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Suek N, Young T, Fu J. Immune cell profiling in intestinal transplantation. Hum Immunol 2024:110808. [PMID: 38762429 DOI: 10.1016/j.humimm.2024.110808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/08/2024] [Accepted: 04/25/2024] [Indexed: 05/20/2024]
Abstract
Since the first published case study of human intestinal transplantation in 1967, there have been significant studies of intestinal transplant immunology in both animal models and humans. An improved understanding of the profiles of different immune cell subsets is critical for understanding their contributions to graft outcomes. While different studies have focused on the contribution of one or a few subsets to intestinal transplant, no study has integrated these data for a comprehensive overview of immune dynamics after intestinal transplant. Here, we provide a systematic review of the literature on different immune subsets and discuss their roles in intestinal transplant outcomes on multiple levels, focusing on chimerism and graft immune reconstitution, clonal alloreactivity, and cell phenotype. In Sections 1, 2 and 3, we lay out a shared framework for understanding intestinal transplant, focusing on the mechanisms of rejection or tolerance in the context of mucosal immunology and illustrate the unique role of the bidirectional graft-versus-host (GvH) and host-versus-graft (HvG) alloresponse. In Sections 4, 5 and 6, we further expand upon these concepts as we discuss the contribution of different cell subsets to intestinal transplant. An improved understanding of intestinal transplantation immunology will bring us closer to maximizing the potential of this important treatment.
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Affiliation(s)
- Nathan Suek
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Tyla Young
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA
| | - Jianing Fu
- Columbia Center for Translational Immunology, Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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Miller C, Kieling RR, Ziegler B, Giesta JM, Signorini AV, Pires GQ, Feldens L, Ceza MR, Adami MR, Kieling CO, Goldani HAS. Is neurodevelopment impaired in Brazilian children with intestinal failure on prolonged parenteral nutrition? A single center study. Pediatr Surg Int 2024; 40:120. [PMID: 38702423 DOI: 10.1007/s00383-024-05694-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE To assess the neurodevelopment outcomes of children younger than 42 months of age with intestinal failure (IF) using prolonged parenteral nutrition (PN) followed by a Pediatric Multidisciplinary Intestinal Rehabilitation Program from a public tertiary hospital in Brazil. METHODS Bayley III scale was administered in children aged 2 to 42 months with IF and receiving PN for more than 60 days. Composite scores in cognitive, motor, and language domains were analyzed. Developmental delay was defined as a performance 2 standard deviations (SD) below the average at the 3 domains. Association between Bayley III composite scores and clinical variables related to IF were tested. RESULTS Twenty-four children with median (IQR) age of 17.5 months (9-28.5) were studied, 58.3% were male. Developmental delay was found in 34%, 33% and 27% of the patients in cognitive, motor, and language domains, respectively. There was no significant association between the Bayley-III composite scores and length of hospitalization, prematurity, and number of surgical procedures with anesthesia. CONCLUSION The study demonstrated impairments in the cognitive, motor and language domains in approximately one-third of young patients with IF on prolonged PN.
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Affiliation(s)
- Cristina Miller
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | | | - Bruna Ziegler
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Giovana Q Pires
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Letícia Feldens
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marília R Ceza
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marina R Adami
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carlos O Kieling
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Helena A S Goldani
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Alves VA, Giesta JM, Bosa VL, Goldani HAS. Bioelectrical impedance phase angle and nutritional status in children with intestinal failure on prolonged parenteral nutrition. J Pediatr (Rio J) 2024:S0021-7557(24)00039-1. [PMID: 38614136 DOI: 10.1016/j.jped.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVE To compare the phase angle (PhA) through bioelectrical impedance (BIA) of children with intestinal failure (IF) using prolonged parenteral nutrition (PN) followed by an Intestinal Rehabilitation Program, with a control group. METHODS Children under 10 years of age with IF using prolonged PN for >60 days (study group) were included. The control group consisted of healthy children without chronic pathologies, matched by sex and age. Anthropometric parameters evaluated were: weight, height, weight/age z-score (W/A), height/age z-score (H/A), BMI, BMI/A z-score, arm circumference, triceps skinfold, subscapular skinfold, mid-arm muscle circumference. BIA parameters were resistance (R), reactance (Xc), and phase angle (PhA). RESULTS Twenty-eight children were included in the study group, median (IQR) age was 11 (8-27) months, 53.6 % were male. In the control group, 28 children were included, median (IQR) age was 12.5 (8-24.7) months, 50 % were male. Children from the study group had W/A z-scores and H/A z-scores significantly lower than controls. There was no significant difference between PhA in the study group and controls, [median (IQR) 4.3° (3.8;4.6) vs 4.0° (3.8;5.4) respectively, p = 0.980]. Prematurity was significantly higher in the study group than in the controls, but there was no significant correlation between gestational age at birth and PhA of the children from the study group. CONCLUSION Children with IF using prolonged PN showed lower W/A and H/A compared to the control group, but without significant difference between the PhA of children with IF compared to controls.
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Affiliation(s)
- Victória A Alves
- Post-Graduate Program of Child and Adolescent Health, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - Juliana M Giesta
- Post-Graduate Program of Child and Adolescent Health, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Vera L Bosa
- Department of Nutrition, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Helena A S Goldani
- Post-Graduate Program of Child and Adolescent Health, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Patrícia da Silva Souza A, Lopes de Souza S, Alves da Silva ÉH, Gomes da Silva K, Almeida Barros WM. Comment on "Implementation of STRONGkids for identifying nutritional risk in outpatients of child health care clinics: Results of a multicentre study" Clinical Nutrition 2023. Clin Nutr 2024; 43:1081-1082. [PMID: 38154987 DOI: 10.1016/j.clnu.2023.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Affiliation(s)
- Ana Patrícia da Silva Souza
- Postgraduate Program in Neuropsychiatry and Behavioral Sciences, Center for Medical Sciences, Federal University of Pernambuco, Recife, Pernambuco, Brazil; Department of Physiotherapy, Health Sciences Center, Osman Lins University Center (UNIFACOL), Vitória de Santo Antão, Pernambuco, Brazil.
| | - Sandra Lopes de Souza
- Postgraduate Program in Neuropsychiatry and Behavioral Sciences, Center for Medical Sciences, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Érica Helena Alves da Silva
- Department of Physiotherapy, Health Sciences Center, Osman Lins University Center (UNIFACOL), Vitória de Santo Antão, Pernambuco, Brazil; Integrated Center for Neuroscience Technologies, Osman Lins University Center (UNIFACOL), Vitória de Santo Antão, Pernambuco, Brazil
| | - Karollainy Gomes da Silva
- Postgraduate Program in Neuropsychiatry and Behavioral Sciences, Center for Medical Sciences, Federal University of Pernambuco, Recife, Pernambuco, Brazil; Integrated Center for Neuroscience Technologies, Osman Lins University Center (UNIFACOL), Vitória de Santo Antão, Pernambuco, Brazil
| | - Waleska Maria Almeida Barros
- Department of Physiotherapy, Health Sciences Center, Osman Lins University Center (UNIFACOL), Vitória de Santo Antão, Pernambuco, Brazil; Integrated Center for Neuroscience Technologies, Osman Lins University Center (UNIFACOL), Vitória de Santo Antão, Pernambuco, Brazil
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Chugh PV, Nes E, Culbreath K, Keefe G, Edwards EM, Morrow KA, Ehret D, Soll RF, Modi BP, Horbar JD, Jaksic T. Comparing Healthcare Needs in Extremely Low Birth Weight Infants With NEC and Spontaneous Intestinal Perforation. J Pediatr Surg 2024:S0022-3468(24)00157-X. [PMID: 38561308 DOI: 10.1016/j.jpedsurg.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/21/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) affect 6-8% of extremely low birth weight (ELBW) infants. SIP has lower mortality than NEC, but with similar short-term morbidity in length of stay, growth failure, and supplemental oxygen requirements. Comparative long-term neurodevelopmental outcomes have not been clarified. METHODS Data were prospectively collected from 59 North American neonatal units, regarding ELBW infants (401-1000 g or 22-27 weeks gestational age) born between 2011 and 2018 and evaluated again at 16-26 months corrected age. Outcomes were collected from infants with laparotomy-confirmed NEC, laparotomy-confirmed SIP, and those without NEC or SIP. The primary outcome was severe neurodevelopmental disability. Secondary outcomes were weight <10th percentile, medical readmission, post-discharge surgery and medical support at home. Adjusted risk ratios (ARR) were calculated. RESULTS Of 13,673 ELBW infants, 6391 (47%) were followed including 93 of 232 (40%) with NEC and 100 of 235 (42%) with SIP. There were no statistically significant differences in adjusted risk of any outcomes when directly comparing NEC to SIP (ARR 2.35; 95% CI 0.89, 6.26). However, infants with NEC had greater risk of severe neurodevelopmental disability (ARR 1.43; 1.09-1.86), rehospitalization (ARR 1.46; 1.17-1.82), and post-discharge surgery (ARR 1.82; 1.48-2.23) compared to infants without NEC or SIP. Infants with SIP only had greater risk of post-discharge surgery (ARR 1.64; 1.34-2.00) compared to infants without NEC or SIP. CONCLUSIONS ELBW infants with NEC had significantly increased risk of severe neurodevelopmental disability and post-discharge healthcare needs, consistent with prior literature. We now know infants with SIP also have increased healthcare needs. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- Priyanka V Chugh
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Emily Nes
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | | | - Gregory Keefe
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Erika M Edwards
- University of Vermont, Department of Mathematics and Statistics, Burlington, VT, USA; Vermont Oxford Network, Burlington, VT, USA
| | | | - Danielle Ehret
- Vermont Oxford Network, Burlington, VT, USA; University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT, USA
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, USA; University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT, USA
| | - Biren P Modi
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, USA; University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, VT, USA
| | - Tom Jaksic
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA.
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Weis VG, Cruz-Diaz N, Rauh JL, Ellison MA, Yamaleyeva LM, Welch CD, Zeller KA, Weis JA. Photoacoustic Imaging as a Novel Non-invasive Biomarker to Assess Intestinal Tissue Oxygenation and Motility in Neonatal Rats. J Pediatr Surg 2024; 59:528-536. [PMID: 37858392 PMCID: PMC10922103 DOI: 10.1016/j.jpedsurg.2023.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Within the premature infant intestine, oxygenation and motility play key physiological roles in healthy development and disease such as necrotizing enterocolitis. To date, there are limited techniques to reliably assess these physiological functions that are also clinically feasible for critically ill infants. To address this clinical need, we hypothesized that photoacoustic imaging (PAI) can provide non-invasive assessment of intestinal tissue oxygenation and motility to characterize intestinal physiology and health. METHODS Ultrasound and photoacoustic images were acquired in 2-day and 4-day old neonatal rats. For PAI assessment of intestinal tissue oxygenation, an inspired gas challenge was performed using hypoxic, normoxic, and hyperoxic inspired oxygen (FiO2). For intestinal motility, oral administration of ICG contrast agent was used to compare control animals to an experimental model of loperamide-induced intestinal motility inhibition. RESULTS PAI demonstrated progressive increases in oxygen saturation (sO2) as FiO2 increased, while the pattern of oxygen localization remained relatively consistent in both 2-day and 4-day old neonatal rats. Analysis of intraluminal ICG contrast enhanced PAI images yielded a map of the motility index in control and loperamide treated rats. From PAI analysis, loperamide significantly inhibited intestinal motility, with a 32.6% decrease in intestinal motility index scores in 4-day old rats. CONCLUSION These data establish the feasibility and application of PAI to non-invasively and quantitatively measure intestinal tissue oxygenation and motility. This proof-of-concept study is an important first step in developing and optimizing photoacoustic imaging to provide valuable insight into intestinal health and disease to improve the care of premature infants.
