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Waasdorp Hurtado C, Neigut D, Hoffenberg EJ, Geyer B, Marable J, Combest N, Yousuf S, Olson CA. Telehealth Coverage for a Pediatric Gastroenterology Consult Service at a Regional Hospital: An Accepted, Useful, and Sustainable Model of Care. J Pediatr 2023; 262:113341. [PMID: 36736891 PMCID: PMC10905322 DOI: 10.1016/j.jpeds.2023.01.015] [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: 08/14/2022] [Revised: 01/05/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To evaluate a novel telehealth inpatient pediatric gastroenterology (GI) consult service at a regional children's hospital in regard to acceptance, utility, quality, sustainability, and provider resiliency. STUDY DESIGN Patients requiring GI care at a regional children's hospital between July 2020 and June 2021 were treated by an in-person or telehealth physician with physician assistant support, randomly assigned based on a weekly preset staffing schedule. A retrospective, multidomain program evaluation was performed based on the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) and STEM (SPROUT Telehealth Evaluation and Management) frameworks, using statistical analysis to compare the patient cohorts and anonymous surveys to assess provider perceptions. RESULTS In total, 1051 patient-days of GI care were provided for 348 patients, 17% by telehealth and 83% in-person. There were no significant differences in diagnosis, transfer, or readmission rates between the cohorts. No transfers occurred for reasons other than need to access specialized services not available at the regional hospital. Daily consult workload was slightly greater for telehealth physicians. Primary and consult team providers accepted the practice. The model continued beyond the first year. In total, 75% of local GI physicians reported greater Brief Resilience Scores in the context of shifting 20% of their inpatient call weeks to another campus's physicians. CONCLUSION Episodic pediatric GI consult service coverage via telehealth at a regional hospital was well accepted, useful, and sustainable, with improved physician resilience and no adverse outcomes seen. Telehealth holds promise for leveraging pediatric subspecialty physicians across hospitals, allowing complex patients to be admitted closer to home while reducing inpatient coverage requirements for smaller physician groups.
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Affiliation(s)
- Christine Waasdorp Hurtado
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Colorado Springs, CO; Children's Hospital Colorado-Colorado Springs Campus, Colorado Springs, CO.
| | - Deborah Neigut
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Colorado Springs, CO; Children's Hospital Colorado-Anschutz Medical Campus, Aurora, CO
| | - Edward J Hoffenberg
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Colorado Springs, CO; Children's Hospital Colorado-Anschutz Medical Campus, Aurora, CO
| | - Brooke Geyer
- Children's Hospital Colorado-Colorado Springs Campus, Colorado Springs, CO; Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Colorado Springs, CO
| | - Jennifer Marable
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Colorado Springs, CO; Children's Hospital Colorado-Colorado Springs Campus, Colorado Springs, CO
| | - Nichole Combest
- Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Colorado Springs, CO; Children's Hospital Colorado-Colorado Springs Campus, Colorado Springs, CO
| | - Sana Yousuf
- Children's Hospital Colorado-Anschutz Medical Campus, Aurora, CO
| | - Christina A Olson
- Children's Hospital Colorado-Anschutz Medical Campus, Aurora, CO; Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Colorado Springs, CO
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deZoeten EF, Battista KD, Colson SB, Lovell MA, Kessler BE, Isfort RW, Fennimore BP, Onyiah JC, Kao DJ, Yeckes A, Keely S, Murray M, Hoffenberg EJ, Colgan SP, Gerich ME. Markers of Hypoxia Correlate with Histologic and Endoscopic Severity of Colitis in Inflammatory Bowel Disease. Hypoxia (Auckl) 2020; 8:1-12. [PMID: 32104717 PMCID: PMC7026141 DOI: 10.2147/hp.s219049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/16/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Inflammation results in significant shifts in tissue metabolism. Recent studies indicate that inflammation and hypoxia occur concomitantly. We examined whether circulating and tissue markers of hypoxia could serve as surrogate indicators of disease severity in adult and pediatric patients with inflammatory bowel disease (IBD). METHODS Serum and colonic biopsies were obtained from pediatric subjects with active IBD colitis and adult subjects with active and inactive ulcerative colitis, along with healthy non-colitis controls of all ages. Disease activity was evaluated by endoscopy and histopathology. Levels of serum hypoxia markers (macrophage inflammatory protein-3α [MIP-3α], vascular endothelial growth factor [VEGF], and erythropoietin [EPO]) were measured. RESULTS Children with active IBD colitis had higher levels of serum MIP-3α and VEGF compared to non-colitis controls (p<0.01 and p<0.05, respectively). In adult subjects with endoscopically active ulcerative colitis, serum MIP-3α and EPO were significantly elevated compared to non-colitis controls (both p<0.01). In parallel, analysis of colon tissue MIP-3α mRNA and protein in pediatric subjects revealed increased expression in those with IBD colitis compared to controls (p<0.05 and p<0.01 for mRNA and protein, respectively). Serum MIP-3α and VEGF significantly increased with histology grade. CONCLUSION Peripheral blood hypoxia markers may be useful indicators of disease activity for pediatric and adult IBD patients.
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Affiliation(s)
- Edwin F deZoeten
- Department of Pediatrics and the Digestive Health Institute, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, CO, USA
| | - Kayla D Battista
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven B Colson
- Department of Pediatrics and the Digestive Health Institute, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, CO, USA
| | - Mark A Lovell
- Department of Pathology, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, CO, USA
| | - Brittelle E Kessler
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert W Isfort
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Blair P Fennimore
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph C Onyiah
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel J Kao
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alyson Yeckes
- Department of Pediatrics and the Digestive Health Institute, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, CO, USA
| | - Simon Keely
- Department of Pediatrics and the Digestive Health Institute, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, CO, USA
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
| | - Monica Murray
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward J Hoffenberg
- Department of Pediatrics and the Digestive Health Institute, University of Colorado School of Medicine/Children’s Hospital Colorado, Aurora, CO, USA
| | - Sean P Colgan
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mark E Gerich
- Department of Medicine and Mucosal Inflammation Program, Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, CO, USA
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O'Gorman MA, Michaels MG, Kaplan SL, Otley A, Kociolek LK, Hoffenberg EJ, Kim KS, Nachman S, Pfefferkorn MD, Sentongo T, Sullivan JE, Sears P. Safety and Pharmacokinetic Study of Fidaxomicin in Children With Clostridium difficile-Associated Diarrhea: A Phase 2a Multicenter Clinical Trial. J Pediatric Infect Dis Soc 2018; 7:210-218. [PMID: 28575523 DOI: 10.1093/jpids/pix037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 05/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fidaxomicin is an approved therapy for Clostridium difficile-associated diarrhea (CDAD) in adults. The safety of fidaxomicin in children has not been reported. METHODS In this study (ClinicalTrials.gov identifier NCT01591863), pediatric patients with CDAD received twice-daily oral fidaxomicin at a dose of 16 mg/kg per day (up to 200 mg) for 10 days in an open-label study. Plasma and fecal samples were collected for pharmacokinetic assessments. The primary outcome measure was safety, which was assessed by adverse-event (AE), laboratory, and physical examination/vital-sign monitoring. Efficacy was determined through early and sustained clinical response rates (clinical response without recurrence of CDAD). RESULTS The study enrolled 40 patients (11 months to 17 years of age), many with underlying comorbidity, including neoplasm (23.7%), gastrointestinal disorder (78.9%), and history of CDAD (60.5%). Plasma fidaxomicin and OP-1118 (the major fidaxomicin metabolite) 3- to 5-hour postdose concentrations were 0.6 to 87.4 and 2.4 to 882.0 ng/mL, respectively, and no age-related trends were seen. Fecal fidaxomicin concentrations within 24 hours of the last dose averaged 3228 µg/g, and higher concentrations and greater variability in the youngest age group were found. AEs were reported in 73.7% of the patients; most of them were mild (44.7%) to moderate (21.1%) and were considered treatment-related in 15.8% of the patients. Overall, the early clinical response rate was 92.1%. The rate of sustained clinical response (clinical response without recurrence through 28 days after treatment) was 65.8% overall. CONCLUSIONS Fidaxomicin was well tolerated in children with CDAD and has a pharmacokinetic profile in children similar to that in adults. The clinical response rate was high.
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Affiliation(s)
- Molly A O'Gorman
- University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Marian G Michaels
- University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh of UPMC, Pennsylvania
| | | | | | | | | | - Kwang Sik Kim
- Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | | | - Marian D Pfefferkorn
- Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - Timothy Sentongo
- University of Chicago Medicine, Comer Children's Hospital, Illinois
| | - Janice E Sullivan
- Kosair Charities Pediatric Clinical Research Unit, University of Louisville and Kosair Children's Hospital, Kentucky
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Liu E, Dong F, Barón AE, Taki I, Norris JM, Frohnert BI, Hoffenberg EJ, Rewers M. High Incidence of Celiac Disease in a Long-term Study of Adolescents With Susceptibility Genotypes. Gastroenterology 2017; 152:1329-1336.e1. [PMID: 28188747 PMCID: PMC5533620 DOI: 10.1053/j.gastro.2017.02.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [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: 07/16/2016] [Revised: 01/27/2017] [Accepted: 02/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Little is known about the incidence of celiac disease in the general population of children in the United States. We aimed to estimate the cumulative incidence of celiac disease in adolescents born in the Denver metropolitan area. METHODS We collected data on HLA-DR, DQ genotypes of 31,766 infants, born from 1993 through 2004 at St. Joseph's Hospital in Denver, from the Diabetes Autoimmunity Study in the Young. Subjects with susceptibility genotypes for celiac disease and type 1 diabetes were followed up for up to 20 years for development of tissue transglutaminase autoantibodies (tTGA). Outcomes were the development of celiac disease autoimmunity (CDA) or celiac disease. CDA was defined as persistence of tTGA for at least 3 months or development of celiac disease. Celiac disease was defined based on detection of Marsh 2 or greater lesions in biopsy specimens or persistent high levels of tTGA. For each genotype, the cumulative incidence of CDA and celiac disease were determined. To estimate the cumulative incidence in the Denver general population, outcomes by each genotype were weighted according to the frequency of each of these genotypes in the general population. RESULTS Of 1339 subjects followed up, 66 developed CDA and met criteria for celiac disease and 46 developed only CDA. Seropositivity for tTGA resolved spontaneously, without treatment, in 21 of the 46 subjects with only CDA (46%). The estimated cumulative incidence for CDA in the Denver general population at 5, 10, and 15 years of age was 2.4%, 4.3%, and 5.1%, respectively, and incidence values for celiac disease were 1.6%, 2.8%, and 3.1%, respectively. CONCLUSIONS In a 20-year prospective study of 1339 children with genetic risk factors for celiac disease, we found the cumulative incidence of CDA and celiac disease to be high within the first 10 years. Although more than 5% of children may experience a period of CDA, not all children develop celiac disease or require gluten-free diets.
