1
|
Lee JK, Levine RB, Yousem DM, Faraday N, Skarupski KA, Ishii M, Daugherty Biddison EL, Oliva-Hemker M. Commitment to inclusion: The importance of collaboration in gender equity work. Womens Health (Lond) 2024; 20:17455057241252574. [PMID: 38742705 PMCID: PMC11095174 DOI: 10.1177/17455057241252574] [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] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 03/12/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024]
Abstract
Despite decades of faculty professional development programs created to prepare women for leadership, gender inequities persist in salary, promotion, and leadership roles. Indeed, men still earn more than women, are more likely than women to hold the rank of professor, and hold the vast majority of positions of power in academic medicine. Institutions demonstrate commitment to their faculty's growth by investing resources, including creating faculty development programs. These programs are essential to help prepare women to lead and navigate the highly matrixed, complex systems of academic medicine. However, data still show that women persistently lag behind men in their career advancement and salary. Clearly, training women to adapt to existing structures and norms alone is not sufficient. To effectively generate organizational change, leaders with power and resources must commit to gender equity. This article describes several efforts by the Office of Faculty in the Johns Hopkins University School of Medicine to broaden inclusivity in collaborative work for gender equity. The authors are women and men leaders in the Office of Faculty, which is within the Johns Hopkins University School of Medicine dean's office and includes Women in Science and Medicine. Here, we discuss potential methods to advance gender equity using inclusivity based on our institutional experience and on the findings of other studies. Ongoing data collection to evaluate programmatic outcomes in the Johns Hopkins University School of Medicine will be reported in the future.
Collapse
Affiliation(s)
- Jennifer K Lee
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| | - Rachel B Levine
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| | - David M Yousem
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Radiology, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| | - Nauder Faraday
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| | - Kimberly A Skarupski
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| | - Masaru Ishii
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| | - EL Daugherty Biddison
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| | - Maria Oliva-Hemker
- Office of Faculty, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine (JHUSOM), Baltimore, MD, USA
| |
Collapse
|
2
|
Oliva-Hemker M, Kahn SA, Steinbach WJ. Fecal Microbiota Transplantation: Information for the Pediatrician. Pediatrics 2023; 152:e2023062922. [PMID: 37981872 DOI: 10.1542/peds.2023-062922] [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] [Accepted: 05/25/2023] [Indexed: 11/21/2023] Open
Abstract
Fecal microbiota transplantation (FMT) involves the delivery of an entire microbial community from a healthy donor to a recipient with the intention of ameliorating or curing a specific disease. Current evidence strongly supports a role for FMT in the treatment of Clostridiodes difficile infection, with cure rates of approximately 80% to 90%. This success has led to increasing attention for FMT as a potential therapeutic intervention for other conditions associated with disturbances of the intestinal microbiome, including inflammatory bowel diseases, autism spectrum disorder, and obesity. This clinical report endorses the joint society statement by the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition and is meant to provide the general pediatrician with a broad overview to enable appropriate guidance to families seeking FMT as treatment of a child's condition.
Collapse
Affiliation(s)
- Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stacy A Kahn
- FMT and Microbial Therapeutics Program, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Cambridge, Massachusetts
| | - William J Steinbach
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's, Fayetteville, Arkansas
| |
Collapse
|
3
|
Chen LA, Oliva-Hemker M, Radin A, Weidner M, O’Laughlin BD, Sears CL, Javitt NB, Hourigan SK. Longitudinal Bile Acid Composition Changes Following Faecal Microbiota Transplantation for Clostridioides difficile Infection in Children With and Without Underlying Inflammatory Bowel Disease. J Crohns Colitis 2023; 17:1364-1368. [PMID: 36988432 PMCID: PMC10441560 DOI: 10.1093/ecco-jcc/jjad057] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND AND AIMS Faecal microbiota transplant [FMT] is effective in treating recurrent Clostridioides difficile infection [CDI] and restores gut microbiota composition. This is unlikely to account for its entire mechanism of efficacy, as studies have shown that factors such as bile acids influence the risk of infection by affecting Clostridioides difficile germination. We therefore aimed to investigate longitudinal changes in the gut bile acid composition after FMT performed for recurrent CDI, in children with and without inflammatory bowel disease [IBD]. METHODS Eight children received FMT; five had underlying IBD. Primary and secondary faecal bile acids were measured by liquid chromatography-mass spectrometry in recipients [pre-FMT and longitudinally post-FMT for up to 6 months] and donors. RESULTS Pre-FMT, recipients had higher primary and lower secondary bile acid proportions compared with donors. Post-FMT, there was a gradual increase of secondary and decrease of primary bile acids. Whereas gut bacterial diversity had been shown to be restored in all children shortly after FMT, normalisation of bile acids to donor levels occurred only by 6 months. In children with IBD, although microbiota diversity returned to pre-FMT levels within 6 months, secondary bile acids remained at donor levels. CONCLUSIONS The differences in bile acid profiles compared with gut bacterial diversity post-FMT suggests that interactions between the two may be more complex than previously appreciated and may contribute to FMT efficacy in different ways. This initial finding demonstrates the need to further investigate gut metabolites in larger cohorts, with longitudinal sampling to understand the mechanisms of FMT effectiveness.
Collapse
Affiliation(s)
- Lea Ann Chen
- Division of Gastroenterology and Hepatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arielle Radin
- Division of Gastroenterology and Hepatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Melissa Weidner
- Division of Pediatric Gastroenterology, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Brynn D O’Laughlin
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children’s National Medical Center, Washington, DC, USA
| | - Cynthia L Sears
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Norman B Javitt
- Division of Gastroenterology and Hepatology,New York University Grossman School of Medicine, New York, NY, USA
| | - Suchitra K Hourigan
- Clinical Microbiome Unit, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
4
|
Conover KR, Absah I, Ballal S, Brumbaugh D, Cho S, Cardenas MC, Knackstedt ED, Goyal A, Jensen MK, Kaplan JL, Kellermayer R, Kociolek LK, Michail S, Oliva-Hemker M, Reed AW, Weatherly M, Kahn SA, Nicholson MR. Fecal Microbiota Transplantation for Clostridioides difficile Infection in Immunocompromised Pediatric Patients. J Pediatr Gastroenterol Nutr 2023; 76:440-446. [PMID: 36720105 PMCID: PMC10627107 DOI: 10.1097/mpg.0000000000003714] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We sought to evaluate the safety and effectiveness of fecal microbiota transplantation (FMT) for recurrent Clostridioides difficile infection (CDI) in pediatric immunocompromised (IC) patients. METHODS This is a multicenter retrospective cohort study of pediatric participants who underwent FMT between March 2013 and April 2020 with 12-week follow-up. Pediatric patients were included if they met the definition of IC and were treated with FMT for an indication of recurrent CDI. We excluded patients over 18 years of age, those with incomplete records, insufficient follow-up, or not meeting study definition of IC. We also excluded those treated for Clostridioides difficile recurrence without meeting the study definition and those with inflammatory bowel disease without another immunocompromising condition. RESULTS Of 59 pediatric patients identified at 9 centers, there were 42 who met inclusion and no exclusion criteria. Included patients had a median age of 6.7 years. Etiology of IC included: solid organ transplantation (18, 43%), malignancy (12, 28%), primary immunodeficiency (10, 24%), or other chronic conditions (2, 5%). Success rate was 79% after first FMT and 86% after 1 or more FMT. There were no statistically significant differences in patient characteristics or procedural components when patients with a failed FMT were compared to those with a successful FMT. There were 15 total serious adverse events (SAEs) in 13 out of 42 (31%) patients that occurred during the follow-up period; 4 (9.5%) of which were likely treatment-related. There were no deaths or infections with multidrug resistant organisms during follow-up and all patients with a SAE fully recovered. CONCLUSIONS The success rate of FMT for recurrent CDI in this pediatric IC cohort is high and mirrors data for IC adults and immunocompetent children. FMT-related SAEs do occur (9.5%) and highlight the need for careful consideration of risk and benefit.
Collapse
Affiliation(s)
- Katie R Conover
- From the Department of General Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Imad Absah
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mayo Clinic Children's Center, Rochester, MN
| | - Sonia Ballal
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - David Brumbaugh
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, Aurora, CO
| | - Stanley Cho
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Texas Children's Hospital, Houston, TX
| | - Maria C Cardenas
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mayo Clinic Children's Center, Rochester, MN
| | - Elizabeth Doby Knackstedt
- the Division of Pediatric Infectious Disease, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Alka Goyal
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children's Hospital, Palo Alto, CA
| | - M Kyle Jensen
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Jess L Kaplan
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mass General Hospital for Children, Boston, MA
| | - Richard Kellermayer
- the Division of Pediatric Infectious Disease, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Larry K Kociolek
- the Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sonia Michail
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, CA
| | - Maria Oliva-Hemker
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins Children's Center, Baltimore, MD
| | - Anna W Reed
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins Children's Center, Baltimore, MD
| | - Madison Weatherly
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Stacy A Kahn
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Maribeth R Nicholson
- the Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital, Nashville, TN
| |
Collapse
|
5
|
Miller SD, Murphy Z, Gray JH, Marsteller J, Oliva-Hemker M, Maslen A, Lehmann HP, Nagy P, Hutfless S, Gurses AP. Human-Centered Design of a Clinical Decision Support for Anemia Screening in Children with Inflammatory Bowel Disease. Appl Clin Inform 2023; 14:345-353. [PMID: 36809791 PMCID: PMC10171996 DOI: 10.1055/a-2040-0578] [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: 11/15/2022] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) commonly leads to iron deficiency anemia (IDA). Rates of screening and treatment of IDA are often low. A clinical decision support system (CDSS) embedded in an electronic health record could improve adherence to evidence-based care. Rates of CDSS adoption are often low due to poor usability and fit with work processes. One solution is to use human-centered design (HCD), which designs CDSS based on identified user needs and context of use and evaluates prototypes for usefulness and usability. OBJECTIVES this study aimed to use HCD to design a CDSS tool called the IBD Anemia Diagnosis Tool, IADx. METHODS Interviews with IBD practitioners informed creation of a process map of anemia care that was used by an interdisciplinary team that used HCD principles to create a prototype CDSS. The prototype was iteratively tested with "Think Aloud" usability evaluation with clinicians as well as semi-structured interviews, a survey, and observations. Feedback was coded and informed redesign. RESULTS Process mapping showed that IADx should function at in-person encounters and asynchronous laboratory review. Clinicians desired full automation of clinical information acquisition such as laboratory trends and analysis such as calculation of iron deficit, less automation of clinical decision selection such as laboratory ordering, and no automation of action implementation such as signing medication orders. Providers preferred an interruptive alert over a noninterruptive reminder. CONCLUSION Providers preferred an interruptive alert, perhaps due to the low likelihood of noticing a noninterruptive advisory. High levels of desire for automation of information acquisition and analysis with less automation of decision selection and action may be generalizable to other CDSSs designed for chronic disease management. This underlines the ways in which CDSSs have the potential to augment rather than replace provider cognitive work.
Collapse
Affiliation(s)
- Steven D. Miller
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Zachary Murphy
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Joshua H. Gray
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Jill Marsteller
- Department of Health Policy and Management, Johns Hopkins University School of Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, United States
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Andrew Maslen
- Information Technology at Johns Hopkins Health System, Epic Project Leadership, Johns Hopkins Health System, Baltimore, Maryland, United States
| | - Harold P. Lehmann
- Division of Health Science Informatics, Johns Hopkins University, Baltimore, Maryland, United States
| | - Paul Nagy
- Department of Radiology, Johns Hopkins University School of Medicine, Johns Hopkins Technology Ventures, Baltimore, Maryland, United States
| | - Susan Hutfless
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Ayse P. Gurses
- Information Technology at Johns Hopkins Health System, Epic Project Leadership, Johns Hopkins Health System, Baltimore, Maryland, United States
| |
Collapse
|
6
|
Nicholson MR, Alexander E, Ballal S, Davidovics Z, Docktor M, Dole M, Gisser JM, Goyal A, Hourigan SK, Jensen MK, Kaplan JL, Kellermayer R, Kelsen JR, Kennedy MA, Khanna S, Knackstedt ED, Lentine J, Lewis JD, Michail S, Mitchell PD, Oliva-Hemker M, Patton T, Queliza K, Sidhu S, Solomon AB, Suskind DL, Weatherly M, Werlin S, de Zoeten EF, Kahn SA. Efficacy and Outcomes of Faecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection in Children with Inflammatory Bowel Disease. J Crohns Colitis 2022; 16:768-777. [PMID: 34788420 PMCID: PMC9228903 DOI: 10.1093/ecco-jcc/jjab202] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Children with inflammatory bowel disease [IBD] are disproportionally affected by recurrent Clostridioides difficile infection [rCDI]. Although faecal microbiota transplantation [FMT] has been used with good efficacy in adults with IBD, little is known about outcomes associated with FMT in paediatric IBD. METHODS We performed a retrospective review of FMT at 20 paediatric centres in the USA from March 2012 to March 2020. Children with and without IBD were compared with determined differences in the efficacy of FMT for rCDI. In addition, children with IBD with and without a successful outcome were compared with determined predictors of success. Safety data and IBD-specific outcomes were obtained. RESULTS A total of 396 paediatric patients, including 148 with IBD, were included. Children with IBD were no less likely to have a successful first FMT then the non-IBD affected cohort [76% vs 81%, p = 0.17]. Among children with IBD, patients were more likely to have a successful FMT if they received FMT with fresh stool [p = 0.03], were without diarrhoea prior to FMT [p = 0.03], or had a shorter time from rCDI diagnosis until FMT [p = 0.04]. Children with a failed FMT were more likely to have clinically active IBD post-FMT [p = 0.002] and 19 [13%] patients had an IBD-related hospitalisation in the 3-month follow-up. CONCLUSIONS Based on the findings from this large US multicentre cohort, the efficacy of FMT for the treatment of rCDI did not differ in children with IBD. Failed FMT among children with IBD was possibly related to the presence of clinically active IBD.
Collapse
Affiliation(s)
- Maribeth R Nicholson
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin Alexander
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Sonia Ballal
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Zev Davidovics
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Michael Docktor
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Michael Dole
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan M Gisser
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alka Goyal
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Suchitra K Hourigan
- Department of Pediatrics, Pediatric Specialists of Virginia, Fairfax, VA, USA
| | - M Kyle Jensen
- Department of Pediatrics, University of Utah Department of Pediatrics, Salt Lake City, UT, USA
| | - Jess L Kaplan
- Department of Pediatrics, MassGeneral Hospital for Children, Boston, MA, USA
| | - Richard Kellermayer
- Baylor College of Medicine, Texas Children's Hospital, USDA Children's Nutrition and Research Center, Houston, TX, USA
| | - Judith R Kelsen
- Department of Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Melissa A Kennedy
- Department of Pediatrics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sahil Khanna
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth D Knackstedt
- Department of Pediatrics, University of Utah Department of Pediatrics, Salt Lake City, UT, USA
| | - Jennifer Lentine
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Jeffery D Lewis
- Children's Center for Digestive Healthcare at Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sonia Michail
- Department of Pediatrics, University of Southern California Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Paul D Mitchell
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Maria Oliva-Hemker
- Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Tiffany Patton
- Department of Pediatrics, University of Chicago, Comer Children's Hospital, Chicago, IL, USA
| | - Karen Queliza
- Baylor College of Medicine, Texas Children's Hospital, USDA Children's Nutrition and Research Center, Houston, TX, USA
| | - Sarah Sidhu
- Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Aliza B Solomon
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - David L Suskind
- Department of Pediatrics, Seattle Children's Hospital and the University of Washington, Seattle, WA, USA
| | - Madison Weatherly
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Steven Werlin
- Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Edwin F de Zoeten
- Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA
| | - Stacy A Kahn
- Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | | |
Collapse
|
7
|
Khushal S, Oliva-Hemker M. Diagnosis and Management of Microscopic Colitis in Pediatric Patients. Paediatr Drugs 2022; 24:217-233. [PMID: 35501559 DOI: 10.1007/s40272-022-00504-3] [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] [Accepted: 03/27/2022] [Indexed: 11/27/2022]
Abstract
Microscopic colitis (MC) is an inflammatory disease of the colon, characterized by chronic watery diarrhea with distinguishing histologic findings despite normal endoscopic appearance of the colonic mucosa. MC is a common cause of diarrhea in older adults, though it has been infrequently reported in children and adolescents. As MC is rare in the pediatric population, and the clinical presentation is non-specific, increased awareness of this disease amongst pediatric clinicians and pathologists is essential for timely diagnosis, which requires performing colonoscopy with biopsy. The etiology of MC is incompletely understood, but current theories in pathogenesis inform management strategies. The goals of management in pediatric MC should be to achieve symptomatic improvement while minimizing adverse effects of treatment. Many patients who achieve clinical response have symptomatic recurrence after discontinuation of initial therapy, and may require maintenance medication therapy to sustain remission. This review aims to summarize the epidemiology and risk factors, clinical features, diagnosis, theories regarding pathogenesis, and suggested management approaches for MC in the pediatric population.
Collapse
Affiliation(s)
- Salina Khushal
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
8
|
Cananzi M, Wohler E, Marzollo A, Colavito D, You J, Jing H, Bresolin S, Gaio P, Martin R, Mescoli C, Bade S, Posey JE, Dalle Carbonare M, Tung W, Jhangiani SN, Bosa L, Zhang Y, Filho JS, Gabelli M, Kellermayer R, Kader HA, Oliva-Hemker M, Perilongo G, Lupski JR, Biffi A, Valle D, Leon A, de Macena Sobreira NL, Su HC, Guerrerio AL. IFIH1 loss-of-function variants contribute to very early-onset inflammatory bowel disease. Hum Genet 2021; 140:1299-1312. [PMID: 34185153 PMCID: PMC8423350 DOI: 10.1007/s00439-021-02300-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/07/2021] [Indexed: 02/06/2023]
Abstract
Genetic defects of innate immunity impairing intestinal bacterial sensing are linked to the development of Inflammatory Bowel Disease (IBD). Although much evidence supports a role of the intestinal virome in gut homeostasis, most studies focus on intestinal viral composition rather than on host intestinal viral sensitivity. To demonstrate the association between the development of Very Early Onset IBD (VEOIBD) and variants in the IFIH1 gene which encodes MDA5, a key cytosolic sensor for viral nucleic acids. Whole exome sequencing (WES) was performed in two independent cohorts of children with VEOIBD enrolled in Italy (n = 18) and USA (n = 24). Luciferase reporter assays were employed to assess MDA5 activity. An enrichment analysis was performed on IFIH1 comparing 42 VEOIBD probands with 1527 unrelated individuals without gastrointestinal or immunological issues. We identified rare, likely loss-of-function (LoF), IFIH1 variants in eight patients with VEOIBD from a combined cohort of 42 children. One subject, carrying a homozygous truncating variant resulting in complete LoF, experienced neonatal-onset, pan-gastrointestinal, IBD-like enteropathy plus multiple infectious episodes. The remaining seven subjects, affected by VEOIBD without immunodeficiency, were carriers of one LoF variant in IFIH1. Among these, two patients also carried a second hypomorphic variant, with partial function apparent when MDA5 was weakly stimulated. Furthermore, IFIH1 variants were significantly enriched in children with VEOIBD as compared to controls (p = 0.007). Complete and partial MDA5 deficiency is associated with VEOIBD with variable penetrance and expressivity, suggesting a role for impaired intestinal viral sensing in IBD pathogenesis.
