Comparing Gastrointestinal Endoscopy Findings in Children with Autism, Developmental Delay, or Typical Development

OBJECTIVE

To compare endoscopic and histologic upper endoscopy (esophagogastroduodenoscopy [EGD]) findings in children with autism spectrum disorders (ASD) to age- and gender-matched controls with developmental delay (DD) or with typical development (TD).

METHODS

Retrospective, cross-sectional study of children undergoing EGD, identifying those diagnosed with ASD, and matching on age and gender to children with DD or TD in ratio of 1:1:2. Rates of EGD findings were compared between the 3 groups using χ² or Fisher exact test. Multivariable linear regression was performed to identify predictors of abnormal histology.

RESULTS

A total of 2104 patients were included (526 ASD; 526 DD; 1052 TD). Children with ASD had higher rates of abnormal esophageal histology (ASD 38.4%; DD 33.4%; TD 30.4%, P = .008), particularly esophagitis. In multivariable modeling, ASD diagnosis was an independent predictor of abnormal esophageal histology (OR [95% CI] 1.38 [1.09, 1.76]) compared with TD. Stomach findings did not differ among the groups. In the duodenum, histologic abnormalities were observed with lower frequency in ASD (ASD 17.0%; DD 20.1%; TD 24.2%, P = .005). In multivariable analysis, ASD diagnosis was not a significant predictor (OR 0.78 [0.56, 1.09]) of abnormal duodenal histology.

CONCLUSIONS

Children with ASD have higher rates of histologic esophagitis compared with age- and gender-matched DD and TD controls. ASD was a significant independent predictor of abnormal esophageal, but not, duodenal, histology. These results underscore the importance of EGD in children with ASD.

The Spectrum of Duodenal Histologic Findings in Patients With Trisomy 21: A Multicenter Study

OBJECTIVES

Patients with Trisomy 21 (T21) commonly have gastrointestinal symptoms and diseases that prompt evaluation with esophagogastroduodenoscopy (EGD). Our objective is to characterize duodenal histological abnormalities in these patients when undergoing EGD. A secondary aim is to explore associations of histologic findings with different therapies.

METHODS

Patients 30 years old or younger with T21 who underwent EGD from 2000 to 2020 at 6 hospitals were included in this retrospective cohort study. Duodenal biopsies were categorized based on reported histopathology findings as normal or abnormal. Abnormal pathology reports were reviewed and categorized into villous atrophy (VA) and duodenitis without VA. The VA group was further categorized based on the presence or absence of celiac disease (CD).

RESULTS

We identified 836 patients with T21 who underwent EGD, 419 (50.1%) of whom had duodenal histologic abnormalities. At the time of the first (index) abnormal duodenal biopsy, 290 of 419 had VA and of those, 172 of 290 met CD diagnostic criteria, while 118 of 290 did not meet CD criteria (nonspecific VA). Among the patients with an abnormal biopsy, acid suppression at the time of the index biopsy was less common in patients with VA-CD compared to patients without VA or patients with nonspecific VA (12.2% vs 45.7% vs 44.9%).

CONCLUSIONS

Half of the T21 patients in this cohort had abnormal duodenal biopsies including a subgroup with nonspecific VA. In this cohort, acid suppression use was more prevalent in patients with abnormalities other than CD.

A266 IS A MULTIVITAMIN SUFFICIENT TO MEET NUTRITIOAL REQUIREMENTS IN CANADIAN ADULTS FOLLOWING A GLUTEN-FREE DIET?

Background

Concerns exist regarding nutritional deficiencies and risk of metabolic syndrome in patients with celiac disease (CD) on a gluten-free diet (GFD).

Aims

This study assessed if patients with CD trying to follow a GFD meet Recommended Dietary Allowance (RDA) targets for macro- and micronutrients and the effect of supplement use in reaching RDA targets.

