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Vuijk SA, Jongsma MME, Hoeven BM, Cozijnsen MA, van Pieterson M, de Meij TGJ, Norbruis OF, Groeneweg M, Wolters VM, van Wering H, Hummel T, Stapelbroek J, van der Feen C, van Rheenen PF, van Wijk MP, Teklenburg S, Rizopoulos D, Poley MJ, Escher JC, de Ridder L. Randomised clinical trial: First-line infliximab biosimilar is cost-effective compared to conventional treatment in paediatric Crohn's disease. Aliment Pharmacol Ther 2024. [PMID: 38644588 DOI: 10.1111/apt.18000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/10/2023] [Accepted: 04/01/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Data on cost-effectiveness of first-line infliximab in paediatric patients with Crohn's disease are limited. Since biologics are increasingly prescribed and accompanied by high costs, this knowledge gap needs to be addressed. AIM To investigate the cost-effectiveness of first-line infliximab compared to conventional treatment in children with moderate-to-severe Crohn's disease. METHODS We included patients from the Top-down Infliximab Study in Kids with Crohn's disease randomised controlled trial. Children with newly diagnosed moderate-to-severe Crohn's disease were treated with azathioprine maintenance and either five induction infliximab (biosimilar) infusions or conventional induction treatment (exclusive enteral nutrition or corticosteroids). Direct healthcare consumption and costs were obtained per patient until week 104. This included data on outpatient hospital visits, hospital admissions, drug costs, endoscopies and surgeries. The primary health outcome was the odds ratio of being in clinical remission (weighted paediatric Crohn's disease activity index<12.5) during 104 weeks. RESULTS We included 89 patients (44 in the first-line infliximab group and 45 in the conventional treatment group). Mean direct healthcare costs per patient were €36,784 for first-line infliximab treatment and €36,874 for conventional treatment over 2 years (p = 0.981). The odds ratio of first-line infliximab versus conventional treatment to be in clinical remission over 104 weeks was 1.56 (95%CI 1.03-2.35, p = 0.036). CONCLUSIONS First-line infliximab treatment resulted in higher odds of being in clinical remission without being more expensive, making it the dominant strategy over conventional treatment in the first 2 years after diagnosis in children with moderate-to-severe Crohn's disease. TRIAL REGISTRATION NUMBER NCT02517684.
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Affiliation(s)
- Stephanie A Vuijk
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maria M E Jongsma
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Britt M Hoeven
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maarten A Cozijnsen
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Merel van Pieterson
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tim G J de Meij
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Obbe F Norbruis
- Department of Paediatric Gastroenterology, Isala Hospital, Zwolle, The Netherlands
| | - Michael Groeneweg
- Department of Paediatric Gastroenterology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Victorien M Wolters
- Department of Paediatric Gastroenterology, UMC Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Herbert van Wering
- Department of Paediatric Gastroenterology, Amphia Hospital, Breda, The Netherlands
| | - Thalia Hummel
- Department of Paediatric Gastroenterology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Janneke Stapelbroek
- Department of Paediatric Gastroenterology, Catharina Hospital, Eindhoven, The Netherlands
| | - Cathelijne van der Feen
- Department of Paediatric Gastroenterology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Michiel P van Wijk
- Department of Paediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Sarah Teklenburg
- Department of Paediatric Gastroenterology, Isala Hospital, Zwolle, The Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Marten J Poley
- Institute for Medical Technology Assessment and Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Department of Pediatric Surgery and Intensive Care, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
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Bevers NC, Keizer RJ, Wong DR, Aliu A, Pierik MJ, Derijks LJJ, van Rheenen PF. Performance of Eight Infliximab Population Pharmacokinetic Models in a Cohort of Dutch Children with Inflammatory Bowel Disease. Clin Pharmacokinet 2024:10.1007/s40262-024-01354-7. [PMID: 38488984 DOI: 10.1007/s40262-024-01354-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND AND OBJECTIVE Efficacy of infliximab in children with inflammatory bowel disease can be enhanced when serum concentrations are measured and further dosing is adjusted to achieve and maintain a target concentration. Use of a population pharmacokinetic model may help to predict an individual's infliximab dose requirement. The aim of this study was to evaluate