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Pauline ML, Labonne E, Wizzard PR, Turner JM, Wales PW. Association between 4%-tetrasodium EDTA and sepsis in neonatal piglets: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:495-501. [PMID: 38400572 DOI: 10.1002/jpen.2609] [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: 06/15/2023] [Revised: 01/10/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Central line-associated bloodstream infections are a major concern for children with intestinal failure and in animal research using parenteral nutrition (PN). In neonatal piglets receiving PN, we compared sepsis, line occlusions, line replacements, mortality, and costs with and without the use of a 4%-tetrasodium ethylenediaminetetraacetic acid (T-EDTA) locking solution. METHODS We performed a retrospective review of piglets with a central venous jugular catheter enrolled in 14-day exclusive PN (TPN) trials or in 7-day short bowel syndrome (SBS) trials, before and after initiation of T-EDTA. Lines were locked with a 1-ml solution for 2 h daily (T-EDTATPN, n = 17; T-EDTASBS, n = 48) and compared with our prior standard of care using 1.5-ml heparin flushes twice daily (CONTPN, n = 34; CONSBS, n = 48). Line patency and signs of sepsis were checked twice daily. Jugular catheters were replaced for occlusions whenever possible. Humane end points were used for sepsis not responding to antibiotic treatment or unresolved catheter occlusions. RESULTS Compared with CON, sepsis was reduced using T-EDTA, significantly for TPN (P = 0.006) and with a trend for SBS piglets (P = 0.059). Line occlusions necessitating line changes were reduced 15% in TPN studies (P = 0.16), and no line occlusions occurred for T-EDTA SBS piglets. CONCLUSION In our neonatal piglet research, use of T-EDTA locking solution decreased sepsis and, although not statistically significant, reduced occlusions requiring line replacements. Given the expense of animal research, adding a locking solution must be cost-effective, and we were able to show that T-EDTA significantly reduced total research costs and improved animal welfare.
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Affiliation(s)
- Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Evan Labonne
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati, Ohio, USA
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
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Sandy NS, Roberts AJ, Wales PW, Toma RK, Belza C, Dogra H, Evans HM, Gattini D, Hind J, Mercer D, Povondra JM, Turner J, Yap J, Wong T, Avitzur Y. Small and large bowel anatomy is associated with enteral autonomy in infants with short bowel syndrome: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:231-238. [PMID: 38062898 DOI: 10.1002/jpen.2587] [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: 02/10/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Achievement of enteral autonomy (EA) is the ultimate treatment goal in pediatric intestinal failure (IF). We aimed to assess predictors of EA in pediatric short bowel syndrome (SBS) and explore the impact of residual small bowel (SB) and large bowel (LB) length on EA. METHODS A retrospective cohort study was performed on infants aged <12 months (n = 367, six centers) with SBS referred between 2010 and 2015. The cohort was stratified based on the achievement of EA. Statistical testing was completed using t-test, chi-square, Cox proportional hazards regression model, and Kaplan-Meier analysis. RESULTS EA was achieved in 229 patients. In the multivariable analysis, the percentage of residual LB (hazard ratio [HR] = 1.02; 95% CI = 1.01-1.02) and SB (HR = 1.01; 95% CI = 1.01-1.02) length, presence of the ileocecal valve (HR = 2.02; 95% CI=1.41-2.88), and not coming from a high-volume transplantation center (HR = 2.42; 95% CI = 1.68-3.49) were positively associated with EA, whereas a negative association was seen with the presence of stoma at the time when shortest remnant was documented (HR = 0.72; 95% CI = 0.52-1.00). EA achievement was significantly different between the anatomical subgroups (log-rank test P < 0.001) with an EA rate of 80.4% in infants with ≥50% SB and LB (median time 209 days); 62.5% with ≥50% SB and <50% LB (397 days); 58.3% with <50% SB and ≥50% LB (1192 days), and 25.9% with <50% SB and LB. Necrotizing enterocolitis (NEC) was not associated with a better achievement of EA (NEC vs other etiologies: log-rank test P = 0.33). CONCLUSIONS Overall, 62% of infants with IF secondary to SBS achieved EA over a mean time of follow-up of 2.3 years. A colon length of >50% can compensate for the loss of small bowel (<50%) and account for similar EA rates as those in children with residual SB > 50%.
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Affiliation(s)
- Natascha S Sandy
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of São Paulo (USP), São Paulo, Brazil
| | - Amin J Roberts
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
- National Intestinal Failure & Rehabilitation Service (NIFRS), Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ricardo K Toma
- Department of Pediatrics, University of São Paulo (USP), São Paulo, Brazil
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harween Dogra
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
- National Intestinal Failure & Rehabilitation Service (NIFRS), Auckland, New Zealand
| | - Daniela Gattini
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Hind
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - David Mercer
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jill M Povondra
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Justine Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Gattini D, Yan H, Belza C, Avitzur Y, Wales PW. Cost-utility analysis of 4% tetrasodium ethylenediaminetetraacetic acid, taurolidine, and heparin lock to prevent central line-associated bloodstream infections in children with intestinal failure. JPEN J Parenter Enteral Nutr 2024; 48:47-56. [PMID: 37465871 DOI: 10.1002/jpen.2551] [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: 11/04/2022] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) are a serious complication in children with intestinal failure. This study assessed the incremental costs of 4% tetrasodium ethylenediaminetetraacetic acid (EDTA) compared with taurolidine lock and heparin lock per quality-adjusted life-year (QALY) gained in children with intestinal failure from the healthcare payer and societal perspective. METHODS A Markov cohort model of a 1-year-old child with intestinal failure was simulated until the age of 17 years (time horizon), with a cycle length of 1 month. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Model parameters were obtained from published literature and institutional data. Deterministic, probabilistic, and scenario sensitivity analyses were performed. RESULTS 4% Tetrasodium EDTA was dominant (more effective and less expensive) compared with taurolidine and heparin, yielding an additional 0.17 QALYs with savings of CAD$88,277 compared with heparin, and an additional 0.06 QALYs with savings of CAD$52,120 compared with taurolidine lock from the healthcare payer perspective. From the societal perspective, 4% tetrasodium EDTA resulted in savings of CAD$90,696 compared with heparin and savings of CAD$36,973 compared with taurolidine lock. CONCLUSIONS This model-based analysis indicates that 4% tetrasodium EDTA can be considered the optimal strategy compared with taurolidine and heparin in terms of cost-effectiveness. The decision uncertainty can be reduced by conducting further research on the model input parameters. An expected value of perfect information analysis can identify what model input parameters would be most valuable to focus on.
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Affiliation(s)
- Daniela Gattini
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Han Yan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christina Belza
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Paul W Wales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Toronto, Cincinnati, Ohio, United States
- Cincinnati Center of Excellence for Intestinal Rehabilitation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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Gattini D, Belza C, Kraus R, Avitzur Y, Ungar WJ, Wales PW. Cost-utility analysis of teduglutide compared to standard care in weaning parenteral nutrition support in children with short bowel syndrome. Clin Nutr 2023; 42:2363-2371. [PMID: 37862822 DOI: 10.1016/j.clnu.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND & AIMS A growing proportion of children with short bowel syndrome (SBS) remain dependent on long-term parenteral nutrition (PN). Teduglutide offers the potential for more children to decrease PN support and achieve enteral autonomy (EA), but at a significant expense. This study aims to assess the incremental costs of teduglutide plus standard of care compared to standard of care alone in weaning PN support per quality-adjusted life year (QALY) gained in children with SBS. METHODS This is a cost-utility analysis comparing teduglutide with standard of care alone in children with SBS. A microsimulation model of children with SBS on PN aged 1-17 years was constructed over a time horizon of six years, with a cycle length of one month. The study adopted the healthcare system and societal payer perspectives in Ontario, Canada. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Scenario analyses were performed to examine the effects of different time horizons, timing of teduglutide initiation, and modeling cost of teduglutide based on pediatric weight-dosing. RESULTS Incremental healthcare system costs for teduglutide compared to standard of care were CAD$441,314 (95% CI, 414,006 to 441,314) and incremental QALYs were 1.80 (95% CI, 1.70 to 1.89) resulting in an incremental cost-effectiveness ratio (ICER) of CAD$285,334 (95% CI, 178,209 to 392,459) per QALY gained. Incremental societal costs were CAD$418,504 (95% CI, 409,487 to 427,522) and incremental societal QALYs were 1.91 (95% CI, 1.85 to 1.98) resulting in an ICER of CAD$261,880 (95% CI, 136,887 to 386,874) per QALY gained. Scenario analysis showed that teduglutide was cost-effective when it was started two years after intestinal resection (ICER CAD$48,741, 95% CI, 17,317 to 80,165) and when its monthly cost was adjusted using weight-based dosing, avoiding wastage of the remaining 5 mg dose vial (Teduglutide dominated over SOC as the less costly and most effective strategy). CONCLUSIONS Although teduglutide was not cost-effective in weaning PN support in children with SBS, starting teduglutide once natural intestinal adaptation is reduced and adjusting its monthly cost to reflect cost by volume as dictated by weight-based dosing rendered the intervention cost-effective relative to standard of care. These results indicate the potential for clinicians to re-assess optimal time for initiation of teduglutide after intestinal resection, drug manufacturers to consider the use of multi-dose or paediatric-dose vials, and the opportunity for decision-makers to re-evaluate teduglutide funding.
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Affiliation(s)
- Daniela Gattini
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Christina Belza
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Raphael Kraus
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Pediatric Rheumatologist, Centre Hospitalier Sainte-Justine (CHUSJ), Montreal, Quebec, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Wendy J Ungar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Paul W Wales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States; Cincinnati Center of Excellence for Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
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Pauline ML, Huynh C, Wizzard PR, Nation PN, Field CJ, Wales PW, Turner JM. In parenteral nutrition-fed piglets, fatty acids vary by lipid emulsion and tissue sampled. JPEN J Parenter Enteral Nutr 2023; 47:1038-1046. [PMID: 37416983 DOI: 10.1002/jpen.2547] [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: 01/19/2023] [Revised: 06/15/2023] [Accepted: 07/04/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Children with intestinal failure without liver disease may be given soy-based lipid emulsion (SLE) or mixed lipid emulsion (MLE; containing soy, medium-chain triglyceride, olive, and/or fish oils). Both differ in essential fatty acid content: MLE has added arachidonic acid (AA) and docosahexaenoic acid (DHA). The aim of this study, in neonatal piglets, was to compare serum and tissue fatty acid composition when the emulsions were given at unrestricted doses. METHODS We compared SLE (n = 15) and MLE (n = 15) at doses of 10-15 g/kg/day in parenteral nutrition (PN). On day 14 we collected serum and tissues. Using gas-liquid chromatography, percentage fatty acids were measured in serum, brain, and liver phospholipid. Comparisons were made to reference values from litter-matched controls (n = 8). RESULTS Comparing median values, linoleic acid (LA) was lower for MLE vs SLE in serum (-27%), liver (-45%), and brain (-33%) (P < 0.001). AA was lower for MLE in serum (-25%), liver (-40%), and brain (-10%). DHA was higher for MLE in serum (+50%), liver (+200%), and brain (+10%). AA levels were lower for MLE vs control piglets in serum (-81%), liver (-63%), and brain (-9%). DHA levels were higher in serum (+41%), liver (+38%), and brain (+19%). CONCLUSION This study in piglets has shown that, at unrestricted doses, MLE treatment is associated with low serum and tissue AA compared with SLE and healthy litter-matched controls. Although not yet proven, low tissue AA levels may have functional consequences, and these data support current practice avoiding MLE dose restriction.