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Affiliation(s)
- Victoria G Weis
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, USA
| | - Nildris Cruz-Diaz
- Department of Surgery-Hypertension, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Cardiovascular Sciences Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jessica L Rauh
- Department of General Surgery, Section of Pediatric Surgery, Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Maryssa A Ellison
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, NC, USA
| | - Liliya M Yamaleyeva
- Department of Surgery-Hypertension, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Cardiovascular Sciences Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Cherrie D Welch
- Division of Neonatology, Department of Pediatrics, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Kristen A Zeller
- Department of General Surgery, Section of Pediatric Surgery, Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Jared A Weis
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Comprehensive Cancer Center, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA; School of Biomedical Engineering and Sciences, Virginia Tech-Wake Forest University, Blacksburg, VA, USA.
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8
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Nes E, Knell J, Keefe G, Culbreath K, Han SM, McGivney M, Staffa SJ, Modi BP, Carey AN, Jaksic T, Duggan CP. Factors associated with D-lactic acidosis in pediatric intestinal failure: A case-control study. J Pediatr Gastroenterol Nutr 2024; 78:217-222. [PMID: 38374557 PMCID: PMC10883598 DOI: 10.1002/jpn3.12075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND D-lactic acidosis (DLA) is a serious complication of short bowel syndrome (SBS) in children with intestinal failure (IF). Malabsorbed carbohydrates are metabolized by bacteria in the intestine to D-lactate which can lead to metabolic acidosis and neurologic symptoms. METHODS A retrospective chart review was performed in children ≤18 years old with SBS who had one of the following criteria: unexplained metabolic acidosis, neurologic signs or symptoms, history of antibiotic therapy for small bowel bacterial overgrowth, or high clinical suspicion of DLA. Cases had serum D-lactate concentration >0.25 mmol/L; controls with concentrations ≤0.25 mmol/L. RESULTS Of forty-six children, median age was 3.16 (interquartile range (IQR): 1.98, 5.82) years, and median residual bowel length was 40 (IQR: 25, 59) cm. There were 23 cases and 23 controls. Univariate analysis showed that cases had significantly lower median bicarbonate (19 vs. 24 mEq/L, p = 0.001), higher anion gap (17 vs. 14 mEq/L, p < 0.001) and were less likely to be receiving parenteral nutrition, compared with children without DLA. Multivariable analysis identified midgut volvulus, history of intestinal lengthening procedure, and anion gap as significant independent risk factors. Midgut volvulus was the strongest independent factor associated with DLA (adjusted odds ratio = 17.1, 95% CI: 2.21, 133, p = 0.007). CONCLUSION DLA is an important complication of pediatric IF due to SBS. Patients with IF, particularly those with history of midgut volvulus, having undergone intestinal lengthening, or with anion gap acidosis, should be closely monitored for DLA.
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Affiliation(s)
- Emily Nes
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jamie Knell
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Keefe
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine Culbreath
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sam M Han
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Megan McGivney
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandra N Carey
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P Duggan
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Gutierrez SA, Pathak S, Raghu V, Shui A, Huang CY, Rhee S, McKenzie-Sampson S, Lai JC, Wadhwani SI. Neighborhood Income Is Associated with Health Care Use in Pediatric Short Bowel Syndrome. J Pediatr 2024; 265:113819. [PMID: 37940084 PMCID: PMC10847979 DOI: 10.1016/j.jpeds.2023.113819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/27/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE To evaluate associations between neighborhood income and burden of hospitalizations for children with short bowel syndrome (SBS). STUDY DESIGN We used the Pediatric Health Information System (PHIS) database to evaluate associations between neighborhood income and hospital readmissions, readmissions for central line-associated bloodstream infections (CLABSI), and hospital length of stay (LOS) for patients <18 years with SBS hospitalized between January 1, 2006, and October 1, 2015. We analyzed readmissions with recurrent event analysis and analyzed LOS with linear mixed effects modeling. We used a conceptual model to guide our multivariable analyses, adjusting for race, ethnicity, and insurance status. RESULTS We included 4289 children with 16 347 hospitalizations from 43 institutions. Fifty-seven percent of the children were male, 21% were Black, 19% were Hispanic, and 67% had public insurance. In univariable analysis, children from low-income neighborhoods had a 38% increased risk for all-cause hospitalizations (rate ratio [RR] 1.38, 95% CI 1.10-1.72, P = .01), an 83% increased risk for CLABSI hospitalizations (RR 1.83, 95% CI 1.37-2.44, P < .001), and increased hospital LOS (β 0.15, 95% CI 0.01-0.29, P = .04). In multivariable analysis, the association between low-income neighborhoods and elevated risk for CLABSI hospitalizations persisted (RR 1.70, 95% CI 1.23-2.35, P < .01, respectively). CONCLUSIONS Children with SBS from low-income neighborhoods are at increased risk for hospitalizations due to CLABSI. Examination of specific household- and neighborhood-level factors contributing to this disparity may inform equity-based interventions.
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Affiliation(s)
- Susan A Gutierrez
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Sagar Pathak
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Vikram Raghu
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Amy Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Sue Rhee
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Safyer McKenzie-Sampson
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Sharad I Wadhwani
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA.
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Zhong J, Martins DS, Piper HG. Standardizing vitamin D supplementation to minimize deficiency in children with intestinal failure. Nutr Clin Pract 2024; 39:177-183. [PMID: 38030590 DOI: 10.1002/ncp.11094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Vitamin D deficiency is present in 40%-70% of children with intestinal failure (IF), yet there are no published guidelines for repleting and maintaining vitamin D levels in this population. The purpose of this study is to evaluate the efficacy of a standardized vitamin D algorithm in reducing the incidence of deficiency. METHODS A retrospective chart review was performed in children with IF who had at least one serum vitamin D (25-hydroxyvitamin D3 ) measurement. Vitamin D levels were compared prealgorithm (2014-2016) and during active-algorithm use (2018-2020). Vitamin D levels were classified as severe deficiency (<12.5 nmol per L), mild deficiency (12.5-39 nmol/L), insufficiency (40-74 nmol/L), optimal (75-224 nmol/L), or toxicity (>225 nmol/L). Descriptive and comparative statistics were calculated using a linear mixed-effects model, with P < 0.05 considered significant. RESULTS Twenty-eight children with IF were enrolled, which included 157 vitamin D measurements (58 in the prealgorithm group and 98 in the active-algorithm group). Algorithm compliance was 4% in the prealgorithm group and 61% in the active-algorithm group. Active-algorithm patients had improved vitamin D levels in all categories compared with those of prealgorithm patients (mild deficiency: 8% vs 9%; insufficiency: 41% vs 72%; optimal: 50% vs 19%). Algorithm use was found to have a statistically significant effect on serum vitamin D levels (β = 21.58; 95% confidence interval, 14.11-29.05; P < 0.005). CONCLUSIONS Children with IF are at high risk for vitamin D deficiency. Use of a standardized vitamin D supplementation algorithm was associated with increased serum vitamin D levels.
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Affiliation(s)
- Jade Zhong
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Debby S Martins
- Complex Feeding and Nutrition Service, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Hannah G Piper
- Division of Pediatric Surgery, University of British Columbia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
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11
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John EM, Sathyan S, Pournami F, Prithvi AK, Nandakumar A, Prabhakar J, Jain N. CODE Think! Rare Mutations of STX3 Causing Microvillus Inclusion Disease. J Pediatr Genet 2023; 12:352. [PMID: 38162158 PMCID: PMC10756714 DOI: 10.1055/s-0043-1772207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 07/11/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Elizabeth Mary John
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Sajina Sathyan
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Femitha Pournami
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Ajai Kumar Prithvi
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Anand Nandakumar
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Jyothi Prabhakar
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
| | - Naveen Jain
- Department of Neonatology, Kerala Institute of Medical Sciences, Trivandrum, Kerala, India
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12
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Tüshaus L, Kelly K, Siebert J, Kohl-Sobania M. About the Usage and Usability of Central Venous Catheters in Children with TPN: the Parents' Viewpoint. KLINISCHE PADIATRIE 2023. [PMID: 37972962 DOI: 10.1055/a-2196-8630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Medical devices are important components of medical care. Therefore, they must be safe and useful for patients. This study aimed to analyze the situation of children with central venous catheters (CVCs) for long-term parenteral nutrition from the parents' perspective with respect to patient safety and usefulness. METHODS An online cross-sectional survey was conducted using a quantitative research approach, with a German patient support group for children with chronic intestinal failure. RESULTS 61 responses were collected between November 202 and January 2021. Concerning the usability of the CVCs, the caregivers assessed overall satisfaction, patient safety, usability, learnability of handling, "self-explanatory ability, " and mental load. Furthermore, various suggestions for improvements have been documented. CONCLUSION Although CVCs can cause a variety of complications in the context of long-term use, the usage for parents in everyday life is feasible. Insufficient fixation and protection outside of the body have been identified as unmet clinical needs. In addition to the underlying disease of chronic intestinal failure, the catheter adds an extra mental burden to families' lives. Furthermore, parents articulated the need for further information and training.
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Affiliation(s)
- Ludger Tüshaus
- Department of Pediatric Surgery, University Medical Center Schleswig Holstein Lübeck Campus, Lubeck, Germany
| | - Kathrin Kelly
- Department of Pediatric Surgery, University Medical Center Schleswig Holstein Lübeck Campus, Lubeck, Germany
| | - Julia Siebert
- Department of Pediatric Surgery, University Medical Center Schleswig Holstein Lübeck Campus, Lubeck, Germany
| | - Martina Kohl-Sobania
- Department of Pediatrics and Adolescent Medicine, University Medical Center Schleswig Holstein Lübeck Campus, Lubeck, Germany
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13
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Salazar JA, Goldsmith JD, Jimenez L, Fox VL, Duggan CP, Carey AN. Gastric Foveolar Hyperplastic Polyps in 2 Children With Short Bowel Syndrome on Long-Term Teduglutide. JPGN REPORTS 2023; 4:e389. [PMID: 38034466 PMCID: PMC10684249 DOI: 10.1097/pg9.0000000000000389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 08/23/2023] [Indexed: 12/02/2023]
Abstract
The natural history of short bowel syndrome involves intestinal adaptation wherein the remnant small intestine undergoes histologic and anatomic changes aimed at increasing absorption. Teduglutide-a glucagon-like peptide 2 analog approved for pediatric use in 2019-stimulates this process by causing proliferation of intestinal epithelial cells resulting in increased villous height and crypt depth. Food and Drug Administration approval for pediatric patients followed safety and efficacy studies in children that were limited to 24-week duration. Pediatric-specific postmarketing studies evaluating long-term safety and efficacy are underway. Formation of colorectal polyps has been repeatedly observed in studies of adult patients on long-term teduglutide, including in individuals without endoscopic evidence of polyps before treatment initiation. Recent studies, however, suggest increased risk of small bowel hyperplastic and dysplastic polyp formation with long-term glucagon-like peptide 2 analog use. We report 2 cases of small bowel foveolar hyperplastic polyps found during surveillance endoscopies after 1 year of treatment with teduglutide.
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Affiliation(s)
- Jonathan A. Salazar
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey D. Goldsmith
- Department of Pathology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Lissette Jimenez
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Victor L. Fox
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Christopher P. Duggan
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Alexandra N. Carey
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA
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14
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Puoti MG, D'Eusebio C, Littlechild H, King E, Koeglmeier J, Hill S. Risk factors for catheter-related bloodstream infections associated with home parental nutrition in children with intestinal failure: A prospective cohort study. Clin Nutr 2023; 42:2241-2248. [PMID: 37806076 DOI: 10.1016/j.clnu.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 08/24/2023] [Accepted: 09/10/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND & AIMS Catheter-related bloodstream infection (CRBSI) is the most common, potentially life-threatening complication of long-term parenteral nutrition (PN). We prospectively assessed the incidence and risk factors for CRBSI in children receiving long-term home PN (HPN) for intestinal failure (IF) in a single IF rehabilitation center. METHODS Data regarding episodes and potential risk factors for CRBSI in children on HPN were prospectively recorded. RESULTS Forty-one of 75 children were diagnosed with CRBSI. The overall CRBSI rate was 1.61 per 1000 catheter days. The indications for HPN were gastrointestinal motility disorders in 35%, short bowel syndrome (SBS) in 28% graft versus host disease (GvHD) post bone marrow transplant in 17%, congenital enteropathy in 15%, and severe neurodevelopmental impairment in 5%. Gastrointestinal motility disorders had significantly higher CRBSI rate compared to other groups (p < 0.0005; 2.74 in motility group vs 1.54 in GvHD group vs 0.52 in congenital enteropathies vs 0.36 in SBS group vs 0.67 in severe neurodevelopmental delay). Multivariate analysis revealed that enterocutaneous distal stoma (ileostomy or colostomy) (HR 3.35 [95% CI, 1.63-6.86]; p < 0.001), age <2 years (HR 0.28 [95% CI, 0.15-0.53]; p < 0.0001), male sex (HR 2.28 [95% CI, 1.51-3.43]; p < 0.0001), non-use of taurolidine citrate lock (HR 2.70 [95% CI, 1.72-4.11]; p < 0.0001) and gastrointestinal motility disorder (HR 3.02 [95% CI, 1.81-4.91]; p < 0.001) were independent risk factors for developing CRBSI. CONCLUSIONS Extra care in managing PN connections and disconnections should be taken in children with an underlying gastrointestinal motility disorder, distal enterocutaneous stoma, male sex and those aged <2 years since they are at a significantly higher risk of CRBSI. Early introduction of taurolidine lock should be considered.
