1
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Kumar M, Murugesan S, Ibrahim N, Elawad M, Al Khodor S. Predictive biomarkers for anti-TNF alpha therapy in IBD patients. J Transl Med 2024; 22:284. [PMID: 38493113 PMCID: PMC10943853 DOI: 10.1186/s12967-024-05058-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/04/2024] [Indexed: 03/18/2024] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic gastrointestinal condition characterized by severe gut inflammation, commonly presenting as Crohn's disease, ulcerative colitis or categorized as IBD- unclassified. While various treatments have demonstrated efficacy in adult IBD patients, the advent of anti-TNF therapies has significantly revolutionized treatment outcomes and clinical management. These therapies have played a pivotal role in achieving clinical and endoscopic remission, promoting mucosal healing, averting disease progression, and diminishing the necessity for surgery. Nevertheless, not all patients exhibit positive responses to these therapies, and some may experience a loss of responsiveness over time. This review aims to present a comprehensive examination of predictive biomarkers for monitoring the therapeutic response to anti-TNF therapy in IBD patients. It will explore their limitations and clinical utilities, paving the way for a more personalized and effective therapeutic approach.
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Affiliation(s)
- Manoj Kumar
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Nazira Ibrahim
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha, Qatar
| | - Mamoun Elawad
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha, Qatar
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2
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Elawad M, Alyousef SZH, Alkhaldi NK, Alamri FA, Bakhsh H. Scar Ectopic Pregnancy as an Uncommon Site of Ectopic Pregnancy: A Case Report and Literature Review. Life (Basel) 2023; 13:2151. [PMID: 38004291 PMCID: PMC10672687 DOI: 10.3390/life13112151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/03/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
A cesarean scar pregnancy is a rare type of ectopic pregnancy that occurs when a fertilized egg implants in the scar from a previous cesarean section. It is a serious condition that can lead to significant morbidity and mortality if not managed promptly and appropriately. In this literature review and case report, we discuss the etiology, diagnosis, and management of cesarean scar pregnancy. We conducted a comprehensive search of relevant literature using electronic databases and included studies that reported on the diagnosis and management of cesarean scar pregnancy. We also present a case report of a patient with cesarean scar pregnancy who was managed surgically. The diagnosis of cesarean scar pregnancy is primarily done via transvaginal or transabdominal ultrasound, and medical or surgical management can be used depending on the gestational age, hemodynamic status, and patient preferences. The surgical approach, which involves hysteroscopy, laparoscopy, or laparotomy, is usually preferred, since it is associated with fast recovery and lower recurrence rates. However, it is crucial to consider the patient's plans for future fertility when selecting the management approach. In conclusion, cesarean scar pregnancy is a rare but potentially life-threatening condition that requires prompt and appropriate management. Early diagnosis and treatment can prevent significant morbidity and mortality, and surgical management is usually preferred due to its higher success rates and lower recurrence rates.
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Affiliation(s)
- Mamoun Elawad
- Obstetrics & Gynecology Department, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia;
| | | | - Njoud Khaled Alkhaldi
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (N.K.A.); (F.A.A.)
| | - Fayza Ahmed Alamri
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (N.K.A.); (F.A.A.)
| | - Hanadi Bakhsh
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (N.K.A.); (F.A.A.)
- Department of Obstetrics and Gynecology, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia
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3
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Elhag DA, Kumar M, Saadaoui M, Akobeng AK, Al-Mudahka F, Elawad M, Al Khodor S. Inflammatory Bowel Disease Treatments and Predictive Biomarkers of Therapeutic Response. Int J Mol Sci 2022; 23:ijms23136966. [PMID: 35805965 PMCID: PMC9266456 DOI: 10.3390/ijms23136966] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 02/08/2023] Open
Abstract
Inflammatory bowel disease (IBD) is a chronic immune-mediated inflammation of the gastrointestinal tract with a highly heterogeneous presentation. It has a relapsing and remitting clinical course that necessitates lifelong monitoring and treatment. Although the availability of a variety of effective therapeutic options including immunomodulators and biologics (such as TNF, CAM inhibitors) has led to a paradigm shift in the treatment outcomes and clinical management of IBD patients, some patients still either fail to respond or lose their responsiveness to therapy over time. Therefore, according to the recent Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE-II) recommendations, continuous disease monitoring from symptomatic relief to endoscopic healing along with short- and long-term therapeutic responses are critical for providing IBD patients with a tailored therapy algorithm. Moreover, considering the high unmet need for novel therapeutic approaches for IBD patients, various new modulators of cytokine signaling events (for example, JAK/TYK inhibitors), inhibitors of cytokines (for example IL-12/IL-23, IL-22, IL-36, and IL-6 inhibitors), anti-adhesion and migration strategies (for example, β7 integrin, sphingosine 1-phosphate receptors, and stem cells), as well as microbial-based therapeutics to decolonize the bed buds (for example, fecal microbiota transplantation and bacterial inhibitors) are currently being evaluated in different phases of controlled clinical trials. This review aims to offer a comprehensive overview of available treatment options and emerging therapeutic approaches for IBD patients. Furthermore, predictive biomarkers for monitoring the therapeutic response to different IBD therapies are also discussed.
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Affiliation(s)
- Duaa Ahmed Elhag
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
| | - Manoj Kumar
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
| | - Marwa Saadaoui
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
| | - Anthony K. Akobeng
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha 26999, Qatar; (A.K.A.); (F.A.-M.); (M.E.)
| | - Fatma Al-Mudahka
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha 26999, Qatar; (A.K.A.); (F.A.-M.); (M.E.)
| | - Mamoun Elawad
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha 26999, Qatar; (A.K.A.); (F.A.-M.); (M.E.)
| | - Souhaila Al Khodor
- Research Department, Sidra Medicine, Doha 26999, Qatar; (D.A.E.); (M.K.); (M.S.)
- Correspondence:
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4
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Augustine T, Badri F, Murugesan S, Espino Guarch M, Ameen Al-Aghbar M, El Nahas R, Akobeng A, Elawad M, Al Khodor S, Adeli M, van Panhuys N. Gut microbial influences on the adaptive immune system and the development of cow milk allergy. Qatar Med J 2022; 2022:17. [PMID: 35909404 PMCID: PMC9284593 DOI: 10.5339/qmj.2022.fqac.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Allergic diseases constitute significant health and economic issues in both developed and developing nations, with epidemiological studies demonstrating a rapid increase in the global prevalence of food allergy among the pediatric population. Cow milk protein allergy (CMPA), one of the most common forms of food allergies observed in early childhood, affects between 2%–6% of infants and children under 3 years of age. CMPA can present as either an IgE-mediated atopic allergy or a non-IgE mediated allergic response. Antigen-specific T cells play a pivotal role in directing the type of inflammatory immune response that occurs as well as in the formation of immunological memory. IgE-mediated CMPA is thought to develop because of an abnormal expansion of allergen-specific type-2 helper T (Th2) cells and a corresponding deficiency in immune regulation by regulatory T cells (Tregs), thereby altering the Th2/Treg balance. The gut microbiota, established very early during childhood through host-microbe interactions, can influence the incidence of allergic diseases. In this study, we aimed to analyze both the microbiome composition and CD4+T cell differentiation patterns in pediatric patients with and without cow milk allergy to establish the association between these factors. Using 16S rRNA sequencing, we analyzed the microbiome composition in stool samples of allergic and non-allergic pediatric patients aged between 1–4 years and identified the microbial species abundant in IgE and non-IgE mediated cow milk allergies. To assess the CD4+T cell differentiation patterns, peripheral blood mononuclear cells (PBMCs) from these patients were re-stimulated with cow milk antigen, and T cell subsets were assessed using flow cytometry. Antigen-specific CD4+T cells were identified and sorted for high throughput sequencing and subsequent gene expression analysis. The CD4+T cell differentiation patterns of the total and antigen-specific T cells were analyzed and statistically compared with controls. The identification of the correlation between the CD4+T cell differentiation patterns and species-specific microbial abundance in IgE and non-IgE mediated cow milk allergies can help in determining how the gut microbiome influences the CD4+T cell immune compartment development, ultimately leading to the development of cow milk allergy in pediatric patients.
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Affiliation(s)
- Tracy Augustine
- Laboratory of Immunoregulation, Sidra Medicine, Doha, Qatar & E-mail:
| | - Fariada Badri
- Laboratory of Immunoregulation, Sidra Medicine, Doha, Qatar & E-mail:
| | | | | | | | - Rana El Nahas
- Laboratory of Immunoregulation, Sidra Medicine, Doha, Qatar & E-mail:
| | | | - Mamoun Elawad
- Division of Gastroenterology, Sidra Medicine, Doha, Qatar
| | - Souhaila Al Khodor
- Microbiome and Host-Microbes Interactions Laboratory, Sidra Medicine, Doha, Qatar
| | - Mehdi Adeli
- Division of Allergy and Immunology, Sidra Medicine, Doha, Qatar
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5
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Manjunath HS, Al Khulaifi M, Sidahmed H, Ammar A, Vadakekolathu J, Rutella S, Al-Mohannadi MJ, Elawad M, Mifsud W, Charles A, Maccalli C, Tomei S. Gene Expression Profiling of FFPE Samples: A Titration Test. Technol Cancer Res Treat 2022; 21:15330338221129710. [PMID: 36415121 PMCID: PMC9706083 DOI: 10.1177/15330338221129710] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/23/2022] [Indexed: 12/23/2023] Open
Abstract
The gene expression analysis of formalin-fixed paraffin-embedded (FFPE) tissues is often hampered by poor RNA quality, which results from the oxidation, cross-linking and other chemical modifications induced by the inclusion in paraffin. Yet, FFPE samples are a valuable source for molecular studies and can provide great insights into disease progression and prognosis. With the advancement of genomic technologies, new methods have been established that offer reliable and accurate gene expression workflows on samples of poor quality. NanoString is a probe-based technology that allows the direct counting of the mRNA transcripts and can be applied to degraded samples. Here, we have tested 2 RNA extraction methods for FFPE samples, and we have performed a titration experiment to evaluate the impact of RNA degradation and RNA input on the gene expression profiles assessed using the NanoString IO360 panel. We have selected FFPE samples of different DV200 values and assessed them on the nCounter platform with 2 different amounts of input RNA. This study concludes that the nCounter is a robust and reliable platform to assess the gene expression of RNA samples with DV200 > 30%; its robustness and ease of use could be of particular benefit to clinical settings.