Collapse
Affiliation(s)
- Mara Cananzi
- Unit of Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy.
| | - Elizabeth Wohler
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Antonio Marzollo
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Istituto di Ricerca Pediatrica, Fondazione Città della Speranza, Padova, Italy
| | - Davide Colavito
- Research & Innovation (R&I Genetics) Srl, C.so Stati Uniti 4, Padova, Italy
| | - Jing You
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Huie Jing
- Human Immunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Silvia Bresolin
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
- Istituto di Ricerca Pediatrica, Fondazione Città della Speranza, Padova, Italy
| | - Paola Gaio
- Unit of Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Renan Martin
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Claudia Mescoli
- Surgical Pathology and Cytopathology Unit, Department of Medicine (DIMED), University Hospital of Padova, Padova, Italy
| | - Sangeeta Bade
- Human Immunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer E Posey
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
| | | | - Wesley Tung
- Human Immunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Shalini N Jhangiani
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Luca Bosa
- Unit of Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Yu Zhang
- Human Immunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Joselito Sobreira Filho
- Division of Genetics, Department of Morphology and Genetics, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Maria Gabelli
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Howard A Kader
- Department of Pediatrics, Division of Pediatric Gastroenterology & Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Maria Oliva-Hemker
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Giorgio Perilongo
- Unit of Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - James R Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Hospital, Houston, Texas, USA
| | - Alessandra Biffi
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - David Valle
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Alberta Leon
- Research & Innovation (R&I Genetics) Srl, C.so Stati Uniti 4, Padova, Italy
| | | | - Helen C Su
- Human Immunological Diseases Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Anthony L Guerrerio
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
9
|
Ta AD, Ollberding NJ, Karns R, Haberman Y, Alazraki AL, Hercules D, Baldassano R, Markowitz J, Heyman MB, Kim S, Kirschner B, Shapiro JM, Noe J, Oliva-Hemker M, Otley A, Pfefferkorn M, Kellermayer R, Snapper S, Rabizadeh S, Xavier R, Dubinsky M, Hyams J, Kugathasan S, Jegga AG, Dillman JR, Denson LA. Association of Baseline Luminal Narrowing With Ileal Microbial Shifts and Gene Expression Programs and Subsequent Transmural Healing in Pediatric Crohn Disease. Inflamm Bowel Dis 2021; 27:1707-1718. [PMID: 33452801 PMCID: PMC8528150 DOI: 10.1093/ibd/izaa339] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Transmural healing (TH) is associated with better long-term outcomes in Crohn disease (CD), whereas pretreatment ileal gene signatures encoding myeloid inflammatory responses and extracellular matrix production are associated with stricturing. We aimed to develop a predictive model for ileal TH and to identify ileal genes and microbes associated with baseline luminal narrowing (LN), a precursor to strictures. MATERIALS AND METHODS Baseline small bowel imaging obtained in the RISK pediatric CD cohort study was graded for LN. Ileal gene expression was determined by RNASeq, and the ileal microbial community composition was characterized using 16S rRNA amplicon sequencing. Clinical, demographic, radiologic, and genomic variables were tested for association with baseline LN and future TH. RESULTS After controlling for ileal location, baseline ileal LN (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.8), increasing serum albumin (OR, 4; 95% CI, 1.3-12.3), and anti-Saccharomyces cerevisiae antibodies IgG serology (OR, 0.97; 95% CI, 0.95-1) were associated with subsequent TH. A multivariable regression model including these factors had excellent discriminant power for TH (area under the curve, 0.86; positive predictive value, 80%; negative predictive value, 87%). Patients with baseline LN exhibited increased Enterobacteriaceae and inflammatory and extracellular matrix gene signatures, coupled with reduced levels of butyrate-producing commensals and a respiratory electron transport gene signature. Taxa including Lachnospiraceae and the genus Roseburia were associated with increased respiratory and decreased inflammatory gene signatures, and Aggregatibacter and Blautia bacteria were associated with reduced extracellular matrix gene expression. CONCLUSIONS Pediatric patients with CD with LN at diagnosis are less likely to achieve TH. The association between specific microbiota, wound healing gene programs, and LN may suggest future therapeutic targets.
Collapse
Affiliation(s)
- Allison D Ta
- Cincinnati Children’s Medical Hospital Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicholas J Ollberding
- Cincinnati Children’s Medical Hospital Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Rebekah Karns
- Cincinnati Children’s Medical Hospital Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Yael Haberman
- Cincinnati Children’s Medical Hospital Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA,Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Tel Aviv, Israel
| | - Adina L Alazraki
- Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - David Hercules
- Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Robert Baldassano
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James Markowitz
- Cohen Children’s Medical Center of New York, New Hyde Park, New York, USA
| | - Melvin B Heyman
- University of California San Francisco, San Francisco, California, USA
| | - Sandra Kim
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | | | | | - Joshua Noe
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | | | - Richard Kellermayer
- Texas Children’s Hospital, Baylor College School of Medicine, Houston, Texas, USA
| | - Scott Snapper
- Children’s Hospital-Boston, Boston, Massachusetts, USA
| | | | - Ramnik Xavier
- Broad Institute at Massachusetts Institute of Technology, Cambridge, Massachusetts, USA,Massachusetts General Hospital, Cambridge, Massachusetts, USA
| | | | - Jeffrey Hyams
- Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Subra Kugathasan
- Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Anil G Jegga
- Cincinnati Children’s Medical Hospital Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan R Dillman
- Cincinnati Children’s Medical Hospital Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Lee A Denson
- Cincinnati Children’s Medical Hospital Center and the University of Cincinnati College of Medicine, Cincinnati, Ohio, USA,Address correspondence to: Lee A. Denson, MD, 3333 Burnett Avenue, MLC 2010, Cincinnati, OH 45229 ()
| |
Collapse
|
10
|
Windon AL, Almazan E, Oliva-Hemker M, Hutchings D, Assarzadegan N, Salimian K, Montgomery EA, Voltaggio L. Lymphocytic and collagenous colitis in children and adolescents: Comprehensive clinicopathologic analysis with long-term follow-up. Hum Pathol 2020; 106:13-22. [PMID: 32991931 DOI: 10.1016/j.humpath.2020.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 11/17/2022]
Abstract
Microscopic colitis (MC) is characterized by chronic watery diarrhea, endoscopically normal findings, and abnormal histology. While mostly encountered in adults, pediatric cases are rare and may show varying presentations. Our pathology data system was searched from 1984 to 2019 for patients ≤18 years of age with a lymphocytic colitis (LC) or collagenous colitis (CC) pattern of injury. Twenty-seven cases (23 LC and 4 CC) were retrieved. LC was more prevalent than CC (85% vs 15%, respectively) and affected slightly younger individuals (mean, 9.8 years versus 12.25 years). Immune dysregulation was documented in 11 (41%) patients. Most patients presented with watery diarrhea (n = 26, 96%) and either abdominal pain (n = 18, 67%), nausea/vomiting (n = 5, 19%), flatulence (n = 6, 22%), and/or weight loss (n = 1, 4%). A subset of patients (n = 10, 37%) demonstrated endoscopic abnormalities. Histologically, some patients with LC and CC displayed focal cryptitis or crypt abscess formation (n = 7, 26%) and focally increased crypt apoptosis (n = 9, 33%) in the absence of chronic injury. Clinical follow-up data were available for 23 (85%) patients with variable clinical responses recorded. Only 8 patients experienced complete symptom resolution. Twelve patients (11 LC and 1 CC) had subsequent biopsy material; of which, one developed histologic features of inflammatory bowel disease and another was found to have a CTLA-4 deficiency. Our study shows that pediatric patients with MC may have atypical clinical, histologic, and endoscopic findings and variable clinical responses. Underlying inflammatory and/or genetic conditions may be eventually unmasked, and genetic testing may be helpful in a small subset of patients.
Collapse
Affiliation(s)
- Annika L Windon
- Department of Pathology and Laboratory Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Erik Almazan
- Johns Hopkins University School of Medicine, 733 N. Broadway, Baltimore, MD, 21205, USA.
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Johns Hopkins Hospital, 200 N. Wolfe Street, Rubenstein Child Health Building, Baltimore, MD, 21287, USA.
| | - Danielle Hutchings
- Department of Pathology and Laboratory Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Naziheh Assarzadegan
- Department of Pathology and Laboratory Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Kevan Salimian
- Department of Pathology and Laboratory Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Elizabeth A Montgomery
- Department of Pathology and Laboratory Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| | - Lysandra Voltaggio
- Department of Pathology and Laboratory Medicine, The Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD, 21287, USA.
| |
Collapse
|
11
|
Haberman Y, Minar P, Karns R, Dexheimer PJ, Ghandikota S, Tegge S, Shapiro D, Shuler B, Venkateswaran S, Braun T, Ta A, Walters TD, Baldassano RN, Noe JD, Rosh J, Markowitz J, Dotson JL, Mack DR, Kellermayer R, Griffiths AM, Heyman MB, Baker SS, Moulton D, Patel AS, Gulati AS, Steiner SJ, LeLeiko N, Otley A, Oliva-Hemker M, Ziring D, Gokhale R, Kim S, Guthery SL, Cohen SA, Snapper S, Aronow BJ, Stephens M, Gibson G, Dillman JR, Dubinsky M, Hyams JS, Kugathasan S, Jegga AG, Denson LA. Mucosal Inflammatory and Wound Healing Gene Programs Reveal Targets for Stricturing Behavior in Pediatric Crohn's Disease. J Crohns Colitis 2020; 15:jjaa166. [PMID: 32770196 PMCID: PMC7904088 DOI: 10.1093/ecco-jcc/jjaa166] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS Ileal strictures are the major indication for resective surgery in Crohn's disease (CD). We aimed to define ileal gene programs present at diagnosis linked with future stricturing behavior during five year follow-up, and to identify potential small molecules to reverse these gene signatures. METHODS Antimicrobial serologies and pre-treatment ileal gene expression were assessed in a representative subset of 249 CD patients within the RISK multicenter pediatric CD inception cohort study, including 113 that are unique to this report. These data were used to define genes associated with stricturing behavior and for model testing to predict stricturing behavior. A bioinformatics approach to define small molecules which may reverse the stricturing gene signature was applied. RESULTS 19 of the 249 patients developed isolated B2 stricturing behavior during follow-up, while 218 remained B1 inflammatory. Using deeper RNA sequencing than in our prior report, we have now defined an inflammatory gene signature including an oncostatin M co-expression signature, tightly associated with extra-cellular matrix (ECM) gene expression in those who developed stricturing complications. We further computationally prioritize small molecules targeting macrophage and fibroblast activation and angiogenesis which may reverse the stricturing gene signature. A model containing ASCA and CBir1 serologies and a refined eight ECM gene set was significantly associated with stricturing development by year five after diagnosis (AUC (95th CI) = 0.82 (0.7-0.94)). CONCLUSION An ileal gene program for macrophage and fibroblast activation is linked to stricturing complications in treatment naïve pediatric CD, and may inform novel small molecule therapeutic approaches.
Collapse
Affiliation(s)
- Yael Haberman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Tel-Aviv, Israel
| | - Phillip Minar
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rebekah Karns
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Phillip J Dexheimer
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sudhir Ghandikota
- Department of Computer Science, University of Cincinnati College of Engineering, Cincinnati, OH, USA
| | - Samuel Tegge
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel Shapiro
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brianne Shuler
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Tzipi Braun
- Department of Pediatrics, Sheba Medical Center, Tel-HaShomer, affiliated with the Tel-Aviv University, Tel-Aviv, Israel
| | - Allison Ta
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Thomas D Walters
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Robert N Baldassano
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joshua D Noe
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joel Rosh
- Department of Pediatrics, Goryeb Children’s Hospital/Atlantic Health, Morristown, NJ, USA
| | - James Markowitz
- Department of Pediatrics, Cohen Children’s Medical Center of New York, New Hyde Park, NY, USA
| | - Jennifer L Dotson
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH, USA
| | - David R Mack
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Richard Kellermayer
- Department of Pediatrics, Texas Children’s Hospital, Baylor College School of Medicine, Houston, TX, USA
| | - Anne M Griffiths
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Melvin B Heyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Susan S Baker
- Department of Pediatrics, University at Buffalo, Buffalo, NY, USA
| | - Dedrick Moulton
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital, Nashville, TN, USA
| | - Ashish S Patel
- Department of Pediatrics, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Ajay S Gulati
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Steven J Steiner
- Department of Pediatrics, Riley Children’s Hospital, Indianapolis, IN, USA
| | - Neal LeLeiko
- Department of Pediatrics, Hasbro Children’s Hospital, Providence, RI, USA
| | - Anthony Otley
- Department of Pediatrics, IWK Health Centre, Halifax, NS, Canada
| | | | - David Ziring
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ranjana Gokhale
- Department of Pediatrics, University of Chicago Comer Children’s Hospital, Chicago, IL, USA
| | - Sandra Kim
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Stephen L Guthery
- Department of Pediatrics, University of Utah and Intermountain Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Stanley A Cohen
- Department of Pediatrics, Children’s Center for Digestive Health Medicine, Atlanta, GA, USA
| | - Scott Snapper
- Department of Pediatrics, Children’s Hospital ‐ Boston, Boston, MA, USA
| | - Bruce J Aronow
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Greg Gibson
- Center for for Integrative Genomics, Georgia Institute of Technology, Atlanta, GA, USA
| | - Jonathan R Dillman
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Marla Dubinsky
- Department of Pediatrics, Mount Sinai Hospital New York, NY, USA
| | - Jeffrey S Hyams
- Department of Pediatrics, Connecticut Children’s Medical Center, Hartford, CT, USA
| | | | - Anil G Jegga
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lee A Denson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
12
|
Nicholson MR, Mitchell PD, Alexander E, Ballal S, Bartlett M, Becker P, Davidovics Z, Docktor M, Dole M, Felix G, Gisser J, Hourigan SK, Jensen MK, Kaplan JL, Kelsen J, Kennedy M, Khanna S, Knackstedt E, Leier M, Lewis J, Lodarek A, Michail S, Oliva-Hemker M, Patton T, Queliza K, Russell GH, Singh N, Solomon A, Suskind DL, Werlin S, Kellermayer R, Kahn SA. Efficacy of Fecal Microbiota Transplantation for Clostridium difficile Infection in Children. Clin Gastroenterol Hepatol 2020; 18:612-619.e1. [PMID: 31009795 PMCID: PMC7549313 DOI: 10.1016/j.cgh.2019.04.037] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [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: 09/05/2018] [Revised: 04/02/2019] [Accepted: 04/05/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Fecal microbiota transplantation (FMT) is commonly used to treat Clostridium difficile infection (CDI). CDI is an increasing cause of diarrheal illness in pediatric patients, but the effects of FMT have not been well studied in children. We performed a multi-center retrospective cohort study of pediatric and young adult patients to evaluate the efficacy, safety, and factors associated with a successful FMT for the treatment of CDI. METHODS We performed a retrospective study of 372 patients, 11 months to 23 years old, who underwent FMT at 18 pediatric centers, from February 1, 2004, to February 28, 2017; 2-month outcome data were available from 335 patients. Successful FMT was defined as no recurrence of CDI in the 2 months following FMT. We performed stepwise logistic regression to identify factors associated with successful FMT. RESULTS Of 335 patients who underwent FMT and were followed for 2 months or more, 271 (81%) had a successful outcome following a single FMT and 86.6% had a successful outcome following a first or repeated FMT. Patients who received FMT with fresh donor stool (odds ratio [OR], 2.66; 95% CI, 1.39-5.08), underwent FMT via colonoscopy (OR, 2.41; 95% CI, 1.26-4.61), did not have a feeding tube (OR, 2.08; 95% CI, 1.05-4.11), or had 1 less episode of CDI before FMT (OR, 1.20; 95% CI, 1.04-1.39) had increased odds for successful FMT. Seventeen patients (4.7%) had a severe adverse event during the 3-month follow-up period, including 10 hospitalizations. CONCLUSIONS Based on the findings from a large multi-center retrospective cohort, FMT is effective and safe for the treatment of CDI in children and young adults. Further studies are required to optimize the timing and method of FMT for pediatric patients-factors associated with success differ from those of adult patients.
