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Reigle J, Lopez-Nunez O, Drysdale E, Abuquteish D, Liu X, Putra J, Erdman L, Griffiths AM, Prasath S, Siddiqui I, Dhaliwal J. Using Deep Learning to Automate Eosinophil Counting in Pediatric Ulcerative Colitis Histopathological Images. medRxiv 2024:2024.04.03.24305251. [PMID: 38633803 PMCID: PMC11023647 DOI: 10.1101/2024.04.03.24305251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Background Accurate identification of inflammatory cells from mucosal histopathology images is important in diagnosing ulcerative colitis. The identification of eosinophils in the colonic mucosa has been associated with disease course. Cell counting is not only time-consuming but can also be subjective to human biases. In this study we developed an automatic eosinophilic cell counting tool from mucosal histopathology images, using deep learning. Method Four pediatric IBD pathologists from two North American pediatric hospitals annotated 530 crops from 143 standard-of-care hematoxylin and eosin (H & E) rectal mucosal biopsies. A 305/75 split was used for training/validation to develop and optimize a U-Net based deep learning model, and 150 crops were used as a test set. The U-Net model was then compared to SAU-Net, a state-of-the-art U-Net variant. We undertook post-processing steps, namely, (1) the pixel-level probability threshold, (2) the minimum number of clustered pixels to designate a cell, and (3) the connectivity. Experiments were run to optimize model parameters using AUROC and cross-entropy loss as the performance metrics. Results The F1-score was 0.86 (95%CI:0.79-0.91) (Precision: 0.77 (95%CI:0.70-0.83), Recall: 0.96 (95%CI:0.93-0.99)) to identify eosinophils as compared to an F1-score of 0.2 (95%CI:0.13-0.26) for SAU-Net (Precision: 0.38 (95%CI:0.31-0.46), Recall: 0.13 (95%CI:0.08-0.19)). The inter-rater reliability was 0.96 (95%CI:0.93-0.97). The correlation between two pathologists and the algorithm was 0.89 (95%CI:0.82-0.94) and 0.88 (95%CI:0.80-0.94) respectively. Conclusion Our results indicate that deep learning-based automated eosinophilic cell counting can obtain a robust level of accuracy with a high degree of concordance with manual expert annotations.
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Dijk S, Jarman M, Zhang Z, Lawley M, Ahmad M, Suarez R, Rossi L, Chen M, Wu J, Carroll MW, Otley A, Sherlock M, Mack DR, Jacobson K, deBruyn JC, El-Matary W, Deslandres C, Rashid M, Church PC, Walters TD, Huynh HQ, Surette MG, Griffiths AM, Wine E. Pre-Diagnosis Diet Predicts Response to Exclusive Enteral Nutrition and Correlates with Microbiome in Pediatric Crohn Disease. Nutrients 2024; 16:1033. [PMID: 38613066 PMCID: PMC11013084 DOI: 10.3390/nu16071033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Abstract
Exclusive enteral nutrition (EEN) is effective in inducing remission in pediatric Crohn disease (CD). EEN alters the intestinal microbiome, but precise mechanisms are unknown. We hypothesized that pre-diagnosis diet establishes a baseline gut microbiome, which then mediates response to EEN. We analyzed prospectively recorded food frequency questionnaires (FFQs) for pre-diagnosis dietary patterns. Fecal microbiota were sequenced (16SrRNA) at baseline and through an 18-month follow-up period. Dietary patterns, Mediterranean diet adherence, and stool microbiota were associated with EEN treatment outcomes, disease flare, need for anti-tumor necrosis factor (TNF)-α therapy, and long-term clinical outcomes. Ninety-eight patients were included. Baseline disease severity and microbiota were associated with diet. Four dietary patterns were identified by FFQs; a "mature diet" high in fruits, vegetables, and fish was linked to increased baseline microbial diversity, which was associated with fewer disease flares (p < 0.05) and a trend towards a delayed need for anti-TNF therapy (p = 0.086). Baseline stool microbial taxa were increased (Blautia and Faecalibacterium) or decreased (Ruminococcus gnavus group) with the mature diet compared to other diets. Surprisingly, a "pre-packaged" dietary pattern (rich in processed foods) was associated with delayed flares in males (p < 0.05). Long-term pre-diagnosis diet was associated with outcomes of EEN therapy in pediatric CD; diet-microbiota and microbiota-outcome associations may mediate this relationship.
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Affiliation(s)
- Stephanie Dijk
- Department of Physiology, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Megan Jarman
- Department of Agriculture, Life, & Environmental Science, University of Alberta, Edmonton, AB T6G 2R3, Canada;
| | - Zhengxiao Zhang
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada;
- College of Food and Biological Engineering, Jimei University, Xiamen 361000, China
| | - Morgan Lawley
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2R3, Canada (M.A.); (R.S.); (M.W.C.); (H.Q.H.)
| | - Muzammil Ahmad
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2R3, Canada (M.A.); (R.S.); (M.W.C.); (H.Q.H.)
| | - Ricardo Suarez
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2R3, Canada (M.A.); (R.S.); (M.W.C.); (H.Q.H.)
| | - Laura Rossi
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4L8, Canada; (L.R.); (M.G.S.)
| | - Min Chen
- Nutrition Services (Child Health), Alberta Health Services, Edmonton, AB T5J 3E4, Canada; (M.C.); (J.W.)
| | - Jessica Wu
- Nutrition Services (Child Health), Alberta Health Services, Edmonton, AB T5J 3E4, Canada; (M.C.); (J.W.)
| | - Matthew W. Carroll
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2R3, Canada (M.A.); (R.S.); (M.W.C.); (H.Q.H.)
| | - Anthony Otley
- Division of Gastroenterology & Nutrition, Department of Pediatrics, Dalhousie University, Halifax, NS B3H 4R2, Canada; (A.O.); (M.R.)
| | - Mary Sherlock
- Division of Gastroenterology and Nutrition, Department of Pediatrics, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - David R. Mack
- CHEO IBD Center, Department of Pediatrics, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Kevan Jacobson
- Division of Gastroenterology, Hepatology and Nutrition, B.C. Children’s Hospital, British Columbia Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada;
| | - Jennifer C. deBruyn
- Section of Pediatric Gastroenterology, Department of Pediatrics, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Wael El-Matary
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3T 2N2, Canada;
| | - Colette Deslandres
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, CHU Sainte-Justine Hospital, Université de Montréal, Montréal, QC H3T 1J4, Canada;
| | - Mohsin Rashid
- Division of Gastroenterology & Nutrition, Department of Pediatrics, Dalhousie University, Halifax, NS B3H 4R2, Canada; (A.O.); (M.R.)
| | - Peter C. Church
- Division of Pediatric Gastroenterology, IBD Center, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1C6, Canada; (P.C.C.); (T.D.W.); (A.M.G.)
| | - Thomas D. Walters
- Division of Pediatric Gastroenterology, IBD Center, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1C6, Canada; (P.C.C.); (T.D.W.); (A.M.G.)
| | - Hien Q. Huynh
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2R3, Canada (M.A.); (R.S.); (M.W.C.); (H.Q.H.)
| | - Michael G. Surette
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON L8S 4L8, Canada; (L.R.); (M.G.S.)
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Anne M. Griffiths
- Division of Pediatric Gastroenterology, IBD Center, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1C6, Canada; (P.C.C.); (T.D.W.); (A.M.G.)
| | - Eytan Wine
- Department of Physiology, University of Alberta, Edmonton, AB T6G 1C9, Canada
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Alberta, Edmonton, AB T6G 2R3, Canada (M.A.); (R.S.); (M.W.C.); (H.Q.H.)
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Crowley E, Ma C, Guizzetti L, Zou G, Lewindon PJ, Gee MS, Hyams JS, Rosen MJ, von Allmen D, de Buck van Overstraeten A, Shackelton LM, Remillard J, Schleicher L, Dillman JR, Rimola J, Taylor SA, Fletcher JG, Church PC, Feagan BG, Griffiths AM, Jairath V, Greer MLC. Recommendations for Standardizing MRI-based Evaluation of Perianal Fistulizing Disease Activity in Pediatric Crohn's Disease Clinical Trials. Inflamm Bowel Dis 2024; 30:357-369. [PMID: 37524088 DOI: 10.1093/ibd/izad134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Perianal fistulas and abscesses occur commonly as complications of pediatric Crohn's disease (CD). A validated imaging assessment tool for quantification of perianal disease severity and activity is needed to evaluate treatment response. We aimed to identify magnetic resonance imaging (MRI)-based measures of perianal fistulizing disease activity and study design features appropriate for pediatric patients. METHODS Seventy-nine statements relevant to MRI-based assessment of pediatric perianal fistulizing CD activity and clinical trial design were generated from literature review and expert opinion. Statement appropriateness was rated by a panel (N = 15) of gastroenterologists, radiologists, and surgeons using modified RAND/University of California Los Angeles appropriateness methodology. RESULTS The modified Van Assche Index (mVAI) and the Magnetic Resonance Novel Index for Fistula Imaging in CD (MAGNIFI-CD) were considered appropriate instruments for use in pediatric perianal fistulizing disease clinical trials. Although there was concern regarding the use of intravascular contrast material in pediatric patients, its use in clinical trials was considered appropriate. A clinically evident fistula tract and radiologic disease defined as at least 1 fistula or abscess on pelvic MRI were considered appropriate trial inclusion criteria. A coprimary clinical and radiologic end point and inclusion of a patient-reported outcome were also considered appropriate. CONCLUSION Outcomes of treatment of perianal fistulizing disease in children must include MRI. Existing multi-item measures, specifically the mVAI and MAGNIFI-CD, can be adapted and used for children. Further research to assess the operating properties of the indices when used in a pediatric patient population is ongoing.
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Affiliation(s)
- Eileen Crowley
- Department of Pediatrics, Division of Pediatric Gastroenterology, Children's Hospital Western Ontario, Western University, London Health Sciences Centre, London, Ontario, Canada
- Alimentiv Inc, London, ON, Canada
| | - Christopher Ma
- Alimentiv Inc, London, ON, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Guangyong Zou
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Peter J Lewindon
- Department of Gastroenterology, Queensland Children's Hospital, University of Queensland, Brisbane, Queensland, Australia
- Children's Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Michael S Gee
- Department of Radiology, Massachusetts General Hospital Boston, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Michael J Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford Medicine, Stanford, CA, USA
| | - Daniel von Allmen
- Department of Pediatric Surgery and Surgical Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jordi Rimola
- IBD Unit, Radiology Department, Hospital Clinic Barcelona, IDIBAPS, Spain
| | - Stuart A Taylor
- Centre for Medical Imaging, Charles Bell House, University College London, London, UK
| | | | - Peter C Church
- Division of Gastroenterology, Hepatology & Nutrition, Department of Paediatrics and IBD Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Brian G Feagan
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology & Nutrition, Department of Paediatrics and IBD Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vipul Jairath
- Alimentiv Inc, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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4
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Dhaliwal J, Tertigas D, Carman N, Lawrence S, Debruyn JC, Wine E, Church PC, Huynh HQ, Rashid M, El-Matary W, Deslandres C, Critch J, Ricciuto A, Carroll MW, Benchimol EI, Muise A, Jacobson K, Otley AR, Vallance B, Mack DR, Walters TD, Surette MG, Griffiths AM. Outcomes Following Acute Severe Colitis at Initial Presentation: A Multi-centre, Prospective, Paediatric Cohort Study. J Crohns Colitis 2024; 18:233-245. [PMID: 37602969 PMCID: PMC10896636 DOI: 10.1093/ecco-jcc/jjad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Indexed: 08/22/2023]
Abstract
AIM To assess contemporary outcomes in children with acute severe ulcerative colitis [ASUC] at initial presentation. METHODS Between April 2014 and January 2019, children aged <17 years, with new onset ASUC (Paediatric Ulcerative Colitis Activity Index [PUCAI ≥65) were prospectively followed in a Canadian inception cohort study. 16S rRNA amplicon sequencing captured microbial composition of baseline faecal samples. Primary endpoint was corticosteroid-free clinical remission with intact colon at 1 year [PUCAI <10, no steroids ≥4 weeks]. RESULTS Of 379 children with new onset UC/IBD-unclassified, 105 [28%] presented with ASUC (42% male; median [interquartile range; [IQR]) age 14 [11-16] years; extensive colitis in all). Compared with mild UC, gut microbiome of ASUC patients had lower α-diversity, decreased beneficial anaerobes, and increased aerobes; 54 [51%] children were steroid-refractory and given infliximab [87% intensified regimen]. Corticosteroid-free remission at 1 year was achieved by 62 [61%] ASUC cohort (by 34 [63%] steroid-refractory patients, all on biologics; by 28 [55%] steroid responders,13 [25%] on 5- aminosalicylic acid [5-ASA], 5 [10%] on thiopurines, 10 [20%] on biologics). By 1 year, 78 [74%] escalated to infliximab including 24 [47%] steroid-responders failed by 5-ASA and/or thiopurines. In multivariable analysis, clinical predictors for commencing infliximab included hypoalbuminaemia, greater PUCAI, higher age, and male sex. Over 18 months, repeat corticosteroid course[s] and repeat hospitalisation were less likely among steroid-refractory versus -responsive but -dependent patients (adjusted odds ratio [aOR] 0.71 [95% CI 0.57-0.89] and 0.54 [95% CI 0.45-0.66], respectively). CONCLUSION The majority of children presenting with ASUC escalate therapy to biologics. Predictors of need for advanced therapy may guide selection of optimal maintenance therapy.
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Affiliation(s)
- Jasbir Dhaliwal
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Dominique Tertigas
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - Nicholas Carman
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Sally Lawrence
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - Jennifer C Debruyn
- Alberta Children’s Hospital, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Calgary, Calgary, AB, Canada
| | - Eytan Wine
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Peter C Church
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Hien Q Huynh
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Mohsin Rashid
- IWK Health Centre, University of Dalhousie, Division of Gastroenterology, Hepatology and Nutrition, Halifax, NS, Canada
| | - Wael El-Matary
- Winnipeg Children’s Hospital, Department of Paediatrics, University of Manitoba, Winnipeg, MN, Canada
| | - Colette Deslandres
- CHU Sainte-Justine, Department of Paediatrics, University of Montreal, Montreal, QC, Canada
| | - Jeffrey Critch
- Janeway Children’s Health and Rehabilitation Centre, Memorial University, St. John’s, NFLD, Canada
| | - Amanda Ricciuto
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Matthew W Carroll
- Stollery Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Edmonton, AB, Canada
| | - Eric I Benchimol
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Aleixo Muise
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Kevan Jacobson
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - Anthony R Otley
- IWK Health Centre, University of Dalhousie, Division of Gastroenterology, Hepatology and Nutrition, Halifax, NS, Canada
| | - Bruce Vallance
- B.C. Children’s Hospital, Division of Gastroenterology, Hepatology and Nutrition, Vancouver, BC, Canada
| | - David R Mack
- Children’s Hospital of Eastern Ontario IBD Centre, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Thomas D Walters
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Michael G Surette
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anne M Griffiths
- SickKids IBD Centre, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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5
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Rosh JR, Turner D, Hyams JS, Dubinsky M, Griffiths AM, Cohen SA, Lo KH, Kim L, Volger S, Zhang R, Strauss R, Conklin LS. Outcomes in Adult Inflammatory Bowel Disease Clinical Trials: Assessment of Similarity Among Participants with Adolescent-Onset and Adult-Onset Disease. J Crohns Colitis 2024:jjae030. [PMID: 38408273 DOI: 10.1093/ecco-jcc/jjae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND AIMS Most pediatric IBD studies are performed after medications are approved in adults and the majority of participants in these studies are adolescents. We hypothesized that adolescent-onset IBD is not fundamentally different than adult-onset IBD. If this is correct, the value of delaying access to novel drugs in adolescents becomes questioned. METHODS Data from 11 randomized, double-blind, placebo-controlled adult phase 2 and 3 trials of 4 biologics were analyzed. Participants were categorized as having adolescent- or adult-onset disease (diagnosed 12 to <18, or ≥18 years). Multivariable modelling explored the association between age at diagnosis and response to treatment after adjustment for disease duration, extent, and severity at baseline. Data from dose arms were pooled to evaluate similarity of therapeutic response between adolescent- and adult-onset IBD within the same trial (not between doses or across trials). Ratios of odds ratios between the two groups were evaluated. RESULTS Data from 6,283 study participants (2,575 with Crohn's disease [CD], 3,708 with ulcerative colitis [UC]) were evaluated. Of 2,575 study participants with CD, 325 were 12-<18 years old at diagnosis; 836 participants (32.4%) received placebo. Of 3,708 participants with UC, 221 were 12-<18 years old at diagnosis; 1,212 (33%) were receiving placebo. The majority of the ratios of ORs were within two-fold, suggesting that responses in adolescent and adult-onset participants are generally similar. CONCLUSION Data presented lend support for extrapolating efficacy of biologics from adults to adolescents with IBD, which would facilitate earlier labeling and patient access.
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Affiliation(s)
- Joel R Rosh
- Division of Pediatric Gastroenterology, Cohen Children's Medical Center, New Hyde Park, USA
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Israel
| | - Jeffrey S Hyams
- Division of Pediatric Gastroenterology, Connecticut Children's, Hartford, CT USA
| | - Marla Dubinsky
- Division of Pediatric Gastroenterology, Mount Sinai Medical Center, New York, NY USA
| | - Anne M Griffiths
- Division of Pediatric Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - Stanley A Cohen
- Division of Pediatric Gastroenterology, Children's Center for Digestive Health Care, Atlanta, GA USA
| | - Kim Hung Lo
- Statistics and Decision Sciences, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Lilianne Kim
- Statistics and Decision Sciences, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Sheri Volger
- Pediatric Development Team, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Renping Zhang
- Data Analytics, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Richard Strauss
- Pediatric Development Team, Johnson & Johnson Innovative Medicine, Spring House, PA USA
| | - Laurie S Conklin
- Child Health Innovation Leadership Department, Johnson & Johnson Innovative Medicine, New Brunswick, NJ USA
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6
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Kuenzig ME, Bitton A, Carroll MW, Otley AR, Singh H, Kaplan GG, Stukel TA, Mack DR, Jacobson K, Griffiths AM, El-Matary W, Targownik LE, Nguyen GC, Jones JL, Murthy SK, Bernstein CN, Lix LM, Peña-Sánchez JN, Dummer TJB, Spruin S, Fung SG, Nugent Z, Coward S, Cui Y, Coulombe J, Filliter C, Benchimol EI. Health Services Utilization and Specialist Care in Pediatric Inflammatory Bowel Disease: A Multiprovince Population-Based Cohort Study. Inflamm Bowel Dis 2024:izae010. [PMID: 38366807 DOI: 10.1093/ibd/izae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Patterns of health services utilization among children with inflammatory bowel disease (IBD) are important to understand as the number of children with IBD continues to increase. We compared health services utilization and surgery among children diagnosed <10 years of age (Paris classification: A1a) and between 10 and <16 years of age (A1b). METHODS Incident cases of IBD diagnosed <16 years of age were identified using validated algorithms from deterministically linked health administrative data in 5 Canadian provinces (Alberta, Manitoba, Nova Scotia, Ontario, Quebec) to conduct a retrospective cohort study. We compared the frequency of IBD-specific outpatient visits, emergency department visits, and hospitalizations across age groups (A1a vs A1b [reference]) using negative binomial regression. The risk of surgery was compared across age groups using Cox proportional hazards models. Models were adjusted for sex, rural/urban residence location, and mean neighborhood income quintile. Province-specific estimates were pooled using random-effects meta-analysis. RESULTS Among the 1165 (65.7% Crohn's) children with IBD included in our study, there were no age differences in the frequency of hospitalizations (rate ratio [RR], 0.88; 95% confidence interval [CI], 0.74-1.06) or outpatient visits (RR, 0.95; 95% CI, 0.78-1.16). A1a children had fewer emergency department visits (RR, 0.70; 95% CI, 0.50-0.97) and were less likely to require a Crohn's-related surgery (hazard ratio, 0.49; 95% CI, 0.26-0.92). The risk of colectomy was similar among children with ulcerative colitis in both age groups (hazard ratio, 0.71; 95% CI, 0.49-1.01). CONCLUSIONS Patterns of health services utilization are generally similar when comparing children diagnosed across age groups.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Harminder Singh
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Therese A Stukel
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, ON, Canada
- CHEO Research Institute, Ottawa, ON, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Kevan Jacobson
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Laura E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sanjay K Murthy
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Gastroenterology, Ottawa Hospital IBD Centre, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Sarah Spruin
- ICES, Toronto, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Stephen G Fung
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, ON, Canada
- CHEO Research Institute, Ottawa, ON, Canada
| | - Zoann Nugent
- University of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Stephanie Coward
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Yunsong Cui
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Janie Coulombe
- Department of Mathematics and Statistics, Université de Montréal, Montréal, QC, Canada
| | - Christopher Filliter
- Lady Davis Institute of Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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7
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Schirmer M, Stražar M, Avila-Pacheco J, Rojas-Tapias DF, Brown EM, Temple E, Deik A, Bullock K, Jeanfavre S, Pierce K, Jin S, Invernizzi R, Pust MM, Costliow Z, Mack DR, Griffiths AM, Walters T, Boyle BM, Kugathasan S, Vlamakis H, Hyams J, Denson L, Clish CB, Xavier RJ. Linking microbial genes to plasma and stool metabolites uncovers host-microbial interactions underlying ulcerative colitis disease course. Cell Host Microbe 2024; 32:209-226.e7. [PMID: 38215740 PMCID: PMC10923022 DOI: 10.1016/j.chom.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 11/08/2023] [Accepted: 12/15/2023] [Indexed: 01/14/2024]
Abstract
Understanding the role of the microbiome in inflammatory diseases requires the identification of microbial effector molecules. We established an approach to link disease-associated microbes to microbial metabolites by integrating paired metagenomics, stool and plasma metabolomics, and culturomics. We identified host-microbial interactions correlated with disease activity, inflammation, and the clinical course of ulcerative colitis (UC) in the Predicting Response to Standardized Colitis Therapy (PROTECT) pediatric inception cohort. In severe disease, metabolite changes included increased dipeptides and tauro-conjugated bile acids (BAs) and decreased amino-acid-conjugated BAs in stool, whereas in plasma polyamines (N-acetylputrescine and N1-acetylspermidine) increased. Using patient samples and Veillonella parvula as a model, we uncovered nitrate- and lactate-dependent metabolic pathways, experimentally linking V. parvula expansion to immunomodulatory tryptophan metabolite production. Additionally, V. parvula metabolizes immunosuppressive thiopurine drugs through xdhA xanthine dehydrogenase, potentially impairing the therapeutic response. Our findings demonstrate that the microbiome contributes to disease-associated metabolite changes, underscoring the importance of these interactions in disease pathology and treatment.