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Affiliation(s)
| | - Moza Al Khulaifi
- Laboratory of Immune and Biological Therapy, Research Department,
Sidra
Medicine, Doha, Qatar
| | - Heba Sidahmed
- Laboratory of Immune and Biological Therapy, Research Department,
Sidra
Medicine, Doha, Qatar
| | - Adham Ammar
- Department of Pathology, Hamad Medical
Corporation, Doha, Qatar
| | - Jayakumar Vadakekolathu
- John van Geest Cancer Research Centre, School of Science and
Technology, Nottingham
Trent University, Nottingham, UK
| | - Sergio Rutella
- John van Geest Cancer Research Centre, School of Science and
Technology, Nottingham
Trent University, Nottingham, UK
| | | | - Mamoun Elawad
- Department of Gastroenterology, Sidra Medicine,
Doha, Qatar
| | - William Mifsud
- Department of Anatomical Pathology,
Sidra
Medicine, Doha, Qatar
| | - Adrian Charles
- Department of Anatomical Pathology,
Sidra
Medicine, Doha, Qatar
| | - Cristina Maccalli
- Laboratory of Immune and Biological Therapy, Research Department,
Sidra
Medicine, Doha, Qatar
| | - Sara Tomei
- Omics Core, Integrated Genomics Services, Research Department,
Sidra
Medicine, Doha, Qatar
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6
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Salter CG, Cai Y, Lo B, Helman G, Taylor H, McCartney A, Leslie JS, Accogoli A, Zara F, Traverso M, Fasham J, Lees JA, Ferla M, Chioza BA, Wenger O, Scott E, Cross HE, Crawford J, Warshawsky I, Keisling M, Agamanolis D, Melver CW, Cox H, Elawad M, Marton T, Wakeling M, Holzinger D, Tippelt S, Munteanu M, Valcheva D, Deal C, Van Meerbeke S, Vockley CW, Butte MJ, Acar U, van der Knaap MS, Korenke GC, Kotzaeridou U, Balla T, Simons C, Uhlig HH, Crosby AH, De Camilli P, Wolf NI, Baple EL. Biallelic PI4KA variants cause neurological, intestinal and immunological disease. Brain 2021; 144:3597-3610. [PMID: 34415310 PMCID: PMC8719846 DOI: 10.1093/brain/awab313] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/14/2021] [Accepted: 08/01/2021] [Indexed: 11/22/2022] Open
Abstract
Phosphatidylinositol 4-kinase IIIα (PI4KIIIα/PI4KA/OMIM:600286) is a lipid kinase generating phosphatidylinositol 4-phosphate (PI4P), a membrane phospholipid with critical roles in the physiology of multiple cell types. PI4KIIIα’s role in PI4P generation requires its assembly into a heterotetrameric complex with EFR3, TTC7 and FAM126. Sequence alterations in two of these molecular partners, TTC7 (encoded by TTC7A or TCC7B) and FAM126, have been associated with a heterogeneous group of either neurological (FAM126A) or intestinal and immunological (TTC7A) conditions. Here we show that biallelic PI4KA sequence alterations in humans are associated with neurological disease, in particular hypomyelinating leukodystrophy. In addition, affected individuals may present with inflammatory bowel disease, multiple intestinal atresia and combined immunodeficiency. Our cellular, biochemical and structural modelling studies indicate that PI4KA-associated phenotypical outcomes probably stem from impairment of PI4KIIIα-TTC7-FAM126's organ-specific functions, due to defective catalytic activity or altered intra-complex functional interactions. Together, these data define PI4KA gene alteration as a cause of a variable phenotypical spectrum and provide fundamental new insight into the combinatorial biology of the PI4KIIIα-FAM126-TTC7-EFR3 molecular complex.
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Affiliation(s)
- Claire G Salter
- RILD Wellcome Wolfson Centre, University of Exeter Medical School, Exeter, UK.,Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, UK
| | - Yiying Cai
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA.,Department of Cell Biology, Yale University School of Medicine, New Haven, CT, USA.,Program in Cellular Neuroscience Neurodegeneration and Repair, Yale University School of Medicine, New Haven, CT, USA.,Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT, USA
| | - Bernice Lo
- Research Branch, Sidra Medicine, Doha, Qatar.,College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Guy Helman
- Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Melbourne, Australia.,Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Henry Taylor
- Department of surgery and Cancer, Imperial College London, London, UK
| | - Amber McCartney
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA.,Department of Cell Biology, Yale University School of Medicine, New Haven, CT, USA.,Program in Cellular Neuroscience Neurodegeneration and Repair, Yale University School of Medicine, New Haven, CT, USA.,Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT, USA
| | - Joseph S Leslie
- RILD Wellcome Wolfson Centre, University of Exeter Medical School, Exeter, UK
| | | | | | | | - James Fasham
- RILD Wellcome Wolfson Centre, University of Exeter Medical School, Exeter, UK.,Peninsula Clinical Genetics Service, Royal Devon and Exeter Hospital, Exeter, UK
| | - Joshua A Lees
- Department of Cell Biology, Yale University School of Medicine, New Haven, CT, USA
| | - Matteo Ferla
- Wellcome Centre Human Genetics, University of Oxford, Oxford, UK
| | - Barry A Chioza
- RILD Wellcome Wolfson Centre, University of Exeter Medical School, Exeter, UK
| | | | | | - Harold E Cross
- Department of Ophthalmology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Joanna Crawford
- Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Melbourne, Australia
| | | | | | | | | | - Helen Cox
- West Midlands Clinical Genetics Service, Birmingham Women's Hospital, Birmingham, UK
| | - Mamoun Elawad
- Department of Gastroenterology, Sidra Medicine, Doha, Qatar
| | - Tamas Marton
- West Midlands Perinatal Pathology, Birmingham Women's Hospital, Edgbaston, Birmingham, UK
| | - Matthew Wakeling
- RILD Wellcome Wolfson Centre, University of Exeter Medical School, Exeter, UK
| | - Dirk Holzinger
- Department of Pediatric Haematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Stephan Tippelt
- Department of Pediatric Haematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Martin Munteanu
- Institute for Human Genetics, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | - Christin Deal
- Children's Hospital of Pittsburgh, UPMC, Division of Pediatric Allergy and Immunology, Pittsburgh, USA
| | - Sara Van Meerbeke
- Children's Hospital of Pittsburgh, UPMC, Division of Pediatric Allergy and Immunology, Pittsburgh, USA
| | - Catherine Walsh Vockley
- Children's Hospital of Pittsburgh, UPMC, Division of Genetic and Genomic Medicine, Pittsburgh, USA
| | - Manish J Butte
- Department of Paediatrics, Division of Immunology, Allergy, and Rheumatology, UCLA, Los Angeles, CA, USA
| | - Utkucan Acar
- Department of Paediatrics, Division of Immunology, Allergy, and Rheumatology, UCLA, Los Angeles, CA, USA
| | - Marjo S van der Knaap
- Amsterdam Leukodystrophy Center, Department of Child Neurology, Emma Children's Hospital, Amsterdam University Medical Center, VU University Amsterdam and Amsterdam Neuroscience, 1081 HV Amsterdam, The Netherlands.,Department of Functional Genomics, Centre for Neurogenomics and Cognitive Research, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - G Christoph Korenke
- Department of Neuropediatrics, University Children's Hospital, Klinikum Oldenburg, 26133 Oldenburg, Germany
| | - Urania Kotzaeridou
- Department of Child Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, D-69120 Heidelberg, Germany
| | - Tamas Balla
- Section on Molecular Signal Transduction, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Cas Simons
- Murdoch Children's Research Institute, The Royal Children's Hospital, Parkville, Melbourne, Australia.,Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Holm H Uhlig
- Translational Gastroenterology Unit, NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxfordshire, UK.,Department of Paediatrics, University of Oxford, Oxfordshire, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Andrew H Crosby
- RILD Wellcome Wolfson Centre, University of Exeter Medical School, Exeter, UK
| | - Pietro De Camilli
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA.,Department of Cell Biology, Yale University School of Medicine, New Haven, CT, USA.,Program in Cellular Neuroscience Neurodegeneration and Repair, Yale University School of Medicine, New Haven, CT, USA.,Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT, USA.,Kavli Institute for Neuroscience, Yale University School of Medicine, New Haven, CT, USA
| | - Nicole I Wolf
- Amsterdam Leukodystrophy Center, Department of Child Neurology, Emma Children's Hospital, Amsterdam University Medical Center, VU University Amsterdam and Amsterdam Neuroscience, 1081 HV Amsterdam, The Netherlands.,Department of Functional Genomics, Centre for Neurogenomics and Cognitive Research, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Emma L Baple
- RILD Wellcome Wolfson Centre, University of Exeter Medical School, Exeter, UK.,Peninsula Clinical Genetics Service, Royal Devon and Exeter Hospital, Exeter, UK
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7
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Al-Shaibi AA, Abdel-Motal UM, Hubrack SZ, Bullock AN, Al-Marri AA, Agrebi N, Al-Subaiey AA, Ibrahim NA, Charles AK, Elawad M, Uhlig HH, Lo B. Human AGR2 Deficiency Causes Mucus Barrier Dysfunction and Infantile Inflammatory Bowel Disease. Cell Mol Gastroenterol Hepatol 2021; 12:1809-1830. [PMID: 34237462 PMCID: PMC8551217 DOI: 10.1016/j.jcmgh.2021.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The gastrointestinal epithelium plays a crucial role in maintaining homeostasis with the gut microbiome. Mucins are essential for intestinal barrier function and serve as a scaffold for antimicrobial factors. Mucin 2 (MUC2) is the major intestinal gel-forming mucin produced predominantly by goblet cells. Goblet cells express anterior gradient 2 (AGR2), a protein disulfide isomerase that is crucial for proper processing of gel-forming mucins. Here, we investigated 2 siblings who presented with severe infantile-onset inflammatory bowel disease. METHODS We performed whole-genome sequencing to identify candidate variants. We quantified goblet cell numbers using H&E histology and investigated the expression of gel-forming mucins, stress markers, and goblet cell markers using immunohistochemistry. AGR2-MUC2 binding was evaluated using co-immunoprecipitation. Endoplasmic reticulum (ER) stress regulatory function of mutant AGR2 was examined by expression studies in Human Embryonic Kidney 293T (HEK293T) using tunicamycin to induce ER stress. RESULTS Both affected siblings were homozygous for a missense variant in AGR2. Patient biopsy specimens showed reduced goblet cells; depletion of MUC2, MUC5AC, and MUC6; up-regulation of AGR2; and increased ER stress. The mutant AGR2 showed reduced capacity to bind MUC2 and alleviate tunicamycin-induced ER stress. CONCLUSIONS Phenotype-genotype segregation, functional experiments, and the striking similarity of the human phenotype to AGR2-/- mouse models suggest that the AGR2 missense variant is pathogenic. The Mendelian deficiency of AGR2, termed "Enteropathy caused by AGR2 deficiency, Goblet cell Loss, and ER Stress" (EAGLES), results in a mucus barrier defect, the inability to mitigate ER stress, and causes infantile-onset inflammatory bowel disease.
