Physical Activity in Pediatric Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, systemic condition affecting the gastrointestinal tract. IBD can be severe and are associated with impairment in growth, school absences, abdominal pain, and fatigue. Physical activity (PA) could have an anti-inflammatory effect in addition to other benefits. It is important to address the possible risks, physiological effects of PA, and potential barriers, and facilitators for PA participation in pediatric IBD. However, potential barriers and facilitators to PA have yet to be adequately described.

METHODS

We conducted a scoping review to map and describe the current literature on PA in pediatric IBD populations between 1980 and April 2022 using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines for Scoping reviews.

RESULTS

Nineteen articles were identified including 10 descriptive, 6 interventional, and 3 physiological responses to PA studies. Patients and healthy controls demonstrated similar responses to exercise. Barriers to participation were low self-esteem, body image, and active IBD symptoms. Facilitators included personal interest, activity with friends, and support from family.

CONCLUSION

This review highlighted that PA participation may reduce in children with IBD-related symptoms. Short- and medium-term impacts of PA on immune modulation require further study; it is possible that regular PA does not negatively affect biomarkers of disease activity.

Microbiota signatures and mucosal healing in the use of enteral nutrition therapy v. corticosteroids for the treatment of children with Crohn's disease: a systematic review and meta-analysis

Corticosteroids (CS) and exclusive and partial enteral nutrition (EEN and PEN) are effective therapies in paediatric Crohn's disease (CD). This systematic review of randomised controlled trials (RCT) and cohort studies analyses the impact of EEN/PEN v. CS on intestinal microbiota, mucosal healing as well as other clinically important outcomes, including clinical remission, relapse, adherence, adverse events and health-related quality of life (HRQL) in paediatric CD. Three RCT (n 76) and sixteen cohort studies (n 1104) compared EEN v. CS. With limited available data (one RCT), the effect on intestinal microbiome indicated a trend towards EEN regarding Shannon diversity. Based on two RCT, EEN achieved higher mucosal healing than CS (risk ratio (RR) 2·36, 95 % CI (1·22, 4·57), low certainty). Compared with CS, patients on EEN were less likely to experience adverse events based on two RCT (RR 0·32, 95 % CI (0·13, 0·80), low certainty). For HRQL, there was a trend in favour of CS based on data from two published abstracts of cohort studies. Based on thirteen cohort studies, EEN achieved higher clinical remission than CS (RR 1·18, 95 % CI (1·02, 1·38), very low certainty). Studies also reported no important differences in relapse and adherence. Compared with CS, EEN may improve mucosal healing with fewer adverse events based on RCT data. While limited data indicate the need for further trials, this is the first systematic review to comprehensively summarise the data on intestinal microbiome, mucosal healing and HRQOL when comparing enteral nutrition and CS in paediatric CD.

A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Background

Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant.

Purpose

The primary aim of our study is to report a case of NALF with successful liver transplant.

Method

We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation.

Result(s)

This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29.

Conclusion(s)

Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less.

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Disclosure of Interest

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MICROBIOME & MICROBIAL THERAPY

A147 “ALREADY GLUTEN-FREE”: A CASE REPORT AND INTERNAL REVIEW OF CHALLENGES IN THE DIAGNOSTIC WORK-UP FOR CHILDREN WITH CELIAC DISEASE

Background

A single positive tissue transglutaminase IgA (TTG) result does not diagnose celiac disease (CeD). Starting a gluten free diet (GFD) without the proper approach to diagnosis can result in misdiagnosis and inappropriate lifelong gluten restriction. Helicobacter pylori (H. pylori) infection can be a mimicker of CeD symptomatically, biochemically, and histologically.

Purpose

We report a case of a patient referred for CeD with a false-positive TTG and severe iron deficiency anemia who had started a GFD at the time of referral.

Method

In addition to the case review, we reviewed referrals for possible CeD from June 1 to September 1, 2022 at McMaster Children’s Hospital to identify the proportion of patients started on a partial or full GFD before their initial gastroenterology consultation.

Result(s)

Case Report:

A 10-year-old female was referred for a positive TTG result 6x the upper limit of normal (72 U/mL; ULN 12U/mL) and iron deficiency anemia with a hemoglobin (Hb) of 85 and MCV of 62. She had been informed her blood work was diagnostic for CeD and to start a GFD prior to referral to Pediatric Gastroenterology. At the time of consultation she had symptoms of GERD, diarrhea, and epigastric pain. Following her consultation, she started a 6-month gluten challenge to proceed to endoscopy. During this time her TTG normalized (2.7 U/ml), however her iron deficiency anemia persisted and was refractory to iron supplementation (Hb 90, MCV 65.9). Endoscopy revealed flattened mucosa in D2 but was otherwise normal. Villous blunting in D1 with severe lymphoplasmacytic gastritis in the body with microabscesses was seen on biopsies. H. pylori was negative on Warthin-Starry staining and the pathologist reported a Marsh stage of 3a. Despite the villous blunting, due to the normalized TTG and ongoing epigastric pain, anemia, and presence of lymphoid follicles, a carbon-14 urea breath test was completed which was positive for H. pylori (count rate 286 dpm, normal < 50 dpm).

The patient received treatment for H. pylori infection for 14 days with 8 week follow-up revealing a negative breath test. There was complete resolution of symptoms, normalization of laboratory results (Hb 143, MCV 82), and negative TTG at 6 months.

Quality improvement review

On internal review of the patients seen in celiac clinic as new referrals from June 1 to September 1 2022, 22/55 patients (42%) had already started a full or partial GFD, therefore requiring gluten challenge and delay in diagnostic investigations.

Conclusion(s)

This case demonstrates the importance of following confirmational testing pathways for CeD. It highlights the role of considering potential causes of false positive TTG and the differential diagnosis of CeD such as H. pylori, NSAIDs, and Crohn’s disease. The identification of 42% of patients referred for suspected CeD who were already on a GFD, suggests a need for improved education of primary care providers to prevent misdiagnosis and unnecessary life-long gluten elimination diets in children.