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Affiliation(s)
- Melanie Schirmer
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Translational Microbiome Data Integration, School of Life Sciences, Technical University of Munich, 85354 Freising, Germany; ZIEL - Institute for Food & Health, Technical University of Munich, 85354 Freising, Germany.
| | - Martin Stražar
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | | | | | - Eric M Brown
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Computational and Integrative Biology and Department of Molecular Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Emily Temple
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Amy Deik
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Kevin Bullock
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Sarah Jeanfavre
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Kerry Pierce
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Shen Jin
- Translational Microbiome Data Integration, School of Life Sciences, Technical University of Munich, 85354 Freising, Germany
| | | | - Marie-Madlen Pust
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Computational and Integrative Biology and Department of Molecular Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Zach Costliow
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - David R Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON K1H 8L1, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Thomas Walters
- Division of Gastroenterology, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Brendan M Boyle
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, OH 43205, USA
| | - Subra Kugathasan
- Department of Pediatrics, Emory University, Atlanta, GA 30322, USA
| | - Hera Vlamakis
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Jeffrey Hyams
- Connecticut Children's Medical Center, Division of Digestive Diseases, Hartford, CT 06106, USA
| | - Lee Denson
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA
| | - Clary B Clish
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Ramnik J Xavier
- The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Center for Computational and Integrative Biology and Department of Molecular Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA; Center for Microbiome Informatics and Therapeutics, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
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8
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Kuenzig ME, Stukel TA, Carroll MW, Kaplan GG, Otley AR, Singh H, Bitton A, Fung SG, Spruin S, Coward S, Cui Y, Nugent Z, Griffiths AM, Mack DR, Jacobson K, Nguyen GC, Targownik LE, El-Matary W, Bernstein CN, Dummer TJB, Jones JL, Lix LM, Murthy SK, Peña-Sánchez JN, Nasiri S, Benchimol EI. Variation in the Care of Children with Inflammatory Bowel Disease Within and Across Canadian Provinces: A Multi-Province Population-Based Cohort Study. Clin Epidemiol 2024; 16:91-108. [PMID: 38374886 PMCID: PMC10875172 DOI: 10.2147/clep.s449183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/25/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose The incidence of childhood-onset inflammatory bowel disease (IBD) is rising. We described variation in health services utilization and need for surgery among children with IBD between six and 60 months following IBD diagnosis across Canadian pediatric centers and evaluated the associations between care provided at diagnosis at each center and the variation in these outcomes. Patients and Methods Using population-based deterministically-linked health administrative data from four Canadian provinces (Alberta, Manitoba, Nova Scotia, Ontario) we identified children diagnosed with IBD <16 years of age using validated algorithms. Children were assigned to a pediatric center of care using a hierarchical approach based on where they received their initial care. Outcomes included IBD-related hospitalizations, emergency department (ED) visits, and IBD-related abdominal surgery occurring between 6 and sixty months after diagnosis. Mixed-effects meta-analysis was used to pool results and examine the association between center-level care provision and outcomes. Results We identified 3784 incident cases of pediatric IBD, of whom 2937 (77.6%) were treated at pediatric centers. Almost a third (31.4%) of children had ≥1 IBD-related hospitalization and there were 0.66 hospitalizations per person during follow-up. More than half (55.8%) of children had ≥1 ED visit and there were 1.64 ED visits per person. Between-center heterogeneity was high for both outcomes; centers where more children visited the ED at diagnosis had more IBD-related hospitalizations and more ED visits during follow-up. Between-center heterogeneity was high for intestinal resection in Crohn's disease but not colectomy in ulcerative colitis. Conclusion There is variation in health services utilization among children with IBD and risk of undergoing intestinal resection in those with Crohn's disease, but not colectomy among children with ulcerative colitis, across Canadian pediatric tertiary-care centers. Improvements in clinical care pathways are needed to ensure all children have equitable and timely access to high quality care.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Therese A Stukel
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gilaad G Kaplan
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Anthony R Otley
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Harminder Singh
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
| | - Stephen G Fung
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Sarah Spruin
- ICES, Toronto, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Stephanie Coward
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yunsong Cui
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Zoann Nugent
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kevan Jacobson
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey C Nguyen
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wael El-Matary
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sanjay K Murthy
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Juan Nicolás Peña-Sánchez
- Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Soheila Nasiri
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - On behalf of the Canadian Gastro-Intestinal Epidemiology Consortium
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (Sickkids), Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
- McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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9
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Turner ST, Focht G, Orlanski-Meyer E, Lev-Tzion R, Ledder O, Yogev D, Assa A, Shaoul R, Crowely E, Otley A, Griffiths AM, Turner D. Fatigue in pediatric inflammatory bowel diseases: A systematic review and a single center experience. J Pediatr Gastroenterol Nutr 2024; 78:241-251. [PMID: 38374545 DOI: 10.1002/jpn3.12039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/03/2023] [Accepted: 09/06/2023] [Indexed: 02/21/2024]
Abstract
OBJECTIVES We aimed to review the literature on fatigue in pediatric inflammatory bowel diseases (PIBD), to explore how it is measured, and approximate its rate in an inception pediatric cohort. METHODS Studies on fatigue were systematically reviewed and selected by two authors. Next, we retrieved the two fatigue-related questions of the IMPACT-III questionnaire at 4 and 12 months after diagnosis from a prospectively maintained cohort of PIBD patients, each scoring 0-100 (lower scores imply more fatigue), and 44 healthy controls. RESULTS The systematic review identified 14 studies reporting fatigue in children, of which nine had fatigue as the primary outcome and only two provided rates of fatigue. No standalone index was identified for measuring fatigue specifically for PIBD. Of 80 children included in the inception cohort, 62 (78%) scored an average of ≤75 on the two IMPACT-III questions (approximating at least mild fatigue), 26 (33%) scored ≤50 (at least moderate fatigue) and nine (11%) scored ≤25 (severe fatigue). In comparison, only four (9%) healthy children scored at least moderate fatigue (p = 0.007). Fatigue rates at 12 months were only slightly and nonsignificantly lower. Fatigue of any severity was reported in 92% children with active disease versus 63% of those in clinical remission (p = 0.01). CONCLUSION Literature reporting on fatigue in PIBD is scarce, and no PIBD-specific tool is available to measure fatigue. In our cohort, fatigue-related questions were frequently scored low in children with IBD, mainly among children with active disease but also during clinical remission.
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Affiliation(s)
- Shira T Turner
- Department of Psychology, Ben Gurion University of the Negev, Beersheba, Israel
| | - Gili Focht
- The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Esther Orlanski-Meyer
- The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raffi Lev-Tzion
- The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oren Ledder
- The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dotan Yogev
- The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amit Assa
- The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ron Shaoul
- Faculty of Medicine, Pediatric Gastroenterology & Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Technion, Haifa, Israel
| | - Eileen Crowely
- Schulich School of Medicine and Dentistry, Division of Pediatric Gastroenterology, Western University, Children's Hospital of Western Ontario, London Health Sciences Center, and Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada
| | - Anthony Otley
- Department of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Anne M Griffiths
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Dan Turner
- The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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10
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Uhlig HH, Booth C, Cho J, Dubinsky M, Griffiths AM, Grimbacher B, Hambleton S, Huang Y, Jones K, Kammermeier J, Kanegane H, Koletzko S, Kotlarz D, Klein C, Lenardo MJ, Lo B, McGovern DPB, Özen A, de Ridder L, Ruemmele F, Shouval DS, Snapper SB, Travis SP, Turner D, Wilson DC, Muise AM. Precision medicine in monogenic inflammatory bowel disease: proposed mIBD REPORT standards. Nat Rev Gastroenterol Hepatol 2023; 20:810-828. [PMID: 37789059 DOI: 10.1038/s41575-023-00838-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 10/05/2023]
Abstract
Owing to advances in genomics that enable differentiation of molecular aetiologies, patients with monogenic inflammatory bowel disease (mIBD) potentially have access to genotype-guided precision medicine. In this Expert Recommendation, we review the therapeutic research landscape of mIBD, the reported response to therapies, the medication-related risks and systematic bias in reporting. The mIBD field is characterized by the absence of randomized controlled trials and is dominated by retrospective observational data based on case series and case reports. More than 25 off-label therapeutics (including small-molecule inhibitors and biologics) as well as cellular therapies (including haematopoietic stem cell transplantation and gene therapy) have been reported. Heterogeneous reporting of outcomes impedes the generation of robust therapeutic evidence as the basis for clinical decision making in mIBD. We discuss therapeutic goals in mIBD and recommend standardized reporting (mIBD REPORT (monogenic Inflammatory Bowel Disease Report Extended Phenotype and Outcome of Treatments) standards) to stratify patients according to a genetic diagnosis and phenotype, to assess treatment effects and to record safety signals. Implementation of these pragmatic standards should help clinicians to assess the therapy responses of individual patients in clinical practice and improve comparability between observational retrospective studies and controlled prospective trials, supporting future meta-analysis.
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Affiliation(s)
- Holm H Uhlig
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK.
- Department of Paediatrics, University of Oxford, Oxford, UK.
- Biomedical Research Centre, University of Oxford, Oxford, UK.
| | - Claire Booth
- UCL Great Ormond Street Institute of Child Health, London, UK
- Department of Paediatric Immunology and Gene Therapy, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Judy Cho
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla Dubinsky
- Department of Paediatric Gastroenterology, Susan and Leonard Feinstein IBD Clinical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre and Cell Biology Program, Research Institute, Toronto, Canada
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Bodo Grimbacher
- Institute for Immunodeficiency, Center for Chronic Immunodeficiency, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
- Department of Rheumatology and Clinical Immunology, Medical Center, Faculty of Medicine, Albert Ludwig University of Freiburg, Freiburg, Germany
- Institute of Immunology and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Sophie Hambleton
- Primary Immunodeficiency Group, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Ying Huang
- Department of Gastroenterology, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Kelsey Jones
- Paediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Kennedy Institute, University of Oxford, Oxford, UK
| | - Jochen Kammermeier
- Gastroenterology Department, Evelina London Children's Hospital, London, UK
| | - Hirokazu Kanegane
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Department of Paediatrics, University Hospital, LMU Munich, Munich, Germany
- Department of Paediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Daniel Kotlarz
- Dr. von Hauner Children's Hospital, Department of Paediatrics, University Hospital, LMU Munich, Munich, Germany
- German Center for Child and Adolescent Health, Munich, Germany
- Institute of Translational Genomics, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Christoph Klein
- Dr. von Hauner Children's Hospital, Department of Paediatrics, University Hospital, LMU Munich, Munich, Germany
- German Center for Child and Adolescent Health, Munich, Germany
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Bernice Lo
- Research Branch, Sidra Medicine, Doha, Qatar
- College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Dermot P B McGovern
- F. Widjaja Foundation, Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ahmet Özen
- Marmara University Division of Allergy and Immunology, Istanbul, Turkey
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus University Medical Center Sophia Children's Hospital, Rotterdam, Netherlands
| | - Frank Ruemmele
- Université Paris Cité, APHP, Hôpital Necker Enfants Malades, Service de Gastroentérologie pédiatrique, Paris, France
| | - Dror S Shouval
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Scott B Snapper
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Paediatrics and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Simon P Travis
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK
- Biomedical Research Centre, University of Oxford, Oxford, UK
- Kennedy Institute, University of Oxford, Oxford, UK
| | - Dan Turner
- Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - David C Wilson
- Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Department of Paediatric Gastroenterology, The Royal Hospital for Children, and Young People, Edinburgh, UK
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Centre and Cell Biology Program, Research Institute, Toronto, Canada
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Paediatrics, University of Toronto, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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11
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Jeong J, Walters TD, Huynh HQ, Lawrence S, Mack DR, Deslandres C, Otley A, El-Matary W, Sherlock M, Griffiths AM, Wine E, Jacobson K, Church P, Carroll MW, Benchimol EI, Brill H, Critch J, Bax K, Jantchou P, Rashid M, Kaplan GG, Seow CH, Novak K, deBruyn JC. Inflammatory Bowel Disease Among Canadian Children: Comparison Between Children of Non-European Descent and Children of European Descent. Inflamm Bowel Dis 2023; 29:1760-1768. [PMID: 36688453 PMCID: PMC10628923 DOI: 10.1093/ibd/izac276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) phenotypes may differ between countries and ancestral groups. The study aim was to examine ancestry and subtype variations of children newly diagnosed with IBD. METHODS Children newly diagnosed with IBD enrolled into the Canadian Children Inflammatory Bowel Disease Network inception cohort study were categorized into 8 ancestral groups. Prospectively collected data at diagnosis and follow-up were compared between ancestral groups. RESULTS Among 1447 children (63.2% Crohn's disease, 30.7% ulcerative colitis), 67.8% were European, 9.4% were South Asian, 3.8% were West Central Asian and Middle Eastern, 2.3% were African, 2.2% were East/South East Asian, 2.0% were Caribbean/Latin/Central/South American, 9.9% were mixed, and 2.6% were other. Children of African descent with ulcerative colitis had an older age of diagnosis compared with children of European descent (median 15.6 years vs 13.3 years; P = .02). Children of European descent had a higher proportion of positive family history with IBD (19.3% vs 12.1%; P = .001) compared with children of non-European descent. Children of European descent also had a lower proportion of immigrants and children of immigrants compared with children of non-European descent (9.8% vs 35.9%; P < .0001; and 3.6% vs 27.2%; P < .0001, respectively) . CONCLUSIONS Important differences exist between different ancestral groups in pediatric patients with IBD with regard to age of diagnosis, family history, and immigrant status. Our study adds to the knowledge of the impact of ancestry on IBD pathogenesis.
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Affiliation(s)
- Jocelyn Jeong
- Department of Community Health Services, University of Calgary, Calgary, AB, Canada
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Thomas D Walters
- SickKids Inflammatory Bowel Disease Centre, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Hien Q Huynh
- Edmonton Pediatric IBD Clinic, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Sally Lawrence
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David R Mack
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | | | - Anthony Otley
- Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Wael El-Matary
- Section of Pediatric Gastroenterology, Winnipeg Children’s Hospital, University of Manitoba, Winnipeg, MB, Canada
| | - Mary Sherlock
- Division of Pediatric Gastroenterology, McMaster Children’s Hospital, Hamilton, ON, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Eytan Wine
- Edmonton Pediatric IBD Clinic, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Kevan Jacobson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Peter Church
- SickKids Inflammatory Bowel Disease Centre, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Matthew W Carroll
- Edmonton Pediatric IBD Clinic, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Herbert Brill
- Division of Pediatric Gastroenterology, McMaster Children’s Hospital, Hamilton, ON, Canada
| | - Jeff Critch
- Department of Pediatrics, Janeway Children’s Hospital, St. John’s, NL, Canada
| | - Kevin Bax
- Department of Pediatrics, Schulich School of Medicine, Western University, Children’s Hospital of Western Ontario, London, ON, Canada
| | - Prévost Jantchou
- Department of Pediatrics, CHU Sainte-Justine, Montréal, QC, Canada
| | - Mohsin Rashid
- Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Gilaad G Kaplan
- Department of Community Health Services, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cynthia H Seow
- Department of Community Health Services, University of Calgary, Calgary, AB, Canada
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kerri Novak
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer C deBruyn
- Department of Community Health Services, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
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12
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deBruyn JC, Huynh HQ, Griffiths AM, Jacobson K, Mack D, Deslandres C, El-Matary W, Otley AR, Church PC, Lawrence S, Wine E, Sherlock M, Critch J, Benchimol EI, Jantchou P, Rashid M, Carroll MW, Bax K, Ricciuto A, Carman N, Walters TD, Crowley E. ADALIMUMAB VERSUS INFLIXIMAB IN LUMINAL PEDIATRIC CROHN'S DISEASE: COMPARABLE OUTCOMES IN A PROSPECTIVE MULTICENTER COHORT STUDY. Am J Gastroenterol 2023:00000434-990000000-00900. [PMID: 37787642 DOI: 10.14309/ajg.0000000000002552] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND This study compared real-world effectiveness between adalimumab (ADA) and infliximab (IFX) in children with Crohn's disease (CD). METHODS Children enrolled into the prospective Canadian Children Inflammatory Bowel Disease Network (CIDsCaNN) National Inception Cohort between 2014 and 2020 who commenced ADA or IFX as first anti-tumor necrosis factor (antiTNF) agent for luminal CD were included. Multivariate logistic regression modelled the propensity of commencing ADA; propensity score matching was used to match IFX-treated children to ADA-treated children. The primary outcome at one year was steroid-free clinical remission (SFCR). Secondary outcomes at one year were I) combined SFCR and c-reactive protein (CRP) remission; II) treatment intensification; and III) antiTNF durability. Odds ratios (aOR) and hazard ratio (aHR) adjusted for concomitant immunomodulator use with 95% confidence interval (CI) are reported. RESULTS In the propensity score matched cohort of 147 ADA-treated and 147 IFX-treated children, 92 (63%) ADA- and 87 (59%) IFX-treated children achieved SFCR at one year (aOR: 1.4, 95% CI 0.9-2.4); 75 of 140 (54%) ADA- and 85 of 144 (59%) IFX-treated children achieved combined SFCR and CRP remission (aOR: 1.0, 95% CI 0.6-1.6). ADA-treated children less frequently underwent treatment intensification (21 [14%]) compared to IFX-treated children (69 [47%]) (P<0.0001). Discontinuation of antiTNF occurred in 18 (12%) ADA-treated and 15 (10%) IFX-treated children (aHR: 1.2, 95% CI 0.6-2.2). CONCLUSION Children with Crohn's disease achieved favourable outcomes at one year with either ADA or IFX as first antiTNF agents. Those receiving IFX did not have significantly superior outcomes compared to clinically similar children receiving ADA.
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Affiliation(s)
| | - Hien Q Huynh
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Anne M Griffiths
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Department of Paediatrics and Institute for Health Policy and Management, University of Toronto
| | - Kevan Jacobson
- British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - David Mack
- Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada
| | | | - Wael El-Matary
- Winnipeg Children's Hospital, University of Manitoba, Winnipeg, Canada
| | | | - Peter C Church
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Department of Paediatrics and Institute for Health Policy and Management, University of Toronto
| | - Sally Lawrence
- British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Eytan Wine
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Mary Sherlock
- McMaster Children's Hospital, McMaster University, Hamilton, Canada
| | - Jeffrey Critch
- Janeway Children's Health and Rehabilitation Centre, Memorial University, St. John's, Canada
| | - Eric I Benchimol
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Department of Paediatrics and Institute for Health Policy and Management, University of Toronto
| | | | - Mohsin Rashid
- IWK Health Centre, Dalhousie University, Halifax, Canada
| | - Matthew W Carroll
- Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Kevin Bax
- Children's Hospital London Health Sciences Centre, London
| | - Amanda Ricciuto
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Department of Paediatrics and Institute for Health Policy and Management, University of Toronto
| | - Nicholas Carman
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Thomas D Walters
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Department of Paediatrics and Institute for Health Policy and Management, University of Toronto
| | - Eileen Crowley
- Children's Hospital London Health Sciences Centre, London
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13
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Raygoza Garay JA, Turpin W, Lee SH, Smith MI, Goethel A, Griffiths AM, Moayyedi P, Espin-Garcia O, Abreu M, Aumais GL, Bernstein CN, Biron IA, Cino M, Deslandres C, Dotan I, El-Matary W, Feagan B, Guttman DS, Huynh H, Dieleman LA, Hyams JS, Jacobson K, Mack D, Marshall JK, Otley A, Panaccione R, Ropeleski M, Silverberg MS, Steinhart AH, Turner D, Yerushalmi B, Paterson AD, Xu W, Croitoru K. Gut Microbiome Composition Is Associated With Future Onset of Crohn's Disease in Healthy First-Degree Relatives. Gastroenterology 2023; 165:670-681. [PMID: 37263307 DOI: 10.1053/j.gastro.2023.05.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND & AIMS The cause of Crohn's disease (CD) is unknown, but the current hypothesis is that microbial or environmental factors induce gut inflammation in genetically susceptible individuals, leading to chronic intestinal inflammation. Case-control studies of patients with CD have cataloged alterations in the gut microbiome composition; however, these studies fail to distinguish whether the altered gut microbiome composition is associated with initiation of CD or is the result of inflammation or drug treatment. METHODS In this prospective cohort study, 3483 healthy first-degree relatives (FDRs) of patients with CD were recruited to identify the gut microbiome composition that precedes the onset of CD and to what extent this composition predicts the risk of developing CD. We applied a machine learning approach to the analysis of the gut microbiome composition (based on 16S ribosomal RNA sequencing) to define a microbial signature that associates with future development of CD. The performance of the model was assessed in an independent validation cohort. RESULTS In the validation cohort, the microbiome risk score (MRS) model yielded a hazard ratio of 2.24 (95% confidence interval, 1.03-4.84; P = .04), using the median of the MRS from the discovery cohort as the threshold. The MRS demonstrated a temporal validity by capturing individuals that developed CD up to 5 years before disease onset (area under the curve > 0.65). The 5 most important taxa contributing to the MRS included Ruminococcus torques, Blautia, Colidextribacter, an uncultured genus-level group from Oscillospiraceae, and Roseburia. CONCLUSION This study is the first to demonstrate that gut microbiome composition is associated with future onset of CD and suggests that gut microbiome is a contributor in the pathogenesis of CD.