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Affiliation(s)
| | | | | | - Alex N Bullock
- Centre for Medicines Discovery, University of Oxford, Oxford, United Kingdom
| | | | | | | | | | | | - Mamoun Elawad
- Department of Gastroenterology, Sidra Medicine, Doha, Qatar
| | - Holm H Uhlig
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom; Oxford Biomedical Research Centre, Oxford, United Kingdom; Department of Pediatrics, University of Oxford, Oxford, United Kingdom
| | - Bernice Lo
- Research Branch, Sidra Medicine, Doha, Qatar; College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar.
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8
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Gad H, Al-Jarrah B, Saraswathi S, Mohamed S, Kalteniece A, Petropoulos IN, Khan A, Ponirakis G, Singh P, Khodor SA, Elawad M, Almasri W, Hendaus MA, Akobeng AK, Hussain K, Malik RA. Corneal confocal microscopy identifies a reduction in corneal keratocyte density and sub-basal nerves in children with type 1 diabetes mellitus. Br J Ophthalmol 2021; 106:1368-1372. [PMID: 33931390 DOI: 10.1136/bjophthalmol-2021-319057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/10/2021] [Accepted: 04/20/2021] [Indexed: 11/08/2022]
Abstract
PURPOSE To assess whether alterations in stromal keratocyte density are related to loss of corneal nerve fibres in children with type 1 diabetes mellitus (T1DM). METHODS Twenty participants with T1DM and 20 age-matched healthy controls underwent corneal confocal microscopy. Corneal sub-basal nerve morphology and corneal keratocyte density (KD) were quantified. RESULTS Corneal nerve fibre density (CNFD) (p<0.001), corneal nerve branch density (p<0.001), corneal nerve fibre length (CNFL) (p<0.001) and inferior whorl length (IWL) (p<0.001) were lower in children with T1DM compared with healthy controls. Anterior (p<0.03) and mid (p=0.03) stromal KDs were lower with no difference in posterior KD (PKD) in children with T1DM compared with controls. Age, duration of diabetes, height, weight and body mass index did not correlate with anterior (AKD), mid (MKD) or PKD. Inverse correlations were found between glycated haemoglobin and PKD (r=-0.539, p=0.026), bilirubin with MKD (r=-0.540, p=0.025) and PKD (r=-0.531, p=0.028) and 25-hydroxycholecalciferol with MKD (r=-0.583, p=0.018). CNFD, CNFL and IWL did not correlate with AKD, MKD or PKD. CONCLUSION This study demonstrates a reduction in corneal nerves and anterior and mid stromal KD in children with T1DM, but no correlation between corneal nerve and keratocyte cell loss.
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Affiliation(s)
- Hoda Gad
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | | | | | - Sara Mohamed
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Alise Kalteniece
- Cardiovascular Medicine, University of Manchester, Manchester, UK
| | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | | | | | | | | | | | | | | | | | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar .,Cardiovascular Medicine, University of Manchester, Manchester, UK
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9
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Singh P, Rawat A, Al-Jarrah B, Saraswathi S, Gad H, Elawad M, Hussain K, Hendaus MA, Al-Masri W, Malik RA, Al Khodor S, Akobeng AK. Distinctive Microbial Signatures and Gut-Brain Crosstalk in Pediatric Patients with Coeliac Disease and Type 1 Diabetes Mellitus. Int J Mol Sci 2021; 22:ijms22041511. [PMID: 33546364 PMCID: PMC7913584 DOI: 10.3390/ijms22041511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
Coeliac disease (CD) and Type 1 diabetes mellitus (T1DM) are immune-mediated diseases. Emerging evidence suggests that dysbiosis in the gut microbiome plays a role in the pathogenesis of both diseases and may also be associated with the development of neuropathy. The primary goal in this cross-sectional pilot study was to identify whether there are distinct gut microbiota alterations in children with CD (n = 19), T1DM (n = 18) and both CD and T1DM (n = 9) compared to healthy controls (n = 12). Our second goal was to explore the relationship between neuropathy (corneal nerve fiber damage) and the gut microbiome composition. Microbiota composition was determined by 16S rRNA gene sequencing. Corneal confocal microscopy was used to determine nerve fiber damage. There was a significant difference in the overall microbial diversity between the four groups with healthy controls having a greater microbial diversity as compared to the patients. The abundance of pathogenic proteobacteria Shigella and E. coli were significantly higher in CD patients. Differential abundance analysis showed that several bacterial amplicon sequence variants (ASVs) distinguished CD from T1DM. The tissue transglutaminase antibody correlated significantly with a decrease in gut microbial diversity. Furthermore, the Bacteroidetes phylum, specifically the genus Parabacteroides was significantly correlated with corneal nerve fiber loss in the subjects with neuropathic damage belonging to the diseased groups. We conclude that disease-specific gut microbial features traceable down to the ASV level distinguish children with CD from T1DM and specific gut microbial signatures may be associated with small fiber neuropathy. Further research on the mechanisms linking altered microbial diversity with neuropathy are warranted.
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Affiliation(s)
- Parul Singh
- Research Department, Sidra Medicine, Doha 26999, Qatar or (P.S.); (A.R.); (B.A.-J.)
- College of Health & Life Sciences, Hamad Bin Khalifa University (HBKU), Qatar Foundation (QF), Doha 24404, Qatar
| | - Arun Rawat
- Research Department, Sidra Medicine, Doha 26999, Qatar or (P.S.); (A.R.); (B.A.-J.)
| | - Bara Al-Jarrah
- Research Department, Sidra Medicine, Doha 26999, Qatar or (P.S.); (A.R.); (B.A.-J.)
| | - Saras Saraswathi
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha 26999, Qatar; (S.S.); (M.E.); (W.A.-M.); (A.K.A.)
| | - Hoda Gad
- Department Medicine, Weill Cornell Medicine-Qatar, Doha 24144, Qatar; (H.G.); (R.A.M.)
| | - Mamoun Elawad
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha 26999, Qatar; (S.S.); (M.E.); (W.A.-M.); (A.K.A.)
| | - Khalid Hussain
- Division of Endocrinology, Sidra Medicine, Doha 26999, Qatar;
| | | | - Wesam Al-Masri
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha 26999, Qatar; (S.S.); (M.E.); (W.A.-M.); (A.K.A.)
| | - Rayaz A. Malik
- Department Medicine, Weill Cornell Medicine-Qatar, Doha 24144, Qatar; (H.G.); (R.A.M.)
| | - Souhaila Al Khodor
- Research Department, Sidra Medicine, Doha 26999, Qatar or (P.S.); (A.R.); (B.A.-J.)
- Correspondence:
| | - Anthony K. Akobeng
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha 26999, Qatar; (S.S.); (M.E.); (W.A.-M.); (A.K.A.)
- Department Medicine, Weill Cornell Medicine-Qatar, Doha 24144, Qatar; (H.G.); (R.A.M.)