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Affiliation(s)
- Maria Giovanna Puoti
- Great Ormond Street Hospital for Children, Department of Paediatric Gastroenterology, Division of Intestinal Failure and Nutritional Rehabilitation, London, UK
| | - Chiara D'Eusebio
- Paediatric Hospital Regina Margherita, Dietetic and Clinical Nutrition Unit, University of Turin, Turin, Italy
| | - Hannah Littlechild
- Great Ormond Street Hospital for Children, Department of Paediatric Gastroenterology, Division of Intestinal Failure and Nutritional Rehabilitation, London, UK
| | - Emily King
- Great Ormond Street Hospital for Children, Department of Paediatric Gastroenterology, Division of Intestinal Failure and Nutritional Rehabilitation, London, UK
| | - Jutta Koeglmeier
- Great Ormond Street Hospital for Children, Department of Paediatric Gastroenterology, Division of Intestinal Failure and Nutritional Rehabilitation, London, UK
| | - Susan Hill
- Great Ormond Street Hospital for Children, Department of Paediatric Gastroenterology, Division of Intestinal Failure and Nutritional Rehabilitation, London, UK.
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15
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Hasegawa T, Takano S, Masuda K, Fujiwara Y, Miyahara A, Miura M. Retrospective Analysis of Neonatal Surgery at Tottori University over the Past Ten Years. Yonago Acta Med 2023; 66:413-421. [PMID: 38028267 PMCID: PMC10674064 DOI: 10.33160/yam.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/13/2023] [Indexed: 12/01/2023]
Abstract
Background In recent years, the number of neonatal surgeries has been on the rise despite the decline in the number of births, and we examined the actual trends and problems at Tottori University Hospital located in the Sanin region. Methods Medical records were retrospectively searched for patients who underwent major surgery during the neonatal period (within 30 days of age) at the Tottori University Hospital over the past 10 years (Jan. 2011 to Dec. 2020). Results Sixty-five cases were included. Early birth infants (< 37 gestational weeks) comprised 15 cases (23%) and low birth weight (< 2500 g) infants involved 27 cases (42%). In the latter half (2016-2020), early birth and low birth weight infants were significantly less than in the first half (2011-2015). The common diseases were anorectal malformation (14 cases), esophageal atresia (10), duodenal atresia (10), and diaphragmatic hernia (9). Prenatal diagnosis was obtained in 26 cases (40%), with high diagnostic rate obtained in duodenal atresia (100%), abdominal wall defect (100%), ileal atresia (75%), meconium peritonitis (67%), and diaphragmatic hernia (67%). Fifty-five cases (85%) were operated on within 7 days of age. Other major malformations were associated in 23 cases (35%). There were 6 deaths (9%), of which 3 cases were low birth weight infants with gastrointestinal perforation, 2 cases with severe chromosomal abnormalities (esophageal atresia, omphalocele), and 1 case with diaphragmatic hernia with severe pulmonary hypertension. Home medical care has been required with gastrostomy tube in 2 cases. Conclusion Neonatal surgery at Tottori University has been well performed as required with acceptable results along with the progression of other perinatal care. However, further investigation for improvements in premature delivery or organ hypoplasia may be required.
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Affiliation(s)
- Toshimichi Hasegawa
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Shuichi Takano
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Kohga Masuda
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Yoshiyuki Fujiwara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Ayako Miyahara
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Mazumi Miura
- Department of Pediatrics, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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16
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Mutanen A, Pakarinen MP. Featuring molecular regulation of bile acid homeostasis in pediatric short bowel syndrome. Clin Res Hepatol Gastroenterol 2023; 47:102220. [PMID: 37769812 DOI: 10.1016/j.clinre.2023.102220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/29/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Disturbed bile acid homeostasis may foster development of short bowel syndrome (SBS) associated liver disease during and after weaning off parenteral nutrition (PN). Our aim was to study hepatic molecular regulation of bile acid homeostasis in relation to serum and fecal bile acid profiles in pediatric SBS. METHODS Liver histopathology and mRNA expression of genes regulating synthesis, uptake and export of bile acids, and cellular receptors involved in bile acid signaling were measured in SBS patients (n = 33, median age 3.2 years). Simultaneously, serum (n = 24) and fecal (n = 10) bile acid profiles were assessed. Sixteen patients were currently on PN. Results of patients were compared to healthy control subjects. RESULTS Nine of ten (90 %) patients with histological cholestasis received current PN, while portal inflammation was present in 60 % (6/10) of patients with cholestasis compared to 13 % (3/23) without cholestasis (P = 0.01). In all SBS patients, hepatic synthesis and uptake of bile acids was increased. Patients on current PN showed widespread repression of hepatic FXR target genes, including downregulated canalicular (BSEP, MDR3) and basolateral (MRP3) bile acid exporters. Serum and fecal primary bile acids were increased both during and after weaning off PN. CONCLUSIONS Bile acid homeostasis in SBS is characterized by interrupted enterohepatic circulation promoting increased hepatic synthesis and conservation of bile acids. In PN dependent SBS patients with hepatic cholestasis and inflammation, the molecular fingerprint of downregulated hepatocyte canalicular and basolateral bile acid export with simultaneously increased synthesis and uptake of bile acids could favor their accumulation in hepatocytes and predispose to liver disease.
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Affiliation(s)
- Annika Mutanen
- Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, The New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, The New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
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17
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Sakurai T, Nakamura M, Sasaki H, Fukuzawa T, Kudo H, Ando R, Okubo R, Hashimoto M, Tada K, Wada M. Risk factors for catheter-related bloodstream infections in patients with intestinal failure undergoing home parenteral nutrition: a single-center study. Pediatr Surg Int 2023; 39:283. [PMID: 37847289 DOI: 10.1007/s00383-023-05555-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 10/18/2023]
Abstract
PURPOSE The incidence and risk factors of catheter-related bloodstream infections (CRBSI) in patients with intestinal failure (IF) have not been established, partly because catheter management methods vary from different facilities. This study aimed to identify the risk factors and incidence rate of CRBSIs in patients with IF who were given prophylactic treatment. METHODS Sixteen patients with IF who required home parenteral nutrition were enrolled in this study. Prophylactic management of CRBSI included monthly ethanol lock therapy and standardized infection prevention education. The outcomes included the incidence and risk factors of CRBSI. RESULTS The median incidence rate of CRBSI was 1.2 per 1000 catheter days. Univariate analysis showed that the risk of developing CRBSI was significantly associated with short bowel syndrome (< 30 cm) (p = 0.016). Other relevant findings included a significant negative correlation between serum albumin and CRBSI rate (r = - 0.505, p = 0.046), and past history of mixed bacterial infections was significantly associated with increased CRBSI rate (p = 0.013). CONCLUSION CRBSIs can still develop despite undergoing prophylactic management. Risk factors for CRBSI include the residual intestinal length, nutritional status, and susceptibility to certain microorganisms.
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Affiliation(s)
- Tsuyoshi Sakurai
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Megumi Nakamura
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Hideyuki Sasaki
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Taichi Fukuzawa
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Hironori Kudo
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Ryo Ando
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Ryuji Okubo
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Masatoshi Hashimoto
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Kesuke Tada
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Motoshi Wada
- Department of Pediatric Surgery, Tohoku University Hospital, Sendai, 980-8574, Japan.
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18
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Carey AN, Quinn N, Arouchon K, Elman DM, Buccigrosso TM, Mitchell PD, Duggan CP. Air Displacement Plethysmography is an Accurate and Feasible Noninvasive Measure of Fat-Free Mass in Children With Intestinal Failure. J Pediatr Gastroenterol Nutr 2023; 77:553-557. [PMID: 37496142 DOI: 10.1097/mpg.0000000000003883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND The nutritional status of children with intestinal failure (IF) can be difficult to determine using body weight and currently available anthropometric techniques. Air displacement plethysmography (ADP) is a noninvasive measure of whole-body composition that measures body mass and volume, with a calculation of percent body fat (%BF) and fat-free mass (FFM) that may be useful during the provision of specialized nutrition. OBJECTIVES To evaluate the validity and feasibility of measuring body composition in children with IF using ADP compared with deuterium dilution (DD), as well as secondarily with other measures of body composition, namely bioelectrical impedance analysis (BIA), dual-energy X-ray absorptiometry (DXA), and four-site skinfold anthropometry. METHODS We conducted a prospective cohort study of 18 children recruited through the Center for Advanced Intestinal Rehabilitation at Boston Children's Hospital. Patients 2-17 years of age with IF dependent on parenteral nutrition (PN) for more than 90 days were included. Spearman rank correlation and Bland-Altman limits of agreement (LOA) analysis were used to compare ADP to 4 alternative measures of body composition. RESULTS Eighteen children with IF, median age 7.1 [interquartile range (IQR) 5.4-9.3] years, 9 female (50%), and median residual bowel length 31 (IQR 22-85) cm were enrolled. Median PN energy intake was 46 (IQR 39-49) kcal/kg/day. Incomplete bladder emptying lead to invalid measures of DD in 4 subjects. Spearman correlation coefficients for %BF were low to moderate between ADP and DD ( r = 0.29), DXA ( r = 0.62), BIA ( r = 0.50), and skinfold ( r = 0.40). Correlations for FFM were high between ADP and these other measures (range 0.95-0.98). Comparing ADP with DD and skinfold measures, Bland-Altman analysis showed small mean bias (-1.9 and +1.5 kg) and acceptable 95% LOA ranges (10.7 and 22.9 kg), respectively, with larger bias (-10.7 and -7.7 kg) and LOA ranges (38.7 and 45.2 kg) compared to DXA and BIA. %BF by ADP and skinfold thickness were moderately correlated ( r = 0.43) with low bias (-0.2%) but very wide LOA (25.7%). CONCLUSIONS Body composition via ADP is feasible and valid in children with IF as a measure of FFM but appears less suitable for the measurement of %BF. The technique holds promise as a noninvasive measure of body composition to assess the efficacy of nutritional, medical, and surgical interventions.
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Affiliation(s)
- Alexandra N Carey
- From the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA
- the Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Nicolle Quinn
- the Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Kayla Arouchon
- the Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Daniel M Elman
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Tess M Buccigrosso
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Paul D Mitchell
- the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Christopher P Duggan
- From the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA
- the Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA
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19
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Lepus CA, Samela K, Mokha JS. Efficacy and safety of intravenous iron sucrose in children younger than 2 years with intestinal failure. Nutr Clin Pract 2023; 38:899-903. [PMID: 36440796 DOI: 10.1002/ncp.10936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/10/2022] [Accepted: 10/30/2022] [Indexed: 07/20/2023] Open
Abstract
Iron-deficiency anemia (IDA) is highly prevalent in children with intestinal failure (IF) and oral iron supplementation is often ineffective in this patient population. Even though various intravenous (IV) iron formulations are available, there is a dearth of data on the use of newer parenteral iron products such as IV iron sucrose, especially in infants and young children (<2 years of age) with IF. To determine safety and efficacy, we performed a retrospective chart review on infants and children younger than 2 years with IF who received IV iron sucrose for IDA between October 2019 and August 2021. The review revealed that 10 events of IV iron sucrose replacement were administered to five children aged 4-22 months with IF and IDA. We observed a mean increase in hemoglobin of 1.9 ± 0.6 g/dl, and peak hemoglobin levels were seen at 4.3 ± 0.8 weeks after the IV iron sucrose dose. The infusions were well tolerated, and no short-term adverse reactions or laboratory abnormalities were observed. Based on these observations, the use of IV iron sucrose appears to be safe and effective in infants and young children with IF and could be considered in the management of IDA in this patient population.