Methods

Adults (>16 years) with biopsy confirmed CD (Marsh 3) were recruited within 6 weeks of starting a GFD. Participants prospectively completed a 3-day food record, including dietary supplement use, at 6, 12, and 24 months after study entry. Macro- and micronutrient consumption was determined using the Nutrition Coordinating Center Food & Nutrient Database (NCCDB), USDA National Nutrient Database for Standard Reference (USDA SR28), and CRON-O-Meter Community Database (CCDB). RDA targets were analyzed using a paired t-test and logistic regression, adjusted for age and sex.

Results

Forty-nine participants (71% female; mean age 49 years) completed interpretable food records at all time points. Most (59%) used supplements and supplement use was highest at 6 months (51%). Considering macronutrients, ≥88% met the RDA for carbohydrates and protein at each time point; however, only 44% met the target for fibre. Participants who took a supplement plus a multivitamin were significantly more likely than those who took only a multivitamin to meet the RDA for vitamins B12 and D. Fewer than 20% of those who took neither a multivitamin nor an iron supplement met the RDA, whereas ≥70% of those taking a multivitamin had adequate iron intake. Participants were significantly more likely to meet RDA targets for calcium with a supplement than with a multivitamin only. Even with supplementation, ≤55% met the RDA for folate.

Conclusions

There is a need for ongoing monitoring and dietician support for GFD treatment in CD. Adults with celiac disease met RDA targets for protein and carbohydrate, but not fibre. While specific calcium supplementation was required to meet RDA targets for calcium, a multivitamin was generally sufficient to meet RDA targets for iron, Vitamin B12 and D. Folate was below target at all time points even with supplementation.

Funding Agencies

CAG, CIHRNIH

A107 PATIENT PERSPECTIVES ON THE LONG-TERM MANAGEMENT OF CELIAC DISEASE

Background

Celiac disease (CD) is a common chronic gastrointestinal illness with a range of manifestations. The only available treatment is strict gluten avoidance, therefore patients are effectively self-managed. Despite the critical role patients play in their treatment, patient perspectives on long-term CD care have not been formally assessed and are therefore not represented in current clinical guidelines.

Aims

To determine the opinions of CD patients on the need for long-term CD follow-up, the utility of various aspects of CD follow-up, and the areas in which further information is desired.

Methods

The Manitoba Celiac Disease Cohort includes newly diagnosed adults with elevated TTG and/or EMA antibodies and Marsh III histology. At the 24-month follow-up visit, participants were asked to rate the utility of various aspects of CD care from 1–5 (low-high) and their desire for further information on CD-related issues from 1–6 (low-high).

Results

A total of 213 patients were recruited and 137 participants completed the online survey (median age 41 [interquartile range 29–57] years; 68% female). Adherence to a gluten free diet was variable, with 29% of patients having TTG antibodies above the upper limit of normal.

Two-thirds of participants felt they should be seen regularly for their celiac disease, while 79.8% of those who wished to be followed felt they should be seen every 6–12 months. Blood tests were the most highly rated component of CD care (scored ≥4 by 78% of respondents). Celiac symptom review, information on research in celiac disease, and the opportunity to ask questions about vitamins and supplements were also positively regarded. Diet review was not generally considered helpful. 79% of patients desired further information on research in CD, while approximately 60% desired information on the long-term complications of CD and the risk of nutritional deficiencies.

Conclusions

The majority of CD patients find regular specialist follow-up helpful, particularly for biochemical assessment of disease activity and its complications. Further information on CD research and the long-term complications of CD should be addressed in follow-up visits. These aspects of follow-up care should be reflected in future guidelines.

Funding Agencies

None

Sequence of acquisition of self-management skills to follow a gluten-free diet by adults with celiac disease

BACKGROUND

Celiac disease (CD) treatment is lifelong adherence to a gluten-free diet (GFD), requiring mastery of numerous skills to maintain health.

AIMS

To assess the rate of self-management skill acquisition following diagnosis, and the influence of demographic factors on this rate.

METHODS

Patients attending a celiac center were invited to complete an anonymous survey which reported demographic information and time for mastery of self-management skills relevant to CD.