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Gad H, Saraswathi S, Al-Jarrah B, Petropoulos IN, Ponirakis G, Khan A, Singh P, Al Khodor S, Elawad M, Almasri W, Abdelrahman H, Hussain K, Hendaus MA, Al-Mudahka F, Abouhazima K, McGrogan P, Malik RA, Akobeng AK. Corneal confocal microscopy demonstrates minimal evidence of distal neuropathy in children with celiac disease. PLoS One 2020; 15:e0238859. [PMID: 32956371 PMCID: PMC7505458 DOI: 10.1371/journal.pone.0238859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 06/02/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The aim of this study was to utilise corneal confocal microscopy to quantify corneal nerve morphology and establish the presence of sub-clinical small fibre damage and peripheral neuropathy in children with celiac disease. METHODS This is a cross-sectional cohort study of twenty children with celiac disease and 20 healthy controls who underwent clinical and laboratory assessments and corneal confocal microscopy. Corneal nerve fiber density (no.mm2), corneal nerve branch density (no.mm2), corneal nerve fiber length (mm.mm2), corneal nerve fiber tortuosity and inferior whorl length (mm.mm2) were quantified manually. RESULTS Corneal nerve fiber density (34.7±8.6 vs. 32.9±8.6; P = 0.5), corneal nerve branch density (47.2±24.5 vs. 47.3±20.0; P = 0.1) and corneal nerve fiber length (20.0±5.1 vs. 19.5±4.5; P = 0.8) did not differ between children with celiac disease and healthy controls. Corneal nerve fiber tortuosity (11.4±1.9 vs 13.5±3.0; P = 0.01) was significantly lower and inferior whorl length (20.0±5.5 vs 23.0±3.8; P = 0.06) showed a non-significant reduction in children with celiac disease compared to healthy controls. Inferior whorl length correlated significantly with corneal nerve fiber density (P = 0.005), corneal nerve branch density (P = 0.04), and corneal nerve fiber length (P = 0.002). CONCLUSION Corneal confocal microscopy demonstrates minimal evidence of neuropathy in children with celiac disease.
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Affiliation(s)
- Hoda Gad
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Saras Saraswathi
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Bara Al-Jarrah
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | | | | | - Adnan Khan
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Parul Singh
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Mamoun Elawad
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Wesam Almasri
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Hatim Abdelrahman
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | | | | | - Fatma Al-Mudahka
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Khaled Abouhazima
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Paraic McGrogan
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Rayaz A. Malik
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, United Kingdom
| | - Anthony K. Akobeng
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
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11
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Alhemyadi SA, Elawad M, Fourtounas K, Abdrabbou Z, Alaraki B, Younis S, Nawaz Z, Alqurashi S, Mohamed S. Screening for Fabry disease among 619 hemodialysis patients in Saudi Arabia. Saudi Med J 2020; 41:813-818. [PMID: 32789421 PMCID: PMC7502976 DOI: 10.15537/smj.2020.8.25184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives: To determine the prevalence of Fabry disease (FD) among Saudi patients on hemodialysis. Methods: This prospective study was conducted in 3 major hospitals in the. All adult patients (>18 years old) attending the dialysis unit who have end-stage renal disease (ESRD) and on hemodialysis were included. Known patients with FD and those who refused to participate in the study were excluded. All eligible patients were screened for FD using dry blood spot (DBS) for alpha-galactosidase A (α-Gal A). A positive DBS (enzyme activity <40%) was followed by another confirmatory enzyme assay. When the second DBS sample was also positive (enzyme activity <40%), a Sanger sequencing of the GLA gene was performed. Results: A total of 619 patients with ESRD and on hemodialysis were screened for FD using DBS for α-Gal A enzyme level. Enzymatic activity was below 40% in 11 samples. On retesting, 3 females had <20% enzymatic activity suggesting FD. Sanger sequencing of these 3 females showed the variant c.1055C>G (p.Ala352Gly) confirming the diagnosis of FD. Family screening of one of these 3 patients revealed one asymptomatic female carrying the same variant. Conclusion: The prevalence of FD in this cohort was 4.8 per 1000 patients. Screening of Fabry patients with ESRD seems to be a cost-effective strategy. Furthermore, relatives of the patients identified by screening enhances this screening strategy.
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Affiliation(s)
- Salwa A Alhemyadi
- Department of Nephrology, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail.
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12
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Gad H, Al-Jarrah B, Saraswathi S, Petropoulos IN, Ponirakis G, Khan A, Singh P, Al Khodor S, Elawad M, Almasri W, Abdelrahman H, Elawwa A, Khalifa A, Shamekh A, Al-Khalaf F, Petrovski G, Al Zyoud M, Al Maadheed M, Hendaus MA, Hussain K, Akobeng AK, Malik RA. Corneal nerve loss in children with type 1 diabetes mellitus without retinopathy or microalbuminuria. J Diabetes Investig 2020; 11:1594-1601. [PMID: 32491258 PMCID: PMC7610109 DOI: 10.1111/jdi.13313] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
Aims/Introduction Corneal confocal microscopy is a rapid, non‐invasive ophthalmic technique to identify subclinical neuropathy. The aim of this study was to quantify corneal nerve morphology in children with type 1 diabetes mellitus compared with age‐matched healthy controls using corneal confocal microscopy. Materials and Methods A total of 20 participants with type 1 diabetes mellitus (age 14 ± 2 years, diabetes duration 4.08 ± 2.91 years, glycated hemoglobin 9.3 ± 2.1%) without retinopathy or microalbuminuria and 20 healthy controls were recruited from outpatient clinics. Corneal confocal microscopy was undertaken, and corneal nerve fiber density (n/mm2), corneal nerve branch density (n/mm2), corneal nerve fiber length (mm/mm2), corneal nerve fiber tortuosity and inferior whorl length (mm/mm2) were quantified manually. Results Corneal nerve fiber density (22.73 ± 8.84 vs 32.92 ± 8.59; P < 0.001), corneal nerve branch density (26.19 ± 14.64 vs 47.34 ± 20.01; P < 0.001), corneal nerve fiber length (13.26 ± 4.06 vs 19.52 ± 4.54; P < 0.001) and inferior whorl length (15.50 ± 5.48 vs 23.42 ± 3.94; P < 0.0001) were significantly lower, whereas corneal nerve fiber tortuosity (14.88 ± 5.28 vs 13.52 ± 3.01; P = 0.323) did not differ between children with type 1 diabetes mellitus and controls. Glycated hemoglobin correlated with corneal nerve fiber tortuosity (P < 0.006) and aspartate aminotransferase correlated with corneal nerve fiber density (P = 0.039), corneal nerve branch density (P = 0.003) and corneal nerve fiber length (P = 0.037). Conclusion Corneal confocal microscopy identifies significant subclinical corneal nerve loss, especially in the inferior whorl of children with type 1 diabetes mellitus without retinopathy or microalbuminuria.
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Affiliation(s)
- Hoda Gad
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Bara Al-Jarrah
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | - Adnan Khan
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Parul Singh
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Mamoun Elawad
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | - Wesam Almasri
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | - Ahmed Elawwa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Amel Khalifa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Ahmed Shamekh
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | | | | | | | | | - Rayaz A Malik
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
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13
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Abdel-Motal UM, Al-Shaibi A, Elawad M, Lo B. Zero tolerance! A perspective on monogenic disorders with defective regulatory T cells and IBD-like disease. Immunol Rev 2019; 287:236-240. [PMID: 30565246 DOI: 10.1111/imr.12717] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/12/2018] [Indexed: 12/27/2022]
Abstract
Recently, several studies have investigated a number of rare monogenic autoimmune disorders, in which the causative genetic defects were identified and found to affect the development or function of regulatory T cells (Tregs). The studies of these disorders have facilitated a deeper understanding of the mechanisms involved in immune regulation and tolerance. Furthermore, these studies have highlighted the importance of Tregs in maintaining homeostasis at the mucosal interface between the host and microbiome. Here, we offer our perspective on these monogenic autoimmune disorders, highlighting their overlapping clinical features with inflammatory bowel disease.
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Affiliation(s)
- Ussama M Abdel-Motal
- Division of Translational Medicine, Research Branch, Sidra Medicine, Doha, Qatar
| | - Ahmad Al-Shaibi
- Division of Translational Medicine, Research Branch, Sidra Medicine, Doha, Qatar
| | - Mamoun Elawad
- Division of Gastroenterology, Hepatology and Nutrition, Sidra Medicine, Doha, Qatar
| | - Bernice Lo
- Division of Translational Medicine, Research Branch, Sidra Medicine, Doha, Qatar
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14
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Maccalli C, Rasul KI, Elawad M, Ferrone S. The role of cancer stem cells in the modulation of anti-tumor immune responses. Semin Cancer Biol 2018; 53:189-200. [DOI: 10.1016/j.semcancer.2018.09.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/12/2018] [Accepted: 09/17/2018] [Indexed: 02/07/2023]
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15
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Amine L, Abdelgadir IS, Neves K, Elawad M, Hassan A, Akobeng AK. Tacrolimus for induction therapy in active Crohn's disease. Hippokratia 2018. [DOI: 10.1002/14651858.cd013142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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16
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McDonald BS, Narayanan S, Elawad M, Kiparissi F, Cullup T, Batta K. Interleukin-10 receptor mutation presenting with severe nappy ulceration and infantile inflammatory bowel disease. Clin Exp Dermatol 2017; 42:771-773. [PMID: 28597964 DOI: 10.1111/ced.13157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2016] [Indexed: 12/31/2022]
Abstract
Inflammatory bowel disease (IBD) can be divided into Crohn disease, ulcerative colitis and inflammatory bowel disease unclassified (IBDU). In most patients, these disorders present in adolescence or early adulthood. Patients with infantile IBD can have an associated underlying immunodeficiency disorder caused by a mutation in interleukin (IL)-10 or its receptor. We describe a child presenting with intractable bloody diarrhoea since 2 weeks of age and with severe nappy ulceration, who was ultimately diagnosed as having inflammatory bowel disease (IBD) due to an immunodeficiency in the IL-10 receptor. This report highlights the importance of considering this rare immunodeficiency in patients with infantile IBD presenting with severe perianal disease to a dermatologist.