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A134 THE PEDIATRIC ENDOSCOPY POCKET GUIDE – DEVELOPMENT OF A NOVEL “IN-THE-MOMENT” ELECTRONIC RESOURCE FOR PEDIATRIC ENDOSCOPY

Background

Endoscopy is vital to pediatric gastroenterology. Performing endoscopic procedures safely, effectively and with age-specific considerations requires integration of technical and cognitive competencies. There are many guidelines for endoscopic diagnosis, classification, and management of pediatric gastrointestinal conditions. To date, there are few collated resources for pediatric endoscopists.

Subspecialty trainee feedback at McMaster University identified the need for an accessible, consolidated resource to improve knowledge and competence. The literature shows a lack of exposure in subspeciality training to uncommon yet high acuity procedures such as gastrointestinal bleeding. In an apprenticeship-based learning model, this poses a challenge for both trainees and trainers. Evidence suggests use of multimedia tools is more effective for learning procedural skills than text alone, which guided the creation of this resource.

Purpose

To develop an “in-the-moment” electronic resource to supplement training of pediatric endoscopic procedures.

Method

A subspeciality trainee and two pediatric gastroenterologists with expertise in medical education and program development identified existing knowledge gaps. An electronic pocket guide with links to relevant guidelines and instructional resources was developed. The guide underwent six rounds of revision to ensure it contained relevant and updated guidelines. A copyright and e-learning expert reviewed the content to certify it complied with copyright laws and McMaster University’s accessibility guidelines. The guide will be uploaded to Pressbooks © which allows for export to multiple formats for distribution.

Result(s)

Based on knowledge gaps identified by local experts, the following six domains were incorporated into the pocket guide:

1. Logistics: safety procedures, colonoscopy preparation regimens, equipment specifications, considerations for urgent endoscopy and reporting guidelines

2. Troubleshooting: patient positioning, loop recognition/management strategies

3. Special tests: method of collection, collection media and lab protocols

4. Scoring systems: validated scoring tools for eosinophilic esophagitis, Barrett’s esophagus, esophageal varices, caustic esophageal injury, bleeding ulcers, and inflammatory bowel disease

5. Endoscopic emergencies: guidelines for esophageal burns, foreign body ingestions and upper gastrointestinal bleeds

6. Endoscopic tools: instructions for tools used in the categories of hemostasis, polypectomy, foreign body removal, esophageal varices, and strictures

Conclusion(s)

This novel teaching tool provides an electronic guide that can be used at all levels of pediatric gastroenterology training to gain familiarity and/or rapidly access resources for complex or infrequently encountered endoscopy techniques. Future studies will aim to evaluate the pocket guide from two aspects – ease of use/accessibility and whether implementation of this guide leads to increased competence with various endoscopic tools and techniques.

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Disclosure of Interest

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A66 THE IMPACT OF A MULTIDISCIPLINARY ADOLESCENT AND YOUNG ADULT (AYA) INFLAMMATORY BOWEL DISEASE (IBD) ON CLINIC NO SHOW RATES

Background

Transitioning from pediatric to adult health care is associated with significant psychosocial and clinical morbidity. Adolescents not only transition their medical care, but also experience vast changes in the physical, social, and psychological spheres of their lives. The medical team must help navigate these changes to provide optimal care.

IBD in adolescence is associated with increased hospitalizations and surgery. This is due to several factors, including medication non-adherence and a failure to attend medical appointments. There has been a greater focus on improving care for this unique population.

McMaster Children’s Hospital has integrated the AYA IBD clinic for patients between the ages of 16 and 22. The goal is to transition patients using a developmentally appropriate framework to facilitate self-efficacy and help identify comorbid mental health conditions while building resilience.

Aims

To explore the impact of the implementation of a dedicated transition clinic on attendance at medical visits for AYA patients with IBD.

Methods

The total numbers of patients booked in the AYA IBD Clinic was compared to an age matched subset of the patients in the adult McMaster Complex IBD (CIBD) Clinic. These visits were assessed based on whether the visit was: attended, cancelled, or no showed. Visits were then stratified between in-person and virtual visits. Unpaired t tests was performed to compare the AYA IBD clinic and the CIBD clinic. Findings were deemed significant based on p-values <0.05.

Results

The percentages of patients that attended visits (in-person or virtually) was similar between both clinics at 86% versus 79% Year 1 (Y1) and 76% versus 81% Year 2 (Y2). The number of patients seen in the AYA clinic increased from Y1 (n=92) to Y2 (n=131). The CIBD clinic saw fewer patients between Y1 (n=202) and Y2 (n=79). There were a higher number of patients who cancelled or no showed in Y2 versus Y1 for the AYA virtual visits (13 versus 8) compared to the CIBD clinic (Y2,1 versus Y1,1).

Conclusions

Our results highlight the challenges of transitioning adolescent patients with IBD. Our retrospective study was not powered to show significance. Given the increase in cancellation and no-show rates in Y2, the AYA clinic has incorporated a patient navigator to issue reminder phone calls and facilitate communication with patients between clinics. Future studies will re-assess how the presence of a patient navigator impacts attendance and cancellation rates. Future studies will also assess how the AYA clinic impacts transition readiness and self-efficacy, which is being measured through validated questionnaires in our clinic.

Funding Agencies

Grants-In-Aid

Nutritional Therapies and Their Influence on the Intestinal Microbiome in Pediatric Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic, autoimmune disorder of the gastrointestinal tract with numerous genetic and environmental risk factors. Patients with Crohn’s disease (CD) or ulcerative colitis (UC) often demonstrate marked disruptions of their gut microbiome. The intestinal microbiota is strongly influenced by diet. The association between the increasing incidence of IBD worldwide and increased consumption of a westernized diet suggests host nutrition may influence the progression or treatment of IBD via the microbiome. Several nutritional therapies have been studied for the treatment of CD and UC. While their mechanisms of action are only partially understood, existing studies do suggest that diet-driven changes in microbial composition and function underlie the diverse mechanisms of nutritional therapy. Despite existing therapies for IBD focusing heavily on immune suppression, nutrition is an important treatment option due to its superior safety profile, potentially low cost, and benefits for growth and development. These benefits are increasingly important to patients. In this review, we will describe the clinical efficacy of the different nutritional therapies that have been described for the treatment of CD and UC. We will also describe the effects of each nutritional therapy on the gut microbiome and summarize the strength of the literature with recommendations for the practicing clinician.