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Affiliation(s)
- Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Caitlin Huynh
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine J Field
- Faculty of Agriculture, Life and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Yanchis D, So S, Patterson C, Belza C, Garofalo E, Wong-Sterling S, Silva C, Avitzur Y, Wales PW, Hulst JM, Kong D, Xu L, Li Y, Courtney-Martin G. Body Composition and Physical Activity in Pediatric Intestinal Failure On and Off Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2023; 77:558-564. [PMID: 37434279 DOI: 10.1097/mpg.0000000000003884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
OBJECTIVES Data on the relationship between body composition (BC) and physical activity (PA) in children with intestinal failure (IF) are lacking. The objectives were to collect data on PA and BC in children with IF, both parenterally and enterally fed, and to assess the relationship between PA and BC. METHODS Cross-sectional study in children 5-18 years with IF including those receiving parenteral nutrition (PN) and those fully enterally fed. PA levels were measured using accelerometry. BC was measured by dual-energy X-ray absorptiometry. Data were compared to age- and sex-matched population norms using t tests. Regression analysis assessed the relationship between BC and PA. RESULTS Fifty-eight children with IF (38 males), mean (SD) age of 10.0 (3.5) years, 20 dependent on PN were included. Patients with IF had significantly fewer steps per day ( P ≤ 0.001) compared with literature controls, with a mean (SD) of 7,972 (3,008) and 11,749 (1,106), respectively. There were no significant differences between patients receiving PN and those enterally fed, but both groups were significantly less active than literature controls ( P < 0.001). Patients with IF had higher fat mass and lower fat-free mass compared to literature controls ( P = 0.008). PA had a significant effect on BC ( r2 = 0.32, P < 0.001). CONCLUSIONS Children with IF, those receiving PN and those fully enterally fed, are at risk of decreased PA and altered BC. PA should be part of ongoing rehabilitation and management to optimize outcomes.
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Affiliation(s)
- Dianna Yanchis
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie So
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Catherine Patterson
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Christina Belza
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Garofalo
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Wong-Sterling
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Carina Silva
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Yaron Avitzur
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Paul W Wales
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jessie M Hulst
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- the Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Dehan Kong
- the Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| | - Libai Xu
- the Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| | - Yuxuan Li
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Glenda Courtney-Martin
- From Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- the Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
- the Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
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Belza C, Courtney-Martin G, Wong-Sterling S, Garofalo E, Silva C, Yanchis D, Avitzur Y, Wales PW. Composite lipid emulsion use and essential fatty acid deficiency in pediatric patients with intestinal failure with high parenteral nutrition dependence: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:930-937. [PMID: 37392380 DOI: 10.1002/jpen.2544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Reports of essential fatty acid deficiency (EFAD) in patients receiving parenteral nutrition (PN) and a composite lipid (mixed oil intravenous lipid emulsion [MO ILE]) are predominantly when managed by lipid restriction. The objective of this study was to determine the prevalence of EFAD in patients with intestinal failure (IF) who are PN dependent without lipid restriction. METHODS We retrospectively evaluated patients, ages 0-17 years, followed by our intestinal rehabilitation program between November 2020 and June 2021 with PN dependency index (PNDI) of >80% on a MO ILE. Demographic data, PN composition, PN days, growth, and plasma fatty acid profile were collected. A plasma triene-tetraene (T:T) ratio >0.2 indicated EFAD. Summary statistics and Wilcoxon rank sum test evaluated to compare between PNDI category and ILE administration (grams/kilograms/day). P < 0.05 was considered significant. RESULTS Twenty-six patients (median age, 4.1 years [interquartile range (IQR) = 2.4-9.6]) were included. The median duration of PN was 1367 days (IQR = 824-3195). Sixteen patients had a PNDI of 80%-120% (61.5%). Fat intake for the group was 1.7 g/kg/day (IQR = 1.3-2.0). The median T:T ratio was 0.1 (IQR = 0.1-0.2) with no values >0.2. Linoleic and arachidonic acid were low in 85% and 19% of patients, respectively; however, Mead acid was normal in all patients. CONCLUSION This report is the largest to date on the EFA status of patients with IF on PN. These results suggest that, in the absence of lipid restriction, EFAD is not a concern when using MO ILEs in children receiving PN for IF.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
| | - Sylvia Wong-Sterling
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Elizabeth Garofalo
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Carina Silva
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Dianna Yanchis
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Canada
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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8
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Yanchis D, So S, Patterson C, Belza C, Garofalo E, Wong-Sterling S, Silva C, Avitzur Y, Wales PW, Hulst JM, Kong D, Xuyx L, Courtney-Martin G. Assessment of body composition in pediatric intestinal failure: A comparison study. JPEN J Parenter Enteral Nutr 2023; 47:920-929. [PMID: 37355855 DOI: 10.1002/jpen.2540] [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: 02/16/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND The objective of the study was to compare bioelectrical impedance analysis (BIA) and skinfolds with dual energy x-ray absorptiometry (DXA) in the assessment of body composition of children with intestinal failure. DXA is the reference method for body composition assessment in clinical settings. METHODS Children aged 1-18 years with intestinal failure whohave DXA as part of routine clinical monitoring were eligible. BIA measured total body water on the same day as DXA. Skinfold measurements were taken at four sites: triceps, biceps, subscapular, and suprailiac. Percentage of fat mass (%FM) and fat-free mass (%FFM) were derived from resistance and reactance measured by BIA by using age-specific equations. Percentage of FM was calculated from skinfold measures by using age-specific equations. Data on patient characteristics, intestinal failure-related factors, and feeding method were collected. Paired t test examined differences in %FM and %FFM and Bland-Altman analysis determined the agreement between BIA, skinfolds, and DXA. Marginal linear model assessed the effect of age, sex, and feeding method on the difference in body composition obtained between DXA and BIA and between DXA and skinfolds. RESULTS Sixty-eight children with intestinal failure, mean age 8.9 ± 4.2 years, were studied. There was no difference between %FFM and %FM obtained by DXA and BIA (P = 0.26), with a mean bias (95% CI) of -0.69 (-1.9 to 0.5) for %FFM. Sex and age were individually and jointly associated with the bias observed between DXA and BIA (P < 0.05). Skinfold and DXA measurements were significantly different (P < 0.05). CONCLUSIONS BIA is an acceptable clinical tool for assessing body composition in pediatric intestinal failure.
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Affiliation(s)
- Dianna Yanchis
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephanie So
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Patterson
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Christina Belza
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Garofalo
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sylvia Wong-Sterling
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carina Silva
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessie M Hulst
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Dehan Kong
- Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Libai Xuyx
- Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
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9
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Schuh S, Man C, Marie E, Alhashmi GHA, Halevy D, Wales PW, Singer-Harel D, Finkelstein A, Sweeney J, Doria AS. Properties of ultrasound-rapid MRI clinical diagnostic pathway in suspected pediatric appendicitis-A prospective cohort study. Am J Emerg Med 2023; 71:217-224. [PMID: 37453161 DOI: 10.1016/j.ajem.2023.06.026] [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: 02/14/2023] [Revised: 05/29/2023] [Accepted: 06/10/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE to determine diagnostic accuracy of an US-MRI clinical diagnostic pathway to detect appendicitis in the emergency department (ED). STUDY DESIGN prospective cohort study of 624 previously healthy children 4-17 years old undergoing US for suspected appendicitis and clinical re-assessment. Children with non-diagnostic USs and persistent appendicitis concern/conclusive US-reassessment discrepancies underwent ultra-rapid MRI (US-MRI pathway), interpreted as positive, negative or non-diagnostic. Cases with missed appendicitis, negative appendectomies, and CT utilization were considered clinically diagnostically inaccurate. Primary outcome was the proportion of accurate diagnoses of appendicitis/lack thereof by the pathway. RESULTS 150/624 (24%) children had appendicitis;255 USs (40.9%) were non-diagnostic. Of 139 US-MRI pathway children (after 117 non-diagnostic and 22 conclusive USs), 137 [98.6%; 95% CI 0.96-1.00] had clinically accurate outcomes (1 CT, 1 negative appendectomy): sensitivity 18/18 [100%], specificity 119/121 [98.3%], positive predictive value 18/20 [90.5%], negative predictive value 119/119 [100%]. MRI imaging accuracy was 134/139 (96.4%); 3 MRIs were non-diagnostic (no appendicitis). In the overall algorithm, 616/624 [98.7% (0.97-0.99)] patients had accurate outcomes: 147/150 (98.0%) appendicitis cases had confirmatory surgeries (3 CTs) and 469/474 (98.9%) appendicitis-negative children had no surgery/CT. CONCLUSION this study demonstrated high clinical accuracy of the US-rapid-MRI pathway in suspected pediatric appendicitis after non-diagnostic US.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada.
| | - Carina Man
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Eman Marie
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | | | - Dan Halevy
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Paul W Wales
- Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto Canada
| | - Dana Singer-Harel
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Toronto, Toronto Canada
| | - Aya Finkelstein
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Judith Sweeney
- The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
| | - Andrea S Doria
- Department Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto Canada; The Hospital for Sick Children Research Institute, University of Toronto, Toronto Canada
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10
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Belza C, Wales PW. Intestinal failure among adults and children: Similarities and differences. Nutr Clin Pract 2023; 38 Suppl 1:S98-S113. [PMID: 37115028 DOI: 10.1002/ncp.10987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 04/29/2023] Open
Abstract
Intestinal failure (IF) is a complex medical condition that is caused by a constellation of disorders, resulting in the gut's inability to adequately absorb fluids and nutrients to sustain hydration, growth, and survival, thereby requiring the use of parenteral fluid and/or nutrition. Significant advancements in intestinal rehabilitation have resulted in improved survival rates for individuals with IF. There are distinct differences, however, related to etiology, adaptive potential and complications, and medical and surgical management when comparing children with adults. The purpose of this review is to contrast the similarities and differences between these two distinct groups and provide insight for future directions, as a growing population of pediatric patients will cross into the adult world for IF management.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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11
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Belza C, Avitzur Y, Ungar WJ, Stremler R, Fehlings D, Wales PW. Stress, anxiety, depression, and health-related quality of life in caregivers of children with intestinal failure receiving parenteral nutrition: A cross-sectional survey study. JPEN J Parenter Enteral Nutr 2023; 47:342-353. [PMID: 36336350 DOI: 10.1002/jpen.2461] [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: 06/22/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Improved survival rates for children with intestinal failure (IF) have resulted in an increased population of children receiving long-term parenteral nutrition (PN). Our objective was to determine burden on caregivers of children with IF receiving long-term PN. METHODS We performed a cross-sectional study of caregivers of children with IF receiving long-term PN in our intestinal rehabilitation program. A healthy comparison group matched on age of the child was enrolled. All participants completed standardized questionnaires, including the Parental Stress Index - Short Form (PSI-SF), Hospital Anxiety and Depression Scale (HADS), and PedsQL Family Impact Module (PedsQL FIM). Univariate analysis was completed using a Student t test and chi-square, with an alpha value of <0.05 considered significant. RESULTS Thirty-eight caregivers of children with IF and 29 caregivers of healthy children consented, with response rates of 89% and 96.5%, respectively. Our study demonstrated increased stress for caregivers compared with comparison parents (PSI-SF total score of 83 [SD = 26.8] vs 62.9 [SD = 13.5]; P < 0.01). Caregivers had increased anxiety (HADS anxiety score of 9.3 [SD = 4.8] vs 6.7 [SD = 3.2]; P = 0.02) and higher depression scores (HADS depression score of 6.3 [SD = 4.3] vs 4.1 [SD = 2.6]; P = 0.02) compared with the comparison group. Caregivers of children with IF demonstrated decreased health-related quality of life (HRQoL) (reduced PedsQL FIM total score of 50.6 [SD = 18.2] vs 84.1 [SD = 20.5]; P < 0.01). CONCLUSIONS Our results demonstrated significant burden of care in caregivers of children with IF receiving long-term PN, with elevated stress, anxiety, and depression and decreased HRQoL.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Wendy J Ungar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada
| | - Robyn Stremler
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Darcy Fehlings
- Holland Bloorview Rehabilitation Hospital, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA.,Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati, Ohio, USA
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12
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Huysentruyt K, Belza C, Wong-Sterling S, Chami R, Siddiqui I, Wales PW, Avitzur Y. Use of a combined transient elastography and biochemical strategy to determine liver fibrosis in pediatric intestinal failure. Clin Nutr 2023; 42:136-142. [PMID: 36563562 DOI: 10.1016/j.clnu.2022.12.002] [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: 06/14/2022] [Revised: 11/02/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Non-invasive monitoring of intestinal failure (IF) associated liver disease is an ongoing challenge in children with IF. Our objective was to develop a combined algorithm of clinical, transient elastography (TE) and biochemical parameters to identify liver fibrosis in this population. METHODS A retrospective cohort study of IF patients followed by our intestinal rehabilitation program between November 2015 to October 2019. Patients with a liver biopsy and TE were included. Demographic and liver function tests were collected. Fibrosis on liver biopsies was graded using the modified Scheuer score. Decision tree based algorithms classified low (F0-F1) versus high (F2-F4) fibrosis scores based on a combination of TE, biochemical and demographic parameters, using 6-fold classification error, sensitivity and specificity cross-validation (CV) scores. RESULTS 42 patients (74% male, median age 7.6 (4.6; 42.7) months) were evaluated. Median length of PN therapy was 182 (121; 556) days. High fibrosis was present in 40.5% with a median TE of 12.1 (6.7; 12.9) kPa in high fibrosis children. An algorithm, based on cut-off values for TE of 11.3 kPa and AST of 40 U/L, and grouping of the underlying etiology resulted in a correct classification of 88.1% of the pathology scores; with sensitivity 0.82 (95% CI 0.57; 0.96), specificity 0.92 (95% CI 0.74; 0.99), positive predictive value 0.88 (95% CI 0.64; 0.96) and negative predictive value 0.88 (95% CI 0.73; 0.96). The CV classification error was 28.6%, CV sensitivity 72.2% and CV specificity 75.5%. CONCLUSIONS This algorithm shows promising results that could simplify non-invasive monitoring of liver fibrosis in children with IF. Validation in additional IF cohorts is needed.