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Affiliation(s)
- Juan Antonio Raygoza Garay
- Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Zane Cohen Center for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Williams Turpin
- Zane Cohen Center for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Sun-Ho Lee
- Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Zane Cohen Center for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michelle I Smith
- Zane Cohen Center for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ashleigh Goethel
- Zane Cohen Center for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Moayyedi
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Osvaldo Espin-Garcia
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Maria Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, Florida
| | - Guy L Aumais
- Hopital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Center and Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Manitoba, Winnipeg, Canada
| | - Irit A Biron
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel
| | - Maria Cino
- Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Colette Deslandres
- Department of Hepatology and Pediatric Nutrition, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel
| | - Wael El-Matary
- Pediatric Gastroenterology, Max Rady College of Medicine, University of Manitoba, Manitoba, Winnipeg, Canada
| | - Brian Feagan
- Departments of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - David S Guttman
- Center for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, Ontario, Canada
| | - Hien Huynh
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Levinus A Dieleman
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Kevan Jacobson
- Research Institute, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - David Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - John K Marshall
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Anthony Otley
- Division of Gastroenterology, Izaak Walton Killam Hospital, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Unit, University of Calgary, Calgary, Alberta, Canada
| | - Mark Ropeleski
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mark S Silverberg
- Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - A Hillary Steinhart
- Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Andrew D Paterson
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Genetics and Genome Biology, The Hospital for Sick Children Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wei Xu
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Biostatistics Department, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada.
| | - Kenneth Croitoru
- Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Zane Cohen Center for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.
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14
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Parigi TL, D'Amico F, Abreu MT, Dignass A, Dotan I, Magro F, Griffiths AM, Jairath V, Iacucci M, Mantzaris GJ, O'Morain C, Reinisch W, Sachar DB, Turner D, Yamamoto T, Rubin DT, Peyrin-Biroulet L, Ghosh S, Danese S. Difficult-to-treat inflammatory bowel disease: results from an international consensus meeting. Lancet Gastroenterol Hepatol 2023; 8:853-859. [PMID: 37423233 DOI: 10.1016/s2468-1253(23)00154-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 07/11/2023]
Abstract
Many patients with inflammatory bowel disease (IBD) have persistent symptoms and disease activity despite the best available medical or surgical treatments. These patients are commonly referred to as having difficult-to-treat IBD and need additional therapeutic strategies. However, the absence of standard definitions has impeded clinical research efforts and comparisons of data. Under the guidance of the endpoints cluster of the International Organization for the Study of Inflammatory Bowel Disease, we held a consensus meeting to propose a common operative definition for difficult-to-treat IBD. 16 participants from 12 countries voted on 20 statements covering various elements of difficult-to-treat IBD, such as failure of medical and surgical treatments, disease phenotypes, and specific complaints from patients. "Agreement" was defined as at least 75% consensus. The group agreed that difficult-to-treat IBD is defined by the failure of biologics and advanced small molecules with at least two different mechanisms of action, or postoperative recurrence of Crohn's disease after two surgical resections in adults, or one in children. In addition, chronic antibiotic-refractory pouchitis, complex perianal disease, and comorbid psychosocial complications that impair disease management also qualified as difficult-to-treat IBD. Adoption of these criteria could serve to standardise reporting, guide enrolment in clinical trials, and help identify candidates for enhanced treatment strategies.
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Affiliation(s)
- Tommaso Lorenzo Parigi
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Ferdinando D'Amico
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Maria T Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt, Germany
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fernando Magro
- Unit of Pharmacology and Therapeutics, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Anne M Griffiths
- Division of Gastroenterology, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Vipul Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | | | - Colm O'Morain
- Department of Gastroenterology, Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Walter Reinisch
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David B Sachar
- The Dr Henry J Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | | | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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15
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El-Matary W, Carroll MW, Deslandres C, Griffiths AM, Kuenzig ME, Mack DR, Wine E, Weinstein J, Geist R, Davis T, Chan J, Khan R, Matthews P, Kaplan GG, Windsor JW, Bernstein CN, Bitton A, Coward S, Jones JL, Lee K, Murthy SK, Targownik LE, Peña-Sánchez JN, Rohatinsky N, Ghandeharian S, Im JHB, Goddard Q, Gorospe J, Verdugo J, Morin SA, Morganstein T, Banning L, Benchimol EI. The 2023 Impact of Inflammatory Bowel Disease in Canada: Special Populations-Children and Adolescents with IBD. J Can Assoc Gastroenterol 2023; 6:S35-S44. [PMID: 37674497 PMCID: PMC10478811 DOI: 10.1093/jcag/gwad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Rates of inflammatory bowel disease (IBD) in Canadian children and adolescents are among the highest in the world, and the incidence is rising most rapidly in children under five years of age. These young children may have either a typical form of IBD with multi-factorial aetiology, or they may have a monogenic form. Despite the growing number of children in Canada living with this important chronic disease, there are few available medical therapies approved by Health Canada due to the omission of children from most clinical trials of newly developed biologics. As a result, off-label use of medications is common, and physicians have learned to use existing therapies more effectively. In addition, most Canadian children are treated in multidisciplinary, specialty clinics by physicians with extra training or experience in IBD, as well as specialist nurses, dietitians, mental health care providers and other allied health professionals. This specialized clinic approach has facilitated cutting edge research, led by Canadian clinicians and scientists, to understand the causes of IBD, the optimal use of therapies, and the best ways to treat children from a biopsychosocial perspective. Canadians are engaged in work to understand the monogenic causes of IBD; the interaction between genes, the environment, and the microbiome; and how to address the mental health concerns and medical needs of adolescents and young adults transitioning from paediatric to adult care.
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Affiliation(s)
- Wael El-Matary
- Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Matthew W Carroll
- Division of Pediatric Gastroenterology and Nutrition, University of Alberta, Edmonton, Alberta, Canada
| | - Colette Deslandres
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David R Mack
- CHEO IBD Centre and Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Eytan Wine
- Departments of Pediatrics and Physiology, University of Alberta, Edmonton, Alberta, Canada
- Edmonton Pediatric IBD Clinic, Edmonton, Alberta, Canada
| | - Jake Weinstein
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rose Geist
- Department of Psychiatry, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Tal Davis
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Justin Chan
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, British Columbia Children Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Rabia Khan
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | - Gilaad G Kaplan
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Joseph W Windsor
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre, IBD Centre, McGill University, Montréal, Quebec, Canada
| | - Stephanie Coward
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer L Jones
- Departments of Medicine, Clinical Health, and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kate Lee
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Sanjay K Murthy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
| | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Juan-Nicolás Peña-Sánchez
- Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Noelle Rohatinsky
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - James H B Im
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Quinn Goddard
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julia Gorospe
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jules Verdugo
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Samantha A Morin
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Taylor Morganstein
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Lisa Banning
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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16
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Focht G, Kuint RC, Greer MLC, Pratt LT, Castro DA, Church PC, Navas-López VM, Baldassano RN, Mortensen JH, Rieder F, Yerushalmi B, Ilivitzki A, Konen O, Griffiths AM, Turner D. Prospective Validation of the Lémann Index in Children: A Report From the Multicentre Image Kids Study. J Crohns Colitis 2023; 17:943-949. [PMID: 36756849 PMCID: PMC11004934 DOI: 10.1093/ecco-jcc/jjad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND The Lémann Index [LI] and the recently updated LI are tools for measuring structural bowel damage in adults with Crohn's disease [CD] but have not been evaluated in children. We aimed to validate the updated LI in the prospective multicentre ImageKids study of paediatric CD. METHODS We included children with CD undergoing magnetic resonance enterography [MRE], pelvic magnetic resonance imaging [MRI] and ileocolonoscopy. Half were followed for 18 months, when MRE was repeated. Serum was collected for fibrosis-related proteomic markers. The LI was calculated by central readers from the MRE, ileocolonoscopy, physical examination and surgical data. Reliability and construct validity were assessed at baseline, while responsiveness and test-retest reliability were explored longitudinally. RESULTS In total, 240 children were included (mean age, 14.2 ± 2.5 years; median disease duration, 2.2 years [interquartile range, IQR 0.25-4.42]; median baseline LI, 4.23 [IQR 2.0-8.8]). The updated LI had excellent inter-observer reliability (interclass correlation coefficient [ICC] = 0.94, 95% confidence interval [CI] 0.92-0.95) but poor, although statistically significant, correlation with radiologist and gastroenterologist global assessments of damage and with serum proteomic levels of fibrotic markers [rho = 0.15-0.30, most p < 0.05]. The updated LI had low discriminative validity for detecting damage (area under the receiver operating characteristic curve [AUC-ROC] 0.69, 95% CI 0.62-0.75). In 116 repeated MREs, responsiveness was suboptimal for differentiating improved from unchanged disease [AUC-ROC 0.58, 95% CI 0.45-0.71]. Test-retest reliability was high among stable patients [ICC = 0.84, 95% CI 0.72-0.91]. CONCLUSION Overall, the updated LI had insufficient psychometric performance for recommending its use in children. An age-specific index may be needed for children with shorter disease duration than typical adult cohorts.
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Affiliation(s)
- Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
- The Hebrew University of Jerusalem, Israel
| | - Ruth Cytter Kuint
- Radiology Department, Shaare Zedek Medical Center, Jerusalem, Israel
- The Hebrew University of Jerusalem, Israel
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Li-Tal Pratt
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Denise A Castro
- Department of Diagnostic Radiology, Kingston Health Science Centre, Queen’s University, Kingston, Canada
| | - Peter C Church
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Víctor Manuel Navas-López
- Pediatric Gastroenterology and Nutrition Unit, Regional University Hospital of Málaga, Málaga, Spain
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Soroka University Medical Center, Soroka, Israel
| | - Anat Ilivitzki
- Pediatric Radiology Unit, Ruth Rappaport Children’s Hospital, Haifa, Israel
- The Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Osnat Konen
- Imaging Department, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel
| | - Anne M Griffiths
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Canada
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
- The Hebrew University of Jerusalem, Israel
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17
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Marcovitch L, Focht G, Carmon N, Tersigni C, Ledder O, Lev-Tzion R, Church PC, Hyams JS, Baldassano RN, Bousvaros A, Mack DR, Hussey S, Otley A, Croft NM, Kappelman MD, Griffiths AM, Turner D. Development and Validation of the TUMMY-UC: A Patient-Reported Outcome for Pediatric Ulcerative Colitis. Gastroenterology 2023; 164:610-618.e4. [PMID: 36539016 DOI: 10.1053/j.gastro.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS The TUMMY-UC is a patient-reported outcome measure for pediatric ulcerative colitis (UC) with an observer-reported outcome version for children aged <8 years. It includes eight items selected by concept elicitation interviews. We aimed to finalize the TUMMY-UC by cognitive interviews (stage 2) and to evaluate the index for its psychometric properties (stage 3). METHODS The TUMMY-UC items were first finalized during 129 cognitive debriefing interviews. Then, in a prospective, multicenter validation study, 84 children who underwent colonoscopy or provided stool for calprotectin completed the TUMMY-UC and various measures of disease activity. Assessments were repeated after 7 and 21 days for evaluating reliability and responsiveness. RESULTS During stage 2, the items were formatted with identical structure to ensure conceptual equivalence and weighted based on ranking of importance. In stage 3, the TUMMY-UC total score had excellent reliability in repeated assessments (intraclass correlation coefficient, 0.90; 95% confidence interval, 0.84-0.94). It also had moderate to strong correlations with all constructs of disease activity: r = 0.70 with UC endoscopic index of severity, r = 0.63 with the IMPACT-III questionnaire, r = 0.43 with calprotectin, r = 0.80 with the Pediatric Ulcerative Colitis Activity Index, r = 0.75 with global assessment of disease activity, and r = 0.46 with C-reactive protein (all P < .015). The index had excellent discrimination of disease activity, with a score of <9 defining remission (area under the receiver operating characteristic curve, 0.95; 95% confidence interval, 0.93-0.99). The ΔTUMMY-UC showed high responsiveness and differentiated well between children who experienced changed from those with no change. CONCLUSIONS The TUMMY-UC, constructed from patient-reported outcome and observer-reported outcome versions, is a reliable, valid and responsive index that can be now used in practice and clinical trials.
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Affiliation(s)
- Liron Marcovitch
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Natalie Carmon
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Claudia Tersigni
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Oren Ledder
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Raffi Lev-Tzion
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter C Church
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology and Nutrition, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - David R Mack
- Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario (CHEO) and Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Séamus Hussey
- National Children's Research Centre, University College Dublin (UCD), Dublin, Ireland
| | - Anthony Otley
- Division of Pediatrics, Izaak Walton Killam (IWK) Health Centre, Halifax, Nova Scotia, Canada
| | - Nicholas M Croft
- Blizard Institute, Faculty of Medicine, Queen Mary University of London, London, United Kingdom
| | - Michael D Kappelman
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne M Griffiths
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.
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18
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Bashir NS, Walters TD, Griffiths AM, Otley A, Critch J, Ungar WJ. A comparison of the Child Health Utility 9D and the Health Utilities Index for estimating health utilities in pediatric inflammatory bowel disease. Qual Life Res 2023:10.1007/s11136-023-03409-x. [PMID: 37004628 PMCID: PMC10393835 DOI: 10.1007/s11136-023-03409-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE Health utilities are challenging to ascertain in children and have not been studied in pediatric Crohn's disease (CD) and ulcerative colitis (UC). The objective was to assess discriminative validity by comparing utilities elicited using the Child Health Utility-9 Dimension (CHU9D) to the Health Utilities Index (HUI) across multiple disease activity scales in pediatric UC and CD. METHODS Preference-based instruments were administered to 188 children with CD and 83 children with UC aged 6 to 18 years. Utilities were calculated using CHU9D adult and youth tariffs, and HUI2 and HUI3 algorithms in children with inactive (quiescent) and active (mild, moderate, and severe) disease. Differences between instruments, tariff sets and disease activity categories and were tested statistically. RESULTS In CD and UC, all instruments detected significantly higher utilities for inactive compared to active disease (p < 0.05). Mean utilities for quiescent disease ranged from 0.810 (SD 0.169) to 0.916 (SD 0.121) in CD and from 0.766 (SD 0.208) to 0.871 (SD 0.186) in UC across instruments. Active disease mean utilities ranged from 0.694 (SD 0.212) to 0.837 (SD 0.168) in CD and from 0.654 (SD 0.226) to 0.800 (SD 0.128) in UC. CONCLUSION CHU9D and HUI discriminated between levels of disease activity in CD and UC regardless of the clinical scale used, with the CHU9D youth tariff most often displaying the lowest utilities for worse health states. Distinct utilities for different IBD disease activity states can be used in health state transition models evaluating the cost-effectiveness of treatments for pediatric CD and UC.
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Affiliation(s)
- Naazish S Bashir
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Thomas D Walters
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Anthony Otley
- Departments of Paediatrics and Medicine, Dalhousie University, Halifax, NS, Canada
- Division of Gastroenterology & Nutrition, IWK Health Centre, Halifax, NS, Canada
| | - Jeff Critch
- Department of Pediatrics, Faculty of Medicine, Janeway Children's Health and Rehabilitation Centre, Memorial University, St. John's, NF, Canada
| | - Wendy J Ungar
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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19
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Croft NM, de Ridder L, Griffiths AM, Hyams JS, Ruemmele FM, Turner D, Cheng K, Lutsar I, Greco M, Gołębiewska Z, Laumond F, Cavaller-Bellaubi M, Elgreey A, Altepeter TA, Pallidis C, Norga K, Nelson R, Crandall W, Vassal G. Paediatric Inflammatory Bowel Disease: A Multi-Stakeholder Perspective to Improve Development of Drugs for Children and Adolescents. J Crohns Colitis 2023; 17:249-258. [PMID: 36130314 PMCID: PMC10024546 DOI: 10.1093/ecco-jcc/jjac135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Despite recent approvals for new drugs to treat adults with Crohn's disease or ulcerative colitis, there are only two approved advanced treatment options [infliximab and adalimumab] for children with inflammatory bowel disease [IBD]. There are many potential new therapies being developed for adult and paediatric IBD. Moreover, regulatory agencies in both the European Union and USA have processes in place to support the early planning and initiation of paediatric studies. Nevertheless, unacceptable delays in approvals for use of drugs in children persist, with an average 7-year gap, or longer, between authorization of new IBD drugs for adults and children. METHODS A 2-day virtual meeting was held during April 14-15, 2021 for multi-stakeholders [clinical academics, patient community, pharmaceutical companies and regulators] to discuss their perspectives on paediatric drug development for IBD. RESULTS The multi-stakeholder group presented, discussed and proposed actions to achieve expediting the approval of new drugs in development for paediatric IBD. CONCLUSIONS Collaborative action points for all stakeholders are required to make progress and facilitate new drug development for children with IBD.