the predictive performance of available infliximab population pharmacokinetic models in an independent cohort of Dutch children with inflammatory bowel disease. METHODS In this retrospective study, we used data of 70 children with inflammatory bowel disease (443 infliximab concentrations) to evaluate eight models that focused on infliximab pharmacokinetic models in individuals with inflammatory bowel disease, preferably aged ≤ 18 years. Predictive performance was evaluated with prior predictions (based solely on patient-specific covariates) and posterior predictions (based on covariates and infliximab trough concentrations). Model accuracy and precision were calculated with relative bias and relative root mean square error and we determined the classification accuracy at the trough concentration target of ≥ 5 mg/L. RESULTS The population pharmacokinetic model by Fasanmade was identified to be most appropriate for the total dataset (relative bias before/after therapeutic drug monitoring: -20.7%/11.2% and relative root mean square error before/after therapeutic drug monitoring: 84.1%/51.6%), although differences between models were small and several were deemed suitable for clinical use. For the Fasanmade model, sensitivity and specificity for maximum posterior predictions for the next infliximab trough concentration to be ≥ 5 mg/L were respectively 83.5% and 80% with an area under the receiver operating characteristic curve of 0.870. CONCLUSIONS In our paediatric cohort, various models provided acceptable predictive performance, with the Fasanmade model deemed most suitable for clinical use. Model-informed precision dosing can therefore be expected to help to maintain infliximab trough concentrations in the target range.
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Affiliation(s)
- Nanja C Bevers
- Department of Paediatrics, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162 BG, Sittard-Geleen, The Netherlands.
- NUTRIM, School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | | | - Dennis R Wong
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Arta Aliu
- Department of Gastroenterology-Hepatology and NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marieke J Pierik
- Department of Gastroenterology-Hepatology and NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy and Clinical Pharmacology, Máxima Medical Center, Veldhoven, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen - Beatrix Children's Hospital, Groningen, The Netherlands
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3
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Varekamp J, Tan JL, Stam J, van den Berg AP, van Rheenen PF, Touw DJ, Dekkers BGJ. Effects of interrupting the enterohepatic circulation in amatoxin intoxications. Clin Toxicol (Phila) 2024; 62:69-75. [PMID: 38411174 DOI: 10.1080/15563650.2024.2312182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/25/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Interruption of the enterohepatic circulation is regarded as an effective way to treat patients with amatoxin poisoning. Nonetheless, its effectiveness has not yet been systematically evaluated. Therefore, we performed a systematic review to investigate the role of enterohepatic circulation on patient outcome and clinical laboratory values. We specifically sought to evaluate the effect of activated charcoal, which absorbs drugs and toxins in the gastrointestinal tract. METHODS A previously established database with data extracted from case reports and series from literature, supplemented with recent publications, was used. Patient characteristics, outcome, and laboratory values were evaluated. RESULTS We included 133 publications describing a total of 1,119 unique cases. Survival was 75 per cent in the control group (n = 452), whereas in the group treated with single or multiple doses of activated charcoal (n = 667) survival was 83 per cent (P < 0.001, odds ratio 1.89 [95 per cent confidence interval 1.40-2.56]). Furthermore, no difference in peak values of alanine aminotransferase and aspartate aminotransferase activities were observed, whereas peak values of total serum bilirubin concentration and international normalized ratio were statistically significantly reduced in patients treated with activated charcoal. DISCUSSION The ability of activated charcoal to enhance the elimination of amatoxin through interruption of the enterohepatic circulation offers a potentially safe and inexpensive therapy for patients in the post-absorptive phase. LIMITATIONS Limitations include the potential for publication bias, the lack of universal confirmation of amatoxin concentrations, and the inability to directly measure enterohepatic circulation of amatoxin. CONCLUSION Treatment with activated charcoal in patients with amatoxin poisoning was associated with a greater chance of a successful outcome. Additionally, activated charcoal was associated with a reduction in markers of liver function, but not markers of liver injury.