Collapse
Affiliation(s)
| | | | | | - Sonia Ballal
- Boston Children’s Hospital, Boston, Massachusetts
| | | | - Penny Becker
- Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Zev Davidovics
- Connecticut Children’s Medical Center, Hartford, Connecticut
| | | | - Michael Dole
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Grace Felix
- Johns Hopkins Children’s Center, Baltimore, Maryland
| | | | - Suchitra K. Hourigan
- Johns Hopkins Children’s Center, Baltimore, Maryland;,Pediatric Specialists of Virginia, Fairfax, Virginia
| | - M. Kyle Jensen
- Primary Children’s Hospital at University of Utah, Salt Lake City, Utah
| | - Jess L. Kaplan
- MassGeneral Hospital for Children, Boston, Massachusetts
| | - Judith Kelsen
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa Kennedy
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | - Jeffery Lewis
- Children’s Center for Digestive Healthcare at Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Sonia Michail
- University of Southern California Children’s Hospital of Los Angeles, Los Angeles, California
| | | | | | - Karen Queliza
- Baylor College of Medicine, Texas Children’s Hospital, Children’s Nutrition and Research Center, Houston, Texas
| | | | - Namita Singh
- Cedars Sinai Medical Center, Los Angeles, California
| | | | - David L. Suskind
- Seattle Children’s Hospital and the University of Washington, Seattle, Washington
| | | | - Richard Kellermayer
- Baylor College of Medicine, Texas Children’s Hospital, Children’s Nutrition and Research Center, Houston, Texas
| | | |
Collapse
|
13
|
Drewes JL, Corona A, Sanchez U, Fan Y, Hourigan SK, Weidner M, Sidhu SD, Simner PJ, Wang H, Timp W, Oliva-Hemker M, Sears CL. Transmission and clearance of potential procarcinogenic bacteria during fecal microbiota transplantation for recurrent Clostridioides difficile. JCI Insight 2019; 4:130848. [PMID: 31578306 DOI: 10.1172/jci.insight.130848] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 06/07/2019] [Accepted: 09/04/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUNDFecal microbiota transplantation (FMT) is an effective treatment for recurrent Clostridioides difficile infection (rCDI) in adults and children, but donor stool samples are currently screened for only a limited number of potential pathogens. We sought to determine whether putative procarcinogenic bacteria (enterotoxigenic Bacteroides fragilis, Fusobacterium nucleatum, and Escherichia coli harboring the colibactin toxin) could be durably transmitted from donors to patients during FMT.METHODSStool samples were collected from 11 pediatric rCDI patients and their respective FMT donors prior to FMT as well as from the patients at 2-10 weeks, 10-20 weeks, and 6 months after FMT. Bacterial virulence factors in stool DNA extracts and stool cultures were measured by quantitative PCR: Bacteroides fragilis toxin (bft), Fusobacterium adhesin A (fadA), and Escherichia coli colibactin (clbB).RESULTSFour of 11 patients demonstrated sustained acquisition of a procarcinogenic bacteria. Whole genome sequencing was performed on colony isolates from one of these donor/recipient pairs and demonstrated that clbB+ E. coli strains present in the recipient after FMT were identical to a strain present in the donor, confirming strain transmission. Conversely, 2 patients exhibited clearance of procarcinogenic bacteria following FMT from a negative donor.CONCLUSIONBoth durable transmission and clearance of procarcinogenic bacteria occurred following FMT, suggesting that additional studies on appropriate screening measures for FMT donors and the long-term consequences and/or benefits of FMT are warranted.FUNDINGCrohn's & Colitis Foundation, the Bloomberg~Kimmel Institute for Cancer Immunotherapy at Johns Hopkins University School of Medicine, the National Cancer Institute, and the Canadian Institutes of Health Research.
Collapse
Affiliation(s)
- Julia L Drewes
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alina Corona
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Uriel Sanchez
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yunfan Fan
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, USA
| | - Suchitra K Hourigan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Melissa Weidner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarah D Sidhu
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Hao Wang
- Department of Oncology, Bioinformatics and Biostatistics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Winston Timp
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, USA
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cynthia L Sears
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Bloomberg-Kimmel Institute for Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
14
|
Hourigan SK, Ahn M, Gibson KM, Pérez-Losada M, Felix G, Weidner M, Leibowitz I, Niederhuber JE, Sears CL, Crandall KA, Oliva-Hemker M. Fecal Transplant in Children With Clostridioides difficile Gives Sustained Reduction in Antimicrobial Resistance and Potential Pathogen Burden. Open Forum Infect Dis 2019; 6:ofz379. [PMID: 31660343 PMCID: PMC6790402 DOI: 10.1093/ofid/ofz379] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [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: 03/21/2019] [Accepted: 08/22/2019] [Indexed: 12/19/2022] Open
Abstract
Background Fecal microbiota transplantation (FMT) treats Clostridioides difficile infection (CDI). Little is known regarding the changes in antimicrobial resistance (AMR) genes and potential pathogen burden that occur in pediatric recipients of FMT. The aim of this study was to investigate changes in AMR genes, potential pathogens, species, and functional pathways with FMT in children. Methods Nine children with recurrent CDI underwent FMT. Stool was collected from donor and recipient pre-FMT and longitudinally post-FMT for up to 24 weeks. Shotgun metagenomic sequencing was performed. Reads were analyzed using PathoScope 2.0. Results All children had resolution of CDI. AMR genes decreased post-FMT (P < .001), with a sustained decrease in multidrug resistance genes (P < .001). Tetracycline resistance genes increased post-FMT (P < .001). Very low levels of potential pathogens were identified in donors and recipients, with an overall decrease post-FMT (P < .001). Prevotella sp. 109 expanded in all recipients post-FMT, and no recipients had any clinical infection. Alpha diversity was lower in recipients vs donors pre-FMT (P < .001), with an increase post-FMT (P ≤ .002) that was sustained. Beta diversity differed significantly in pre- vs post-FMT recipient samples (P < .001). Bacterial species Faecalibacterium prausnitzii and Bacteroides ovatus showed higher abundance in donors than recipients (P = .008 and P = .040, respectively), with expansion post-FMT. Biosynthetic pathways predominated in the donor and increased in the recipient post-FMT. Conclusions FMT for CDI in children decreases AMR genes and potential pathogens and changes microbiota composition and function. However, acquisition of certain AMR genes post-FMT combined with low levels of potential pathogens found in donors suggests that further study is warranted regarding screening donors using metagenomics sequencing before FMT.
Collapse
Affiliation(s)
- Suchitra K Hourigan
- Inova Translational Medicine Institute, Falls Church, Virginia.,Inova Children's Hospital, Falls Church, Virginia.,Pediatric Specialists of Virginia, Fairfax, Virginia.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle Ahn
- Computational Biology Institute and, Washington, DC
| | | | - Marcos Pérez-Losada
- Computational Biology Institute and, Washington, DC.,Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, DC.,CIBIO-InBIO, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Campus Agrário de Vairão, Vairão, Portugal
| | - Grace Felix
- Pediatric Specialists of Virginia, Fairfax, Virginia.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa Weidner
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian Leibowitz
- Pediatric Specialists of Virginia, Fairfax, Virginia
| | - John E Niederhuber
- Inova Translational Medicine Institute, Falls Church, Virginia.,Johns Hopkins University School of Medicine, Baltimore, Maryland.,Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Cynthia L Sears
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Keith A Crandall
- Computational Biology Institute and, Washington, DC.,Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Washington, DC
| | | |
Collapse
|
15
|
Krishnakumar C, Ballengee CR, Liu C, Kim MO, Baker SS, Baldassano RN, Cohen SA, Crandall WV, Denson LA, Dubinsky MC, Evans J, Gokhale R, Griffiths A, Guthery SL, Oliva-Hemker M, Heyman MB, Keljo D, Kellermayer R, Leleiko NS, Mack DR, Markowitz JF, Moulton DE, Noe JD, Otley AR, Patel AS, Pfefferkorn M, Rabizadeh S, Rosh JR, Snapper S, Walters TD, Ziring D, Mondal K, Kappelman MD, Hyams JS, Kugathasan S. Variation in Care in the Management of Children With Crohn's Disease: Data From a Multicenter Inception Cohort Study. Inflamm Bowel Dis 2019; 25:1208-1217. [PMID: 30601983 DOI: 10.1093/ibd/izy363] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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] [Indexed: 12/19/2022]
Abstract
BACKGROUND Variation in care is common in medical practice. Reducing variation in care is shown to improve quality and increase favorable outcomes in chronic diseases. We sought to identify factors associated with variation in care in children with newly diagnosed Crohn's disease (CD). METHODS Prospectively collected data from a 28-site multicenter inception CD cohort were analyzed for variations in diagnostic modalities, treatment, and follow-up monitoring practices, along with complicated disease outcomes over 3 years in 1046 children. Generalized linear mixed effects models were used to investigate the intercenter variations in each outcome variable. RESULTS The mean age at diagnosis was 12 years, and 25.9% were nonwhite. The number of participants ranged from 5 to 112 per site. No variation existed in the initial diagnostic approach. When medication exposure was analyzed, steroid exposure varied from 28.6% to 96.9% (P < 0.01) within 90 days, but variation was not significant over a 3-year period (P = 0.13). Early anti-tumor necrosis factor (anti-TNF) exposure (within 90 days) varied from 2.1% to 65.7% (P < 0.01), but variation was not significant over a 3-year period (P > 0.99). Use of immunomodulators (IMs) varied among centers both within 90 days (P < 0.01) and during 3 years of follow-up (P < 0.01). A significant variation was seen at the geographic level with follow-up small bowel imaging and colonoscopy surveillance after initial therapy. CONCLUSIONS Intercenter variation in care was seen with the initial use of steroids and anti-TNF, but there was no difference in total 3-year exposure to these drugs. Variation in the initiation and long-term use of IMs was significant among sites, but further research with objective measures is needed to explain this variation of care. Small bowel imaging or repeat colonoscopy in CD patients was not uniformly performed across sites. As our data show the widespread existence of variation in care and disease monitoring at geographic levels among pediatric CD patients, future implementation of various practice strategies may help reduce the variation in care.
Collapse
Affiliation(s)
- Chenthan Krishnakumar
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Cortney R Ballengee
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Susan S Baker
- Department of Digestive Diseases and Nutrition Center, University at Buffalo, Buffalo, New York
| | - Robert N Baldassano
- Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stanley A Cohen
- Department of Pediatrics, Children's Center for Digestive Health Care, LLC, Atlanta, Georgia
| | - Wallace V Crandall
- Department of Pediatric Gastroenterology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Marla C Dubinsky
- Department of Pediatrics, Mount Sinai Hospital, New York, New York
| | - Jonathan Evans
- Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, Florida
| | - Ranjana Gokhale
- Department of Pediatrics, The University of Chicago, Chicago, Illinois
| | - Anne Griffiths
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Maria Oliva-Hemker
- Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, Maryland
| | - Melvin B Heyman
- Department of Pediatrics, University of California at San Francisco, San Francisco, California
| | - David Keljo
- Department of Gastroenterology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Philadelphia
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Neal S Leleiko
- Department of Pediatrics, Hasbro Children's Hospital, Brown Medical School, Providence, Rhode Island
| | - David R Mack
- Department of Pediatrics, Children's Hospital of Eastern Ontario IBD Centre and University of Ottawa, Ottawa, Ontario, Canada
| | - James F Markowitz
- Department of Pediatrics, Cohen Children's Medical Center of New York, Northwell Health, New Hyde Park, New York
| | - Dedrick E Moulton
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joshua D Noe
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ashish S Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Marian Pfefferkorn
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shervin Rabizadeh
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joel R Rosh
- Department of Pediatrics, Goryeb Children's Hospital, Morristown, New Jersey
| | - Scott Snapper
- Department of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Thomas D Walters
- Department of Pediatrics, The University of Chicago, Chicago, Illinois
| | - David Ziring
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Kajari Mondal
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael D Kappelman
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jeffrey S Hyams
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana.,Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Department of Pediatrics, Emory University School of Medicine & Children's Healthcare of Atlanta, Atlanta, Georgia
| |
Collapse
|
16
|
Hyams JS, Davis Thomas S, Gotman N, Haberman Y, Karns R, Schirmer M, Mo A, Mack DR, Boyle B, Griffiths AM, LeLeiko NS, Sauer CG, Keljo DJ, Markowitz J, Baker SS, Rosh J, Baldassano RN, Patel A, Pfefferkorn M, Otley A, Heyman M, Noe J, Oliva-Hemker M, Rufo PA, Strople J, Ziring D, Guthery SL, Sudel B, Benkov K, Wali P, Moulton D, Evans J, Kappelman MD, Marquis MA, Sylvester FA, Collins MH, Venkateswaran S, Dubinsky M, Tangpricha V, Spada KL, Saul B, Wang J, Serrano J, Hommel K, Marigorta UM, Gibson G, Xavier RJ, Kugathasan S, Walters T, Denson LA. Clinical and biological predictors of response to standardised paediatric colitis therapy (PROTECT): a multicentre inception cohort study. Lancet 2019; 393:1708-1720. [PMID: 30935734 PMCID: PMC6501846 DOI: 10.1016/s0140-6736(18)32592-3] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [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] [Received: 08/12/2018] [Revised: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Lack of evidence-based outcomes data leads to uncertainty in developing treatment regimens in children who are newly diagnosed with ulcerative colitis. We hypothesised that pretreatment clinical, transcriptomic, and microbial factors predict disease course. METHODS In this inception cohort study, we recruited paediatric patients aged 4-17 years with newly diagnosed ulcerative colitis from 29 centres in the USA and Canada. Patients initially received standardised mesalazine or corticosteroids, with pre-established criteria for escalation to immunomodulators (ie, thiopurines) or anti-tumor necrosis factor-α (TNFα) therapy. We used RNA sequencing to define rectal gene expression before treatment, and 16S sequencing to characterise rectal and faecal microbiota. The primary outcome was week 52 corticosteroid-free remission with no therapy beyond mesalazine. We assessed factors associated with the primary outcome using logistic regression models of the per-protocol population. This study is registered with ClinicalTrials.gov, number NCT01536535. FINDINGS Between July 10, 2012, and April 21, 2015, of 467 patients recruited, 428 started medical therapy, of whom 400 (93%) were evaluable at 52 weeks and 386 (90%) completed the study period with no protocol violations. 150 (38%) of 400 participants achieved week 52 corticosteroid-free remission, of whom 147 (98%) were taking mesalazine and three (2%) were taking no medication. 74 (19%) of 400 were escalated to immunomodulators alone, 123 (31%) anti-TNFα therapy, and 25 (6%) colectomy. Low baseline clinical severity, high baseline haemoglobin, and week 4 clinical remission were associated with achieving week 52 corticosteroid-free remission (n=386, logistic model area under the curve [AUC] 0·70, 95% CI 0·65-0·75; specificity 77%, 95% CI 71-82). Baseline severity and remission by week 4 were validated in an independent cohort of 274 paediatric patients with newly diagnosed ulcerative colitis. After adjusting for clinical predictors, an antimicrobial peptide gene signature (odds ratio [OR] 0·57, 95% CI 0·39-0·81; p=0·002) and abundance of Ruminococcaceae (OR 1·43, 1·02-2·00; p=0·04), and Sutterella (OR 0·81, 0·65-1·00; p=0·05) were independently associated with week 52 corticosteroid-free remission. INTERPRETATION Our findings support the utility of initial clinical activity and treatment response by 4 weeks to predict week 52 corticosteroid-free remission with mesalazine alone in children who are newly diagnosed with ulcerative colitis. The development of personalised clinical and biological signatures holds the promise of informing ulcerative colitis therapeutic decisions. FUNDING US National Institutes of Health.
Collapse
Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA.
| | - Sonia Davis Thomas
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA; Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA; RTI International, Research Triangle Park, NC, USA
| | - Nathan Gotman
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Yael Haberman
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA; Sheba Medical Center, affiliated with the Tel Aviv University, Tel Hashomer, Israel
| | - Rebekah Karns
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Melanie Schirmer
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Angela Mo
- Georgia Institute of Technology, Atlanta, GA, USA
| | - David R Mack
- School of Biological Sciences, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Brendan Boyle
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Anne M Griffiths
- Divisioin of Pediatric Gastroenterology, Hospital For Sick Children, Toronto, ON, Canada
| | - Neal S LeLeiko
- IBD Centre, Department of Paediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - Cary G Sauer
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - David J Keljo
- Division of Gastroenterology, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James Markowitz
- Division of Gastroenterology, Hepatology, and Nutrition, Cohen Children's Medical Center Of New York, New Hyde Park, NY, USA
| | - Susan S Baker
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Women & Children's Hospital of Buffalo WCHOB, Buffalo, NY, USA
| | - Joel Rosh
- Division of Gastroenterology, Hepatology, and Nutrition, Goryeb Children's Hospital, Atlantic Health, Morristown, NJ, USA
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology, and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashish Patel
- Division of Gastroenterology, Hepatology, and Nutrition, UT Southwestern, Dallas, TX, USA
| | - Marian Pfefferkorn
- Division of Gastroenterology, Hepatology, and Nutrition, Riley Children's Hospital Indiana, Indianapolis, IN, USA
| | - Anthony Otley
- Division of Gastroenterology, Hepatology, and Nutrition, IWK Health Centre, Halifax, NS, Canada
| | - Melvin Heyman
- Division of Gastroenterology, Hepatology, and Nutrition, University of California at San Francisco, San Francisco, CA, USA
| | - Joshua Noe
- Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maria Oliva-Hemker
- Division of Gastroenterology, Hepatology, and Nutrition, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Paul A Rufo
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Boston, Harvard Medical School Boston, MA, USA
| | - Jennifer Strople
- Division of Gastroenterology, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Ziring
- Division of Gastroenterology, Hepatology, and Nutrition, UCLA Medical Center, Los Angeles, CA, USA
| | - Stephen L Guthery
- Division of Gastroenterology, Hepatology, and Nutrition, Primary Children's Hospital and the University of Utah, Salt Lake City, UT, USA
| | - Boris Sudel
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Keith Benkov
- Division of Gastroenterology, Hepatology, and Nutrition, Mt Sinai Hospital, New York City, NY, USA
| | - Prateek Wali
- Division of Gastroenterology, Hepatology, and Nutrition, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Dedrick Moulton
- Division of Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr Children's Hospital of Vanderbilt, Nashville, TN, USA
| | - Jonathan Evans
- Division of Gastroenterology, Hepatology, and Nutrition, Nemours Children's Clinic, Jacksonville, FL, USA
| | - Michael D Kappelman
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - M Alison Marquis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Margaret H Collins
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Suresh Venkateswaran
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - Marla Dubinsky
- Division of Gastroenterology, Hepatology, and Nutrition, Mt Sinai Hospital, New York City, NY, USA
| | - Vin Tangpricha
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - Krista L Spada
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Bradley Saul
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jessie Wang
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jose Serrano
- National Institutes of Diabetes, Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Kevin Hommel
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Greg Gibson
- Georgia Institute of Technology, Atlanta, GA, USA
| | - Ramnik J Xavier
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Center for Computational and Integrative Biology, Gastrointestinal Unit, and Center for the Study of Inflammatory Bowel Disease, Massachusetts General Hospital, Boston, MA, USA; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Subra Kugathasan
- Divisioin of Pediatric Gastroenterology, Nutritiion, and Liver Disease, Emory University, Atlanta, GA, USA
| | - Thomas Walters
- Divisioin of Pediatric Gastroenterology, Hospital For Sick Children, Toronto, ON, Canada
| | - Lee A Denson
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
17
|
Schirmer M, Denson L, Vlamakis H, Franzosa EA, Thomas S, Gotman NM, Rufo P, Baker SS, Sauer C, Markowitz J, Pfefferkorn M, Oliva-Hemker M, Rosh J, Otley A, Boyle B, Mack D, Baldassano R, Keljo D, LeLeiko N, Heyman M, Griffiths A, Patel AS, Noe J, Kugathasan S, Walters T, Huttenhower C, Hyams J, Xavier RJ. Compositional and Temporal Changes in the Gut Microbiome of Pediatric Ulcerative Colitis Patients Are Linked to Disease Course. Cell Host Microbe 2018; 24:600-610.e4. [PMID: 30308161 PMCID: PMC6277984 DOI: 10.1016/j.chom.2018.09.009] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/28/2018] [Accepted: 09/03/2018] [Indexed: 12/11/2022]
Abstract
Evaluating progression risk and determining optimal therapy for ulcerative colitis (UC) is challenging as many patients exhibit incomplete responses to treatment. As part of the PROTECT (Predicting Response to Standardized Colitis Therapy) Study, we evaluated the role of the gut microbiome in disease course for 405 pediatric, new-onset, treatment-naive UC patients. Patients were monitored for 1 year upon treatment initiation, and microbial taxonomic composition was analyzed from fecal samples and rectal biopsies. Depletion of core gut microbes and expansion of bacteria typical of the oral cavity were associated with baseline disease severity. Remission and refractory disease were linked to species-specific temporal changes that may be implicative of therapy efficacy, and a pronounced increase in microbiome variability was observed prior to colectomy. Finally, microbial associations with disease-associated serological markers suggest host-microbial interactions in UC. These insights will help improve existing treatments and develop therapeutic approaches guiding optimal medical care.