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Affiliation(s)
- Nicholas M Croft
- Corresponding author: Nicholas M Croft, Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, UK. Tel: +44 20 7882 2642;
| | | | - Anne M Griffiths
- Inflammatory Bowel Disease Centre, The Hospital for Sick Children, University of Toronto, Canada
| | | | - Frank M Ruemmele
- Université de Paris, Faculté de Médecine, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Necker Enfants Malades, Service de Gastroentérologie Pédiatrique, Paris, France
| | - Dan Turner
- Shaare Zedek Medical Center, the Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Tartu, Estonia
| | - Marco Greco
- European Patients’ Forum (EPF), Chaussée d’Etterbeek, Brussels, Belgium
| | - Zuzanna Gołębiewska
- J-elita, Polish Society for the Support of People with Inflammatory Bowel Disease, Warsaw, Poland
| | | | | | - Adam Elgreey
- Crohn and Colitis Foundation Israel (CCFI), Tel Aviv, Israel
| | - Tara A Altepeter
- Division of Gastroenterology, Office of Immunology and Inflammation, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Chrissi Pallidis
- Paediatric Medicines, European Medicines Agency, The Netherlands
| | - Koen Norga
- Paediatric Committee (PDCO), European Medicines Agency, The Netherlands
| | | | - Wallace Crandall
- Pediatric Immunology, Eli Lilly and Company, Indianapolis, IN, USA
| | - Gilles Vassal
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Comprehensive Cancer Center and Paris Saclay University, Villejuif, France
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20
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Suarez RG, Guruprasad N, Tata G, Zhang Z, Focht G, Navas-López V, Koletzko S, Griffiths AM, Wishart D, Wine E. A164 IDENTIFYING THE MOST IMPORTANT PREDICTORS TO CORRELATE SERUM METABOLITES WITH MRE CHANGES IN PATIENTS WITH PEDIATRIC CROHN DISEASE. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991251 DOI: 10.1093/jcag/gwac036.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Endoscopy has been the gold standard for assessing activity in Pediatric Crohn disease (pCD); however, it is limited by its invasiveness and partial assessment of small intestine and transmural inflammation. To that end, the Pediatric Inflammatory Crohn's MRE Index (PICMI) is a valid, reliable, non-invasive, and responsive index that includes transmural inflammation when assessing disease activity. The pathogenesis of pCD remains poorly understood, but evidence suggests that endogenous metabolites produced in the intestinal tract might mediate pathogenesis. Despite the important applicability of metabolomics in increasing the understanding of pCD, there has been limited research on this topic. Purpose Serum metabolomic profiles are linked to disease activity in pediatric Crohn disease. Method ImageKids is a multicenter, prospective, observational cohort study, designed to develop PICMI for pCD. The study was conducted over 18 months with paired serum specimens collected at study initiation and completion for 56 pCD patients. Due to the long time between the visits and the fact that during the study variables that highly affect serum metabolites were not controlled, we considered each patient visit as an individual measure point. Metabolites were identified using a quantitative metabolomics approach through The Metabolomics Innovation Centre (TMIC; University of Alberta). Disease activity was determined by the cutoff values in the total PICMI score of each patient. The most relevant serum metabolites were identified by medium-level and high-level variable selection analysis. Pearson correlation and hypothesis testing were used to select important metabolites. Decision trees, regularization techniques, and support vector machines were used to assess explicit importance of metabolites in disease activity. Result(s) This work provides a strategy to reduce a dimensional dataset from a metabolomic experiment. By medium-level selection analysis we were able to identify 117 statistical important metabolites for disease activity. The high-level selection analysis allowed to indicate the importance of the top 10 metabolites trough disease activity (defined by PICMI index). Results, also show that the evaluation of importance of metabolites through multivariate statistical models is dependent of the intrinsic variable selection model. Figure 1 reveals that Tryptophan ranked highest in the feature importance scoring. Histidine, Methylhistidine, Citric acid, Isoleucine, and Decanoylcarnitine also correlated well with disease severity. Image ![]()
Conclusion(s) This work uses a unique approach of multivariate statistical analyses, to identify metabolites associated with pCD disease activity. Tryptophan has been previously identified as significantly altered in the blood of IBD patients compared to controls. Histidine is known to be involved in the mediation of oxidative stress, potentially influencing intestinal inflammation. These metabolites could serve as biomarkers and help define pCD pathogenesis. Disclosure of Interest None Declared
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Affiliation(s)
| | - N Guruprasad
- Computing Science, University of Alberta, Edmonton, Canada
| | - G Tata
- Computing Science, University of Alberta, Edmonton, Canada
| | - Z Zhang
- Food Nutrition and Gastrointestinal Microbiome, Jimei University, Xiamen, China
| | - G Focht
- Hebrew University, Jerusalem, Israel
| | | | | | | | - D Wishart
- Computing Science, University of Alberta, Edmonton, Canada
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21
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Xue M, Turpin W, Haim L, Lee SH, Neustaeter A, Mei D, Xu W, Espin-Garcia O, Madsen KL, Guttman DS, Griffiths AM, Huynh H, Turner D, Panancionne R, Steinhart H, Aumais G, Bitton A, Jacobson K, Mack D, Croitoru K. A198 THE LONG-TERM IMPACT OF ENVIRONMENTAL EXPOSURES ON HOST HEALTH AND THE RISK FACTORS OF CROHN'S DISEASE. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991169 DOI: 10.1093/jcag/gwac036.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Several environmental factors are associated with Crohn’s disease (CD) in large case-control studies; however, it is not clear how these factors maybe be influenced by age of exposure and if they are related to alterations in pre-disease biological markers of CD risk. Purpose To investigate the association between environmental factors in different age groups with future risk of CD onset and assess their relation to other pre-disease biomarkers. Method We used an environmental risk assessment questionnaire (ERA) to collect information from healthy first-degree relatives(FDR) of CD enrolled in the CCC-GEM project. ERA was a multi-item questionnaire querying 69 questions under 7 section headings: background, cultural/ethnic, smoking history, medical history, family history, environmental history and pet history. For the environmental and pet sections, current and historical (<1, 2-4, 5-15 years old) data was captured at the time of recruitment. We used Cox proportional hazard models to identify exposures associated with future CD onset. Next, we used regression models to identify the relationship of exposures with biological factors associated with CD risk previously identified by our group i.e.: i) intestinal permeability using urinary fractional excretion of lactulose to mannitol ratio (LMR) with LMR≥0.025 defined as abnormal; ii) subclinical inflammation using fecal calprotectin (FCP) with FCP≥100µg/g; and iii) fecal microbiome composition and diversity using 16S rDNA sequencing. Two-sided p<0.05 (or false discovery rate corrected p<0.05) were considered significant. Result(s) A total of 4289 FDRs were recruited, 47% were male, median recruitment age was 17.0 years[6-35]. After a median follow-up of 5.6-years (IQR=3.42-8.67), 86 FDRs developed CD. Living with a dog between age 5-15 (Hazard Ratio (HR)=0.61; 95% confidence interval (CI)=0.39-0.95), and a large family size (>3) in the first year of life (HR=0.41; 95% CI=0.22-0.89) were protective against CD onset. Conversely, having a bird at time of survey (HR=2.84; CI=1.37-5.90), and having a sibling with CD (HR=2.07; 95% CI=1.18-3.63) were risk factors for CD onset. We found that owning a dog between age of 5-15 (Odd Ratio(OR)=0.77, 95% CI=0.65-0.90) was significantly associated with LMR, nine taxa bacterial and higher chao1 diversity index. Having a bird at time of survey was significantly associated with FCP (OR=2.04, 95% CI=1.33-3.11). There was no association between large family size and having a CD sibling with gut microbiome, FCP or LMR. Conclusion(s) The study identified four environmental factors associated with future development of CD. Among them, exposure to dogs during early life was protective against CD onset and might be explained by its association with normal gut permeability and microbiome. We also identified that having a bird at recruitment increased risk of CD onset which might be mediated by an increase in subclinical inflammation. Submitted on behalf of the CCC-GEM consortium Disclosure of Interest None Declared
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Affiliation(s)
- M Xue
- Lunenfeld-Tanenbaum Research Institute
| | - W Turpin
- Lunenfeld-Tanenbaum Research Institute
| | - L Haim
- Lunenfeld-Tanenbaum Research Institute
| | - S -H Lee
- Lunenfeld-Tanenbaum Research Institute
| | | | - D Mei
- Dalla Lana School of Public Health, University of Toronto, Toronto
| | - W Xu
- Dalla Lana School of Public Health, University of Toronto, Toronto
| | - O Espin-Garcia
- Dalla Lana School of Public Health, University of Toronto, Toronto
| | | | - D S Guttman
- Department of Cell & Systems Biology, University of Toronto
| | - A M Griffiths
- Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - H Huynh
- University of Alberta, Alberta
| | - D Turner
- The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | | | | | | | - K Jacobson
- University of British Columbia, Vancouver
| | - D Mack
- Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada
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22
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Kuenzig E, Singh H, Bitton A, Kaplan GG, Carroll MW, Otley AR, Stukel TA, Spruin S, Griffiths AM, Mack DR, Jacobson K, Nguyen GC, Targownik LE, El-Matary W, Nasiri S, Benchimol EI. A183 VARIATION IN HEALTH SERVICES UTILIZATION AND RISK OF SURGERY ACROSS CHILDREN WITH INFLAMMATORY BOWEL DISEASE: A MULTIPROVINCE COHORT STUDY. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991127 DOI: 10.1093/jcag/gwac036.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Marked variation in access to care and health services utilization is a marker of variation in quality of care. With the rising incidence of pediatric inflammatory bowel disease (IBD), we must understand variation in access to and outcomes of care to improve quality. Purpose Describe variation in care for pediatric IBD treated in 4 Canadian provinces. Method Incident cases of IBD diagnosed in children <16y were identified from health administrative data in Alberta (AB), Manitoba, Nova Scotia, and Ontario (ON) using validated algorithms. Children were assigned to one of 8 centres of care using a hierarchical assessment of health services use within 6 months of diagnosis. Children treated by adult gastroenterologists or community-based pediatric gastroenterologists were excluded due to small sample size. Outcomes included IBD-related hospitalizations, emergency department (ED) visits (AB/ON only), and IBD-related abdominal surgery. Hospitalizations and ED visits were counted cumulatively from 6-60 months after diagnosis. The risk of first surgery was defined during the same 6-60 month period. Mixed-effects meta-analysis was used to pool results across centres. Heterogeneity among centres was quantified using I2 (variation in pooled event rates between centres) and τ (standard deviation of the true event rates). R2 quantified the residual heterogeneity in outcomes not attributable to among-province variation. Result(s) We identified 3777 incident cases of pediatric IBD, 2936 (78%) of which were treated at 8 pediatric centres. The number of hospitalizations was 0.67 (95% CI 0.56-0.79) per person with high between-centre heterogeneity (I2 84%, τ 0.1556). Provincial differences accounted for 93% of heterogeneity across centres (residual heterogeneity: I2 29%, τ 0.0412). Hospitalizations were less frequent in AB than other provinces (0.43 vs. 0.72-0.78). Children averaged 1.94 IBD-related ED visits, with significant heterogeneity (I2 99%, τ 1.33) with 99.7% of heterogeneity attributable to among-province differences (residual heterogeneity: I2 32%; τ 0.074). Mean ED visits were 1.1 visits in ON (I2 39%) and 3.7 in AB (I2 0%). Intestinal resection was required by 12% (95% CI 0.08-0.15) of Crohn’s patients with high among-centre heterogeneity (I2 81%, τ 0.042), and low (19%) heterogeneity due to provincial differences (residual heterogeneity: I2 76%; τ 0.039). Colectomy was required by 12% (95% CI 10-14) of children with ulcerative colitis (UC) with no between-centre heterogeneity (I2 0%, τ 0). Conclusion(s) There is a high degree of between-province (but not between-centre, within province) variability in health services utilization among children with IBD. There was significant between-centre variability in surgery rates for Crohn’s, but not colectomy for UC. Differences in patient characteristics or provincial health systems may be more important predictors of variation in care. Surgery for Crohn’s disease may be a target for inter-centre quality improvement efforts. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest None Declared
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Affiliation(s)
- E Kuenzig
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto
| | - H Singh
- University of Manitoba IBD Clinical and Research Centre,Department of Internal Medicine, Max Rady College of Medicine, , University of Manitoba,Research Institute at CancerCare Manitoba, Winnipeg
| | - A Bitton
- Gastroenterology and Hepatology, McGill University Health Centre, Montreal
| | - G G Kaplan
- Medicine & Community Health Sciences, University of Calgary, Calgary
| | | | - A R Otley
- Pediatrics, Dalhousie University, Halifax
| | - T A Stukel
- ICES,Institute of Health Policy, Management and Evaluation
| | | | - A M Griffiths
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,Paediatrics, University of Toronto, Toronto
| | - D R Mack
- Pediatrics, University of Ottawa,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO,CHEO Research Institute, Ottawa
| | - K Jacobson
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver
| | - G C Nguyen
- ICES,Institute of Health Policy, Management and Evaluation,Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - L E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - W El-Matary
- Pediatrics, University of Manitoba, Winnipeg, Canada
| | | | - E I Benchimol
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,ICES,Institute of Health Policy, Management and Evaluation,Paediatrics, University of Toronto, Toronto
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23
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Kuenzig E, Duchen R, Walters TD, Mack DR, Griffiths AM, Bernstein CN, Kaplan GG, Otley AR, Yu W, Wang X, Guan J, Fung S, Benchimol EI. A182 PREDICTING HIGH DIRECT HEALTHCARE COSTS IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE IN THE FIRST YEAR FOLLOWING DIAGNOSIS. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991220 DOI: 10.1093/jcag/gwac036.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background The incidence of inflammatory bowel disease (IBD) continues to rise rapidly among Canadian children. The care of children results in higher direct healthcare costs than adults with IBD. It is imperative that we identify individuals who will become the highest-cost users of the health system in order to intervene early and decrease the individual- and system-level burden of IBD. Purpose To develop a predictive-model for high-cost health system users and (2) identify factors associated with high-cost healthcare use. Method Incident cases of IBD diagnosed ≤17y residing in Ontario and enrolled in the Canadian Children IBD Network (CIDsCaNN) between Dec 31 2013 and Jan 31 2019 were linked deterministically using health card number to health administrative data. Using a validated algorithm, direct healthcare costs accumulated between the 31st and 365th day after diagnosis were calculated using data from CIDsCaNN (medications) and health administrative data (health system encounters, including surgery). A predictive model was created to determine high-cost (≤25th percentile) and medium-cost (26th to 75th) users, compared to low-cost users (>75th) using ordinal logistic regression. Potential predictive variables were determined a priori based on clinical significance and magnitude of univariable association, based on sample size-informed degrees of freedom. Variables from CIDsCaNN data included: IBD type, age at diagnosis, sex, first line of therapy (steroids, aminosalicylates, exclusive enteral nutrition; yes or no, not mutually exclusive), disease activity (severe vs. moderate vs. none/mild based on PUCAI [UC] or wPCDAI [Crohn’s]). Predictive variables from the health administrative data included: rural/urban residence, hospitalization at diagnosis, intestinal resection or colectomy within 3 months of diagnosis, emergency department visit ±1 month of diagnosis, and a mental health encounter within the first year following diagnosis. Anti-TNF treatment was excluded from models due to the strong correlation with the outcome (direct costs). Overall model fit was estimated with a c-statistic. Result(s) Among the 487 (57% Crohn’s) children included in the study, the mean (sd) direct costs accumulated between the 31st and 365th days following IBD diagnosis was $14,451 (14,665). The mean cost among high-cost users was $33,533 (16,530); medium-cost users, $11,038 (5322); low-cost users, $2530 (831). The predictive model identified high-cost users of the health system with acceptable model fit (c-statistic 0.69). The relative contribution of individual variables, as measured by odds ratio (OR), is reported in the Table. Image ![]()
Conclusion(s) The direct healthcare costs of pediatric IBD are substantial. Children with IBD who become high-cost users of the health system were identifiable using characteristics at diagnosis (e.g., need for mental health care, emergency visits, older age). Further research should assess whether interventions in patients at-risk for becoming high-cost users may help to reduce costs. Please acknowledge all funding agencies by checking the applicable boxes below Other Please indicate your source of funding; Ontario Academic Health Sciences Centres Alternate Funding Plan Innovation Fund Disclosure of Interest E. Kuenzig: None Declared, R. Duchen: None Declared, T. Walters Grant / Research support from: Janssen, Abbvie, Psfizer, Ferring, Amgen, Consultant of: Janssen, Abbvie, Psfizer, Ferring, Amgen, D. Mack: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, C. Bernstein Grant / Research support from: Research grants from Abbvie Canada, Amgen Canada, Pfizer Canada, and Sandoz Canada and contract grants from Janssen, Abbvie and Pfizer, Consultant of: Abbvie Canada, Amgen Canada, Bristol Myers Squibb Canada, JAMP Pharmaceuticals, Janssen Canada, Pfizer Canada, Sandoz Canada, Takeda, Speakers bureau of: Abbvie Canada, Janssen Canada, Pfizer Canada and Takeda Canada, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, W. Yu: None Declared, X. Wang: None Declared, J. Guan: None Declared, S. Fung: None Declared, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)
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Affiliation(s)
- E Kuenzig
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children
| | | | - T D Walters
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children
| | - D R Mack
- Pediatrics, University of Ottawa,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO,CHEO Research Institute, Ottawa
| | - A M Griffiths
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children,Paediatrics, University of Toronto, Toronto
| | - C N Bernstein
- Univeristy of Manitoba IBD Clinical and Research Centre,Department of Internal Medicine, Max Rady College of Medicine, , University of Manitoba, Winnipeg
| | - G G Kaplan
- Medicine & Community Health Sciences, University of Calgary, Calgary
| | - A R Otley
- Pediatrics, Dalhousie University, Halifax
| | | | | | | | - S Fung
- CHEO Research Institute, Ottawa
| | - E I Benchimol
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children,ICES, Toronto,Paediatrics, University of Toronto, Toronto,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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24
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Kuenzig E, Singh H, Bitton A, Kaplan GG, Carroll MW, Otley AR, Stukel TA, Spruin S, Griffiths AM, Mack DR, Jacobson K, Nguyen GC, Targownik LE, El-Matary W, Benchimol EI. A189 EMERGENCY DEPARTMENT UTILIZATION AND RISK OF INTESTINAL RESECTION IS LOWER AMONG CHILDREN DIAGNOSED WITH INFLAMMATORY BOWEL DISEASE BEFORE 10 YEARS OF AGE: A MULTIPROVINCE POPULATION-BASED COHORT STUDY. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991184 DOI: 10.1093/jcag/gwac036.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background In Canada, the incidence of inflammatory bowel disease (IBD) is increasing faster among those <10 years (y) of age than in any other age group. Understanding the health services burden of IBD in this population is important for health system planning. Purpose To compare healthcare utilization and risk of surgery among children diagnosed with IBD across age groups defined by the Paris Classification (A1a: <10y; A1b: 10 to <16y) across 5 Canadian provinces. Method Children diagnosed with IBD <16 years of age were identified from health administrative data using validated algorithms in Alberta, Manitoba, Nova Scotia, Ontario, and Québec. Negative binomial regression models were used to compare (1) the pre-diagnosis frequency of health services utilization (outpatient, emergency department (ED), and hospitalization) using diagnostic codes suggestive of future IBD and (2) the annual post-diagnosis frequency of IBD-specific and IBD-related (signs, symptoms, and extra-intestinal manifestations of IBD) visits among children diagnosed <10y (A1a) and 10 to <16y (A1b). Cox proportional hazard models compared the risk of surgery (identified with validated procedure codes) across age groups. All regression models were adjusted for sex, rural/urban residence, and mean neighbourhood income quintile. Province-specific event counts (all ages combined) and models (comparing age groups; reference: A1b [10 to <16y]) were pooled using random-effects meta-analysis. Result(s) Among 5124 children with IBD (1165 [23%] were <10y at diagnosis), the mean number of pre-diagnosis healthcare encounters was 1.0 (95% CI 0.38 to 1.68, I2=99.6%). The mean annual post-diagnosis number of IBD-specific outpatient visits was 3.2 (95% CI 1.9-4.4, I2=99.6%); hospitalizations, 0.19 (95% CI 0.17-0.21, I2=74%); ED visits, 0.17 (95% CI 0.19-0.39, I2=99%). The mean annual post-diagnosis number of IBD-related outpatient visits was 3.9 (95% CI 2.3-5.5, I2=99.7%); hospitalizations, 0.21 (95% CI 0.19-0.23, I2=79%); ED visits, 0.29 (95% CI 0.19-0.39, I2=97%). Intestinal resection or colectomy within 5y of diagnosis occurred in 13% (95%CI 8-22, I2=93%) with Crohn’s disease (CD) and 16% (95% CI 14-18, I2=40%) with ulcerative colitis. IBD-specific ED visits (RR 0.70, 95% CI 0.50-0.97, I2=80) and the risk of intestinal resection in CD (HR 0.49, 95% CI 0.26-0.92, I2=40%) were significantly lower among children diagnosed <10y. There were no age-related differences in pre-diagnosis health services utilization or other post-diagnosis outcomes, including frequency of outpatient visits to a gastroenterologist. Conclusion(s) Health services utilization was generally similar for children diagnosed with IBD at <10y and between 10 and <16y, except for lower rates of IBD-specific ED visits and intestinal resection in children with CD. Further exploration of between-province differences, represented by the high statistical heterogeneity (I2) in the meta-analyses, is needed to understand sources of variation in care. Please acknowledge all funding agencies by checking the applicable boxes below CCC Disclosure of Interest E. Kuenzig: None Declared, H. Singh Consultant of: Amgen Canada, Bristol-Myers Squibb Canada, Sandoz Canada, Roche Canada, Takeda Canada and Guardant Health, A. Bitton: None Declared, G. Kaplan Grant / Research support from: Ferring, Consultant of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Amgen, Sandoz, Pendophram, and Takeda, M. Carroll: None Declared, A. Otley Grant / Research support from: Research support: AbbVie Global. Research site: AbbVie, Pfizer, Eli-Lily, Janssen, Consultant of: AbbVie Canada, T. Stukel: None Declared, S. Spruin: None Declared, A. Griffiths Grant / Research support from: Abbvie, Consultant of: Abbvie, Amgen, BristolMyersSquibb, Janssen, Lilly, Takeda, Speakers bureau of: Abbvie, Janssen, Takeda, D. Mack: None Declared, K. Jacobson Grant / Research support from: Abbvie Canada and Janssen Canada, Consultant of: Abbvie Canada, Janssen Canada, Merck Canada and Mylan Pharmaceuticals, Speakers bureau of: Abbvie Canada and Janssen Canada, G. Nguyen: None Declared, L. Targownik Grant / Research support from: Janssen Canada, Consultant of: AbbVie Canada, Sandoz Canada, Takeda Canada, Merck Canada, Pfizer Canada, Janssen Canada, and Roche Canada, W. El-Matary Consultant of: Abbvie and MERCK, Speakers bureau of: Abbvie and MERCK, E. Benchimol Consultant of: McKesson Canada, Dairy Farmers of Ontario (unrelated to medications used to treat inflammatory bowel disease)