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Affiliation(s)
- B S McDonald
- Department of Dermatology, Watford General Hospital, Watford, Hertfordshire, UK
| | - S Narayanan
- Department of Paediatrics, Watford General Hospital, Watford, Hertfordshire, UK
| | - M Elawad
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - F Kiparissi
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - T Cullup
- Regional Molecular Genetics Laboratory, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - K Batta
- Department of Dermatology, Watford General Hospital, Watford, Hertfordshire, UK
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17
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Kammermeier J, Dziubak R, Pescarin M, Drury S, Godwin H, Reeve K, Chadokufa S, Huggett B, Sider S, James C, Acton N, Cernat E, Gasparetto M, Noble-Jamieson G, Kiparissi F, Elawad M, Beales PL, Sebire NJ, Gilmour K, Uhlig HH, Bacchelli C, Shah N. Phenotypic and Genotypic Characterisation of Inflammatory Bowel Disease Presenting Before the Age of 2 years. J Crohns Colitis 2017; 11:60-69. [PMID: 27302973 PMCID: PMC5885808 DOI: 10.1093/ecco-jcc/jjw118] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [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: 12/15/2022]
Abstract
OBJECTIVES Inflammatory bowel disease [IBD] presenting in early childhood is extremely rare. More recently, progress has been made to identify children with monogenic forms of IBD predominantly presenting very early in life. In this study, we describe the heterogeneous phenotypes and genotypes of patients with IBD presenting before the age of 2 years and establish phenotypic features associated with underlying monogenicity. METHODS Phenotype data of 62 children with disease onset before the age of 2 years presenting over the past 20 years were reviewed. Children without previously established genetic diagnosis were prospectively recruited for next-generation sequencing. RESULTS In all, 62 patients [55% male] were identified. The median disease onset was 3 months of age (interquartile range [IQR]: 1 to 11). Conventional IBD classification only applied to 15 patients with Crohn's disease [CD]-like [24%] and three with ulcerative colitis [UC]-like [5%] phenotype; 44 patients [71%] were diagnosed with otherwise unclassifiable IBD. Patients frequently required parenteral nutrition [40%], extensive immunosuppression [31%], haematopoietic stem-cell transplantation [29%], and abdominal surgery [19%]. In 31% of patients, underlying monogenic diseases were established [EPCAM, IL10, IL10RA, IL10RB, FOXP3, LRBA, SKIV2L, TTC37, TTC7A]. Phenotypic features significantly more prevalent in monogenic IBD were: consanguinity, disease onset before the 6th month of life, stunting, extensive intestinal disease and histological evidence of epithelial abnormalities. CONCLUSIONS IBD in children with disease onset before the age of 2 years is frequently unclassifiable into Crohn's disease and ulcerative colitis, particularly treatment resistant, and can be indistinguishable from monogenic diseases with IBD-like phenotype.
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Affiliation(s)
- Jochen Kammermeier
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK,Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Matilde Pescarin
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Suzanne Drury
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK,NE Thames Regional Genetics Laboratory, Great Ormond Street Hospital, London, UK
| | - Heather Godwin
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Kate Reeve
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | | | - Bonita Huggett
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Sara Sider
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Chela James
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Nikki Acton
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Elena Cernat
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Gabi Noble-Jamieson
- Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
| | - Fevronia Kiparissi
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Mamoun Elawad
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Phil L. Beales
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Neil J. Sebire
- Department of Histopathology, Great Ormond Street Hospital, London, UK
| | - Kimberly Gilmour
- Department of Immunology, Great Ormond Street Hospital, London, UK
| | - Holm H. Uhlig
- Transitional Gastroenterology Unit, Nuffield Department of Medicine and Department of Paediatrics, University of Oxford, UK
| | - Chiara Bacchelli
- Genetics and Genomic Medicine, Institute of Child Health, University College London, London, UK
| | - Neil Shah
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
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18
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Mutalib M, Bezanti K, Elawad M, Kiparissi F. The role of exclusive enteral nutrition in the management of orofacial granulomatosis in children. World J Pediatr 2016; 12:421-424. [PMID: 27457793 DOI: 10.1007/s12519-016-0045-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 04/24/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Orofacial granulomatosis (OFG) is a term used to describe a persistent, painless swelling of lips and orofacial region. It can be associated with ulceration, gingival hypertrophy and cobble stone appearance of the buccal mucosa. OFG is commonly associated with Crohn's disease and can precede the intestinal manifestation of the disease. Exclusive enteral nutrition (EEN) is a recognized treatment for induction of remission for Crohn's disease. The aim of this study was to review the use of EEN in the management of OFG in children. METHODS Retrospective review of medical records of all children diagnosed with OFG between 2007 and 2012 was conducted. Presence of comorbidities, progression to inflammatory bowel disease (IBD) and response to EEN was evaluated. RESULTS Twenty-nine children were included, mean age at diagnosis was 9 years (standard deviation 3.9) years. Ten children had isolated OFG and 19 had OFG and IBD, of which 12 presented with OFG and IBD and 7 developed IBD later. Median time to progression to IBD was 33 months (inter quartile range: 9.8-85.5). Twenty-two children completed 6 weeks of EEN, and 19 showed clinical improvement in the OFG appearance. CONCLUSION EEN appears to be an effective treatment option for children with isolated OFG or OFG and IBD.
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Affiliation(s)
- Mohamed Mutalib
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK.
| | - Khaled Bezanti
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - Mamoun Elawad
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
| | - Fevronia Kiparissi
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK
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19
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Wahabi H, Fayed A, Esmaeil S, Alzeidan R, Elawad M, Tabassum R, Hansoti S, Magzoup ME, Al-Kadri H, Elsherif E, Al-Mandil H, Al-Shaikh G, Zakaria N. Riyadh Mother and Baby Multicenter Cohort Study: The Cohort Profile. PLoS One 2016; 11:e0150297. [PMID: 26937965 PMCID: PMC4777404 DOI: 10.1371/journal.pone.0150297] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/11/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To assess the effects of non-communicable diseases, such as diabetes, hypertension and obesity, on the mother and the infant. METHODS A multicentre cohort study was conducted in three hospitals in the city of Riyadh in Saudi Arabia. All Saudi women and their babies who delivered in participating hospitals were eligible for recruitment. Data on socio-demographic characteristics in addition to the maternal and neonatal outcomes of pregnancy were collected. The cohort demographic profile was recorded and the prevalence of maternal conditions including gestational diabetes, pre-gestational diabetes, hypertensive disorders in pregnancy and obesity were estimated. FINDINGS The total number of women who delivered in participating hospitals during the study period was 16,012 of which 14,568 women participated in the study. The mean age of the participants was 29 ± 5.9 years and over 40% were university graduates. Most of the participants were housewives, 70% were high or middle income and 22% were exposed to secondhand smoke. Of the total cohort, 24% were married to a first cousin. More than 68% of the participants were either overweight or obese. The preterm delivery rate was 9%, while 1.5% of the deliveries were postdate. The stillbirth rate was 13/1000 live birth. The prevalence of gestational diabetes was 24% and that of pre-gestational diabetes was 4.3%. The preeclampsia prevalence was 1.1%. The labour induction rate was 15.5% and the cesarean section rate was 25%. CONCLUSION Pregnant women in Saudi Arabia have a unique demographic profile. The prevalence of obesity and diabetes in pregnancy are among the highest in the world.
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Affiliation(s)
- Hayfaa Wahabi
- Chair of Evidence Based Health Care and Knowledge Translation, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Department of Community and Family Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Amel Fayed
- Department of Biostatistics, High Institute of Public Health, Alexandria University, Alexandria, Egypt
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Samia Esmaeil
- Chair of Evidence Based Health Care and Knowledge Translation, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rasmieh Alzeidan
- Chair of Evidence Based Health Care and Knowledge Translation, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mamoun Elawad
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Rabeena Tabassum
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Shehnaz Hansoti
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohie Edein Magzoup
- Department of Medical Education, College of Medicine, King Saud Bin Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hanan Al-Kadri
- Department of Medical Education, College of Medicine, King Saud Bin Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Obstetrics and Gynecology, King Abdul Aziz Medical City, Riyadh, Saudi Arabia
| | - Elham Elsherif
- Department of Obstetrics and Gynecology, King Abdul Aziz Medical City, Riyadh, Saudi Arabia
| | - Hazim Al-Mandil
- Department of Obstetrics and Gynecology, King Khaled University Hospital, Riyadh, Saudi Arabia
| | - Ghadeer Al-Shaikh
- Department of Obstetrics and Gynecology, King Khaled University Hospital, Riyadh, Saudi Arabia
| | - Nasria Zakaria
- Department of Medical Informatics and E-Learning Unit, Medical Education Department, King Saud University, Riyadh, Saudi Arabia
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Abstract
BACKGROUND Crohn's disease is a chronic relapsing condition of the alimentary tract with a high morbidity secondary to bowel inflammation. Glutamine plays a key role in maintaining the integrity of the intestinal mucosa and has been shown to reduce inflammation and disease activity in experimental models of Crohn's disease. OBJECTIVES To evaluate the efficacy and safety of glutamine supplementation for induction of remission in Crohn's disease. SEARCH METHODS We searched the following databases from inception to November 15, 2015: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane IBD Group Specialised Register. Study references were also searched for additional trials. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) that compared glutamine supplementation administered by any route to a placebo, active comparator or no intervention in people with active Crohn's disease were considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the methodological quality of the included studies. The Cochrane risk of bias tool was used to assess methodological quality. The primary outcome measure was clinical or endoscopic remission. Secondary outcomes included intestinal permeability, clinical response, quality of life, growth in children and adverse events. Risk ratios and 95% confidence intervals were calculated for dichotomous outcomes. The overall quality of the evidence supporting the primary outcome was evaluated using the GRADE criteria. MAIN RESULTS Two small RCTs (total 42 patients) met the inclusion criteria and were included in the review. One study (18 patients) compared four weeks of treatment with a glutamine-enriched polymeric diet (42% amino acid composition) to a standard polymeric diet (4% amino acid composition) with low glutamine content in paediatric patients (< 18 years of age) with active Crohn's disease. The other study (24 patients) compared glutamine-supplemented total parenteral nutrition to non-supplemented total parenteral nutrition in adult patients (> 18 years of age) with acute exacerbation of inflammatory bowel disease. The paediatric study was rated as low risk of bias. The study in adult patients was rated as unclear risk of bias for blinding and low risk of bias for all other items. It was not possible to pool data for meta-analysis because of significant differences in study populations, nature of interventions, and the way outcomes were assessed. Data from one study showed no statistically significant difference in clinical remission rates at four weeks. Forty-four per cent (4/9) of patients who received a glutamine-enriched polymeric diet achieved remission compared to 56% (5/9) of patients who received a standard low-glutamine polymeric diet (RR 0.80, 95% CI 0.31 to 2.04). A GRADE analysis indicated that the overall quality of evidence for this outcome was low due to serious imprecision (9 events). In both included studies, no statistically significant changes in intestinal permeability were found between patients who received glutamine supplementation and those who did not. Neither study reported on clinical response, quality of life or growth in children. Adverse event data were not well documented. There were no serious adverse events in the paediatric study. The study in adult patients reported three central catheter infections with positive blood cultures in the glutamine group compared to none in the control group (RR 7.00, 95% CI 0.40 to 122.44). AUTHORS' CONCLUSIONS Currently there is insufficient evidence to allow firm conclusions regarding the efficacy and safety of glutamine for induction of remission in Crohn's disease. Data from two small studies suggest that glutamine supplementation may not be beneficial in active Crohn's disease but these results need to be interpreted with caution as they are based on small numbers of patients. This review highlights the need for adequately powered randomised controlled trials to investigate the efficacy and safety of glutamine for induction of remission in Crohn's disease.