Pediatric Patients with a Dual Diagnosis of Inflammatory Bowel Disease and Chronic Recurrent Multifocal Osteomyelitis

ABSTRACT

There is a paucity of information about the epidemiology, pathophysiology, and treatment of patients with a dual diagnosis of inflammatory bowel disease (IBD) and chronic recurrent multifocal osteomyelitis (CRMO). A retrospective chart review was performed of patients at McMaster Children's Hospital with a diagnosis of either IBD or CRMO, to identify those with the dual diagnosis over a 10-year period. A dual diagnosis was identified in seven patients. Most patients (6/7) had a diagnosis of IBD first and were subsequently diagnosed with CRMO. At the time of CRMO diagnosis, IBD treatment regimens included one or more of, sulfasalazine (1/6), infliximab (3/6), adalimumab (1/6), or no treatment (1/6). Although the etiology of the link remains unknown, there does not seem to be an association to a specific IBD subtype, age, or treatment. Our patient population demonstrated a response to biologic agents, specifically tumor necrosis factor-α inhibitors, as treatment for both conditions.

Clinical and Laboratory Characteristics Are Associated With Biologic Therapy Use in Pediatric Inflammatory Bowel Disease: A Retrospective Cohort Study

Background

Biologic agents are a highly useful class of medications for treating inflammatory bowel disease (IBD). Limited evidence exists to guide initiation of biologic therapy, especially in pediatric patients. It is unclear if disease severity is connected to biologic response. We hypothesized that the clinical, biochemical and radiographic characteristics of pediatric IBD at diagnosis were associated with subsequent initiation of biologic therapy.

Methods

We performed a retrospective analysis of the charts of all pediatric patients diagnosed with IBD at our centre over 14 years. Kaplan–Meier curves evaluated patient characteristics at diagnosis with time to initiation of biologic therapy. A Cox proportional hazards model was used for multivariate characteristic analysis.

Results

A total of 198 patients were included, 57.6% had Crohn’s disease, 27.8% had ulcerative colitis and 14.6% had IBD type unclassified. Mean follow-up time was 47.8 months. About 55.5% of the patients received a biologic medication, the mean time to biologic initiation was 21.5 months. Earlier initiation of biologic therapy was frequently associated with older age, higher disease activity index and lower serum albumin.

Conclusions

Older pediatric patients with more severely active disease and lower serum albumin levels at the time of IBD diagnosis were more likely to initiate biologic therapy when considering biologic initiation, even many years after diagnosis. Identification of these characteristics may help inform decisions to initiate biologic therapy earlier in the IBD disease course.

A184 INCIDENCE OF VENOUS THROMBOTIC EVENTS AND RISK FACTORS IN CHILDREN HOSPITALIZED WITH INFLAMMATORY BOWEL DISEASE: A RETROSPECTIVE, CASE-CONTROL STUDY

Background

Limited research has been published to describe the incidence of venous thromboembolism (VTE) and relevant risk factors in Canadian children with inflammatory bowel disease (IBD).

Aims

The present study aimed to investigate the incidence of VTE amongst hospitalized pediatric IBD patients over a 10-year period and identify risk factors for the development of VTE.

Methods

A retrospective, matched case-control study was performed at McMaster Children’s Hospital. Hospitalized pediatric patients with IBD (&lt;18 years old) from September 2009 to August 2020 were selected. Inpatient data was extracted from the medical record database, including baseline demographic data, thromboembolic events and potential risk factors for VTE.

Results

There were 890 hospitalizations of IBD patients during the study period. 15 (1.69%) were diagnosed with a VTE, including 4 males and 11 females (mean age 13.4±2.9 years old). 12 ulcerative colitis (UC) (80%) and 3 Crohn’s disease (CD) (20%) hospitalizations were comprised in the VTE group. There was a significant difference in VTE rate between females (2.7%) and males (0.8%) (P = 0.03). The VTE rate in the UC group (4.2%) was significantly higher than in the CD group (0.6%) (P = 0.001). The incidence of VTE amongst hospitalized IBD patients did not vary over the 10-year period (P = 0.496). Length of stay in hospital, albumin level and central venous catheter were shown to be significantly different, although they were not identified as independent risk factors (P &gt;0 .05). Of the 15 hospitalizations with VTE, 6/15 (40%) were superficial VTEs in the extremities and 9/15 (60%) had a deep vein thrombosis (DVT) including 6 in the extremities and 3 in the abdomen. VTEs were associated with a peripheral line in 7 patients and with a PICC line in 4 hospitalizations. 2 of 9 (22%) with extremity DVT developed symptomatic pulmonary embolism. An inherited thrombotic condition was identified in 2 of 15 with VTEs. 12/15 (80%) with VTEs were symptomatic and all VTE related symptoms happened in patients with extremity thrombosis and pulmonary embolism. 7 of 15 (47%) VTEs were treated with anticoagulation therapy for 1–6 months. VTE related symptoms and repeat imaging tests significantly improved, and no patient developed a bleeding complication as a result of treatment.

Conclusions

The VTE rate in pediatric IBD patients was relatively low at McMaster Children’s hospital. Children with VTE were disproportionately females with ulcerative colitis compared with children with no VTE. Central venous line insertion may be correlated with the risk for VTE in children with IBD. Most VTEs and related symptoms happened in patients with extremity thrombosis and secondary pulmonary embolus. Anticoagulation therapy in children with IBD with active disease appears to be safe.

Funding Agencies

Kids Dig Health Funding from McMaster Children’s Hospital, McMaster University

A173 RECOGNIZING RARE PRESENTATIONS OF POLYPOSIS SYNDROMES AND THEIR ASSOCIATED MALIGNANCIES IN PEDIATRIC PATIENTS

Background

There is a range of polyposis syndromes and presentations in pediatrics. There are also associated extra-colonic malignancies of which to be cognizant when orchestrating the initial work-up of the various polyposis syndromes.