RESULTS

Completed surveys were returned by 137 patients (79% female). Most participants reported mastering skills that involved identifying gluten-containing versus gluten-free foods within 6 months. Explaining CD and GFD to others required 1-2 years. Identifying gluten in medications and supplements required 3-5 years. Traveling internationally with GFD adherence required more than five years to learn. Demographic factors were not associated with the rate of acquisition.

CONCLUSIONS

This is the first description of a timeline for relevant skill acquisition following diagnosis for CD. A sequence emerges, with most patients learning skills relevant to home, then social settings, then the workplace, and, finally, unfamiliar settings. Awareness of this progression of mastery, and particular recognition of difficult skills will allow physicians and dietitians to provide CD patients with targeted education and resources to facilitate adherence.

Serum zonulin is elevated in IBS and correlates with stool frequency in IBS-D

Background

Studies have shown increased intestinal permeability in irritable bowel syndrome. Validating serum biomarkers for altered intestinal permeability in irritable bowel syndrome will facilitate research and pathophysiology-based therapy.

Objective

To measure serum zonulin and intestinal fatty acid binding protein levels in diarrhea-predominant irritable bowel syndrome and constipation-predominant irritable bowel syndrome and compare with healthy controls and celiac disease.

Methods

Serum zonulin and intestinal fatty acid binding protein levels were measured using enzyme-linked immunosorbent assays in constipation-predominant irritable bowel syndrome (n = 50), diarrhea-predominant irritable bowel syndrome (n = 50), celiac disease (n = 53) and healthy controls (n = 42). Irritable bowel syndrome symptom severity was measured using the irritable bowel syndrome-symptom severity scale.

Results

Patients with constipation-predominant irritable bowel syndrome and diarrhea-predominant irritable bowel syndrome had higher zonulin levels compared with healthy controls (p = 0.006 and 0.009 respectively), which was comparable to those with active celiac disease. Although zonulin levels did not correlate with the overall irritable bowel syndrome symptom severity scale, it positively correlated with stool frequency per week (p = 0.03) and dissatisfaction with bowel habits (p = 0.007) in diarrhea-predominant irritable bowel syndrome. Patients with diarrhea-predominant irritable bowel syndrome and constipation-predominant irritable bowel syndrome had lower intestinal fatty acid binding protein levels compared with celiac patients (p = 0.005 and p = 0.047 respectively).

Conclusion

Serum zonulin is upregulated in irritable bowel syndrome and the levels are comparable to those in celiac disease. Zonulin levels correlated with severity of bowel habits in diarrhea-predominant irritable bowel syndrome. Intestinal fatty acid binding protein levels in irritable bowel syndrome patients were not increased suggesting no significant increase in enterocyte death.

The interaction between caveolin-1 and Rho-GTPases promotes metastasis by controlling the expression of alpha5-integrin and the activation of Src, Ras and Erk

Proteins containing a caveolin-binding domain (CBD), such as the Rho-GTPases, can interact with caveolin-1 (Cav1) through its caveolin scaffold domain. Rho-GTPases are important regulators of p130(Cas), which is crucial for both normal cell migration and Src kinase-mediated metastasis of cancer cells. However, although Rho-GTPases (particularly RhoC) and Cav1 have been linked to cancer progression and metastasis, the underlying molecular mechanisms are largely unknown. To investigate the function of Cav1-Rho-GTPase interaction in metastasis, we disrupted Cav1-Rho-GTPase binding in melanoma and mammary epithelial tumor cells by overexpressing CBD, and examined the loss-of-function of RhoC in metastatic cancer cells. Cancer cells overexpressing CBD or lacking RhoC had reduced p130(Cas) phosphorylation and Rac1 activation, resulting in an inhibition of migration and invasion in vitro. The activity of Src and the activation of its downstream targets FAK, Pyk2, Ras and extracellular signal-regulated kinase (Erk)1/2 were also impaired. A reduction in α5-integrin expression, which is required for binding to fibronectin and thus cell migration and survival, was observed in CBD-expressing cells and cells lacking RhoC. As a result of these defects, CBD-expressing melanoma cells had a reduced ability to metastasize in recipient mice, and impaired extravasation and survival in secondary sites in chicken embryos. Our data indicate that interaction between Cav1 and Rho-GTPases (most likely RhoC but not RhoA) promotes metastasis by stimulating α5-integrin expression and regulating the Src-dependent activation of p130(Cas)/Rac1, FAK/Pyk2 and Ras/Erk1/2 signaling cascades.