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Affiliation(s)
- Chelsea A Lepus
- Connecticut Children's Medical Center, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hartford, Connecticut, USA
| | - Kate Samela
- Connecticut Children's Medical Center, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hartford, Connecticut, USA
| | - Jasmeet S Mokha
- Connecticut Children's Medical Center, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Hartford, Connecticut, USA
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20
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Ali F, Cole CR, Hornung L, Mouzaki M, Wasserman H, Kalkwarf HJ. Age-related trajectory of bone density in children with intestinal failure: A longitudinal retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:736-745. [PMID: 37227158 PMCID: PMC10875680 DOI: 10.1002/jpen.2525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Longitudinal changes in bone health in children with intestinal failure (IF) are unclear. We aimed to better understand the trajectory of bone mineral status over time in children with IF and identify clinical factors that influence the trajectory. METHODS Clinical records of patients attending the Intestinal Rehabilitation Center of Cincinnati Children's Hospital Medical Center between 2012 and 2021 were reviewed. Children diagnosed with IF before age 3 years with at least two lumbar spine dual-energy x-ray absorptiometry scans were included. We abstracted information on medical history, parenteral nutrition, bone density, and growth. We calculated bone density z scores with and without adjustment for height z scores. RESULTS Thirty-four children with IF met inclusion criteria. Children were shorter than average with a mean height z score of -1.5 ± 1.3. The mean bone density z score was -1.5 ± 1.3 with 25 of the cohort having a z score < -2.0. After height adjustment, the mean bone density z score was -0.42 ± 1.4 with 11% below -2.0. Most dual-energy x-ray absorptiometry scans (60%) had a feeding tube artifact. Bone density z scores increased slightly with age and lower parenteral nutrition dependency and were higher in scans without an artifact. Etiologies of IF, line infections, prematurity, and vitamin D status were not associated with height-adjusted bone density z scores. CONCLUSION Children with IF were shorter than expected for age. Deficits in bone mineral status were less common when adjusting for short stature. Etiologies of IF, prematurity, and vitamin D deficiency were not associated with bone density.
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Affiliation(s)
- Farhana Ali
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Conrad R. Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Lindsey Hornung
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Halley Wasserman
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Heidi J. Kalkwarf
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Mutanen A, Demirok A, Wessel L, Tabbers M. Pediatric Intestinal Pseudo-Obstruction: An International Survey on Diagnostic and Management Strategies in the European Reference Network for Rare Inherited and Congenital Anomalies Intestinal Failure Teams. J Pediatr Gastroenterol Nutr 2023; 77:24-30. [PMID: 37027146 PMCID: PMC10697283 DOI: 10.1097/mpg.0000000000003788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 04/04/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES Pediatric intestinal pseudo-obstruction (PIPO) management is based on nutritional, medical, and surgical care while available evidence is scarce. The aim of this study was to outline the current diagnostic and management strategies in intestinal failure (IF) teams of the European Reference Network for rare Inherited and Congenital Anomalies (ERNICA) and to compare these practices to the latest PIPO international guidelines. METHODS An online survey on institutional diagnostic and management strategies of PIPO was conducted among the ERNICA IF teams. RESULTS In total, 11 of 21 ERNICA IF centers from 8 countries participated. On average, 64% of teams had ≥6 and 36% had 1-5 PIPO patients under active follow-up. In total, 80 of 102 PIPO patients were parenteral nutrition (PN) dependent while each IF team had median 4 (range 0-19) PN dependent PIPO patients under follow-up. On average, each center received 1-2 new PIPO patients per year. Diagnostics mostly followed current guidelines while medical and surgical management strategies were diverse. CONCLUSIONS Numbers of PIPO patients are low and management strategies are diverse among ERNICA IF teams. To improve PIPO patient care, regional reference centers with specialized multidisciplinary IF teams and continuous collaboration across centers are needed.
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Affiliation(s)
- Annika Mutanen
- From the Pediatric Surgery, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Aysenur Demirok
- the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lucas Wessel
- the Department of Pediatric Surgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Merit Tabbers
- the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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22
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Mutanen A, Engstrand Lilja H, Wester T, Norrby H, Borg H, Persson S, Bjornland K, Brun AC, Telborn L, Stenström P, Pakarinen MP. A nordic multicenter study on contemporary outcomes of pediatric short bowel syndrome in 208 patients. Clin Nutr 2023; 42:1095-1103. [PMID: 37270343 DOI: 10.1016/j.clnu.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/05/2023] [Accepted: 05/21/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND & AIMS Despite advances in the management of short bowel syndrome related intestinal failure (SBS-IF), large-scale contemporary pediatric studies are scarce. The aim of this multicenter study was to assess key outcomes and clinical prognostic factors in a recent Nordic pediatric SBS-IF population. METHODS Patients with SBS-IF treated during 2010-2019, whose parenteral support (PS) started at age <1 year and continued >60 consecutive days were included and retrospectively reviewed. All six participating centers followed multidisciplinary SBS-IF management. Risk factors for PS dependency, intestinal failure associated liver disease (IFALD) and mortality were assessed with Cox regression and Kaplan Meier analyses. IFALD was defined with serum liver biochemistry levels. RESULTS Among 208 patients, SBS-IF resulted from NEC in 49%, gastroschisis w/wo atresia in 14%, small bowel atresia in 12%, volvulus in 11%, and other diagnoses in 14%. Median age-adjusted small bowel length was 43% (IQR 21-80%). After median follow up of 4.4 years (IQR 2.5-6.9), enteral autonomy was reached by 76%, none had undergone intestinal transplantation, and overall survival was 96%. Half of deaths (4/8) were caused by septic complications. Although biochemical cholestasis occurred only in 3% at latest follow-up and none of deaths were directly caused by IFALD, elevated liver biochemistry (HR 0.136; P = 0.017) and shorter remaining small bowel (HR 0.941; P = 0.040) predicted mortality. Shorter remaining small bowel and colon, and presence of end-ostomy were the main predictors of PS dependency, but not IFALD. Patients with NEC reached enteral autonomy more efficiently and had decreased incidence of IFALD compared to other etiologies. CONCLUSIONS Although with current multidisciplinary management, prognosis of pediatric SBS is encouraging, septic complications and IFALD still associated with the remaining low mortality rate.
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Affiliation(s)
- Annika Mutanen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland.
| | - Helene Engstrand Lilja
- Department of Pediatric Surgery, University Children's Hospital, Uppsala University, Uppsala, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
| | - Heimir Norrby
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Borg
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Sara Persson
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Kristin Bjornland
- Department of Pediatric Surgery, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Lovisa Telborn
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
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23
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Zorzetti N, Marino IR, Sorrenti S, Navarra GG, D'Andrea V, Lauro A. Small bowel transplant - novel indications and recent progress. Expert Rev Gastroenterol Hepatol 2023; 17:677-690. [PMID: 37264646 DOI: 10.1080/17474124.2023.2221433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years. AREAS COVERED Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed. EXPERT COMMENTARY Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.
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Affiliation(s)
- Noemi Zorzetti
- General Surgery, Ospedale Civile "A. Costa", Alto Reno Terme, Bologna, Italy
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
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24
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Garg PM, Pittman I, Yi J, Weis VG, Rodriguez RJ, Ladd MR, Rauh JL, McDonald AG, Welch C, Premkumar MH, Garg PP, Maheshwari A. Clinical Correlates of Cholestasis in Preterm Infants with Surgical Necrotizing Enterocolitis. NEWBORN (CLARKSVILLE, MD.) 2023; 2:191-197. [PMID: 37974929 PMCID: PMC10653206 DOI: 10.5005/jp-journals-11002-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Background We sought to investigate the clinical determinants and outcomes of cholestasis in preterm infants with surgical necrotizing enterocolitis (sNEC). Methods Retrospective comparison of clinical information in preterm infants who developed cholestasis vs those who did not. Results Sixty-two (62/91, 68.1%) infants with NEC developed cholestasis at any time following the onset of illness. Cholestasis was seen more frequently in those who had received ionotropic support at 24 hours following sNEC diagnosis (87.1% vs 58.6%; p = 0.002), had higher mean C-reactive protein levels 2 weeks after NEC diagnosis (p = 0.009), had blood culture-positive sepsis [25 (40.3%) vs 4 (13.8%); p = 0.011], received parenteral nutrition (PN) for longer durations (108.4 ± 56.63 days vs 97.56 ± 56.05 days; p = 0.007), had higher weight-for-length z scores at 36 weeks' postmenstrual age [-1.0 (-1.73, -0.12) vs -1.32 (-1.76, -0.76); p = 0.025], had a longer length of hospital stay (153.7 ± 77.57 days vs 112.51 ± 85.22 days; p = 0.024), had intestinal failure more often (61% vs 25.0%, p = 0.003), had more surgical complications (50% vs 27.6%; p = 0.044), and had >1 complication (21% vs 3.4%; p = 0.031). Using linear regression, the number of days after surgery when feeds could be started [OR 15.4; confidence interval (CI) 3.71, 27.13; p = 0.009] and the postoperative ileus duration (OR 11.9, CI 1.1, 22.8; p = 0.03) were independently associated with direct bilirubin between 2 and 5 mg/dL (mild-moderate cholestasis) at 2 months of age. The duration of PN was independently associated with direct bilirubin >5 mg/dL (severe cholestasis) at 2 months of age in these patients. Conclusion Cholestasis was seen in 68% of infants following surgical NEC. The most likely contributive factors are intestinal failure and subsequent PN dependence for longer periods. Our data suggest that identification and prevention of risk factors such as sepsis and surgical complications and early feeds following NEC surgery may improve outcomes.
