Risk factors for surgery in stricturing small bowel Crohn's disease: A retrospective cohort study from the GETAID pédiatrique

OBJECTIVES

Previous studies have shown rates of surgical resection of up to 41% in stricturing pediatric Crohn's disease. In this retrospective multicenter study, our aims were to identify clinical risk factors and magnetic resonance enterography (MRE) features of small bowel strictures associated with surgery.

METHODS

Pediatric patients with symptomatic stricturing small bowel CD (defined as obstructive symptoms or proximal dilatation on MRE) confirmed by MRE between 2010 and 2020 were recruited from 12 French tertiary hospitals. Patient characteristics were compared by surgical outcome multivariable Cox regression.

RESULTS

Fifty-six patients (61% boys) aged 12.2 ± 2.7 years at diagnosis of CD were included. Median duration of CD before diagnosis of stricture was 11.7 months (interquartile range [IQR]: 25-75: 1.2-29.9). Nineteen (34%) patients had stricturing phenotype (B2) at baseline. Treatments received  before stricture diagnosis included MODULEN-IBD (n = 31), corticosteroids (n = 35), antibiotics (n = 10), anti-TNF (n = 27), immunosuppressants (n = 28). Thirty-six patients (64%) required surgery, within 4.8 months (IQR: 25-75: 1.8-17.3) after stricture diagnosis. Parameters associated with surgical resection were antibiotic exposure before stricture diagnosis (adjusted odds ratio [aOR]: 15.62 [3.35-72.73], p = 0.0005), Crohn's disease obstructive symptoms score (CDOS) > 4 (aOR: 3.04 [1.15-8.03], p = 0.02) and dilation proximal to stricture >28 mm (aOR: 3.62 [1.17-11.20], p = 0.03).

CONCLUSION

In this study, antibiotic treatment before stricture diagnosis, intensity of obstructive symptoms, and diameter of dilation proximal to small bowel stricture on MRE were associated with risk for surgical resection.

Pre-hospital triage of children at risk of oesophageal button battery impaction: the button battery impaction score

INTRODUCTION

Button battery ingestion in children can be fatal if oesophageal perforation occurs. Such children require chest radiography in the emergency department to determine the button battery position and number. Current guidelines recommend that a button battery impacted in the oesophagus should be removed within two hours. We developed a clinical tool (the button battery impaction score) to estimate the risk of oesophageal impaction and help determine the most appropriate healthcare facility for initial assessment, either a local medical centre or a medical centre with the infrastructure for endoscopic retrieval.

METHODS

A multi-centre retrospective study was conducted over seven years in eight French poison centres. We included patients aged less than 12 years with radiography showing the button battery position and a symptom description before radiography. Button battery impaction scores were calculated using backward stepwise selection.

RESULTS AND DISCUSSION

A total of 1,430 patients were included, of whom 86, 461, and 375 had a button battery in their oesophagus, stomach, and post-pyloric position, respectively. No button batteries were identified by radiography in 508 patients. Sixteen of thirty-five factors independently predicted oesophageal impaction before chest radiography (P < 0.05). After the backward stepwise selection, the following seven factors contributed to the button battery impaction score: cough, drooling, dysphagia/food refusal, fever, pain (unspecified location), vomiting, and button battery ≥ 15 mm. The button battery impaction score showed an area under the curve value of 0.87, a negative predictive value of 0.98, and a sensitivity of 0.86. No cases of death, stricture, or haemorrhage were observed in patients with negative scores, including those with oesophageal impaction.

CONCLUSIONS

A button battery impaction score used readily available data to predict the risk of oesophageal impaction after button battery ingestion and before chest radiography. When further validated, this rapid tool may be widely applicable in determining an appropriate facility for patient transfer to either a local medical centre or a medical centre with the infrastructure for endoscopic retrieval.

Severe post-pyloric injury after button battery ingestion: Systematic literature review and case report

BACKGROUND

The health and safety hazards related to button batteries (BB) have been extensively studied, highlighting that the presence of a button battery in the esophagus is a life-threatening emergency. However, complications related to bowel BB are poorly evaluated and not well known. The objective of this review of the literature was to describe severe cases of BB that have passed the pylorus.