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Affiliation(s)
- Edwin Liu
- Digestive Health Institute and Colorado Center for Celiac Disease, Children's Hospital Colorado, University of Colorado Denver, Aurora, Colorado; Barbara Davis Center, University of Colorado Denver, Aurora, Colorado.
| | - Fran Dong
- Barbara Davis Center, University of Colorado Denver
| | - Anna E. Barón
- Biostatics and Informatics, Colorado School of Public Health, University of Colorado Denver
| | - Iman Taki
- Barbara Davis Center, University of Colorado Denver
| | - Jill M. Norris
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver
| | | | - Edward J Hoffenberg
- Digestive Health Institute and Colorado Center for Celiac Disease, Children’s Hospital Colorado, University of Colorado Denver
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Flass T, Tong S, Frank DN, Wagner BD, Robertson CE, Kotter CV, Sokol RJ, Zemanick E, Accurso F, Hoffenberg EJ, Narkewicz MR. Intestinal lesions are associated with altered intestinal microbiome and are more frequent in children and young adults with cystic fibrosis and cirrhosis. PLoS One 2015; 10:e0116967. [PMID: 25658710 PMCID: PMC4319904 DOI: 10.1371/journal.pone.0116967] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/17/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIMS Cirrhosis (CIR) occurs in 5-7% of cystic fibrosis (CF) patients. We hypothesized that alterations in intestinal function in CF contribute to the development of CIR. AIMS Determine the frequency of macroscopic intestinal lesions, intestinal inflammation, intestinal permeability and characterize fecal microbiome in CF CIR subjects and CF subjects with no liver disease (CFnoLIV). METHODS 11 subjects with CFCIR (6 M, 12.8 yrs ± 3.8) and 19 matched with CFnoLIV (10 M, 12.6 yrs ± 3.4) underwent small bowel capsule endoscopy, intestinal permeability testing by urinary lactulose: mannitol excretion ratio, fecal calprotectin determination and fecal microbiome characterization. RESULTS CFCIR and CFnoLIV did not differ in key demographics or CF complications. CFCIR had higher GGT (59±51 U/L vs 17±4 p = 0.02) and lower platelet count (187±126 vs 283±60 p = 0.04) and weight (-0.86 ± 1.0 vs 0.30 ± 0.9 p = 0.002) z scores. CFCIR had more severe intestinal mucosal lesions on capsule endoscopy (score ≥4, 4/11 vs 0/19 p = 0.01). Fecal calprotectin was similar between CFCIR and CFnoLIV (166 μg/g ±175 vs 136 ± 193 p = 0.58, nl <120). Lactulose:mannitol ratio was elevated in 27/28 subjects and was slightly lower in CFCIR vs CFnoLIV (0.08±0.02 vs 0.11±0.05, p = 0.04, nl ≤0.03). Small bowel transit time was longer in CFCIR vs CFnoLIV (195±42 min vs 167±68 p<0.001, nl 274 ± 41). Bacteroides were decreased in relative abundance in CFCIR and were associated with lower capsule endoscopy score whereas Clostridium were more abundant in CFCIR and associated with higher capsule endoscopy score. CONCLUSIONS CFCIR is associated with increased intestinal mucosal lesions, slower small bowel transit time and alterations in fecal microbiome. Abnormal intestinal permeability and elevated fecal calprotectin are common in all CF subjects. Disturbances in intestinal function in CF combined with changes in the microbiome may contribute to the development of hepatic fibrosis and intestinal lesions.
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Affiliation(s)
- Thomas Flass
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, United States of America
| | - Suhong Tong
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital, Aurora, Colorado, United States of America
| | - Daniel N. Frank
- Department of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, United States of America
| | - Brandie D. Wagner
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital, Aurora, Colorado, United States of America
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, United States of America
| | - Charles E. Robertson
- Department of Molecular, Cellular, and Developmental Biology, University of Colorado Boulder, Boulder, Colorado, United States of America
| | - Cassandra Vogel Kotter
- Department of Infectious Diseases, University of Colorado Denver, Aurora, Colorado, United States of America
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, United States of America
- Colorado Clinical and Translational Sciences Institute, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Edith Zemanick
- Section of Pediatric Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, United States of America
| | - Frank Accurso
- Section of Pediatric Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, United States of America
| | - Edward J. Hoffenberg
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, United States of America
| | - Michael R. Narkewicz
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, United States of America
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Kulungowski AM, Acker SN, Hoffenberg EJ, Neigut D, Partrick DA. Initial operative treatment of isolated ileal Crohn's disease in adolescents. Am J Surg 2014; 210:141-5. [PMID: 25457242 DOI: 10.1016/j.amjsurg.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/20/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We hypothesize that in children with Crohn's disease (CD) isolated to a single site, resection leads to clinical improvement, decreased medication requirements, and improved growth. METHODS A retrospective review was conducted of children with CD isolated to the terminal ileum undergoing operative intervention at Children's Hospital Colorado between 2002 and 2013. RESULTS Twenty-six patients underwent ileocecetomy (mean age at diagnosis 14.1 ± 2.6 years; mean age at resection 15.7 ± 2.5 years; median follow-up 2 ± 1.5 years). Twenty-two (84.6%) patients reported clinical improvement and 17 (65.4%) were able to decrease the number or dosage of medications. Average weight increased from the 29th to the 45th percentile (P = .09) at 1 year and to the 56th percentile (P = .02) at 3 years post resection. Average body mass index increased from the 30th to the 48th and 49th percentile at 1 and 3 years (P < .05 for both), respectively. Height increased from the 39th percentile at the time of resection to the 51st percentile at 3 years (P = nonsignificant). CONCLUSION Surgical resection of an isolated ileal segment in adolescents with CD allows for catch-up growth and reduction in medication requirements.
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Affiliation(s)
- Ann M Kulungowski
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA.
| | - Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Edward J Hoffenberg
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - Deborah Neigut
- Department of Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado, School of Medicine, Aurora, CO 80045, USA
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, 13123 E 16th Avenue, Aurora, CO 80045, USA; Division of Surgery, University of Colorado, School of Medicine, Aurora, CO 80045, USA
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Forrest CB, Crandall WV, Bailey LC, Zhang P, Joffe MM, Colletti RB, Adler J, Baron HI, Berman J, del Rosario F, Grossman AB, Hoffenberg EJ, Israel EJ, Kim SC, Lightdale JR, Margolis PA, Marsolo K, Mehta DI, Milov DE, Patel AS, Tung J, Kappelman MD. Effectiveness of anti-TNFα for Crohn disease: research in a pediatric learning health system. Pediatrics 2014; 134:37-44. [PMID: 24935993 PMCID: PMC4531278 DOI: 10.1542/peds.2013-4103] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES ImproveCareNow (ICN) is the largest pediatric learning health system in the nation and started as a quality improvement collaborative. To test the feasibility and validity of using ICN data for clinical research, we evaluated the effectiveness of anti-tumor necrosis factor-α (anti-TNFα) agents in the management of pediatric Crohn disease (CD). METHODS Data were collected in 35 pediatric gastroenterology practices (April 2007 to March 2012) and analyzed as a sequence of nonrandomized trials. Patients who had moderate to severe CD were classified as initiators or non-initiators of anti-TNFα therapy. Among 4130 patients who had pediatric CD, 603 were new users and 1211 were receiving anti-TNFα therapy on entry into ICN. RESULTS During a 26-week follow-up period, rate ratios obtained from Cox proportional hazards models, adjusting for patient and disease characteristics and concurrent medications, were 1.53 (95% confidence interval [CI], 1.20-1.96) for clinical remission and 1.74 (95% CI, 1.33-2.29) for corticosteroid-free remission. The rate ratio for corticosteroid-free remission was comparable to the estimate produced by the adult SONIC study, which was a randomized controlled trial on the efficacy of anti-TNFα therapy. The number needed to treat was 5.2 (95% CI, 3.4-11.1) for clinical remission and 5.0 (95% CI, 3.4-10.0) for corticosteroid-free remission. CONCLUSIONS In routine pediatric gastroenterology practice settings, anti-TNFα therapy was effective at achieving clinical and corticosteroid-free remission for patients who had Crohn disease. Using data from the ICN learning health system for the purpose of observational research is feasible and produces valuable new knowledge.