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Affiliation(s)
- Parvesh Mohan Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Global Newborn Society, Clarksville, Maryland, United States of America
| | - Isabella Pittman
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Joe Yi
- Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, NC, United States of America
| | - Victoria G Weis
- Department of Regenerative Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Ricardo Jorge Rodriguez
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Mitchell R Ladd
- Department of Pediatric Surgery, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Jessica L Rauh
- Department of Pediatric Surgery, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Anna Greene McDonald
- Department of Pathology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | - Cherrie Welch
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, North Carolina, United States of America
| | | | - Padma P Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Akhil Maheshwari
- Global Newborn Society, Clarksville, Maryland, United States of America
- Louisiana State University Health Sciences Center – Shreveport, LA, United States of America
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25
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Weis VG, Cruz-Diaz N, Rauh JL, Ellison MA, Yamaleyeva LM, Welch CD, Zeller KA, Weis JA. Photoacoustic Imaging as a Novel Non-Invasive Biomarker to Assess Intestinal Tissue Oxygenation and Motility in Neonatal Rats. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.27.545971. [PMID: 37425813 PMCID: PMC10326976 DOI: 10.1101/2023.06.27.545971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Background Within the premature infant intestine, oxygenation and motility play key physiological roles in healthy development and disease such as necrotizing enterocolitis. To date, there are limited techniques to reliably assess these physiological functions that are also clinically feasible for critically ill infants. To address this clinical need, we hypothesized that photoacoustic imaging (PAI) can provide non-invasive assessment of intestinal tissue oxygenation and motility to characterize intestinal physiology and health. Methods Ultrasound and photoacoustic images were acquired in 2-day and 4-day old neonatal rats. For PAI assessment of intestinal tissue oxygenation, an inspired gas challenge was performed using hypoxic, normoxic, and hyperoxic inspired oxygen (FiO2). For intestinal motility, oral administration of ICG contrast agent was used to compare control animals to an experimental model of loperamide-induced intestinal motility inhibition. Results PAI demonstrated progressive increases in oxygen saturation (sO2) as FiO2 increased, while the pattern of oxygen localization remained relatively consistent in both 2-day and 4-day old neonatal rats. Analysis of intraluminal ICG contrast enhanced PAI images yielded a map of the motility index in control and loperamide treated rats. From PAI analysis, loperamide significantly inhibited intestinal motility, with a 32.6% decrease in intestinal motility index scores in 4-day old rats. Conclusion These data establish the feasibility and application of PAI to non-invasively and quantitatively measure intestinal tissue oxygenation and motility. This proof-of-concept study is an important first step in developing and optimizing photoacoustic imaging to provide valuable insight into intestinal health and disease to improve the care of premature infants. Highlights Intestinal tissue oxygenation and intestinal motility are important biomarkers of intestinal physiology in health and disease of premature infants.This proof-of-concept preclinical rat study is the first to report application of photoacoustic imaging for the neonatal intestine.Photoacoustic imaging is demonstrated as a promising non-invasive diagnostic imaging method for quantifying intestinal tissue oxygenation and intestinal motility in premature infants. Graphical abstract
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26
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Sukhotnik I, Levi R, Moran-Lev H. Impact of Dietary Protein on the Management of Pediatric Short Bowel Syndrome. Nutrients 2023; 15:2826. [PMID: 37447153 DOI: 10.3390/nu15132826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Essential amino acids (AAs) play a key role in stimulating intestinal adaptation after massive small gut resection. The nutritional effect of dietary amino acids during intestinal regrowth has received considerable attention in recent years. This review explores the significance of dietary amino acids in the nutritional management of infants and children with intestinal failure and short bowel syndrome (SBS) as reported in the medical literature over the last three decades. A literature search was conducted using electronic databases. Breast milk emerged as the first-line enteral regimen recommended for infants with SBS. Hydrolyzed formulas (HFs) or amino acid formulas (AAFs) are recommended when breast milk is not available or if the infant cannot tolerate whole protein milk. The superiority of AAFs over HFs has never been demonstrated. Although glutamine (GLN) is the main fuel for enterocytes, GLN supplementation in infants with SBS showed no difference in the child's dependence upon parenteral nutrition (PN). Circulating citrulline is considered a major determinant of survival and nutritional prognosis of SBS patients. Early enteral nutrition and dietary supplementation of AAs following bowel resection in children are essential for the development of intestinal adaptation, thereby eliminating the need for PN.
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Affiliation(s)
- Igor Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Reut Levi
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Hadar Moran-Lev
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
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27
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Wei X, Tan X, Chen Q, Jiang Y, Wu G, Ma X, Fu J, Li Y, Gang K, Yang Q, Ni R, He J, Luo L. Extensive jejunal injury is repaired by migration and transdifferentiation of ileal enterocytes in zebrafish. Cell Rep 2023; 42:112660. [PMID: 37342912 DOI: 10.1016/j.celrep.2023.112660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 04/07/2023] [Accepted: 06/01/2023] [Indexed: 06/23/2023] Open
Abstract
A major cause of intestinal failure (IF) is intestinal epithelium necrosis and massive loss of enterocytes, especially in the jejunum, the major intestinal segment in charge of nutrient absorption. However, mechanisms underlying jejunal epithelial regeneration after extensive loss of enterocytes remain elusive. Here, we apply a genetic ablation system to induce extensive damage to jejunal enterocytes in zebrafish, mimicking the jejunal epithelium necrosis that causes IF. In response to injury, proliferation and filopodia/lamellipodia drive anterior migration of the ileal enterocytes into the injured jejunum. The migrated fabp6+ ileal enterocytes transdifferentiate into fabp2+ jejunal enterocytes to fulfill the regeneration, consisting of dedifferentiation to precursor status followed by redifferentiation. The dedifferentiation is activated by the IL1β-NFκB axis, whose agonist promotes regeneration. Extensive jejunal epithelial damage is repaired by the migration and transdifferentiation of ileal enterocytes, revealing an intersegmental migration mechanism of intestinal regeneration and providing potential therapeutic targets for IF caused by jejunal epithelium necrosis.
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Affiliation(s)
- Xiangyong Wei
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Xinmiao Tan
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Qi Chen
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Yan Jiang
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Guozhen Wu
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Xue Ma
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Jialong Fu
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Yongyu Li
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Kai Gang
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Qifen Yang
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Rui Ni
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Jianbo He
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China
| | - Lingfei Luo
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Beibei, Chongqing 400715, China.
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Li J, Feng S, Wang Z, He J, Zhang Z, Zou H, Wu Z, Liu X, Wei H, Tao S. Limosilactobacillus mucosae-derived extracellular vesicles modulates macrophage phenotype and orchestrates gut homeostasis in a diarrheal piglet model. NPJ Biofilms Microbiomes 2023; 9:33. [PMID: 37280255 DOI: 10.1038/s41522-023-00403-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/22/2023] [Indexed: 06/08/2023] Open
Abstract
The diarrheal disease causes high mortality, especially in children and young animals. The gut microbiome is strongly associated with diarrheal disease, and some specific strains of bacteria have demonstrated antidiarrheal effects. However, the antidiarrheal mechanisms of probiotic strains have not been elucidated. Here, we used neonatal piglets as a translational model and found that gut microbiota dysbiosis observed in diarrheal piglets was mainly characterized by a deficiency of Lactobacillus, an abundance of Escherichia coli, and enriched lipopolysaccharide biosynthesis. Limosilactobacillus mucosae and Limosilactobacillus reuteri were a signature bacterium that differentiated healthy and diarrheal piglets. Germ-free (GF) mice transplanted with fecal microbiota from diarrheal piglets reproduced diarrheal disease symptoms. Administration of Limosilactobacillus mucosae but not Limosilactobacillus reuteri alleviated diarrheal disease symptoms induced by fecal microbiota of diarrheal piglets and by ETEC K88 challenge. Notably, Limosilactobacillus mucosae-derived extracellular vesicles alleviated diarrheal disease symptoms caused by ETEC K88 by regulating macrophage phenotypes. Macrophage elimination experiments demonstrated that the extracellular vesicles alleviated diarrheal disease symptoms in a macrophage-dependent manner. Our findings provide insights into the pathogenesis of diarrheal disease from the perspective of intestinal microbiota and the development of probiotic-based antidiarrheal therapeutic strategies.
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Affiliation(s)
- Jingjing Li
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China
| | - Shuaifei Feng
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China
| | - Zhenyu Wang
- State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, No. 2 Yuanmingyuan West Road, Beijing, 100193, China
| | - Jinhui He
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China
| | - Zeyue Zhang
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China
| | - Huicong Zou
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China
| | - Zhifeng Wu
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China
| | - Xiangdong Liu
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China.
| | - Hong Wei
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China.
| | - Shiyu Tao
- College of Animal Sciences and Technology, Huazhong Agricultural University, Wuhan, 430070, China.
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29
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Hudson AS, Tyminski N, Turner JM, Silverman JA. Intestinal Failure-Associated Liver Disease and Growth Pre- and Post-Transition to a Composite Lipid Emulsion. J Pediatr Gastroenterol Nutr 2023; 76:830-836. [PMID: 36930972 DOI: 10.1097/mpg.0000000000003763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
OBJECTIVES Infants with intestinal failure have an increased risk of intestinal failure-associated liver disease (IFALD). Composite intravenous lipid emulsion (ILE) may reduce the risk of cholestasis. The primary outcome was to compare IFALD rates in infants with intestinal failure, between those receiving a composite ILE versus soybean oil ILE. The secondary outcome compared growth between these 2 groups. METHODS At our 2 tertiary neonatal/pediatric hospitals, we identified all patients (≤1 year old) who received ≥6 weeks parenteral nutrition (PN) from 2010 to 2018. Data included liver and growth parameters. IFALD was defined as serum conjugated bilirubin (CB) >33 µmol/L (≥2 mg/dL). Nonparametric tests were used for all comparisons. RESULTS Fifty infants (35 composite ILE, 15 soybean oil ILE) were included. Those on composite ILE received PN for longer (10.1 vs 7.6 weeks; P = 0.001) and had higher baseline CB (29 vs 6.5 μmol/L; P = 0.001). No differences were found by 6 weeks (14.5 vs 5 μmol/L; P = 0.54) and by PN cessation (4 vs 4 μmol/L; P = 0.33). The proportion of patients with IFALD decreased from 54% to 20% for composite ILE, while stable given soybean oil ILE (7%). There were no differences in weight, length, or head circumference z scores ( P > 0.05). CONCLUSIONS In our institutions, over 8 years, chronic intestinal failure was rare. Composite ILE was the predominant lipid choice for infants who needed longer courses of PN or had developed cholestasis. Despite longer PN duration, and higher baseline CB, overall rates of IFALD decreased with composite ILE. Regardless of parenteral lipid used, there were no differences in growth.
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Affiliation(s)
- Alexandra S Hudson
- From the Division of Pediatric Gastroenterology & Nutrition, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Nicole Tyminski
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Justine M Turner
- From the Division of Pediatric Gastroenterology & Nutrition, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jason A Silverman
- From the Division of Pediatric Gastroenterology & Nutrition, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Caporilli C, Giannì G, Grassi F, Esposito S. An Overview of Short-Bowel Syndrome in Pediatric Patients: Focus on Clinical Management and Prevention of Complications. Nutrients 2023; 15:nu15102341. [PMID: 37242224 DOI: 10.3390/nu15102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection or disease-associated loss of absorption. SBS is the leading cause of intestinal failure in children and the underlying cause in 50% of patients on home parental nutrition. It is a life-altering and life-threatening disease due to the inability of the residual intestinal function to maintain nutritional homeostasis of protein, fluid, electrolyte or micronutrient without parenteral or enteral supplementation. The use of parenteral nutrition (PN) has improved medical care in SBS, decreasing mortality and improving the overall prognosis. However, the long-term use of PN is associated with the incidence of many complications, including liver disease and catheter-associated malfunction and bloodstream infections (CRBSIs). This manuscript is a narrative review of the current available evidence on the management of SBS in the pediatric population, focusing on prognostic factors and outcome. The literature review showed that in recent years, the standardization of management has demonstrated to improve the quality of life in these complex patients. Moreover, the development of knowledge in clinical practice has led to a reduction in mortality and morbidity. Diagnostic and therapeutic decisions should be made by a multidisciplinary team that includes neonatologists, pediatric surgeons, gastroenterologists, pediatricians, nutritionists and nurses. A significant improvement in prognosis can occur through the careful monitoring of nutritional status, avoiding dependence on PN and favoring an early introduction of enteral nutrition, and through the prevention, diagnosis and aggressive treatment of CRSBIs and SIBO. Multicenter initiatives, such as research consortium or data registries, are mandatory in order to personalize the management of these patients, improve their quality of life and reduce the cost of care.
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Affiliation(s)
- Chiara Caporilli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giuliana Giannì
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Federica Grassi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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Gibson B, McNiven C, Sebastianski M, Vandermeer B, Persad R, Robinson JL. Systematic Review of Antimicrobial Lock Solutions for Prevention of Bacteremia in Pediatric Patients With Intestinal Failure. J Pediatr Gastroenterol Nutr 2023; 76:410-417. [PMID: 36730306 DOI: 10.1097/mpg.0000000000003658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The goal of this systematic review was to determine whether antimicrobial lock (AML) solutions prevent catheter-related bloodstream infections (CRBSI) in children with intestinal failure (IF). METHODS Electronic databases were searched: Ovid MEDLINE (1946-), Ovid Embase (1974-), Wiley Cochrane Library (inception-), and Web of Science Core Collection via Clarivate Analytics (1900-). Randomized and nonrandomized trials, case or cohort studies that studied any AML solution, and used comparator groups were included if they studied children with IF. A meta-analysis compared the rates of CRBSI with AML solutions versus controls, and a Boucher analysis was used to indirectly compare AML solutions. RESULTS Twenty-eight studies met eligibility criteria (1 open label and 27 observational studies). Quality was good (N = 13), fair (N = 9), and poor (N = 6). All but 4 studied ethanol and taurolidine. Of 15 ethanol studies, 11 reported a decrease and 3 reported a trend toward a decreased incidence of CRBSI compared to controls; 1 reported no difference. Of 9 taurolidine studies, 7 reported a decrease and 2 a trend toward decreased CRBSI rates. There was a decrease in CRBSI with ethanol versus control ( P = 0.008) and with taurolidine-citrate versus control ( P < 0.0005). Using Bucher indirect comparison of the pooled estimates from ethanol versus control to taurolidine versus control, the estimated difference was -0.99 (-4.125, 2.27; P = 0.55). CONCLUSIONS There were no randomized trials and over half of the 28 included studies were fair or poor quality. All but 1 reported at least a trend toward reduction in CRBSI. AML solutions appear to prevent CRBSI.