CASE REPORT

This case, from the PilBouTox cohort, is the first report of small-bowel occlusion following ingestion of an LR44 BB (diameter: 11.4 mm) by a 7-month-old infant with a history of intestinal resections. In this case, the BB was ingested without a witness. The initial presentation mimicked acute gastroenteritis evolving into hypovolemic shock. An X-ray revealed a foreign body stuck in the small bowel causing an intestinal occlusion and local necrosis without perforation. The patient's history of intestinal stenosis and intestinal surgery were the contributing factor of impaction.

SYSTEMATIC LITERATURE REVIEW

The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The research was conducted on September 12, 2022 through five database and the U.S. Poison Control Center website. An additional 12 severe cases of intestinal or colonic injury after ingestion of a single BB were identified. Of these, 11 were related to small BBs (< 15 mm) that impacted Meckel's diverticulum and one was related to postoperative stenosis.

CONCLUSION

In view of the findings, the indications for digestive endoscopy for extraction of a BB in the stomach should include a history of intestinal stenosis or intestinal surgery so as to avoid delayed intestinal perforation or occlusion and prolonged hospitalization.

Ustekinumab Use in Pediatric Inflammatory Bowel Disease: A French Multicenter Study From the Pediatric GETAID

OBJECTIVES

Ustekinumab is known to be efficient in adult patients suffering from moderate to severe Crohn disease (CD) and ulcerative colitis (UC) resistant to anti-tumor necrosis factor-alpha (TNF-α). Here, we described the clinical course of treatment with ustekinumab in French pediatric inflammatory bowel disease (IBD) patients treated with ustekinumab.

METHODS

This study includes all pediatric patients treated by ustekinumab injection for IBD (CD and UC), between January 2016 and December 2019.

RESULTS

Fifty-three patients were enrolled, 15 males and 38 females. Forty-eight patients (90%) had a diagnosis of CD and 5 (9.4%) had UC. Sixty-five percent of CD patients presented an ileocolitis. Perineal disease was observed in 20 out of 48 CD patients (41.7%), among them 9 were treated surgically. All patients included were resistant to anti-TNF-α treatment. Fifty-one percent had presented side effects linked to anti-TNF-α, including psoriasis and anaphylactic reaction. The average Pediatric Crohn Disease Activity Index (PCDAI) at induction was 28.7 (5-85), 18.7 (0-75) at 3 months of treatment and 10 (0-35) at the last follow-up. The average Pediatric Ulcerative Colitis Activity Index at induction was 47 (25-65), 25 (15-40) at 3 months of treatment and 18.3 (0-35) at the last follow-up. No severe side effects were observed.

CONCLUSION

In this retrospective, multicentral study, ustekinumab proved to be efficient in pediatric patients resistant to anti-TNF-α. PCDAI has been significantly improved in patients with severe disease, treated with ustekinumab.

Effects of Lumacaftor-Ivacaftor on Airway Microbiota-Mycobiota and Inflammation in Patients with Cystic Fibrosis Appear To Be Linked to Pseudomonas aeruginosa Chronic Colonization

The management of cystic fibrosis has been transformed recently by the advent of CFTR modulators, including lumacaftor-ivacaftor. However, the effects of such therapies on the airway ecosystem, particularly on the microbiota-mycobiota and local inflammation, which are involved in the evolution of pulmonary damage, are unclear.

Proton pump inhibitors are still overprescribed for hospitalized children

OBJECTIVE

The use of proton pump inhibitors has increased exponentially over the past 20 years. Several side effects have been reported and concerns exist about the consequences of long-term proton pump inhibitors on health, leading to limitation of their use. The present study analyzed prescriptions of proton pump inhibitors at inpatient units and assessed their compliance with current recommendations.

METHODS

This single-center, observational, retrospective study reviewed medical file of patients hospitalized at the pediatric medical departments of the Bordeaux University Hospital between April 1 and September 30, 2019. Patients younger than 18 years, hospitalized in the pediatric hospital units and treated with proton pump inhibitors were included. Prescriptions of proton pump inhibitors were compared with French and international guidelines.

RESULTS

Proton pump inhibitors were prescribed for 251 of 2237 children (11%), mainly for gastroesophageal reflux disease (47%) and prevention of peptic ulcer disease (32.7%). Proton pump inhibitor prescription complied to recommendations in 34.5% of cases, less often in children aged younger than 1 year (13.5%) than in older children. Compliance to recommendations was lower when proton pump inhibitors were indicated for the prevention of peptic disease (5%) than for gastroesophageal reflux disease (48%).