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Affiliation(s)
- Jurriaan Varekamp
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jia Lin Tan
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janine Stam
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Analytical Biochemistry, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Bart G J Dekkers
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Gordon H, Burisch J, Ellul P, Karmiris K, Katsanos K, Allocca M, Bamias G, Barreiro-de Acosta M, Braithwaite T, Greuter T, Harwood C, Juillerat P, Lobaton T, Müller-Ladner U, Noor N, Pellino G, Savarino E, Schramm C, Soriano A, Michael Stein J, Uzzan M, van Rheenen PF, Vavricka SR, Vecchi M, Zuily S, Kucharzik T. ECCO Guidelines on Extraintestinal Manifestations in Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:1-37. [PMID: 37351850 DOI: 10.1093/ecco-jcc/jjad108] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, London, Centre for Immunobiology, Blizard Institute, Faculty of Medicine, Barts & The London Medical School, Queen Mary University of London, UK
| | - Johan Burisch
- Gastrounit, medical division, Hvidovre Hospital, University of Copenhagen, Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgos Bamias
- GI Unit, 3rd Academic Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Manuel Barreiro-de Acosta
- University Hospital Santiago De Compostela CHUS, Department of Gastroenterology - IBD Unit, Santiago De Compostela, Spain
| | - Tasanee Braithwaite
- School of Immunology and Microbiology, King's College London, The Medical Eye Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, GZO - Zurich Regional Health Center, Wetzikon, Division of Gastroenterology and Hepatology, University Hospital Lausanne - CHUV, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland; Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent; Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus Liebig University Giessen, Bad Nauheim, Germany
| | - Nurulamin Noor
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gianluca Pellino
- Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Christoph Schramm
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Soriano
- Gastroenterology Division and IBD Center, Internal Medicine Department, Azienda Unità Sanitaria Locale - IRCCS, 42122 Reggio Emilia, Italy
| | - Jürgen Michael Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt/Main, Germany
| | - Mathieu Uzzan
- Department of Gastroenterology, Hôpital Henri Mondor, APHP, Créteil, France
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
| | - Maurizio Vecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stephane Zuily
- Vascular Medicine Division and French Referral Center for Rare Auto-Immune Diseases, Université de Lorraine, INSERM, DCAC and CHRU-Nancy, Nancy, France
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Münster, Lüneburg, Germany
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Bevers N, Aliu A, Wong DR, Winkens B, Vreugdenhil A, Pierik MJ, Derijks LJJ, van Rheenen PF. Early infliximab trough levels in paediatric IBD patients predict sustained remission. Therap Adv Gastroenterol 2023; 17:17562848231222337. [PMID: 38164362 PMCID: PMC10757796 DOI: 10.1177/17562848231222337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/06/2023] [Indexed: 01/03/2024] Open
Abstract
Background Exposure-response studies have shown that higher infliximab concentrations are associated with better outcomes in inflammatory bowel disease. There is little agreement about the optimal time to measure infliximab levels in children. Objectives We aimed to evaluate whether trough levels at week 6 or week 14 predict sustained remission. The secondary aim was to define target trough levels at weeks 6 and 14. Design We used routinely collected electronic healthcare data of 70 anti-tumour necrosis factor naïve children with inflammatory bowel disease treated with a standard infliximab induction- and variable maintenance scheme. Methods Trough levels and blood and faecal markers for disease activity were measured before every infliximab administration. Sustained remission was defined as the absence of symptoms and low inflammatory markers between weeks 26 and 52 after the start of infliximab therapy. Optimal infliximab levels at weeks 6 and 14 were determined using the receiver operating characteristic curve. Results The median infliximab level at week 6 was not significantly higher in children who achieved sustained remission compared to those who did not (16.9 mg/L versus 12.0 mg/L; p = 0.058) but the median infliximab level at week 14 was significantly higher in those with sustained remission (7.7 mg/L versus 3.8 mg/L; p = 0.006). The area under the receiver operating characteristics curves at weeks 6 and 14 to predict sustained remission was 0.67 (95% CI 0.51-0.83) and 0.75 (95% CI 0.60-0.90), respectively. Target trough levels at weeks 6 and 14 were ⩾13.2 and ⩾6.9 mg/L, respectively. Conclusion An infliximab measurement at week 14 with a target through level ⩾6.9 mg/L best predicted sustained remission.