Collapse
Affiliation(s)
- Melanie Schirmer
- The Broad Institute of MIT and Harvard, Infectious Disease and Microbiome, Cambridge, MA 02142, USA; Harvard T.H. Chan School of Public Health, Biostatistics Department, Boston, MA 02115, USA
| | - Lee Denson
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Hera Vlamakis
- The Broad Institute of MIT and Harvard, Infectious Disease and Microbiome, Cambridge, MA 02142, USA; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Molecular Biology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric A Franzosa
- The Broad Institute of MIT and Harvard, Infectious Disease and Microbiome, Cambridge, MA 02142, USA; Harvard T.H. Chan School of Public Health, Biostatistics Department, Boston, MA 02115, USA
| | - Sonia Thomas
- Collaborative Studies Coordinating Center, Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27516, USA; RTI International, Biostatistics and Epidemiology Division, Research Triangle Park, NC 27709, USA
| | - Nathan M Gotman
- Collaborative Studies Coordinating Center, Department of Biostatistics, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Paul Rufo
- Children's Hospital Boston, Boston, MA 02115, USA
| | - Susan S Baker
- Women and Children's Hospital of Buffalo WCHOB, Buffalo, NY 14222, USA
| | - Cary Sauer
- Emory Children's Center, Atlanta, GA 30322, USA
| | - James Markowitz
- Cohen Children's Medical Center, Pediatric Gastroenterology, New York, NY 11040, USA
| | - Marian Pfefferkorn
- Riley Children's Hospital Indiana University, School of Medicine, Section of Gastroenterology/Hepatology/Nutrition, Indianapolis, IN 46202, USA
| | - Maria Oliva-Hemker
- Johns Hopkins Children's Center, Department of Pediatrics, Baltimore, MD 21287, USA
| | - Joel Rosh
- Goryeb Children's Hospital/Atlantic Health, Pediatric Gastroenterology, Morristown, NJ 07960, USA
| | - Anthony Otley
- IWK Health Centre, Division of Gastroenterology and Nutrition, Halifax, NS B3K 6R8, Canada
| | - Brendan Boyle
- Nationwide Children's Hospital, Pediatrics, Columbus, OH 43205, USA
| | - David Mack
- Children's Hospital of Eastern Ontario and University of Ottawa, Department of Pediatrics, Ottawa, ON K1H 8L1, Canada
| | - Robert Baldassano
- Children's Hospital of Philadelphia CHOP, Pediatric Gastroenterologist, Philadelphia, PA 19104, USA
| | - David Keljo
- UPMC Children's Hospital of Pittsburgh, Department of Pediatrics, Pittsburgh, PA 15224, USA
| | - Neal LeLeiko
- Hasbro Children's Hospital, Pediatric Gastroenterology, Providence, RI 02903, USA
| | - Melvin Heyman
- University of California at San Francisco, Pediatric Gastroenterology, San Francisco, CA 94158, USA
| | - Anne Griffiths
- Sickkids Hospital, University of Toronto, Gastroenterology, Hepatology and Nutrition, Toronto, ON M5G 1X8, Canada
| | - Ashish S Patel
- UT Southwestern, Department of Pediatrics, Dallas, TX 75390, USA
| | - Joshua Noe
- Medical College of Wisconsin, Gastroenterology, Milwaukee, WI 53226, USA
| | | | - Thomas Walters
- Sickkids Hospital, University of Toronto, Gastroenterology, Hepatology and Nutrition, Toronto, ON M5G 1X8, Canada
| | - Curtis Huttenhower
- The Broad Institute of MIT and Harvard, Infectious Disease and Microbiome, Cambridge, MA 02142, USA; Harvard T.H. Chan School of Public Health, Biostatistics Department, Boston, MA 02115, USA
| | - Jeffrey Hyams
- Connecticut Children's Medical Center, Division of Digestive Diseases, Hartford, CT 06106, USA
| | - Ramnik J Xavier
- The Broad Institute of MIT and Harvard, Infectious Disease and Microbiome, Cambridge, MA 02142, USA; Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA 02114, USA; Gastrointestinal Unit and Center for the Study of Inflammatory Bowel Disease, Massachusetts General Hospital, Boston, MA 02114, USA; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Molecular Biology, Massachusetts General Hospital, Boston, MA 02114, USA.
| |
Collapse
|
18
|
Kerur B, Machan JT, Shapiro JM, Cerezo CS, Markowitz J, Mack DR, Griffiths AM, Otley AR, Pfefferkorn MD, Rosh JR, Keljo DJ, Boyle B, Oliva-Hemker M, Kay MH, Saeed SA, Grossman AB, Sudel B, Kappelman MD, Schaefer M, Tomer G, Bousvaros A, Lerer T, Hyams JS, LeLeiko NS. Biologics Delay Progression of Crohn's Disease, but Not Early Surgery, in Children. Clin Gastroenterol Hepatol 2018; 16:1467-1473. [PMID: 29486253 DOI: 10.1016/j.cgh.2018.02.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [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: 05/31/2017] [Revised: 02/09/2018] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Up to 30% of patients with Crohn's disease (CD) require surgery within the first 5 years from diagnosis. We investigated the recent risk of bowel surgery in an inception cohort of pediatric patients with CD and whether early use of biologics (tumor necrosis factor antagonists) alters later disease course. METHODS We collected data from the Pediatric Inflammatory Bowel Disease Collaborative Research Group registry on 1442 children (age, ≤16 y) diagnosed with CD from January 2002 through December 2014. Data were collected at diagnosis, 30 days following diagnosis, and then quarterly and during hospitalizations for up to 12 years. Our primary aim was to determine the 10-year risk for surgery in children with CD. Our secondary aim was to determine whether early use of biologics (<3 mo of diagnosis) affected risk of disease progression. RESULTS The 10-year risk of first bowel surgery was 26%. The 5-year risk of bowel surgery did not change from 2002 through 2014, and remained between 13% and 14%. Most surgeries occurred within 3 years from diagnosis. The only predictor of surgery was disease behavior at diagnosis. CD with inflammatory behavior had the lowest risk of surgery compared to stricturing disease, penetrating disease, or both. We associated slowing of disease progression to stricturing or penetrating disease (but not surgery) with early use of biologics, but this effect only became evident after 5 years of disease. Our results indicate that biologics slow disease progression over time (hazard ratio, 0.85; 95% CI, 0.76-0.95). CONCLUSIONS In an analysis of data from a registry of pediatric patients with CD, we found that among those with significant and progressing disease at or shortly after presentation, early surgery is difficult to prevent, even with early use of biologics. Early use of biologics (<3 mo of diagnosis) can delay later disease progression to stricturing and/or penetrating disease, but this affect could become evident only years after initial management decisions are made.
Collapse
Affiliation(s)
- Basavaraj Kerur
- Pediatric Gastroenterology and Nutrition, Hasbro Children Hospital, Providence, Rhode Island; The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Jason T Machan
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island; Lifespan Biostatistics Core, Rhode Island Hospital, Providence, Rhode Island
| | - Jason M Shapiro
- Pediatric Gastroenterology and Nutrition, Hasbro Children Hospital, Providence, Rhode Island; The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Carolina S Cerezo
- Pediatric Gastroenterology and Nutrition, Hasbro Children Hospital, Providence, Rhode Island; The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - James Markowitz
- Steven & Alexandra Cohen Children's Medical Center, Lake Success, New York
| | - David R Mack
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | | | | | - Joel R Rosh
- Goryeb Children's Hospital/Atlantic Health, Morristown, New Jersey
| | - David J Keljo
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Marsha H Kay
- The Cleveland Clinic Foundation, Cleveland, Ohio
| | | | | | - Boris Sudel
- University of Minnesota, Minneapolis, Minnesota
| | | | - Marc Schaefer
- Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Gitit Tomer
- Children's Hospital at Montefiore, Bronx, New York
| | | | - Trudy Lerer
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Jeffrey S Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Neal S LeLeiko
- Pediatric Gastroenterology and Nutrition, Hasbro Children Hospital, Providence, Rhode Island; The Warren Alpert Medical School, Brown University, Providence, Rhode Island.
| |
Collapse
|
19
|
Affiliation(s)
- Joseph A. Murray
- Professor of Medicine, Director, Celiac Disease Program, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. Tel: 507-255-5713. Fax: 507-255-6318
| | - Mark R. Frey
- Associate Professor of Pediatrics and Biochemistry & Molecular Medicine, The Saban Research Institute at Children’s Hospital Los Angeles, University of Southern California, 4650 Sunset Blvd, Mailstop #137, Los Angeles, CA 90027. Tel: 323-361-7204
| | - Maria Oliva-Hemker
- Stermer Family Professor of Pediatric Inflammatory Bowel Disease, Director, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins University School of Medicine, CMSC 2-116, 600 N. Wolfe Street, Baltimore, MD 21287-2631. Tel: 410-955-8769. Fax: 410-955-1464
| |
Collapse
|
20
|
Spencer EA, Davis SM, Mack DR, Boyle BM, Griffiths AM, LeLeiko NS, Sauer CG, Keljo DJ, Markowitz JF, Baker SS, Rosh JR, Baldassano RN, Oliva-Hemker M, Pfefferkorn MD, Otley AR, Heyman MB, Noe JD, Patel AS, Rufo PA, Alison Marquis M, Walters TD, Collins MH, Kugathasan S, Denson LA, Hyams JS, Dubinsky MC. Serologic Reactivity Reflects Clinical Expression of Ulcerative Colitis in Children. Inflamm Bowel Dis 2018; 24:1335-1343. [PMID: 29718391 PMCID: PMC6093192 DOI: 10.1093/ibd/izy009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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] [Received: 09/07/2017] [Indexed: 12/18/2022]
Abstract
Background In contrast to pediatric Crohn's disease (CD), little is known in pediatric ulcerative colitis (UC) about the relationship between disease phenotype and serologic reactivity to microbial and other antigens. Aim The aim of this study was to examine disease phenotype and serology in a well-characterized inception cohort of children newly diagnosed with UC during the PROTECT Study (Predicting Response to Standardized Pediatric Colitis Therapy). Methods Patients were recruited from 29 participating centers. Demographic, clinical, laboratory, and serologic (pANCA, ASCA IgA/IgG, Anti-CBir1, and Anti-OmpC) data were obtained from children 4-17 years old with UC. Results Sixty-five percent of the patients had positive serology for pANCA, with 62% less than 12 years old and 66% 12 years old or older. Perinuclear anti-neutrophil cytoplasmic antibodies did not correspond to a specific phenotype though pANCA ≥100, found in 19%, was strongly associated with pancolitis (P = 0.003). Anti-CBir1 was positive in 19% and more common in younger children with 32% less than 12 years old as compared with 14% 12 years old or older (P < 0.001). No association was found in any age group between pANCA and Anti-CBir1. Relative rectal sparing was more common in +CBir1, 16% versus 7% (P = 0.02). Calprotectin was lower in Anti-CBir1+ (Median [IQR] 1495 mcg/g [973-3333] vs 2648 mcg/g [1343-4038]; P = 0.04). Vitamin D 25-OH sufficiency was associated with Anti-CBir1+ (P = 0.0009). Conclusions The frequency of pANCA in children was consistent with adult observations. High titer pANCA was associated with more extensive disease, supporting the idea that the magnitude of immune reactivity may reflect disease severity. Anti-CBir1+ was more common in younger ages, suggesting host-microbial interactions may differ by patient age.
Collapse
Affiliation(s)
| | - Sonia M Davis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - David R Mack
- Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | | | - Neal S LeLeiko
- Hasbro Children’s Hospital, Providence, Rhode Island, USA
| | | | - David J Keljo
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | | | | | - Joel R Rosh
- Goryeb Children’s Hospital, Morristown, New Jersey, USA
| | | | | | | | | | - Melvin B Heyman
- University of California at San Francisco, San Francisco, California, USA
| | - Joshua D Noe
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Paul A Rufo
- Boston Children’s Hospital, Boston, Massachusetts, USA
| | - M Alison Marquis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | | | - Lee A Denson
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey S Hyams
- Connecticut Children’s Medical Center, Hartford, Connecticut, USA
| | - Marla C Dubinsky
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| |
Collapse
|
21
|
Venkateswaran S, Prince J, Cutler DJ, Marigorta UM, Okou DT, Prahalad S, Mack D, Boyle B, Walters T, Griffiths A, Sauer CG, LeLeiko N, Keljo D, Markowitz J, Baker SS, Rosh J, Pfefferkorn M, Heyman MB, Patel A, Otley A, Baldassano R, Noe J, Rufo P, Oliva-Hemker M, Davis S, Zwick ME, Gibson G, Denson LA, Hyams J, Kugathasan S. Enhanced Contribution of HLA in Pediatric Onset Ulcerative Colitis. Inflamm Bowel Dis 2018; 24:829-838. [PMID: 29562276 PMCID: PMC6350448 DOI: 10.1093/ibd/izx084] [Citation(s) in RCA: 18] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The genetic contributions to pediatric onset ulcerative colitis (UC), characterized by severe disease and extensive colonic involvement, are largely unknown. In adult onset UC, Genome Wide Association Study (GWAS) has identified numerous loci, most of which have a modest susceptibility risk (OR 0.84-1.14), with the exception of the human leukocyte antigen (HLA) region on Chromosome 6 (OR 3.59). METHOD To study the genetic contribution to exclusive pediatric onset UC, a GWAS was performed on 466 cases with 2099 healthy controls using UK Biobank array. SNP2HLA was used to impute classical HLA alleles and their corresponding amino acids, and the results are compared with adult onset UC. RESULTS HLA explained the almost entire association signal, dominated with 191 single nucleotide polymorphisms (SNPs) (p = 5 x 10-8 to 5 x 10-10). Although very small effects, established SNPs in adult onset UC loci had similar direction and magnitude in pediatric onset UC. SNP2HLA imputation identified HLA-DRB1*0103 (odds ratio [OR] = 6.941, p = 1.92*10-13) as the most significant association for pediatric UC compared with adult onset UC (OR = 3.59). Further conditioning showed independent effects for HLA-DRB1*1301 (OR = 2.25, p = 7.92*10-9) and another SNP rs17188113 (OR = 0.48, p = 7.56*10-9). Two HLA-DRB1 causal alleles are shared with adult onset UC, while at least 2 signals are unique to pediatric UC. Subsequent stratified analyses indicated that HLA-DRB1*0103 has stronger association for extensive disease (E4: OR = 8.28, p = 4.66x10-10) and female gender (OR = 8.85, p = 4.82x10-13). CONCLUSION In pediatric onset UC, the HLA explains almost the entire genetic associations. In addition, the HLA association is approximately twice as strong in pediatric UC compared with adults, due to a combination of novel and shared effects. We speculate the paramount importance of antigenic stimulation either by infectious or noninfectious stimuli as a causal event in pediatric UC onset.
