC Gastroenterol 2004; 4:14. [PMID: 15285784 PMCID: PMC514704 DOI: 10.1186/1471-230x-4-14] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Accepted: 07/31/2004] [Indexed: 01/09/2023] Open
Abstract
Background Biliary atresia (BA) is a neonatal cholestatic disease of unknown etiology. It is the leading cause of liver transplantation in children. Many similarities exist between BA and graft versus host disease suggesting engraftment of maternal cells during gestation could result in immune responses that lead to BA. The aim of this study was to determine the presence and extent of maternal microchimerism (MM) in the livers of infants with BA. Methods Using fluorescent in situ hybridization (FISH), 11 male BA & 4 male neonatal hepatitis (NH) livers, which served as controls, were analyzed for X and Y-chromosomes. To further investigate MM in BA, 3 patients with BA, and their mothers, were HLA typed. Using immunohistochemical stains, the BA livers were examined for MM. Four additional BA livers underwent analysis by polymerase chain reaction (PCR) for evidence of MM. Results By FISH, 8 BA and 2 NH livers were interpretable. Seven of eight BA specimens showed evidence of MM. The number of maternal cells ranged from 2–4 maternal cells per biopsy slide. Neither NH specimen showed evidence of MM. In addition, immunohistochemical stains confirmed evidence of MM. Using PCR, a range of 1–142 copies of maternal DNA per 25,000 copies of patients DNA was found. Conclusions Maternal microchimerism is present in the livers of patients with BA and may contribute to the pathogenesis of BA.
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Affiliation(s)
| | - Philip Rosenthal
- Department of Pediatrics, University of California, San Francisco, USA
| | - Melvin B Heyman
- Immunogenetics, University of California, San Francisco, USA
| | - Denice Kong
- Laboratory Medicine, University of California, San Francisco, USA
| | - Greg Magrane
- Department of Pediatrics, University of California, San Francisco, USA
| | | | - Marcus O Muench
- Laboratory Medicine, University of California, San Francisco, USA
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Abstract
Although less common in childhood, hepatitis B virus (HBV) and hepatitis C virus (HCV) remain the most common causes of chronic hepatitis in the United States and worldwide. Children with chronic HBV or HCV are often asymptomatic, with normal or mildly elevated serum transaminases. Although chronic HBV and HCV are indolent diseases in childhood, they cause significant morbidity and mortality later in life. Because the dreaded complications of chronic HBV and HCV--cirrhosis with liver failure and hepatocellular carcinoma--can be seen in childhood, routine follow-up with a pediatric gastroenterologist or hepatologist is recommended. The most important role of the primary care physician and pediatric gastroenterologist or hepatologist is prevention of chronic viral hepatitis through education and screening programs.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics, University of California at San Francisco, 500 Parnassus Avenue, MU E406, Box 0136, San Francisco, CA 94143, USA
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Suskind DL, Muench MO. Searching for common stem cells of the hepatic and hematopoietic systems in the human fetal liver: CD34+ cytokeratin 7/8+ cells express markers for stellate cells. J Hepatol 2004; 40:261-8. [PMID: 14739097 DOI: 10.1016/j.jhep.2003.11.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND/AIMS The hematopoietic and hepatic systems are intertwined in the liver during fetal life. Cells expressing the hematopoietic stem cell marker CD34 and cytokeratin 7/8 (CK7/8) are hypothesized to be common stem cells for the hematopoietic and hepatic systems. Our aim was to determine if human fetal liver cells expressing CD34 and CK7/8 represent a common stem cell for both the hematopoietic and hepatic systems. METHODS CD34+CK7/8+ cells from midgestation livers were analyzed for the expression of various markers by flow cytometry and isolated based on their expression of CD34, nerve growth factor receptor (NGFR) and lack of CD45 expression. CD34+CD38- hematopoietic stem cells were also isolated and cultured in the presence of various hepatopoietins. RESULTS CD34+CK7/8+ cells comprised 3.4-8.5% of the erythrocyte-depleted liver. CD34+CK7/8+ cells had unique light-scatter properties compared to hematopoietic precursors and did not express most markers associated with hematopoietic cells. They did stain with CD13, CD59, NGFR, desmin and alpha-smooth muscle actin. In culture, these cells had a stellate appearance. Cultured hematopoietic stem cells failed to generate hepatocytes. CONCLUSIONS CD34+CK7/8+ cells are not common stem cells but rather appear to be hepatic stellate cells. A link between the hematopoietic and hepatic systems during fetal life requires further investigation.