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Affiliation(s)
- E Kuenzig
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto
| | - H Singh
- University of Manitoba IBD Clinical and Research Centre,Department of Internal Medicine, Max Rady College of Medicine, , University of Manitoba,Research Institute at CancerCare Manitoba, Winnipeg
| | - A Bitton
- Gastroenterology and Hepatology, McGill University Health Centre, Montreal
| | - G G Kaplan
- Medicine & Community Health Sciences, University of Calgary, Calgary
| | | | - A R Otley
- Pediatrics, Dalhousie University, Halifax
| | - T A Stukel
- ICES,Institute of Health Policy, Management and Evaluation
| | | | - A M Griffiths
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,Paediatrics, University of Toronto, Toronto
| | - D R Mack
- Pediatrics, University of Ottawa,CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO,CHEO Research Institute, Ottawa
| | - K Jacobson
- Department of Pediatrics, BC Children's Hospital Research Institute, University of British Columbia, Vancouver
| | - G C Nguyen
- ICES,Institute of Health Policy, Management and Evaluation,Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - L E Targownik
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto
| | - W El-Matary
- Pediatrics, University of Manitoba, Winnipeg, Canada
| | - E I Benchimol
- Child Health Evaluative Sciences, SickKids Research Institute,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto,ICES,Institute of Health Policy, Management and Evaluation,Paediatrics, University of Toronto, Toronto
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25
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Neustaeter A, Lee SH, Xue M, Leibovitzh H, Madsen K, Meddings JB, Espin-Garcia O, Griffiths AM, Moayyedi P, Steinhart AH, Panancionne R, Huynh H, Jacobson K, Aumais G, Mack D, Bernstein C, Marshall JK, Xu W, Turpin W, Croitoru K. A218 ASSOCIATIONS BETWEEN ADHERENCE TO LITERATURE-DERIVED DIETARY INDICES AND PRE-DISEASE BIOMARKERS: IMPLICATIONS FOR CROHN’S DISEASE PREVENTION. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991210 DOI: 10.1093/jcag/gwac036.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background The incidence of Crohn’s disease (CD) is increasing globally, indicating a significant environmental influence such as diet. A plethora of dietary adherence (DA) patterns exist in the literature: the Mediterranean Diet (MD), Empirical Dietary Inflammatory Pattern (EDIP), Specific Carbohydrate Diet (SCD), and low Fermentable Oligosaccharide, Disaccharide, Monosaccharide, or Polyol diet (FODMAP) are all potential candidates to maintain a reduced level of inflammation, improving gastrointestinal function. Contrary, the Westernized diet (WD) is generally reported as a diet promoting inflammation in humans. Purpose To determine if DA to literature-derived dietary indices in a cohort of first-degree relatives (FDRs) of CD patients can modulate pre-disease biomarkers. Method We used food frequency questionnaire (FFQ) data from 2,696 healthy FDR subjects of the Crohn’s Colitis Canada- Genes, Environment, Microbial (CCC-GEM) project. We rederived each of the following scores using our FFQ data, utilizing originally described methods for the MD, EDIP, SCD, low FODMAP, and WD to obtain DA. Each diet was correlated pairwise via Kendall’s Tau. We fit multivariable regression models to identify the association of DA (top quintile vs remaining) and: i) intestinal permeability using urinary fractional excretion of lactulose to mannitol ratio (LMR), LMR≥0.03 defined abnormal; ii) subclinical inflammation using fecal calprotectin (FCP) measured with BÜHLMANN fCAL® ELISA, FCP≥250µg/g defined inflammation; and iii) fecal microbiome richness and composition using 16S rRNA sequencing. Two-sided p<0.05 for primary and q<0.05 for secondary analysis defined significance. Result(s) There were positive correlations between the MD, SCD, and low FODMAP, these diets negatively correlated with the WD. The EDIP negatively correlated with the SCD and low FODMAP, did not correlate with the MD, and positively correlated with the WD. No diet was associated with abnormal LMR or FCP. Only the SCD was associated with increased microbial richness (q=0.03). All diets were associated with microbial genera: the MD (n=18 taxa, (2.0-7<q-values< 0.04), EDIP (n=9, [2.8-4-0.05]), SCD (n=13, [3.7-11-0.05]), low FODMAP (n=14, [1.3-7-0.05]), and WD (n=1, [0.03]). Conclusion(s) This study shows that literature-derived dietary indices correlate generally with each other, yet none were not associated with abnormal LMR or FCP. However, we found that diet can impact microbiome richness and composition. Thus, it is tempting to speculate that diet is a possible intervention capable of maintain microbiome homeostasis to reduce future risk of CD. Submitted on behalf of the CCC-GEM consortium. Funding Crohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III The Leona M. and Harry B. Helmsley Charitable Trust Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Disease Disclosure of Interest None Declared
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Affiliation(s)
| | | | - M Xue
- University of Toronto, Toronto
| | | | | | | | | | | | | | | | | | - H Huynh
- University of Alberta, Calgary
| | - K Jacobson
- University of British Columbia, Vancouver
| | | | - D Mack
- University of Ottawa, Ottawa
| | | | | | - W Xu
- University of Toronto, Toronto
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26
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Neustaeter A, Shao J, Xue M, Antonio Hernández Rocha C, Lee SH, Leibovitzh H, Madsen K, Meddings JB, Espin-Garcia O, Griffiths AM, Moayyedi P, Steinhart AH, Panancionne R, Huynh H, Jacobson K, Aumais G, Mack D, Bernstein C, Marshall JK, Xu W, Turpin W, Croitoru K. A238 BILE ACID COMPOSITION AND DIETARY FAT: IMPLICATIONS FOR CROHN’S DISEASE IN A COHORT OF HEALTHY FIRST-DEGREE RELATIVES. J Can Assoc Gastroenterol 2023. [PMCID: PMC9991268 DOI: 10.1093/jcag/gwac036.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background Crohn’s disease (CD) is a chronic relapsing inflammatory disease of the gastrointestinal tract. The etiology of CD may arise from complex interactions including host genetics, diet, and the intestinal microbiome. Increased consumption of saturated fats, characteristic of the Western diet, is a known risk factor for CD. Dietary fat (DF) is absorbed by the host through the release of primary bile acids (PBAs) and bio-transformed by the microbiome into secondary bile acids (SBAs). Altogether, bile acids (BAs) can act as signaling molecules involved in host immune regulation and potentially in CD onset. Purpose To investigate the relationship between CD risk, BAs, and DF, and evaluate the predictive performance of CD onset of these factors by developing machine learning models. Method We used samples healthy first-degree relatives (FDRs) recruited as part of the Crohn’s Colitis Canada- Genes, Environment, Microbial (GEM) project. Those who developed CD (n=87) were matched 1:4 by age, sex, follow-up time, and geographic location with control FDRs remaining healthy (n=347). Serum, urine, and stool BA were measured using ultrahigh Performance Liquid Chromatography-Tandem Mass Spectroscopy. DF types were derived from food frequency questionnaire data. We used conditional logistic regressions to identify associations between CD onset, BAs (n=93), and DFs (n=9). We further explored the relationships of significant CD-related BAs and DF via Generalized Estimation Equations. Finally, we used a tree-based machine-learning algorithm (XGBoost) with 5-fold cross-validation to assess the prediction performance of CD onset using BA from all sources as well as DF. Two-sided p<0.05 was considered significant. Result(s) In total, 10 of 93 BAs, and two of nine DFs were significantly associated with increased odds of CD onset (p<0.05). Additionally, five BAs were significantly associated with DF (p<0.05). Serum-derived BAs had the best predictive performance for CD, with a mean AUC of 0.70 [95% CI: 0.63;0.76], followed by stool derived BAs with a mean AUC= 0.65 [0.55;0.75], and followed by urine derived Bas with a mean AUC= 0.57 [0.48;0.66]. Lastly DF was not a predictive marker of CD onset with a mean AUC= 0.50 [0.41;0.60]. Conclusion(s) This study suggests that BAs are associated with the pathogenesis of CD and the effects may be influenced by DF. Serum-derived BAs may be able to better predict the risk of CD than other stool or urine derived BA, while DF is not directly implicated in CD risk. Submitted on behalf of the CCC-GEM consortium. Funding Crohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III The Leona M. and Harry B. Helmsley Charitable Trust Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases The International Organization for the Study of Inflammatory Bowel Diseases (IOIBD) Jingcheng Shao is the recipient of a Data Science Institute Summer Undergraduate Data Science award Disclosure of Interest None Declared
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Affiliation(s)
| | - J Shao
- University of Toronto, Toronto
| | - M Xue
- University of Toronto, Toronto
| | | | | | | | | | | | | | | | | | | | | | - H Huynh
- University of Alberta, Calgary
| | - K Jacobson
- University of British Columbia, Vancouver
| | | | - D Mack
- University of Ottawa, Ottawa
| | | | | | - W Xu
- University of Toronto, Toronto
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27
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Leibovitzh H, Lee SH, Raygoza Garay JA, Espin-Garcia O, Xue M, Neustaeter A, Goethel A, Huynh HQ, Griffiths AM, Turner D, Madsen KL, Moayyedi P, Steinhart AH, Silverberg MS, Deslandres C, Bitton A, Mack DR, Jacobson K, Cino M, Aumais G, Bernstein CN, Panaccione R, Weiss B, Halfvarson J, Xu W, Turpin W, Croitoru K. Immune response and barrier dysfunction-related proteomic signatures in preclinical phase of Crohn's disease highlight earliest events of pathogenesis. Gut 2023:gutjnl-2022-328421. [PMID: 36788016 DOI: 10.1136/gutjnl-2022-328421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE The measure of serum proteome in the preclinical state of Crohn's disease (CD) may provide insight into biological pathways involved in CD pathogenesis. We aimed to assess associations of serum proteins with future CD onset and with other biomarkers predicting CD risk in a healthy at-risk cohort. DESIGN In a nested case-control study within the Crohn's and Colitis Canada Genetics Environment Microbial Project (CCC-GEM) cohort, which prospectively follows healthy first-degree relatives (FDRs), subjects who developed CD (n=71) were matched with four FDRs remaining healthy (n=284). Using samples at recruitment, serum protein profiles using the Olink Proximity Extension Assay platform was assessed for association with future development of CD and with other baseline biomarkers as follows: serum antimicrobial antibodies (AS: positive antibody sum) (Prometheus); faecal calprotectin (FCP); gut barrier function using the fractional excretion of lactulose-to-mannitol ratio (LMR) assay. RESULTS We identified 25 of 446 serum proteins significantly associated with future development of CD. C-X-C motif chemokine 9 (CXCL9) had the highest OR with future risk of CD (OR=2.07 per SD, 95% CI 1.58 to 2.73, q=7.9e-5), whereas matrix extracellular phosphoglycoprotein had the lowest OR (OR 0.44, 95% CI 0.29 to 0.66, q=0.02). Notably, CXCL9 was the only analyte significantly associated with all other CD-risk biomarkers with consistent direction of effect (FCP: OR=2.21; LMR: OR=1.67; AS: OR=1.59) (q<0.05 for all). CONCLUSION We identified serum proteomic signatures associated with future CD development, reflecting potential early biological processes of immune and barrier dysfunction.
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Affiliation(s)
- Haim Leibovitzh
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Gastroenterology & Hepatology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Sun-Ho Lee
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Gastroenterology & Hepatology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Juan Antonio Raygoza Garay
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Gastroenterology & Hepatology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Osvaldo Espin-Garcia
- Division of Biostatistics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Mingyue Xue
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anna Neustaeter
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ashleigh Goethel
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hien Q Huynh
- Division of Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Anne M Griffiths
- IBD Center, Department of Paediatrics, Faculty of Medicine, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, The Hebrew University of Jerusalem, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Karen L Madsen
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Paul Moayyedi
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Gastroenterology & Hepatology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Gastroenterology & Hepatology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Colette Deslandres
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Montreal, Saint Justine Hospital, Montreal, Quebec, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - David R Mack
- Division of Gastroenterology, Hepatology & Nutrition, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kevan Jacobson
- Canadian Gastro-Intestinal Epidemiology Consortium, British Columbia Children's Hospital Research Institute, University of British Columbia, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Maria Cino
- Department of Medicine, Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
| | - Guy Aumais
- Department of Medicine, Montreal University, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Charles N Bernstein
- University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre and Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Batia Weiss
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, The Edmond and Lily Safra Children's Hospital, Tel Aviv, Israel
| | - Jonas Halfvarson
- School of Medical Sciences. Department of Gastroenterology, Örebro University, Orebro, Sweden
| | - Wei Xu
- Division of Biostatistics, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Williams Turpin
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Gastroenterology & Hepatology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Kenneth Croitoru
- Zane Cohen Centre for Digestive Diseases, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada .,Division of Gastroenterology & Hepatology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
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Bashir NS, Walters TD, Griffiths AM, Otley A, Critch J, Ungar WJ. A Comparison of Preference-Based, Generic and Disease-Specific Health-Related Quality of Life in Pediatric Inflammatory Bowel Disease. J Can Assoc Gastroenterol 2023; 6:73-79. [PMID: 37025514 PMCID: PMC10071296 DOI: 10.1093/jcag/gwac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Abstract
Objective
Generic preference-based HRQOL assessments used expressly for economic evaluation have not been examined in pediatric Crohn’s disease (CD) and ulcerative colitis (UC). The objective was to further assess the construct validity of preference-based HRQOL measures in pediatric IBD by comparing the Child Health Utility 9 Dimensions (CHU9D) and Health Utilities Index (HUI) to the disease-specific IMPACT-III and to the generic PedsQL in children with CD and with UC.
Methods
The CHU9D, HUI, IMPACT-III and/or PedsQL were administered to Canadian children aged 6 to 18 years with CD and UC. CHU9D total and domain utilities were calculated using adult and youth tariffs. HUI total and attribute utilities were determined for the HUI2 and HUI3. Total scores for IMPACT-III and PedsQL were determined. Spearman correlations were calculated between generic preference-based utilities and the IMPACT-III and PedsQL scores.
Results
The questionnaires were administered to 157 children with CD and 73 children with UC. Moderate to strong correlations were observed between the CHU9D, HUI2, HUI3 and the disease-specific IMPACT-III or generic PedsQL. As hypothesized, domains with similar constructs demonstrated stronger correlations, such as the Pain and Well-being domains.
Conclusions
While all questionnaires were moderately correlated with the IMPACT-III and PedsQL questionnaires, the CHU9D using youth tariffs and the HUI3 were most strongly correlated and would be suitable choices to generate health utilities for children with CD or UC for the purpose of economic evaluation of treatments in pediatric IBD.
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Affiliation(s)
- Naazish S Bashir
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute , Toronto, Ontario , Canada
| | - Thomas D Walters
- Division of Gastroenterology, Hepatology and Nutrition, IBD Centre, The Hospital for Sick Children , Toronto, ON , Canada
- Department of Paediatrics, University of Toronto , Toronto, ON , Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, IBD Centre, The Hospital for Sick Children , Toronto, ON , Canada
- Department of Paediatrics, University of Toronto , Toronto, ON , Canada
| | - Anthony Otley
- Departments of Paediatrics and Medicine, Dalhousie University, Halifax , Nova Scotia , Canada
- Division of Gastroenterology and Nutrition, IWK Health Centre , Halifax, NS , Canada
| | - Jeff Critch
- Janeway Children’s Health and Rehabilitation Centre and Department of Pediatrics, Memorial University , St. John’s, NL , Canada
| | - Wendy J Ungar
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute , Toronto, Ontario , Canada
- The Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, ON , Canada
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Guez I, Focht G, Greer MLC, Cytter-Kuint R, Pratt LT, Castro DA, Turner D, Griffiths AM, Freiman M. Development of a multimodal machine-learning fusion model to non-invasively assess ileal Crohn's disease endoscopic activity. Comput Methods Programs Biomed 2022; 227:107207. [PMID: 36375417 DOI: 10.1016/j.cmpb.2022.107207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/22/2022] [Accepted: 10/27/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Recurrent attentive non-invasive observation of intestinal inflammation is essential for the proper management of Crohn's disease (CD). The goal of this study was to develop and evaluate a multi-modal machine-learning (ML) model to assess ileal CD endoscopic activity by integrating information from Magnetic Resonance Enterography (MRE) and biochemical biomarkers. METHODS We obtained MRE, biochemical and ileocolonoscopy data from the multi-center ImageKids study database. We developed an optimized multimodal fusion ML model to non-invasively assess terminal ileum (TI) endoscopic disease activity in CD from MRE data. We determined the most informative features for model development using a permutation feature importance technique. We assessed model performance in comparison to the clinically recommended linear-regression MRE model in an experimental setup that consisted of stratified 2-fold validation, repeated 50 times, with the ileocolonoscopy-based Simple Endoscopic Score for CD at the TI (TI SES-CD) as a reference. We used the predictions' mean-squared-error (MSE) and the receiver operation characteristics (ROC) area under curve (AUC) for active disease classification (TI SEC-CD≥3) as performance metrics. RESULTS 121 subjects out of the 240 subjects in the ImageKids study cohort had all required information (Non-active CD: 62 [51%], active CD: 59 [49%]). Length of disease segment and normalized biochemical biomarkers were the most informative features. The optimized fusion model performed better than the clinically recommended model determined by both a better median test MSE distribution (7.73 vs. 8.8, Wilcoxon test, p<1e-5) and a better aggregated AUC over the folds (0.84 vs. 0.8, DeLong's test, p<1e-9). CONCLUSIONS Optimized ML models for ileal CD endoscopic activity assessment have the potential to enable accurate and non-invasive attentive observation of intestinal inflammation in CD patients. The presented model is available at https://tcml-bme.github.io/ML_SESCD.html.
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Affiliation(s)
- Itai Guez
- Faculty of Industrial Engineering, Technion - Israel Institute of Technology, Haifa, Israel.
| | - Gili Focht
- Shaare Zedek Medical Center, Jerusalem, Israel
| | | | | | - Li-Tal Pratt
- Kingston Health Sciences Centre, Queen's University, Kingston, Canada
| | - Denise A Castro
- Kingston Health Sciences Centre, Queen's University, Kingston, Canada
| | - Dan Turner
- Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Moti Freiman
- Faculty of Biomedical Engineering, Technion - Israel Institute of Technology, Haifa, Israel
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Crowley E, Griffiths AM, Jairath V. Heterogeneity in Efficacy and Safety Endpoints for Pediatric Clinical Trials in Inflammatory Bowel Disease: A Need for Harmonization. Gastroenterology 2022; 163:1137-1144. [PMID: 35850191 DOI: 10.1053/j.gastro.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Eileen Crowley
- Division of Pediatric Gastroenterology, Department of Pediatrics, Children's Hospital Western Ontario, London Health Sciences Centre, Western University and Alimentiv Inc, London, Ontario, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, IBD Centre SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, London Health Sciences Centre and Department of Epidemiology and Biostatistics, Western University and Alimentiv Inc, London, Ontario, Canada
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31
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Focht G, Cytter-Kuint R, Greer MLC, Pratt LT, Castro DA, Church PC, Walters TD, Hyams J, Navon D, Martin de Carpi J, Ruemmele F, Russell RK, Gavish M, Griffiths AM, Turner D. Development, Validation, and Evaluation of the Pediatric Inflammatory Crohn's Magnetic Resonance Enterography Index From the ImageKids Study. Gastroenterology 2022; 163:1306-1320. [PMID: 35872072 DOI: 10.1053/j.gastro.2022.07.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 06/21/2022] [Accepted: 07/17/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Cross-sectional imaging is important in the assessment of transmural inflammation in Crohn's disease (CD). Small bowel involvement is often more extensive in pediatric CD, requiring a panentering measuring tool. We undertook to develop a magnetic resonance enterography (MRE)-based index that would measure inflammation in all segments of the intestine, without rectal contrast. METHODS Children with CD underwent ileocolonoscopy and MRE and half were prospectively followed for 18 months when MRE was repeated. Item generation and reduction were performed by a Delphi panel of pediatric radiologists, a systematic literature review, a cross-sectional study of 48 MREs, and a steering committee. Formatting and weighting were performed using multivariate modeling adjusted by a steering committee. MREs were read locally and centrally. Reliability, validity, and responsiveness were determined using several clinimetric and psychometric approaches. RESULTS Thirty items were initially generated and reduced to 5 using regression analysis on 159 MREs: wall thickness, wall diffusion weighted imaging, ulcerations, mesenteric edema, and comb sign. In the validation cohort of 81 MREs, the weighted global PICMI correlated well with the radiologist global assessment (r = 0.85; P < .001) and with the simple endoscopic score in a subsample with ileocolonic disease (r = 0.63; P < .001). Interobserver and test-retest reliability were high (interclass correlation coefficients, 0.84; 95% confidence interval [CI], 0.79-0.87; and 0.81, 95% CI, 0.65-0.90, respectively; both P < .001). Excellent responsiveness was found at repeated visits (n = 116 MREs; area under the receiver operating characteristic curve 0.96; 95% CI, 0.93-0.99). Transmural healing was defined as PICMI ≤10 and response as a change of >20 points with excellent discriminative validity (area under the receiver operating characteristic curve = 0.96; 95% CI, 0.93-0.99). CONCLUSIONS The PICMI is a valid, reliable, and responsive index for assessing transmural inflammation in pediatric CD. It scores the entire bowel length and does not require intravenous contrast or rectal enema and, therefore, is suitable for use in children. (ClinicalTrials.gov, Number: NCT01881490.).