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Affiliation(s)
- Anthony K Akobeng
- Sidra Medical & Research CenterPO Box 26999DohaQatar
- University of ManchesterManchesterUK
| | - Mamoun Elawad
- Sidra Medical & Research CenterPO Box 26999DohaQatar
| | - Morris Gordon
- University of Central LancashireSchool of Medicine and DentistryPrestonUK
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21
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Shah N, Foong RXM, Borrelli O, Volonaki E, Dziubak R, Meyer R, Elawad M, Sebire NJ. Histological findings in infants with Gastrointestinal food allergy are associated with specific gastrointestinal symptoms; retrospective review from a tertiary centre. BMC Clin Pathol 2015; 15:12. [PMID: 26085814 PMCID: PMC4469460 DOI: 10.1186/s12907-015-0012-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/05/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Gastrointestinal food allergy (GIFA) occurs in 2 to 4 % of children, the majority of whom are infants (<1 year of age). Although endoscopy is considered the gold standard for diagnosing GIFA, it is invasive and requires general anaesthesia. Therefore, we aimed to investigate whether in infants with GIFA, gastrointestinal symptoms predict histological findings in order to help optimise the care pathway for such patients. METHODS All infants <1 year of age over a 20 year period who underwent an endoscopic procedure gastroscopy or colonoscopy for GIFA were evaluated for the study. Symptoms at presentation were reviewed and compared with mucosal biopsy histological findings, which were initially broadly classified for study purposes as "Normal" or "Abnormal" (defined as the presence of any mucosal inflammation by the reporting pathologist at the time of biopsy). RESULTS Of a total of 1319 cases, 544 fitted the inclusion criteria. 62 % of mucosal biopsy series in this group were reported as abnormal. Infants presenting with diarrhoea, rectal (PR) bleeding, irritability and urticaria in any combination had a probability >85 % (OR > 5.67) of having abnormal histological findings compared to those without. Those with isolated PR bleeding or diarrhoea were associated with 74 % and 68 % probability (OR: 2.85 and 2.13) of an abnormal biopsy, respectively. Conversely, children presenting with faltering growth or reflux/vomiting showed any abnormal mucosal histology in only 50.8 % and 45.3 % (OR: 1.04 and 0.82) respectively. CONCLUSIONS Food allergy may occur in very young children and is difficult to diagnose. Since endoscopy in infants has significant risks, stratification of decision-making may be aided by symptoms. At least one mucosal biopsy demonstrated an abnormal finding in around half of cases in this selected population. Infants presenting with diarrhoea, PR bleeding, urticaria and irritability are most likely to demonstrate abnormal histological findings.
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Affiliation(s)
- Neil Shah
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom.,Institute of Child Health/UCL, London, WC1N 1EH UK
| | - Ru-Xin Melanie Foong
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Osvaldo Borrelli
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Eleni Volonaki
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Robert Dziubak
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Rosan Meyer
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Mamoun Elawad
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, WC1N 3JH United Kingdom
| | - Neil J Sebire
- Histopathology Department, Great Ormond Street Hospital, London, United Kingdom
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Mutalib M, Blackstock S, Evans V, Huggett B, Chadokufa S, Kiparissi F, Elawad M. Eosinophilic gastrointestinal disease and inflammatory bowel disease in children: is it a disease continuum? Eur J Gastroenterol Hepatol 2015; 27:20-3. [PMID: 25358014 DOI: 10.1097/meg.0000000000000230] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Eosinophilic gastrointestinal disease (EGID) and inflammatory bowel disease (IBD) are two distinct disorders that share some clinical manifestations but have different diagnostic criteria. In this article, we reviewed the clinical data of three children with EGID who later developed IBD. This study is a retrospective case note review that was conducted between 2007 and 2012. EGID seems to precede IBD in some subsets of children in whom the diagnosis of IBD may take a few years to fully develop.
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Affiliation(s)
- Mohamed Mutalib
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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23
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Mutalib M, Borrelli O, Blackstock S, Kiparissi F, Elawad M, Shah N, Lindley K. The use of sirolimus (rapamycin) in the management of refractory inflammatory bowel disease in children. J Crohns Colitis 2014; 8:1730-4. [PMID: 25240477 DOI: 10.1016/j.crohns.2014.08.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 08/24/2014] [Accepted: 08/31/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Management of refractory inflammatory bowel disease (IBD) in children is challenging and once response to conventional medical therapy deviates from the expected, options are often limited. Sirolimus is commonly used in post-transplantation management and is used sparsely as rescue therapy in refractory Crohn's disease. In the present study, we report the efficacy of sirolimus as an adjuvant immunosuppressive therapy in a retrospective case review of a selected group of IBD children who were refractory to the conventional treatments. METHODS Medical records of children with refractory IBD unresponsive to conventional therapy and started on sirolimus between 2006 and 2012 were retrospectively reviewed. Clinical response, through Pediatric Ulcerative Colitis Activity Index (PUCAI) and Pediatric Crohn's Disease Activity Index (PCDAI), as well as intestinal inflammation, through specific histological scores, was evaluated. RESULTS The records of 14 patients were analyzed. Eleven of them had ulcerative colitis (UC) and 3 Crohn's disease (CD); mean age at diagnosis was 9.1 years (standard deviation 3.8). Of UC patients, 5 (45%) achieved clinical remission and 2 (18%) showed clinical response. All CD patients went into clinical remission. Mucosal healing was achieved by 5 children (45%) with UC and 2 (67%) with CD patients. One child with ulcerative colitis was weaned off adalimumab, while 2 children with CD were weaned off prednisolone and methotrexate successfully. CONCLUSION Our data provide evidence that sirolimus seems to be effective as rescue therapy in a subgroup of children with severe IBD refractory to conventional therapies by inducing both clinical remission and mucosal healing.
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Affiliation(s)
- Mohamed Mutalib
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children NHS Foundation Trust, United Kingdom.
| | - Osvaldo Borrelli
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children NHS Foundation Trust, United Kingdom
| | - Sarah Blackstock
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children NHS Foundation Trust, United Kingdom
| | - Fevronia Kiparissi
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children NHS Foundation Trust, United Kingdom
| | - Mamoun Elawad
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children NHS Foundation Trust, United Kingdom
| | - Neil Shah
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children NHS Foundation Trust, United Kingdom
| | - Keith Lindley
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Sick Children NHS Foundation Trust, United Kingdom
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24
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Kammermeier J, Drury S, James CT, Dziubak R, Ocaka L, Elawad M, Beales P, Lench N, Uhlig HH, Bacchelli C, Shah N. Targeted gene panel sequencing in children with very early onset inflammatory bowel disease--evaluation and prospective analysis. J Med Genet 2014; 51:748-55. [PMID: 25194001 DOI: 10.1136/jmedgenet-2014-102624] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multiple monogenetic conditions with partially overlapping phenotypes can present with inflammatory bowel disease (IBD)-like intestinal inflammation. With novel genotype-specific therapies emerging, establishing a molecular diagnosis is becoming increasingly important. DESIGN We have introduced targeted next-generation sequencing (NGS) technology as a prospective screening tool in children with very early onset IBD (VEOIBD). We evaluated the coverage of 40 VEOIBD genes in two separate cohorts undergoing targeted gene panel sequencing (TGPS) (n=25) and whole exome sequencing (WES) (n=20). RESULTS TGPS revealed causative mutations in four genes (IL10RA, EPCAM, TTC37 and SKIV2L) discovered unexpected phenotypes and directly influenced clinical decision making by supporting as well as avoiding haematopoietic stem cell transplantation. TGPS resulted in significantly higher median coverage when compared with WES, fewer coverage deficiencies and improved variant detection across established VEOIBD genes. CONCLUSIONS Excluding or confirming known VEOIBD genotypes should be considered early in the disease course in all cases of therapy-refractory VEOIBD, as it can have a direct impact on patient management. To combine both described NGS technologies would compensate for the limitations of WES for disease-specific application while offering the opportunity for novel gene discovery in the research setting.