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Affiliation(s)
- David L Suskind
- Department of Pediatrics, University of California, San Francisco, CA 94143-0793, USA
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Muench MO, Suskind DL, Bárcena A. Isolation, growth and identification of colony-forming cells with erythroid, myeloid, dendritic cell and NK-cell potential from human fetal liver. Biol Proced Online 2002; 4:10-23. [PMID: 12734573 PMCID: PMC145552 DOI: 10.1251/bpo29] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2002] [Revised: 05/16/2002] [Accepted: 05/27/2002] [Indexed: 12/04/2022] Open
Abstract
The study of hematopoietic stem cells (HSCs) and the process by which they differentiate into committed progenitors has been hampered by the lack of in vitro clonal assays that can support erythroid, myeloid and lymphoid differentiation. We describe a method for the isolation from human fetal liver of highly purified candidate HSCs and progenitors based on the phenotypes CD38(-)CD34(++) and CD38(+)CD34(++), respectively. We also describe a method for the growth of colony-forming cells (CFCs) from these cell populations, under defined culture conditions, that supports the differentiation of erythroid, CD14/CD15(+) myeloid, CD1a(+) dendritic cell and CD56(+) NK cell lineages. Flow cytometric analyses of individual colonies demonstrate that CFCs with erythroid, myeloid and lymphoid potential are distributed among both the CD38(-) and CD38(+) populations of CD34(++) progenitors.
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Affiliation(s)
- Marcus O Muench
- Department of Laboratory Medicine, University of California at San Francisco. 3rd & Parnassus Ave., Room U-440; San Francisco, CA 94143-0793.
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Abstract
OBJECTIVE To demonstrate the safety of conscious sedation in draining peritonsillar abscesses (PTAs). DESIGN Children diagnosed as having a PTA in the pediatric emergency department were identified, and their medical records were retrospectively reviewed. Results of the present study were compared with those of a previous report. SETTING A tertiary referral children's hospital pediatric emergency department. PARTICIPANTS Ninety-one consecutive children initially evaluated in the emergency department and managed for a PTA. INTERVENTIONS Peritonsillar abscess incision and drainage with or without sedation. A team of physicians whose activities were documented on a formal conscious-sedation record was present. Patients were monitored for major and minor complications. OUTCOME MEASURES The primary outcome measures were major and minor complications. Secondary outcome measures were recurrence of PTA and the need for admission. RESULTS There were 62 episodes of conscious sedation for drainage of a PTA. Among the 91 patients, 3 had a recurrence and 24 were admitted after the procedure. A previous study evaluated 30 episodes of conscious sedation for drainage of a PTA. No major complications occurred in either series. Combining the previous data with the present data produced 92 episodes of conscious sedation for drainage of a PTA. The 1-sided upper 95% confidence limit for the rate of major complications is 3.2%. CONCLUSION Our series, when combined with previously published data, demonstrates that conscious sedation can be safely used when draining a PTA in pediatric patients.
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Affiliation(s)
- P W Bauer
- Division of Pediatric Otolaryngology, St Louis Children's Hospital, Washington University School of Medicine, One Children's Place, Suite 3S-35, St Louis, MO 63110-1077, USA.
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Payne MS, Suskind DL, Vargas A, Craver R, Liu DC. Parathyroid hyperplasia: an unusual cause of neonatal hypercalcemia. Int J Pediatr Otorhinolaryngol 2001; 61:253-7. [PMID: 11700196 DOI: 10.1016/s0165-5876(01)00560-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Primary hyperparathyroidism (PHPT) in infants is caused by parathyroid chief cell hyperplasia. Patients present with symptoms of chronic hypercalcemia, such as failure to thrive, irritability, abdominal pain, and anorexia. Medical therapy is inadequate, often resulting in chronic hypercalcemia or death. Partial or total surgical removal of the parathyroid gland is the preferred treatment. We describe a case of a 7-month-old infant with PHPT secondary to hyperplasia successfully treated with a subtotal parathyroidectomy.