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Affiliation(s)
- Koen Huysentruyt
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Brussels Centrum for Intestinal Failure in Children (B-CIRC), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Christina Belza
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia Wong-Sterling
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rose Chami
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Iram Siddiqui
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Yaron Avitzur
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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13
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Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Avitzur Y. An international multicenter validation study of the Toronto listing criteria for pediatric intestinal transplantation. Am J Transplant 2022; 22:2608-2615. [PMID: 35833730 DOI: 10.1111/ajt.17150] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/21/2022] [Accepted: 07/10/2022] [Indexed: 01/25/2023]
Abstract
Deciding which patients would benefit from intestinal transplantation (IT) remains an ethical/clinical dilemma. New criteria* were proposed in 2015: ≥2 intensive care unit (ICU) admissions, loss of ≥3 central venous catheter (CVC) sites, and persistently elevated conjugated bilirubin (CB ≥ 75 μmol/L) despite 6 weeks of lipid modification strategies. We performed a retrospective, international, multicenter validation study of 443 children (61% male, median gestational age 34 weeks [IQR 29-37]), diagnosed with IF between 2010 and 2015. Primary outcome measure was death or IT. Sensitivity, specificity, NPV, PPV, and probability of death/transplant (OR, 95% confidence intervals) were calculated for each criterion. Median age at IF diagnosis was 0.1 years (IQR 0.03-0.14) with median follow-up of 3.8 years (IQR 2.3-5.3). Forty of 443 (9%) patients died, 53 of 443 (12%) were transplanted; 11 died posttransplant. The validated criteria had a high predictive value of death/IT; ≥2 ICU admissions (p < .0001, OR 10.2, 95% CI 4.0-25.6), persistent CB ≥ 75 μmol/L (p < .0001, OR 8.2, 95% CI 4.8-13.9). and loss of ≥3 CVC sites (p = .0003, OR 5.7, 95% CI 2.2-14.7). This large, multicenter, international study in a contemporary cohort confirms the validity of the Toronto criteria. These validated criteria should guide listing decisions in pediatric IT.
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Affiliation(s)
- Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sue V Beath
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Helen M Evans
- New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - David Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutritional Support and Intestinal Failure Team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jason Yap
- Division of Pediatric Gastroenterology, University of Alberta, Edmonton, Canada.,Department of Paediatric Gastroenterology and Nutrition, The Royal Children's Hospital, Melbourne, Australia
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
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14
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Belza C, Ungar WJ, Avitzur Y, Stremler R, Fehlings D, Wales PW. Carrying the Burden: Informal Care Requirements by Caregivers of Children with Intestinal Failure Receiving Home Parenteral Nutrition. J Pediatr 2022; 250:75-82.e3. [PMID: 35660493 DOI: 10.1016/j.jpeds.2022.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/14/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To measure the time that caregivers spend on tasks related to providing care to their child with intestinal failure receiving home parenteral nutrition (PN). STUDY DESIGN We conducted an exploratory cross-sectional study of caregivers of children with intestinal failure receiving long-term PN followed by our intestinal rehabilitation program. Caregivers completed a daily diary of care-related tasks. Data were analyzed using descriptive statistics. Exploratory models were completed to evaluate factors that influenced the amount of time that caregivers spent providing care. SAS University Edition 2018 (SAS Institute, Cary, NC) was used for data analysis with a P value of less than .05 considered significant. RESULTS Thirty-four caregivers of children with intestinal failure consented with response rates of 85%. The mean age of the primary caregiver was 37 ± 7.9 years of age with 97% being the child's mother. The median PN exposure was 1239 days (IQR, 432-3012). Caregivers reported a median of 29.2 hours per week (IQR, 20.8-45.7 hours per week) of direct medical care. The majority of time was spent on providing PN and care of the central venous catheter (6.1 hours; IQR, 5.2-8.8). CONCLUSIONS Caregivers of children with intestinal failure receiving long-term PN provide a significant amount of care to ensure their child remains healthy at home. The most significant amounts of time were spent on the administration of the PN and care of the central venous catheter.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robyn Stremler
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Darcy Fehlings
- Holland Bloorview Rehabilitation Hospital, Department of Pediatrics, Toronto, Ontario, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Intestinal Rehabilitation, Cincinnati Children's Hospital, Cincinnati, OH.
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15
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Abstract
Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring. The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinatti Children's Hospital Medical Center, University of Cincinnati, Cincinnatii, USA; Cincinnati Children's Intestinal Rehabilitation Program, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2023, Cincinnati, Ohio 45229, USA.
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16
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Sandy NS, Huysentruyt K, Mulder DJ, Warner N, Chong K, Morel C, AlQahtani S, Wales PW, Martin MG, Muise AM, Avitzur Y. The Diverse Phenotype of Intestinal Dysmotility Secondary to ACTG2-related Disorders. J Pediatr Gastroenterol Nutr 2022; 74:575-581. [PMID: 35149643 PMCID: PMC9632465 DOI: 10.1097/mpg.0000000000003400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The initial description of a heterozygous dominant ACTG2 variant in familial visceral myopathy was followed by the identification of additional variants in other forms of intestinal dysmotility disorders. we aimed to describe the diverse phenotype of this newly reported and rare disease. METHODS Report of 4 new patients, and a systematic review of ACTG2-related disorders. we analyzed the population frequency and used in silico gene damaging predictions. Genotype-phenotype correlations were explored. RESULTS One hundred three patients (52% girls), from 14 publications, were included. Twenty-eight unique variants were analyzed, all exceedingly rare, and 27 predicted to be highly damaging. The median Combined Annotation Dependent Depletion (CADD) score was 29.2 (Interquartile range 26.3-29.4). Most patients underwent abdominal surgery (66%), about half required intermittent bladder catheterization (48.5%), and more than half were parenteral nutrition (PN)-dependent (53%). One-quarter of the patients died (25.7%), and 6 required transplant (5.8%). Girls had a higher rate of microcolon (P = 0.009), PN dependency (P = 0.003), and death/transplant (P = 0.029) compared with boys, and early disease onset (<2 years of age) was associated with megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) features. There was no statistical association between disease characteristics and CADD scores. CONCLUSIONS Damaging ACTG2 variants are rare, often associated with MMIHS phenotype, and overall have a wide phenotypic variation. Symptoms usually present in the perinatal period but can also appear at a later age. The course of the disease is marked by frequent need for surgical interventions, PN support, and mortality. Poor outcomes are more common among girls with ACTG2 variants.
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Affiliation(s)
- Natascha S. Sandy
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Koen Huysentruyt
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatric Gastroenterology, Universitair Ziekenhuis Brussel, vrije Universiteit Brussel (vUB), Brussels, Belgium
| | - Daniel J. Mulder
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Neil Warner
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karen Chong
- The Prenatal Diagnosis and Medical Genetics Program. Mount Sinai Hospital, Toronto, ON
| | - Chantal Morel
- Cancer Clinical Research Unit (CCRU), Princess Margaret Cancer Centre, The Hospital for Sick Children, University ofToronto, Toronto, Ontario, Canada
| | - Saleh AlQahtani
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of general and thoracic Surgery, The Hospital for Sick Children, University ofToronto, Toronto, Ontario, Canada
| | - Martin G. Martin
- # Division of Gastroenterology and Nutrition, Department of Pediatrics, Mattel Children’s Hospital and the David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Aleixo M. Muise
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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17
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Belza C, Patterson C, Ghent E, Avitzur Y, Ungar WJ, Fehlings D, Stremler R, Wales PW. "Line care governs our entire world": Understanding the Experience of Caregivers of Children with Intestinal Failure on Long-term Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2022; 46:1602-1613. [PMID: 35088428 DOI: 10.1002/jpen.2337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/08/2022] [Accepted: 01/21/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Children with intestinal failure (IF) on long-term parenteral nutrition (PN) require significant medical care, including high risk procedures such as accessing a central venous catheter, with the majority provided by family caregivers in the home. This study sought to understand the experiences of family caregivers of children. METHODS This was a qualitative study of family caregivers of children with IF. Participants were recruited from an intestinal rehabilitation program to participate in virtual focus groups, which were recorded and transcribed. Thematic analysis was used to capture and describe experiences. RESULTS Thirteen caregivers providing care to eleven children participated in three virtual focus groups held between May to June 2020. Data analysis revealed five primary themes: 1) Caregiving as a 24/7 commitment; 2) facing constant risk of death, 3) chronic illness creates difficult feelings and emotions; 4) effects on all aspects of family life; 5) adapting and functioning as a family. The findings of this study pair well with the biopsychosocial model highlighting the need for multifaceted assessment and supports. CONCLUSION The impact of caring for a child with IF on long-term PN is significant for caregivers and their families and has implications for all aspects of their lives. A better understanding of the impact on caregivers and their coping strategies lays the groundwork for optimization of quality of life for caregivers and their family. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT).,Institute for Health Policy Management and Evaluation, University of Toronto
| | - Catherine Patterson
- Group for Improvement of Intestinal Function and Treatment (GIFT).,Department of Rehabilitation Services, The Hospital for Sick Children
| | - Emily Ghent
- Group for Improvement of Intestinal Function and Treatment (GIFT).,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT).,Institute for Health Policy Management and Evaluation, University of Toronto.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children
| | - Wendy J Ungar
- Institute for Health Policy Management and Evaluation, University of Toronto.,Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute
| | - Darcy Fehlings
- Institute for Health Policy Management and Evaluation, University of Toronto.,Holland Bloorview Rehabilitation Hospital, Department of Pediatrics
| | - Robyn Stremler
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT).,Institute for Health Policy Management and Evaluation, University of Toronto.,Division of General and Thoracic Surgery, The Hospital for Sick Children
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18
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Hinchliffe T, Pauline ML, Wizzard PR, Jovel J, Nation PN, Wales PW, Madsen KL, Turner JM. The effect of fecal microbial transplant on intestinal microbial composition in short bowel neonatal piglets. JPEN J Parenter Enteral Nutr 2022; 46:1393-1403. [PMID: 35043436 DOI: 10.1002/jpen.2333] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/29/2021] [Accepted: 01/03/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Short bowel syndrome (SBS) in neonates is associated with microbial dysbiosis due to intestinal surgery, prolonged hospitalization, enteral nutrition, and repeated antibiotic exposure. Sepsis and liver disease, leading causes of morbidity and mortality in SBS, may relate to such intestinal dysbiosis. We investigated the safety and feasibility of fecal microbial transplant (FMT) to alter intestinal microbial composition in SBS piglets. METHODS Following a 75% distal small intestinal resection, piglets were fed parenteral nutrition (PN) and elemental diet (ED), and randomized to saline (SAL, n=12) or FMT (n=12) treatments delivered by gastric tube on day 2 (d2). FMT donor was a healthy adult pig. Comparisons were also made to healthy sow-fed littermate controls (SOW, n=6). Stool samples were collected daily, and tissue samples were collected at baseline and termination. Microbial DNA was extracted from stool and analyzed using 16S rRNA sequencing. RESULTS All piglets survived to the endpoint. On d2-4, FMT piglets had some differences in microbiota composition, compared to SAL, SOW, and donor. Between base and term, there were transitory changes to alpha and beta diversity in FMT and SAL. CONCLUSION FMT treatment in post-surgical neonatal piglets with SBS appears safe, with no increase in sepsis and no mortality. In SBS piglets, FMT induced transient changes to the intestinal microbiota. However, these changes did not persist long-term. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Juan Jovel
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati
| | - Karen L Madsen
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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19
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Gattini D, Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Huysentruyt K, Avitzur Y. Trends in Pediatric Intestinal Failure: A Multicenter, Multinational Study. J Pediatr 2021; 237:16-23.e4. [PMID: 34153281 DOI: 10.1016/j.jpeds.2021.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To assess the natural history and outcomes of children with intestinal failure in a large, multicenter, geographically diverse contemporary cohort (2010-2015) from 6 pediatric intestinal failure programs. STUDY DESIGN Retrospective analysis of a multicenter intestinal failure cohort (n = 443). Competing-risk analysis was used to obtain cumulative incidence rates for the primary outcome (enteral autonomy, transplantation, or death). The χ2 test and Cox proportional hazard regression were used for bivariate and multivariable analyses. RESULTS The study cohort comprised 443 patients (61.2% male). Primary etiologies included short bowel syndrome (SBS), 84.9%; dysmotility disorder, 7.2%; and mucosal enteropathy, 7.9%. Cumulative incidences for enteral autonomy, transplantation, and death at 6 years of follow-up were 53.0%, 16.7%, and 10.5%, respectively. Enteral autonomy was associated with SBS, ≥50% of small bowel length, presence of an ileocecal valve (ICV), absence of portal hypertension, and follow-up in a non-high-volume transplantation center. The composite outcome of transplantation/death was associated with persistent advanced cholestasis and hypoalbuminemia; age <1 year at diagnosis, ICV, and intact colon were protective. CONCLUSIONS The rates of death and transplantation in children with intestinal failure have decreased; however, the number of children achieving enteral autonomy has not changed significantly, and a larger proportion of patients remain parenteral nutrition dependent. New strategies to achieve enteral autonomy are needed to improve patient outcomes.