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Affiliation(s)
| | - Wallace V. Crandall
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - L. Charles Bailey
- Department of Pediatrics, and,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Marshall M. Joffe
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard B. Colletti
- Department of Pediatrics, The University of Vermont College of Medicine, Burlington, Vermont
| | - Jeremy Adler
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Howard I. Baron
- Department of Pediatrics, University of Nevada School of Medicine, Pediatric Gastroenterology and Nutrition Associates, Las Vegas, Nevada
| | - James Berman
- Advocate Children's Hospital, UIC College of Medicine, Loyola University School of Medicine, Chicago, Illinois
| | - Fernando del Rosario
- Department of Pediatrics, Division of Pediatric Gastroenterology Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Andrew B. Grossman
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Edward J. Hoffenberg
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Esther J. Israel
- Department of Pediatrics, Massachusetts General Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Sandra C. Kim
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | | | - Peter A. Margolis
- Department of Pediatrics, James M. Anderson Center for Health Systems Excellence, and
| | - Keith Marsolo
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio;,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Devendra I. Mehta
- Department of Pediatrics, Arnold Palmer Hospital for Children, Florida State University, Orlando, Florida
| | - David E. Milov
- Department of Pediatrics, Nemour’s Children’s Hospital, Orlando, Florida
| | - Ashish S. Patel
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas;,Department of Pediatrics, Children’s Medical Center, Dallas, Texas
| | - Jeanne Tung
- Department of Pediatric and Adolescent Medicine, Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; and
| | - Michael D. Kappelman
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Park KT, Crandall WV, Fridge J, Leibowitz IH, Tsou M, Dykes D, Hoffenberg EJ, Kappelman MD, Colletti RB. Implementable strategies and exploratory considerations to reduce costs associated with anti-TNF therapy in inflammatory bowel disease. Inflamm Bowel Dis 2014; 20:946-51. [PMID: 24451222 PMCID: PMC3997595 DOI: 10.1097/01.mib.0000441349.40193.aa] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 12/21/2022]
Abstract
A health care system is needed where care is based on the best available evidence and is delivered reliably, efficiently, and less expensively (best care at lower cost). In gastroenterology, anti-tumor necrosis factor agents represent the most effective medical therapeutic option for patients with moderate-to-severe inflammatory bowel disease (IBD), but are very expensive and account for nearly a quarter of the cost of IBD care, representing a major area of present and future impact in direct health care costs. The ImproveCareNow Network, consisting of over 55 pediatric IBD centers, seeks ways to improve the value of care in IBD, curtailing unnecessary costs and promoting better health outcomes through systematic and incremental quality improvement initiatives. This report summarizes the key evidence to facilitate the cost-effective use of anti-tumor necrosis factor agents for patients with IBD. Our review outlines the scientific rationale for initiating cost-reducing measures in anti-tumor necrosis factor use and focuses on 3 implementable strategies and 4 exploratory considerations through practical clinical guidelines, as supported by existing evidence. Implementable strategies can be readily integrated into today's daily practice, whereas exploratory considerations can guide research to support future implementation.
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Affiliation(s)
- KT Park
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Center for Health Policy/Primary Care Outcomes Research, Stanford University School of Medicine, Palo Alto, CA
| | - Wallace V. Crandall
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Jacqueline Fridge
- Northwest Pediatric Gastroenterology LLC, Randall Children’s Hospital, Portland, OR
| | - Ian H. Leibowitz
- Children’s Digestive Disease Program, Inova Fairfax Hospital for Children, Fairfax, VA
| | - Marc Tsou
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA
| | - Dana Dykes
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Edward J. Hoffenberg
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado Denver School of Medicine, Denver, CO
| | - Michael D. Kappelman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Richard B. Colletti
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT
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Van Der Werf CS, Wabbersen TD, Hsiao NH, Paredes J, Etchevers HC, Kroisel PM, Tibboel D, Babarit C, Schreiber RA, Hoffenberg EJ, Vekemans M, Zeder SL, Ceccherini I, Lyonnet S, Ribeiro AS, Seruca R, Te Meerman GJ, van Ijzendoorn SCD, Shepherd IT, Verheij JBGM, Hofstra RMW. CLMP is required for intestinal development, and loss-of-function mutations cause congenital short-bowel syndrome. Gastroenterology 2012; 142:453-462.e3. [PMID: 22155368 DOI: 10.1053/j.gastro.2011.11.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 10/24/2011] [Accepted: 11/22/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Short-bowel syndrome usually results from surgical resection of the small intestine for diseases such as intestinal atresias, volvulus, and necrotizing enterocolitis. Patients with congenital short-bowel syndrome (CSBS) are born with a substantial shortening of the small intestine, to a mean length of 50 cm, compared with a normal length at birth of 190-280 cm. They also are born with intestinal malrotation. Because CSBS occurs in many consanguineous families, it is considered to be an autosomal-recessive disorder. We aimed to identify and characterize the genetic factor causing CSBS. METHODS We performed homozygosity mapping using 610,000 K single-nucleotide polymorphism arrays to analyze the genomes of 5 patients with CSBS. After identifying a gene causing the disease, we determined its expression pattern in human embryos. We also overexpressed forms of the gene product that were and were not associated with CSBS in Chinese Hamster Ovary and T84 cells and generated a zebrafish model of the disease. RESULTS We identified loss-of-function mutations in Coxsackie- and adenovirus receptor-like membrane protein (CLMP) in CSBS patients. CLMP is a tight-junction-associated protein that is expressed in the intestine of human embryos throughout development. Mutations in CLMP prevented its normal localization to the cell membrane. Knock-down experiments in zebrafish resulted in general developmental defects, including shortening of the intestine and the absence of goblet cells. Because goblet cells are characteristic for the midintestine in zebrafish, which resembles the small intestine in human beings, the zebrafish model mimics CSBS. CONCLUSIONS Loss-of-function mutations in CLMP cause CSBS in human beings, likely by interfering with tight-junction formation, which disrupts intestinal development. Furthermore, we developed a zebrafish model of CSBS.
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Affiliation(s)
- Christine S Van Der Werf
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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10
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Hoffenberg EJ, Liu E. Screening-identified celiac disease: who needs treatment and when? Clin Gastroenterol Hepatol 2011; 9:284-5. [PMID: 21238607 DOI: 10.1016/j.cgh.2011.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 01/04/2011] [Accepted: 01/06/2011] [Indexed: 02/07/2023]
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Simmons JH, Klingensmith GJ, McFann K, Rewers M, Ide LM, Taki I, Liu E, Hoffenberg EJ. Celiac autoimmunity in children with type 1 diabetes: a two-year follow-up. J Pediatr 2011; 158:276-81.e1. [PMID: 20817171 PMCID: PMC2999645 DOI: 10.1016/j.jpeds.2010.07.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [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: 11/02/2009] [Revised: 06/09/2010] [Accepted: 07/16/2010] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine the benefits of screening for celiac autoimmunity via immunoglobulin A transglutaminase autoantibodies (TG) in children with type 1 diabetes (T1D). STUDY DESIGN We followed up 79 screening-identified TG+ and 56 matched TG- children with T1D for 2 years to evaluate growth, bone mineral density, nutritional status, and diabetes control. TG+ subjects self-selected to gluten-free or gluten-containing diet. RESULTS Of the initial cohort, 80% were available for reexamination after 2 years. TG+ subjects had consistently lower weight z-scores and higher urine N-telopeptides than TG- subjects, but similar measures of bone density and diabetes outcomes. TG+ children who remained on a gluten-containing diet had lower insulin-like growth factor binding protein 3 z-scores compared with TG+ subjects who reported following a gluten-free diet. Children who continued with high TG index throughout the study had lower bone mineral density z-scores, ferritin, and vitamin D 25OH levels, compared with the TG- group. CONCLUSIONS No significant adverse outcomes were identified in children with T1D with screening-identified TG+ who delay therapy with a gluten-free diet for 2 years. Children with persistently high levels of TG may be at greater risk. The optimal timing of screening and treatment for celiac disease in children with T1D requires further investigation.
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Affiliation(s)
- Jill H Simmons
- Department of Pediatrics, Division of Endocrinology and Diabetes, Vanderbilt Children’s Hospital, Nashville, TN
| | | | - Kim McFann
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Marian Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Lisa M Ide
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Iman Taki
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Edwin Liu
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, Department of Pediatrics, University of Colorado Denver, Aurora, CO
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12
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Kramer RE, Brumbaugh DE, Soden JS, Capocelli KE, Hoffenberg EJ. First successful antegrade single-balloon enteroscopy in a 3-year-old with occult GI bleeding. Gastrointest Endosc 2009; 70:546-9. [PMID: 19559431 DOI: 10.1016/j.gie.2009.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [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: 12/29/2008] [Accepted: 04/10/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND Balloon enteroscopy is an emerging technique to allow access to the small intestine for both diagnostic and therapeutic purposes. To date, there have been few published data documenting the safety and efficacy of balloon enteroscopy in small children. OBJECTIVE To describe our experience with single-balloon enteroscopy (SBE) in a 37-month-old toddler with occult GI bleeding. DESIGN A single case report. SETTING A free-standing, academic children's hospital in Denver, Colorado. PATIENT The patient was a 37-month-old, 13.5-kg toddler with persistent heme-positive stools, severe microcytic anemia, and hypoalbuminemia. Previous workup was significant for eosinophilic inflammation in the antrum and a video capsule study showing erythematous lesions in the small bowel. INTERVENTION An antegrade SBE was performed with the child under general endotracheal anesthesia, with biopsy specimens obtained from identified lesions in the jejunum and ileum. MAIN OUTCOME MEASUREMENTS Complications and successful treatment of symptoms were the primary endpoints. RESULTS The procedure was performed successfully in 85 minutes, passing an estimated 200 cm beyond the pylorus, without complications. Identification of the lesions as consistent with eosinophilic enteropathy led to successful treatment with an elimination diet and corticosteroids. LIMITATIONS The primary limitation of this study is that it is a single case report. Therefore, it is difficult to make a generalized statement regarding the safety and efficacy of balloon enteroscopy in toddlers of this size. CONCLUSIONS Antegrade SBE can be a well-tolerated and effective procedure to evaluate occult GI bleeding in children as young as 3 years of age. Further study is needed to better establish safety parameters for balloon enteroscopy in small pediatric patients.