The Cancer Research UK experience of pre-clinical toxicology studies to support early clinical trials with novel cancer therapies

Pre-clinical toxicology studies in rodents and Phase I clinical trial data are summarised for 14 novel anticancer therapies. With only one exception, an antifolate antimetabolite, rodent toxicology predicted a safe Phase I trial starting dose and the majority of the dose limiting toxicities, in particular haematological toxicity. For targeted agents with well-defined pharmacodynamic markers, illustrated in the current study by 3 anti-endocrine drugs and one resistance modifier, the definition of a maximum tolerated dose can be avoided. Together with earlier data, the current study confirms that pre-clinical toxicology studies in a non-rodent species are not routinely needed for the safe conduct of early clinical trials with new cancer chemotherapies.

Pulmonary availability of isotretinoin in rats after inhalation of a powder aerosol

Repeated oral administration of chemopreventive retinoids such as isotretinoin over extended periods of time is associated with intolerable systemic toxicity. Here isotretinoin was formulated as a powder aerosol, and its delivery to the lungs of rats was studied with the aim to explore the possibility of minimizing adverse effects associated with its oral administration. Rats received isotretinoin orally (0.5, 1 or 10 mg kg(-1)) or by inhalation (theoretical dose approximately 1 or approximately 10 mg kg(-1)) in a nose-only inhalation chamber. Isotretinoin was quantitated by high-pressure liquid chromatography in plasma and lung tissue. The ratios of mean area of concentration-vs-time curve (AUC) values in the lungs over mean AUCs in the plasma for isotretinoin following single or repeated aerosol exposure surpassed those determined for the oral route by factors of between two (single low-dose) and five (single high-dose). Similarly, the equivalent ratios for the maximal peak concentrations in lungs and plasma obtained after aerosol exposure consistently exceeded those seen after oral administration, suggesting that lungs were exposed to higher isotretinoin concentrations after aerosol inhalation than after oral administration of similar doses. Repeated high doses of isotretinoin by inhalation resulted in moderate loss of body weight, but microscopic investigation of ten tissues including lung and oesophagus did not detect any significant aerosol-induced damage. The results suggest that administration of isotretinoin via powder aerosol inhalation is probably superior to its application via the oral route in terms of achieving efficacious drug concentrations in the lungs.

Using spoken attributions to classify abusive families

Despite claims that beliefs held by abusive parents are important indicators of family functioning, few studies have explored the relationship between patterns of beliefs and severity of abuse. This study applies findings from marital research that demonstrate that maladaptive attributional patterns predict the level of distress experienced in adult relationships. It examines spoken attributions produced by 18 families during diagnostic therapy sessions following serious abuse of a child. Attributions were identified from transcripts and coded using a standard system. Patterns of attributions, defined on the basis of previous work, successfully predicted classification of families by therapists as Good, Uncertain, and Poor, in terms of prognosis for rehabilitation. Using this classification to test hypotheses based on attributional style, group differences were found. In families rated Good, parents were more likely to attribute more control to self than child for negative outcomes. They were also more likely to nominate themselves as causing negative events. Case accounts of families from each category are presented to illustrate how attributional analysis can contribute to an understanding of the individual nature of child abuse.

Locally Optimal Run-Length Compression Applied to CT Images

Run-length data compression techniques are described that preserve image content. After decompression, images are restored to their original state without loss in image gray scale or resolution. The first technique introduces terminology and illustrates a simple method for efficient picture archiving. It demonstrates the principle of run-length techniques. A second more general approach encodes picture information in a manner that adapts to local variation in pixel standard deviation. Among several options of compression formats, the one that delivers the best local compression is selected. Results of our compression techniques are given for several hundred computed tomography (CT) pictures with comparison to image entropy measures. A general solution to the optimal run-length compression of digital data is outlined. Routine application of the locally optimal method is also described.