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Affiliation(s)
- Daniela Gattini
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sue V Beath
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI, and Nutrition Centre, King's College Hospital, London, United Kingdom
| | - David Mercer
- Organ Transplant Center, University of Nebraska Medical Center, Omaha, NE
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Jason Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada
| | - Koen Huysentruyt
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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20
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Yanchis D, Belza C, Harrison D, Wong-Sterling S, Kean P, So S, Patterson C, Wales PW, Avitzur Y, Courtney-Martin G. Normal anthropometry does not equal normal body composition in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:207-214. [PMID: 34510469 DOI: 10.1002/jpen.2265] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Published reports on abnormal body composition in pediatric patients with intestinal failure have been in patients with poor growth. The goal of the current study is to report the body composition of normally growing patients with intestinal failure. METHODS Children 8-18 years old with a dual-energy x-ray absorptiometry (DXA) between January 1, 2013, and July 15, 2018, were included in the study. Data were retrospectively collected from the medical charts and included demographics, residual bowel anatomy, nutrition support, height, and weight. DXA data, including total body less head bone mineral density (BMD), fat mass (FM), and fat-free mass (FFM), were collected and compared with published literature controls matched for age and sex. RESULTS Thirty-four children met inclusion criteria. Mean age at the time of DXA was 9.6 ± 1.8 years. Weight- and height-for-age z-scores were -0.4 ± 0.9 and -0.5 ± 1.0, respectively. Mean BMD z-score was -1.0 ± 1.3. Twenty-six percent of patients (n = 9) had reduced BMD. Patients with intestinal failure had higher FM (P = .02) and lower FFM (P = .02) compared with controls. CONCLUSIONS These data show that, despite reference range z-scores for height and weight, children with intestinal failure are at risk for abnormal body composition. Body composition should be routinely measured in children with intestinal failure to direct nutrition interventions.
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Affiliation(s)
- Dianna Yanchis
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Christina Belza
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Debra Harrison
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Wong-Sterling
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Penni Kean
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie So
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Catherine Patterson
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
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21
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Modi BP, Galloway DP, Gura K, Nucci A, Plogsted S, Tucker A, Wales PW. ASPEN definitions in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:42-59. [PMID: 34287974 DOI: 10.1002/jpen.2232] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [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: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen Gura
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Alyssa Tucker
- Department of Clinical Nutrition, Children's National Medical Center, Washington, District of Columbia, USA
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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22
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Abstract
OBJECTIVES With improved survival of children with intestinal failure (IF), it is important to examine the impact on long-term physical function, physical activity (PA), and fatigue and identify clinical factors that may be predictive of impairment. METHODS Cross-sectional study in children with IF on parenteral nutrition (PN) compared with healthy age- and sex-matched controls (HCs). Assessments included: Paediatric Quality of Life (PedsQL) Physical Function subscale, PedsQL Multi-Dimensional Fatigue Scale, and PA Perceived Benefits and Barriers scale. PA was measured using an accelerometer. Medical data was collected by chart abstraction. RESULTS Participants included 21 children with IF (14 girls), median age 8.33 (interquartile range [IQR] 6.96-11.04) years and 33 HCs (20 boys), 8.25 (6.67-10.79) years. In those with IF, 13 (62%) were born prematurely with a median of 15 (7.5-24.5) in-patient hospitalizations. There was a significant difference (P = 0.033) in mean steps/day in children with IF (9709 +/- 3975) compared with HCs (13104 +/- 5416), and a correlation between moderate-to-vigorous PA and gestational age (r = 0.642, P = 0.010). Child and parent proxy scores indicate poorer physical function and greater fatigue in the IF group, along with a correlation between greater fatigue (r = -0.538, P = 0.012), poorer physical function (r = -0.0650, P = 0.0001) in children with more hospitalizations. Barriers to PA include "I am tired" and "I am worried about my line." CONCLUSIONS Children with IF present with lower levels of PA and physical function and greater fatigue compared with their peers. Ongoing development of medical and rehabilitation intervention strategies is vital to optimize outcomes.
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Affiliation(s)
- Stephanie So
- Department of Rehabilitation Services
- Transplant and Regenerative Medicine Centre
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Catherine Patterson
- Department of Rehabilitation Services
- Transplant and Regenerative Medicine Centre
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Zachary Betts
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Belza
- Transplant and Regenerative Medicine Centre
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre
- Division of Gastroenterology, Hepatology and Nutrition
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
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23
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Lansing M, Slim G, Wizzard P, Rafii M, Pencharz PB, Nation PN, Beggs MR, Alexander RT, Wales PW, Turner JM, Ball RO. Intestinal resection affects whole-body arginine synthesis in neonatal piglets. Pediatr Res 2021; 89:1420-1426. [PMID: 32920606 DOI: 10.1038/s41390-020-01139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/01/2020] [Accepted: 08/06/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies in piglets show a direct relationship between intestinal mass and arginine (Arg) synthesis. We aimed to study the effects of 75% intestinal resection on whole-body Arg synthesis. METHODS Piglets were allocated to sham or jejunocolic (JC) surgery and to enteral nutrition (EN) at 20% [sham (n = 8), JC (n = 10)], or 40% [sham (n = 4), JC (n = 5)]. A gastric tube was placed for EN and a venous catheter for parenteral nutrition and blood sampling. On day 6, a primed bolus and constant infusion of Arg m + 2 label and proline m + 1 label was delivered. In addition, 40% EN piglets received a citrulline (Cit) m + 3 tracer. Blood sampling was undertaken and whole-body Arg synthesis was calculated. On day 7, intestinal length was measured, and samples were collected for gene expression (PCR quantification) and histopathology. RESULTS On Day 7, sham piglets showed intestinal lengthening compared to JC (p = 0.02). Whole-body Arg synthesis was similar between groups (p = 0.50). Adjusting for absolute small intestinal length, JC piglets had greater Arg synthesis (p = 0.01). Expression of arginosuccinase was upregulated in the jejunum of JC compared to sham on 20% EN (p = 0.03). CONCLUSION This demonstrates for the first-time adaptive changes in intestinal Arg synthesis following intestinal resection. IMPACT The intestine makes a critical contribution to whole-body arginine synthesis, particularly in neonates, a human population at risk for short bowel syndrome. Therefore, we studied intestinal arginine synthesis in a neonatal piglet model of short bowel syndrome and demonstrated adaptive changes in the intestine that may preserve whole-body arginine synthesis, despite loss of intestinal mass. This research adds new information to our understanding of the effects a massive intestinal resection has on amino acid metabolism during neonatal development.
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Affiliation(s)
- Marihan Lansing
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - George Slim
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Pamela Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Mahroukh Rafii
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paul B Pencharz
- Departments of Pediatrics and Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Patrick N Nation
- Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Megan R Beggs
- Department of Physiology at the University of Alberta, Edmonton, AB, Canada
| | - R Todd Alexander
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Physiology at the University of Alberta, Edmonton, AB, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Division of General and Thoracic Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Ron O Ball
- Department of Agricultural, Life & Environmental Sciences, University of Alberta, Edmonton, AB, Canada
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24
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Hill S, Carter BA, Cohran V, Horslen S, Kaufman SS, Kocoshis SA, Mercer DF, Merritt RJ, Pakarinen MP, Protheroe S, Thompson JF, Vanderpool CPB, Venick RS, Wales PW, Smith SE, Yoon M, Grimm AA. Safety Findings in Pediatric Patients During Long‐Term Treatment With Teduglutide for Short‐Bowel Syndrome–Associated Intestinal Failure: Pooled Analysis of 4 Clinical Studies. JPEN J Parenter Enteral Nutr 2021; 45:1456-1465. [PMID: 33305440 PMCID: PMC8647158 DOI: 10.1002/jpen.2061] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 01/23/2023]
Affiliation(s)
- Susan Hill
- Great Ormond Street Hospital for Children NHS Foundation Trust London UK
| | - Beth A. Carter
- Children's Hospital Los Angeles and Keck School of Medicine University of Southern California Los Angeles California USA
| | - Valeria Cohran
- Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
| | - Simon Horslen
- Seattle Children's Hospital and University of Washington School of Medicine Seattle Washington USA
| | | | | | | | - Russell J. Merritt
- Children's Hospital Los Angeles and Keck School of Medicine University of Southern California Los Angeles California USA
| | | | - Susan Protheroe
- Birmingham Children's Hospital NHS Foundation Trust Birmingham UK
| | | | | | - Robert S. Venick
- Mattel Children's Hospital UCLA California Los Angeles California USA
| | - Paul W. Wales
- The Hospital for Sick Children Toronto Ontario Canada
| | - Sharon E. Smith
- Shire Human Genetic Therapies, Inc, a Takeda company Cambridge Massachusetts USA
| | - MinJung Yoon
- Shire Human Genetic Therapies, Inc, a Takeda company Cambridge Massachusetts USA
| | - Andrew A. Grimm
- Shire Human Genetic Therapies, Inc, a Takeda company Cambridge Massachusetts USA
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25
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Hinchliffe T, Pauline ML, Wizzard PR, Nation PN, Brubaker P, Campbell JR, Kim Y, Dimitriadou V, Wales PW, Turner JM. Durability of Linear Small-Intestinal Growth Following Treatment Discontinuation of Long-Acting Glucagon-Like Peptide 2 (GLP-2) Analogues. JPEN J Parenter Enteral Nutr 2020; 45:1466-1474. [PMID: 33241564 DOI: 10.1002/jpen.2053] [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: 07/26/2020] [Revised: 10/23/2020] [Accepted: 11/17/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Short-bowel syndrome is the leading cause of pediatric intestinal failure, resulting in dependency on long-term parenteral nutrition (PN). To promote enteral autonomy in neonates, a key outcome may be intestinal growth in length. The purpose of this study was to determine if intestinal lengthening persists following discontinuation of treatment with 1 of 2 GLP-2 analogues with different pharmacokinetic profiles. METHODS Neonatal short-bowel piglets were assigned to saline control (S), 7-day treatment with teduglutide (T) (0.05 mg/kg twice daily), or 7-day treatment with apraglutide (A) (5 mg/kg twice weekly). Comparisons were made between day 7 and day 14 endpoints using analysis of variance. Data included small-intestine length, weight, histology, and quantitative polymerase chain reaction analysis of mucosal transcripts for peptide growth factors and their receptors, nutrient transporters, and tight-junction proteins. RESULTS Compared with control, 7 days of GLP-2 analogue treatment induced mucosal adaptation based on villus hyperplasia (P = .003), which was not durable 7 days after treatment cessation (day 14; P = .081). Treatment increased intestinal growth in length by day 7 (P = .005), which was maintained (by T) or further increased (by A) at day 14 (P < .001). No significant differences in mucosal transcripts were detected. CONCLUSION Unlike mucosal adaptation, intestinal growth appears to be a lasting outcome of treatment with long-acting GLP-2 analogues in a neonatal piglet short-bowel model. This has significant clinical implications for neonates, given their potential for intestinal growth. Intestinal lengthening varies between analogues with different half-lives; however, molecular mechanisms require further elucidation.