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Affiliation(s)
- M S Payne
- Children's Hospital of New Orleans, LSU Health Sciences Center, Division of Otolaryngology, 200 Henry Clay Ave, New Orleans LA 70118, USA
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Suskind DL, Zeringue GP, Kluka EA, Udall J, Liu DC. Gastroesophageal reflux and pediatric otolaryngologic disease: the role of antireflux surgery. Arch Otolaryngol Head Neck Surg 2001; 127:511-4. [PMID: 11346425 DOI: 10.1001/archotol.127.5.511] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine the role of antireflux surgery in the treatment of gastroesophageal reflux-induced otolaryngologic disease (GEROD). DESIGN A retrospective medical record analysis was performed. Patient demographics, otolaryngologic disease secondary to gastroesophageal reflux (GER), method of GER diagnosis, medical treatment used before antireflux surgery, and response to surgical intervention were considered. SETTING Tertiary care children's hospital. PATIENTS Among patients undergoing antireflux surgery between January 1, 1996, and December 31, 1999, children with GEROD were included in the study. INTERVENTIONS Children with GEROD who failed medical therapy underwent antireflux surgery. MAIN OUTCOME MEASURES The demographics of patients requiring antireflux surgery for treatment of their otolaryngologic disease and their clinical response to surgery were reviewed. RESULTS Fourteen (17%) of 82 children, ranging in age from 48 days to 3 years (mean age, 9.7 months), who underwent antireflux surgery for GER at our institution between 1996 and 1999 were diagnosed as having GEROD. Twelve (86%) of the 14 patients were found to have upper airway abnormalities, including subglottic edema, fixed subglottic stenosis, reflex apnea, and recurrent croup. Two patients (14%) had severe chronic sinusitis and otitis media. Nine (64%) of the 14 had normal neurologic function for their age vs 5 (36%) who had neurologic impairment. After antireflux surgery, all 14 patients with GEROD had complete resolution of clinical symptoms. CONCLUSIONS Gastroesophageal reflux has an important role in the cause of numerous otolaryngologic disorders. Although medical management should remain the mainstay of GER therapy, antireflux surgery provided definitive and successful treatment of potentially life-threatening manifestations of GEROD.
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Affiliation(s)
- D L Suskind
- Department of Otolaryngology, Louisiana State University Medical Center at New Orleans, 70118, USA.
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Abstract
A dermoid cyst is an ectodermal cyst that contains an epithelial lining as well as adnexal structures, and may occur in numerous areas of the body. The nasal dermoid accounts for 1% of all dermoid cysts and 3-12% of head and neck dermoid cysts. While there have been familial cases reported, a genetic inheritance for nasal dermoids has not been suggested. We present the first reported case of a mother and her identical twin daughters who were all found to have evidence of frontonasal dermoid cysts. Our case and a review of literature seem to implicate an autosomal dominant inheritance in certain instances of nasal dermoids.
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Affiliation(s)
- C Bratton
- Departments of Otolaryngology and Pediatrics, Louisiana State University Medical Center, New Orleans, LA, USA
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Abstract
Benign lymphoepithelial cysts (BLCs) of the parotid gland are associated with human immunodeficiency virus infections in both children and adults. These cysts may become painful and unsightly, often initiating a request for therapeutic intervention. There are several treatment options described in the literature. We report the use of doxycycline sclerotherapy in the treatment of a child with BLCs of the parotid.
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Affiliation(s)
- D L Suskind
- Division of Otolaryngology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA
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Abstract
The pediatric tracheostomy stoma can be matured via a technique that places 4-quadrant sutures from the tracheal cartilage to the dermis. This has the potential of decreasing the risk of accidental decannulation and the formation of granulation tissue. A retrospective analysis of 149 tracheostomies performed between January 1989 and December 1996 was done for the following factors: age, underlying diagnosis, indication for tracheostomy, type of tracheal incision, maturation of stoma, duration of tracheostomy, and early and late (>7 days) complications. Maturation of the stoma was performed in 88 (59.1%) of the 149 tracheostomies. There was an overall complication rate of 21.5% (32/149, not including granulation tissue formation). There were 9 (6.0%) early complications and 23 (15.4%) late complications. The overall incidence of tracheocutaneous fistulas occurred in 11 (11.2%) of the 98 decannulated patients: 6 (10.2%) of the 59 matured stomas and 5 (12.8%) of the 39 nonmatured stomas. Granulation tissue was found on subsequent laryngoscopy in 24 (27.3%) of the 88 matured stomas versus 23 (37.7%) of the 61 nonmatured stomas. There were no tracheostomy-related mortalities. Maturing the tracheostomy stoma resulted in a decreased morbidity from accidental decannulations and did not increase the incidence of tracheocutaneous fistulas or granulation tissue formation.