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Affiliation(s)
- Nanja Bevers
- Department of Paediatrics, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162 BG Sittard, The Netherlands
| | - Arta Aliu
- Department of Gastroenterology and Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dennis R. Wong
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Anita Vreugdenhil
- Department of Paediatrics, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marieke J. Pierik
- Division of Gastroenterology and Hepatology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Luc J. J. Derijks
- Department of Clinical Pharmacy and Pharmacology, Máxima Medical Center, Veldhoven, The Netherlands Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Patrick F. van Rheenen
- Department of Paediatric Gastroenterology Hepatology and Nutrition, University Medical Center Groningen – Beatrix Children’s Hospital, University of Groningen, Groningen, The Netherlands
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Bouhuys M, Mian P, van Rheenen PF. Ustekinumab trough levels in children with Crohn's disease refractory to anti-tumor necrosis factor agents: a prospective case series of off-label use. Front Pharmacol 2023; 14:1180750. [PMID: 37818191 PMCID: PMC10561290 DOI: 10.3389/fphar.2023.1180750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
Background: Ustekinumab is used off-label in pediatric Crohn's disease refractory to anti-tumor necrosis factor. Data on optimal dosing, target trough levels, and potential benefit of therapeutic drug monitoring in children treated with ustekinumab are limited. Materials and Methods: We describe a series of six adolescents who consented to be treated with ustekinumab. We measured their trough levels, C-reactive protein, and fecal calprotectin before every administration. Results: Standard adult dosing was effective to achieve biochemical remission (fecal calprotectin < 250 mg/kg) in one patient and clinical remission (resolution of symptoms) in another. The other four patients failed to respond on standard dosing and underwent intravenous re-induction and interval shortening to increase ustekinumab trough levels. This resulted in biochemical remission in one patient and clinical remission in another, suggesting an exposure-response relationship. The remaining two patients had no therapeutic benefit, and ustekinumab was discontinued. Conclusion: In this report, we show that ustekinumab can induce remission in pediatric patients with anti-tumor necrosis factor refractory Crohn's disease. It is worth escalating the dose before abandoning the drug as ineffective. Prospective studies in children are needed to determine long-term efficacy of ustekinumab, usefulness of therapeutic drug monitoring strategies, and, if applicable, optimal target trough levels.
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Affiliation(s)
- Marleen Bouhuys
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Beatrix Children’s Hospital, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, Groningen, Netherlands
| | - Patrick F. van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Beatrix Children’s Hospital, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
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Jagt JZ, van Schie DA, Benninga MA, van Rheenen PF, de Boer NKH, de Meij TGJ. Endoscopic Surveillance for Colorectal Cancer in Pediatric Ulcerative Colitis: A Survey Among Dutch Pediatric Gastroenterologists. JPGN Rep 2023; 4:e341. [PMID: 37600610 PMCID: PMC10435030 DOI: 10.1097/pg9.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023]
Abstract
Objectives This study aimed to evaluate the current clinical practice of Dutch pediatric gastroenterologists regarding the surveillance for colorectal dysplasia and cancer in pediatric ulcerative colitis (UC), including adherence to guidelines, the initiation and interval of surveillance and applied endoscopy techniques. Methods A clinical vignette-based survey was distributed among all 47 pediatric gastroenterologists who are registered and working in the Netherlands. Results Thirty-three pediatric gastroenterologists treating children with UC, completed the questionnaire (response rate 70%). Of these respondents, 23 (70%) do conduct endoscopic surveillance in their UC patients. Adherence to any of the available guidelines was reported by 82% of respondents. Twenty-four of 31 respondents (77%) indicated the need for development of a new guideline. Profound variation was witnessed concerning the initiation and interval of surveillance, and risk factors taken into consideration, such as disease extent and concomitant diagnosis of primary sclerosing cholangitis (PSC). The available national and European guidelines recommend the use of chromoendoscopy in the performance of surveillance. This technique was conducted by 8% of respondents, whereas 50% conducted conventional endoscopy with random biopsies. Conclusions The heterogeneity in surveillance practices underlines the need for consistency among the guidelines, explicitly stated by 77% of the respondents. For this, future research on surveillance in pediatric UC is warranted, focusing on the risk of UC-associated colorectal cancer related to risk factors and optimal endoscopy techniques.