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Affiliation(s)
- Robert E Kramer
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital/University of Colorado Denver, Denver, Colorado, USA
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13
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Mierau GW, Wills EJ, Wyatt-Ashmead J, Hoffenberg EJ, Cutz E. Microvillous Inclusion Disease: Report of a Case with Atypical Features. Ultrastruct Pathol 2009. [DOI: 10.1080/01913120119148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Li M, Yu L, Tiberti C, Bonamico M, Taki I, Miao D, Murray JA, Rewers MJ, Hoffenberg EJ, Agardh D, Mueller P, Stern M, Bonifacio E, Liu E. A report on the International Transglutaminase Autoantibody Workshop for Celiac Disease. Am J Gastroenterol 2009; 104:154-63. [PMID: 19098864 PMCID: PMC2904747 DOI: 10.1038/ajg.2008.8] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [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: 12/11/2022]
Abstract
OBJECTIVES Measurement of transglutaminase autoantibodies (TGAA) is considered to be the most efficient single serologic test for celiac disease (CD) by the American Gastroenterological Association Institute. We hypothesized that a large international collaborative effort toward improving and standardizing TGAA measurement is both feasible and necessary. The primary aim of this workshop is to compare TGAA assays among various research and clinical laboratories to examine assay concordance and improve (and eventually standardize) the TGAA assay. METHODS A total of 20 laboratories (5 commercial laboratories, 15 research and clinical laboratories) participated that included enzyme-linked immunosorbent assay (ELISA) and radiobinding assays. A total of 150 serum samples were distributed to each laboratory, with each laboratory receiving an equal aliquot that was coded and blinded, composed of 100 healthy control sera and 50 CD sera. RESULTS Laboratory sensitivity ranged from 69% to 93% and specificity ranged from 96% to 100%. By receiver operator characteristic analysis, the area under the curve (C index) ranged from 0.9488 to 0.9904. When analyzing for linear correlation, r-squared was as high as 0.8882 but as low as 0.4244 for the celiac samples between different laboratories performing ELISA. CONCLUSIONS This transglutaminase autoantibody workshop allows for larger-scale international participation for the purposes of improving and eventually standardizing the TGAA assay with subsequent workshops.
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Affiliation(s)
- Marcella Li
- University of Colorado Denver, Anshultz Medical Campus, Aurora, Colorado, USA
| | - Liping Yu
- University of Colorado Denver, Anshultz Medical Campus, Aurora, Colorado, USA
| | - Claudio Tiberti
- Department of Clinical Sciences, University of Rome La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Margherita Bonamico
- Department of Clinical Sciences, University of Rome La Sapienza, Policlinico Umberto I, Rome, Italy
| | - Iman Taki
- University of Colorado Denver, Anshultz Medical Campus, Aurora, Colorado, USA
| | - Dongmei Miao
- University of Colorado Denver, Anshultz Medical Campus, Aurora, Colorado, USA
| | - Joseph A. Murray
- Division of Gastroenterology and Hepatology, The Mayo Clinic, Rochester, Minnesota, USA
| | - Marian J. Rewers
- University of Colorado Denver, Anshultz Medical Campus, Aurora, Colorado, USA
| | | | - Daniel Agardh
- Unit of Diabetes and Celiac Disease, Department of Clinical Sciences, Malmö University Hospital, Lund University, Sweden
| | - Patricia Mueller
- Molecular Risk Assessment Laboratory, NSMBB, DLS, NCEH, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Martin Stern
- Department of Pediatrics, University Children's Hospital, Tübingen, Germany
| | - Ezio Bonifacio
- Diabetes Research Institute, Kölner Platz 1, Munich, Germany
| | - Edwin Liu
- University of Colorado Denver, Anshultz Medical Campus, Aurora, Colorado, USA
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Liu E, Li M, Emery L, Taki I, Barriga K, Tiberti C, Eisenbarth GS, Rewers MJ, Hoffenberg EJ. Natural history of antibodies to deamidated gliadin peptides and transglutaminase in early childhood celiac disease. J Pediatr Gastroenterol Nutr 2007; 45:293-300. [PMID: 17873740 DOI: 10.1097/mpg.0b013e31806c7b34] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [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: 12/13/2022]
Abstract
INTRODUCTION Gliadin proteins play a key role in the pathogenesis of celiac disease; however, as a screen for celiac disease, anti-gliadin antibody testing has been replaced by the more sensitive and specific serological assays for transglutaminase autoantibodies (TGAA). A new generation of anti-gliadin antibody assays has been developed to detect synthetic, deamidated homologous gliadin peptides (DGP) with high sensitivity and specificity. METHODS Sera were collected prospectively from children with an increased risk for celiac disease as part of an ongoing study at Denver, and studied for the development of celiac autoimmunity. We investigated the high-performance DGP antibody assay in 50 TGAA-positive children both before the development of celiac autoimmunity and following the institution of a gluten-free diet to determine the relationship of DGP antibodies to TGAA. TGAA were measured by an in-house radioassay. RESULTS DGP antibodies and TGAA parallel each other over the period of years children were studied. DGP antibodies resolved sooner than TGAA in subjects on a gluten-free diet. DGP antibodies appeared earlier than TGAA in 9 children. CONCLUSIONS Measuring DGP antibodies may be more useful than TGAA in monitoring children on a gluten-free diet. DGP antibodies can precede the appearance of TGAA in some at-risk children.
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Affiliation(s)
- Edwin Liu
- Section of Gastroenterology, Hepatology and Nutrition, The Children's Hospital, and Department of Pediatrics, Barbara Davis Center for Childhood Diabetes, University of Colorado at Denver and Health Sciences Center, Denver, CO, USA.
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16
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Simmons JH, Klingensmith GJ, McFann K, Rewers M, Taylor J, Emery LM, Taki I, Vanyi S, Liu E, Hoffenberg EJ. Impact of celiac autoimmunity on children with type 1 diabetes. J Pediatr 2007; 150:461-6. [PMID: 17452216 DOI: 10.1016/j.jpeds.2006.12.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Revised: 10/24/2006] [Accepted: 12/22/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Children with type 1 diabetes (T1DM) are at increased risk for celiac disease (CD); however, the benefits of screening for IgA tissue transglutaminase autoantibodies (TG), a marker for CD, are unclear. STUDY DESIGN We compared 71 screening-identified TG+ with 63 matched TG- children with TIDM. Growth, bone density, and diabetes control measures were obtained. RESULTS The group was 10 +/- 3 years of age, 46% male, with TIDM for 4 +/- 3 years. Z scores for weight (0.3 +/- 1 vs 0.7 +/- 0.8, P = .024), body mass index (BMI) (0.3 +/- 0.9 vs 0.8 +/- -0.8, P = .005), and midarm circumference (0.3 +/- 1.1 vs 0.6 +/- 0.9, P = .031) were lower in the TG+ group. Bone mineral density and diabetes control measures were similar. When limiting the analysis to the 35 TG+ subjects with biopsy changes of CD, the BMI Z score was lower than the control group (0.4 +/- 0.9 vs 0.7 +/- 0.7, P = .05). CONCLUSIONS In children with TIDM, screening-identified evidence of CD is associated with altered body composition, but not bone mineral density or diabetes control. Further study is needed to determine the benefit of early diagnosis and treatment of CD in TIDM children.
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Affiliation(s)
- Jill H Simmons
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado, USA.
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17
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Abstract
Several hereditary and nonhereditary gastrointestinal tract polyposis syndromes exhibit extra-intestinal manifestations, including cutaneous findings. However, a lack of information exists regarding cutaneous features of juvenile polyposis. Our objective was to document the prevalence of cutaneous hyperpigmented lesions in children with juvenile polyposis coli or juvenile polyposis coli and their first degree relatives.Children seen in the gastroenterology practice at The Children's Hospital in Denver, Colorado with polyps (juvenile polyposis coli, sporadic juvenile polyps, and familial adenomatous polyposis coli) and their first degree relatives were invited to participate in the study. A comprehensive skin examination was performed on those who consented to participate. We found that 8 of 14 patients (eight with juvenile polyposis coli, four with juvenile polyposis, and two with familial adenomatous polyposis coli) had at least one café-au-lait macule, compared with three of 27 relatives (p=0.003).The prevalence of at least one café-au-lait macule in our patients (8/14 or 57.1%, CI: 28.9–82.3%) was significantly higher than the general population prevalence of 28.5% (p=0.023). However, if the two patients with familial adenomatous polyposis coli were excluded, the comparison with the general population prevalence did not reach statistical significance (p=0.095). The prevalence of multiple cafe´-au-lait macules in our patients (4/14 or 28.6%; CI:8.4–58.1%) was significantly higher than the general population prevalence of 5.2% (p ¼ 0.005). A notable finding was the presence of multiple café -au-lait macules in 4 of 12 juvenile polyposis coli/juvenile polyposis patients.Two patients with juvenile polyposis coli also had lentigines. In this selected case series, we observed single or multiple café-au-lait macules in a high proportion of children with the three types of polyps. Further studies are needed to assess a possible common pathway for hamartomatous polypsand café-au-lait macules.
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Affiliation(s)
- Theresa R Pacheco
- Department of Dermatology, University of Colorado at Denver and the Health Sciences Center, Aurora,Colorado, USA.
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Abstract
This article is meant to guide the allergist in clinical practice. Current understanding of the pathogenesis and epidemiology of celiac disease is reviewed. Issues of screening and genetic testing are discussed and current controversies and additional resources are highlighted.
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Affiliation(s)
- Edward J Hoffenberg
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado Denver Health Sciences Center, USA
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19
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Stene LC, Honeyman MC, Hoffenberg EJ, Haas JE, Sokol RJ, Emery L, Taki I, Norris JM, Erlich HA, Eisenbarth GS, Rewers M. Rotavirus infection frequency and risk of celiac disease autoimmunity in early childhood: a longitudinal study. Am J Gastroenterol 2006; 101:2333-40. [PMID: 17032199 DOI: 10.1111/j.1572-0241.2006.00741.x] [Citation(s) in RCA: 365] [Impact Index Per Article: 20.3] [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: 12/11/2022]
Abstract
OBJECTIVE Few studies have assessed the role of specific gastrointestinal infections in celiac disease. We investigated whether increased frequency of rotavirus infection, a common cause of gastrointestinal infection and inflammation, predicts increased risk of celiac disease autoimmunity. METHODS A cohort of 1,931 children from the Denver metropolitan area who carried celiac disease human leukocyte antigen (HLA) risk alleles were followed from infancy for development of celiac disease autoimmunity, defined as positivity at two or more subsequent clinic visits for tissue transglutaminase (tTG) autoantibodies measured using a radioimmunoassay with human recombinant tTG. Blood samples were obtained at ages 9, 15, and 24 months, and annually thereafter. Rotavirus antibodies were assayed using an indirect enzyme immunoassay in serial serum samples from each case and two matched controls. Frequency of infections were estimated by the number of increases (> 2 assay coefficient of variation) in rotavirus antibody between clinic visits. RESULTS Fifty-four cases developed celiac disease autoimmunity at a median age of 4.4 yr. Thirty-six had an intestinal biopsy, of which 27 (75%) were positive for celiac disease. Frequent rotavirus infections predicted a higher risk of celiac disease autoimmunity (compared with zero infections, rate ratio 1.94, 95% confidence interval [CI] 0.39-9.56, for one infection and rate ratio 3.76, 95% CI 0.76-18.7, for > or = 2 infections, rate ratio for trend per increase in number of infections = 1.94, 95% CI 1.04-3.61, p = 0.037). The result was similar after adjustment for gender, ethnic group, maternal education, breast-feeding, day-care attendance, number of siblings, season of birth, and number of HLA DR3-DQ2 haplotypes. CONCLUSIONS This prospective study provides the first indication that a high frequency of rotavirus infections may increase the risk of celiac disease autoimmunity in childhood in genetically predisposed individuals.