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Affiliation(s)
- Gili Focht
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ruth Cytter-Kuint
- Radiology Department, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Li-Tal Pratt
- Pediatric Imaging Unit, Imaging Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Denise A Castro
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Diagnostic Radiology, Kingston Health Science Centre, Queen's University, Kingston, Ontario, Canada
| | - Peter C Church
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Thomas D Walters
- Department of Gastroenterology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Hyams
- Connecticut Children's Medical Center, Hartford, Connecticut
| | - Dan Navon
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Frank Ruemmele
- Université Paris Descartes - Sorbonne Paris Cité, Assistance Publique - Hôpitaux de Paris, Hôpital Necker Enfants Malades, Service de Gastroentérologie, Paris, France
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Sick Children, National Health Services Lothian, Edinburgh, United Kingdom
| | - Matan Gavish
- School of Computer Science and Engineering, The Hebrew University, Jerusalem, Israel
| | - Anne M Griffiths
- Department of Diagnostic Radiology, Kingston Health Science Centre, Queen's University, Kingston, Ontario, Canada
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology Hepatology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.
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Leibovitzh H, Lee SH, Xue M, Raygoza Garay JA, Hernandez-Rocha C, Madsen KL, Meddings JB, Guttman DS, Espin-Garcia O, Smith MI, Goethel A, Griffiths AM, Moayyedi P, Steinhart AH, Panaccione R, Huynh HQ, Jacobson K, Aumais G, Mack DR, Abreu MT, Bernstein CN, Marshall JK, Turner D, Xu W, Turpin W, Croitoru K. Altered Gut Microbiome Composition and Function Are Associated With Gut Barrier Dysfunction in Healthy Relatives of Patients With Crohn's Disease. Gastroenterology 2022; 163:1364-1376.e10. [PMID: 35850197 DOI: 10.1053/j.gastro.2022.07.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 07/04/2022] [Accepted: 07/08/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS The gut microbiome has been suggested to play a role in gut barrier hemostasis, but data are scarce and limited to animal studies. We therefore aimed to assess whether alterations in gut microbial composition and functional pathways are associated with gut barrier function in a cohort of healthy first-degree relatives of patients with Crohn's disease. METHODS We used the Crohn's and Colitis Canada Genetic Environmental Microbial (CCC-GEM) cohort of healthy first-degree relatives of patients with Crohn's disease. Gut barrier function was assessed using the urinary fractional excretion of lactulose-to-mannitol ratio (LMR). Microbiome composition was assessed by sequencing fecal 16S ribosomal RNA. The cohort was divided into a discovery cohort (n = 2472) and a validation cohort (n = 655). A regression model was used to assess microbial associations with the LMR. A random forest classifier algorithm was performed to assess microbial community contribution to barrier function. RESULTS Individuals with impaired barrier function (LMR >0.025) had reduced alpha-diversity (Chao1 index, P = 4.0e-4) and altered beta-diversity (Bray-Curtis dissimilarity index, R2 = 0.001, P = 1.0e-3) compared with individuals with an LMR ≤0.025. When taxa were assessed individually, we identified 8 genera and 52 microbial pathways associated with an LMR >0.025 (q < 0.05). Four genera (decreased prevalence of Adlercreutzia, Clostridia UCG 014, and Clostridium sensu stricto 1 and increased abundance of Colidextribacter) and 8 pathways (including decreased biosynthesis of glutamate, tryptophan, and threonine) were replicated in the validation cohort. The random forest approach revealed that the bacterial community is associated with gut barrier function (area under the curve, 0.63; P = 1.4e-6). CONCLUSIONS The gut microbiome community and pathways are associated with changes in gut barrier function. These findings may identify potential microbial targets to modulate gut barrier.
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Affiliation(s)
- Haim Leibovitzh
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sun-Ho Lee
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mingyue Xue
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Juan Antonio Raygoza Garay
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cristian Hernandez-Rocha
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jonathan B Meddings
- Department of Medicine, Cumming School of Medicine, Calgary, Alberta, Canada
| | - David S Guttman
- Department of Cell & Systems Biology, University of Toronto, Toronto, Ontario, Canada; Centre for the Analysis of Genome Evolution & Function, University of Toronto, Toronto, Ontario, Canada
| | - Osvaldo Espin-Garcia
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle I Smith
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ashleigh Goethel
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne M Griffiths
- IBD Center, The Hospital for Sick Children, Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul Moayyedi
- Department of Medicine, McMaster University, Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Hien Q Huynh
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kevan Jacobson
- Canadian Gastro-Intestinal Epidemiology Consortium, Toronto, Ontario, Canada; British Columbia Children's Hospital, British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Guy Aumais
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal University, Montreal, Quebec, Canada
| | - David R Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Maria T Abreu
- Division of Gastroenterology, Crohn's and Colitis Center, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Charles N Bernstein
- University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre and Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John K Marshall
- Department of Medicine, McMaster University, Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Wei Xu
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Williams Turpin
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth Croitoru
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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El-Matary W, Witt J, Bernstein CN, Jacobson K, Mack D, Otley A, Walters TD, Huynh HQ, deBruyn J, Griffiths AM, Benchimol EI. Indirect and Out-of-Pocket Disease-associated Costs in Pediatric Inflammatory Bowel Disease: A Cross-sectional Analysis. J Pediatr Gastroenterol Nutr 2022; 75:466-472. [PMID: 35758424 DOI: 10.1097/mpg.0000000000003545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Data on pediatric inflammatory bowel disease (IBD)-associated indirect and out-of-pocket (OOP) costs are limited. We aimed to estimate indirect (lost work hours and productivity) and OOP pediatric IBD-associated costs in Canada. METHODS In a nation-wide cross-sectional analysis, caregivers of children with IBD were invited to complete a questionnaire on lost work hours and OOP costs related to IBD in the 4 weeks prior to the survey. Participants were reinvited to periodically answer the same questionnaire every 3-9 months for 2 years. Lost productivity was calculated using the Human Capital method. Costs were reported in 2018 inflation-adjusted Canadian dollars. Predictors of high cost users (top 25%) were examined using binary logistic regression. RESULTS Consecutive 243 (82 incident cases) of 262 (92.7%) approached participants completed the first survey with a total of 450 surveys longitudinally completed over 2 years. The median annual indirect cost per patient was $5966 (IQR $1809-$12,676), with $5721 (IQR $1366-$11,545) for Crohn's disease (CD) and $7007 (IQR $2428-$14,057) for ulcerative colitis (UC) ( P = 0.11). The annual median per patient OOP costs were $4550 with $4550 for CD and $5038 for UC ( P = 0.53). Longer travel distance to clinic was associated with higher OOP costs (odds ratio = 4.55; P < 0.0001; 95% confidence interval: 1.99-10.40). CONCLUSIONS Indirect and OOP IBD-associated costs are substantial and more likely to affect families living in remote communities.
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Affiliation(s)
- Wael El-Matary
- From the Section of Pediatric Gastroenterology, Department of Pediatrics, Max Rady College of Medicine, Rady Faculty of Medicine, University of Manitoba, Winnipeg, Canada
- Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, Canada
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
| | - Julia Witt
- Department of Economics, University of Manitoba, Winnipeg, Canada
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
- Section of Gastroenterology, Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Medicine, University of Manitoba, Winnipeg, Canada
| | - Kevan Jacobson
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, British Columbia Children's Hospital and British Columbia Children Hospital Research Institute, Vancouver, BC, Canada
| | - David Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anthony Otley
- Division of Gastroenterology & Nutrition, Department of Paediatrics, IWK Health and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Thomas D Walters
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hien Q Huynh
- Edmonton Pediatric Inflammatory bowel disease Clinic (EPIC), Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Jennifer deBruyn
- Division of Gastroenterology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canadaand
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Eric I Benchimol
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
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34
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Turpin W, Dong M, Sasson G, Raygoza Garay JA, Espin-Garcia O, Lee SH, Neustaeter A, Smith MI, Leibovitzh H, Guttman DS, Goethel A, Griffiths AM, Huynh HQ, Dieleman LA, Panaccione R, Steinhart AH, Silverberg MS, Aumais G, Jacobson K, Mack D, Murthy SK, Marshall JK, Bernstein CN, Abreu MT, Moayyedi P, Paterson AD, Xu W, Croitoru K. Mediterranean-Like Dietary Pattern Associations With Gut Microbiome Composition and Subclinical Gastrointestinal Inflammation. Gastroenterology 2022; 163:685-698. [PMID: 35643175 DOI: 10.1053/j.gastro.2022.05.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Case-control studies have shown that patients with Crohn's disease (CD) have a microbial composition different from healthy individuals. Although the causes of CD are unknown, epidemiologic studies suggest that diet is an important contributor to CD risk, potentially via modulation of bacterial composition and gut inflammation. We hypothesized that long-term dietary clusters (DCs) are associated with gut microbiome compositions and gut inflammation. Our objectives were to identify dietary patterns and assess whether they are associated with alterations in specific gut microbial compositions and subclinical levels of gut inflammation in a cohort of healthy first-degree relatives (FDRs) of patients with CD. METHODS As part of the Genetic, Environmental, Microbial (GEM) Project, we recruited a cohort of 2289 healthy FDRs of patients with CD. Individuals provided stool samples and answered a validated food frequency questionnaire reflecting their habitual diet during the year before sample collection. Unsupervised analysis identified 3 dietary and 3 microbial composition clusters. RESULTS DC3, resembling the Mediterranean diet, was strongly associated with a defined microbial composition, with an increased abundance of fiber-degrading bacteria, such as Ruminococcus, as well as taxa such as Faecalibacterium. The DC3 diet was also significantly associated with lower levels of subclinical gut inflammation, defined by fecal calprotectin, compared with other dietary patterns. No significant associations were found between individual food items and fecal calprotectin, suggesting that long-term dietary patterns rather than individual food items contribute to subclinical gut inflammation. Additionally, mediation analysis demonstrated that DC3 had a direct effect on subclinical inflammation that was partially mediated by the microbiota. CONCLUSIONS Overall, these results indicated that Mediterranean-like dietary patterns are associated with microbiome and lower intestinal inflammation. This study will help guide future dietary strategies that affect microbial composition and host gut inflammation to prevent diseases.
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Affiliation(s)
- Williams Turpin
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mei Dong
- Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gila Sasson
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Juan Antonio Raygoza Garay
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Osvaldo Espin-Garcia
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, and Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sun-Ho Lee
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anna Neustaeter
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michelle I Smith
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Haim Leibovitzh
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David S Guttman
- Department of Cell & Systems Biology, University of Toronto, Toronto, Ontario, Canada; Centre for the Analysis of Genome Evolution & Function, University of Toronto, Toronto, Ontario, Canada
| | - Ashleigh Goethel
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hien Q Huynh
- Division of Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Levinus A Dieleman
- Division of Gastroenterology and the Centre of Excellence for Gastrointestinal Inflammation and Immunity Research (CEGIIR), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, and Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Guy Aumais
- Department of Medicine, Hôpital Maisonneuve-Rosemont, Montreal University, Montreal, Quebec, Canada
| | - Kevan Jacobson
- Canadian Gastro-Intestinal Epidemiology Consortium (CanGIEC); British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Sanjay K Murthy
- The Ottawa Hospital Inflammatory Bowel Disease Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - John K Marshall
- Department of Medicine, McMaster University, Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, and Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maria T Abreu
- Department of Medicine, Crohn's and Colitis Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Paul Moayyedi
- Department of Medicine, McMaster University, Farncombe Family Digestive Health Research Institute, Hamilton, Ontario, Canada
| | - Andrew D Paterson
- Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Genetics and Genome Biology, The Hospital for Sick Children Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Wei Xu
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, and Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Kenneth Croitoru
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada.
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Kuenzig ME, Benchimol EI, Bernstein CN, Bitton A, Carroll MW, Griffiths AM, Kaplan GG, Nguyen GC, Otley AR, Stukel TA, Dummer TJ, El-Matary W, Jacobson K, Jones JL, Lix LM, Mack DR, Murthy SK, Peña-Sánchez JN, Targownik LE, Fung SG, Spruin S, Coward S, Cui Y, Filliter C, Nugent Z, Siddiq S, Singh H. Hospitalization With Clostridioides difficile in Pediatric Inflammatory Bowel Disease: a Population-Based Study. J Pediatr Gastroenterol Nutr 2022; 75:173-180. [PMID: 35675701 PMCID: PMC9278713 DOI: 10.1097/mpg.0000000000003489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/25/2022] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Several studies have demonstrated higher rates of Clostridioides difficile infection (CDI) in adults with inflammatory bowel disease (IBD). We conducted a population-based study comparing the risk of hospitalization with CDI in children with and without IBD. METHODS Using health administrative data and validated algorithms, we identified all children (<16 years) diagnosed with IBD in 5 Canadian provinces, then age and sex matched to 5 children without IBD. Province-specific 5-year incidence rates of hospitalization with CDI were pooled and generalized linear mixed-effects models were used to estimate the crude incidence rate ratio (IRR) comparing (1) children with and without IBD and (2) children with Crohn disease and ulcerative colitis. Hazard ratios (HR) from Cox proportional hazards models adjusting for age, sex, rural/urban household, and income were pooled using fixed-effects models. RESULTS The incidence rate of CDI identified during hospitalization was 49.06 [95% confidence interval (CI), 39.40-61.08] per 10,000 person-years (PY) in 3593 children with IBD compared to 0.39 (95% CI, 0.13-1.21) per 10,000 PY in 16,284 children without IBD (crude IRR, 133.4, 95% CI, 42.1-422.7; adjusted HR, 68.2, 95% CI, 24.4-190.4). CDI was identified less often in children with Crohn disease than ulcerative colitis (crude IRR, 0.51, 95% CI, 0.32-0.82; adjusted HR, 0.69, 95% CI, 0.46-1.05). CONCLUSIONS Children with IBD have a markedly higher incidence of CDI identified during a hospitalization relative to children without IBD. Consequently, symptomatic children with IBD who are hospitalized should be screened for CDI.
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Affiliation(s)
- M. Ellen Kuenzig
- From the SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- the Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Eric I. Benchimol
- From the SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- the Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- the ICES, Toronto, Ontario, Canada
- the Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- the Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- the CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- the CHEO Research Institute, Ottawa, Ontario, Canada
| | - Charles N. Bernstein
- the Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- the Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- the McGill University Health Centre, Division of Gastroenterology and Hepatology, Montreal, Québec, Canada
| | - Matthew W. Carroll
- the Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Anne M. Griffiths
- From the SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- the Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- the Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Gilaad G. Kaplan
- the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Geoffrey C. Nguyen
- the ICES, Toronto, Ontario, Canada
- the Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Anthony R. Otley
- the Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Therese A. Stukel
- the ICES, Toronto, Ontario, Canada
- the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Trevor J.B. Dummer
- the School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wael El-Matary
- the Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevan Jacobson
- the Department of Pediatrics, BC Children’s Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer L. Jones
- the Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lisa M. Lix
- the Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- the George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Manitoba, Winnipeg, Manitoba, Canada
| | - David R. Mack
- the Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- the CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- the CHEO Research Institute, Ottawa, Ontario, Canada
| | - Sanjay K. Murthy
- the Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- the Division of Gastroenterology, The Ottawa Hospital IBD Centre, Ottawa, Ontario, Canada
- the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Laura E. Targownik
- the Mount Sinai Hospital Centre for Inflammatory Bowel Disease, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen G. Fung
- the ICES, Toronto, Ontario, Canada
- the CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- the CHEO Research Institute, Ottawa, Ontario, Canada
| | - Sarah Spruin
- the ICES, Toronto, Ontario, Canada
- the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Stephanie Coward
- the Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Yunsong Cui
- the Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christopher Filliter
- the Lady Davis Institute of Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Zoann Nugent
- the Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shabnaz Siddiq
- the ICES, Toronto, Ontario, Canada
- the CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, CHEO, Ottawa, Ontario, Canada
- the CHEO Research Institute, Ottawa, Ontario, Canada
| | - Harminder Singh
- the Univeristy of Manitoba IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- the Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- the Research Institute at CancerCare Manitoba, Winnipeg, Manitoba, Canada
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Kerur B, Fiedler K, Stahl M, Hyams J, Stephens M, Lu Y, Pfefferkorn M, Alkhouri R, Strople J, Kelsen J, Siebold L, Goyal A, Rosh JR, LeLeiko N, Van Limbergen J, Guerrerio AL, Maltz RM, Karam L, Crowley E, Griffiths AM, Heyman MB, Deneau M, Benkov K, Noe J, Moulton D, Pappa H, Galanko J, Snapper S, Muise AM, Kappelman MD, Benchimol EI. Utilization of Antitumor Necrosis Factor Biologics in Very Early Onset Inflammatory Bowel Disease: A Multicenter Retrospective Cohort Study From North America. J Pediatr Gastroenterol Nutr 2022; 75:64-69. [PMID: 35622080 DOI: 10.1097/mpg.0000000000003464] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Research on the utilization and effectiveness of antitumor necrosis factor (TNF) biologics in children with very early onset inflammatory bowel disease (VEOIBD) is urgently needed. Here we describe anti-TNF use and durability in a multicenter cohort. METHODS We performed a retrospective cohort study of patients diagnosed with VEOIBD (<6 years) between 2008 and 2013 at 25 North American centers. We performed chart abstraction at diagnosis and 1, 3, and 5 years after diagnosis. We examined the rate of initiation and durability of infliximab and adalimumab and evaluated associations between treatment durability and the following covariates with multivariate Cox proportional hazard regression: age at diagnosis, sex, disease duration, disease classification, and presence of combined immunomodulatory treatment versus monotherapy. RESULTS Of 294 children with VEOIBD, 120 initiated treatment with anti-TNF therapy and 101 had follow-up data recorded [50% Crohn disease (CD), 31% ulcerative colitis (UC), and 19% IBD unclassified (IBD-U)]. The cumulative probability of anti-TNF treatment was 15% at 1 year, 30% at 3 years, and 45% at 5 years from diagnosis; 56 (55%) were treated between 0 and 6 years old. Anti-TNF durability was 90% at 1 year, 75% at 3 years, and 55% at 5 years. The most common reason for discontinuation of anti-TNF were loss of response in 24 (57%) children. Children with UC/IBD-U had lower durability than those with CD (hazard ratio [HR] 0.17; 95% confidence interval [CI], 0.06-0.51; P = 0.001). CONCLUSIONS Utilization and durability of anti-TNF in VEOIBD is relatively high and comparable with older children. Having Crohn disease (compared with UC/IBD-U) is associated with greater durability.
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Affiliation(s)
- Basavaraj Kerur
- From the University of Massachusetts Medical School (UMMS), Worcester, MA
| | - Karoline Fiedler
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Jeffrey Hyams
- the Connecticut Children's Medical Center, Hartford, CT
| | - Michael Stephens
- the Center for Individualized Medicine, Mayo Clinic, Rochester, MN
| | - Ying Lu
- the Cohen Children's Medical Center of New York, New Hyde Park, NY
| | | | | | - Jennifer Strople
- the Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Judith Kelsen
- the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Leah Siebold
- the UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Alka Goyal
- the Stanford University School of Medicine, Palo Alto, CA
| | - Joel R Rosh
- the Goryeb Children's Hospital/Atlantic Health System, Morristown, NJ
| | - Neal LeLeiko
- the Morgan Stanley Children's Hospital of NewYork, Columbia University, New York, NY
| | - Johan Van Limbergen
- the Amsterdam University Medical Centres, Emma Children's Hospital, Amsterdam, Netherlands
| | | | - Ross M Maltz
- the Nationwide Children's Hospital, Columbus, OH
| | - Lina Karam
- the Texas Children's Hospital, Houston, TX
| | - Eileen Crowley
- the Children's Hospital, London Health Science Centre, University of Western Ontario, London, Ontario, Canada
| | - Anne M Griffiths
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark Deneau
- the University of Utah/Intermountain Primary Children's Hospital, Salt Lake City, UT
| | - Keith Benkov
- the Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Noe
- the Medical College of Wisconsin, Milwaukee, WI
| | - Dedrick Moulton
- the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Helen Pappa
- the Cardinal Glennon Children's Hospital, St Louis, MO
| | - Joseph Galanko
- the University of North Carolina in Chapel Hill, Chapel Hill, NC
| | - Scott Snapper
- the Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aleixo M Muise
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Eric I Benchimol
- the Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa
- the The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Clarkston K, Karns R, Jegga AG, Sharma M, Fox S, Ojo BA, Minar P, Walters TD, Griffiths AM, Mack DR, Boyle B, LeLeiko NS, Markowitz J, Rosh JR, Patel AS, Shah S, Baldassano RN, Pfefferkorn M, Sauer C, Kugathasan S, Haberman Y, Hyams JS, Denson LA, Rosen MJ. Targeted Assessment of Mucosal Immune Gene Expression Predicts Clinical Outcomes in Children with Ulcerative Colitis. J Crohns Colitis 2022; 16:1735-1750. [PMID: 35665804 PMCID: PMC9683081 DOI: 10.1093/ecco-jcc/jjac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS We aimed to determine whether a targeted gene expression panel could predict clinical outcomes in paediatric ulcerative colitis [UC] and investigated putative pathogenic roles of predictive genes. METHODS In total, 313 rectal RNA samples from a cohort of newly diagnosed paediatric UC patients (PROTECT) were analysed by a real-time PCR microfluidic array for expression of type 1, 2 and 17 inflammation genes. Associations between expression and clinical outcomes were assessed by logistic regression. Identified prognostic markers were further analysed using existing RNA sequencing (RNA-seq) data sets and tissue immunostaining. RESULTS IL13RA2 was associated with a lower likelihood of corticosteroid-free remission (CSFR) on mesalamine at week 52 (p = .002). A model including IL13RA2 and only baseline clinical parameters was as accurate as an established clinical model, which requires week 4 remission status. RORC was associated with a lower likelihood of colectomy by week 52. A model including RORC and PUCAI predicted colectomy by 52 weeks (area under the receiver operating characteristic curve 0.71). Bulk RNA-seq identified IL13RA2 and RORC as hub genes within UC outcome-associated expression networks related to extracellular matrix and innate immune response, and lipid metabolism and microvillus assembly, respectively. Adult UC single-cell RNA-seq data revealed IL13RA2 and RORC co-expressed genes were localized to inflammatory fibroblasts and undifferentiated epithelial cells, respectively, which was supported by protein immunostaining. CONCLUSION Targeted assessment of rectal mucosal immune gene expression predicts 52-week CSFR in treatment-naïve paediatric UC patients. Further exploration of IL-13Rɑ2 as a therapeutic target in UC and future studies of the epithelial-specific role of RORC in UC pathogenesis are warranted.