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Affiliation(s)
- Jasmijn Z. Jagt
- From the Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam University Medical Centre, VU University Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, VU University Amsterdam, Pediatric Gastroenterology, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), Amsterdam, The Netherlands
| | - Daniëlle A. van Schie
- Faculty of Medicine, Amsterdam University Medical Centre, VU University Amsterdam, Amsterdam, The Netherlands
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Patrick F. van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Nanne K. H. de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Amsterdam University Medical Centre, VU University Amsterdam, Amsterdam, The Netherlands
| | - Tim G. J. de Meij
- From the Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam University Medical Centre, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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Jagt JZ, van Rheenen PF, Thoma SMA, Gower J, Reimering-Hartgerink PB, van der Wielen HJHL, van Steenbergen EJ, Goutbeek AM, van Dijk-Lokkart EM, Vlietstra S, Reinders D, den Otter Y, Schoonderwoert I, Schoonderwoert B, Schoonderwoert H, van der Weide G, van Harten S, Mouthaan K, Benninga MA, de Boer NKH, van der Horst D, Scherpenzeel M, de Meij TGJ. The top 10 research priorities for inflammatory bowel disease in children and young adults: results of a James Lind Alliance Priority Setting Partnership. Lancet Gastroenterol Hepatol 2023:S2468-1253(23)00140-1. [PMID: 37230110 DOI: 10.1016/s2468-1253(23)00140-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Jasmijn Z Jagt
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam 1105, Netherlands; Paediatric Gastroenterology, Amsterdam University Medical Centre, VU University Amsterdam, Amsterdam, Netherlands.
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Sophia M A Thoma
- Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, and Faculty of Medicine, Amsterdam University Medical Centre, VU University Amsterdam, Amsterdam, Netherlands
| | | | | | | | - Esther J van Steenbergen
- Department of Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Anne-Marije Goutbeek
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam 1105, Netherlands
| | - Elisabeth M van Dijk-Lokkart
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam 1105, Netherlands
| | | | | | | | | | | | | | | | | | | | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam 1105, Netherlands
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, VU University Amsterdam, Amsterdam, Netherlands
| | | | | | - Tim G J de Meij
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam 1105, Netherlands
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9
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Esmati H, van Rosmalen M, van Rheenen PF, de Boer MT, van den Berg AP, van der Doef HPJ, Rayar M, de Kleine RHJ, Porte RJ, de Meijer VE, Verkade HJ. Waitlist mortality of young patients with biliary atresia: Impact of allocation policy and living donor liver transplantation. Liver Transpl 2023; 29:157-163. [PMID: 37160064 PMCID: PMC9869936 DOI: 10.1002/lt.26529] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 01/29/2023]
Abstract
Patients with biliary atresia (BA) below 2 years of age in need of a transplantation largely rely on partial grafts from deceased donors (deceased donor liver transplantation [DDLT]) or living donors (living donor liver transplantation [LDLT]). Because of high waitlist mortality in especially young patients with BA, the Eurotransplant Liver Intestine Advisory Committee (ELIAC) has further prioritized patients with BA listed before their second birthday for allocation of a deceased donor liver since 2014. We evaluated whether this Eurotransplant (ET) allocation prioritization changed the waitlist mortality of young patients with BA. We used a pre-post cohort study design with the implementation of the new allocation rule between the two periods. Participants were patients with BA younger than 2 years who were listed for liver transplantation in the ET database between 2001 and 2018. Competing risk analyses were performed to assess waitlist mortality in the first 2 years after listing. We analyzed a total of 1055 patients with BA, of which 882 had been listed in the preimplementation phase (PRE) and 173 in the postimplementation phase (POST). Waitlist mortality decreased from 6.7% in PRE to 2.3% in POST ( p = 0.03). Interestingly, the proportion of young patients with BA undergoing DDLT decreased from 32% to 18% after ET allocation prioritization ( p = 0.001), whereas LDLT increased from 55% to 74% ( p = 0.001). The proportional increase in LDLT decreased the median waitlist duration of transplanted patients from 1.5 months in PRE to 0.85 months in POST ( p = 0.003). Since 2014, waitlist mortality in young patients with BA has strongly decreased in the ET region. Rather than associated with prioritized allocation of deceased donor organs, the decreased waitlist mortality was related to a higher proportion of patients undergoing LDLT.