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Affiliation(s)
- Lars C Stene
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado 80045-6511, USA
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Affiliation(s)
- Paulina Ordonez
- University of Colorado Denver Health Sciences Center/The Children's Hospital, Denver, Colorado, USA
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21
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Abstract
OBJECTIVE To determine the frequency of anti-Saccharomyces cerevisiae antibodies (ASCA) seropositivity in pediatric patients with cystic fibrosis (CF) and correlate ASCA with clinical features. METHODS Prospective study of children with CF aged 2 to 21 years enrolled from The Children's Hospital Cystic Fibrosis Center. Exclusion criteria included Crohn disease, immunodeficiency or immunoglobulin A deficiency. The frequency of ASCA (ASCA immunoglobulin A and immunoglobulin G) was measured by an enzyme-linked immunosorbent assay kit provided by Inova, Inc. (San Diego, CA). The CF Foundation database was queried for clinical data on ASCA seropositive patients. RESULTS Seventeen (20.7%) of 82 patients were seropositive for ASCA. Of these, eight had immunoglobulin A antibodies, six had immunoglobulin G antibodies and three had both. ASCA seropositivity in CF patients was significantly greater than the general population (20.7% versus 4%, P < 0.0001), using an exact binomial test on a single proportion. The 95% confidence limits around our observed proportion were 12.6% to 31.1%. Of 17 ASCA positive patients, 1 (5.8%) had a history of meconium ileus, 14 (82.4%) had DeltaF508 gene mutation, 9 (52.9%) had positive sputum cultures for fungal organisms, and 17 (100%) had an ideal body weight % >or=85%. CONCLUSION Patients with CF have a higher frequency of ASCA seropositivity than the general population. When evaluating CF patients for Crohn disease, ASCA should be used with caution. The reasons for higher ASCA seropositivity in CF patients are unknown, but may include exposure to fungal organisms via intestinal or pulmonary sources.
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Affiliation(s)
- Adria A Condino
- The Children's Hospital, University of Colorado Health Sciences Center, Department of Pediatrics, Denver, USA
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22
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Norris JM, Barriga K, Hoffenberg EJ, Taki I, Miao D, Haas JE, Emery LM, Sokol RJ, Erlich HA, Eisenbarth GS, Rewers M. Risk of celiac disease autoimmunity and timing of gluten introduction in the diet of infants at increased risk of disease. JAMA 2005; 293:2343-51. [PMID: 15900004 DOI: 10.1001/jama.293.19.2343] [Citation(s) in RCA: 249] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CONTEXT While gluten ingestion is responsible for the signs and symptoms of celiac disease, it is not known what factors are associated with initial appearance of the disease. OBJECTIVE To examine whether the timing of gluten exposure in the infant diet was associated with the development of celiac disease autoimmunity (CDA). DESIGN, SETTING, AND PATIENTS Prospective observational study conducted in Denver, Colo, from 1994-2004 of 1560 children at increased risk for celiac disease or type 1 diabetes, as defined by possession of either HLA-DR3 or DR4 alleles, or having a first-degree relative with type 1 diabetes. The mean follow-up was 4.8 years. MAIN OUTCOME MEASURE Risk of CDA defined as being positive for tissue transglutaminase (tTG) autoantibody on 2 or more consecutive visits or being positive for tTG once and having a positive small bowel biopsy for celiac disease, by timing of introduction of gluten-containing foods into the diet. RESULTS Fifty-one children developed CDA. Findings adjusted for HLA-DR3 status indicated that children exposed to foods containing wheat, barley, or rye (gluten-containing foods) in the first 3 months of life (3 [6%] CDA positive vs 40 [3%] CDA negative) had a 5-fold increased risk of CDA compared with children exposed to gluten-containing foods at 4 to 6 months (12 [23%] CDA positive vs 574 [38%] CDA negative) (hazard ratio [HR], 5.17; 95% confidence interval [CI], 1.44-18.57). Children not exposed to gluten until the seventh month or later (36 [71%] CDA positive vs 895 [59%] CDA negative) had a marginally increased risk of CDA compared with those exposed at 4 to 6 months (HR, 1.87; 95% CI, 0.97-3.60). After restricting our case group to only the 25 CDA-positive children who had biopsy-diagnosed celiac disease, initial exposure to wheat, barley, or rye in the first 3 months (3 [12%] CDA positive vs 40 [3%] CDA negative) or in the seventh month or later (19 [76%] CDA positive vs 912 [59%] CDA negative) significantly increased risk of CDA compared with exposure at 4 to 6 months (3 [12%] CDA positive vs 583 [38%] CDA negative) (HR, 22.97; 95% CI, 4.55-115.93; P = .001; and HR, 3.98; 95% CI, 1.18-13.46; P = .04, respectively). CONCLUSION Timing of introduction of gluten into the infant diet is associated with the appearance of CDA in children at increased risk for the disease.
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Affiliation(s)
- Jill M Norris
- Department of Preventive Medicine and Biometrics, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262, USA.
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Liu E, Li M, Bao F, Miao D, Rewers MJ, Eisenbarth GS, Hoffenberg EJ. Need for quantitative assessment of transglutaminase autoantibodies for celiac disease in screening-identified children. J Pediatr 2005; 146:494-9. [PMID: 15812452 DOI: 10.1016/j.jpeds.2004.11.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [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: 12/21/2022]
Abstract
OBJECTIVES To assess several transglutaminase autoantibody (TGAA) assays in their ability to distinguish celiac disease (CD) in screening-identified children with abnormal intestine biopsy specimens from those with normal biopsy specimens. STUDY DESIGN Children at risk for CD (n = 54) composed of type 1 diabetics, first-degree relatives of type 1 diabetics or CD, and HLA-DQ2+ individuals followed from birth received intestine biopsy. Sera obtained at the time of biopsy were tested for TGAA, using the radioimmunoassay and 5 other commercially available enzyme-linked immunosorbent assays. RESULTS False-positive rates ranged from 28% to 80%. The positive predictive value (PPV) of the tests ranged from 63% to 84% (lower than reported for symptomatic children). Setting a higher cutoff for each assay maximized PPV. CONCLUSIONS There are significant quantitative differences among all TGAA assays that could affect interpretation of a positive test for CD. The overall false-positive rate for all assays was high in this population. Using the assay as a quantitative rather than qualitative tool by increasing the cutoff of positivity to indicate biopsy increases PPV. Multicenter workshops are needed to identify critical differences and to standardize TGAA assays among laboratories.
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Affiliation(s)
- Edwin Liu
- Davis Center for Childhood Diabetes, School of Medicine, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA
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Abstract
To address the issue of screening children for celiac disease, current evidence has been summarized and placed within the context of 8 established criteria for childhood screening. Screening all children for celiac disease is not recommended at this time. Areas with gaps in knowledge are identified as areas in need of further study. These include the timing of screening, defining the natural history of screening-identified celiac disease, developing tools to predict disease onset and disease remission, and the risks of screening.
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Affiliation(s)
- Edward J Hoffenberg
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado Health Sciences Center, The Children's Hospital, Denver, Colorado, USA.
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Abstract
INTRODUCTION Infliximab is a promising advance in the treatment of pediatric inflammatory bowel disease. Infliximab is an effective therapy for selected children with Crohn disease but is both costly and time consuming. OBJECTIVES To analyze our center's experience with a program of home-based infliximab infusion. METHODS Between September, 2001, and October, 2003 we reviewed the charts of all children receiving home infliximab infusions focusing on cost, safety, and patient satisfaction. Children were enrolled in the home infusion program if they were compliant with hospital-based infliximab infusions and other medications, had no adverse events during hospital-based infliximab infusions, were in remission and had access to experienced pediatric homecare nursing. RESULTS Ten children received 59 home infusions with a dose range of 7.5 to 10 mg/kg/dose. The calculated average savings per patient was 1335 US dollar/100 mg infliximab. Home infusions ranged from 2 to 5 hours. Since infusions could be performed any day of the week, school absenteeism was decreased. The average patient satisfaction rating for home infusions was 9 on a scale from 1 to 10 (10 = most satisfied). Three patients experienced difficulty with IV access requiring multiple attempts, but all were able to receive their infusions. One infusion was stopped because of arm pain above the IV site. This patient had his next infusion in the hospital before returning to the home infusion program. No severe adverse events (palpitations, blood pressure instability, hyperemia, respiratory symptoms) occurred during home infusions. CONCLUSIONS In our carefully selected patients, infliximab infusions administered at home were safe and are cost-effective. Patients and families preferred home infusions, since time missed from school and work was reduced.