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Affiliation(s)
- J Y Park
- Division of Pediatric Otolaryngology, St Louis Children's Hospital, Missouri 63110, USA
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Suskind DL, Park J, Piccirillo JF, Lusk RP, Muntz HR. Conscious sedation: a new approach for peritonsillar abscess drainage in the pediatric population. Arch Otolaryngol Head Neck Surg 1999; 125:1197-200. [PMID: 10555689 DOI: 10.1001/archotol.125.11.1197] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of conscious sedation (CS) in children undergoing emergency department incision and drainage (I&D) of peritonsillar abscesses (PTAs). DESIGN A 33-month retrospective chart review of all children presenting to the emergency department with the diagnosis of a PTA or peritonsillar cellulitis. Children who underwent CS prior to I&D were compared with children without CS for complications and efficacy. SETTING St Louis Children's Hospital, an academic tertiary care pediatric hospital. PATIENTS Fifty-two children were enrolled; 30 PTAs were drained with CS in 27 children (3 underwent I&D twice), and 25 PTAs were drained in 25 children without CS. INTERVENTIONS The CS team included an otolaryngologist, a pediatric emergency department physician, and a registered nurse. A standardized CS protocol assessing vital signs and level of consciousness was employed during each procedure. A combination of midazolam, ketamine hydrochloride, and glycopyrrolate was used in appropriately weighted calculated doses. Patients were assessed for major and minor airway complications. MAIN OUTCOME MEASURES Airway complications related to CS were reviewed. Patients who underwent I&D with and without CS were compared with regard to purulent drainage. RESULTS There were no major airway complications in patients undergoing I&D with CS. There was 1 minor complication in this group, oxygen desaturation to 88%, which resolved with stimulation. Of the 55 procedures, 45 (82%) yielded purulence: 29 (97%) of 30 in the CS group and 16 (64%) of 25 in the non-CS group (chi2 = 9.8; P = .002). Of those children undergoing CS, 3 (10%) of 30 were admitted to the hospital from the emergency department as compared with 6 (24%) of 25 without CS (chi2 = 1.95; P = .16). In the CS group, PTAs had a low recurrence rate of 1 (3.3%) of 30 compared with 2 (8%) of 25 in the non-CS group (chi2 = 0.57; P = .45). No one in the CS group required a secondary procedure under general anesthesia. CONCLUSIONS This preliminary study demonstrates CS to be a potentially safe and efficacious approach to drainage of PTAs in children. Given its efficacy and its associated lower levels of anxiety and pain for the patient, CS seems to be a promising new approach to caring for children with PTAs.
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Affiliation(s)
- D L Suskind
- St Louis Children's Hospital, Washington University School of Medicine, Division of Pediatric Otolaryngology, MO, USA
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Affiliation(s)
- D L Suskind
- Department of Otorhinolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
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Abstract
Granulomatous inflammation is a common finding in pathologic evaluation of surgically excised chronic lymphadenopathy in children. Confusion exists regarding diagnosis and management of these lesions. Over a 10-year period at The Children's Hospital of Philadelphia, a total of 81 children were identified with biopsy-confirmed granulomatous lesions of the head and neck, with nontuberculous mycobacteria (NTM) accounting for 67 of the cases. The typical presentation was that of a nontender mass in the cervicofacial area present for weeks to months, unresponsive to antimicrobials. All underwent surgical excision, which was curative in 54 patients; 13 children required additional procedures. This paper reviews NTM, its typical clinical presentation, difficulty in diagnosis, and the methods of treatment.
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Affiliation(s)
- D L Suskind
- Division of Otolaryngology, Children's Hospital of Philadelphia, PA 19104, USA
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