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Affiliation(s)
- Kathryn Clarkston
- Division of Gastroenterology, Hepatology and Nutrition,Division of Pediatric Gastroenterology, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Rebekah Karns
- Division of Gastroenterology, Hepatology and Nutrition
| | - Anil G Jegga
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mihika Sharma
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sejal Fox
- Division of Gastroenterology, Hepatology and Nutrition
| | - Babajide A Ojo
- Division of Pediatric Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Phillip Minar
- Division of Gastroenterology, Hepatology and Nutrition,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Thomas D Walters
- Division of Pediatric Gastroenterology, Hospital for Sick Children, Toronto, ON, Canada
| | - Anne M Griffiths
- Division of Pediatric Gastroenterology, Hospital for Sick Children, Toronto, ON, Canada
| | - David R Mack
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - Brendan Boyle
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Neal S LeLeiko
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York, NY, USA
| | - James Markowitz
- Division of Gastroenterology, Hepatology, and Nutrition, Cohen Children’s Medical Center of New York, New Hyde Park, NY, USA
| | - Joel R Rosh
- Division of Gastroenterology, Hepatology, and Nutrition, Goryeb Children’s Hospital, Atlantic Health, Morristown, NJ, USA
| | - Ashish S Patel
- Division of Gastroenterology, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - Sapana Shah
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marian Pfefferkorn
- Division of Gastroenterology, Hepatology, and Nutrition, Riley Children’s Hospital, Indianapolis, IN, USA
| | - Cary Sauer
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Subra Kugathasan
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Yael Haberman
- Division of Gastroenterology, Hepatology and Nutrition,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA,Sheba Medical Center, Tel Hashomer, Israel
| | - Jeffrey S Hyams
- Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children’s Medical Center, Hartford, CT, USA
| | - Lee A Denson
- Division of Gastroenterology, Hepatology and Nutrition,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael J Rosen
- Corresponding author: Michael J. Rosen, MD, MSCI, Division of Pediatric Gastroenterology, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Rd, Suite 116, Palo Alto, CA 94304, USA. E-mail:
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Bollegala N, Barwick M, Fu N, Griffiths AM, Keefer L, Kohut SA, Kroeker KI, Lawrence S, Lee K, Mack DR, Walters TD, de Guzman J, Tersigni C, Miatello A, Benchimol EI. Multimodal intervention to improve the transition of patients with inflammatory bowel disease from pediatric to adult care: protocol for a randomized controlled trial. BMC Gastroenterol 2022; 22:251. [PMID: 35585484 PMCID: PMC9118697 DOI: 10.1186/s12876-022-02307-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transition in care is defined as the "purposeful and planned movement of adolescents and young adults with a chronic medical condition from pediatric to adult-oriented healthcare systems/care providers." Currently, there are no Level 1 evidence-based interventions to improve the care of transitioning adolescents and young adults (AYAs) with inflammatory bowel disease (IBD). The development of a transition program using a biopsychosocial approach will improve the standards for healthcare delivery to transitioning IBD patients. This is a protocol for a structured randomized controlled trial (RCT) to assess the clinical and implementation effectiveness of a multimodal intervention focused on improving patient function, transition readiness and outcomes among AYA patients with IBD being cared for at pediatric centers in Canada. METHODS This multi-center RCT is a type 1 hybrid effectiveness-implementation trial to evaluate effectiveness of the intervention and how it can be implemented more widely after the trial. We will include patients aged 16.0-17.5 years. The intervention program consists of 4 core components: (1) individualized assessment, (2) transition navigator, (3) virtual patient skills-building with a focus on building resilience, self-management and self-efficacy, and (4) a virtual structured education program. The control group will undergo standard-of-care defined by each participating center. The primary outcome will be the IBD Disability Index, a validated measure to assess patient functioning. Secondary outcomes include transition readiness and success, anxiety and depression scales, and health service utilization rates. Additionally, we will measure implementation outcomes and related barriers and facilitators for the intervention program. DISCUSSION The type 1 hybrid effectiveness-implementation design will allow for the development of a feasible, sustainable, and acceptable final intervention model. The intervention will consist of modules that can be accessed in an online, virtual platform. The implementation will allow centralization of interventions and funding in order to minimize the impact on local clinical practice or hospital resources. The authors anticipate that the main study limitation will relate to study subjects not completely adhering to every component of the intervention, which will be evaluated and addressed using the implementation science approach. TRIAL REGISTRATION NCT05221281. Registry: ClinicalTrials.gov. Date of registration: February 2, 2022. https://clinicaltrials.gov/ct2/show/NCT05221281 .
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Affiliation(s)
- Natasha Bollegala
- Division of Gastroenterology, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Melanie Barwick
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,Department of Psychiatry, University of Toronto, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Nancy Fu
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Anne M Griffiths
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Laurie Keefer
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Ahola Kohut
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Karen I Kroeker
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sally Lawrence
- Division of Gastroenterology, Hepatology and Nutrition, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Thomas D Walters
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | | | - Claudia Tersigni
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Ashleigh Miatello
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Eric I Benchimol
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada. .,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. .,ICES, Toronto, Canada.
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39
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Ricciuto A, Lamb CA, Benchimol EI, Walker GJ, Kennedy NA, Kuenzig ME, Kaplan GG, Kappelman MD, Ungaro RC, Colombel JF, Brenner EJ, Agrawal M, Reinisch W, Griffiths AM, Sebastian S. Inflammatory Bowel Disease Clinical Activity is Associated with COVID-19 Severity Especially in Younger Patients. J Crohns Colitis 2022; 16:591-600. [PMID: 34570886 PMCID: PMC8522422 DOI: 10.1093/ecco-jcc/jjab172] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Age is a major prognostic factor for COVID-19 outcomes. The effect of inflammatory bowel disease [IBD] activity on COVID-19 is unclear. We examined the relationship between IBD activity and COVID-19 severity according to age. METHODS We included IBD patients diagnosed with COVID-19, reported to SECURE-IBD between March 13, 2020 and August 3, 2021. Clinical IBD activity was measured by physician global assessment [PGA]. COVID-19-related outcomes were [1] intensive care unit [ICU] admission, ventilation or death, and [2] hospitalization. Using generalized estimating equations, we determined adjusted odds ratios [aOR, 95% confidence interval] for moderate and severe PGA vs clinical remission/mild PGA, controlling for demographics, medications and COVID-19 diagnosis period. We performed stratified analyses by age [≤50 vs >50 years]. RESULTS Among 6078 patients, adverse COVID-19 outcomes were more common with active IBD: ICU/ventilation/death in 3.6% [175/4898] of remission/mild, 4.9% [45/920] of moderate and 8.8% [23/260] of severe [p < 0.001]; and hospitalization in 13% [649/4898] of remission/mild, 19% [178/920] of moderate and 38% [100/260] of severe [p < 0.001]. Stratified by decade, effect sizes were larger for younger patients. In patients ≤50 years, severe PGA was independently associated with ICU/ventilation/death (aOR 3.27 [1.15-9.30]) and hospitalization (aOR 4.62 [2.83-7.55]). In contrast, severe PGA was not independently associated with COVID-19 outcomes in those older than 50 years. CONCLUSIONS Clinically active IBD may be a risk factor for severe COVID-19, particularly in younger patients. IBD disease control, including through medication compliance, and strategies to mitigate the risk of COVID-19 infection amongst patients with active IBD [e.g. distancing, immunization] are key to limit adverse COVID-19 outcomes.
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Affiliation(s)
- Amanda Ricciuto
- SickKids IBD Centre, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Christopher A Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Eric I Benchimol
- SickKids IBD Centre, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Gareth J Walker
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Nicholas A Kennedy
- Department of Gastroenterology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- Exeter IBD Research Group, University of Exeter, Exeter, UK
| | - M Ellen Kuenzig
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Ryan C Ungaro
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Erica J Brenner
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Manasi Agrawal
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Anne M Griffiths
- SickKids IBD Centre, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Faculty of Health Sciences, University of Hull, Hull, UK
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van Wassenaer EA, Benninga MA, van Limbergen JL, D’Haens GR, Griffiths AM, Koot BGP. Intestinal Ultrasound in Pediatric Inflammatory Bowel Disease: Promising, but Work in Progress. Inflamm Bowel Dis 2022; 28:783-787. [PMID: 34013955 PMCID: PMC9071066 DOI: 10.1093/ibd/izab125] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 12/22/2022]
Abstract
Intestinal ultrasound (IUS) is increasingly used and promulgated as a noninvasive monitoring tool for children with inflammatory bowel disease because other diagnostic modalities such as colonoscopy and magnetic resonance imaging cause significant stress in the pediatric population. The most important parameters of inflammation that can be assessed using IUS are bowel wall thickness and hyperemia of the bowel wall. Research has shown that IUS has the potential to be a valuable additional point-of-care tool to guide treatment choice and to monitor and predict treatment response, although evidence of its accuracy and value in clinical practice is still limited. This review gives an update and overview of the current evidence on the use and accuracy of IUS in children with inflammatory bowel disease.
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Affiliation(s)
- Elsa A van Wassenaer
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam,The Netherlands
| | - Marc A Benninga
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam,The Netherlands
| | - Johan L van Limbergen
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam,The Netherlands
| | - Geert R D’Haens
- Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam,The Netherlands
| | - Anne M Griffiths
- Hospital for Sick Children, University of Toronto, Department of Pediatrics, Toronto, Ontario,Canada
| | - Bart G P Koot
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam,The Netherlands
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41
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Nambu R, Warner N, Mulder DJ, Kotlarz D, McGovern DPB, Cho J, Klein C, Snapper SB, Griffiths AM, Iwama I, Muise AM. A Systematic Review of Monogenic Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2022; 20:e653-e663. [PMID: 33746097 PMCID: PMC8448782 DOI: 10.1016/j.cgh.2021.03.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Advances in genomic technologies have led to increasing reports of monogenic inflammatory bowel disease (IBD). Here, we systematically review the literature to determine the clinical features, genetic profile, and previously used treatment strategies in monogenic IBD. METHODS A systematic review of MEDLINE articles published between January 2000 and December 2020 was conducted. A total of 750 individual monogenic IBD cases were identified from 303 eligible articles. RESULTS The most frequently reported monogenic IBD genes were IL10RA/B, XIAP, CYBB, LRBA, and TTC7A. In total, 63.4% of patients developed IBD before 6 years of age, 17.4% developed IBD between ages 10 and 17.9 years, and 10.9% developed IBD after age 18. There was a substantial difference between these age groups and the underlying monogenic disorders. Only 31.7% had any history of extraintestinal comorbidity (EIC) before IBD onset, but 76.0% developed at least 1 EIC during their clinical course. The most common EICs were atypical infection (44.7%), dermatologic abnormality (38.4%), and autoimmunity (21.9%). Bowel surgery, biologic therapy, and hematopoietic stem cell transplantation were performed in 27.1%, 32.9%, and 23.1% of patients, respectively. CONCLUSIONS Monogenic IBD cases, although rare, have varied extraintestinal comorbidities and limited treatment options including surgery and transplant. Early identification and improved understanding of the characteristics of the genes and underlying disease processes in monogenic IBD is important for effective management.
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Affiliation(s)
- Ryusuke Nambu
- SickKids Inflammatory Bowel Disease Centre, the Hospital for Sick Children, Toronto, Canada,Cell Biology Program, Research Institute, the Hospital for Sick Children, Toronto, Canada,Division of Gastroenterology and Hepatology, Saitama Children’s Medical Center, Japan
| | - Neil Warner
- SickKids Inflammatory Bowel Disease Centre, the Hospital for Sick Children, Toronto, Canada,Cell Biology Program, Research Institute, the Hospital for Sick Children, Toronto, Canada
| | - Daniel J Mulder
- SickKids Inflammatory Bowel Disease Centre, the Hospital for Sick Children, Toronto, Canada,Cell Biology Program, Research Institute, the Hospital for Sick Children, Toronto, Canada
| | - Daniel Kotlarz
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Dermot PB McGovern
- F. Widjaja Foundation Inflammatory Bowel Disease Center and Immunobiology Research Institute at Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Judy Cho
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, NY, USA
| | - Christoph Klein
- Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, Munich, Germany
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School; Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, the Hospital for Sick Children, Toronto, Canada,Department of Pediatrics, Institute of Medical Science and Biochemistry, University of Toronto, the Hospital for Sick Children, Toronto, Canada
| | - Itaru Iwama
- Division of Gastroenterology and Hepatology, Saitama Children’s Medical Center, Japan
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Centre, Hospital for Sick Children, Toronto, Canada; Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, Institute of Medical Science and Biochemistry, University of Toronto, Hospital for Sick Children, Toronto, Canada.
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42
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Yao Y, Kim G, Shafer S, Chen Z, Kubo S, Ji Y, Luo J, Yang W, Perner SP, Kanellopoulou C, Park AY, Jiang P, Li J, Baris S, Aydiner EK, Ertem D, Mulder DJ, Warner N, Griffiths AM, Topf-Olivestone C, Kori M, Werner L, Ouahed J, Field M, Liu C, Schwarz B, Bosio CM, Ganesan S, Song J, Urlaub H, Oellerich T, Malaker SA, Zheng L, Bertozzi CR, Zhang Y, Matthews H, Montgomery W, Shih HY, Jiang J, Jones M, Baras A, Shuldiner A, Gonzaga-Jauregui C, Snapper SB, Muise AM, Shouval DS, Ozen A, Pan KT, Wu C, Lenardo MJ. Mucus sialylation determines intestinal host-commensal homeostasis. Cell 2022; 185:1172-1188.e28. [PMID: 35303419 PMCID: PMC9088855 DOI: 10.1016/j.cell.2022.02.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/18/2021] [Accepted: 02/09/2022] [Indexed: 02/07/2023]
Abstract
Intestinal mucus forms the first line of defense against bacterial invasion while providing nutrition to support microbial symbiosis. How the host controls mucus barrier integrity and commensalism is unclear. We show that terminal sialylation of glycans on intestinal mucus by ST6GALNAC1 (ST6), the dominant sialyltransferase specifically expressed in goblet cells and induced by microbial pathogen-associated molecular patterns, is essential for mucus integrity and protecting against excessive bacterial proteolytic degradation. Glycoproteomic profiling and biochemical analysis of ST6 mutations identified in patients show that decreased sialylation causes defective mucus proteins and congenital inflammatory bowel disease (IBD). Mice harboring a patient ST6 mutation have compromised mucus barriers, dysbiosis, and susceptibility to intestinal inflammation. Based on our understanding of the ST6 regulatory network, we show that treatment with sialylated mucin or a Foxo3 inhibitor can ameliorate IBD.
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Affiliation(s)
- Yikun Yao
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA
| | - Girak Kim
- Experimental Immunology Branch, National Cancer Institute, NIH, Bethesda, MD 20892, USA
| | - Samantha Shafer
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA
| | - Zuojia Chen
- Experimental Immunology Branch, National Cancer Institute, NIH, Bethesda, MD 20892, USA
| | - Satoshi Kubo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA
| | - Yanlong Ji
- Hematology/Oncology, Department of Medicine II, Johann Wolfgang Goethe University, 60590 Frankfurt am Main, Germany; Frankfurt Cancer Institute, Goethe University, 60596 Frankfurt am Main, Germany; Bioanalytical Mass Spectrometry Group, Max Planck Institute for Multidisciplinary Sciences, 37077 Göttingen, Germany
| | - Jialie Luo
- Experimental Immunology Branch, National Cancer Institute, NIH, Bethesda, MD 20892, USA
| | - Weiming Yang
- Section on Biological Chemistry, National Institute of Dental and Craniofacial Research (NIDCR), NIH, Bethesda, MD 20892, USA
| | - Sebastian P Perner
- Hematology/Oncology, Department of Medicine II, Johann Wolfgang Goethe University, 60590 Frankfurt am Main, Germany; Frankfurt Cancer Institute, Goethe University, 60596 Frankfurt am Main, Germany
| | - Chrysi Kanellopoulou
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ann Y Park
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA
| | - Ping Jiang
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jian Li
- Experimental Immunology Branch, National Cancer Institute, NIH, Bethesda, MD 20892, USA
| | - Safa Baris
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, Marmara University, 34722 Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Marmara University, 34722 Istanbul, Turkey
| | - Elif Karakoc Aydiner
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, Marmara University, 34722 Istanbul, Turkey; The Isil Berat Barlan Center for Translational Medicine, Marmara University, 34722 Istanbul, Turkey
| | - Deniz Ertem
- Marmara University School of Medicine, Division of Pediatric Gastroenterology Hepatology and Nutrition, 34854 Istanbul, Turkey
| | - Daniel J Mulder
- Departments of Pediatrics, Medicine, and Biomedical and Molecular Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Neil Warner
- SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Chani Topf-Olivestone
- Pediatric Gastroenterology, Kaplan Medical Center, Pasternak St., POB 1, Rehovot 76100, Israel
| | - Michal Kori
- Pediatric Gastroenterology, Kaplan Medical Center, Pasternak St., POB 1, Rehovot 76100, Israel
| | - Lael Werner
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva 4920235, Israel
| | - Jodie Ouahed
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
| | - Michael Field
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
| | - Chengyu Liu
- Transgenic Core Facility, National Heart, Lung, and Blood Institute, Bethesda, MD 20892, USA
| | - Benjamin Schwarz
- Immunity to Pulmonary Pathogens Section, Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT 59840, USA
| | - Catharine M Bosio
- Immunity to Pulmonary Pathogens Section, Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, MT 59840, USA
| | - Sundar Ganesan
- Biological Imaging Section, Research Technologies Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jian Song
- Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases (NIAID), Bethesda, MD 20892, USA
| | - Henning Urlaub
- Bioanalytical Mass Spectrometry Group, Max Planck Institute for Multidisciplinary Sciences, 37077 Göttingen, Germany; Institute of Clinical Chemistry, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Thomas Oellerich
- Hematology/Oncology, Department of Medicine II, Johann Wolfgang Goethe University, 60590 Frankfurt am Main, Germany; Frankfurt Cancer Institute, Goethe University, 60596 Frankfurt am Main, Germany; German Cancer Consortium/German Cancer Research Center, 69120 Heidelberg, Germany
| | - Stacy A Malaker
- Yale University, Department of Chemistry, New Haven, CT 06511, USA
| | - Lixin Zheng
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA
| | - Carolyn R Bertozzi
- Department of Chemistry, Stanford University, Stanford, CA 94305, USA; Howard Hughes Medical Institute, Stanford, CA 94305, USA
| | - Yu Zhang
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD 20892, USA
| | - Helen Matthews
- Laboratory of Clinical Immunology and Microbiology, NIAID, NIH, Bethesda, MD 20892, USA
| | - Will Montgomery
- Neuro-Immune Regulome Unit, National Eye Institute, NIH, Bethesda, MD 20892, USA
| | - Han-Yu Shih
- Neuro-Immune Regulome Unit, National Eye Institute, NIH, Bethesda, MD 20892, USA
| | - Jiansheng Jiang
- Molecular Biology Section, Laboratory of Immune System Biology, NIAID, NIH, Bethesda, MD 20892, USA
| | - Marcus Jones
- Regeneron Genetics Center, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Aris Baras
- Regeneron Genetics Center, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Alan Shuldiner
- Regeneron Genetics Center, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA
| | - Claudia Gonzaga-Jauregui
- Regeneron Genetics Center, 777 Old Saw Mill River Road, Tarrytown, NY 10591, USA; International Laboratory for Human Genome Research, Laboratorio Internacional de Investigación sobre el Genoma Humano, Universidad Nacional Autónoma de México, Juriquilla, Querétaro 04510, Mexico
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Boston Children's Hospital, Boston, MA 02115, USA
| | - Aleixo M Muise
- SickKids Inflammatory Bowel Disease Center and Cell Biology Program, Research Institute, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; Department of Pediatrics, IMS, and Biochemistry, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Dror S Shouval
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva 4920235, Israel
| | - Ahmet Ozen
- The Isil Berat Barlan Center for Translational Medicine, Marmara University, 34722 Istanbul, Turkey; Marmara University School of Medicine, Division of Pediatric Gastroenterology Hepatology and Nutrition, 34854 Istanbul, Turkey
| | - Kuan-Ting Pan
- Hematology/Oncology, Department of Medicine II, Johann Wolfgang Goethe University, 60590 Frankfurt am Main, Germany; Frankfurt Cancer Institute, Goethe University, 60596 Frankfurt am Main, Germany
| | - Chuan Wu
- Experimental Immunology Branch, National Cancer Institute, NIH, Bethesda, MD 20892, USA.
| | - Michael J Lenardo
- Molecular Development of the Immune System Section, Laboratory of Immune System Biology, and Clinical Genomics Program, NIAID, National Institutes of Health, Bethesda, MD 20892, USA.