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Affiliation(s)
- Adria A Condino
- The Childrens Hospital, University of Colorado Health Sciences Center, Denver, Colorado, USA
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Iwamoto M, Hoffenberg EJ, Carethers JM, Doctolero R, Tajima A, Sugano K, Franklin WA, Ahnen DJ. Nuclear accumulation of beta-catenin occurs commonly in the epithelial cells of juvenile polyps. Pediatr Res 2005; 57:4-9; discussion 1-3. [PMID: 15557107 DOI: 10.1203/01.pdr.0000148062.57051.8f] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [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: 11/06/2022]
Abstract
In the two conditions juvenile polyps (JPs) and juvenile polyposis coli (JPC), colonic polyps may have overlapping histologic and phenotypic appearance, but JPC confers a significant risk for colon adenocarcinoma. Although not thought to contain adenomatous polyposis coli (APC) mutations, the status of beta-catenin and full-length APC protein expression in JPs is not known. We evaluated beta-catenin and full-length APC protein expression in JPs from children with JPs and JPC. Cases were identified through endoscopic procedure records. Immunohistochemistry was performed for beta-catenin and full-length APC protein. Loss of heterozygosity at the APC gene locus on chromosome 5 was assessed using two APC-linked microsatellite markers. Polyp and normal colonic tissue were analyzed from 36 children with JPs and 9 with JPC. Both APC and beta-catenin immunoreactivity were present in epithelial cells from all samples but in different patterns. In all normal colon and polyp samples, APC expression was cytoplasmic with maximal immunoreactivity in the goblet cells. In contrast, beta-catenin immunoreactivity in epithelial cells was limited to the plasma membrane in normal colon but was both cytoplasmic and nuclear in all 45 JPs. No evidence of APC gene loss of heterozygosity was found. In polyps from children with JPs and JPC, nuclear beta-catenin accumulation is a consistent feature, and it is not due to APC gene mutation or loss of full-length APC protein expression. Thus, beta-catenin accumulation may be intrinsic to the formation of juvenile-type polyps through an as-yet-undefined mechanism.
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Affiliation(s)
- Michiko Iwamoto
- Department Medicine, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Hill ID, Dirks MH, Liptak GS, Colletti RB, Fasano A, Guandalini S, Hoffenberg EJ, Horvath K, Murray JA, Pivor M, Seidman EG. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2005; 40:1-19. [PMID: 15625418 DOI: 10.1097/00005176-200501000-00001] [Citation(s) in RCA: 684] [Impact Index Per Article: 36.0] [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] [Indexed: 02/08/2023]
Abstract
Celiac disease is an immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals. It occurs in children and adolescents with gastrointestinal symptoms, dermatitis herpetiformis, dental enamel defects, osteoporosis, short stature, delayed puberty and persistent iron deficiency anemia and in asymptomatic individuals with type 1 diabetes, Down syndrome, Turner syndrome, Williams syndrome, selective immunoglobulin (Ig)A deficiency and first degree relatives of individuals with celiac disease. The Celiac Disease Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has formulated a clinical practice guideline for the diagnosis and treatment of pediatric celiac disease based on an integration of a systematic review of the medical literature combined with expert opinion. The Committee examined the indications for testing, the value of serological tests, human leukocyte antigen (HLA) typing and histopathology and the treatment and monitoring of children with celiac disease. It is recommended that children and adolescents with symptoms of celiac disease or an increased risk for celiac disease have a blood test for antibody to tissue transglutaminase (TTG), that those with an elevated TTG be referred to a pediatric gastroenterologist for an intestinal biopsy and that those with the characteristics of celiac disease on intestinal histopathology be treated with a strict gluten-free diet. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition on the diagnosis and treatment of celiac disease in children and adolescents.
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Affiliation(s)
- Ivor D Hill
- North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Flourtown, PA 19031, USA
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Hoffenberg EJ, Emery LM, Barriga KJ, Bao F, Taylor J, Eisenbarth GS, Haas JE, Sokol RJ, Taki I, Norris JM, Rewers M. Clinical features of children with screening-identified evidence of celiac disease. Pediatrics 2004; 113:1254-9. [PMID: 15121938 DOI: 10.1542/peds.113.5.1254] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [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: 12/18/2022] Open
Abstract
OBJECTIVE At-risk groups commonly undergo screening for autoantibodies associated with celiac disease (CD). However, the clinical significance of a positive test remains uncertain. The objective of this study was to evaluate growth and clinical features of children who test positive for an autoantibody associated with CD. METHODS A case-control study of Denver area healthy infants and young children with and without CD autoantibodies was conducted. A cohort of HLA-characterized children were followed prospectively since birth for the development of immunoglobulin A antitissue transglutaminase autoantibodies (TG). Clinical evaluation, questionnaire, blood draw, and small bowel biopsy were performed. Growth and nutrition and frequency of positive responses were measured. RESULTS Compared with 100 age- and gender-matched TG-negative controls, 18 TG-positive children, 5.5 +/- 0.5 years of age, had a greater number of symptoms and lower z scores for weight-for-height and for body mass index. Responses that were independently associated with TG-positive status were irritability/lethargy, abdominal distention/gas, and difficulty with weight gain. CONCLUSIONS Screening-identified TG-positive children demonstrate mild alterations in growth and nutrition and report more symptoms than control subjects. Additional study is needed on the benefit and risk of identifying CD in at-risk groups.
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Affiliation(s)
- Edward J Hoffenberg
- Department of Pediatrics, Children's Hospital, and the University of Colorado School of Medicine, Denver, Colorado, USA.
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Affiliation(s)
- Marian Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, 4200 East 9th Avenue, B-140, Denver, CO 80262, USA.
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Hoffenberg EJ, MacKenzie T, Barriga KJ, Eisenbarth GS, Bao F, Haas JE, Erlich H, Bugawan Tl TL, Sokol RJ, Taki I, Norris JM, Rewers M. A prospective study of the incidence of childhood celiac disease. J Pediatr 2003; 143:308-14. [PMID: 14517510 DOI: 10.1067/s0022-3476(03)00282-8] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To estimate the frequency of celiac disease (CD) in children in the general population of Denver, Colorado. STUDY DESIGN From 22,346 newborns characterized as expressing 0, 1, or 2 HLA-DR3(DQB1*0201) alleles, 987 were selected for a prospective stratified cohort study. Participants were followed for as long as 7 years with serial testing for serum IgA anti-transglutaminase antibodies and for evidence of CD (intestinal mucosal changes or persistent seropositivity). RESULTS Of 40 children with at least one positive serologic test, 19 had evidence of CD (10 by biopsy, 9 by persistent seropositivity). Those expressing 0, 1, or 2 HLA-DR3 alleles had, respectively, 0.3% (95% CI, 0.0-2.7), 3.4% (3.0-11.7), and 3.2% (1.0-11.0) risk for evidence of CD by age 5 years. The adjusted risk estimate for evidence of CD by age 5 years for the Denver general population was 0.9% (0.4-2.0), or 1 in 104 (1:49-221). After adjusting for number of HLA-DR3 alleles expressed, risk was higher in females: RR=3.34 (1.00-10.9, P=.048). Evidence of CD was not observed before age 2.6 years. CONCLUSIONS Celiac disease may affect 0.9% of Denver children by 5 years of age. Children positive for the HLA-DR3 allele and females appear to be at increased risk.
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Affiliation(s)
- Edward J Hoffenberg
- Department of Pediatrics, Barbara Davis Center for Childhood Diabetes, University of Colorado, Denver, USA
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31
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Affiliation(s)
- Edward J Hoffenberg
- Section of Gastroenterology, Hepatology and Nutrition, University of Colorado Health Sciences Center and the Children's Hospital, Denver, CO, USA
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32
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Liu E, Bao F, Barriga K, Miao D, Yu L, Erlich HA, Haas JE, Eisenbarth GS, Rewers MJ, Hoffenberg EJ. Fluctuating transglutaminase autoantibodies are related to histologic features of celiac disease. Clin Gastroenterol Hepatol 2003; 1:356-62. [PMID: 15017653 DOI: 10.1053/s1542-3565(03)00180-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [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: 02/07/2023]
Abstract
BACKGROUND & AIMS Asymptomatic children at risk for celiac disease (CD) and seropositive for immunoglobulin A anti-TG autoantibodies (TGAA) may lack small intestinal mucosal changes characteristic of CD. We have followed a group of children with serial testing for TGAA. METHODS Subjects were a group of at-risk children comprised of infants expressing HLA-DR3 on newborn screening, those with type 1A diabetes, or a first-degree relative of someone with type 1 diabetes. All children participating in the prospective study for development of CD underwent serial testing for TGAA. Data from clinical evaluation and small intestinal biopsy were compared to the TGAA levels followed over time. RESULTS In 42 children, serial TGAA determinations while on a gluten-containing diet showed levels fluctuating 10-100-fold over 3-12 months. A TGAA index more than 0.5 had a positive predictive value (PPV) for histologic confirmation of CD of 96% (22/23). A TGAA index above the usual cutoff for positivity (0.05) had a PPV of only 76% (28/37). CONCLUSIONS In children with TGAA seropositivity, the TGAA level varied over time and a higher titer predicted an abnormal biopsy characteristic of CD. A threshold for biopsy for diagnosis of CD could be set higher for screening-identified cases than for clinically identified cases to decrease the frequency of performing "normal" biopsies.
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Affiliation(s)
- Edwin Liu
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Roche Molecular Systems, Alameda, CA, USA.
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33
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Hoffenberg EJ. A confusing case report about an important issue. J Pediatr Gastroenterol Nutr 2003; 36:509-10. [PMID: 12872780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Edward J Hoffenberg
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado Health Sciences Center, The Children's Hospital, Denver, CO, USA
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34
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Wershil B, Hoffenberg EJ, Winter HS. Research agenda for pediatric gastroenterology, hepatology and nutrition: allergy and immunology. Report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition for the Children's Digestive Health and Nutrition Foundation. J Pediatr Gastroenterol Nutr 2003; 35 Suppl 3:S291-5. [PMID: 12394368 DOI: 10.1097/00005176-200210003-00013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Barry Wershil
- Children's Digestive Health and Nutrition Foundation, PO Box 6, Flourtown, PA 19031, USA.
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35
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Abstract
Microvillous inclusion disease is a rare lethal disorder characterized by intractable, severe, watery diarrhea beginning in early infancy. The underlying defect is thought to be an autosomal recessive genetic abnormality resulting in defective brush-border assembly and differentiation. Normally, this diagnosis is easily established through the electron microscopic demonstration of characteristic microvilli-lined inclusions lying within the apical cytoplasm of surface enterocytes. In a small number of patients appearing to have microvillous inclusion disease it has not proven possible to demonstrate the typical inclusions. The existence of another entity, termed intestinal microvillous dystrophy, has been proposed to account for such occurrences. This assertion was founded in large part upon the observation that the few subjects studied all displayed a slightly atypical clinical presentation. The case now being presented exhibited the morphologic features ascribed to intestinal microvillous dystrophy but had a clinical presentation that was entirely typical of microvillous inclusion disease. It serves thus to conceptually unite intestinal microvillous dystrophy with microvillous inclusion disease.