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Affiliation(s)
- Hedayatullah Esmati
- Department of Pediatric Gastroenterology and Hepatology , University Medical Center Groningen, University of Groningen , Groningen , the Netherlands
| | | | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology and Hepatology , University Medical Center Groningen, University of Groningen , Groningen , the Netherlands
| | - Marieke T de Boer
- Department of Surgery, University Medical Center Groningen , University of Groningen , Groningen , the Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen , University of Groningen , Groningen , the Netherlands
| | - Hubert P J van der Doef
- Department of Pediatric Gastroenterology and Hepatology , University Medical Center Groningen, University of Groningen , Groningen , the Netherlands
| | - Michel Rayar
- Department of Surgery, University Medical Center Groningen , University of Groningen , Groningen , the Netherlands
| | - Ruben H J de Kleine
- Department of Surgery, University Medical Center Groningen , University of Groningen , Groningen , the Netherlands
| | - Robert J Porte
- Department of Surgery, University Medical Center Groningen , University of Groningen , Groningen , the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen , University of Groningen , Groningen , the Netherlands
| | - Henkjan J Verkade
- Department of Pediatric Gastroenterology and Hepatology , University Medical Center Groningen, University of Groningen , Groningen , the Netherlands
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10
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Berhane B, van Rheenen PF, Verkade HJ. Gamma-glutamyl transferase and disease course in pediatric-onset primary sclerosing cholangitis: A single-center cohort study. Health Sci Rep 2023; 6:e1086. [PMID: 36751275 PMCID: PMC9892024 DOI: 10.1002/hsr2.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/29/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
Background and Aims Patients with pediatric-onset primary sclerosing cholangitis (PSC) are at risk of developing hepatic complications with liver transplantation as only curative treatment. Complications usually occur over many years, underlining the need for reliable surrogate markers to predict the clinical course. Recently, gamma-glutamyl transferase (GGT) has been suggested to allow prediction of the clinical course. In a single-center cohort study, we tested the potency of GGT in this respect. Methods We used longitudinal data of patients from our academic center, diagnosed with pediatric-onset PSC between 2000 and 2020. Patients with a GGT decrease from baseline >25% (n = 36) were compared with those who did not have this decrease (n = 7). We performed Kaplan-Meier analysis and log-rank testing to assess the occurrence of portal hypertensive or biliary complications, hepatobiliary malignancies, liver transplantation, or death. Results The median age diagnosis was 15.2 years and 12.1 years in the group with ≤25% decrease of GGT and the group with >25% decrease, respectively (p = 0.078). The probability of developing ≥1 complications in the first 5 years after diagnosis was 50% in the group with ≤25% decrease of GGT and 20% in the group with >25% decrease of GGT (p = 0.031). The use of medication was not associated with the development of complications. Conclusion In a retrospective cohort study, we report that a GGT decrease of >25% within 1 year of diagnosis of pediatric-onset PSC is associated with a lower occurrence of complications within 5 years. Our results provide further support for the recently hypothesized predictive value of first-year GGT change in predicting the disease course in pediatric-onset PSC.