CONCLUSIONS

Proton pump inhibitors are frequently prescribed for hospitalized children, and indications comply with recommendations in only 35% of the cases. Efforts in spreading awareness of the recommendations on the use of proton pump inhibitors in children are mandatory among hospital pediatricians.

Cystic fibrosis and noninvasive liver fibrosis assessment methods in children

BACKGROUND

Noninvasive assessments of liver fibrosis are currently used to evaluate cystic fibrosis (CF)-related liver disease. However, there is scarce data regarding their repeatability and reproducibility, especially in children with CF. The present study aimed to evaluate the repeatability and reproducibility of transient elastography (TE) (FibroScan®) and point shear-wave elastography using virtual touch quantification (pSWE VTQ) in children with CF.

METHODS

TE and pSWE VTQ were performed in 56 children with CF by two different operators. Analysis of repeatability and reproducibility was available in 33 patients for TE and 46 patients for pSWE VTQ. Intra- and interobserver agreement were assessed using the intraclass correlation coefficient (ICC) and their 95% confidence interval (CI), and Bland and Altman graphs.

RESULTS

For TE, ICC was 0.91 (0.83-0.95) for intraobserver agreement and 0.92 (95% CI: 0.86-0.96) for interobserver agreement. For pSWE VTQ, ICC was 0.83 (0.72-0.90) for intraobserver agreement and 0.67 (0.48-0.80) for interobserver agreement.

CONCLUSIONS

Both technics can be proposed in the follow-up of patients, according to their availability in CF centers.

IMPACT

This study shows that TE and pSWE VTQ are reliable methods to evaluate liver fibrosis in children with CF. This study shows for the first time that TE and pSWE VTQ are both repeatable and reproducible in children with CF. These data indicate that both TE and pSWE VTQ can be proposed for the follow-up of patients with CF, according to their availability in each CF center.

New Insights in Microbial Species Predicting Lung Function Decline in CF: Lessons from the MucoFong Project

Several predictive models have been proposed to understand the microbial risk factors associated with cystic fibrosis (CF) progression. Very few have integrated fungal airways colonisation, which is increasingly recognized as a key player regarding CF progression. To assess the association between the percent predicted forced expiratory volume in 1 s (ppFEV1) change and the fungi or bacteria identified in the sputum, 299 CF patients from the “MucoFong” project were included and followed-up with over two years. The relationship between the microorganisms identified in the sputum and ppFEV1 course of patients was longitudinally analysed. An adjusted linear mixed model analysis was performed to evaluate the effect of a transient or chronic bacterial and/or fungal colonisation at inclusion on the ppFEV1 change over a two-year period. Pseudomonas aeruginosa, Achromobacter xylosoxidans, Stenotrophomonas maltophilia, and Candida albicans were associated with a significant ppFEV1 decrease. No significant association was found with other fungal colonisations. In addition, the ppFEV1 outcome in our model was 11.26% lower in patients presenting with a transient colonisation with non-pneumoniae Streptococcus species compared to other patients. These results confirm recently published data and provide new insights into bacterial and fungal colonisation as key factors for the assessment of lung function decline in CF patients.

Satisfaction of mothers regarding human milk donation

In France, human milk banks are in charge of the collection, analysis, processing, and distribution of human milk to neonatology centers for preterm infants. Knowledge of what motivates mothers to donate their milk could lead to better communication regarding human milk donation. A satisfaction survey was conducted among mothers who were donating their milk to a human milk bank. In total, 214 mothers answered a questionnaire in the presence of the collector during a home visit. The median age of the mothers was 31 years (18-46), mainly high school (19%) or university (65%) graduates, and the median duration of donation was 3 months (0.5-22). At the time of the study, the median age of infants was 3 months (0.5-25), and 88% of infants were exclusively breastfed. About three quarters of mothers were motivated by willingness to help others, a quarter of them being especially sensitive to premature neonatal care; 30% of mothers were motivated by having a high supply of milk. Around 25% of mothers were given information on human milk donation during pregnancy, and two thirds after delivery, mainly by the maternity ward midwives (53.4%) or by collectors during their visit (14.1%). Most mothers (72%) found the human milk donation process easy and most of them (92.5%) were willing to donate their milk again after their next pregnancy. This survey shows that more than 90% of mothers are satisfied with donation to human milk banks. However, efforts should be made to provide information on breastfeeding and human milk donation to the general population and health professionals.