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Affiliation(s)
- G W Mierau
- Department of Pathology, The Children's Hospital, Denver, Colorado 80218, USA.
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36
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Affiliation(s)
- E Liu
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children's Hospital, University of Colorado School of Medicine, 1056 East 9th Ave., Denver, CO 80218, USA
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37
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Abstract
BACKGROUND Large-volume paracentesis has been evaluated for both therapeutic and diagnostic purposes in the management of ascites in cirrhotic adults. There are no published data relating to the safety, efficacy, or methods of this procedure in children. The objective of this study was to characterize the authors' initial experience with large-volume paracentesis (> 50 ml/kg of ascites) for removal of tense abdominal ascites in the pediatric population. METHODS Retrospective chart review was performed of 21 large-volume paracentesis sessions in seven children (ages 6 months-18 years) with tense ascites that did not respond to other measures. RESULTS Mean volume removed was 3,129 +/- 2,966 ml (mean +/- standard deviation) or 118 +/- 56 ml/kg over 2.9 +/- 3.7 hours by a 16-gauge intravascular catheter in 6 sessions, by an 18-gauge intravascular catheter in three sessions, and by a 15-gauge fenestrated, stainless-steel paracentesis needle in 12 sessions. Large-volume paracenteses performed with the paracentesis needle had significantly shorter duration of drainage and faster flow rates than those performed with the intravascular catheter. The only complication encountered was decreased urine output in one session. CONCLUSIONS Large-volume paracentesis is a safe and effective therapeutic method for managing tense abdominal ascites in children. The use of the paracentesis needle significantly improved the speed and efficiency of large-volume paracentesis compared with the intravascular catheter.
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Affiliation(s)
- R E Kramer
- Pediatric Liver Center and Liver Transplantation Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital and University of Colorado Health Sciences Center, Denver, Colorado 80218, USA
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38
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Mierau GW, Wills EJ, Wyatt-Ashmead J, Hoffenberg EJ, Cutz E. Microvillous inclusion disease: report of a case with atypical features. Ultrastruct Pathol 2001; 25:275-9. [PMID: 11465482] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Microvillous inclusion disease is a rare lethal disorder characterized by intractable, severe, watery diarrhea beginning in early infancy. The underlying defect is thought to be an autosomal recessive genetic abnormality resulting in defective brush-border assembly and differentiation. Normally, this diagnosis is easily established through the electron microscopic demonstration of characteristic microvilli-lined inclusions lying within the apical cytoplasm of surface enterocytes. In a small number of patients appearing to have microvillous inclusion disease it has not proven possible to demonstrate the typical inclusions. The existence of another entity, termed intestinal microvillous dystrophy, has been proposed to account for such occurrences. This assertion was founded in large part upon the observation that the few subjects studied all displayed a slightly atypical clinical presentation. The case now being presented exhibited the morphologic features ascribed to intestinal microvillous dystrophy but had a clinical presentation that was entirely typical of microvillous inclusion disease. It serves thus to conceptually unite intestinal microvillous dystrophy with microvillous inclusion disease.
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Affiliation(s)
- G W Mierau
- Department of Pathology, The Children's Hospital, Denver, Colorado 80218, USA.
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39
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Abstract
OBJECTIVES The transglutaminase (TG) antibody test is accurate in identifying celiac disease in symptomatic children. We sought to determine the positive predictive value of this test in asymptomatic children at genetic risk for celiac disease. STUDY DESIGN Asymptomatic children with a genetic risk for celiac disease were studied to investigate the relationships between TG antibody titer, small bowel histology, growth, and clinical features. Small bowel biopsy histology was graded by using the system of Marsh. RESULTS Of 30 children with a positive TG antibody test result, 21 (70%) had definite (Marsh score 2 or 3) and 4 (13%) had possible (Marsh score 1) biopsy evidence of celiac disease. TG antibody titer correlated with Marsh score (r = 0.569, P <.01). There was an inverse correlation between Marsh score and height z score (r = -0.361, P =. 05). CONCLUSIONS In this group of asymptomatic children screened because of a genetic risk, TG antibodies have a positive predictive value of 70% to 83% for biopsy evidence of celiac disease and may identify children before clinical features of celiac disease develop.
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Affiliation(s)
- E J Hoffenberg
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Center for Pediatric Inflammatory Bowel Diseases, Department of Pediatrics, Barbara Davis Center for Childhood Diabetes, Denver, Colorado, USA
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Abstract
OBJECTIVE To determine whether consumption of oats is safe in children with newly diagnosed celiac disease who are starting a gluten-free diet. STUDY DESIGN We conducted a self-controlled, open-label, 6-month trial of a commercial oat breakfast cereal product. Primary outcome variables were small bowel histomorphology and anti-tissue transglutaminase IgA antibody titer. RESULTS The 10 children who completed the study were 6.8 +/- 4.0 (mean +/- SD) years of age and 5 were male. Over 6.6 +/- 0.7 months, they consumed 24 grams of oat cereal per day, or 1.2 +/- 0.9 g/kg/d. Compared with start of study, at completion there was a significant decrease in biopsy score (P <.01), intra-epithelial lymphocyte count (P <.005), anti-tissue transglutaminase IgA antibody titer (P <.01), and number of symptoms (P <.01). CONCLUSIONS We conclude that consumption of a commercially available oat cereal product for 6 months is safe for children with celiac disease beginning a gluten-free diet. Studies are needed to determine the long-term safety of including oat cereal in the gluten-free diet.
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Affiliation(s)
- E J Hoffenberg
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Center for Pediatric Inflammatory Bowel Diseases, Department of Pediatrics, The Children's Hospital, Denver, Colorado, USA
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Bao F, Yu L, Babu S, Wang T, Hoffenberg EJ, Rewers M, Eisenbarth GS. One third of HLA DQ2 homozygous patients with type 1 diabetes express celiac disease-associated transglutaminase autoantibodies. J Autoimmun 1999; 13:143-8. [PMID: 10441179 DOI: 10.1006/jaut.1999.0303] [Citation(s) in RCA: 166] [Impact Index Per Article: 6.6] [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] [Indexed: 12/12/2022]
Abstract
Type 1 diabetes and celiac disease are both immunologic disorders where specific HLA alleles are associated with disease risk. We have developed a radioassay for autoantibodies to tissue transglutaminase (tTG) following the report that this enzyme is 'the' endomysial autoantigen (EMA) of celiac disease. The radioassay for transglutaminase autoantibodies is similar to that utilized for detecting anti-islet autoantibodies. The 'cut-off' for the IgA autoantibody assay was established as 3 x 100th percentile of 184 healthy control subjects at an index of 0.05. Ninety-eight of 847 patients with type 1 diabetes (11.6%) had tissue transglutaminase autoantibodies (tTG). All EMA-positive patients were positive (49/49) for transglutaminase autoantibodies, as were 49/540 EMA-negative patients. Twenty transglutaminase-positive patients consented to intestinal biopsy and 15 biopsies were positive for celiac disease. All patients with a transglutaminase level greater than 0.70 (13/13) had a positive biopsy, while none (0/3) with a level <0.3 had a positive biopsy. The prevalence of transglutaminase autoantibodies was higher in diabetic patients with HLA DQ2 or DQ8. One third of DQ2 homozygous patients (22/68) expressed transglutaminase autoantibodies vs. less than 2% of patients lacking DQ2 or DQ8. A simple radioassay for IgA transglutaminase autoantibodies detects all endomysial antibody positive patients and detects transglutaminase autoantibodies in 5% of endomysial autoantibody negative patients. The prevalence of transglutaminase autoantibodies is associated with DQ2 and DQ8 and in particular DQ2 homozygosity. Autoimmunity to transglutaminase is remarkably prevalent amongst patients with type 1 diabetes expressing certain class II HLA alleles.
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Affiliation(s)
- F Bao
- Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA
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42
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Abstract
OBJECTIVES To determine the accuracy of anti-neutrophil cytoplasmic antibodies (ANCAs) and anti-Saccharomyces cerevisiae antibodies (ASCA) in distinguishing patients with inflammatory bowel disease from patients with other disorders, seen in a pediatric gastroenterology clinic setting, and in distinguishing ulcerative colitis (UC) from Crohn's disease (CD). STUDY DESIGN Serum samples from 120 children with new or established diagnoses of UC (n = 25) or CD (n = 20) and control children (n = 74) were analyzed in blinded fashion for the presence of IgG ANCAs and IgA and IgG ASCA. RESULTS The highest sensitivity for detecting inflammatory bowel disease, 71%, was achieved by using ANCAs and ASCA together. The best test for UC was ANCAs, which had a sensitivity of 80%. However, the ANCA pattern characteristic of UC, perinuclear ANCAs eliminated by DNAse, had a sensitivity of 60%. High-titer ANCAs were specific for UC, whereas ASCA were specific for CD. CONCLUSIONS Testing for ANCAs and ASCA together did not achieve sensitivity necessary for population screening. However, ANCAs and ASCA may be helpful in evaluating children suspected of having inflammatory bowel disease and in distinguishing UC from CD.