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Affiliation(s)
- Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Patricia Brubaker
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jhenielle R Campbell
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yunji Kim
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Paul W Wales
- Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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26
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Turner JM, George P, Lansing M, Slim G, Wizzard PR, Nation P, Brubaker PL, Wales PW. In the Short-term, Milk Fat Globule Epidermal Growth Factor-8 Causes Site-specific Intestinal Growth in Resected Piglets. J Pediatr Gastroenterol Nutr 2020; 71:543-549. [PMID: 32910624 DOI: 10.1097/mpg.0000000000002818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Short bowel syndrome (SBS) remains the leading cause of neonatal intestinal failure. Milk fat globule epidermal growth factor-8 (MFG-E8), present in human milk, has homology with epidermal growth factor (EGF), known to enhance adaptation in SBS. In this pilot study, the role of oral MFG-E8 treatment in SBS was explored in neonatal piglets. METHODS Neonatal piglets underwent 75% intestinal resection, either distal (jejunal-colonic [JC] anastomosis) or mid-intestinal (jejunal-ileal [JI] anastomosis). Piglets were randomized to intragastric treatment with MFG-E8 (5 mg/kg per day) or saline and were maintained on parenteral nutrition and enteral nutrition for 7 days. Adaptation was assessed by intestinal length and weight, histopathology, fecal fat analysis and RT-qPCR analysis of mucosal transcripts, including growth factors. RESULTS JI piglets demonstrated intestinal lengthening (P < 0.001), 2-fold greater in ileum than jejunum (P = 0.02), where lengthening was increased by MFG-E8 treatment (P = 0.02). JC piglets did not exhibit jejunal lengthening, regardless of treatment. Fat absorption was greater for JI piglets (P = 0.02), unaffected by treatment. In JI piglets, expression of Egf was increased in the ileum (P < 0.01) and MFG-E8 treatment increased Egfr (receptor) expression (P = 0.02). CONCLUSIONS MF-EG8 demonstrated site-specific trophic effects, only with JI anatomy. This may limit the utility of this treatment for SBS, except for rare patients with retained ileum. The mechanisms of these site-specific effects, however, and the role of MFG-E8 in neonatal gut growth and in diseases, such as necrotizing enterocolitis that commonly target ileum, warrant further exploration.
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Affiliation(s)
| | | | | | | | | | - Patrick Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta
| | | | - Paul W Wales
- Department of Pediatrics.,Department of Surgery, University of Toronto.,Group for the Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, Toronto, Ontario, Canada
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27
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Quirt J, Belza C, Pai N, Clause R, Markovic F, Wong‐Sterling S, Avitzur Y, Wales PW. Reduction of Central Line–Associated Bloodstream Infections and Line Occlusions in Pediatric Intestinal Failure Patients Receiving Long‐Term Parenteral Nutrition Using an Alternative Locking Solution, 4% Tetrasodium Ethylenediaminetetraacetic Acid. JPEN J Parenter Enteral Nutr 2020; 45:1286-1292. [DOI: 10.1002/jpen.1989] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Jill Quirt
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children University of Toronto Toronto Canada
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
| | - Nikhil Pai
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Rose‐Frances Clause
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Filip Markovic
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Sylvia Wong‐Sterling
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of Gastroenterology, Hepatology, and Nutrition The Hospital for Sick Children University of Toronto Toronto Canada
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children University of Toronto Toronto Canada
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28
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Pauline ML, Nation PN, Wizzard PR, Hinchliffe T, Wu T, Dimitriadou V, Turner JM, Wales PW. Comparing the Intestinotrophic Effects of 2 Glucagon-Like Peptide-2 Analogues in the Treatment of Short-Bowel Syndrome in Neonatal Piglets. JPEN J Parenter Enteral Nutr 2020; 45:538-545. [PMID: 32437048 DOI: 10.1002/jpen.1853] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/06/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In treating short-bowel syndrome (SBS), autonomy from parenteral nutrition (PN) relies upon intestinal adaptation, which can be augmented by glucagon-like peptide-2 (GLP-2) analogues. In neonatal piglets with SBS, we compared intestinal adaptation following treatment with 2 GLP-2 analogues: teduglutide (TED) and apraglutide (APRA) METHODS: Following 75% distal small-intestinal resection, piglets were allocated to 4 treatment groups: saline (CON: n = 8), twice weekly APRA (5 mg/kg/dose; n = 8), and TED once daily (TED, 0.05 mg/kg/dose; n = 8) or twice daily (TEDBID, 0.05 mg/kg/dose; n = 7). Pharmacokinetic (PK) studies were undertaken, and on day 7, small-intestinal length and weight were measured and jejunal tissue collected for histology. RESULTS PK profiles were different between the 2 analogues. To achieve a comparable exposure to APRA, TED requires twice daily injection (TEDBID). Compared with CON, APRA and TEDBID increased small-bowel length (cm) (CON: 141, APRA: 166, TED: 153, TEDBID: 165; P = .004), whereas APRA increased small-bowel weight (g) (CON: 26, APRA: 33, TED: 28, TEDBID: 31; P = .007) and villus height (mm) (CON: 0.59, APRA: 0.90, TED: 0.58, TEDBID: 0.74; P < .001). CONCLUSION APRA injected only twice during the 7 consecutive days demonstrated a superior intestinotrophic effect compared with TED injected once daily. Even at more comparable drug exposure, when TED was injected twice a day, APRA showed superior trophic activity at the mucosal level. This is highly relevant for the treatment of pediatric SBS, given the markedly lower dose frequency by subcutaneous injection of APRA.
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Affiliation(s)
- Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Tong Wu
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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29
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Srikrishnaraj A, Chambers K, South C, Arppe Robertson M, Vresk L, Tedesco-Bruce A, Haliburton B, Yanchis D, Belza C, Zietsma J, Benec J, Carricato M, Kean P, Avitzur Y, Wales PW, Harrison D, Courtney-Martin G. Trace Elements' Contamination of Pediatric Parenteral Nutrition Solutions in Canada: A Cause for Concern. JPEN J Parenter Enteral Nutr 2020; 45:347-356. [PMID: 32338772 DOI: 10.1002/jpen.1836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Trace elements' (TEs) contamination of parenteral nutrition (PN) solutions is an ongoing concern. The aims of this study were 1) to measure actual TE concentrations in PN admixtures compared with ordered concentrations and 2) compare TE intake with current recommendations. METHODS PN admixtures from discarded bags were collected from patients receiving home PN and on inpatient wards. Samples were collected from 72 patients (39 inpatients, 33 receiving home PN). Age, percentage energy intake from PN, and PN orders were collected from patients' charts. PN samples were analyzed for TEs, including chromium (Cr) and manganese (Mn), and concentration measurements compared with ordered concentrations and current recommendations. RESULTS Measured Cr and Mn concentrations were higher than ordered concentrations: 5.3 ± 1.7 vs 2.8 ± 1.5 µg/L; P < 0.0001 and 11.9 ± 5.9 vs 0.00 µg/L; P < 0.0001, respectively. Chromium contamination alone accounted for over 100% of current recommendations for patients 0-12 months and between 63% and 92% for children >1 year. Contamination of Mn provided all the measured Mn in PN admixtures, since Mn is excluded from PN orders at our institution. Between 70% and 120% of current Mn recommendations were met from contamination. CONCLUSIONS Cr should be excluded from PN admixtures for children 0-12 months and only one-fourth the current recommendation should be added for pediatric patients >1 year. Manganese should also be excluded from PN admixture for pediatric patients but plasms monitoring 2-3 times per year is recommended for those on long-term PN.
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Affiliation(s)
| | - Kathryn Chambers
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Courtney South
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | | | - Laura Vresk
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | | | - Beth Haliburton
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Dianna Yanchis
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Christina Belza
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Jordan Zietsma
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Joanna Benec
- Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Megan Carricato
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Penni Kean
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Debra Harrison
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Faculty of Kinesiology, University of Toronto, Toronto, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Canada
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30
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Lurz E, Patel H, Lebovic G, Quammie C, Woolfson JP, Perez M, Ricciuto A, Wales PW, Kamath BM, Chavhan GB, Jüni P, Ng VL. Paediatric reference values for total psoas muscle area. J Cachexia Sarcopenia Muscle 2020; 11:405-414. [PMID: 31920002 PMCID: PMC7113526 DOI: 10.1002/jcsm.12514] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/03/2019] [Accepted: 10/17/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sarcopenia, the unintentional loss of skeletal muscle mass, is associated with poor outcomes in adult patient populations. In adults, sarcopenia is often ascertained by cross-sectional imaging of the psoas muscle area (PMA). Although children with chronic medical illnesses may be at increased risk for muscle loss because of nutritional deficiencies, physical deconditioning, endocrine anomalies, and systemic inflammation, consistent quantitative definitions for sarcopenia in children are lacking. We aimed to generate paediatric reference values for PMA at two intervertebral lumbar levels, L3-4 and L4-5. METHODS In this cross-sectional study, we analysed abdominal computed tomography scans of consecutive children presenting to the emergency department. Participants were children 1-16 years who required abdominal cross-sectional imaging after paediatric trauma between January 1, 2005 and December 31, 2015 in a large Canadian quaternary care centre. Children with a documented chronic medical illness or an acute spinal trauma at presentation were excluded. Total PMA (tPMA) at levels L3-4 and L4-5 were measured in square millimetres (mm2 ) as the sum of left and right PMA. Age-specific and sex-specific tPMA percentile curves were modelled using quantile regression. RESULTS Computed tomography images from 779 children were included. Values of tPMA at L4-5 were significantly larger than at L3-4 at all ages, but their correlation was high for both girls (r = 0.95) and boys (r = 0.98). Amongst girls, tPMA 50th percentile values ranged from 365 to 2336 mm2 at L3-4 and from 447 to 2704 mm2 for L4-5. Amongst boys, 50th percentile values for tPMA ranged between 394 and 3050 mm2 at L3-4 and from 498 to 3513 mm2 at L4-5. Intraclass correlation coefficients were excellent at L3-4 (0.97, 95% CI 0.94 to 0.981) and L4-5 (0.99, 95% CI 0.986 to 0.995). Weight and tPMA were correlated, stratified by sex for boys (L3-4 r = 0.90; L4-5 r = 0.90) and for girls (L3-4 r = 0.87; L4-5 r = 0.87). An online application was subsequently developed to easily calculate age-specific and sex-specific z-scores and percentiles. CONCLUSIONS We provide novel paediatric age-specific and sex-specific growth curves for tPMA at intervertebral L3-4 and L4-5 levels for children between the ages of 1-16 years. Together with an online tool (https://ahrc-apps.shinyapps.io/sarcopenia/), these tPMA curves should serve as a reference enabling earlier identification and targeted intervention of sarcopenia in children with chronic medical conditions.