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Affiliation(s)
- Bridget Gibson
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Claire McNiven
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Meghan Sebastianski
- the Alberta Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit Knowledge Translation Platform, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- the Alberta Centre for Health Research Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Rabin Persad
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joan L Robinson
- From the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Culbreath K, Keefe G, Nes E, Staffa SJ, Carey AN, Jaksic T, Goldsmith JD, Modi BP, Ouahed JD, Jimenez L. Factors Associated With Chronic Intestinal Inflammation Resembling Inflammatory Bowel Disease in Pediatric Intestinal Failure: A Matched Case-Control Study. J Pediatr Gastroenterol Nutr 2023; 76:468-474. [PMID: 36720109 DOI: 10.1097/mpg.0000000000003718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS There is a subset of intestinal failure patients with associated chronic intestinal inflammation resembling inflammatory bowel disease. This study aimed to evaluate factors associated with chronic intestinal inflammation in pediatric intestinal failure. METHODS This was a single-center retrospective case-control study of children <18 years old with intestinal failure. Cases were defined by abnormal amounts of chronic intestinal inflammation on biopsies. Children with diversion colitis, eosinophilic colitis, or isolated anastomotic ulceration were excluded. Cases were matched 1:2 to intestinal failure controls based on sex, etiology of intestinal failure, and duration of intestinal failure. Multivariable conditional logistic regression was used to compare clinical factors between cases and controls, accounting for clustering within matched sets. A subgroup analysis was performed assessing factors associated with escalation of anti-inflammatory therapy. RESULTS Thirty cases were identified and matched to 60 controls. On univariate analysis, longer parenteral nutrition (PN) duration (1677 vs 834 days, P = 0.03), current PN use (33.3% vs 20.0%, P = 0.037), and culture-proven bacterial overgrowth (53.3% vs 31.7%, P = 0.05) were associated with chronic intestinal inflammation. On multivariable analysis, no variable reached statistical significance. On subgroup analysis, duration of intestinal failure, location of inflammation, and worst degree of inflammation on histology were associated with escalation of therapy. CONCLUSIONS PN dependence and intestinal dysbiosis are associated with chronic intestinal inflammation in children with intestinal failure. Severity of inflammation is associated with escalation of therapy. Further analysis is needed to assess these associations and the efficacy of treatments in this population.
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Affiliation(s)
- Katherine Culbreath
- From the Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Gregory Keefe
- From the Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Emily Nes
- From the Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Steven J Staffa
- From the Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Alexandra N Carey
- the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Tom Jaksic
- From the Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey D Goldsmith
- the Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Biren P Modi
- From the Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jodie D Ouahed
- the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Lissette Jimenez
- the Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital and Harvard Medical School, Boston, MA
- the Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Kim ES, Lee LJ, Romero T, Calkins KL. Outcomes in preterm infants who received a lipid emulsion with fish oil: An observational study. JPEN J Parenter Enteral Nutr 2023; 47:354-363. [PMID: 36398422 PMCID: PMC10953698 DOI: 10.1002/jpen.2464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/02/2022] [Accepted: 11/10/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND 100% soybean oil emulsions (SO100) are associated with poor docosahexaenoic acid (DHA) and arachidonic acid (ARA) status in extremely low birth weight (ELBW) infants. A multi-oil emulsion with 15% fish oil (FO15) contains more DHA and ARA than SO100. This study compares clinical outcomes, namely growth and fatty acids, in ELBW infants who received S0100 or FO15. METHODS This observational study included ELBW infants born between 2014 and 2019 who received SO100 or FO15 for >7 days. Gas chromatography/mass spectrometry was used to measure erythrocyte fatty acids. RESULTS The mean ± SD gestational age was 27 ± 3 and 26 ± 2 weeks for SO100 (n = 43) and FO15 (n = 43), respectively (P = 0.2). DHA (-0.3 ± 0.10% per week, P = 0.026, for FO15 vs -0.2 ± 0.05% per week, P < 0.001, for SO100) and ARA (-0.8 ± 0.21% per week for FO15 vs -0.9 ± 0.17% per week for SO100; P < 0.001 for both) declined in both groups with no difference between groups (P interaction > 0.7 for both). After controlling for days to reach full feeds, the mean difference in weight z score trajectories was similar (Est = -0.08; 95% CI, -0.82 to 0.04; P = 0.2), and SO100 was associated with a nonsignificant increased odds for cholestasis (odds ratio, 3.1; 95% CI, 0.96-10.2; P = 0.059). There was no difference in other clinical comorbidities. CONCLUSIONS In comparison with ELBW infants who received SO100, infants who received FO15 still demonstrated a decline in DHA and ARA. Growth and other clinical outcomes were unchanged.
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Affiliation(s)
- Esther S. Kim
- Department of Pediatrics, Neonatal Research Center of the UCLA of Children’s Discovery and Innovation Institute, David Geffen School of Medicine UCLA and UCLA Mattel Children’s Hospital, Los Angeles CA
| | - Lauren J. Lee
- David Geffen School of Medicine, University of California Los Angeles, CA
| | - Tahmineh Romero
- Department of Medicine, David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Kara L. Calkins
- Department of Pediatrics, Neonatal Research Center of the UCLA of Children’s Discovery and Innovation Institute, David Geffen School of Medicine UCLA and UCLA Mattel Children’s Hospital, Los Angeles CA
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Smith A, Namjoshi S, Kerner JA, Dunn JCY. Importance of Ileum and Colon in Children with Short Bowel Syndrome. J Pediatr Surg 2023:S0022-3468(23)00089-1. [PMID: 36894441 DOI: 10.1016/j.jpedsurg.2023.01.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND It is well known that small bowel length is a dominant prognostic indicator in patients with short bowel syndrome (SBS). The relative importance of jejunum, ileum, and colon is less well defined in children with SBS. Here we review the outcome of children with SBS with respect to the type of remnant intestine. METHODS A retrospective review of 51 children with SBS was conducted at a single institution. The duration of parenteral nutrition use was the main outcome variable. The length of the remaining intestine as well as the type of intestine were recorded for each patient. Kaplan-Meier analyses were conducted to compare the subgroups. RESULTS Children with greater than 10% expected small bowel length or more than 30 cm of small bowel achieved enteral autonomy faster than those with less. The presence of ileocecal valve enhanced the ability to wean from parenteral nutrition. The presence of ileum significantly enhanced the ability to wean from parenteral nutrition. Patients with the entire colon also achieved enteral autonomy sooner than those with partial colon. CONCLUSIONS The preservation of ileum and colon is important in patients with SBS. Approaches to preserve or lengthen ileum and colon may be beneficial for these patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Asia Smith
- Division of Pediatric Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Shweta Namjoshi
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - John A Kerner
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - James C Y Dunn
- Division of Pediatric Surgery, Department of Surgery, Stanford University, Stanford, CA, USA.
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White E, Mutalib M. Parenteral Nutrition in Pediatric Patients with Neurodisability: Current Perspectives. Pediatric Health Med Ther 2023; 14:11-17. [PMID: 36776411 PMCID: PMC9912341 DOI: 10.2147/phmt.s366635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/31/2023] [Indexed: 02/06/2023] Open
Abstract
Pediatric neurodisability describes functional limitations in children with varied severity and complexity often attributed to brain or neuromuscular abnormalities. The life expectancy of children with neurodisability is improving, but many will require significant medical support. The gastrointestinal tract is usually affected in children with neurodisability and can lead to a wide range of symptoms. In gastrointestinal (GI) dystonia, a newly coined term, feeding will trigger a distressing dystonia and symptoms can improve with cessation of feed. Parenteral nutrition (PN) is often viewed as a viable option in severe GI dystonia or when enteral feeding does not support sufficient nutrition. The use of PN in children with severe neurodisability is complex. It involves an intricate interplay between medical, psychological and ethical factors. In the absence of a universally agreed guidance on the use of PN in this cohort, paediatricians should maintain the individual need of the child at the centre of the decision-making process and work closely with families and other healthcare professionals before initiating or withholding PN in children with severe neurodisability. In this article, we discuss the complex and multifaceted approach to the use of PN in children with severe neurodisability and aimed to explore the medical, psychological and ethical aspect dilemmas facing clinicians looking after children with declining gut function who may require PN support.
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Affiliation(s)
- Emily White
- Department of Paediatric Gastroenterology, Evelina London Children’ Hospital, London, UK
| | - Mohamed Mutalib
- Department of Paediatric Gastroenterology, Evelina London Children’ Hospital, London, UK,Faculty of Life Sciences and Medicine, King’s College London, London, UK,Correspondence: Mohamed Mutalib, Department of Paediatric Gastroenterology, Evelina London Children’ Hospital, London, SE1 7EH, UK, Email
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36
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Huysentruyt K, Belza C, Wong-Sterling S, Chami R, Siddiqui I, Wales PW, Avitzur Y. Use of a combined transient elastography and biochemical strategy to determine liver fibrosis in pediatric intestinal failure. Clin Nutr 2023; 42:136-142. [PMID: 36563562 DOI: 10.1016/j.clnu.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/02/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Non-invasive monitoring of intestinal failure (IF) associated liver disease is an ongoing challenge in children with IF. Our objective was to develop a combined algorithm of clinical, transient elastography (TE) and biochemical parameters to identify liver fibrosis in this population. METHODS A retrospective cohort study of IF patients followed by our intestinal rehabilitation program between November 2015 to October 2019. Patients with a liver biopsy and TE were included. Demographic and liver function tests were collected. Fibrosis on liver biopsies was graded using the modified Scheuer score. Decision tree based algorithms classified low (F0-F1) versus high (F2-F4) fibrosis scores based on a combination of TE, biochemical and demographic parameters, using 6-fold classification error, sensitivity and specificity cross-validation (CV) scores. RESULTS 42 patients (74% male, median age 7.6 (4.6; 42.7) months) were evaluated. Median length of PN therapy was 182 (121; 556) days. High fibrosis was present in 40.5% with a median TE of 12.1 (6.7; 12.9) kPa in high fibrosis children. An algorithm, based on cut-off values for TE of 11.3 kPa and AST of 40 U/L, and grouping of the underlying etiology resulted in a correct classification of 88.1% of the pathology scores; with sensitivity 0.82 (95% CI 0.57; 0.96), specificity 0.92 (95% CI 0.74; 0.99), positive predictive value 0.88 (95% CI 0.64; 0.96) and negative predictive value 0.88 (95% CI 0.73; 0.96). The CV classification error was 28.6%, CV sensitivity 72.2% and CV specificity 75.5%. CONCLUSIONS This algorithm shows promising results that could simplify non-invasive monitoring of liver fibrosis in children with IF. Validation in additional IF cohorts is needed.