Collapse
Affiliation(s)
- Suresh Venkateswaran
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - Jarod Prince
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - David J Cutler
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA
| | - Urko M Marigorta
- Center for Integrative Genomics, Georgia Institute of Technology, Atlanta, GA
| | - David T Okou
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - Sampath Prahalad
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - David Mack
- Department of Pediatrics, Children’s Hospital of Eastern Ontario IBD Centre and University of Ottawa, Ontario, Canada
| | - Brendan Boyle
- Department of Gastroenterology, Nationwide Children’s Hospital Columbus, OH
| | - Thomas Walters
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Anne Griffiths
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Cary G Sauer
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA
| | - Neal LeLeiko
- Division of Pediatric Gastroenterology, Nutrition, and Liver Diseases, Hasbro Children’s Hospital, Providence, RI
| | - David Keljo
- Gastroenterology, Hepatology and Nutrition Department, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - James Markowitz
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cohen Children’s Medical Center of NY, New Hyde Park, NY
| | - Susan S Baker
- Department of Digestive Diseases and Nutrition Center, University at Buffalo, Buffalo, NY
| | - Joel Rosh
- Department of Pediatrics, Goryeb Children’s Hospital, Morristown, NJ
| | - Marian Pfefferkorn
- Bronson Pediatric Gastroenterology, Bronson Children’s Hospital, Kalamazoo, MI
| | - Melvin B Heyman
- Department of Pediatrics, University of California at San Francisco, San Francisco, CA
| | - Ashish Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anthony Otley
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Robert Baldassano
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA
| | - Joshua Noe
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Paul Rufo
- Division of Gastroenterology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Maria Oliva-Hemker
- Department of Pediatrics, John Hopkins University School of Medicine, Baltimore, MD
| | - Sonia Davis
- Collaborative Studies Coordinating Center Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Michael E Zwick
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA
| | - Greg Gibson
- Center for Integrative Genomics, Georgia Institute of Technology, Atlanta, GA
| | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jeffrey Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children’s Medical Center, Hartford, CT
| | - Subra Kugathasan
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, GA,Address correspondence to: Subra Kugathasan, MD, Division of Pediatric Gastroenterology, Emory University School of Medicine, 1760 Haygood Drive, W427, Atlanta, GA 30322. E-mail: Tel: 404 727 4542; Fax: 404 727 4069
| |
Collapse
|
22
|
Hankinson JC, Borden L, Allen T, Santo Domingo L, Oliva-Hemker M, Mathews T, Brock K, Perry-Parrish C, Reynolds EK, Specht M, Ostrander R. Outcomes of combined medical and behavioral treatments for constipation within a specialty outpatient clinic. Clinical Practice in Pediatric Psychology 2018. [DOI: 10.1037/cpp0000202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
23
|
Haberman Y, BenShoshan M, Di Segni A, Dexheimer PJ, Braun T, Weiss B, Walters TD, Baldassano RN, Noe JD, Markowitz J, Rosh J, Heyman MB, Griffiths AM, Crandall WV, Mack DR, Baker SS, Kellermayer R, Patel A, Otley A, Steiner SJ, Gulati AS, Guthery SL, LeLeiko N, Moulton D, Kirschner BS, Snapper S, Avivi C, Barshack I, Oliva-Hemker M, Cohen SA, Keljo DJ, Ziring D, Anikster Y, Aronow B, Hyams JS, Kugathasan S, Denson LA. Long ncRNA Landscape in the Ileum of Treatment-Naive Early-Onset Crohn Disease. Inflamm Bowel Dis 2018; 24:346-360. [PMID: 29361088 PMCID: PMC6231367 DOI: 10.1093/ibd/izx013] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [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: 07/14/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long noncoding RNAs (lncRNA) are key regulators of gene transcription and many show tissue-specific expression. We previously defined a novel inflammatory and metabolic ileal gene signature in treatment-naive pediatric Crohn disease (CD). We now extend our analyses to include potential regulatory lncRNA. METHODS Using RNAseq, we systematically profiled lncRNAs and protein-coding gene expression in 177 ileal biopsies. Co-expression analysis was used to identify functions and tissue-specific expression. RNA in situ hybridization was used to validate expression. Real-time polymerase chain reaction was used to test lncRNA regulation by IL-1β in Caco-2 enterocytes. RESULTS We characterize widespread dysregulation of 459 lncRNAs in the ileum of CD patients. Using only the lncRNA in discovery and independent validation cohorts showed patient classification as accurate as the protein-coding genes, linking lncRNA to CD pathogenesis. Co-expression and functional annotation enrichment analyses across several tissues and cell types 1showed that the upregulated LINC01272 is associated with a myeloid pro-inflammatory signature, whereas the downregulated HNF4A-AS1 exhibits association with an epithelial metabolic signature. We confirmed tissue-specific expression in biopsies using in situ hybridization, and validated regulation of prioritized lncRNA upon IL-1β exposure in differentiated Caco-2 cells. Finally, we identified significant correlations between LINC01272 and HNF4A-AS1 expression and more severe mucosal injury. CONCLUSIONS We systematically define differentially expressed lncRNA in the ileum of newly diagnosed pediatric CD. We show lncRNA utility to correctly classify disease or healthy states and demonstrate their regulation in response to an inflammatory signal. These lncRNAs, after mechanistic exploration, may serve as potential new tissue-specific targets for RNA-based interventions.
Collapse
Affiliation(s)
- Yael Haberman
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Sheba Medical Center, Israel,Address correspondence to: Yael Haberman, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, MLC 2010, 3333 Burnet Avenue, Cincinnati, OH 45229 ()
| | | | | | | | | | - Batia Weiss
- Sheba Medical Center, Israel,Tel Aviv University, Israel
| | - Thomas D Walters
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Joshua D Noe
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Joel Rosh
- Goryeb Children’s Hospital/Atlantic Health, Morristown, New Jersey
| | - Melvin B Heyman
- University of California, San Francisco, San Francisco, California
| | - Anne M Griffiths
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - David R Mack
- Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | | | | | - Ashish Patel
- UT Southwestern Medical Center at Dallas, Dallas, Texas
| | | | | | - Ajay S Gulati
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | | | | | | | - Iris Barshack
- Sheba Medical Center, Israel,Tel Aviv University, Israel
| | | | - Stanley A Cohen
- Children’s Center for Digestive Healthcare, Atlanta, Georgia
| | - David J Keljo
- Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Yair Anikster
- Sheba Medical Center, Israel,Tel Aviv University, Israel
| | - Bruce Aronow
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey S Hyams
- Connecticut Children’s Medical Center, Hartford, Connecticut
| | | | - Lee A Denson
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| |
Collapse
|
24
|
Hyams JS, Davis S, Mack DR, Boyle B, Griffiths AM, LeLeiko NS, Sauer CG, Keljo DJ, Markowitz J, Baker SS, Rosh J, Baldassano RN, Patel A, Pfefferkorn M, Otley A, Heyman M, Noe J, Oliva-Hemker M, Rufo P, Strople J, Ziring D, Guthery SL, Sudel B, Benkov K, Wali P, Moulton D, Evans J, Kappelman MD, Marquis A, Sylvester FA, Collins MH, Venkateswaran S, Dubinsky M, Tangpricha V, Spada KL, Britt A, Saul B, Gotman N, Wang J, Serrano J, Kugathasan S, Walters T, Denson LA. Factors associated with early outcomes following standardised therapy in children with ulcerative colitis (PROTECT): a multicentre inception cohort study. Lancet Gastroenterol Hepatol 2017; 2:855-868. [PMID: 28939374 PMCID: PMC5695708 DOI: 10.1016/s2468-1253(17)30252-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/25/2017] [Accepted: 07/28/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Previous retrospective studies of paediatric ulcerative colitis have had limited ability to describe disease progression and identify predictors of treatment response. In this study, we aimed to identify characteristics associated with outcomes following standardised therapy after initial diagnosis. METHODS The PROTECT multicentre inception cohort study was based at 29 centres in the USA and Canada and included paediatric patients aged 4-17 years who were newly diagnosed with ulcerative colitis. Guided by the Pediatric Ulcerative Colitis Activity Index (PUCAI), patients received initial standardised treatment with mesalazine (PUCAI 10-30) oral corticosteroids (PUCAI 35-60), or intravenous corticosteroids (PUCAI ≥65). The key outcomes for this analysis were week 12 corticosteroid-free remission, defined as PUCAI less than 10 and taking only mesalazine, and treatment escalation during the 12 study weeks to anti-tumour necrosis factor α (TNFα) agents, immunomodulators, or colectomy among those initially treated with intravenous corticosteroids. We identified independent predictors of outcome through multivariable logistic regression using a per-protocol approach. This study is registered with ClinicalTrials.gov, number NCT01536535. FINDINGS Patients were recruited between July 10, 2012, and April 21, 2015. 428 children initiated mesalazine (n=136), oral corticosteroids (n=144), or intravenous corticosteroids (n=148). Initial mean PUCAI was 31·1 (SD 13·3) in children initiating with mesalazine, 50·4 (13·8) in those initiating oral corticosteroids, and 66·9 (13·7) in those initiating intravenous corticosteroids (p<0·0001 for between-group comparison). Week 12 outcome data were available for 132 patients who initiated with mesalazine, 141 with oral corticosteroids, and 143 with intravenous corticosteroids. Corticosteroid-free remission with the patient receiving mesalazine treatment only at 12 weeks was achieved by 64 (48%) patients in the mesalazine group, 47 (33%) in the oral corticosteroid group, and 30 (21%) in the intravenous corticosteroid group (p<0·0001). Treatment escalation was required by nine (7%) patients in the mesalazine group, 21 (15%) in the oral corticosteroid group, and 52 (36%) in the intravenous corticosteroid group (p<0·0001). Eight patients, all of whom were initially treated with intravenous corticosteroids, underwent colectomy. Predictors of week 12 corticosteroid-free remission were baseline PUCAI less than 35 (odds ratio 2·44, 95% CI 1·41-4·22; p=0·0015), higher baseline albumin by 1 g/dL increments among children younger than 12 years (4·05, 1·90-8·64; p=0·00030), and week 4 remission (6·26, 3·79-10·35; p<0·0001). Predictors of treatment escalation by week 12 in patients initially treated with intravenous corticosteroids included baseline total Mayo score of 11 or higher (2·59, 0·93-7·21; p=0·068 [retained in model due to clinical relevance]), rectal biopsy eosinophil count less than or equal to 32 cells per high power field (4·55, 1·62-12·78; p=0·0040), rectal biopsy surface villiform changes (3·05, 1·09-8·56; p=0·034), and not achieving week 4 remission (30·28, 6·36-144·20; p<0·0001). INTERPRETATION Our findings provide guidelines to assess the response of children newly diagnosed with ulcerative colitis to standardised initial therapy and identify predictors of treatment response and failure. These data suggest that additional therapeutic interventions might be warranted to improve early outcomes, especially in patients presenting with severe disease and requiring intravenous corticosteroids. FUNDING National Institutes of Health.
Collapse
Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA.
| | - Sonia Davis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - David R Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of East Ontario, Ottawa, ON, Canada
| | - Brendan Boyle
- Gastroenterology & Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Anne M Griffiths
- Gastroenterology, Hepatology and Nutrition, Hospital For Sick Children, Toronto, ON, Canada
| | - Neal S LeLeiko
- Division of Pediatric Gastroenterology, Nutrition & Liver Diseases, Hasbro Children's Hospital, Providence, RI, USA
| | - Cary G Sauer
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - David J Keljo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - James Markowitz
- Division of Pediatric Gastroenterology, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Susan S Baker
- Gastroenterology (Digestive Diseases and Nutrition), Women & Children's Hospital of Buffalo WCHOB, Buffalo, NY, USA
| | - Joel Rosh
- Pediatric Gastroenterology and Nutrition, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashish Patel
- Pediatric Gastroenterology, UT Southwestern, Dallas, TX, USA
| | - Marian Pfefferkorn
- Pediatric Gastroenterology, Hepatology and Nutrition, Riley Children's Hospital Indiana, Indianapolis, IN, USA
| | - Anthony Otley
- Division of Gastroenterology and Nutrition, IWK Health Centre, Halifax, NS, Canada
| | - Melvin Heyman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of California at San Francisco, San Francisco, CA, USA
| | - Joshua Noe
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Maria Oliva-Hemker
- Pediatric Gastroenterology, Hepatology and Nutrition, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Paul Rufo
- Gastroenterology, Hepatology and Nutrition, Harvard-Children's Hospital Boston, Boston, MA, USA
| | - Jennifer Strople
- Gastroenterology, Hepatology & Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David Ziring
- Division of Digestive Diseases and Nutrition, UCLA Medical Center, Los Angeles, CA, USA
| | - Stephen L Guthery
- Pediatric Gastroenterology, Hepatology, Nutrition, Primary Children's Medical Center University of Utah, Salt Lake City, UT, USA
| | - Boris Sudel
- Division of Gastroenterology Hepatology and Nutrition, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Keith Benkov
- Division of Pediatric Gastroenterology, Mt Sinai Hospital, New York City, NY, USA
| | - Prateek Wali
- Division of Pediatric Gastroenterology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Dedrick Moulton
- Division of Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr Children's Hospital of Vanderbilt, Nashville, TN, USA
| | - Jonathan Evans
- Division of Pediatric Gastroenterology and Nutrition Nemours Children's Clinic, Jacksonville, FL, USA
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alison Marquis
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Francisco A Sylvester
- Division of Pediatric Gastroenterology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Margaret H Collins
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Marla Dubinsky
- Division of Pediatric Gastroenterology, Mt Sinai Hospital, New York City, NY, USA
| | - Vin Tangpricha
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - Krista L Spada
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Ashley Britt
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Bradley Saul
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Nathan Gotman
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jessie Wang
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jose Serrano
- National Institutes of Diabetes, Digestive and Kidney Diseases, Bethesda, MD, USA
| | - Subra Kugathasan
- Division of Pediatric Gastroenterology, Emory University, Atlanta, GA, USA
| | - Thomas Walters
- Gastroenterology, Hepatology and Nutrition, Hospital For Sick Children, Toronto, ON, Canada
| | - Lee A Denson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
25
|
Kugathasan S, Denson LA, Walters TD, Kim MO, Marigorta UM, Schirmer M, Mondal K, Liu C, Griffiths A, Noe JD, Crandall WV, Snapper S, Rabizadeh S, Rosh JR, Shapiro JM, Guthery S, Mack DR, Kellermayer R, Kappelman MD, Steiner S, Moulton DE, Keljo D, Cohen S, Oliva-Hemker M, Heyman MB, Otley AR, Baker SS, Evans JS, Kirschner BS, Patel AS, Ziring D, Trapnell BC, Sylvester FA, Stephens MC, Baldassano RN, Markowitz JF, Cho J, Xavier RJ, Huttenhower C, Aronow BJ, Gibson G, Hyams JS, Dubinsky MC. Prediction of complicated disease course for children newly diagnosed with Crohn's disease: a multicentre inception cohort study. Lancet 2017; 389:1710-1718. [PMID: 28259484 PMCID: PMC5719489 DOI: 10.1016/s0140-6736(17)30317-3] [Citation(s) in RCA: 407] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 11/18/2016] [Accepted: 11/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Stricturing and penetrating complications account for substantial morbidity and health-care costs in paediatric and adult onset Crohn's disease. Validated models to predict risk for complications are not available, and the effect of treatment on risk is unknown. METHODS We did a prospective inception cohort study of paediatric patients with newly diagnosed Crohn's disease at 28 sites in the USA and Canada. Genotypes, antimicrobial serologies, ileal gene expression, and ileal, rectal, and faecal microbiota were assessed. A competing-risk model for disease complications was derived and validated in independent groups. Propensity-score matching tested the effect of anti-tumour necrosis factor α (TNFα) therapy exposure within 90 days of diagnosis on complication risk. FINDINGS Between Nov 1, 2008, and June 30, 2012, we enrolled 913 patients, 78 (9%) of whom experienced Crohn's disease complications. The validated competing-risk model included age, race, disease location, and antimicrobial serologies and provided a sensitivity of 66% (95% CI 51-82) and specificity of 63% (55-71), with a negative predictive value of 95% (94-97). Patients who received early anti-TNFα therapy were less likely to have penetrating complications (hazard ratio [HR] 0·30, 95% CI 0·10-0·89; p=0·0296) but not stricturing complication (1·13, 0·51-2·51; 0·76) than were those who did not receive early anti-TNFα therapy. Ruminococcus was implicated in stricturing complications and Veillonella in penetrating complications. Ileal genes controlling extracellular matrix production were upregulated at diagnosis, and this gene signature was associated with stricturing in the risk model (HR 1·70, 95% CI 1·12-2·57; p=0·0120). When this gene signature was included, the model's specificity improved to 71%. INTERPRETATION Our findings support the usefulness of risk stratification of paediatric patients with Crohn's disease at diagnosis, and selection of anti-TNFα therapy. FUNDING Crohn's and Colitis Foundation of America, Cincinnati Children's Hospital Research Foundation Digestive Health Center.
Collapse
Affiliation(s)
- Subra Kugathasan
- Division of Pediatric Gastroenterology, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Lee A Denson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas D Walters
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mi-Ok Kim
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Urko M Marigorta
- Center for Integrative Genomics, Georgia Institute of Technology, Atlanta, GA, USA
| | - Melanie Schirmer
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Kajari Mondal
- Division of Pediatric Gastroenterology, Emory University School of Medicine, Atlanta, GA, USA
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Anne Griffiths
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Joshua D Noe
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Wallace V Crandall
- Department of Pediatric Gastroenterology, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH, USA
| | - Scott Snapper
- Department of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Shervin Rabizadeh
- Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joel R Rosh
- Department of Pediatrics, Goryeb Children's Hospital, Morristown, NJ, USA
| | - Jason M Shapiro
- Department of Pediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - Stephen Guthery
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - David R Mack
- Department of Pediatrics, Children's Hospital of Eastern Ontario IBD Centre and University of Ottawa, ON, Canada
| | - Richard Kellermayer
- Section of Pediatric Gastroenterology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Michael D Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Steven Steiner
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dedrick E Moulton
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David Keljo
- Department of Gastroenterology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Stanley Cohen
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Children's Center for Digestive Health Care, Atlanta, GA, USA
| | - Maria Oliva-Hemker
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melvin B Heyman
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Susan S Baker
- Department of Digestive Diseases and Nutrition Center, University at Buffalo, Buffalo, NY, USA
| | - Jonathan S Evans
- Department of Pediatrics, Nemours Children's Specialty Care, Jacksonville, FL, USA
| | | | - Ashish S Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Ziring
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Bruce C Trapnell
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Francisco A Sylvester
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael C Stephens
- Department of Pediatric Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Judy Cho
- Department of Pediatrics, Mount Sinai Hospital, New York, NY, USA
| | - Ramnik J Xavier
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Center for Computational and Integrative Biology, Gastrointestinal Unit and Center for the Study of Inflammatory Bowel Disease, Massachusetts General Hospital, Boston, MA, USA; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Curtis Huttenhower
- The Broad Institute of MIT and Harvard, Cambridge, MA, USA; Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Bruce J Aronow
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Greg Gibson
- Center for Integrative Genomics, Georgia Institute of Technology, Atlanta, GA, USA
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Marla C Dubinsky
- Department of Pediatrics, Mount Sinai Hospital, New York, NY, USA
| |
Collapse
|
26
|
Abstract
There has been a growing interest in fecal microbiota transplantation (FMT) over recent years, in part due to the increasing prevalence of Clostridium difficile infection (CDI) and expanding association of intestinal dysbiosis with a wide range of human diseases. Many adult studies have shown that FMT is an effective treatment for recurrent CDI and may possibly have applications in other illnesses such as inflammatory bowel disease (IBD); however, there is a paucity of data available in children who may differ from adults for many reasons including having a dynamic developing microbiome compared to adults who have a relatively stable microbiome. Here, we review published studies looking at FMT in children, for CDI and IBD, and discuss special considerations needed when conducting FMT in children.