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Affiliation(s)
- Besrat Berhane
- Pediatric Gastroenterology & Hepatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Patrick F. van Rheenen
- Pediatric Gastroenterology & Hepatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Henkjan J. Verkade
- Pediatric Gastroenterology & Hepatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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11
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Noor NM, Sousa P, Bettenworth D, Gomollon F, Lobaton T, Bossuyt P, Casanova MJ, Ding NS, Dragoni G, Furfaro F, van Rheenen PF, Chaparro M, Gisbert JP, Louis E, Papamichael K. ECCO Topical Review on Biological Treatment Cycles in Crohn's Disease. J Crohns Colitis 2023:6982839. [PMID: 36626338 DOI: 10.1093/ecco-jcc/jjad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Indexed: 01/11/2023]
Abstract
There are now a growing number of licensed biological therapies for patients with Crohn's disease. However, there can be significant costs associated with long-term maintenance treatment, as well as some concerns about potential side effects. As a result, there has been increasing interest in elective biological treatment discontinuation in selected patients, after a sustained period of remission. Following discontinuation, in cases of relapse, evidence to date has suggested that remission may often be regained by retreatment with the same biological agent. Therefore, a concept has emerged where cycles of biological therapy might be used. If this treatment strategy were to be applied in a subgroup of patients at low-risk of relapse, cycling might allow a substantial number of patients to have a lower, overall therapeutic burden - ensuring decreased exposure to biological therapy but still enabling appropriate disease control. Currently, there remains uncertainty about the benefit-risk balance for using cycles of biological treatment for patients with Crohn's disease. Accordingly, an expert panel was convened by the European Crohn's and Colitis Organisation (ECCO) to review the published literature and agree a series of consensus practice points. The panel aimed to provide evidence-based guidance on multiple aspects of biological treatment discontinuation and cycling, including the risk of relapse after elective treatment discontinuation, predictors of likely relapse or remission, safety, patient preferences and pharmacoeconomic aspects. Crucially, discussions about biological treatment discontinuation and cycling should be individualised, to enable shared decision-making by patients with their clinicians.
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Affiliation(s)
- Nurulamin M Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Paula Sousa
- Department of Gastroenterology, Viseu Unit, Tondela-Viseu Hospital Centre, 3504-509 Viseu, Portugal
| | | | - Fernando Gomollon
- Department of Gastroenterology, Hospital Clínico Universitario Lozano Blesa, CIBERehd Avenida San Juan Bosco 15, 50009 Zaragoza, Spain; Aragón Health Research Institute (IIS Aragón), Avenida San Juan Bosco 9, 50009 Zaragoza, Spain; University of Zaragoza, School of Medicine, Spain
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium.,Department of Gastroenterology, University Hospital Ghent, Ghent, Belgium
| | - Peter Bossuyt
- Imelda GI Clinical Research Centre, Department of Gastroenterology, Imelda General Hospital, Bonheiden, Belgium
| | - Maria Jose Casanova
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Nik S Ding
- Department of Gastroenterology, University of Melbourne, St Vincent's Hospital, Melbourne, Australia
| | - Gabriele Dragoni
- Gastroenterology Research Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence, Italy.,IBD Referral Center, Gastroenterology Department, Careggi University Hospital, Florence, Italy
| | - Federica Furfaro
- Department of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Patrick F van Rheenen
- University of Groningen, Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, Groningen, The Netherlands
| | - Maria Chaparro
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Edouard Louis
- Department of Hepato-Gastroenterology and Digestive Oncology, Liege University Hospital, CHU Liege, Belgium
| | - Konstantinos Papamichael
- Center for Inflammatory Bowel Diseases, Division of Gastroenterology, Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
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12
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Abstract
Inflammatory bowel diseases (IBDs) are chronic, immune-mediated disorders that include Crohn's disease and ulcerative colitis. A pediatric onset of disease occurs in about 10% of all cases. Clinical presentation of IBD with rectal bleeding or perianal disease warrants direct referral for endoscopic evaluation. In the absence of red-flag symptoms, a combination of patient history and blood and fecal biomarkers can help to distinguish suspected IBD from other causes of abdominal pain or diarrhea. The therapeutic management of pediatric IBD has evolved by taking into account predictors of poor outcome, which justifies the upfront use of anti-tumor necrosis factor therapy for patients at high risk for complicated disease. In treating patients with IBD, biochemical or endoscopic remission, rather than clinical remission, is the therapeutic goal because intestinal inflammation often persists despite resolution of abdominal symptoms. Pediatric IBD comes with unique additional challenges, such as growth impairment, pubertal delay, the psychology of adolescence, and development of body image. Even after remission has been achieved, many patients with IBD continue to experience nonspecific symptoms like abdominal pain and fatigue. Transfer to adult care is a well-recognized risk for disease relapse, which highlights patient vulnerability and the need for a transition program that is continued by the adult-oriented IBD team. The general pediatrician is an invaluable link in integrating these challenges in the clinical care of patients with IBD and optimizing their outcomes. This state-of-the-art review aims to provide general pediatricians with an update on pediatric IBD to facilitate interactions with pediatric gastrointestinal specialists.