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43
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Fu N, Bollegala N, Jacobson K, Kroeker KI, Frost K, Afif W, El-Matary W, Fowler SA, Griffiths AM, Huynh HQ, Jantchou P, Karimuddin A, Nguyen GC, Otley AR, Pears C, Seow CH, Toulany A, Tersigni C, Tignanelli J, Marshall JK, Boctor M, Hansen T, Pattni C, Wong A, Benchimol EI. Canadian Consensus Statements on the Transition of Adolescents and Young Adults with Inflammatory Bowel Disease from Pediatric to Adult Care: A Collaborative Initiative Between the Canadian IBD Transition Network and Crohn’s and Colitis Canada. J Can Assoc Gastroenterol 2022; 5:105-115. [PMID: 35669843 PMCID: PMC9157291 DOI: 10.1093/jcag/gwab050] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn’s and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care. Methods Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice. Results The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research. Conclusions These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care.
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Affiliation(s)
- Nancy Fu
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Natasha Bollegala
- Division of Gastroenterology, Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Kevan Jacobson
- Division of Gastroenterology, Hepatology and Nutrition, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Karen I Kroeker
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Frost
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Waqqas Afif
- Division of Gastroenterology, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Wael El-Matary
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sharyle A Fowler
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hien Q Huynh
- Division of Pediatric GI Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Prévost Jantchou
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montréal, Quebec, Canada
| | - Ahmer Karimuddin
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey C Nguyen
- Department of Medicine, Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, Toronto, Ontario, Canada
| | - Anthony R Otley
- Division of Pediatric Gastroenterology & Nutrition, IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | - Cynthia H Seow
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alene Toulany
- Division of Adolescent Medicine, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Claudia Tersigni
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - John K Marshall
- Division of Gastroenterology, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Monica Boctor
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tawnya Hansen
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Chandni Pattni
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Wong
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
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44
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Abstract
BACKGROUND AND AIMS Timely access to approved medications is a priority in paediatric inflammatory bowel disease [IBD]. To date, the timing of drug studies in paediatric IBD has been suboptimal, with most studies conducted long after approval has been granted for adult IBD. This delay in approval leads to extensive off-label prescribing of medications in children, often without clear guidance on optimal dosing. The European Medicines Agency [EMA] and U.S. Food and Drug Administration [FDA] have implemented drug development frameworks in an attempt to address these challenges. However, access to information on these regulatory pathways in paediatric IBD is limited. We summarised the time from adult to paediatric approval of IBD therapies, outlining the regulatory approval pathway between the EMA and FDA, with the goal of identifying areas for improvement. METHODS We reviewed publicly accessible data from the EMA and the FDA to identify therapeutic agents approved over 2005-2021 for paediatric IBD. RESULTS AND CONCLUSIONS Five drugs are currently approved for use in the paediatric IBD population, with long interval delays after adult approval. The impact of these drug development processes in paediatric IBD is awaited. Further consideration needs to be given to the age of enrolment along with novel, more efficient trial designs in an effort to improve access for paediatric IBD patients to newer therapies.
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Affiliation(s)
- Eileen Crowley
- Department of Pediatrics, Division of Pediatric Gastroenterology & Hepatology, Children's Hospital Western Ontario, Western University, London, ON, Canada.,Alimentiv Inc. [formerly Robarts Clinical Trials, Inc.], London, ON, Canada
| | - Christopher Ma
- Alimentiv Inc. [formerly Robarts Clinical Trials, Inc.], London, ON, Canada.,Division of Gastroenterology & Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marija Andic
- Alimentiv Inc. [formerly Robarts Clinical Trials, Inc.], London, ON, Canada
| | - Brian G Feagan
- Alimentiv Inc. [formerly Robarts Clinical Trials, Inc.], London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, Hepatology & Nutrition, Department of Paediatrics and IBD Centre, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Vipul Jairath
- Alimentiv Inc. [formerly Robarts Clinical Trials, Inc.], London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
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45
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Benchimol EI, Carroll MW, Geist R, Griffiths AM, Huang JG, Mack DR, Bernstein CN, Bitton A, Jones JL, Kaplan GG, Kuenzig ME, Lee K, Mukhtar MS, Murthy SK, Tandon P, Targownik LE, Windsor JW, Seow CH. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Children and Expectant Mothers With Inflammatory Bowel Disease. J Can Assoc Gastroenterol 2021; 4:S27-S33. [PMID: 34755036 PMCID: PMC8570420 DOI: 10.1093/jcag/gwab030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) in children with inflammatory bowel disease (IBD) typically results in a mild infection, similar to those without IBD. Children and adolescents have less severe manifestations of COVID-19 compared to older people, whether or not they have IBD. However, some IBD medications (in particular, corticosteroids) are associated with more severe COVID-19. During the first year of the global pandemic, more IBD care was provided with online technology, necessitated by efforts to reduce hospital and clinic visits. Additionally, non-endoscopic monitoring of inflammation has been required due to the cancellation of non-urgent procedures, resulting in longer endoscopy wait-times. In contrast, pregnant people (with and without IBD) who contract COVID-19 are at increased risk of severe manifestations, death and preterm delivery, making them a priority for severe acute respiratory syndrome coronavirus 2 protective measures and vaccination. Few studies have examined effect of COVID-19 on IBD-related disease activity in pregnant people with IBD. The pandemic has significantly affected the mental health and sense of well-being of children and their families, as well as pregnant people with IBD. These groups were much more likely to experience anxiety and depression compared with prior to the pandemic, even while concern has mostly abated regarding the effect of IBD medications and COVID-19 severity. Unfortunately, the availability of mental health care providers who specialize in people with IBD has not kept pace with the increasing demand.
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Affiliation(s)
- Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Matthew W Carroll
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Rose Geist
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - James Guoxian Huang
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre and Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Kate Lee
- Crohn’s and Colitis Canada, Toronto, Ontario, Canada
| | - Mariam S Mukhtar
- Department of Internal Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sanjay K Murthy
- The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joseph W Windsor
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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46
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Dhaliwal J, Tuna M, Shah BR, Murthy S, Herrett E, Griffiths AM, Benchimol EI. Incidence of Inflammatory Bowel Disease in South Asian and Chinese People: A Population-Based Cohort Study from Ontario, Canada. Clin Epidemiol 2021; 13:1109-1118. [PMID: 34876857 PMCID: PMC8643128 DOI: 10.2147/clep.s336517] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/12/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD) is now a global disease with incidence increasing throughout Asia. AIM To determine the incidence of IBD among South Asians and Chinese people residing in Ontario, Canada's most populous province. METHODS All incident cases of IBD in children (1994-2015) and adults (1999-2015) were identified from population-based health administrative data. We classified South Asian and Chinese ethnicity using immigration records and surnames. We determined standardized incidence of IBD and adjusted incidence rate ratio (aIRR) in South Asians and Chinese compared to the general population. RESULTS Among 16,230,638 people living in Ontario, standardized incidence of IBD per 100,000 person-years was 24.7 (95% CI 24.4-25.0), compared with 14.6 (95% CI 13.7-15.5) in 982,472 South Asians and with 5.4 (95% CI 4.8-5.9) in 764,397 Chinese. The risk of IBD in South Asians was comparable to the general population after adjusting for immigrant status and confounders (aIRR 1.03, 95% CI 0.96-1.10). South Asians had a lower risk of Crohn's disease (CD) (aIRR 0.66, 95% CI 0.60-0.77), but a higher risk of ulcerative colitis (UC) (aIRR 1.47, 95% CI 1.34-1.61). Chinese people had much lower rates of IBD (aIRR 0.24, 95% CI 0.20-0.28), CD (aIRR 0.21, 95% CI 0.17-0.26), and UC (aIRR 0.28, 95% CI 0.23-0.25). CONCLUSION Canadians of South Asian ethnicity had a similarly high risk of developing IBD compared to other Canadians, and a higher risk of developing UC, a finding distinct from the Chinese population. Our findings indicate the importance of genetic and environmental risk factors in people of Asian origin who live in the Western world.
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Affiliation(s)
- Jasbir Dhaliwal
- ICES, Toronto, ON, Canada
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- London School of Hygiene and Tropical Medicine, London, UK
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | | | - Baiju R Shah
- ICES, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sanjay Murthy
- ICES, Toronto, ON, Canada
- The Ottawa Hospital IBD Centre, The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Emily Herrett
- London School of Hygiene and Tropical Medicine, London, UK
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Eric I Benchimol
- ICES, Toronto, ON, Canada
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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47
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Kaplan GG, Windsor JW, Crain J, Barrett L, Bernstein CN, Bitton A, Chauhan U, Coward S, Fowler S, Ghia JE, Gibson DL, Griffiths AM, Jones JL, Khanna R, Kuenzig ME, Lakatos PL, Lee K, Mack DR, Marshall JK, Mawani M, Murthy SK, Panaccione R, Seow CH, Targownik LE, Zelinsky S, Benchimol EI. Crohn's and Colitis Canada's 2021 Impact of COVID-19 & Inflammatory Bowel Disease in Canada: A Knowledge Translation Strategy. J Can Assoc Gastroenterol 2021; 4:S10-S19. [PMID: 34755034 PMCID: PMC8570425 DOI: 10.1093/jcag/gwab028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 11/25/2022] Open
Abstract
The prevalence of inflammatory bowel diseases (IBD), Crohn’s disease and ulcerative colitis, in Canada, is over 0.75% in 2021. Many individuals with IBD are immunocompromised. Consequently, the World Health Organization’s declaration of a global pandemic uniquely impacted those with IBD. Crohn’s and Colitis Canada (CCC) formed the COVID-19 and IBD Taskforce to provide evidence-based guidance during the pandemic to individuals with IBD and their families. The Taskforce met regularly through the course of the pandemic, synthesizing available information on the impact of COVID-19 on IBD. At first, the information was extrapolated from expert consensus guidelines, but eventually, recommendations were adapted for an international registry of worldwide cases of COVID-19 in people with IBD. The task force launched a knowledge translation initiative consisting of a webinar series and online resources to communicate information directly to the IBD community. Taskforce recommendations were posted to CCC’s website and included guidance such as risk stratification, management of immunosuppressant medications, physical distancing, and mental health. A weekly webinar series communicated critical information directly to the IBD community. During the pandemic, traffic to CCC’s website increased with 484,755 unique views of the COVID-19 webpages and 126,187 views of the 23 webinars, including their video clips. CCC’s COVID-19 and IBD Taskforce provided critical guidance to the IBD community as the pandemic emerged, the nation underwent a lockdown, the economy reopened, and the second wave ensued. By integrating public health guidance through the unique prism of a vulnerable population, CCC’s knowledge translation platform informed and protected the IBD community.
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Affiliation(s)
- Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Joseph W Windsor
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Janet Crain
- KTE Bridge Consulting, Toronto, Ontario, Canada
| | - Lisa Barrett
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Usha Chauhan
- Hamilton Health Science, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Coward
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sharyle Fowler
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jean-Eric Ghia
- Department of Immunology and Internal Medicine section of Gastroenterology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba and University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Deanna L Gibson
- Department of Biology, Faculty of Science; Department of Medicine, Faculty of Medicine, The University of British Columbia, Okanagan campus, Kelowna, British Columbia, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Reena Khanna
- London Health Sciences Centre-University Campus, Western University, London, Ontario, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Peter L Lakatos
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.,1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre and Department of Pediatrics, University of Ottawa, Ontario, Canada
| | - John K Marshall
- Hamilton Health Science, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mina Mawani
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | - Sanjay K Murthy
- The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Zelinsky
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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48
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Murthy SK, Kuenzig ME, Windsor JW, Ghia JE, Griffiths AM, Panaccione R, Seow CH, Benchimol EI, Bernstein CN, Bitton A, Huang JG, Jones JL, Lee K, Kaplan GG, Mukhtar MS, Tandon P, Targownik LE, Gibson DL. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: COVID-19 Vaccines-Biology, Current Evidence and Recommendations. J Can Assoc Gastroenterol 2021; 4:S54-S60. [PMID: 34755040 PMCID: PMC8570416 DOI: 10.1093/jcag/gwab033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/14/2021] [Indexed: 12/19/2022] Open
Abstract
The COVID-19 pandemic has ushered a globally focused vaccine development program that produced multiple successful vaccines within a year. Four SARS-CoV-2 vaccines have been approved for use in Canada, using two different technologies, all of which have shown excellent efficacy in reducing the rate of symptomatic COVID-19 infection and 100% efficacy in preventing death from COVID-19. People with inflammatory bowel disease (IBD), like many others with immune-mediated chronic diseases, were excluded from the pivotal trials of these vaccines, leading to early hesitancy by regulatory bodies to endorse administering the vaccines to these groups. However, recent data has shown that the adverse event rate to SARS-CoV-2 vaccine among people with IBD is similar to the general population. Early data has further shown that people with IBD are capable of mounting a robust immune response to SARS-CoV-2 vaccines, particularly following a second dose, whereas the response to the first dose is blunted in those receiving anti-TNF therapy or conventional immunosuppressants (azathioprine, 6-mercaptopurine, methotrexate). Based on these data and evidence from previous vaccine programs among people with IBD, multiple national and international expert panels have recommended that individuals with IBD receive complete vaccination against SARS-CoV-2 as soon as possible.
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Affiliation(s)
- Sanjay K Murthy
- The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Joseph W Windsor
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jean-Eric Ghia
- Department of Immunology & Internal Medicine section of Gastroenterology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba and University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, McGill University, Quebec, Canada
| | - James Guoxian Huang
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mariam S Mukhtar
- Department of Internal Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Deanna L Gibson
- Department of Biology, Faculty of Science; Department of Medicine, Faculty of Medicine, The University of British Columbia, Okanagan campus, Kelowna, British Columbia, Canada
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49
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Ellen Kuenzig M, Windsor JW, Barrett L, Bernstein CN, Bitton A, Carroll MW, Chauhan U, Coward S, Fowler S, Ghia JE, Geist R, Gibson DL, Graff LA, Griffiths AM, Guoxian Huang J, Jones JL, Khanna R, Lakatos PL, Lee K, Mack DR, Marshall JK, Mukhtar MS, Murthy SK, Nguyen GC, Panaccione R, Seow CH, Singh H, Tandon P, Targownik LE, Zelinsky S, Benchimol EI, Kaplan GG. Crohn's and Colitis Canada's 2021 Impact of COVID-19 and Inflammatory Bowel Disease in Canada: Executive Summary. J Can Assoc Gastroenterol 2021; 4:S1-S9. [PMID: 34755033 PMCID: PMC8570424 DOI: 10.1093/jcag/gwab027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 12/20/2022] Open
Abstract
Persons with inflammatory bowel disease (IBD) make up more than 0.75% of the Canadian population in 2021. Early in the COVID-19 pandemic, individuals with IBD, particularly those on immunosuppressive therapies, were concerned that their health status may place them at higher risk of contracting COVID-19 or experiencing more severe disease course if infected with SARS-CoV-2. In response, Crohn’s and Colitis Canada developed the COVID-19 and IBD Taskforce in March 2020 to rapidly synthesize the evolving knowledge of COVID-19 as relevant to Canadians with IBD. The Taskforce communicated expert information directly to the Canadian IBD community through online tools and a webinar series. In order to understand the full impact of COVID-19 on the IBD community, Crohn’s and Colitis Canada commissioned a policy report that was informed through a systematic literature review and synthesized across working groups along the following domains: Epidemiology, Children and Expectant Mothers with IBD, Seniors with IBD, Mental Health, Risk Factors and Medications, Vaccines, and Healthcare Delivery during the Pandemic and the Future Model of IBD Care. This report from Canadian physicians, researchers, and IBD community representatives highlights the physical, mental, and health systems impact of COVID-19 on the entire spectrum of the IBD community, including children, adolescents, adults, seniors, and pregnant people with IBD. This executive summary provides an overview of the crucial information from each of the chapters of the policy report, supplemented with additional information made available through Crohn’s and Colitis Canada’s webinar-based knowledge translation platform.
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Affiliation(s)
- M Ellen Kuenzig
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Joseph W Windsor
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lisa Barrett
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Charles N Bernstein
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Alain Bitton
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Matthew W Carroll
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Usha Chauhan
- Hamilton Health Science, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie Coward
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Departments of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sharyle Fowler
- Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jean-Eric Ghia
- Department of Immunology and Internal Medicine section of Gastroenterology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba and University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Rose Geist
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Deanna L Gibson
- Department of Biology, Faculty of Science; Department of Medicine, Faculty of Medicine, The University of British Columbia, Okanagan campus, Kelowna, British Columbia, Canada
| | - Lesley A Graff
- University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada.,Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne M Griffiths
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - James Guoxian Huang
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer L Jones
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Reena Khanna
- London Health Sciences Centre-University Campus, Western University, London, Ontario, Canada
| | - Peter L Lakatos
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.,1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Ontario, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre and Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - John K Marshall
- Hamilton Health Science, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mariam S Mukhtar
- Department of Internal Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sanjay K Murthy
- The Ottawa Hospital IBD Centre, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey C Nguyen
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, University of Toronto, Toronto, Ontario, Canada
| | - Remo Panaccione
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Cynthia H Seow
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Departments of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Harminder Singh
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada
| | - Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Laura E Targownik
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Zelinsky
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eric I Benchimol
- SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Departments of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Lee SH, Turpin W, Espin-Garcia O, Raygoza Garay JA, Smith MI, Leibovitzh H, Goethel A, Turner D, Mack D, Deslandres C, Cino M, Aumais G, Panaccione R, Jacobson K, Bitton A, Steinhart AH, Huynh HQ, Princen F, Moayyedi P, Griffiths AM, Silverberg MS, Paterson AD, Xu W, Croitoru K. Anti-Microbial Antibody Response is Associated With Future Onset of Crohn's Disease Independent of Biomarkers of Altered Gut Barrier Function, Subclinical Inflammation, and Genetic Risk. Gastroenterology 2021; 161:1540-1551. [PMID: 34293299 DOI: 10.1053/j.gastro.2021.07.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/28/2021] [Accepted: 07/13/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Altered host immune reactivity to microbial antigens is hypothesized to trigger the onset of Crohn's disease (CD). We aimed to assess whether increased serum anti-microbial antibody response in asymptomatic first-degree relatives (FDRs) of CD patients is an independent risk factor for future CD development. METHODS We measured host serum antibody response to 6 microbial antigens at enrollment (Prometheus enzyme-linked immunosorbent assay test: anti-Saccharomyces cerevisiae antibodies immunoglobulin A/immunoglobulin G, anti-OmpC, anti-A4-Fla2, anti-FlaX, anti-CBir1) and derived the sum of positive antibodies (AS). We used samples at enrollment of prospectively followed healthy FDRs from a nested case-control cohort of the Crohn's and Colitis Canada Genetics Environment Microbial Project. Those who later developed CD (n = 77) were matched 1:4 by age, sex, follow-up duration, and geographic location with control FDRs remaining healthy (n = 307). To address our research aims, we fitted a multivariable conditional logistic regression model and performed causal mediation analysis. RESULTS High baseline AS (≥2) (43% of cases, 11% of controls) was associated with higher risk of developing CD (adjusted odds ratio, 6.5; 95% confidence interval, 3.4-12.7; P < .001). Importantly, this association remained significant when adjusted for markers of gut barrier function, fecal calprotectin, C-reactive protein, and CD-polygenic risk score, and in subjects recruited more than 3 years before diagnosis. Causal mediation analysis showed that the effect of high AS on future CD development is partially mediated (42%) via preclinical gut inflammation. CONCLUSIONS Our results suggest that increased anti-microbial antibody responses are associated with risk of future development of CD, independent of biomarkers of abnormal gut barrier function, subclinical inflammation, and CD-related genetic risks. This suggests that anti-microbial antibody responses are an early predisease event in the development of CD.
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Affiliation(s)
- Sun-Ho Lee
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Williams Turpin
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Osvaldo Espin-Garcia
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto and Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Juan Antonio Raygoza Garay
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michelle I Smith
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Haim Leibovitzh
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ashleigh Goethel
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Mack
- Division of Gastroenterology, Hepatology & Nutrition, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Colette Deslandres
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Quebec, Canada
| | - Maria Cino
- Division of Gastroenterology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Guy Aumais
- Hôpital Maisonneuve-Rosemont, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Remo Panaccione
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Kevan Jacobson
- Canadian Gastro-Intestinal Epidemiology Consortium, Canada, British Columbia Children's Hospital, British Columbia Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alain Bitton
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - A Hillary Steinhart
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hien Q Huynh
- Division of Gastroenterology and Nutrition, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | - Paul Moayyedi
- Department of Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Anne M Griffiths
- Division of Gastroenterology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark S Silverberg
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew D Paterson
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto and Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Genetics and Genome Biology, The Hospital for Sick Children Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wei Xu
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto and Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
| | - Kenneth Croitoru
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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