Collapse
Affiliation(s)
- Suchitra K Hourigan
- Department of Pediatrics, Inova Children's Hospital, Fairfax, Virginia.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Pediatrics, Pediatric Specialists of Virginia, Fairfax, Virginia.,Inova Translational Medicine Institute, Inova Health System, Fairfax, Virginia
| | - Maria Oliva-Hemker
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
27
|
Grossi V, Lerer T, Griffiths A, LeLeiko N, Cabrera J, Otley A, Rick J, Mack D, Bousvaros A, Rosh J, Grossman A, Saeed S, Kay M, Boyle B, Oliva-Hemker M, Keljo D, Pfefferkorn M, Faubion W, Kappelman MD, Sudel B, Markowitz J, Hyams JS. Concomitant Use of Immunomodulators Affects the Durability of Infliximab Therapy in Children With Crohn's Disease. Clin Gastroenterol Hepatol 2015; 13:1748-56. [PMID: 25911120 DOI: 10.1016/j.cgh.2015.04.010] [Citation(s) in RCA: 69] [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: 01/05/2015] [Revised: 04/01/2015] [Accepted: 04/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is important to determine the effects of immunomodulators on the ability of children to remain on infliximab therapy for Crohn's disease (durability of therapy), given the potential benefits and risks of concomitant therapy-especially with thiopurines in male patients. We investigated how immunomodulatory treatment affects the durability of infliximab therapy. METHODS We collected data from the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry, from January 2002 through August 2014, on 502 children with Crohn's disease who participated in a prospective multicenter study. Data were collected from patients who received at least a 3-dose induction regimen of infliximab, and their concomitant use of immunomodulators: no thiopurine or methotrexate treatment, treatment for 6 months or less during infliximab therapy, or treatment for more than 6 months during infliximab therapy. RESULTS The probabilities (± standard error) that children remained on infliximab therapy for 1 year, 3 years, and 5 years after the treatment began were 0.84 ± 0.02, 0.69 ± 0.03, and 0.60 ± 0.03, respectively. Age, sex, and disease extent or location did not affect the durability of infliximab therapy. Greater length of concomitant use of immunomodulators was associated with increased time of infliximab therapy. The probability that patients with more than 6 months of immunomodulator use remained on infliximab therapy for 5 years was 0.70 ± 0.04, compared with 0.48 ± 0.08 for patients who did not receive immunomodulators and 0.55 ± 0.06 for patients who received immunomodulators for 6 months or less (P < .001). In boys who received immunomodulators for 6 months or more after starting infliximab, the overall durability of infliximab therapy was greater among patients receiving methotrexate than thiopurine (P < .01); the probabilities that they remained on infliximab therapy for 5 years were 0.97 ± 0.03 vs 0.58 ± 0.08, respectively. CONCLUSIONS In children with Crohn's disease, concomitant treatment with an immunomodulator for more than 6 months after starting infliximab therapy increases the chances that patients will remain on infliximab. In boys, methotrexate appears to increase the durability of infliximab therapy compared with thiopurine.
Collapse
Affiliation(s)
- Victoria Grossi
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Trudy Lerer
- Connecticut Children's Medical Center, Hartford, Connecticut
| | | | - Neal LeLeiko
- Hasbro Children's Hospital, Providence, Rhode Island
| | - Jose Cabrera
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anthony Otley
- Izack Walton Killam Health Centre, Halifax, Nova Scotia
| | | | - David Mack
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Joel Rosh
- Goryeb Children's Hospital, Morristown, New Jersey
| | - Andrew Grossman
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | | | - David Keljo
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | | | | | - Jeffrey S Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut.
| |
Collapse
|
28
|
Hourigan SK, Chen LA, Grigoryan Z, Laroche G, Weidner M, Sears CL, Oliva-Hemker M. Microbiome changes associated with sustained eradication of Clostridium difficile after single faecal microbiota transplantation in children with and without inflammatory bowel disease. Aliment Pharmacol Ther 2015. [PMID: 26198180 DOI: 10.1111/apt.13326] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Little data are available regarding the effectiveness and associated microbiome changes of faecal microbiota transplantation (FMT) for Clostridium difficile infection (CDI) in children, especially in those with inflammatory bowel disease (IBD) with presumed underlying dysbiosis. AIM To investigate C. difficile eradication and microbiome changes with FMT in children with and without IBD. METHODS Children with a history of recurrent CDI (≥3 recurrences) underwent FMT via colonoscopy. Stool samples were collected pre-FMT and post-FMT at 2-10 weeks, 10-20 weeks and 6 months. The v4 hypervariable region of the 16S rRNA gene was sequenced. C. difficile toxin B gene polymerase chain reaction was performed. RESULTS Eight children underwent FMT for CDI; five had IBD. All had resolution of CDI symptoms. All tested had eradication of C. difficile at 10-20 weeks and 6 months post-FMT. Pre-FMT patient samples had significantly decreased bacterial richness compared with donors (P = 0.01), in those with IBD (P = 0.02) and without IBD (P = 0.01). Post-FMT, bacterial diversity in patients increased. Six months post-FMT, there was no significant difference between bacterial diversity of donors and patients without IBD; however, bacterial diversity in those with IBD returned to pre-FMT baseline. Microbiome composition at 6 months in IBD-negative patients more closely approximated donor composition compared to IBD-positive patients. CONCLUSIONS FMT gives sustained C. difficile eradication in children with and without IBD. FMT-restored diversity is sustained in children without IBD. In those with IBD, bacterial diversity returns to pre-FMT baseline by 6 months, suggesting IBD host-related mechanisms modify faecal microbiome diversity.
Collapse
Affiliation(s)
- S K Hourigan
- Johns Hopkins School of Medicine, Baltimore, MD, USA.,Pediatric Specialists of Virginia, Fairfax, VA, USA
| | - L A Chen
- Johns Hopkins School of Medicine, Baltimore, MD, USA.,NYU School of Medicine, New York, NY, USA
| | | | - G Laroche
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M Weidner
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - C L Sears
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
29
|
Borschel MW, Antonson DL, Murray ND, Oliva-Hemker M, Mattis LE, Baggs GE. Evaluation of a free amino acid-based formula in infants with presumptive food protein-induced proctocolitis. SAGE Open Med 2014; 2:2050312114551857. [PMID: 26770741 PMCID: PMC4607205 DOI: 10.1177/2050312114551857] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 08/26/2014] [Indexed: 12/26/2022] Open
Abstract
Objective: Food protein–induced proctocolitis usually occurs early in life and is characterized by blood-streaked stools and pain during defecation in an otherwise healthy infant. While many infants with food protein–induced proctocolitis respond well to a casein hydrolysate formula, some require an amino acid–based formula. The objective of the study was to measure the change in physician-rated symptom score from enrollment to study completion in infants with presumptive food protein–induced proctocolitis fed with a specific amino acid-based formula. Methods: In this study, infants ≤6 months of age diagnosed with presumptive food protein–induced proctocolitis received an amino acid-based formula for 42 days. Intake, stool patterns, weight, stool occult blood, and questionnaires assessing infant feeding and stool patterns and parental formula satisfaction were collected. Results: The full analysis set included 43 infants. The mean age at enrollment was 59 ± 5 days. A significant improvement was observed from enrollment to exit in physician-rated symptom score (9.1 ± 0.5 to 4.8 ± 0.5, p < 0.0001), the number of infants with occult blood in stool, and weight-for-age Z-scores during the study. Parental satisfaction with the formula was high. Conclusion: The results confirm that the amino acid-based formula studied is efficacious for managing symptoms of presumptive food protein–induced proctocolitis.
Collapse
Affiliation(s)
- Marlene W Borschel
- Scientific & Medical Affairs, Abbott Nutrition, Abbott Laboratories, Columbus, OH, USA
| | - Dean L Antonson
- Division of Pediatric Gastroenterology, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Maria Oliva-Hemker
- Department of Pediatrics, TheJohnsHopkinsUniversitySchool of Medicine, Baltimore, MD, USA
| | | | - Geraldine E Baggs
- Scientific & Medical Affairs, Abbott Nutrition, Abbott Laboratories, Columbus, OH, USA
| |
Collapse
|
30
|
Sunseri W, Hyams JS, Lerer T, Mack DR, Griffiths AM, Otley AR, Rosh JR, Carvalho R, Grossman AB, Cabrera J, Pfefferkorn MD, Rick J, Leleiko NS, Hitch MC, Oliva-Hemker M, Saeed SA, Kappelman M, Markowitz J, Keljo DJ. Retrospective cohort study of methotrexate use in the treatment of pediatric Crohn's disease. Inflamm Bowel Dis 2014. [PMID: 24983976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Methotrexate (MTX) use as an alternative to thiopurines in the treatment of Crohn's disease (CD) in children is increasing. This study was undertaken to assess safety and efficacy of MTX in children with CD. METHODS Patients treated with MTX with a minimum of 1-year follow-up were identified in the Pediatric IBD Collaborative Research Group Registry, a prospective inception cohort study started in 2002. The clinical efficacy and safety of MTX were analyzed retrospectively. RESULTS Two hundred ninety patients treated with MTX were identified. One hundred seventy-two patients received at least 3 months of MTX without thiopurine or biologicals and had ≥1 year of follow-up. Eighty-one of 172 patients (47%) received MTX as first immunomodulator (IMM), of which 22 (27%) achieved ≥12 months of sustained clinical remission without surgery, thiopurine, biologicals, or corticosteroids. Those receiving MTX as second IMM achieved similar remission rate (35%, P = not significant). Fourteen percent received MTX as first IMM in 2002 and 60% in 2010 (P = 0.005). Disease location did not affect outcomes. MTX doses were equivalent in both groups. Fifteen percent of patients developed an alanine aminotransferase >60 international units/liter and 12% developed a white blood cell <4000 cells per microliter while on MTX. Only 4% of these discontinued MTX completely. A small group of 6 centers, which contributed only about one-third of patients with CD in the registry, contributed nearly two-thirds of the patients receiving MTX (P < 0.001). CONCLUSIONS MTX use as first choice IMM is increasing in pediatric CD. MTX provided sustained clinical remission in nearly one-third of patients with minimal toxicity. There is large center-to-center variability in its use.
Collapse
Affiliation(s)
- Whitney Sunseri
- 1Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; 2Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut; 3Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; 4Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, ON, Canada; 5Department of Pediatrics, I.W.K. Health Center, Halifax, NS, Canada; 6Pediatric Gastroenterology, Goryeb Children's Hospital, Morristown, New Jersey; 7Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; 8Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; 9Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; 10Section of Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indianapolis, Indiana; 11Department of Gastroenterology, Dayton Children's, Dayton, Ohio; 12Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, Rhode Island; 13Department of Pediatrics, Russell Children's Hospital, Birmingham, Alabama; 14Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland; 15Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Medical Center, Cincinnati, Ohio; 16Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina; and 17Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Borschel MW, Antonson DL, Murray ND, Oliva-Hemker M, Mattis LE, Kerzner B, Tolia V, Baggs G. Two single group, prospective, baseline-controlled feeding studies in infants and children with chronic diarrhea fed a hypoallergenic free amino acid-based formula. BMC Pediatr 2014; 14:136. [PMID: 24885833 PMCID: PMC4061110 DOI: 10.1186/1471-2431-14-136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 05/16/2014] [Indexed: 11/30/2022] Open
Abstract
Background Infants and children with chronic diarrhea (CD) often require specialized foods or parenteral nutrition (PN) to achieve adequate nutrient intakes to support growth and development. We assessed the efficacy of an amino acid-based formula (AAF) in supporting growth and improving symptoms in infants and children with CD from multiple etiologies. Methods Two studies were conducted: CD study in children (CD-C) and CD study in infants (CD-I). Each was a single group, baseline-controlled study in which each subject served as his/her own control. At enrollment, all subjects had CD lasting > 2 weeks and had ≥ 4 stools/day. Subjects were fed an AAF for 80 days starting at SD5, and were assessed at SD 28 and 84. Results CD-C: 18 of 19 subjects completed the study. At enrollment, the mean age was 5.6 ± 0.7 years, the most common diagnosis was short bowel syndrome (SBS) (n = 13), and 5 subjects with SBS were on PN. Subjects achieved significant increases in weight-for-age z-scores (p = 0.026). Over 50% of subjects achieved improvements in clinical outcomes targeted most frequently by their physicians. Of the five subjects on PN at enrollment, four had substantial weight gain and four had their PN requirements decreased. CD-I: 22 of 27 subjects completed the study. At enrollment, the mean age was 3.3 ± 0.3 months, the most common diagnosis was food allergy (n = 20), and no subjects were on PN. Subjects achieved significant increases in weight-for-age z-scores (p = 0.0023), significant decreases in the number of stools/day (p = 0.0012), and improvements in stool consistency (p = 0.0024). Over 80% of subjects achieved improvements in the clinical outcomes targeted most frequently by their physicians. Conclusions Infants and children with CD fed an AAF for three months displayed significant improvements in weight-for-age z-scores and clinical symptoms. Children dependent on PN also grew well and four of five decreased their dependence on PN. Trial registration Both trials were registered on ClinTrials.gov (CD-C, NCT01812629; CD-I, NCT01820494).
Collapse
Affiliation(s)
- Marlene W Borschel
- Scientific & Medical Affairs, Abbott Nutrition, Abbott Laboratories, 3300 Stelzer Road, Columbus, Ohio 43219, USA.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Frischmeyer-Guerrerio PA, Guerrerio AL, Oswald G, Chichester K, Myers L, Halushka MK, Oliva-Hemker M, Wood RA, Dietz HC. TGFβ receptor mutations impose a strong predisposition for human allergic disease. Sci Transl Med 2014; 5:195ra94. [PMID: 23884466 DOI: 10.1126/scitranslmed.3006448] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Transforming growth factor-β (TGFβ) is a multifunctional cytokine that plays diverse roles in physiologic processes as well as human disease, including cancer, heart disease, and fibrotic disorders. In the immune system, TGFβ regulates regulatory T cell (Treg) maturation and immune homeostasis. Although genetic manipulation of the TGFβ pathway modulates immune tolerance in mouse models, the contribution of this pathway to human allergic phenotypes is not well understood. We demonstrate that patients with Loeys-Dietz syndrome (LDS), an autosomal dominant disorder caused by mutations in the genes encoding receptor subunits for TGFβ, TGFBR1 and TGFBR2, are strongly predisposed to develop allergic disease, including asthma, food allergy, eczema, allergic rhinitis, and eosinophilic gastrointestinal disease. LDS patients exhibited elevated immunoglobulin E levels, eosinophil counts, and T helper 2 (TH2) cytokines in their plasma. They had an increased frequency of CD4(+) T cells that expressed both Foxp3 and interleukin-13, but retained the ability to suppress effector T cell proliferation. TH2 cytokine-producing cells accumulated in cultures of naïve CD4(+) T cells from LDS subjects, but not controls, after stimulation with TGFβ, suggesting that LDS mutations support TH2 skewing in naïve lymphocytes in a cell-autonomous manner. The monogenic nature of LDS demonstrates that altered TGFβ signaling can predispose to allergic phenotypes in humans and underscores a prominent role for TGFβ in directing immune responses to antigens present in the environment and foods. This paradigm may be relevant to nonsyndromic presentations of allergic disease and highlights the potential therapeutic benefit of strategies that inhibit TGFβ signaling.
Collapse
|
33
|
Walters TD, Kim MO, Denson LA, Griffiths AM, Dubinsky M, Markowitz J, Baldassano R, Crandall W, Rosh J, Pfefferkorn M, Otley A, Heyman MB, LeLeiko N, Baker S, Guthery SL, Evans J, Ziring D, Kellermayer R, Stephens M, Mack D, Oliva-Hemker M, Patel AS, Kirschner B, Moulton D, Cohen S, Kim S, Liu C, Essers J, Kugathasan S, Hyams JS. Increased effectiveness of early therapy with anti-tumor necrosis factor-α vs an immunomodulator in children with Crohn's disease. Gastroenterology 2014; 146:383-91. [PMID: 24162032 DOI: 10.1053/j.gastro.2013.10.027] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [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: 06/03/2013] [Revised: 10/07/2013] [Accepted: 10/19/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND & AIMS Standard therapy for children newly diagnosed with Crohn's disease (CD) includes early administration of immunomodulators after initial treatment with corticosteroids. We compared the effectiveness of early (≤3 mo after diagnosis) treatment with an anti-tumor necrosis factor (TNF)α with that of an immunomodulator in attaining clinical remission and facilitating growth of pediatric patients. METHODS We analyzed data from the RISK study, an observational research program that enrolled patients younger than age 17 diagnosed with inflammatory (nonpenetrating, nonstricturing) CD from 2008 through 2012 at 28 pediatric gastroenterology centers in North America. Patients were managed by physician dictate. From 552 children (median age, 11.8 y; 61% male; 63% with pediatric CD activity index scores >30; and median C-reactive protein level 5.6-fold the upper limit of normal), we used propensity score methodology to identify 68 triads of patients matched for baseline characteristics who were treated with early anti-TNFα therapy, early immunomodulator, or no early immunotherapy. We evaluated relationships among therapies, corticosteroid and surgery-free remission (pediatric CD activity index scores, ≤10), and growth at 1 year for 204 children. Treatment after 3 months was a covariate. RESULTS Early treatment with anti-TNFα was superior to early treatment with an immunomodulator (85.3% vs 60.3% in remission; relative risk, 1.41; 95% confidence interval [CI], 1.14-1.75; P = .0017), whereas early immunomodulator therapy was no different than no early immunotherapy (60.3% vs 54.4% in remission; relative risk, 1.11; 95% CI, 0.83-1.48; P = .49) in achieving remission at 1 year. Accounting for therapy after 3 months, early treatment with anti-TNFα remained superior to early treatment with an immunomodulator (relative risk, 1.51; 95% CI, 1.20-1.89; P = .0004), whereas early immunomodulator therapy was no different than no early immunotherapy (relative risk, 1.00; 95% CI, 0.75-1.34; P = .99). The mean height z-score increased compared with baseline only in the early anti-TNFα group. CONCLUSIONS In children newly diagnosed with comparably severe CD, early monotherapy with anti-TNFα produced better overall clinical and growth outcomes at 1 year than early monotherapy with an immunomodulator. Further data will be required to best identify children most likely to benefit from early treatment with anti-TNFα therapy.