Aims

To use case review to highlight the importance of recognizing the breadth of presentations of polyposis syndromes in pediatrics.

Methods

Two recent pediatric presentations of polyposis with extra-intestinal manifestations were identified, chart review completed, and compared with newly published ESPGHAN guidelines.

Results

Two patients with intestinal polyposis are presented, in which extra-colonic malignancies and genetic mutations were identified.

The first patient presented at age 16 with a history of fatigue and abdominal pain, and was found to have pancytopenia and splenomegaly. Initial work up included a bone marrow biopsy that was normal. The patient then underwent upper and lower endoscopic evaluation for increasing abdominal pain and persistent anemia and was found to have polymorphic polyps in the duodenum, sigmoid and rectum. On pathology, polyps were mostly inflammatory, but one was found to be hamartomatous. Additional screening revealed a thyroid nodule, found to be follicular carcinoma, requiring hemithyroidectomy. The patient was confirmed to have a PTEN mutation and was diagnosed with Cowden syndrome; following this diagnosis proceeded with a prophylactic bilateral mastectomy.

The second patient was referred at age 15 with a strong family history of APC-associated FAP. At the time of consultation she was asymptomatic and she remained so throughout her work-up. Screening endoscopy revealed 70–90 recto-sigmoid adenomatous polyps as well as scattered gastric and duodenal polyps. Her initial work-up also uncovered an early papillary thyroid carcinoma. Her treatment included a total thyroidectomy and total proctocolectomy with J-pouch and ileoanal anastomosis. Follow-up endoscopy continues for surveillance of numerous gastric adenomas which to this point have not progressed to high-grade dysplasia or malignancy.

Conclusions

These 2 cases highlight the importance of recognizing that neoplastic conditions typically diagnosed in adulthood can also present in the pediatric age group. Ideally, further guidelines in pediatrics would be beneficial to ensure a consistent approach to investigating polyposis and associated malignancies. Pertaining to our specific patients, each had identification of a thyroid malignancy before the recommended screening age of 18 as per the currently accepted guideline, and neither were symptomatic. More cases are needed to establish if this earlier recognition of disease is meaningful in postulating potential mortality associated with a later diagnosis.

Funding Agencies

None

Enteral nutritional therapy for induction of remission in Crohn's disease

BACKGROUND

Corticosteroids are often preferred over enteral nutrition (EN) as induction therapy for Crohn's disease (CD). Prior meta-analyses suggest that corticosteroids are superior to EN for induction of remission in CD. Treatment failures in EN trials are often due to poor compliance, with dropouts frequently due to poor acceptance of a nasogastric tube and unpalatable formulations. This systematic review is an update of a previously published Cochrane review.

OBJECTIVES

To evaluate the effectiveness and safety of exclusive EN as primary therapy to induce remission in CD and to examine the importance of formula composition on effectiveness.

SEARCH METHODS

We searched MEDLINE, Embase and CENTRAL from inception to 5 July 2017. We also searched references of retrieved articles and conference abstracts.

SELECTION CRITERIA

Randomized controlled trials involving patients with active CD were considered for inclusion. Studies comparing one type of EN to another type of EN or conventional corticosteroids were selected for review.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by at least two authors. The primary outcome was clinical remission. Secondary outcomes included adverse events, serious adverse events and withdrawal due to adverse events. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (CI). A random-effects model was used to pool data. We performed intention-to-treat and per-protocol analyses for the primary outcome. Heterogeneity was explored using the Chi² and I² statistics. The studies were separated into two comparisons: one EN formulation compared to another EN formulation and EN compared to corticosteroids. Subgroup analyses were based on formula composition and age. Sensitivity analyses included abstract publications and poor quality studies. We used the Cochrane risk of bias tool to assess study quality. We used the GRADE criteria to assess the overall quality of the evidence supporting the primary outcome and selected secondary outcomes.

MAIN RESULTS

Twenty-seven studies (1,011 participants) were included. Three studies were rated as low risk of bias. Seven studies were rated as high risk of bias and 17 were rated as unclear risk of bias due to insufficient information. Seventeen trials compared different formulations of EN, 13 studies compared one or more elemental formulas to a non-elemental formula, three studies compared EN diets of similar protein composition but different fat composition, and one study compared non-elemental diets differing in glutamine enrichment. Meta-analysis of 11 trials (378 participants) demonstrated no difference in remission rates. Sixty-four per cent (134/210) of patients in the elemental group achieved remission compared to 62% (105/168) of patients in the non-elemental group (RR 1.02, 95% CI 0.88 to 1.18; GRADE very low quality). A per-protocol analysis (346 participants) produced similar results (RR 1.04, 95% CI 0.91 to 1.18). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no differences in remission rates. An analysis of 7 trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no difference in remission rates (RR 1.03; 95% CI 0.85 to 1.26). Very low fat content (< 3 g/1000 kCal) and very low long chain triglycerides demonstrated higher remission rates than higher content EN formulas. There was no difference between elemental and non-elemental diets in adverse event rates (RR 1.00, 95% CI 0.63 to 1.60; GRADE very low quality), or withdrawals due to adverse events (RR 1.29, 95% CI 0.80 to 2.09; GRADE very low quality). Common adverse events included nausea, vomiting, diarrhea and bloating.Ten trials compared EN to steroid therapy. Meta-analysis of eight trials (223 participants) demonstrated no difference in remission rates between EN and steroids. Fifty per cent (111/223) of patients in the EN group achieved remission compared to 72% (133/186) of patients in the steroid group (RR 0.77, 95% CI 0.58 to 1.03; GRADE very low quality). Subgroup analysis by age showed a difference in remission rates for adults but not for children. In adults 45% (87/194) of EN patients achieved remission compared to 73% (116/158) of steroid patients (RR 0.65, 95% CI 0.52 to 0.82; GRADE very low quality). In children, 83% (24/29) of EN patients achieved remission compared to 61% (17/28) of steroid patients (RR 1.35, 95% CI 0.92 to 1.97; GRADE very low quality). A per-protocol analysis produced similar results (RR 0.93, 95% CI 0.75 to 1.14). The per-protocol subgroup analysis showed a difference in remission rates for both adults (RR 0.82, 95% CI 0.70 to 0.95) and children (RR 1.43, 95% CI 1.03 to 1.97). There was no difference in adverse event rates (RR 1.39, 95% CI 0.62 to 3.11; GRADE very low quality). However, patients on EN were more likely to withdraw due to adverse events than those on steroid therapy (RR 2.95, 95% CI 1.02 to 8.48; GRADE very low quality). Common adverse events reported in the EN group included heartburn, flatulence, diarrhea and vomiting, and for steroid therapy acne, moon facies, hyperglycemia, muscle weakness and hypoglycemia. The most common reason for withdrawal was inability to tolerate the EN diet.

