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Ferreiro AL, Choi J, Ryou J, Newcomer EP, Thompson R, Bollinger RM, Hall-Moore C, Ndao IM, Sax L, Benzinger TLS, Stark SL, Holtzman DM, Fagan AM, Schindler SE, Cruchaga C, Butt OH, Morris JC, Tarr PI, Ances BM, Dantas G. Gut microbiome composition may be an indicator of preclinical Alzheimer's disease. Sci Transl Med 2023; 15:eabo2984. [PMID: 37315112 PMCID: PMC10680783 DOI: 10.1126/scitranslmed.abo2984] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/26/2023] [Indexed: 06/16/2023]
Abstract
Alzheimer's disease (AD) pathology is thought to progress from normal cognition through preclinical disease and ultimately to symptomatic AD with cognitive impairment. Recent work suggests that the gut microbiome of symptomatic patients with AD has an altered taxonomic composition compared with that of healthy, cognitively normal control individuals. However, knowledge about changes in the gut microbiome before the onset of symptomatic AD is limited. In this cross-sectional study that accounted for clinical covariates and dietary intake, we compared the taxonomic composition and gut microbial function in a cohort of 164 cognitively normal individuals, 49 of whom showed biomarker evidence of early preclinical AD. Gut microbial taxonomic profiles of individuals with preclinical AD were distinct from those of individuals without evidence of preclinical AD. The change in gut microbiome composition correlated with β-amyloid (Aβ) and tau pathological biomarkers but not with biomarkers of neurodegeneration, suggesting that the gut microbiome may change early in the disease process. We identified specific gut bacterial taxa associated with preclinical AD. Inclusion of these microbiome features improved the accuracy, sensitivity, and specificity of machine learning classifiers for predicting preclinical AD status when tested on a subset of the cohort (65 of the 164 participants). Gut microbiome correlates of preclinical AD neuropathology may improve our understanding of AD etiology and may help to identify gut-derived markers of AD risk.
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Affiliation(s)
- Aura L. Ferreiro
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - JooHee Choi
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jian Ryou
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Erin P. Newcomer
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Regina Thompson
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Rebecca M. Bollinger
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Carla Hall-Moore
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - I. Malick Ndao
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Laurie Sax
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Tammie L. S. Benzinger
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Susan L. Stark
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - David M. Holtzman
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Washington University School of Medicine, St. Louis, MO 63110, USA
- Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Anne M. Fagan
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Washington University School of Medicine, St. Louis, MO 63110, USA
- Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Suzanne E. Schindler
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Carlos Cruchaga
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO 63110, USA
- NeuroGenomics and Informatics, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Omar H. Butt
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - John C. Morris
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Phillip I. Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Beau M. Ances
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Washington University School of Medicine, St. Louis, MO 63110, USA
- Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Gautam Dantas
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
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Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O'Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med 2018; 379:2002-2014. [PMID: 30462938 PMCID: PMC6358014 DOI: 10.1056/nejmoa1802598] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [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: 12/19/2022]
Abstract
BACKGROUND Acute gastroenteritis develops in millions of children in the United States every year, and treatment with probiotics is common. However, data to support the use of probiotics in this population are limited. METHODS We conducted a prospective, randomized, double-blind trial involving children 3 months to 4 years of age with acute gastroenteritis who presented to one of 10 U.S. pediatric emergency departments. Participants received a 5-day course of Lactobacillus rhamnosus GG at a dose of 1×1010 colony-forming units twice daily or matching placebo. Follow-up surveys were conducted daily for 5 days and again 14 days after enrollment and 1 month after enrollment. The primary outcome was moderate-to-severe gastroenteritis, which was defined as an illness episode with a total score on the modified Vesikari scale of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease), within 14 days after enrollment. Secondary outcomes included the duration and frequency of diarrhea and vomiting, the duration of day-care absenteeism, and the rate of household transmission (defined as the development of symptoms of gastroenteritis in previously asymptomatic household contacts). RESULTS Among the 971 participants, 943 (97.1%) completed the trial. The median age was 1.4 years (interquartile range, 0.9 to 2.3), and 513 participants (52.9%) were male. The modified Vesikari scale score for the 14-day period after enrollment was 9 or higher in 55 of 468 participants (11.8%) in the L. rhamnosus GG group and in 60 of 475 participants (12.6%) in the placebo group (relative risk, 0.96; 95% confidence interval, 0.68 to 1.35; P=0.83). There were no significant differences between the L. rhamnosus GG group and the placebo group in the duration of diarrhea (median, 49.7 hours in the L. rhamnosus GG group and 50.9 hours in the placebo group; P=0.26), duration of vomiting (median, 0 hours in both groups; P=0.17), or day-care absenteeism (median, 2 days in both groups; P=0.67) or in the rate of household transmission (10.6% and 14.1% in the two groups, respectively; P=0.16). CONCLUSIONS Among preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT01773967 .).
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Affiliation(s)
- David Schnadower
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Phillip I Tarr
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - T Charles Casper
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Marc H Gorelick
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - J Michael Dean
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Karen J O'Connell
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Prashant Mahajan
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Adam C Levine
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Seema R Bhatt
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cindy G Roskind
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Elizabeth C Powell
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Alexander J Rogers
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cheryl Vance
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Robert E Sapien
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cody S Olsen
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Melissa Metheney
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Viani P Dickey
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Carla Hall-Moore
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Stephen B Freedman
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
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