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Affiliation(s)
- Eberhard Lurz
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Division of Gastroenterology, Hepatology and Nutrition, von Haunersches Kinderspital, LMU, Munich, Germany
| | - Hiten Patel
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Radiology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Gerald Lebovic
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Claudia Quammie
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jessica P Woolfson
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Manuela Perez
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Amanda Ricciuto
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Govind B Chavhan
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Vicky L Ng
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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31
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Belza C, Betts Z, de Silva N, Avitzur Y, Wales PW. Factors Related to the Development of Small-Bowel Bacterial Overgrowth in Pediatric Intestinal Failure: A Retrospective Cohort Study. JPEN J Parenter Enteral Nutr 2020; 44:1280-1284. [PMID: 32167608 DOI: 10.1002/jpen.1809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/27/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Small bowel bacterial overgrowth (SBBO) is a challenge in the management of pediatric intestinal failure (PIF). Our goal was to determine the proportion of patients treated for SBBO and factors related to its development. METHODS We completed a retrospective analysis of PIF patients referred between 2008 and 2014. Data were collected on factors related to intestinal failure (IF) and SBBO. The cohort was stratified on the diagnosis of SBBO and refractory SBBO. Statistical testing completed using t-test, χ2 test, and logistic regression. RESULTS Thirty-five of 102 patients developed SBBO (34%), and 16 (16%) had refractory SBBO. SBBO was more likely in gastroschisis (40.0% vs 19.4%, P = .025), a shorter residual small bowel (SB) (45.4% vs 66.5%, P = .004), and patients were less likely to wean from parenteral nutrition (PN) (51.4% vs 85.1%, P < .0001). Refractory SBBO patients were likely to have gastroschisis (50.0% vs 22.1%, P = .020) and a shorter residual SB and large bowel remaining (23.2% vs 65.9%, P < .0001 and 60.6% vs 79.4%, P = .03, respectively) and less likely to wean from PN (37.5% vs 80.2%, P = .001). Logistic regression demonstrated that longer SB residual was protective (P = .001; odds ratio [OR], 0.95; 95% CI, 0.93-0.99), and short bowel syndrome (SBS) as a cause of IF was a risk factor (P = .001; OR, 0.04; 95% CI, 0.01-0.27). CONCLUSION A longer SB remnant was protective against SBBO. Patients with SBBO were more likely to have PIF caused by SBS.
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Affiliation(s)
- Christina Belza
- Transplant and Regenerative Medicine Centre, Toronto, Canada
| | - Zachary Betts
- Transplant and Regenerative Medicine Centre, Toronto, Canada
| | | | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, Toronto, Canada.,Division of Neonatology, Toronto, Canada
| | - Paul W Wales
- Transplant and Regenerative Medicine Centre, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Oliveira C, de Silva NT, Ungar WJ, Bayoumi AM, Avitzur Y, Hoch JS, Maxwell J, Wales PW. Health-related quality of life in neonates and infants: a conceptual framework. Qual Life Res 2020; 29:1159-1168. [PMID: 31997081 DOI: 10.1007/s11136-020-02432-6] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE With reduced mortality of neonatal conditions, health-related quality of life (HRQOL) has become an important clinical outcome. However, since the meaning of HRQOL in dependent, non-autonomous infants and neonates remains largely undefined, HRQOL measurement and economic evaluation are limited due to the lack of age-specific methodology. The objective was to construct a conceptual framework of neonatal and infant HRQOL (NIHRQOL) which identifies factors relevant to the neonate and infant, their relationship with each other and the caregiving environment. METHODS Using qualitative methods, a concept was developed based on in-depth analysis of verbatim records of two focus groups (6 caregivers, 6 healthcare providers) and five interviews with caregivers of chronically ill neonates/infants (n = 2), and healthcare professionals of a pediatric tertiary healthcare center (n = 3). Two analysts independently performed thematic analysis using an inductive and contextual approach. RESULTS The majority of participants regarded NIHRQOL as an individual entity, which was closely related and strongly influenced by caregivers and family. It may be gauged by the perceived degree of effort required to achieve expected normalcy in everyday life for the neonate/infant and its family. The importance of individual HRQOL factors is developmental stage-dependent. CONCLUSION Neonatal and infant HRQOL is a multidimensional, multilayered and interconnected concept, where the child's needs contribute most directly, and the caregiver's and society's ability to meet those needs characterize the interdependence between the child and its caregiving environment. Developmental stage-specific HRQOL instruments for premature and mature neonates, and infants are warranted to allow for valid HRQOL measurement.
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Affiliation(s)
- Carol Oliveira
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Nicole T de Silva
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Ahmed M Bayoumi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Centre for Research On Inner City Health, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Jeffrey S Hoch
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital, Toronto, Canada
| | - Julia Maxwell
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Abstract
Pediatric intestinal failure (IF) remains a complex and devastating condition resulting in the inability of the gastrointestinal tract to absorb adequate fluids and nutrients to sustain life. The goal in the management of IF is to achieve enteral autonomy and when not possible to avoid and minimize the development of long-term complications. Survival rates for children with IF have continued to improve resulting in an increased population of children with more altered anatomy. While IF remains a rare disease, children with IF secondary to ultrashort bowel syndrome comprise an even smaller patient population. The goal of this article is to review the recent literature related to the impact of multidisciplinary intestinal rehabilitation programs (IRPs) on the management and outcomes of intestinal failure in children with ultrashort bowel syndrome and potential avenues to further improve the long-term outcomes of this patient population.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Kocoshis SA, Merritt RJ, Hill S, Protheroe S, Carter BA, Horslen S, Hu S, Kaufman SS, Mercer DF, Pakarinen MP, Venick RS, Wales PW, Grimm AA. Safety and Efficacy of Teduglutide in Pediatric Patients With Intestinal Failure due to Short Bowel Syndrome: A 24-Week, Phase III Study. JPEN J Parenter Enteral Nutr 2019; 44:621-631. [PMID: 31495952 PMCID: PMC7318247 DOI: 10.1002/jpen.1690] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/08/2019] [Indexed: 12/27/2022]
Abstract
Background This study evaluated the safety and efficacy of teduglutide in pediatric patients with short bowel syndrome–associated intestinal failure (SBS‐IF). Methods A 24‐week, phase III trial with 2 randomized, double‐blind teduglutide dose groups and a nonblinded standard of care (SOC) arm was used; patients received 0.025 mg/kg or 0.05 mg/kg teduglutide once daily. Safety end points included treatment‐emergent adverse events (TEAEs) and growth parameters. The primary efficacy/pharmacodynamic end point was the number of patients who achieved a ≥20% reduction in parenteral support (PS) from baseline at week 24. Results All 59 enrolled patients completed the study (0.025 mg/kg, n = 24; 0.05 mg/kg, n = 26; SOC, n = 9). Baseline demographics and disease characteristics were comparable among groups. TEAEs were reported by 98% and 100% of patients in the teduglutide and SOC groups, respectively. The most common TEAEs in the teduglutide‐treated groups were pyrexia and vomiting. The primary end point was achieved by 13 (54.2%), 18 (69.2%), and 1 (11.1%) patients who received 0.025 mg/kg teduglutide, 0.05 mg/kg teduglutide, and SOC, respectively (P < 0.05 vs SOC). Both 0.025‐mg/kg and 0.05‐mg/kg teduglutide groups showed clinically significant reductions in PS volume (P < 0.05 vs SOC), PS calories, days per week and hours per day of PS infusions, and increases in enteral nutrition and plasma citrulline at week 24 compared with baseline. Two (8.3%, 0.025 mg/kg teduglutide) and 3 patients (11.5%, 0.05 mg/kg teduglutide) achieved enteral autonomy. Conclusion The safety profile of teduglutide was similar to that reported previously in children and adults. Treatment with teduglutide was associated with significant reductions in PS for pediatric patients with SBS‐IF over 24 weeks.
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Affiliation(s)
- Samuel A Kocoshis
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Russell J Merritt
- Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Susan Hill
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Susan Protheroe
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Beth A Carter
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Simon Horslen
- Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington, USA
| | - Simin Hu
- Shire Human Genetic Therapies, Inc, Lexington, Massachusetts, USA
| | - Stuart S Kaufman
- MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - David F Mercer
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mikko P Pakarinen
- Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Robert S Venick
- Mattel Children's Hospital UCLA, Department of Pediatrics, Los Angeles, California, USA
| | - Paul W Wales
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew A Grimm
- Shire Human Genetic Therapies, Inc, Cambridge, Massachusetts, USA
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Belza C, Fitzgerald K, Silva N, Avitzur Y, Wales PW. Early Predictors of Enteral Autonomy in Pediatric Intestinal Failure Resulting From Short Bowel Syndrome: Development of a Disease Severity Scoring Tool. JPEN J Parenter Enteral Nutr 2019; 43:961-969. [DOI: 10.1002/jpen.1691] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/12/2019] [Accepted: 06/28/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
| | - Kevin Fitzgerald
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
| | - Nicole Silva
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
- Division of Gastroenterology, Hepatology and NutritionUniversity of Toronto Toronto Canada
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
- Division of General and Thoracic SurgeryThe Hospital for Sick ChildrenUniversity of Toronto Toronto Canada
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Belza C, Wales JC, Courtney-Martin G, de Silva N, Avitzur Y, Wales PW. An Observational Study of Smoflipid vs Intralipid on the Evolution of Intestinal Failure-Associated Liver Disease in Infants With Intestinal Failure. JPEN J Parenter Enteral Nutr 2019; 44:688-696. [PMID: 31448447 DOI: 10.1002/jpen.1692] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/23/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND SMOFlipid has a more diverse lipid profile than traditional Intralipid and has become the standard lipid for patients in our intestinal rehabilitation program. Our objective was to compare outcomes in neonates with intestinal failure (IF) who received SMOFlipid against those receiving Intralipid. METHODS This was a retrospective cohort study of infants with IF with a minimum follow-up of 12 months in 2008-2016. Patients were stratified into 2 groups: group 1 received SMOFlipid; group 2 was a historical cohort who received Intralipid. The primary outcome was liver function evaluated using conjugated bilirubin (CB) levels. Statistical analysis included the Mann-Whitney U and χ2 tests, with an α value < 0.05 considered significant. Approval was obtained from our institutional review board. RESULTS Thirty-seven patients were evaluated (17 = SMOFlipid, 20 = Intralipid). SMOFlipid patients were less likely to reach CB of 34 (24% vs 55%, P = 0.05), 50 µmol/L (11.8% vs 45%; P = 0.028), and did not require Omegaven (0% vs 30%; P = 0.014). CB level at 3 months after initiation of parenteral nutrition (PN) was lower in patients receiving SMOFlipid (0 vs 36 µmol/L; P = 0.01). Weight z-scores were improved for patients receiving SMOFlipid at 3 months (-0.932 vs -2.092; P = 0.028) and 6 months (-0.633 vs -1.614; P = 0.018). There were no differences in PN-supported patients or demographics between the groups. CONCLUSION Use of SMOFlipid resulted in decreased development of IF-associated liver disease in patients with IF when assessed using biochemical tests.
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Affiliation(s)
- Christina Belza
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada
| | - John C Wales
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada
| | - Glenda Courtney-Martin
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada
| | - Nicole de Silva
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada
| | - Yaron Avitzur
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada
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Fitzgerald K, Muto M, Belza C, De Silva N, Avitzur Y, Wales PW. The evolution of the serial transverse enteroplasty for pediatric short bowel syndrome at a single institution. J Pediatr Surg 2019; 54:993-998. [PMID: 30803790 DOI: 10.1016/j.jpedsurg.2019.01.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 01/21/2019] [Accepted: 01/27/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE The serial transverse enteroplasty (STEP) tapers and lengthens the gut to improve adaptation. Mortality has decreased with multidisciplinary intestinal rehabilitation programs (IRP) allowing more time to reach adaptive potential. We reviewed our STEP experience to compare surgical outcomes between early and late eras of our IRP. METHODS A retrospective cohort study of all STEP patients managed by our IRP (Jan 2003-Dec 2016; era 1 2003-2005, era 2 2006-2016) was completed. Patient demographics, operative data, complications, and outcome data were collected. Univariate analysis between eras with nonparametric statistics was performed. RESULTS Thirty-six patients received STEP (Era 1 = 12; Era 2 = 24) [median age 5mo; males 22/36 (61.1%)]. In Era 2 a higher proportion had gastroschisis (8.3% vs 58.3%); p = 0.004) and shorter pre-STEP small bowel remnant (48 vs 111 cm, p = 0.001). The median increase in bowel length post-STEP was 52.9%. Overall, 42% of patients reached enteral autonomy (Era 1 7/12 (58%) vs Era 2 8/24 (33%); p = 0.15). Median time to PN discontinuation was shorter in Era 1 (259 vs 968 days, p = .208). Staple line complications were higher in Era 1 (16.7% vs 0%; p = 0.040). CONCLUSION Presently, STEP is reserved for a specific subset of IRP patients, allowing 42% to wean off PN. STEP's use should be under the umbrella of a multidisciplinary IRP. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kevin Fitzgerald
- The Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA; Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA
| | - Mitsuru Muto
- The Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA; Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA
| | - Christina Belza
- The Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA; Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA
| | - Nicole De Silva
- The Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA
| | - Yaron Avitzur
- The Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA; Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA
| | - Paul W Wales
- The Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA; Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA; Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, CANADA.