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Affiliation(s)
- Koen Huysentruyt
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Brussels Centrum for Intestinal Failure in Children (B-CIRC), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Christina Belza
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia Wong-Sterling
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rose Chami
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Iram Siddiqui
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Yaron Avitzur
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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37
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Keefe G, Culbreath K, Staffa SJ, Carey AN, Jaksic T, Kumar R, Modi BP. High Rate of Venous Thromboembolism in Severe Pediatric Intestinal Failure. J Pediatr 2023; 253:152-157. [PMID: 36181872 DOI: 10.1016/j.jpeds.2022.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/15/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To quantify the rate of venous thromboembolism (VTE) in patients with pediatric intestinal failure and identify associated risk factors. STUDY DESIGN We performed a retrospective cohort study in pediatric patients (<21 years old) with severe pediatric intestinal failure (≥90 consecutive days of parenteral nutrition) secondary to short bowel syndrome who were treated from 2014 to 2021 at an interdisciplinary intestinal rehabilitation program. The primary outcome was the incidence of VTE. Multivariable regression was performed to identify independent clinical predictors of VTE. RESULTS A total of 263 patients (59.7% male) met the criteria for inclusion. The cumulative incidence of VTE was 28.1%, with a rate of 0.32 VTEs per 1000 catheter-days. On univariate analysis, the number of catheter days, number of catheters, and history of central line-associated blood stream infection were associated with VTE. On multivariable logistic regression, a higher number of catheters was an independent risk factor for VTE (aOR, 1.17; 95% CI, 1.06-1.29). Additionally, earlier gestational age was a risk factor for VTE such that every week decrease in gestational age conferred a 9% increased risk of VTE (aOR, 1.09; 95% CI, 1.02-1.16). CONCLUSIONS In this retrospective study, 28.1% of patients with severe pediatric intestinal failure developed VTE; the number of catheters and early gestational age were noted to be independent risk factors for VTE. This high incidence of VTE highlights the need to investigate VTE in pediatric intestinal failure prospectively, including the potential benefit of prophylactic anticoagulation.
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Affiliation(s)
- Gregory Keefe
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Katherine Culbreath
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Alexandra N Carey
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Riten Kumar
- Department of Pediatrics, Harvard Medical School, Boston, MA; Dana Farber/Boston Children's Hospital Cancer and Blood Disorders Center, Boston, MA
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery, Boston Children's Hospital, Boston, MA.
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38
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Roggero P, Liotto N, Piemontese P, Menis C, Perrone M, Tabasso C, Amato O, Orsi A, Pesenti N, Leva E, Mosca F. Neonatal intestinal failure: Growth pattern and nutrition intakes in accordance with weaning from parenteral nutrition. JPEN J Parenter Enteral Nutr 2023; 47:236-244. [PMID: 36398420 DOI: 10.1002/jpen.2465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/08/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Short bowel syndrome is the most common cause of intestinal failure (IF) in infants. We aimed to evaluate growth, nutrition intakes, and predictors of weaning from parenteral nutrition (PN) of infants with IF. METHODS Clinical parameters, nutrition intakes, body weight and length z-scores were compared monthly from the 1st to 12th and at 18 and 24 months among infants receiving PN and those weaned. Logistic regression analysis was conducted to explore the predictors of weaning. RESULTS We included 23 infants (10/23 weaned). Median [range: minimum; maximum] birth weight and gestational age were 1620 [590; 3490] g and 31 [24; 39] weeks, respectively. All infants showed growth retardation with similar median delta weight z-score from birth to discharge: -1.48 [-1.92; -0.94] in not-weaned and -1.18 [-2.70; 0.31] in weaned infants (P = 0.833) and a subsequent regain after the discharge: 0.20 [-3.47; 3.25] and 0.84 [-0.03; 2.58], respectively (P = 0.518). No differences in length z-score were found. After the sixth month, infants weaned from PN received lower PN energy and protein intakes compared with those not-weaned. Infants weaned from PN showed lower PN dependency index (PNDI%) from 5 months onward (45% for weaned and 113% for not-weaned infants at 5 months: P < 0.001). The Belza score, a predictor of enteral autonomy computed at 6 months, is associated with being weaned from PN within 24 months (odds ratio: 1.906; P = 0.039). CONCLUSION Infants weaned and not-weaned showed similar growth patterns. Our findings support the clinical relevance of Belza score and PNDI% as predictors of weaning from PN.
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Affiliation(s)
- Paola Roggero
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Nadia Liotto
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Pasqua Piemontese
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Camilla Menis
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Michela Perrone
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Chiara Tabasso
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Orsola Amato
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Anna Orsi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Nicola Pesenti
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
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39
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Jaksic T. Current short bowel syndrome management: An era of improved outcomes and continued challenges. J Pediatr Surg 2023; 58:789-798. [PMID: 36870826 DOI: 10.1016/j.jpedsurg.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 01/22/2023]
Abstract
Prior to the late 1960s, pediatric short bowel syndrome was a frequently fatal disease. Currently, pediatric interdisciplinary bowel rehabilitation centers report very high survival rates. The mortality trends, up-to-date definitions, incidence, causes, and clinical manifestations of short bowel syndrome are reviewed. Emphasis is placed upon the nutritional, medical, and surgical advances that have contributed to the dramatic improvement in outcomes for pediatric short bowel syndrome patients. Recent findings and remaining challenges are highlighted.
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Affiliation(s)
- Tom Jaksic
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 333 Longwood Avenue, Boston MA, 02115, USA.
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40
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Bagias G, Misiakos EP, Charalampopoulos A, Zavras N, Sakellariou S, Schizas D, Sukhotnik I, Giamarelos E, Pikoulis E. The effect of hepatocyte growth factor on intestinal adaption in an experimental model of short bowel syndrome. Pediatr Surg Int 2023; 39:80. [PMID: 36631569 DOI: 10.1007/s00383-022-05341-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE Nowadays, the standard therapy for patients with short bowel syndrome is parenteral nutrition (PN). Various growth factors have been tested to achieve weaning from prolonged PN administration. We evaluated the effect of hepatocyte growth factor (HGF) on structural intestinal adaptation and cell proliferation in a rat model of SBS. METHODS Thirty Sprague-Dawley rats were divided into three groups; group A rats (sham) underwent bowel transection, group B rats underwent a 75% bowel resection, and group C rats underwent the same procedure but were treated postoperatively with HGF. Histopathologic parameters of intestinal adaptation were determined, while microarray and rt-PCR analyses of ileal RNA were also performed. RESULTS Treatment with HGF resulted in significant increase in body weight, while the jejunal and ileal villus height and crypt depth were increased in HGF rats (36%, p < 0.05 and 27%, p < 0.05 respectively). Enterocyte proliferation was also significantly increased in HGF rats (21% p < 0.05). Microarray and quantitative rt-PCR analyses showed that the genes hgfac, rac 1, cdc42, and akt 1 were more than twofold up-regulated after HGF treatment. CONCLUSION HGF emerges as a growth factor that enhances intestinal adaptation. The future use of HGF may potentially reduce the requirement for PN in SBS patients.
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Affiliation(s)
- George Bagias
- 3rd Department of Surgery, Attikon University Hospital, Athens, Greece.
| | | | | | - Nick Zavras
- 3rd Department of Surgery, Attikon University Hospital, Athens, Greece
| | | | | | - Igor Sukhotnik
- Department of Pediatric Surgery B, Rappaport Faculty of Medicine, Haifa, Israel
| | - Evangelos Giamarelos
- 4th Department of Internal Medicine, Attikon University Hospital, Athens, Greece
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Garg PM, Denton MX, Talluri R, Ansari MAY, Riddick R, Ostrander MM, McDonald AG, Premkumar MH, Hillegass WB, Garg PP. Clinical determinants of intestinal failure and death in preterm infants with surgical necrotizing enterocolitis. J Neonatal Perinatal Med 2023; 16:589-596. [PMID: 38007677 PMCID: PMC10841979 DOI: 10.3233/npm-230157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
OBJECTIVE We sought to investigate the clinical determinants of intestinal failure and death in preterm infants with surgical NEC. METHODS Retrospective comparison of clinical information between Group A = intestinal failure (Parenteral nutrition (PN) >90 days) and death and Group B = survivors and with PN dependence < 90 days in preterm infants with surgical NEC. RESULTS Group A (n = 99/143) had a lower mean gestational age (26.4 weeks [SD3.5] vs. 29.4 [SD 3.5]; p = 0.013), lower birth weight (873 gm [SD 427g] vs. 1425 gm [894g]; p = <0.001), later age of NEC onset (22 days [SD20] vs. 16 days [SD 17]; p = 0.128), received surgery later (276 hours [SD 544] vs. 117 hours [SD 267]; p = 0.032), had cholestasis, received dopamine (80.6% vs. 58.5%; p = 0.010) more frequently and had longer postoperative ileus time (19.8 days [SD 15.4] vs. 11.8 days [SD 6.5]; p = <0.001) and reached full feeds later (93 days [SD 45] vs. 44 [SD 22]; p = <0.001) than Group B.On multivariate logistic regression, higher birth weight was associated with lower risk (OR 0.35, 95% CI 0.15-0.82; p = 0.016) of TPN > 90 days or death. Longer length of bowel resected (OR 1.76, 95% CI 1.02-3.02; p = 0.039) and longer postoperative ileus (OR 2.87, 95% CI 1.26-6.53; p = 0.011) were also independently associated with TPN >90days or death adjusted for gestational age and antenatal steroid treatment. CONCLUSION In preterm infants with surgical NEC, clinical factors such as lower birth weight, longer bowel loss, and postoperative ileus days were significantly and independently associated with TPN >90 days or death.
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Affiliation(s)
- P M Garg
- Department of Pediatrics/Neonatology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - M X Denton
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - R Talluri
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - M A Y Ansari
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - R Riddick
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - M M Ostrander
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
| | - A G McDonald
- Department of Pathology, Atrium Health Wake Forest Baptist, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - M H Premkumar
- Department of Pediatrics/Neonatology, Texas Children Hospital, Baylor College of Medicine, Houston, TX, USA
| | - W B Hillegass
- Department of Data Sciences, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - P P Garg
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
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Roche KF, Bower KL, Collier B, Neel D, Esry L. When Should the Appropriateness of PEG be Questioned? Curr Gastroenterol Rep 2023; 25:13-19. [PMID: 36480136 DOI: 10.1007/s11894-022-00857-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review aims to analyze the evidence regarding the appropriateness of PEG placement in the following clinical situations: short bowel syndrome, head and neck cancer, dementia and palliative use in malignant bowel obstruction. RECENT FINDINGS Percutaneous endoscopic gastrostomy (PEG) tubes are placed for a variety of clinical indications by numerous different specialties. First described in 1980, PEG tubes are now the dominant method of enteral access. Typically, PEG tubes are technically feasible procedures that can come with significant risk for both minor and major complications. Therefore, it is important to perform an in-depth, patient specific risk-benefit analysis when considering insertion. By analyzing the current evidence regarding benefits in these situations, superimposed by the lens of biomedical ethics, we make recommendations that are accessible to any provider who may be a consultant or proceduralist, helping to provide informed care that is in the patient's best interest.
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Affiliation(s)
- Keelin Flannery Roche
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), East Tennessee State University, Johnson City, TN, USA
| | - Katie L Bower
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Bryan Collier
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Dustin Neel
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), University of Missouri-Kansas City, Kansas City, MO, USA
| | - Laura Esry
- Department of Surgery (Trauma Surgery, Critical Care & Acute Care Surgery), University of Missouri-Kansas City, Kansas City, MO, USA
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43
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Protheroe S, Sugarman I. Neonatal intestinal failure - improved outcomes. Frontline Gastroenterol 2022; 14:4-5. [PMID: 36561783 PMCID: PMC9763648 DOI: 10.1136/flgastro-2022-102234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sue Protheroe
- Department of Paediatric Gastroenterology & Nutrition, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Ian Sugarman
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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44
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Predictors of Social-Emotional Development and Adaptive Functioning in School-Age Children with Intestinal Failure. J Clin Psychol Med Settings 2022:10.1007/s10880-022-09919-z. [PMID: 36371790 DOI: 10.1007/s10880-022-09919-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Despite a focus on neurocognition in pediatric intestinal failure (IF) to date, we examined social-emotional and adaptive functioning. METHODS Children (N = 63) in our IF rehabilitation program underwent neuropsychological assessments including caregiver- and teacher-reported questionnaires. Results were compared to norms using z-tests. Caregiver and teacher reports were compared using t tests. Medical and demographic factors were examined in an exploratory manner using correlation and targeted regression analyses, adjusting for gestational age and full-scale IQ. RESULTS Caregiver and teacher reports indicated poorer executive, internalizing, behavioral, and adaptive functioning compared to norms. Teachers reported more executive dysfunctions than caregivers. Necrotizing enterocolitis diagnosis predicted internalizing emotional problems. Immigrant status predicted poorer social and practical adaptive functioning. Living with biological parents predicted fewer externalizing emotional and behavioral problems. CONCLUSIONS The group displayed social-emotional and adaptive functioning concerns. Identifying medical and demographic risks can allow for screening and intervention.