Collapse
Affiliation(s)
| | - Mi-Ok Kim
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lee A Denson
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | | | | | - Joel Rosh
- Goryeb Children's Hospital, Morristown, New Jersey
| | | | | | | | - Neal LeLeiko
- Hasbro Children's Hospital, Providence, Rhode Island
| | - Susan Baker
- Children's Hospital of Buffalo, Buffalo, New York
| | - Stephen L Guthery
- University of Utah and Primary Children's Medical Center, Salt Lake City, Utah
| | | | - David Ziring
- Children's Hospital of Los Angeles, Los Angeles, California
| | | | | | - David Mack
- Children's Hospital of Eastern Ontario, Ottawa, Canada
| | | | | | | | | | | | - Sandra Kim
- University of North Carolina, Chapel Hill, North Carolina
| | - Chunyan Liu
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut.
| | | |
Collapse
|
34
|
Frischmeyer-Guerrerio PA, Guerrerio A, Oswald G, Chichester K, Meyers L, Halushka M, Oliva-Hemker M, Wood RA, Dietz H. A Mendelian Presentation of Multiple TH2-Mediated Allergic Diseases. J Allergy Clin Immunol 2013. [DOI: 10.1016/j.jaci.2012.12.1187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
35
|
Wang MH, Okazaki T, Kugathasan S, Cho JH, Isaacs KL, Lewis JD, Smoot DT, Valentine JF, Kader HA, Ford JG, Harris ML, Oliva-Hemker M, Cuffari C, Torbenson MS, Duerr RH, Silverberg MS, Rioux JD, Taylor KD, Nguyen GC, Wu Y, Datta LW, Hooker S, Dassopoulos T, Kittles RA, Kao LW, Brant SR. Contribution of higher risk genes and European admixture to Crohn's disease in African Americans. Inflamm Bowel Dis 2012; 18:2277-87. [PMID: 22411504 PMCID: PMC3810419 DOI: 10.1002/ibd.22931] [Citation(s) in RCA: 22] [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: 01/20/2012] [Accepted: 02/02/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND African Americans (AAs) are an admixed population of West African (WA) and European ancestry (EA). Crohn's disease (CD) susceptibility genes have not been established. We therefore evaluated the contribution of European admixture and major established risk genes to AA CD. METHODS Ninety-seven admixture informative markers were genotyped for ancestry estimates using STRUCTURE. Overall, 354 AA CD cases and 354 ethnicity-matched controls were genotyped for total 21 single nucleotide polymorphisms (SNPs) in ATG16L1, NOD2, IBD5, IL23R and IRGM by TaqMan or direct sequencing. Association was evaluated by logistic regression, adjusted for ancestry. RESULTS Mean EA was similar among the CD cases and controls (20.9% and 20.4%, respectively, P = 0.58). No significant admixture differences were observed among 211 to 227 cases stratified by phenotypic subclassifications including onset, surgery, site, and behavior. CD was associated with NOD2 carrier (6.93% CD, 2.15% Controls, P = 0.007), ATG16L1 Thr300Ala (36.1% CD, 29.3% Controls, P = 0.003), SLC22A4 and SLC22A5 (IBD5 locus) functional SNPs (Leu503Phe [10.5% CD, 7.6% Controls, P = 0.05] and g-207c [41.3% CD, 35.7% Controls, P = 0.03], respectively), and IL23R rs2201841 (18.2% CD, 13.8% Controls, P = 0.03), but not IRGM variants, nor three African ancestral NOD2 nonsynonymous variants. IBD5 risk was recessive. An all-minor allele IBD5 haplotype from EA was associated (P = 0.05), whereas a more common haplotype isolating g-207c was not. CONCLUSIONS Specific functional gene variations contribute significantly to AA CD risk. Established NOD2, SLC22A4-A5, and ATG16L1 variants show increased CD risk, with IBD5 recessive. Although CD is more common in whites, European admixture is similar among AA cases and controls.
Collapse
Affiliation(s)
- Ming-Hsi Wang
- Lyn P. and Harvey M. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Medicine, St Agnes Hospital Center, Baltimore, MD
| | - Toshihiko Okazaki
- Lyn P. and Harvey M. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Judy H. Cho
- Department of Medicine and Genetics, Yale University, New Haven, CT
| | - Kim L. Isaacs
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Duane T. Smoot
- Department of Medicine, Howard University College of Medicine, Washington, DC
| | - John F. Valentine
- Division of Gastroenterology, Hepatology & Nutrition, University of Florida, Gainesville, FL
| | - Howard A. Kader
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Jean G. Ford
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Mary L. Harris
- Lyn P. and Harvey M. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD,The Institute for Digestive Health & Liver Disease at Mercy Hospital, Baltimore, Maryland
| | - Maria Oliva-Hemker
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Carmen Cuffari
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael S. Torbenson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard H. Duerr
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, and Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Mark S. Silverberg
- Departments of Medicine, Surgery, Public Health Sciences, Immunology, and Molecular and Medical Genetics, University of Toronto, Samuel Lunenfeld Research Institute and Mount Sinai Hospital, Toronto, Canada; The Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - John D. Rioux
- Université de Montréal and the Montreal Heart Institute, Research Center, 5000 rue Belanger, Montreal, Quebec H1T 1C8, Canada.; The Broad Institute of MIT and Harvard, Cambridge, MA
| | - Kent D. Taylor
- Medical Genetics Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Geoffrey C. Nguyen
- Lyn P. and Harvey M. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD,Departments of Medicine, Surgery, Public Health Sciences, Immunology, and Molecular and Medical Genetics, University of Toronto, Samuel Lunenfeld Research Institute and Mount Sinai Hospital, Toronto, Canada; The Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Yuqiong Wu
- Lyn P. and Harvey M. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lisa W. Datta
- Lyn P. and Harvey M. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stanley Hooker
- Section of Genetic Medicine, Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Themistocles Dassopoulos
- The Institute for Digestive Health & Liver Disease at Mercy Hospital, Baltimore, Maryland,Gastroenterology Division, Washington University School of Medicine, St. Louis, MO
| | - Rick A. Kittles
- Section of Genetic Medicine, Department of Medicine, Pritzker School of Medicine, University of Chicago, Chicago, IL,Department of Medicine and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois
| | - Linda W.H. Kao
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Steven R. Brant
- Lyn P. and Harvey M. Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
36
|
Abstract
Ulcerative colitis is a chronic, idiopathic, inflammatory disease of the colon and rectum that may be associated with growth failure, nutritional derangements and psychosocial ramifications in affected children. Multiple medical options are available to achieve disease remission; however, some of these medications can have unwanted side effects, especially in younger patients. With increased understanding of the etiology of the disease, newer therapeutic alternatives have arisen in the form of biologic therapies, namely monoclonal antibodies targeted to a specific protein or receptor. Specifically, infliximab, an anti-TNF-α agent, has been shown to be safe and effective for the treatment of moderate-to-severe pediatric ulcerative colitis.
Collapse
Affiliation(s)
- Gia M Bradley
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
37
|
Bradley GM, Carson KA, Leonard AR, Mogayzel PJ, Oliva-Hemker M. Nutritional outcomes following gastrostomy in children with cystic fibrosis. Pediatr Pulmonol 2012; 47:743-8. [PMID: 22298389 PMCID: PMC3343175 DOI: 10.1002/ppul.22507] [Citation(s) in RCA: 28] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 01/05/2012] [Indexed: 01/19/2023]
Abstract
OBJECTIVE In 2005 the Cystic Fibrosis (CF) Foundation recommended that children with CF maintain a body mass index (BMI) ≥ 50th percentile. Our study evaluated if gastrostomy (GT) placement increases the likelihood of reaching that goal compared to a standardized nutrition protocol. STUDY DESIGN Retrospective study of 20 children with CF ages 2-20 years with GTs placed from 2005 to 2010. Each case was pair-matched on age, sex, pancreatic status, BMI, and lung function with a nonGT child with CF. Outcome measures included nutritional status and lung function at 6 months and 1 year. RESULTS At baseline, mean ± SD BMI Z-scores were similar (cases -1.19 ± 0.60, controls -1.10 ± 0.50; P = 0.10). Cases had a significant 6-month increase in mean BMI Z-score to -0.29 ± 0.84 compared to -1.02 ± 0.67 for controls (P < 0.001). By 1 year, the change in mean BMI Z-score was less different (cases -0.41 ± 0.76, controls -0.71 ± 0.51; P = 0.07). Both groups had stable lung function. From exact logistic regression analysis, the odds ratio for cases compared to controls of reaching BMI ≥ 50th percentile was 9.70 (95% CI: 1.05-484.7; P = 0.04) at 6 months and 3.65 (95%CI: 0.69-25.86; P = 0.16) at 1 year. CONCLUSION Our study suggests that children with CF who receive GTs are more likely to achieve BMI ≥ 50th percentile than matched children without GTs.
Collapse
Affiliation(s)
- Gia M Bradley
- Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | |
Collapse
|
38
|
Abstract
Ulcerative colitis is a chronic inflammatory bowel disease that can lead to derangements in the growth, nutritional status, and psychosocial development of affected children. There are several medical options for the induction and maintenance of disease remission, but the benefits of these medications need to be carefully weighed against the risks, especially in the pediatric population. As the etiology of the disease has become increasingly understood, newer therapeutic alternatives have arisen in the form of biologic therapies, which are monoclonal antibodies targeted to a specific protein or receptor. This review will discuss the classical treatments for children with ulcerative colitis, including 5-aminosalicylates, corticosteroids, thiopurine immunomodulators, and calcineurin inhibitors, with a particular focus on the newer class of anti-tumor necrosis factor-α agents.
Collapse
Affiliation(s)
- Gia M Bradley
- Division of Pediatric, Gastroenterology and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
39
|
Oliva-Hemker M, Yeung KA, Cuffari C, Scheimann A, Wilson L. Annual update of pediatric digestive diseases. Expert Rev Gastroenterol Hepatol 2011; 5:21-3. [PMID: 21309668 DOI: 10.1586/egh.10.91] [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] [Indexed: 11/08/2022]
Abstract
The 24th Annual Meeting of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition provided a comprehensive overview of pediatric digestive diseases. The meeting and its adjunct events, including a postgraduate course and 1-day symposium, enabled a diverse group of physicians, trainees and nurses to have the opportunity to discuss the latest developments in pediatric gastrointestinal, liver and nutritional disorders.
Collapse
Affiliation(s)
- Maria Oliva-Hemker
- Division of Pediatric Gastroenterology and Nutrition, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | | | | | | | | |
Collapse
|
40
|
Siegel CA, Siegel LS, Hyams JS, Kugathasan S, Markowitz J, Rosh JR, Leleiko N, Mack DR, Crandall W, Evans J, Keljo DJ, Otley AR, Oliva-Hemker M, Farrior S, Langton CR, Wrobel IT, Wahbeh G, Quiros JA, Silber G, Bahar RJ, Sands BE, Dubinsky MC. Real-time tool to display the predicted disease course and treatment response for children with Crohn's disease. Inflamm Bowel Dis 2011. [PMID: 20812335 DOI: 10.1002/ibd.21386]] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Immunomodulators and biologics are effective treatments for children with Crohn's disease (CD). The challenge of communicating the anticipated disease course with and without therapy to patients and parents is a barrier to the timely use of these agents. The aim of this project was to develop a tool to graphically display the predicted risks of CD and expected benefits of therapy. METHODS Using prospectively collected data from 796 pediatric CD patients we developed a model using system dynamics analysis (SDA). The primary model outcome is the probability of developing a CD-related complication. Input variables include patient and disease characteristics, magnitude of serologic immune responses expressed as the quartile sum score (QSS), and exposure to medical treatments. RESULTS Multivariate Cox proportional analyses show variables contributing a significant increase in the hazard ratio (HR) for a disease complication include female gender, older age at diagnosis, small bowel or perianal disease, and a higher QSS. As QSS increases, the HR for early use of corticosteroids increases, in contrast to a decreasing HR with early use of immunomodulators, early or late biologics, and early combination therapy. The concordance index for the model is 0.81. Using SDA, results of the Cox analyses are transformed into a simple graph displaying a real-time individualized probability of disease complication and treatment response. CONCLUSIONS We have developed a tool to predict and communicate individualized risks of CD complications and how this is modified by treatment. Once validated, it can be used at the bedside to facilitate patient decision making.
Collapse
Affiliation(s)
- Corey A Siegel
- Dartmouth-Hitchcock Inflammatory Bowel Disease Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Siegel CA, Siegel LS, Hyams JS, Kugathasan S, Markowitz J, Rosh JR, Leleiko N, Mack DR, Crandall W, Evans J, Keljo DJ, Otley AR, Oliva-Hemker M, Farrior S, Langton CR, Wrobel IT, Wahbeh G, Quiros JA, Silber G, Bahar RJ, Sands BE, Dubinsky MC. Real-time tool to display the predicted disease course and treatment response for children with Crohn's disease. Inflamm Bowel Dis 2011; 17:30-8. [PMID: 20812335 PMCID: PMC2998586 DOI: 10.1002/ibd.21386] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 05/17/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immunomodulators and biologics are effective treatments for children with Crohn's disease (CD). The challenge of communicating the anticipated disease course with and without therapy to patients and parents is a barrier to the timely use of these agents. The aim of this project was to develop a tool to graphically display the predicted risks of CD and expected benefits of therapy. METHODS Using prospectively collected data from 796 pediatric CD patients we developed a model using system dynamics analysis (SDA). The primary model outcome is the probability of developing a CD-related complication. Input variables include patient and disease characteristics, magnitude of serologic immune responses expressed as the quartile sum score (QSS), and exposure to medical treatments. RESULTS Multivariate Cox proportional analyses show variables contributing a significant increase in the hazard ratio (HR) for a disease complication include female gender, older age at diagnosis, small bowel or perianal disease, and a higher QSS. As QSS increases, the HR for early use of corticosteroids increases, in contrast to a decreasing HR with early use of immunomodulators, early or late biologics, and early combination therapy. The concordance index for the model is 0.81. Using SDA, results of the Cox analyses are transformed into a simple graph displaying a real-time individualized probability of disease complication and treatment response. CONCLUSIONS We have developed a tool to predict and communicate individualized risks of CD complications and how this is modified by treatment. Once validated, it can be used at the bedside to facilitate patient decision making.
Collapse
Affiliation(s)
- Corey A. Siegel
- Dartmouth-Hitchcock Inflammatory Bowel Disease Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Jeffrey S. Hyams
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Subra Kugathasan
- Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | | | - Joel R. Rosh
- Department of Pediatrics, Morristown Memorial Hospital, Morristown, NJ, USA
| | - Neal Leleiko
- Department of Pediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - David R. Mack
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Wallace Crandall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jonathan Evans
- Department of Pediatrics, Nemours Children's Clinic, Jacksonville, FL, USA
| | - David J. Keljo
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anthony R. Otley
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | - Sharmayne Farrior
- Department of Pediatrics, IBD Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christine R. Langton
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Iwona T. Wrobel
- Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Ghassan Wahbeh
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Gary Silber
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Ron J. Bahar
- Department of Pediatrics, IBD Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Bruce E. Sands
- Gastrointestinal Unit, MGH Crohn's and Colitis Center, Massachusetts General Hospital, Boston, MA, USA
| | - Marla C. Dubinsky
- Department of Pediatrics, IBD Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
42
|
Schaefer ME, Machan JT, Kawatu D, Langton CR, Markowitz J, Crandall W, Mack DR, Evans JS, Pfefferkorn MD, Griffiths AM, Otley AR, Bousvaros A, Kugathasan S, Rosh JR, Keljo DJ, Carvalho RS, Tomer G, Mamula P, Kay MH, Kerzner B, Oliva-Hemker M, Kappelman MD, Saeed SA, Hyams JS, Leleiko NS. Factors that determine risk for surgery in pediatric patients with Crohn's disease. Clin Gastroenterol Hepatol 2010; 8:789-94. [PMID: 20566311 DOI: 10.1016/j.cgh.2010.05.021] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 04/14/2010] [Accepted: 05/08/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We examined the incidence of Crohn's disease (CD)-related surgery in a multi-center, inception cohort of pediatric patients with CD. We also examined the effect of starting immunomodulator therapy within 30 days of diagnosis. METHODS Data from 854 children with CD from the Pediatric Inflammatory Bowel Disease Collaborative Research Group who were diagnosed with CD between 2002 and 2008 were analyzed. RESULTS Overall, 76 (9%) underwent a first CD-related surgery, 57 (7%) underwent a first bowel surgery (bowel resection, ostomy, strictureplasty, or appendectomy), and 19 (2%) underwent a first non-bowel surgery (abscess drainage or fistulotomy). The cumulative risks for bowel surgery, non-bowel surgery, and all CD-related surgeries were 3.4%, 1.4%, and 4.8%, respectively, at 1 year after diagnosis and 13.8%, 4.5%, and 17.7%, respectively, at 5 years after diagnosis. Older age at diagnosis, greater disease severity, and stricturing or penetrating disease increased the risk of bowel surgery. Disease between the transverse colon and rectum decreased the risk. Initiation of immunomodulator therapy within 30 days of diagnosis, sex, race, and family history of inflammatory bowel disease did not influence the risk of bowel surgery. CONCLUSIONS In an analysis of pediatric patients with CD, the 5-year cumulative risk of bowel surgery was lower than that reported in recent studies of adult and pediatric patients but similar to that of a recent retrospective pediatric study. Initiation of immunomodulator therapy at diagnosis did not alter the risk of surgery within 5 years of diagnosis.
Collapse
Affiliation(s)
- Marc E Schaefer
- Pediatric Inflammatory Bowel Disease Collaborative Research Group, Hartford, Connecticut, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Abstract
Nutrition is a critical part of the management of inflammatory bowel disease (IBD) in children and adults. Malnutrition and micronutrient deficiencies are common at the time of diagnosis and may persist throughout the course of the disease. There are a number of similarities with regards to the nutritional complications and the approach to nutritional management in IBD in both children and adults, but there are also important differences. Growth failure, pubertal delay and the need for corticosteroid-sparing regimens are of higher importance in pediatrics. In the pediatric population, exclusive enteral nutrition may be equivalent to corticosteroids in inducing remission in acute Crohn's disease, and may have benefits over corticosteroids in children. Adherence with exclusive enteral nutrition is better in children than in adults. Iron deficiency anemia is an important problem for adults and children with IBD. Intravenous iron administration may be superior to oral iron supplementation. Ensuring adequate bone health is another critical component of nutritional management in IBD, but guidelines for screening and therapeutic interventions for low bone mineral density are lacking in children.