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Shivji S, Wales PW, Putra J. Gastric Heterotopia: Ileal Thickening in a Patient With Jejunal Atresia Type IIIb. Int J Surg Pathol 2019; 27:887. [PMID: 30942105 DOI: 10.1177/1066896919840434] [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: 11/16/2022]
Affiliation(s)
- Sameer Shivji
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Juan Putra
- The Hospital for Sick Children, Toronto, Ontario, Canada
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So S, Patterson C, Gold A, Rogers A, Belza C, de Silva N, Avitzur Y, Wales PW. Neurodevelopmental outcomes of infants with intestinal failure at 12 and 26 months corrected age. Early Hum Dev 2019; 130:38-43. [PMID: 30660017 DOI: 10.1016/j.earlhumdev.2018.12.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival rates of infants with intestinal failure (IF) are increasing, yet multiple medical factors may impact development. AIMS This study examines neurodevelopmental outcomes at 12-15 and 26-32 months corrected age in a cohort of children with IF. STUDY DESIGN Prospective single centre neurodevelopmental assessments of children admitted to an intestinal rehabilitation program between 2011 and 2013. Outcome measures include: Mullen Scales of Early Learning (12 and 26 months), and Vineland-II Adaptive Behaviour Scales - Caregiver Report (26 months). Standard scores were correlated with medical and demographic factors. RESULTS Thirty-one children (17 males), median gestational age 34 weeks (IQR 30-36) with birth weight (BW) 2.12 kg (IQR 1.24-2.52). Ten (32.2%) were dependent on parental nutrition (PN) at the second assessment. At 12 months, 11/30 (36.7%) scored below average (>1SD below mean) on the early learning composite and 24/30 (80%) were below average on the gross motor subscale. Comparatively, at 26 months, mean early learning scores were significantly lower with >50% scoring below average. Mean gross motor scores remained low, and 14/27 (51.9%) were below average on the Vineland-II motor domain. At 12 months, factors significantly associated with lower scores are primarily related to prematurity. At 26 months, the impact of IF-related variables such as bowel length and PN days are more apparent. CONCLUSION Children with IF are at risk of developmental delay in multiple domains. While gross motor skills appear to be most significantly affected, cognitive deficits become more apparent at 26 months, highlighting the importance of early developmental follow up.
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Affiliation(s)
- Stephanie So
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Catherine Patterson
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anna Gold
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alaine Rogers
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Belza
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicole de Silva
- Department of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
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Slim GM, Lansing M, Wizzard P, Nation PN, Wheeler SE, Brubaker PL, Jeppesen PB, Wales PW, Turner JM. Novel Long‐Acting GLP‐2 Analogue, FE 203799 (Apraglutide), Enhances Adaptation and Linear Intestinal Growth in a Neonatal Piglet Model of Short Bowel Syndrome with Total Resection of the Ileum. JPEN J Parenter Enteral Nutr 2019; 43:891-898. [DOI: 10.1002/jpen.1500] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/10/2018] [Indexed: 12/14/2022]
Affiliation(s)
- George M. Slim
- Department of PediatricsUniversity of Alberta Edmonton Alberta Canada
| | - Marihan Lansing
- Department of PediatricsUniversity of Alberta Edmonton Alberta Canada
| | - Pamela Wizzard
- Department of PediatricsUniversity of Alberta Edmonton Alberta Canada
| | - Patrick N. Nation
- Department of Laboratory Medicine and PathologyUniversity of Alberta Edmonton Alberta Canada
| | - Sarah E. Wheeler
- Departments of Physiology and MedicineUniversity of Toronto Toronto Ontario Canada
| | - Patricia L. Brubaker
- Departments of Physiology and MedicineUniversity of Toronto Toronto Ontario Canada
| | - Palle B. Jeppesen
- Department of Medical GastroenterologyCopenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Paul W. Wales
- Department of PediatricsUniversity of Alberta Edmonton Alberta Canada
- Division of General SurgeryHospital for Sick Children Toronto Ontario Canada
- Group for Improvement of Intestinal Function and TreatmentHospital for Sick Children Toronto Ontario Canada
| | - Justine M. Turner
- Department of PediatricsUniversity of Alberta Edmonton Alberta Canada
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Gibb ACN, Crosby MA, McDiarmid C, Urban D, Lam JYK, Wales PW, Brockel M, Raval M, Offringa M, Skarsgard ED, Wester T, Wong K, de Beer D, Nelson G, Brindle ME. Creation of an Enhanced Recovery After Surgery (ERAS) Guideline for neonatal intestinal surgery patients: a knowledge synthesis and consensus generation approach and protocol study. BMJ Open 2018; 8:e023651. [PMID: 30530586 PMCID: PMC6303622 DOI: 10.1136/bmjopen-2018-023651] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) guidelines integrate evidence-based practices into multimodal care pathways designed to optimise patient recovery following surgery. The objective of this project is to create an ERAS protocol for neonatal abdominal surgery. The protocol will identify and attempt to bridge the gaps between current practices and best evidence. Our study is the first paediatric ERAS protocol endorsed by the International ERAS Society. METHODS A research team consisting of international clinical and family stakeholders as well as methodological experts have iteratively defined the scope of the protocol in addition to individual topic areas. A modified Delphi method was used to reach consensus. The second phase will include a series of knowledge syntheses involving a rapid review coupled with expert opinion. Potential protocol elements supported by synthesised evidence will be identified. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system will be used to determine strength of recommendations and the quality of evidence. The third phase will involve creation of the protocol using a modified RAND/UCLA Appropriateness Method. Group consensus will be used to rate each element in relation to the quality of evidence supporting the recommendation and the appropriateness for guideline inclusion. This protocol will form the basis of a future implementation study. ETHICS AND DISSEMINATION This study has been registered with the ERAS Society. Human ethics approval (REB 18-0579) is in place to engage patient families within protocol development. This research is to be published in peer-reviewed journals and will form the care standard for neonatal intestinal surgery.
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Affiliation(s)
- Ashleigh C N Gibb
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Megan A Crosby
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Caraline McDiarmid
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Denisa Urban
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Y K Lam
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul W Wales
- Department of Pediatric Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Megan Brockel
- Department of Pediatric Anesthesia, University of Colorado, Aurora, Colorado, USA
| | - Mehul Raval
- Department of Pediatric Anesthesia, University of Colorado, Aurora, Colorado, USA
- Department of Pediatric Surgery, Northwestern University, Chicago, Illinois, USA
| | - Martin Offringa
- Department of Neonatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Erik D Skarsgard
- Department of Pediatric Surgery, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University, Stockholm, Sweden
| | - Kenneth Wong
- Department of Surgery, University of Hong Kong, Li Ka Shing Faculty of Medicine, Hong Kong, China
| | - David de Beer
- Department of Pediatric Anesthesia, Great Ormond Street Hospital, London, UK
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mary E Brindle
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Dhaliwal J, Chavhan GB, Lurz E, Shalabi A, Yuen N, Williams B, Martincevic I, Amirabadi A, Wales PW, Lee W, Ling SC, Mouzaki M. Hepatic steatosis is highly prevalent across the paediatric age spectrum, including in pre-school age children. Aliment Pharmacol Ther 2018; 48:556-563. [PMID: 29998462 DOI: 10.1111/apt.14900] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 04/09/2018] [Revised: 05/21/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prevalence of non-alcoholic fatty liver disease (NAFLD) in children is 8% in the general population, and 34% in the context of obesity. There is a paucity of data on the prevalence of hepatic steatosis in healthy children in Ontario. AIMS To determine the prevalence of hepatic steatosis using abdominal computed tomography (CT) scans in a cohort of previously healthy children across the paediatric age spectrum in Ontario, Canada, and to determine any association between measures of abdominal adiposity and hepatic steatosis. METHODS Retrospective review of the SickKids Trauma Database from 2004-2015. Previously healthy children ages 1-17 years having undergone an abdominal CT scan as a part of routine trauma assessment were included, and those with an intra-abdominal injury excluded. Steatosis was defined as a difference between liver and spleen attenuation ≤-25HU. The percentage of the total area occupied by abdominal subcutaneous adipose and visceral adipose tissue was measured. Anthropometrics and baseline demographics were collected. RESULTS A total of 503 (51% male) children with mean (±SD) age 9.5 ± 4.5 years and weight z-score of 0.37 ± 1.05 were studied. Seventy-seven (15%, 95% CI [12%-18%]) had hepatic steatosis; no differences found between sexes or across age quartiles. The abdominal subcutaneous adipose tissue area was greater in those with hepatic steatosis compared to those without (32% [22-42] vs 24% [17-36], P = 0.003). The visceral adipose tissue area was significantly greater in older children ≥9.8 years with hepatic steatosis (7.7% [5.1-10] vs 6.6% (4.9-8.5), P = 0.04). CONCLUSION Hepatic steatosis was highly prevalent in previously healthy children in Ontario, including children of pre-school age. We found an association between hepatic steatosis and abdominal subcutaneous adipose tissue, and in older children with visceral adipose tissue.
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Affiliation(s)
- J Dhaliwal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - G B Chavhan
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - E Lurz
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - A Shalabi
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - N Yuen
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - B Williams
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - I Martincevic
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - A Amirabadi
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - P W Wales
- The Hospital for Sick Children, Toronto, ON, Canada.,Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - W Lee
- The Hospital for Sick Children, Toronto, ON, Canada.,Department of Radiology, University of Toronto, Toronto, ON, Canada
| | - S C Ling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - M Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Lavallee CM, Lim DW, Wizzard PR, Mazurak VC, Mi S, Curtis JM, Willing BP, Yap JY, Wales PW, Turner JM. Impact of Clinical Use of Parenteral Lipid Emulsions on Bile Acid Metabolism and Composition in Neonatal Piglets. JPEN J Parenter Enteral Nutr 2018; 43:668-676. [PMID: 30137679 DOI: 10.1002/jpen.1437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 01/29/2018] [Accepted: 07/18/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neonates with intestinal failure dependent on parenteral nutrition (PN) are at risk of intestinal failure-associated liver disease (IFALD). PN lipid composition relates to the risk of IFALD, but the mechanisms are poorly understood. We investigated the effects of soybean oil (SO), a mixed-lipid (ML) emulsion containing fish oil (FO), and a pure FO. We hypothesized FO-containing PN lipids would result in increased gene expression of canalicular bile acid transporters and a larger, more hydrophilic bile acid pool, predictive of increased bile flow. METHODS Neonatal piglets were allocated to receive 1 of SO, ML, or FO throughout 14 days of PN feeding. Relative expression of genes involved in bile acid synthesis and transport were determined through quantitative polymerase chain reaction. Bile secreted from the liver was collected and measured. Bile acid composition was determined using tandem mass spectrometry. Regression analysis was used to determine predictors of bile flow. RESULTS PN reduced bile acid secretion (P < .001). FO-containing PN lipids were associated with greater expression of bile acid and organic solute transport genes (P < .05) and greater secretion of hydrophobic bile acids (P < .001). Farnesoid X receptor (P = .01), bile salt export pump (P < .01), multidrug resistant protein 2 (P < .01), and unconjugated hyocholic acid (P < .001) independently predicted bile flow. CONCLUSIONS PN lipid modulation altered bile acid metabolism and composition. These alterations may explain the hepatoprotective effects of FO-containing PN lipids and support their use in the prevention and treatment of IFALD.
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Affiliation(s)
- Celeste M Lavallee
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - David W Lim
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Vera C Mazurak
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Si Mi
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada.,Institute of Food Science and Technology, Chinese Academy of Agricultural Science, Beijing, China
| | - Jonathan M Curtis
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin P Willing
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Y Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Abstract
Pediatric intestinal failure is a complex and devastating condition defined as the inability of the intestine to absorb an adequate amount of fluid and nutrients to sustain life. The primary goal of intestinal failure treatment is to achieve enteral autonomy with a customized treatment plan. Although recent improvements in intestinal failure patient care have led to significant improvements in the morbidity and mortality rate, children with intestinal failure are at risk for multiple complications such as intestinal failure associated liver disease, recurrent septic episodes, central line complications, metabolic bone disease, impaired kidney function, and failure to thrive. In this article, we review the current literature on the etiology and factors affecting prognosis of pediatric IF.