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Affiliation(s)
- Jochen Kammermeier
- Department of Gastroenterology, Great Ormond Street Hospital for Children, London, UK Experimental & Personalised Medicine Section, Genetics and Genomic Medicine, UCL Institute of Child Health, London, UK
| | - Suzanne Drury
- North East Thames Regional Genetics Service, Hospital for Children, London, UK
| | - Chela T James
- Centre for Translational Omics-GOSgene, Genetics and Genomic Medicine, UCL Institute of Child Health, London, UK
| | - Robert Dziubak
- Department of Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | - Louise Ocaka
- Centre for Translational Omics-GOSgene, Genetics and Genomic Medicine, UCL Institute of Child Health, London, UK
| | - Mamoun Elawad
- Department of Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | - Philip Beales
- Experimental & Personalised Medicine Section, Genetics and Genomic Medicine, UCL Institute of Child Health, London, UK
| | - Nicholas Lench
- North East Thames Regional Genetics Service, Hospital for Children, London, UK
| | - Holm H Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK Department of Pediatrics, University of Oxford, Oxford, UK
| | - Chiara Bacchelli
- Experimental & Personalised Medicine Section, Genetics and Genomic Medicine, UCL Institute of Child Health, London, UK
| | - Neil Shah
- Department of Gastroenterology, Great Ormond Street Hospital for Children, London, UK Katholic University Leuven, Leuven, Belgium
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Cristofori F, Thapar N, Saliakellis E, Kumaraguru N, Elawad M, Kiparissi F, Köglmeier J, Andrews P, Lindley KJ, Borrelli O. Efficacy of the neurokinin-1 receptor antagonist aprepitant in children with cyclical vomiting syndrome. Aliment Pharmacol Ther 2014; 40:309-17. [PMID: 24898244 DOI: 10.1111/apt.12822] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [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: 03/01/2014] [Revised: 03/25/2014] [Accepted: 05/13/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Aprepitant (Emend, Merck Sharp & Dohme Ltd, Haarlem, the Netherlands), a neurokinin-1 receptor antagonist, prevents vomiting in a range of conditions. No data are available on its use in children with cyclical vomiting syndrome (CVS). AIM We investigated the efficacy of aprepitant as prophylactic treatment or acute intervention in CVS children refractory to conventional therapies. METHODS Forty-one children (median age: 8 years) fulfilling NASPGHAN criteria treated acutely (RegA) or prophylactically (RegP) with aprepitant were retrospectively reviewed. Primary outcome was the clinical response (decrease in frequency and intensity of CVS episodes). Secondary outcomes were: number of CVS episodes/year, number of hospital admissions/year, CVS episode duration, number of vomits/h, symptom-free interval length (days), and school attendance percentage. The follow-up period was 18-60 months. RESULTS Sixteen children received RegP and 25 RegA. One child on RegP stopped treatment due to severe migraine. At 12-months on intention-to-treat analysis, 13 children on RegP (81%) achieved either complete (3/16, 19%) or partial (10/16, 62%) clinical response. On RegA, 19 children (76%) had either complete (3/25, 12%) or partial (16/25, 64%) response (P = 0.8 vs. RegP). In both RegP and RegA, there was a significant decrease in CVS episodes/year, hospital admission number/year, CVS episode length, number of vomits/h, as well as an increase in symptom-free interval duration and school attendance percentage. Side effects were reported only in RegP (5/16, 31%) including hiccough (3/16, 19%), asthenia/fatigue (2/16, 12.5%), increased appetite (2/16, 12.5%), mild headache (1/16, 6%) and severe migraine (1/16, 6%). CONCLUSION Aprepitant appears effective for both acute and prophylactic management of paediatric cyclical vomiting syndrome refractory to conventional therapies.
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Affiliation(s)
- F Cristofori
- Department of Gastroenterology, Great Ormond Street Hospital, Institute of Child Health, London, UK
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Worth AJ, Nademi Z, Kammermeier J, Bunn S, Chiesa R, Cant A, Hambleton S, Shah N, Slatter M, Rao K, Gennery A, Elawad M, Amrolia P, Veys P. Allogeneic Stem Cell Transplant Offers Cure for Intractable Childhood Enteropathy. Biol Blood Marrow Transplant 2014. [DOI: 10.1016/j.bbmt.2013.12.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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27
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Speckmann C, Lehmberg K, Albert MH, Damgaard RB, Fritsch M, Gyrd-Hansen M, Rensing-Ehl A, Vraetz T, Grimbacher B, Salzer U, Fuchs I, Ufheil H, Belohradsky BH, Hassan A, Cale CM, Elawad M, Strahm B, Schibli S, Lauten M, Kohl M, Meerpohl JJ, Rodeck B, Kolb R, Eberl W, Soerensen J, von Bernuth H, Lorenz M, Schwarz K, Zur Stadt U, Ehl S. X-linked inhibitor of apoptosis (XIAP) deficiency: the spectrum of presenting manifestations beyond hemophagocytic lymphohistiocytosis. Clin Immunol 2013; 149:133-41. [PMID: 23973892 DOI: 10.1016/j.clim.2013.07.004] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 07/14/2013] [Accepted: 07/23/2013] [Indexed: 02/08/2023]
Abstract
X-linked inhibitor of apoptosis (XIAP) deficiency caused by mutations in BIRC4 was initially described in patients with X-linked lymphoproliferative syndrome (XLP) who had no mutations in SH2D1A. In the initial reports, EBV-associated hemophagocytic lymphohistiocytosis (HLH) was the predominant clinical phenotype. Among 25 symptomatic patients diagnosed with XIAP deficiency, we identified 17 patients who initially presented with manifestations other than HLH. These included Crohn-like bowel disease (n=6), severe infectious mononucleosis (n=4), isolated splenomegaly (n=3), uveitis (n=1), periodic fever (n=1), fistulating skin abscesses (n=1) and severe Giardia enteritis (n=1). Subsequent manifestations included celiac-like disease, antibody deficiency, splenomegaly and partial HLH. Screening by flow cytometry identified 14 of 17 patients in our cohort. However, neither genotype nor protein expression nor results from cell death studies were clearly associated with the clinical phenotype. Only mutation analysis can reliably identify affected patients. XIAP deficiency must be considered in a wide range of clinical presentations.
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Affiliation(s)
- C Speckmann
- Centre of Chronic Immunodeficiency, University Medical Center Freiburg, Germany; Center for Pediatrics and Aldolescent Medicine, University Medical Center Freiburg, Germany.
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Jafari NV, Kuehne SA, Bryant CE, Elawad M, Wren BW, Minton NP, Allan E, Bajaj-Elliott M. Clostridium difficile modulates host innate immunity via toxin-independent and dependent mechanism(s). PLoS One 2013; 8:e69846. [PMID: 23922820 PMCID: PMC3726775 DOI: 10.1371/journal.pone.0069846] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [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: 04/01/2013] [Accepted: 06/13/2013] [Indexed: 11/30/2022] Open
Abstract
Clostridium difficile infection (CDI) is the leading cause of hospital and community-acquired antibiotic-associated diarrhoea and currently represents a significant health burden. Although the role and contribution of C. difficile toxins to disease pathogenesis is being increasingly understood, at present other facets of C. difficile-host interactions, in particular, bacterial-driven effects on host immunity remain less studied. Using an ex-vivo model of infection, we report that the human gastrointestinal mucosa elicits a rapid and significant cytokine response to C. difficile. Marked increase in IFN-γ with modest increase in IL-22 and IL-17A was noted. Significant increase in IL-8 suggested potential for neutrophil influx while presence of IL-12, IL-23, IL-1β and IL-6 was indicative of a cytokine milieu that may modulate subsequent T cell immunity. Majority of C. difficile-driven effects on murine bone-marrow-derived dendritic cell (BMDC) activation were toxin-independent; the toxins were however responsible for BMDC inflammasome activation. In contrast, human monocyte-derived DCs (mDCs) released IL-1β even in the absence of toxins suggesting host-specific mediation. Infected DC-T cell crosstalk revealed the ability of R20291 and 630 WT strains to elicit a differential DC IL-12 family cytokine milieu which culminated in significantly greater Th1 immunity in response to R20291. Interestingly, both strains induced a similar Th17 response. Elicitation of mucosal IFN-γ/IL-17A and Th1/Th17 immunity to C. difficile indicates a central role for this dual cytokine axis in establishing antimicrobial immunity to CDI.