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Affiliation(s)
- E J Hoffenberg
- Center for Pediatric Inflammatory Bowel Diseases, Section of Pediatric Gastroenterology, University of Colorado School of Medicine, Denver, USA
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Abstract
BACKGROUND The clinical spectrum of symptomatic polyps and the frequency of familial polyposis is not well defined in children. In the present study, a series of children with juvenile polyposis coli (JPC) and non-JPC polyps were studied. METHODS Children with symptomatic colonic polyps and negative family history of polyps were ascertained by review of endoscopic records. Juvenile polyposis coli was defined as 10 or more juvenile polyps or any juvenile polyp in a relative of an index case of JPC. Polyps were tested for Ki-ras mutations, p53 overexpression, and aneuploidy. RESULTS Seventy-eight children (age range, 0.4-18 years) were identified, all evaluated for lower gastrointestinal bleeding. Nine (12%) had JPC, 66 (84%) had isolated juvenile polyps, and 3 (4%) had other types of polyps. The JPC and non-JPC groups were similar in age (p = 0.4) and symptom duration (p = 0.3). The JPC group had more polyps (p = 0.0001), and greater likelihood of anemia (p = 0.01), polyps with adenomatous change (p = 0.03), and right-colon polyps (p = 0.001). In three of eight JPC families, polyps were identified in asymptomatic first-degree relatives. No abnormalities in Ki-ras, p53, or aneuploidy were identified. CONCLUSIONS Juvenile polyposis coli is common in children with symptomatic polyps, and is associated with anemia, right-colon polyps, and adenomas. The risk of polyps and of colorectal cancer in relatives of persons with JPC requires further study.
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Affiliation(s)
- E J Hoffenberg
- Department of Pediatrics, University of Colorado School of Medicine, and The Children's Hospital, Denver, USA
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Abstract
Little is known about the specific psychosocial factors that influence quality of life in adolescents with newly diagnosed inflammatory bowel disease (IBD). We adapted a model by Garrett and Drossman to assess adolescent adjustment to recent-onset IBD. Thirty adolescent-parent pairs completed a set of standardized questionnaires. The inclusion criteria were adolescents 12-18 years of age with Crohn's disease or ulcerative colitis of < 5 years' duration. Adolescents' health-related quality-of-life scores significantly correlated with satisfaction and degree of closeness with their social support members, such as parents. An unexpected finding was that the adolescents included more extended family than peers in their social support networks. Also of note was that parental coping styles rather than adolescent coping styles significantly correlated with adolescents' quality-of-life health scores. Severity of illness did not correlate with adolescent quality-of-life health scores. There was significant agreement between adolescent and parental quality-of-life health scores and stressful event ratings. Adolescents with recent-onset IBD rely more on family members than their peers for emotional support, and they depend more on their parents' coping skills than their own. These findings may indicate lags in normal adolescent development. Adolescents and parents do communicate and share concerns with each other. Support programs for adolescents with IBD should reinforce existing coping skills and parent-adolescent communication while promoting normative development.
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Affiliation(s)
- M MacPhee
- Department of Pediatrics, University of Colorado School of Medicine, Denver, USA
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Hoffenberg EJ, Rothenberg SS, Bensard D, Sondheimer JM, Sokol RJ. Outcome after exploratory laparoscopy for unexplained abdominal pain in childhood. Arch Pediatr Adolesc Med 1997; 151:993-8. [PMID: 9343009 DOI: 10.1001/archpedi.1997.02170470027006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Abdominal pain in childhood is common yet frustrating when unexplained. OBJECTIVE To describe the clinical features and outcome of 8 children (6 girls and 2 boys; mean[+/- SD] age, 13 +/- 2 years) with unexplained abdominal pain who underwent exploratory laparoscopy. SETTING All 8 patients were examined at an academic pediatric gastroenterology center and referred for exploratory laparoscopy because of unexplained abdominal pain. Laparoscopy was offered after family agreement to pursue behavioral management if the pain and disability did not improve. RESULTS In all 8 children, laparoscopy detected an anomaly at a site corresponding to that of the abdominal pain. Findings were adhesions in 7 children (3 colonic, 2 ileocecal, 1 gastric, and 1 appendiceal) and ovarian torsion in 1 child. At a mean follow-up of 12.6 months, the abdominal pain had completely resolved in 6 children, notably improved in 1 child, and continued unchanged in 1 child. Disability completely resolved in 2 of 3 children. CONCLUSIONS In children with unexplained abdominal pain that is acute in onset, well described, and suggestive of peritoneal involvement, exploratory laparoscopy (1) successfully ends the cycle of abdominal pain in most cases; and (2) commonly identifies abnormalities, usually adhesions. However, whether laparoscopy, the placebo effect, or both promote the healing process is unclear. Further study is needed to develop criteria for referral for laparoscopic evaluation of unexplained abdominal pain.
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Affiliation(s)
- E J Hoffenberg
- Department of Pediatrics, University of Colorado School of Medicine, Denver, USA
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Abstract
The mechanisms by which inflammatory bowel disease causes chronic injury to the gastrointestinal tract are poorly understood. To determine whether antioxidant defenses might be altered, we evaluated plasma antioxidant concentrations in 24 children with inflammatory bowel disease (12 with Crohn disease and 12 with ulcerative colitis) and in 23 healthy control subjects. Anthropometric measurements and disease activity scores were obtained. The groups were of similar age and sex distribution; most children had quiescent or mild disease. The children with Crohn disease were malnourished compared with the ulcerative colitis and control groups. Children with inflammatory bowel disease had decreased plasma ascorbic acid and increased glutathione peroxidase, glutathione, and alpha-tocopherol (vitamin E) concentrations compared with control subjects. These differences were found primarily in the children with Crohn disease. This study provides evidence that children with Crohn disease have alterations in circulating antioxidant defenses, possibly related to an ongoing oxidant stress.
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Affiliation(s)
- E J Hoffenberg
- Department of Pediatrics, University of Colorado School of Medicine, Denver, USA
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Abstract
Oxidant stress seems to be involved in the pathogenesis of several important gastroenterologic disorders in infants and children. The question can still be asked, in most circumstances, whether the oxidant stress precedes, and therefore is involved in, tissue or cellular injury or is a result of injury and not of clinical importance. The data favor the former situation in several inflammatory conditions of the bowel and in a variety of liver diseases. Experimental and clinical testing of this possible basic mechanism of tissue injury over the next few years will shed light on the role of antioxidants in treating gastrointestinal disorders.
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Affiliation(s)
- R J Sokol
- Pediatric Liver Center, University of Colorado School of Medicine, Denver, USA
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Hoffenberg EJ, Narkewicz MR, Sondheimer JM, Smith DJ, Silverman A, Sokol RJ. Outcome of syndromic paucity of interlobular bile ducts (Alagille syndrome) with onset of cholestasis in infancy. J Pediatr 1995; 127:220-4. [PMID: 7636645 DOI: 10.1016/s0022-3476(95)70298-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.4] [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] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine the outcome, in index patients followed at an American Center, of syndromic paucity of interlobular bile ducts (sPILBD; Alagille syndrome), with onset of cholestasis in infancy. DESIGN Cohort. SETTING Regional referral center for infants and children with liver disease. RESULTS During the past 10 years, 26 unrelated children with sPILBD were identified. Fifteen (58%) are alive without liver transplantation at a median age of 12.1 years. Three (11%) died, all before 2 years of age. Eight patients (31%) underwent liver transplantation at a median age of 6.5 years; all eight are alive a median 5.4 years after transplantation. The most common factors contributing to the decision for transplantation were bone fractures, pruritus, and severe xanthoma. The predicted probability of reaching 19 years of age without transplantation is about 50%; however, with transplantation, the predicted probability of long-term survival is 87%. Of 26 patients 4 (15%) have had significant central nervous system disease, and two of them have died of intracranial hemorrhage. Of the four patients who underwent cholecystoportostomy or portoenterostomy, three required liver transplantation. CONCLUSIONS Children with sPILBD identified in infancy because of cholestasis have a 50% probability of long-term survival without liver transplantation, a worse prognosis than other follow-up studies have reported. In selected patients, liver transplantation provides the opportunity for long-term survival with improved quality of life. Patients with sPILBD are at risk of having intracranial hemorrhage.
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Affiliation(s)
- E J Hoffenberg
- Section of Pediatric Gastroenterology and Nutrition, Children's Hospital, Denver, CO 80218, USA
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Abstract
The humoral and cellular immune response after symptomatic, primary rotavirus infection was examined in 8 children < 2 years old. Rotavirus-specific IgA, rotavirus-specific helper T (Th) cells, and neutralizing antibody responses were evaluated at the time of illness, 2-8 weeks later, and 3-5 months later. In addition, rotavirus strains associated with infection were tested by polymerase chain reaction analysis using oligonucleotide primers specific for genes 4 (P type) and 9 (G type). The absence of rotavirus-specific IgA or rotavirus-specific helper T cell activity at the time of illness was consistent with a primary infection in 7 of 8 children. Two children were infected with serotype 1 (P type 1, G type 1), 3 with serotype 3 (P type 1, G type 3), and 3 with serotype 4 (P type 1, G type 4) strains. Neutralizing antibodies were directed against the gene 4 (P type) protein product (vp4). Because all infecting strains were P type 1, convalescent antisera did not distinguish among different rotavirus G types. Rotavirus-specific IgA responses were detected in 6 of 8 and rotavirus-specific Th cell responses in 7 of 8 children during convalescence.
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Affiliation(s)
- P A Offit
- Division of Allergy, Immunology and Infectious Diseases, Children's Hospital of Philadelphia, PA 19104
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Abstract
An obstacle to developing a successful rotavirus vaccine has been the inability to consistently correlate the humoral immune response with protection against disease. Transplacental transfer of maternal rotavirus-specific antibodies may obscure the capacity to discriminate an active from a passively acquired humoral immune response in infants. In an attempt to circumvent this problem, an assay was developed to detect rotavirus-specific helper T cells among circulating mononuclear cells. Rotavirus-specific lymphoproliferative responses and rotavirus-specific neutralizing antibody titers in blood were determined in 11 mother/newborn pairs at the time of delivery and in 54 infants, children, and adults ranging in age from 16 days to 40 years. Only 1 of 11 infants tested between 16 days and 6 months of age had detectable rotavirus-specific helper T cell activity whereas 8 of 11 had circulating rotavirus-specific neutralizing antibodies. Acquisition of rotavirus-specific helper T cell activity over the first few years of life correlated with the age at which infants and young children are known to be infected with rotavirus. These findings support the hypothesis that detection of rotavirus-specific lymphoproliferative activity in infants may more accurately determine previous exposure to rotavirus than detection of rotavirus-specific antibodies.
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Affiliation(s)
- P A Offit
- Division of Infectious Diseases and Immunology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia 19104
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