AUTHORS' CONCLUSIONS

Very low quality evidence suggests that corticosteroid therapy may be more effective than EN for induction of clinical remission in adults with active CD. Very low quality evidence also suggests that EN may be more effective than steroids for induction of remission in children with active CD. Protein composition does not appear to influence the effectiveness of EN for the treatment of active CD. EN should be considered in pediatric CD patients or in adult patients who can comply with nasogastric tube feeding or perceive the formulations to be palatable, or when steroid side effects are not tolerated or better avoided. Further research is required to confirm the superiority of corticosteroids over EN in adults. Further research is required to confirm the benefit of EN in children. More effort from industry should be taken to develop palatable polymeric formulations that can be delivered without use of a nasogastric tube as this may lead to increased patient adherence with this therapy.

Drug-induced esophageal injury with an occult vascular ring

Drug-induced esophageal injury is an under-recognized clinical problem, and is associated with antibiotic use in more than 50% of cases. The current report describes a teenage girl who presented with symptoms of pill-induced esophagitis following doxycycline use. Subsequent investigations identified a previously undiagnosed vascular ring. Although most patients who experience drug-induced esophageal injury have no underlying anatomical or functional disorder of the esophagus, the condition is more common in areas of esophageal narrowing. The present case illustrates the possibility of an occult esophageal obstruction representing a risk factor for pill esophagitis. The etiologies, mechanisms and management of drug-induced esophageal injury are reviewed, and aspects of vascular rings that are relevant to paediatricians are discussed.

Assessment of knowledge in adolescents with inflammatory bowel disease using a novel transition tool

BACKGROUND

In the transition from pediatric to adult care, patients are expected to increase their level of self-care. Knowledge of disease characteristics, medications, and resources is crucial. This study evaluated the knowledge of adolescents with inflammatory bowel disease (IBD) and their parents in four major domains: disease characteristics, treatments, medical history, and health services resources.

METHODS

Patients age 14-18 years and their parents completed MyHealth Passport for IBD as a cross-sectional assessment of knowledge. Responses were evaluated for accuracy using medical records. The proportion of correct responses between patients/parents were compared.

RESULTS

In all, 78 patients (age 16.2 ± 1.2 years, IBD duration 3.6 ± 2.5 years), and 64 parents participated. Patients and parents were equally likely to answer questions correctly regarding disease characteristics and treatment, but not health services resources. Most patients accurately identified IBD classification and listed medications. Neither patients nor parents accurately identified disease location or previous investigation results. Parents more likely correctly named insurance provider (odds ratio [OR] 6.33, 95% confidence intervals [CI] 2.68-15.0), and pharmacy location (OR 18.5, 95% CI 4.6-76.8). Multivariate regression revealed that patients with IBD type unclassified were more likely to be aware of their diagnostic classification (OR 17.2, 95% CI 2.81-105.4 compared with Crohn's disease patients). Older patients were less likely to recall if they had a small bowel x-ray (OR 0.59, 95% CI 0.35-0.996).

CONCLUSIONS

Future educational interventions should target areas of weakness in adolescent knowledge, particularly health services resources. The MyHealth Passport for IBD (available freely online) could educate and instill independence in the transitioning adolescent.

Vulvar inflammation as the only clinical manifestation of Crohn disease in an 8-year-old girl

Recognition of Crohn disease in children who present with cutaneous vulvar lesions as their initial clinical manifestation is often difficult. We report here the case of an 8-year-old girl with chronic vulvar edema, which on biopsy revealed granulomatous inflammation of the vulva. Further investigation and biopsy of the terminal ileum demonstrated similar findings and was consistent with a diagnosis of Crohn disease.

Development, validation, and evaluation of a pediatric ulcerative colitis activity index: a prospective multicenter study

BACKGROUND AND AIMS

Colonoscopic appearance, the primary measure of disease activity in adult ulcerative colitis, is less acceptable to children. Our aim was to develop a noninvasive activity index of pediatric ulcerative colitis.

METHODS

Item selection was performed judgmentally using a Delphi group of 36 experts in pediatric inflammatory bowel disease. Item weighting was performed by regression modeling using a prospective cohort of 157 pediatric ulcerative colitis patients. Validation was assessed on a separate prospective cohort of 48 children with ulcerative colitis undergoing complete colonoscopy. Responsiveness was evaluated at a follow-up visit of 75 children using effect size statistics and diagnostic utility approaches.

RESULTS

A list of 41 items was generated and reduced to 11 by rank order. Two physicians completed the Pediatric Ulcerative Colitis Activity Index (PUCAI) on each of the patients in the weighting cohort. Six clinical items were significant in the regression analysis; the laboratory items and an endoscopic appearance item did not improve the PUCAI performance. In the validation cohort, the PUCAI was highly correlated with the Physician's Global Assessment (r = 0.91, P < .001), Mayo score (r = 0.95, P < .001), and colonoscopic appearance (r = 0.77, P < .001). Correlations were higher than 2 noninvasive adult indices calculated concurrently. Interobserver and test-retest reliability were excellent (intraclass correlation coefficient = 0.95; 95% CI: 0.93-0.97). Cut-off points were established using receiver operator characteristic curves on the full cohort. Excellent responsiveness was found at repeated visits (effect size = 1.9, area under the receiver operator characteristic curve = 0.97).