Collapse
|
44
|
Conklin LS, Cohen B, Wilson L, Cuffari C, Oliva-Hemker M. Rash induced by anti-tumor necrosis factor agents in an adolescent with Crohn's disease. Nat Rev Gastroenterol Hepatol 2010; 7:174-7. [PMID: 20203680 DOI: 10.1038/nrgastro.2010.7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [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: 02/08/2023]
Abstract
BACKGROUND A 17-year-old white male with Crohn's disease who was receiving maintenance infusions of the anti-tumor necrosis factor (TNF) agent, infliximab, presented with a new-onset psoriasiform skin rash. The rash was not responsive to topical or oral corticosteroids and worsened after infliximab infusions and after subsequent administration of a second anti-TNF drug, adalimumab. INVESTIGATIONS Full medical history and physical examination, including assessment of the morphology of rash and the temporal correlation with administration of anti-TNF agents. DIAGNOSIS Anti-TNF-agent induced psoriasiform skin rash. MANAGEMENT Discontinuation of anti-TNF therapy. The patient opted to have his gastrointestinal symptoms treated with oral mesalazine and metronidazole.
Collapse
Affiliation(s)
- Laurie S Conklin
- Division of Gastroenterology and Nutrition, Children's National Medical Center, 111 Michigan Avenue NW, West Wing 2.5, Suite 600, Washington DC 20010, USA
| | | | | | | | | |
Collapse
|
45
|
Dassopoulos T, Nguyen GC, Talor MV, Datta LW, Isaacs KL, Lewis JD, Gold MS, Valentine JF, Smoot DT, Harris ML, Oliva-Hemker M, Bayless TM, Burek CL, Brant SR. NOD2 mutations and anti-Saccharomyces cerevisiae antibodies are risk factors for Crohn's disease in African Americans. Am J Gastroenterol 2010; 105:378-86. [PMID: 19826411 PMCID: PMC3339041 DOI: 10.1038/ajg.2009.575] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES NOD2 mutations and anti-Saccharomyces cerevisiae antibodies (ASCAs) are established risk factors of Crohn's disease (CD) in whites but have not been assessed in African-American (AA) adults with CD. METHODS AAs with CD and controls were recruited by the Mid-Atlantic African-American IBD Study as part of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) IBD Genetics Consortium. Genotyping for the three common CD NOD2 mutations (Leu1007fsinsC, G908R/2722g>c, and R702W/2104c>t) and ASCA enzyme-linked immunosorbent assays were performed in 183 AA CD patients and in 143 controls. Logistic regression was used to calculate adjusted odds ratios (ORs) for the association between ASCA and disease phenotype. RESULTS ASCA sensitivity and specificity values were 70.5 and 70.4%, respectively. On univariate analysis, ASCA was significantly associated with younger age at diagnosis, ileal involvement, and complicated (stricturing/penetrating) behavior. On multivariate analysis, ASCA titer (per 25 Units) was associated with ileal involvement (OR 1.18, 95% confidence interval (CI): 1.04-1.34), complicated behavior (OR 1.13, 95% CI: 1.01-1.28), and surgery (hazard ratio: 1.11, 95% CI: 1.02-1.21). Cigarette smoking and CD family history were also significantly associated with surgery. NOD2 carriers (all heterozygotes) were more common among CD cases than controls (8.2 vs. 2.1%; OR 4.17%, 95% CI: 1.18-14.69). The NOD2 mutation population attributable risk was 6.2%. CONCLUSIONS In comparison with whites, ASCA in AAs has a similar sensitivity but a lower specificity for CD. ASCA is associated with ileal involvement, complicated behavior, and surgery in AAs with CD. NOD2 is a risk gene for AA CD, although mutation frequency and population attributable risk are much lower than in whites.
Collapse
Affiliation(s)
- Themistocles Dassopoulos
- The Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Gastroenterology Division, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geoffrey C. Nguyen
- The Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Gastroenterology Division, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
,Mount Sinai Hospital IBD Centre, University of Toronto, Toronto, ON, Canada
| | - Monica Vladut Talor
- The Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lisa Wu Datta
- The Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Gastroenterology Division, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kim L. Isaacs
- The Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - James D. Lewis
- The Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Michael S. Gold
- The Department of Medicine, Washington Hospital Center, Washington, DC, USA.
| | - John F. Valentine
- The Department of Medicine, University of Florida, Gainesville, FL, USA.
| | - Duane T. Smoot
- The Department of Medicine, Howard University, Washington, DC, USA.
| | - Mary L. Harris
- The Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Gastroenterology Division, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maria Oliva-Hemker
- The Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theodore M. Bayless
- The Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Gastroenterology Division, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - NIDDK IBD Genetics Consortium
- National Institutes of Diabetes, Digestion and Kidney Diseases Inflammatory Bowel Disease Gentics Consortium. Member sites at Cedars Sinai Medical Center, Johns Hopkins University, University of Chicago, University of Pittsburgh, University of Toronto, and Yale University
| | - C. Lynne Burek
- The Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven R. Brant
- The Harvey M. and Lyn P. Meyerhoff Inflammatory Bowel Disease Center, Gastroenterology Division, Department of Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD, USA
,The Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
46
|
Rosh JR, Lerer T, Markowitz J, Goli SR, Mamula P, Noe JD, Pfefferkorn MD, Kelleher KT, Griffiths AM, Kugathasan S, Keljo D, Oliva-Hemker M, Crandall W, Carvalho RS, Mack DR, Hyams JS. Retrospective Evaluation of the Safety and Effect of Adalimumab Therapy (RESEAT) in pediatric Crohn's disease. Am J Gastroenterol 2009; 104:3042-9. [PMID: 19724267 DOI: 10.1038/ajg.2009.493] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Adalimumab, an anti-tumor necrosis factor immunoglobulin-1 antibody, is increasingly being reported as a potential treatment option for children with moderate-to-severe Crohn's disease (CD). The aim of this study was to characterize common indications, safety, tolerability, and clinical response to adalimumab in pediatric CD in a large, multicenter, patient cohort. METHODS Data were obtained using a retrospective, uncontrolled chart review at 12 sites of the Pediatric Inflammatory Bowel Disease Collaborative Research Group. Clinical, laboratory, and demographic data were obtained for CD patients who received at least one dose of adalimumab. Indication for adalimumab, concomitant medications, and clinical outcome at 3, 6, and 12 months for each patient were recorded using physician global assessment (PGA) and Pediatric CD Activity Index scores. Serious adverse events were identified. RESULTS A total of 115 patients (54% female) received at least one dose of adalimumab. The mean age at the diagnosis of CD was 11.1+/-3.1 years, with the first adalimumab dose administered at 4.7+/-2.8 years after diagnosis. The most common dosing frequency was every other week with induction doses of 160/80 mg in 19%, 80/40 mg in 44%, and 40/40 mg in 15% of patients. Maintenance dosing was 40 mg every other week in 88% of patients. Mean follow-up after initial adalimumab dose was 10+/-8.6 months. Infliximab treatment preceded adalimumab in 95% of patients, with a mean of 12 infliximab infusions (range: 1-44). Infliximab discontinuation was due to loss of response (47%), infusion reaction or infliximab intolerance (45%), or preference for a subcutaneous medication (9%). Concomitant medications at the commencement of adalimumab were corticosteroids (38%), azathioprine/6-mercaptopurine (41%), and methotrexate (23%). Clinical response measured by PGA at 3, 6, and 12 months was 65, 71, and 70%, respectively, with steroid-free remission at 3, 6, and 12 months of 22, 33, and 42%, respectively. There were no malignancies, serious infections, or deaths in the study subjects. CONCLUSIONS Adalimumab was a well-tolerated and effective rescue therapy for moderate-to-severe pediatric CD patients previously treated with infliximab. Adalimumab demonstrated a steroid-sparing effect, and >70% of patients achieved rapid response that was sustained through 12 months.
Collapse
Affiliation(s)
- Joel R Rosh
- Division of Pediatric Gastroenterology, Goryeb Children's Hospital/Atlantic Health, Morristown, New Jersey 07962 , USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Turner D, Hyams J, Markowitz J, Lerer T, Mack DR, Evans J, Pfefferkorn M, Rosh J, Kay M, Crandall W, Keljo D, Otley AR, Kugathasan S, Carvalho R, Oliva-Hemker M, Langton C, Mamula P, Bousvaros A, LeLeiko N, Griffiths AM. Appraisal of the pediatric ulcerative colitis activity index (PUCAI). Inflamm Bowel Dis 2009; 15:1218-23. [PMID: 19161178 DOI: 10.1002/ibd.20867] [Citation(s) in RCA: 191] [Impact Index Per Article: 12.7] [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: 12/12/2022]
Abstract
BACKGROUND We evaluated the psychometric performance of the Pediatric Ulcerative Colitis Activity Index (PUCAI) in a real-life cohort from the Pediatric IBD Collaborative Research Group. METHODS Two consecutive visits of 215 children with ulcerative colitis (UC) were included (mean age 11.2 +/- 3.6 years; 112 (52%) males; 63 (29%) newly diagnosed and the others after disease duration of 24 +/- 15.6 months). Validity was assessed using several constructs of disease activity. Distributional and anchor-based strategies were used to assess the responsiveness of the PUCAI to change over time following treatment. RESULTS Reflecting feasibility, 97.6% of 770 eligible registry visits had a completed PUCAI score versus only 47.6% for a contemporaneously collected Pediatric Crohn's Disease Activity Index (odds ratio = 45.8, 95% confidence interval [CI] 28.6-73.5) obtained for children with Crohn's disease accessioned into the same database. The PUCAI score was significantly higher in patients requiring escalation of medical therapy (45 points [interquartile range, IQR, 30-60]) versus those who did not, (0 points [IQR 0-10]; P < 0.001), and was highly correlated with physician's global assessment of disease activity (r = 0.9, P < 0.001). The best cutoff to differentiate remission from active disease was 10 points (area under receiver operating characteristic curve [AUC] 0.94; 95% CI 0.90-0.97). Test-retest reliability was excellent (intraclass correlation coefficient = 0.89; 95% CI 0.84-0.92, P < 0.001) as well as responsiveness to change (AUC 0.96 [0.92-0.99]; standardized response mean 2.66). CONCLUSION This study on real-life, prospectively obtained data confirms that the PUCAI is highly feasible by virtue of the noninvasiveness, valid, and responsive index. The PUCAI can be used as a primary outcome measure to reflect disease activity in pediatric UC.
Collapse
Affiliation(s)
- Dan Turner
- Pediatric Gastroenterology Unit, Shaare Zedek Medical Center, Jerusalem, Israel.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Hyams JS, Lerer T, Griffiths A, Pfefferkorn M, Kugathasan S, Evans J, Otley A, Carvalho R, Mack D, Bousvaros A, Rosh J, Mamula P, Kay M, Crandall W, Oliva-Hemker M, Keljo D, LeLeiko N, Markowitz J. Long-term outcome of maintenance infliximab therapy in children with Crohn's disease. Inflamm Bowel Dis 2009; 15:816-22. [PMID: 19107783 DOI: 10.1002/ibd.20845] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [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: 01/06/2023]
Abstract
BACKGROUND Infliximab therapy has short-term benefits in children with moderate-to-severe Crohn's disease (CD). We assessed the long-term outcome of infliximab maintenance therapy in children with CD. METHODS We performed a multicenter cohort study of 729 pediatric patients with CD enrolled in the Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry. Children younger than 16 years and newly diagnosed with CD were eligible for this study. Disease and medication information were collected prospectively from the treating physician at diagnosis, 30 days, and quarterly thereafter. No interventions were specified, per protocol. RESULTS In all, 202 of 729 patients received infliximab: 62%, 23%, and 15% within 1, 1-2, and >2 years of diagnosis, respectively. The mean age at infliximab initiation was 12.7 years. A total of 158 infliximab-treated patients received maintenance therapy, 29 episodic (8 converted to maintenance), and 15 had incomplete follow-up. Among 128 patients administered maintenance infliximab and followed for >or=1 year, concomitant medications at infliximab initiation included corticosteroids (52%) and immunomodulators (90%). By 1, 2, and 3 years, <10% of patients continuing on maintenance infliximab were receiving corticosteroids (P < 0.001). Following maintenance therapy initiation, 26%, 44%, and 33% of patients continuing on maintenance infliximab over 0-1, 1-2, and 2-3 years, respectively, had clinically inactive disease not requiring corticosteroids or surgery. The likelihood of continuing maintenance infliximab at 1, 2, and 3 years was 93%, 78%, and 67%, respectively. CONCLUSIONS Infliximab maintenance therapy was a durable and effective treatment that was associated with prolonged corticosteroid withdrawal over a 3-year period in children with CD.
Collapse
Affiliation(s)
- Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT 06106, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Markowitz J, Kugathasan S, Dubinsky M, Mei L, Crandall W, LeLeiko N, Oliva-Hemker M, Rosh J, Evans J, Mack D, Otley A, Pfefferkorn M, Bahar R, Vasiliauskas E, Wahbeh G, Silber G, Quiros JA, Wrobel I, Nebel J, Landers C, Picornell Y, Targan S, Lerer T, Hyams J. Age of diagnosis influences serologic responses in children with Crohn's disease: a possible clue to etiology? Inflamm Bowel Dis 2009; 15:714-9. [PMID: 19107777 PMCID: PMC2726983 DOI: 10.1002/ibd.20831] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND Crohn's disease (CD) is often associated with antibodies to microbial antigens. Differences in immune response may offer clues to the pathogenesis of the disease. The aim was to examine the influence of age at diagnosis on the serologic response in children with CD. METHODS Data were drawn from 3 North American multicenter pediatric inflammatory bowel disease (IBD) research consortia. At or shortly after diagnosis, pANCA, ASCA IgA, ASCA IgG, anti-ompC, and anti-CBir1 were assayed. The results were compared as a function of age at CD diagnosis (0-7 years versus 8-15 years). RESULTS In all, 705 children (79 <8 years of age at diagnosis, 626 >or=8 years) were studied. Small bowel CD was less frequent in the younger group (48.7% versus 72.6%; P < 0.0001), while colonic involvement was comparable (91.0% versus 86.5%). ASCA IgA and IgG were seen in <20% of those 0-7 years old compared to nearly 40% of those 8-15 years old (P < 0.001), while anti-CBir1 was more frequent in the younger children (66% versus 54%, P < 0.05). Anti-CBir1 detected a significant number of children in both age groups who otherwise were serologically negative. Both age at diagnosis and site of CD involvement were independently associated with expression of ASCA and anti-CBir1. CONCLUSIONS Compared to children 8-15 years of age at diagnosis, those 0-7 years are more likely to express anti-CBir1 but only half as likely to express ASCA. These age-associated differences in antimicrobial seropositivity suggest that there may be different, and as yet unrecognized, genetic, immunologic, and/or microbial factors leading to CD in the youngest children.
Collapse
Affiliation(s)
- James Markowitz
- Division of Pediatric Gastroenterology, North Shore - LIJ Health System, New Hyde Park, NY, USA, Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA
| | - Subra Kugathasan
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Wisconsin Pediatric IBD Research Group, Milwaukee, WI, USA, Emory University, Atlanta GA
| | - Marla Dubinsky
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ling Mei
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Wallace Crandall
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Nationwide Children’s Hospital, Columbus, OH
| | - Neal LeLeiko
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Hasbro Children’s Hospital, Providence, RI
| | - Maria Oliva-Hemker
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joel Rosh
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Morristown Memorial Hospital, Morristown, NJ
| | - Jonathan Evans
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Nemours Children’s Clinic, Jacksonville, FL
| | - David Mack
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Children’s Hospital of Eastern Ontario, Ottawa, Ontario
| | - Anthony Otley
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, IWK Grace Health Centre, Halifax, Nova Scotia
| | - Marian Pfefferkorn
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Riley Children’s Hospital, Indianapolis, IN
| | - Ron Bahar
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eric Vasiliauskas
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ghassan Wahbeh
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Seattle Children’s Hospital, Seattle, WA
| | - Gary Silber
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Phoenix Children’s Hospital, Phoenix, AZ
| | - J. Antonio Quiros
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, California Pacific Hospital, San Francisco, CA
| | - Iwona Wrobel
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Alberta Children’s Hospital, Calgary, Canada
| | - Justin Nebel
- Wisconsin Pediatric IBD Research Group, Milwaukee, WI, USA, Medical College of Wisconsin, Milwaukee, WI
| | - Carol Landers
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Yoanna Picornell
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephan Targan
- Western Regional Alliance for Pediatric IBD Research, Los Angeles, CA, USA, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Trudy Lerer
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Connecticut Children’s Medical Center, Hartford, CT
| | - Jeffrey Hyams
- Pediatric IBD Collaborative Research Group Registry, Hartford, CT, USA, Connecticut Children’s Medical Center, Hartford, CT
| |
Collapse
|
50
|
Keljo DJ, Markowitz J, Langton C, Lerer T, Bousvaros A, Carvalho R, Crandall W, Evans J, Griffiths A, Kay M, Kugathasan S, LeLeiko N, Mack D, Mamula P, Moyer MS, Oliva-Hemker M, Otley A, Pfefferkorn M, Rosh J, Hyams JS. Course and treatment of perianal disease in children newly diagnosed with Crohn's disease. Inflamm Bowel Dis 2009; 15:383-7. [PMID: 19023863 DOI: 10.1002/ibd.20767] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [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: 12/25/2022]
Abstract
BACKGROUND We sought to characterize perianal disease and its treatment in pediatric patients newly diagnosed with Crohn's disease. METHODS Data were obtained from the Pediatric Inflammatory Bowel Disease (IBD) Collaborative Group Registry, a prospective, multicenter observational registry recording clinical and laboratory outcomes in children under 16 years of age newly diagnosed with IBD. Patients with Crohn's disease were selected who had data on perianal disease and at least 24 months of follow-up. The records of patients with a Pediatric Crohn's Disease Activity Index perianal subscore greater than 0 were reviewed, and patients with abscesses or fistulas were selected. The therapies used and the course of their perianal disease were then assessed. RESULTS Of the 276 patients identified, 41 had perianal lesions within 30 days of diagnosis. Thirteen of these had skin tags and fissures only, whereas 28 had fistulas and/or abscesses. The latter lesions resolved by 1 year in 20 patients, and 8 had chronic/recurrent perianal disease persisting for more than 1 year following diagnosis. Patients with fistulizing disease were much more likely to be treated and were treated earlier with antibiotics, infliximab, and immunomodulators than were nonfistulizing patients. Patients who developed chronic perianal disease were more likely to have low body mass indices and required more perianal surgery than did patients whose perianal disease resolved. CONCLUSIONS Approximately 10% of newly diagnosed pediatric patients with Crohn's disease will have perianal fistulas and/or abscesses at the time of diagnosis. Most of these will resolve within a year with medical therapy alone.
Collapse
Affiliation(s)
- David J Keljo
- Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15213, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|