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Cerdó T, García-Santos JA, Rodríguez-Pöhnlein A, García-Ricobaraza M, Nieto-Ruíz A, G. Bermúdez M, Campoy C. Impact of Total Parenteral Nutrition on Gut Microbiota in Pediatric Population Suffering Intestinal Disorders. Nutrients 2022; 14:4691. [PMID: 36364953 PMCID: PMC9658482 DOI: 10.3390/nu14214691] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 08/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving therapy providing nutritional support in patients with digestive tract complications, particularly in preterm neonates due to their gut immaturity during the first postnatal weeks. Despite this, PN can also result in several gastrointestinal complications that are the cause or consequence of gut mucosal atrophy and gut microbiota dysbiosis, which may further aggravate gastrointestinal disorders. Consequently, the use of PN presents many unique challenges, notably in terms of the potential role of the gut microbiota on the functional and clinical outcomes associated with the long-term use of PN. In this review, we synthesize the current evidence on the effects of PN on gut microbiome in infants and children suffering from diverse gastrointestinal diseases, including necrotizing enterocolitis (NEC), short bowel syndrome (SBS) and subsequent intestinal failure, liver disease and inflammatory bowel disease (IBD). Moreover, we discuss the potential use of pre-, pro- and/or synbiotics as promising therapeutic strategies to reduce the risk of severe gastrointestinal disorders and mortality. The findings discussed here highlight the need for more well-designed studies, and harmonize the methods and its interpretation, which are critical to better understand the role of the gut microbiota in PN-related diseases and the development of efficient and personalized approaches based on pro- and/or prebiotics.
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Affiliation(s)
- Tomás Cerdó
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Reina Sofia University Hospital, University of Córdoba, 14004 Córdoba, Spain
| | - José Antonio García-Santos
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Anna Rodríguez-Pöhnlein
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - María García-Ricobaraza
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Ana Nieto-Ruíz
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Mercedes G. Bermúdez
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Cristina Campoy
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
- Spanish Network of Biomedical Research in Epidemiology and Public Health (CIBERESP), Granada’s Node, Carlos III Health Institute, Avda. Monforte de Lemos 5, 28028 Madrid, Spain
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46
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Bettag J, Po L, Cunningham C, Tallam R, Kurashima K, Nagarapu A, Hutchinson C, Morfin S, Nazzal M, Lin CJ, Mathur A, Aurora R, Jain AK. Novel Therapeutic Approaches for Mitigating Complications in Short Bowel Syndrome. Nutrients 2022; 14:nu14214660. [PMID: 36364922 PMCID: PMC9658734 DOI: 10.3390/nu14214660] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Short bowel syndrome (SBS) is a particularly serious condition in which the small intestine does not absorb sufficient nutrients for biological needs, resulting in severe illness and potentially death if not treated. Given the important role of the gut in many signaling cascades throughout the body, SBS results in disruption of many pathways and imbalances in various hormones. Due to the inability to meet sufficient nutritional needs, an intravenous form of nutrition, total parental nutrition (TPN), is administered. However, TPN presents difficulties such as severe liver injury and altered signaling secondary to the continued lack of luminal contents. This manuscript aims to summarize relevant studies into the systemic effects of TPN on systems such as the gut–brain, gut-lung, and gut-liver axis, as well as present novel therapeutics currently under use or investigation as mitigation strategies for TPN induced injury.
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Affiliation(s)
- Jeffery Bettag
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
- Correspondence:
| | - Loren Po
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Cassius Cunningham
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Rahul Tallam
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Kento Kurashima
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Aakash Nagarapu
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Chelsea Hutchinson
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Sylvia Morfin
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Mustafa Nazzal
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Chien-Jung Lin
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Amit Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Rajeev Aurora
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Ajay K. Jain
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
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47
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Beanland BT, McNeill EP, Sequeira DJ, Xue H, Shroyer NF, Speer AL. Investigation of murine host sex as a biological variable in epithelial barrier function and muscle contractility in human intestinal organoids. FASEB J 2022; 36:e22613. [PMID: 36250916 PMCID: PMC9645459 DOI: 10.1096/fj.202101740rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 08/23/2022] [Accepted: 10/02/2022] [Indexed: 01/06/2023]
Abstract
Intestinal failure (IF) occurs when intestinal surface area or function is not sufficient to support digestion and nutrient absorption. Human intestinal organoid (HIO)-derived tissue-engineered intestine is a potential cure for IF. Research to date has demonstrated successful HIO transplantation (tHIO) into mice with significant in vivo maturation. An area lacking in the literature is exploration of murine host sex as a biological variable (SABV) in tHIO function. In this study, we investigate murine host SABV in tHIO epithelial barrier function and muscle contractility. HIOs were generated in vitro and transplanted into nonobese diabetic, severe combined immunodeficiency gamma chain deficient male and female mice. tHIOs were harvested after 8-12 weeks in vivo. Reverse transcriptase polymerase chain reaction and immunohistochemistry were conducted to compare tight junctions and contractility-related markers in tHIOs. An Ussing chamber and contractility apparatus were used to evaluate tHIO epithelial barrier and muscle contractile function, respectively. The expression and morphology of tight junction and contractility-related markers from tHIOs in male and female murine hosts is not significantly different. Epithelial barrier function as measured by transepithelial resistance, short circuit current, and fluorescein isothiocyanate-dextran permeability is no different in tHIOs from male and female hosts, although these results may be limited by HIO epithelial immaturity and a short flux time. Muscle contractility as measured by total contractile activity, amplitude, frequency, and tension is not significantly different in tHIOs from male and female hosts. The data suggest that murine host sex may not be a significant biological variable influencing tHIO function, specifically epithelial barrier maintenance and muscle contractility, though limitations exist in our model.
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Affiliation(s)
- Brooke T. Beanland
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Eoin P. McNeill
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - David J. Sequeira
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Hasen Xue
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Noah F. Shroyer
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, United States
| | - Allison L. Speer
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
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48
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Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Avitzur Y. An international multicenter validation study of the Toronto listing criteria for pediatric intestinal transplantation. Am J Transplant 2022; 22:2608-2615. [PMID: 35833730 DOI: 10.1111/ajt.17150] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/21/2022] [Accepted: 07/10/2022] [Indexed: 01/25/2023]
Abstract
Deciding which patients would benefit from intestinal transplantation (IT) remains an ethical/clinical dilemma. New criteria* were proposed in 2015: ≥2 intensive care unit (ICU) admissions, loss of ≥3 central venous catheter (CVC) sites, and persistently elevated conjugated bilirubin (CB ≥ 75 μmol/L) despite 6 weeks of lipid modification strategies. We performed a retrospective, international, multicenter validation study of 443 children (61% male, median gestational age 34 weeks [IQR 29-37]), diagnosed with IF between 2010 and 2015. Primary outcome measure was death or IT. Sensitivity, specificity, NPV, PPV, and probability of death/transplant (OR, 95% confidence intervals) were calculated for each criterion. Median age at IF diagnosis was 0.1 years (IQR 0.03-0.14) with median follow-up of 3.8 years (IQR 2.3-5.3). Forty of 443 (9%) patients died, 53 of 443 (12%) were transplanted; 11 died posttransplant. The validated criteria had a high predictive value of death/IT; ≥2 ICU admissions (p < .0001, OR 10.2, 95% CI 4.0-25.6), persistent CB ≥ 75 μmol/L (p < .0001, OR 8.2, 95% CI 4.8-13.9). and loss of ≥3 CVC sites (p = .0003, OR 5.7, 95% CI 2.2-14.7). This large, multicenter, international study in a contemporary cohort confirms the validity of the Toronto criteria. These validated criteria should guide listing decisions in pediatric IT.
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Affiliation(s)
- Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sue V Beath
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Helen M Evans
- New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - David Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutritional Support and Intestinal Failure Team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jason Yap
- Division of Pediatric Gastroenterology, University of Alberta, Edmonton, Canada.,Department of Paediatric Gastroenterology and Nutrition, The Royal Children's Hospital, Melbourne, Australia
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
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49
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Mutanen A, Pöntinen V, Gunnar R, Merras-Salmio L, Pakarinen MP. Efficient achievement of enteral autonomy facilitates resolution of liver injury in necrotizing enterocolitis induced short bowel syndrome. Sci Rep 2022; 12:17516. [PMID: 36266329 PMCID: PMC9584958 DOI: 10.1038/s41598-022-22414-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/14/2022] [Indexed: 01/12/2023] Open
Abstract
Children with short bowel syndrome (SBS) are at high risk for intestinal failure associated liver disease (IFALD). The aim of this retrospective follow-up study was to compare weaning off parenteral nutrition (PN) and IFALD between necrotizing enterocolitis (NEC) and non-NEC induced SBS. Altogether, 77 patients with neonatal SBS treated by our multidisciplinary intestinal failure unit (NEC n = 38, non-NEC SBS n = 39) were included and followed-up at least for 2 years until median age of 10 years (interquartile range, 6.0-16). Occurrence and characteristics of IFALD was assessed with liver biopsies obtained at median age of 3.2 (1.0-6.7) years (n = 62) and serum liver biochemistry. Overall, NEC patients had less end-jejunostomies and autologous intestinal reconstruction surgeries performed compared to non-NEC patients (< 0.05), while remaining small bowel anatomy was comparable between groups. Cumulative weaning off PN was more frequent and duration of PN shorter among NEC patients (P < 0.05). Overall cumulative probability of histological IFALD was lower among NEC patients during whole follow-up period (P = 0.052) and at 10 years (P = 0.024). NEC patients had lower ALT and GGT levels at last follow-up (P < 0.05 for all). In univariate Cox regression analysis, absence of end-jejunostomy, NEC diagnosis, longer remaining small bowel length, multidisciplinary treatment and prematurity were predictive for weaning off PN, while NEC diagnosis and lower birth weight in addition to multidisciplinary care protected from histological IFALD. Neonates with NEC induced SBS reached enteral autonomy earlier than those with non-NEC SBS, which associated with more efficient resolution of histological IFALD among long-term survivors.
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Affiliation(s)
- Annika Mutanen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
| | - Ville Pöntinen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
| | - Riikka Gunnar
- grid.7737.40000 0004 0410 2071Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- grid.7737.40000 0004 0410 2071Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P. Pakarinen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
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50
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Teduglutide in pediatric intestinal failure: A position statement of the Italian society of pediatric gastroenterology, hepatology and nutrition (SIGENP). Dig Liver Dis 2022; 54:1320-1327. [PMID: 35654733 DOI: 10.1016/j.dld.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/05/2022] [Accepted: 04/29/2022] [Indexed: 12/29/2022]
Abstract
In recent years, the spectrum of possible treatments for Intestinal Failure (IF)-Short Bowel Syndrome (SBS) has been enriched by the implementation of GLP-2 analogues. In Italy, teduglutide (Ted), an analogue of GLP-2, was approved in January 2021 by the Italian Regulatory Agency for Drugs (AIFA) for IF-SBS patients ≥1 year old. According to the Agency indications, Ted can now be prescribed by regional reference centers, with costs fully charged to the National Health Service. Following pediatric-use approval in our country and in light of scarce evidence in childhood, the pediatric network for IF of the Italian Society for Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) planned to share management methods of Ted in pediatric IF. The main purpose was to identify the best candidates from a cost-effective perspective. Thus, focusing on available literature and on expert opinions, the present position statement provides consensus-based recommendations on the use of Ted for pediatric gastroenterologists and nutritionists treating children with SBS.
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