CONCLUSIONS

The rigorously developed PUCAI is a noninvasive, valid, highly reliable, and responsive index with which to assess disease activity in pediatric ulcerative colitis.

Enteral nutritional therapy for induction of remission in Crohn's disease

BACKGROUND

The role of enteral nutrition in Crohn's disease is controversial. Increasing research on the mechanisms by which nutritional therapy improves the clinical well being of patients with Crohn's disease has led to novel formula design and trials comparing two different forms of enteral nutrition. This meta-analysis aims to provide an update on the existing effectiveness data for both corticosteroids versus enteral nutrition and for one form of enteral nutrition versus another for inducing remission of active Crohn's disease.

OBJECTIVES

To evaluate the effectiveness of exclusive enteral nutrition (EN) as primary therapy to induce remission in Crohn's disease and to examine the importance of formula composition on effectiveness.

SEARCH STRATEGY

Studies were selected using a computer-assisted search of the on-line bibliographic databases MEDLINE (1966-2006) and EMBASE (1984-2006), as well as the Science Citation Index on Web of Science. Additional citations were sought by manual search of references of articles retrieved from the computerized search, abstracts submitted to major gastroenterologic meetings and published in the journals: American Journal of Gastroenterology, Gut, Gastroenterology, Journal of Pediatric Gastroenterology and Nutrition, and Journal of Parenteral and Enteral Nutrition, and from the reviewers' personal files or contact with leaders in the field.

SELECTION CRITERIA

All randomized and quasi-randomized controlled trials involving patients with active Crohn's disease defined by a clinical disease activity index were considered for review. Studies evaluating the administration of one type of enteral nutrition to one group of patients and another type of enteral nutrition or conventional corticosteroids to the other group were selected for review.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two authors and any discrepancies were resolved by rereading and discussion. For the dichotomous variable, achievement of remission, individual and pooled trial statistics were calculated as odds ratios (OR) with 95% confidence intervals (CI); both fixed and random effect models were used. The results for each analysis were tested for heterogeneity using the chi square statistic. The studies were separated into two groups: A. one form of enteral nutrition compared with another form of enteral nutrition and B. one form of enteral nutrition compared with corticosteroids. Subgroup analyses were conducted on the basis of clinical or disease criteria and formula composition. Sensitivity analyses were conducted on the basis of the inclusion of abstract publications, methodologic quality and by random or fixed effects models.

MAIN RESULTS

In part A, of the 15 included eligible trials (one abstract) comparing different formulations of EN for the treatment of active CD, 11 compared one (or more) elemental formula to a non-elemental one, three compared enteral diets of similar protein composition but different fat composition, and one compared non-elemental diets differing only in glutamine enrichment. Meta-analysis of ten trials comprising 334 patients demonstrated no difference in the efficacy of elemental versus non-elemental formulas (OR 1.10; 95% CI 0.69 to 1.75). Subgroup analyses performed to evaluate the different types of elemental and non-elemental diets (elemental, semi-elemental and polymeric) showed no statistically significant differences. Further analysis of seven trials including 209 patients treated with EN formulas of differing fat content (low fat: < 20 g/1000 kCal versus high fat: > 20 g/1000 kCal) demonstrated no statistically significant difference in efficacy (OR 1.13; 95% CI 0.63 to 2.01). Similarly, the effect of very low fat content (< 3 g/1000 kCal) or type of fat (long chain triglycerides) were investigated, but did not demonstrate a difference in efficacy in the treatment of active CD, although a non significant trend was demonstrated favoring very low fat and very low long chain triglyceride content. This result should be interpreted with caution due to statistically significant heterogeneity and small sample size. Sensitivity analyses had no significant effects on the results. The role of specific fatty acids or disease characteristics on response to therapy could not be evaluated. In part B, eight trials (including two abstracts) comparing enteral nutrition to steroid therapy met the inclusion criteria for review. Meta-analysis of six trials that included 192 patients treated with enteral nutrition and 160 treated with steroids yielded a pooled OR of 0.33 favouring steroid therapy (95% CI 0.21 to 0.53). A sensitivity analysis including the abstracts resulted in an increase in the number of participants to 212 in the enteral nutrition group and 179 in the steroid group but the meta-analysis yielded a similar result (OR 0.36; 95% CI 0.23 to 0.56). There were inadequate data from full publications to perform further subgroup analyses by age, disease duration and disease location.

AUTHORS' CONCLUSIONS

Corticosteroid therapy is more effective than enteral nutrition for inducing remission of active Crohn's disease as was found in previous systematic reviews. Protein composition does not influence the effectiveness of EN in the treatment of active CD. A non significant trend favouring very low fat and/or very low long chain triglyceride content exists but larger trials are required to explore the significance of this finding.

Tumor necrosis factor-alpha antibody for induction of remission in Crohn's disease

BACKGROUND

Crohn's disease may be refractory to conventional treatments such as corticosteroids, enteral nutrition and immuno-suppressive agents. A number of patients with the disease may also become steroid-dependent leading to increased risk of developing steroid-related adverse effects. Recent studies suggest that TNF-a blocking agents may be effective in inducing remission in Crohn's disease.

OBJECTIVES

To conduct a systematic review to evaluate the effectiveness of TNF-a blocking agents in inducing remission in patients with active Crohn's disease.

SEARCH STRATEGY

We searched MEDLINE (1966-June 2003), EMBASE (1984-June 2003), the Cochrane Central Register of Controlled Trials from the Cochrane Library (Issue 2, 2003) and the IBD Review Group Specialized Trials Register. We hand-searched the articles cited in each publication obtained.

SELECTION CRITERIA

We included only randomised controlled trials in which patients with active Crohn's disease (defined by a validated Crohn's disease activity index) were randomly allocated to receive a TNF-a blocking agent in the treatment arm, or to receive placebo or another treatment in the comparison arm.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of the methodological quality of each trial were independently performed by two reviewers. Any disagreement among reviewers was resolved by consensus. Outcome measures reported in the primary studies included clinical remission, clinical response and changes in disease activity index.