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Affiliation(s)
- Nazila V. Jafari
- Infectious Diseases and Microbiology Unit, Institute of Child Health, University College London, London, United Kingdom
| | - Sarah A. Kuehne
- Clostridia Research Group, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Clare E. Bryant
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mamoun Elawad
- Gastroenterology Department, Great Ormond Street Hospital, London, United Kingdom
| | - Brendan W. Wren
- Department of Pathogen Molecular Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nigel P. Minton
- Clostridia Research Group, Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Elaine Allan
- Research Department of Microbial Diseases, Eastman Dental Institute, University College London, London, United Kingdom
| | - Mona Bajaj-Elliott
- Infectious Diseases and Microbiology Unit, Institute of Child Health, University College London, London, United Kingdom
- * E-mail:
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Engelhardt KR, Shah N, Faizura-Yeop I, Kocacik Uygun DF, Frede N, Muise AM, Shteyer E, Filiz S, Chee R, Elawad M, Hartmann B, Arkwright PD, Dvorak C, Klein C, Puck JM, Grimbacher B, Glocker EO. Clinical outcome in IL-10- and IL-10 receptor-deficient patients with or without hematopoietic stem cell transplantation. J Allergy Clin Immunol 2012; 131:825-30. [PMID: 23158016 DOI: 10.1016/j.jaci.2012.09.025] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 09/26/2012] [Accepted: 09/26/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Inherited deficiencies of IL-10 or IL-10 receptor (IL-10R) lead to immune dysregulation with life-threatening early-onset enterocolitis. OBJECTIVES We sought to gather clinical data of IL-10/IL-10R-deficient patients and devise guidelines for diagnosis and management, including hematopoietic stem cell transplantation (HSCT). METHODS We enrolled 40 patients with early-onset enterocolitis and screened for mutations in IL10/IL10R using genetic studies, functional studies, or both of the IL-10 signaling pathway. Medical records of IL-10/IL-10R-deficient patients were reviewed and compiled. RESULTS Of 40 patients, we identified 7 with novel mutations, predominantly in consanguineous families with more than 1 affected member. IL-10/IL-10R-deficient patients had intractable enterocolitis, perianal disease, and fistula formation. HSCT was carried out in 2 patients with IL-10 deficiency and 1 patient with IL-10R α chain deficiency and proved to be an effective therapy, leading to rapid improvement of clinical symptoms and quality of life. CONCLUSION Because the defect in patients with IL-10/IL-10R deficiency resides in hematopoietic lineage cells and their colitis is resistant to standard immunosuppressive therapy, HSCT should be considered early as a potentially curative therapeutic option.
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Affiliation(s)
- Karin R Engelhardt
- Department of Immunology, University College London Medical School (Royal Free Campus), London, United Kingdom
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Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disease characterized by abdominal pain, bloody diarrhoea, and malabsorption leading to weight loss. It is considered the result of inadequate control of an excessive reaction of the immune system to the resident flora of the gut. Like other primary immunodeficiencies, IL-10 and IL-10 receptor (IL10R) deficiency present with IBD and demonstrate the sensitivity of the intestine to any changes of the immune system. Both IL-10 and IL10R deficiency cause severe early-onset enterocolitis and can be successfully treated by hematopoietic stem cell transplantation (HSCT).
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Affiliation(s)
- Neil Shah
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital, University College London, London, UK
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31
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Borrelli O, Mancini V, Thapar N, Giorgio V, Elawad M, Hill S, Shah N, Lindley KJ. Cow's milk challenge increases weakly acidic reflux in children with cow's milk allergy and gastroesophageal reflux disease. J Pediatr 2012; 161:476-481.e1. [PMID: 22513270 DOI: 10.1016/j.jpeds.2012.03.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 02/06/2012] [Accepted: 03/02/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess and compare the pattern of reflux in a selected population of infants with cow's milk (CM) allergy (CMA) and suspected gastroesophageal reflux disease (GERD) while on dietary exclusion and following challenge with CM. STUDY DESIGN Seventeen children (median age: 14 months) with a proven diagnosis of CMA and suspected GERD underwent 48-hour multichannel intraluminal impedance-pH monitoring. For the first 24 hours, the infants were kept on amino acid-based formula, and for the subsequent 24 hours, they were challenged with CM. RESULTS The total reflux episodes and the number of weakly acidic episodes were higher during CM challenge compared with the amino acid-based formula period [total reflux episodes: 105 (58-127.5) vs 65 (39-87.5), P < .001; weakly acidic episodes: 53 (38.5-60.5) vs 19 (13-26.5), P < .001; median (25th-75th)]. No differences were found for either acid or weakly alkaline episodes (not significant). The number of weakly acidic episodes reaching the proximal, mid, and distal esophagus was higher during CM challenge (P < .001). No differences were found in either acid exposure time or number of long-lasting episodes (not significant). CONCLUSIONS In children with CMA and suspected GERD, CM exposure increases the number of weakly acidic reflux episodes. CM challenge during 48-hour multichannel intraluminal impedance-pH monitoring identifies a subgroup of patients with allergen-induced reflux, and in selected cases of children with CMA in whom GERD is suspected, its use could be considered as part of diagnostic work-up.
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Affiliation(s)
- Osvaldo Borrelli
- Neurogastroenterology and Motility Division, Department of Gastroenterology, Great Ormond Street Hospital for Sick Children and Institute of Child Health, London, United Kingdom.
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Abstract
BACKGROUND Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. OBJECTIVES To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2009) and bibliographies of all located articles for any unidentified articles. SELECTION CRITERIA Randomized or quasi-randomized controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage. DATA COLLECTION AND ANALYSIS At least two authors assessed the trials for inclusion in the review and extracted the data. MAIN RESULTS Two studies (84 participants) were included in the meta-analysis. In one study, all the participants met the inclusion criteria and in the other study, only the subgroup of participants who met the inclusion criteria was included in the meta-analysis. There was no evidence of effectiveness with the use vaginal progesterone compared to placebo in reducing the risk of miscarriage (risk ratio 0.47; 95% confidence interval 0.17 to 1.30). AUTHORS' CONCLUSIONS Based on scarce data from two methodologically poor trials, there is no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. Information about potential harms to the mother or child, or both, with the use of progestogens is lacking. Further, larger, randomized controlled trials on the effect of progestogens on the treatment of threatened miscarriage, which investigate potential harms as well as benefits, are needed.
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Affiliation(s)
- Hayfaa A Wahabi
- King Saud University, Department of Obstetrics and Gynaecology, Riyadh, Saudi Arabia, 11451
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Affiliation(s)
- Erik-Oliver Glocker
- Department of Immunology, Division of Infection and Immunity, University College London, Royal Free Hospital, London, UK
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Abstract
BACKGROUND Miscarriage is a common complication encountered during pregnancy. The role of progesterone in preparing the uterus for the implantation of the embryo and its role in maintaining the pregnancy have been known for a long time. Inadequate secretion of progesterone in early pregnancy has been linked to the aetiology of miscarriage and progesterone supplementation has been used as a treatment for threatened miscarriage to prevent spontaneous pregnancy loss. OBJECTIVES To determine the efficacy and the safety of progestogens in the treatment of threatened miscarriage. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (January 1966 to April 2006), EMBASE (1980 to April 2006) and CINAHL (1982 to April 2006). We scanned bibliographies of all located articles for any unidentified articles. SELECTION CRITERIA Randomized or quasi-randomized controlled trials that compare progestogen with placebo, no treatment or any other treatment given in an effort to treat threatened miscarriage. DATA COLLECTION AND ANALYSIS At least two authors assessed the trials for inclusion in the review and extracted the data. MAIN RESULTS Two studies (84 participants) were included in the meta-analysis. In one study, all the participants met the inclusion criteria and in the other study, only the subgroup of participants who met the inclusion criteria was included in the meta-analysis. There was no evidence of effectiveness with the use vaginal progesterone compared to placebo in reducing the risk of miscarriage (relative risk 0.47; 95% confidence interval (CI) 0.17 to 1.30). AUTHORS' CONCLUSIONS Based on scarce data from two methodologically poor trials, there is no evidence to support the routine use of progestogens for the treatment of threatened miscarriage. Information about potential harms to the mother or child, or both, with the use of progestogens is lacking. Further, larger, randomized controlled trials on the effect of progestogens on the treatment of threatened miscarriage, which investigate potential harms as well as benefits, are needed.
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Affiliation(s)
- H A Wahabi
- King Fahad National Guard Hospital, Department of Obstetrics and Gynaecology, MC 1216, PO Box 22490, Riyadh, Saudi Arabia, 11426.
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Elliott HL, Elawad M, Wilkinson R, Singh SP. Persistence of antihypertensive efficacy after missed doses: comparison of amlodipine and nifedipine gastrointestinal therapeutic system. J Hypertens 2002; 20:333-8. [PMID: 11821720 DOI: 10.1097/00004872-200202000-00025] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In this randomized, double-blind, crossover study, the antihypertensive efficacy of amlodipine and nifedipine gastrointestinal therapeutic system (GITS) was compared following missed doses. Design and methods In a randomized crossover design, 42 patients were randomized to receive amlodipine (5-10 mg) or the GITS formulation of nifedipine (nifedipine GITS) (30-60 mg) once daily for 12 weeks, then vice versa. During weeks 8, 10 and 12 of each treatment period, compliance failures were simulated by patients missing 0, 1 or 2 doses of their medication, and ambulatory systolic (SBP) and diastolic (DBP) blood pressure measurements were obtained. RESULTS Following steady-state treatment (i.e. 'perfect compliance'), there was no difference between amlodipine and nifedipine GITS in SBP (140.1 versus 134.2 mmHg) or DBP (84.0 versus 85.8 mmHg) at 0-24 h post-dose. When compliance was not perfect, i.e. when one or two doses were missed, DBP was maintained at a significantly lower level with amlodipine compared with nifedipine GITS at 24-48 h post-dose (83.1 versus 86.4 mmHg, P = 0.005) and at 48-72 h post-dose (84.2 versus 89.7 mmHg, P < 0.001). Plasma concentrations of amlodipine were better maintained than those of nifedipine GITS. At 72 h post-dose, the plasma concentration of amlodipine was 61% (17.0 +/- 11.2 ng/ml) compared with < 25% (28.3 +/- 49.9 ng/ml) for nifedipine GITS. CONCLUSION During short periods of non-compliance, antihypertensive efficacy remains more predictable with amlodipine than with nifedipine GITS.
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Abstract
A 12-year-old Saudi boy with falciparum malaria developed profound thrombocytopenia with associated significant bleeding. Immunoglobulin was used to treat this case.
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Affiliation(s)
- M Elawad
- Department of Child Health & Paediatrics, College of Medicine, King Khalid University, Abha, Saudi Arabia
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