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Affiliation(s)
- Annika Mutanen
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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Lavallee CM, Wizzard PR, Lansing M, Vine DF, Nation PN, Yap JY, Willing BP, Wales PW, Turner JM. Surgical Anatomy Does Not Affect the Progression of Intestinal Failure-Associated Liver Disease in Neonatal Piglets. JPEN J Parenter Enteral Nutr 2017; 42:14-23. [PMID: 28719764 DOI: 10.1177/0148607117718478] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intestinal failure-associated liver disease (IFALD) causes significant morbidity in neonates with short bowel syndrome (SBS) dependent on parenteral nutrition (PN). Resected ileum, with loss of the ileocecal valve (ICV), is the most common anatomy in SBS, yet its impact on IFALD has not been adequately studied. METHODS Neonatal piglets were randomized to 75% intestinal resection with jejunocolic anastomosis (JC, n = 12), 75% resection with jejunoileal anastomosis and intact ICV (JI, n = 13), PN-fed sham (sham, n = 14), or sow-fed control (SF, n = 8). Surgical and sham piglets received 100% PN for 14 days before bile flow was measured and blood chemistry, liver pathology, jejunal permeability, and bacterial translocation were assessed. RESULTS Bile flow was lower for PN-fed compared with SF (P = .002) but not different between the PN-fed groups. Total bilirubin (P = .03) and liver pathology (P < .001) were greater in PN-fed than SF groups but not different between PN-fed groups. Serum bile acids were increased in sham (P = .01) but not different between SBS groups. PN-fed piglets with sepsis had lower bile flow (P = .001) and increased bilirubin (P = .04). Neither jejunal permeability nor bacterial translocation were different between JC, JI, or sham groups. CONCLUSION Contrary to our hypothesis, the remnant anatomy does not appear to worsen the progression of IFALD. However, the role of sepsis in IFALD should be further explored, in addition to other mechanisms, including PN factors, host immune responses, and intestinal bacterial dysbiosis.
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Affiliation(s)
- Celeste M Lavallee
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Marihan Lansing
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Donna F Vine
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Y Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin P Willing
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Belza C, Fitzgerald K, Amaral J, Steinberg K, Avitzur Y, Wales PW. Use of balloon dilatation for management of postoperative intestinal strictures in children with short bowel syndrome. J Pediatr Surg 2017; 52:760-763. [PMID: 28190552 DOI: 10.1016/j.jpedsurg.2017.01.040] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/23/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Children with short bowel syndrome (SBS) often require numerous operations to optimize intestinal function. Postoperative intestinal strictures are a complication that inhibits enteral feeding advancement and prolongs parenteral nutrition dependency, often requiring reoperation. Our objective was to review our experience with fluoroscopic balloon dilatation to treat intestinal strictures. METHODS A retrospective cohort study of intestinal failure patients with SBS was completed. Patients who had radiologically diagnosed intestinal strictures and treated with fluoroscopic guided balloon dilatation were included [n=6]. Data related to demographics, anatomy, surgical procedures, and dilatation procedures were collected. Descriptive summary statistics were employed. RESULTS 98 intestinal failure patients were recruited between 2011 and 2015. Five of 98 patients (5.1%) [2 males; median age 4.4months] underwent fluoroscopy guided balloon dilatation of 6 strictures. Balloon dilatation was successful in 4/6 (67%). The median number of dilatations was 2 per patient (range=1-3). Median time to feed initiation postdilatation was 3days. One patient developed an anastomotic leak after dilatation that required antibiotics, but no reoperation. CONCLUSION Four of six (67%) postoperative bowel strictures in 5 patients with SBS were successfully treated with fluoroscopically guided balloon dilatation. Balloon dilatation is less invasive than reoperation, preserves bowel length and reduces time to reinitiation of enteral feeding. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Kevin Fitzgerald
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
| | - Karen Steinberg
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.
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Belza C, Thompson R, Somers GR, de Silva N, Fitzgerald K, Steinberg K, Courtney-Martin G, Wales PW, Avitzur Y. Persistence of hepatic fibrosis in pediatric intestinal failure patients treated with intravenous fish oil lipid emulsion. J Pediatr Surg 2017; 52:795-801. [PMID: 28189450 DOI: 10.1016/j.jpedsurg.2017.01.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pediatric intestinal failure (PIF) is a life-altering chronic condition with significant morbidity and mortality. Omegaven® therapy has been used to treat children with advanced intestinal failure associated liver disease. Our objective was to determine the evolution of hepatic fibrosis in PIF patients who received Omegaven® and describe their clinical outcome. METHODS A retrospective review in PIF patients who received Omegaven® was performed. Patients were included if they had liver biopsies completed before Omegaven® therapy and after resolution of hyperbilirubinemia. Biopsy results were evaluated to determine the degree of fibrosis, inflammation, and cholestasis. Clinical and biochemical data was collected. RESULTS Six patients were identified. Assessment of fibrosis at last follow-up demonstrated improvement in 2 patients and progression or stable fibrosis in 4/6. All patients demonstrated reduction in cholestasis and inflammation. One patient received a liver/intestine transplant and a second is listed, both of them with progressive fibrosis. One patient achieved full enteral nutrition, while the rest remain partially parenteral nutrition dependent. CONCLUSION Use of Omegaven® is associated with reduced cholestasis and inflammation, but with persistence or worsening of fibrosis in some patients. A subset of patients with progressive fibrosis may develop portal hypertension and progressive liver disease.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Rory Thompson
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Gino R Somers
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Nicole de Silva
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Kevin Fitzgerald
- The Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Karen Steinberg
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; The Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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Lim DW, Levesque CL, Vine DF, Muto M, Koepke JR, Nation PN, Wizzard PR, Li J, Bigam DL, Brubaker PL, Turner JM, Wales PW. Synergy of glucagon-like peptide-2 and epidermal growth factor coadministration on intestinal adaptation in neonatal piglets with short bowel syndrome. Am J Physiol Gastrointest Liver Physiol 2017; 312:G390-G404. [PMID: 28104586 DOI: 10.1152/ajpgi.00281.2016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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] [Received: 08/08/2016] [Revised: 01/06/2017] [Accepted: 01/16/2017] [Indexed: 01/31/2023]
Abstract
Glucagon-like peptide-2 (GLP-2) and epidermal growth factor (EGF) treatment enhance intestinal adaptation. To determine whether these growth factors exert synergistic effects on intestinal growth and function, GLP-2 and EGF-containing media (EGF-cm) were administered, alone and in combination, in neonatal piglet models of short bowel syndrome (SBS). Neonatal Landrace-Large White piglets were block randomized to 75% midintestinal [jejunoileal (JI) group] or distal intestinal [jejunocolic (JC) group] resection or sham control, with 7-day infusion of saline (control), intravenous human GLP-2 (11 nmol·kg-1·day-1) alone, enteral EGF-cm (80 μg·kg-1·day-1) alone, or GLP-2 and EGF-cm in combination. Adaptation was assessed by intestinal length, histopathology, Üssing chamber analysis, and real-time quantitative PCR of intestinal growth factors. Combined EGF-cm and GLP-2 treatment increased intestinal length in all three surgical models (P < 0.01). EGF-cm alone selectively increased bowel weight per length and jejunal villus height in the JI group only. The JC group demonstrated increased intestinal weight and villus height (P < 0.01) when given either GLP-2 alone or in combination with EGF-cm, with no effect of EGF-cm alone. Jejunal permeability of mannitol and polyethylene glycol decreased with combination therapy in both SBS groups (P < 0.05). No difference was observed in fat absorption or body weight gain. IGF-1 mRNA was differentially expressed in JI vs. JC piglets with treatment. Combined treatment with GLP-2 and EGF-cm induced intestinal lengthening and decreased permeability, in addition to the trophic effects of GLP-2 alone. Our findings demonstrate the benefits of novel combination GLP-2 and EGF treatment for neonatal SBS, especially in the JC model representing most human infants with SBS.NEW & NOTEWORTHY Glucagon-like peptide-2 (GLP-2) and epidermal growth factor (EGF) are intestinotrophic, with demonstrated benefit in both animal models and human studies of short bowel syndrome (SBS). The current research shows that over and above known trophic effects, the combination of GLP-2 and EGF synergistically lengthens the bowel in neonatal piglet models of SBS. Most notable benefit occurred with resection of the terminal ileum, the common clinical anatomy seen in neonatal SBS and associated with least de novo lengthening postsurgery.
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Affiliation(s)
- David W Lim
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Crystal L Levesque
- Department of Animal Science, South Dakota State University, Brookings, South Dakota
| | - Donna F Vine
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Mitsuru Muto
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jacob R Koepke
- Department of Animal Science, South Dakota State University, Brookings, South Dakota
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Julang Li
- Department of Animal and Poultry Science, University of Guelph, Guelph, Ontario, Canada
| | - David L Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Patricia L Brubaker
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine M Turner
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada; .,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Surgery and Group for the Improvement of Intestinal Function and Treatment, Hospital for Sick Children, Toronto, Ontario, Canada; and
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Turner JM, Sauvé Y, Suh M, Wales PW, Wizzard P, Goruk S, Field CJ. A Third-Generation Lipid Emulsion that Contains n-3 Long-Chain PUFAs Preserves Retinal Function in Parenterally Fed Neonatal Piglets. J Nutr 2016; 146:2260-2266. [PMID: 27733528 DOI: 10.3945/jn.116.237669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/12/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Preterm neonates and those with intestinal failure require prolonged parenteral nutrition (PN) during a critical time of early central nervous system maturation. Conventional lipid emulsions fed to preterm neonates lack n-3 (ω-3) long-chain polyunsaturated fatty acids (LC-PUFAs; >20 carbon chain in length). Recently, fish oil lipid emulsions have been developed that provide both n-6 (ω-6) and n-3 LC-PUFAs, precursors of very long-chain PUFAs (VLC-PUFAs; >24 carbon chain in length). OBJECTIVE Our objective was to determine the effect of fish oil lipid on retinal function in neonatal piglets fed total PN with the use of the lipid emulsions available in clinical practice. We hypothesized that fish oil-containing parenteral lipid would preserve retinal function more than conventional parenteral lipid. METHODS Male neonatal piglets (2-5 d of age) were fed isonitrogenous (16 g · kg-1 · d-1), isocaloric (1.1 MJ · kg-1 · d-1) PN that varied only in the lipid emulsion: Intralipid or SMOFlipid at 10 g · kg-1 · d-1 (n = 8/group). Retinal function was assessed after 14 d of treatment by recording electroretinograms under various light intensity conditions. Retinas were then harvested for histology and to determine fatty acid composition. RESULTS Electroretinogram intensity response curves showed greater photoreceptor a-wave amplitude in piglets fed SMOFlipid than in those fed Intralipid (percentage), for postsynaptic depolarizing bipolar cell b-waves (percentage) and for flicker electroretinogram amplitudes (percentage) (P < 0.05). Compared with those fed Intralipid, SMOFlipid-fed piglets had greater retinal total n-3 LC-PUFAs (15.7% compared with 18.4%; P = 0.04) and n-3 VLC-PUFAs (0.9% compared with 1.5%; P = 0.02), whereas Intralipid-fed piglets had greater total n-6 LC-PUFAs (13.1% compared with 10.5%; P < 0.01) and n-6 VLC-PUFAs (0.7% compared with 0.5%; P = 0.01). Histologically, retinas were indistinguishable between groups. CONCLUSIONS In a neonatal piglet model of PN feeding, the inclusion of fish oil-based n-3 LC-PUFAs in the lipid emulsion leads to their accretion and endogenous elongation to VLC-PUFAs in the retina, which is associated with better retinal function.
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Affiliation(s)
| | - Yves Sauvé
- Department of Ophthalmology and Visual Sciences, and.,Department of Physiology, University of Alberta, Edmonton, Canada
| | - Miyoung Suh
- Department of Human Nutritional Sciences, University of Manitoba, Winnipeg, Canada
| | - Paul W Wales
- Department of Pediatrics.,Department of Pediatric Surgery, Hospital for Sick Children, Toronto, Canada; and.,Research Institute, University of Toronto, Toronto, Canada
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