MAIN RESULTS

Ten studies were identified of which 4 met the inclusion criteria. The included studies either differed in the type of TNF-a blocking agent used or in the way outcomes were assessed to such an extent that we considered it inappropriate to combine the data statistically. There is evidence from one randomised controlled trial that suggests that a single intravenous infusion of the monoclonal antibody cA2, infliximab, may be effective for induction of remission in Crohn's disease. There was no difference in response rates among infliximab doses of 5, 10 or 20 mg/kg. The results of two other trials suggested that CDP571, the genetically engineered human TNF monoclonal antibody, may also be effective in reducing disease activity index at 2 weeks after an infusion. We did not find any evidence to support the use of etanercept in Crohn's disease.

REVIEWER'S CONCLUSIONS

Evidence from one randomized controlled trial suggests that a single infusion of infliximab may be effective for induction of remission in Crohn's disease. Based on this study, we can recommend a dose of 5 mg/kg. There is also some evidence that CDP571 may be effective in inducing remission in Crohn's disease. We did not find any evidence that supports the use of etanercept in Crohn's disease. The period of follow up for the patients in these studies was probably too short to allow adequate assessment of recently reported serious adverse effects such as tuberculosis and lymphoma.

Canadian Association of Gastroenterology Clinical Practice Guidelines: The Use of Infliximab in Crohn's Disease

These guidelines are presented as a follow-up to the original Canadian Association of Gastroenterology Clinical Practice Guidelines: The use of infliximab in Crohn's disease, published in the Canadian Journal of Gastroenterology (1). The original guidelines represented publications between 1998 and 2000. The current guidelines have been updated to reflect knowledge gained from two pivotal randomized clinical trails, with the use of infliximab in the maintenance of inflammatory Crohn's disease in remission (2) and in the maintenance of fistulous Crohn's disease in remission (3).

Gastral antral biopsy in the differentiation of pediatric colitides

OBJECTIVES

Differentiation of Crohn's disease (CD) from ulcerative colitis (UC) is problematic, primarily when inflammation is confined to the colon. In a historical cohort study, we evaluated the usefulness of baseline gastric antral biopsies in the differentiation of pediatric chronic colitides.

METHODS

During initial investigation for suspected inflammatory bowel disease, 39 children and adolescents with colitis but normal small bowel radiography underwent pretreatment upper endoscopy concurrently with colonoscopy. Two reviewers assigned a colonoscopic diagnosis (colonic CD, UC, or indeterminate colitis) based on the macroscopic and microscopic appearances of the colonic mucosa. Antral histological findings were compared between groups using Fisher's exact test.

RESULTS

Five (14%) of colonoscopic diagnoses (four indeterminate, one UC) were changed to CD by the finding of granulomatous inflammation in antral biopsies. Nonspecific antral gastritis was found in similar proportions of children and adolescents with Crohn's colitis and UC (92% vs 75%). Focal antral gastritis was more common in patients with Crohn's colitis than UC (52% vs 8%).

CONCLUSIONS

Nonspecific antral gastritis is common in all forms of chronic colitis. Nevertheless, upper gastrointestinal endoscopy with biopsy is useful in the differentiation of inflammatory bowel disease confined to the colon, particularly when colonoscopic findings are indeterminate.

Pediatric Crohn Disease Activity Index: responsive to short-term change

BACKGROUND/AIMS

Despite documented feasibility, reliability, and validity, the Pediatric Crohn's Disease Activity Index (PCDAI) has yet to be demonstrated to be sensitive to change in the time frame of acute treatment trials. We evaluated short-term responsiveness and determined the minimal change in PCDAI score associated with a clinically meaningful improvement in disease activity.

METHODS

Standardized effect size (SES) and standardized response mean (SRM) were calculated as measures of responsiveness among pediatric patients being treated for acute exacerbations of Crohn disease 1) in a regular clinical practice setting and 2) as part of a multicenter, randomized controlled trial (RCT). Receiver operating characteristic (ROC) curves were constructed to determine the minimal PCDAI score change associated with significant clinical improvement used as the gold standard in 1) physician global assessment of change and in 2) change in adult Crohn disease activity index (CDAI).

RESULTS

Among responders, the SES and SRM of the PCDAI were 1.78 and 1.41 (95% CI: 0.89-1.92) and 2.10 and 1.95 (95% CI: 1.70-2.20) in the clinical practice setting and RCT setting, respectively. The optimal minimal PCDAI change score associated with clinically significant change in physician global assessment was determined to be -12.5 (sensitivity 83.3%, specificity 92.3%). In the RCT setting a change in PCDAI of -10 corresponded to a change in CDAI of not greater-than-or-equal 70 points.

CONCLUSIONS

The PCDAI is responsive to improvement in disease activity in Crohn disease patients over a short interval. As such, the PCDAI is an appropriate instrument to use in pediatric acute treatment trials.

Controlled ileal release budesonide in pediatric Crohn disease: efficacy and effect on growth

BACKGROUND

Although the effectiveness of controlled ileal release (CIR) budesonide in children can be extrapolated from adult studies, there are currently no data available concerning the effects of CIR budesonide therapy on linear growth. In the absence of controlled, prospective pediatric clinical trials, we reviewed the outcomes, particularly linear growth, of children and adolescents given CIR budesonide to treat active intestinal inflammation and to maintain remission.

METHODS

Thirty-two children (20 males) aged 14.1 +/- 2.7 years with Crohn disease of the distal ileum with or without right colon involvement were treated for active Crohn disease (baseline Pediatric Crohn Disease Activity Index, 34 +/- 14) with 9 mg daily of CIR budesonide through the Hospital for Sick Children, University of Toronto, Inflammatory Bowel Diseases program.