Respiratory mycobiome and suggestion of inter-kingdom network during acute pulmonary exacerbation in cystic fibrosis

Lung infections play a critical role in cystic fibrosis (CF) pathogenesis. CF respiratory tract is now considered to be a polymicrobial niche and advances in high-throughput sequencing allowed to analyze its microbiota and mycobiota. However, no NGS studies until now have characterized both communities during CF pulmonary exacerbation (CFPE). Thirty-three sputa isolated from patients with and without CFPE were used for metagenomic high-throughput sequencing targeting 16S and ITS2 regions of bacterial and fungal rRNA. We built inter-kingdom network and adapted Phy-Lasso method to highlight correlations in compositional data. The decline in respiratory function was associated with a decrease in bacterial diversity. The inter-kingdom network revealed three main clusters organized around Aspergillus, Candida, and Scedosporium genera. Using Phy-Lasso method, we identified Aspergillus and Malassezia as relevantly associated with CFPE, and Scedosporium plus Pseudomonas with a decline in lung function. We corroborated in vitro the cross-domain interactions between Aspergillus and Streptococcus predicted by the correlation network. For the first time, we included documented mycobiome data into a version of the ecological Climax/Attack model that opens new lines of thoughts about the physiopathology of CF lung disease and future perspectives to improve its therapeutic management.

A European ECMM-ESCMID survey on goals and practices for mycobiota characterisation using next-generation sequencing

Although substantial efforts have been made to investigate about the composition of the microbiota, fungi that constitute the mycobiota play a pivotal role in maintaining microbial communities and physiological processes in the body. Here, we conducted an international survey focusing on laboratory's current procedures regarding their goals and practices of mycobiota characterisation using NGS. A questionnaire was proposed to laboratories affiliated to working groups from ECMM (NGS study group) and ESCMID (ESGHAMI and EFISG study groups). Twenty-six questionnaires from 18 countries were received. The use of NGS to characterise the mycobiota was not in routine for most of the laboratories (N = 23, 82%), and the main reason of using NGS was primary to understand the pathophysiology of a dysbiosis (N = 20), to contribute to a diagnosis (N = 16) or to implement a therapeutic strategy (N = 12). Other reported reasons were to evaluate the exposome (environmental studies) (N = 10) or to investigate epidemics (N = 8). Sputum is the main sample studied, and cystic fibrosis represents a major disease studied via the analysis of pulmonary microbiota. No consensus has emerged for the choice of the targets with 18S, ITS1 and ITS2 used alternatively among the laboratories. Other answers are detailed in the manuscript. We report a photography of mycobiota analysis that may become a major tool in the near future. We can draw some conclusions on the diversity of approaches within the answers of the 27 laboratories and underline the need for standardisation.

Altered pulmonary gas transfer capacity and capillary blood volume in pediatric Crohn's disease

OBJECTIVES

To describe diffusing capacity for carbon monoxide (DLCO) and its components, that is, membrane diffusing capacity (DmCO) and pulmonary capillary blood volume (Vc) in children with Crohn's disease (CD), and to investigate the correlation between these parameters and disease activity.

WORKING HYPOTHESIS

The most common lung function abnormalities are a reduced pulmonary DLCO and small airways disorders which are in many instances, clinically silent. No valid explanations have been proposed regarding the modifications in gas transfer capacity in active CD.

METHODS

DLCO, DmCO, and Vc were measured in 25 CD children by the simultaneous single breath lung diffusing capacity method using nitric oxide (NO) and carbon monoxide (CO) transfer. These parameters were analyzed in relation to the CD disease activity index.

RESULTS

DLCO (90.7 ± 4.5% vs 128.5 ± 4.7%; P < 0.001), Dm (92.4 ± 5.9% vs 125.6 ± 6.3%; P < 0.001), and Vc (72.6 ± 3.7% vs 104.4 ± 4.0%; P < 0.001) were significantly decreased in the active CD group in comparison with the inactive CD group. DLCO (r = -0.60; P < 0.01), DmCO (r = -0.45; P < 0.01), and Vc (r = -0.60; P < 0.01) were inversely correlated to the PCDAI. In 8 patients who participated to the study at initial diagnosis then during remission, DmCO and Vc increased significantly between the active and the inactive period of the disease.

CONCLUSION

Pulmonary diffusing capacity is impaired in children with active CD, mainly because of a decrease of the pulmonary capillary volume.