RESULTS

At first follow-up visit 8.7 +/- 6.0 weeks later, 19 of 32 (59%) were judged by the physician to have responded. In the subset of 22 patients who had laboratory tests repeated at the first follow-up visit, their Pediatric Crohn Disease Activity Index fell from 33 +/- 14 to 22 +/- 16 (P = 0.001). The Pediatric Crohn Disease Activity Index score fell to less than 15 (cut-off score remission) in 29%. Six prepubertal responders continued to receive 6 mg CIR budesonide for 6 to 13 months. Five of the 6 experienced only mild or no gastrointestinal symptoms and gained weight. Nevertheless, their mean height velocity was only 2.3 +/- 1.0 cm/year, and none grew at a rate of more than 4cm/year whilst receiving CIR budesonide.

CONCLUSIONS

These data provide grade III evidence of modest effectiveness of CIR budesonide in children with active Crohn disease confined to the ileum with or without right colon involvement. The subnormal growth observed with continued therapy is concerning and may reflect either inadequately controlled intestinal inflammation or direct suppression of linear growth, as is observed with conventional corticosteroids. Randomized controlled pediatric trials of CIR budesonide must include parameters of linear growth as an outcome variable.

Enteral feeding and Crohn disease

Enteral nutrition is an established therapeutic option in the treatment of patients with Crohn disease. The mode of action for enteral nutrition remains unknown but research efforts have begun to elucidate the complex interaction between nutritional luminal contents, intestinal epithelium, and mucosal immune response. Trials of novel enteral diet formulations have been conducted to explore the antiinflammatory role of specific nutrients.

Enteral nutritional therapy for inducing remission of Crohn's disease

BACKGROUND

The role of enteral nutrition in Crohn's disease is controversial. Increasing research on the mechanisms by which nutritional therapy improves the clinical well being of patients with Crohn's disease has led to novel formula design and trials comparing two different forms of enteral nutrition. This systematic review aims to provide an update on the existing efficacy data for both corticosteroids versus enteral nutrition and for one form of enteral nutrition versus another for inducing remission of active Crohn's disease.

OBJECTIVES

To evaluate the efficacy of exclusive enteral nutrition as primary therapy to induce remission in Crohn's disease and to examine the importance of formula composition on efficacy.

SEARCH STRATEGY

Studies were selected using a computer-assisted search of the on-line bibliographic databases MEDLINE (1966-2000) and EMBASE (1984-2000), as well as the Science Citation Index on Web of Science. Additional citations were sought by manual search of references of articles retrieved from the computerized search, abstracts submitted to major gastroenterologic meetings and published in the journals: Gut, Gastroenterology, Journal of Pediatric Gastroenterology and Nutrition, and Journal of Parenteral and Enteral Nutrition, and from the reviewers' personal files or contact with leaders in the field.

SELECTION CRITERIA

All randomized and quasi-randomized controlled trials involving patients with active Crohn's disease defined by a clinical disease activity index were considered for review. Studies evaluating the administration of one type of enteral nutrition to one group of patients and another type of enteral nutrition or conventional corticosteroids to the other group were selected for review.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers and any discrepancies were resolved by rereading and discussion. For the dichotomous variable, achievement of remission, individual and pooled trial statistics were calculated as odds ratios (OR) with 95% confidence intervals (CI); both fixed and random effect models were used. The results for each analysis were tested for heterogeneity using the chi square statistic. The studies were separated into two groups: A. one form of enteral nutrition compared with another form of enteral nutrition and B. one form of enteral nutrition compared with corticosteroids. Subgroup analyses were conducted on the basis of clinical or disease criteria and formula composition. Sensitivity analyses were conducted on the basis of the inclusion of abstracts of studies not yet fully published, methodologic quality and by random or fixed effects models.

MAIN RESULTS

In part A, of the 11 trials (one abstract) comparing different formulations of enteral nutrition ten compared one [or more (Middleton (a)1995)] elemental formulas to a non-elemental diet. The eleventh study (Akobeng 2000) compared two non-elemental diets differing only by glutamine enrichment in one group. This study was therefore not included in the primary analysis but was part of the subgroup analyses. Meta-analysis of nine studies which included 170 patients treated with an elemental diet and 128 patients treated with a non-elemental diet for active Crohn's disease demonstrated no significant difference among diet formulations [OR 1.15 (95% CI: 0.64, 2.08)]. Significant heterogeneity was not present [chi-square 9.77 (df=8)]. Subgroup and sensitivity analyses had no significant effect on the results. In part B, six trials (two abstracts) comparing enteral nutrition to steroid therapy met the inclusion criteria for review. Meta-analysis of four trials that included 130 patients treated with enteral nutrition and 123 treated with steroids yielded a pooled OR of 0.30 favouring steroid therapy (95% CI: 0.17, 0.52). Heterogeneity was not demonstrated [chi-square 0.43 (df=3)]. The risk difference calculated from this meta-analysis was 0.26, and the NNT (number of patients needed to treat with steroids rather than enteral nutrition to achieve one remission) was four. The same result was found in a sensitivity analysis that included abstracts. The inclusion of abstracts resulted in an increase in the number of participants to 150 in the enteral nutrition group and 142 in the steroid group but the meta-analysis yielded a similar result [OR 0.34 (95% CI: 0.20, 0.56)]. There were inadequate data from full publications to perform further subgroup analyses by age, disease duration and disease location.

REVIEWER'S CONCLUSIONS

Corticosteroid therapy is more effective than enteral nutrition for inducing remission of active Crohn's disease as was found in past meta-analyses. There is no significant difference in the efficacy of elemental and non-elemental diets for induction of remission of Crohn's disease.

Purification of the testicular galactolipid: 3'-phosphoadenosine 5'-phosphosulfate sulfotransferase

The rat testicular galactolipid sulfotransferase has been purified by affinity chromatography using 3'5'-adenosine diphosphate-agarose affinity chromatography. Both galactosyl glycerolipid and galactosyl ceramide were effective substrates with Km values of 4.8 and 1.1 microM respectively. A single protein of molecular mass 56 kDa was present in the purified sulfotransferase preparation as monitored by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and silver staining. Specific photoaffinity substrate labeling, using an azido derivative of galactosyl ceramide, was used to identify this protein, both in crude extracts and when purified. The protein was also selectively phosphorylated in the presence of the rat testicular galactolipid sulfotransferase stimulatory protein kinase.