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13
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Bevers N, Van de Vijver E, Aliu A, Rezazadeh Ardabili A, Rosias P, Stapelbroek J, Bertrams Maartens IA, van de Feen C, Escher H, Oudshoorn A, Teklenburg S, Vande Velde S, Winkens B, Raijmakers M, Vreugdenhil A, Pierik MJ, van Rheenen PF. Ferric Carboxymaltose Versus Ferrous Fumarate in Anemic Children with Inflammatory Bowel Disease: The POPEYE Randomized Controlled Clinical Trial. J Pediatr 2022; 256:113-119.e4. [PMID: 36563900 DOI: 10.1016/j.jpeds.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/29/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine whether intravenous (IV) or oral iron suppletion is superior in improving physical fitness in anemic children with inflammatory bowel disease (IBD). STUDY DESIGN We conducted a clinical trial at 11 centers. Children aged 8-18 with IBD and anemia (defined as hemoglobin [Hb] z-score < -2) were randomly assigned to a single IV dose of ferric carboxymaltose or 12 weeks of oral ferrous fumarate. Primary end point was the change in 6-minute walking distance (6MWD) from baseline, expressed as z-score. Secondary outcome was a change in Hb z-score from baseline. RESULTS We randomized 64 patients (33 IV iron and 31 oral iron) and followed them for 6 months. One month after the start of iron therapy, the 6MWD z-score of patients in the IV group had increased by 0.71 compared with -0.11 in the oral group (P = .01). At 3- and 6-month follow-ups, no significant differences in 6MWD z-scores were observed. Hb z-scores gradually increased in both groups and the rate of increase was not different between groups at 1, 3, and 6 months after initiation of iron therapy (overall P = .97). CONCLUSION In this trial involving anemic children with IBD, a single dose of IV ferric carboxymaltose was superior to oral ferrous fumarate with respect to quick improvement of physical fitness. At 3 and 6 months after initiation of therapy, no differences were discovered between oral and IV therapies. The increase of Hb over time was comparable in both treatment groups. TRIAL REGISTRATION NTR4487 [Netherlands Trial Registry].
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Affiliation(s)
- Nanja Bevers
- Department of Paediatrics, Zuyderland Medical Center, Sittard, The Netherlands.
| | - Els Van de Vijver
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Antwerp University Hospital, Edegem, Belgium
| | - Arta Aliu
- Department of Paediatrics, Zuyderland Medical Center, Sittard, The Netherlands
| | | | - Philippe Rosias
- Department of Paediatrics, Zuyderland Medical Center, Sittard, The Netherlands
| | | | | | | | - Hankje Escher
- Erasmus Medical Center, Children's Hospital Department of Paediatric Gastroenterology, Rotterdam, The Netherlands
| | | | - Sarah Teklenburg
- Department of Paediatrics, Isala Hospitals, Zwolle, The Netherlands
| | | | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | - Maarten Raijmakers
- Laboratory of Clinical Chemistry and Haematology, Zuyderland Medical Centre, Heerlen, Limburg, The Netherlands
| | - Anita Vreugdenhil
- Department of Paediatrics and NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marieke J Pierik
- Division of Gastroenterology-Hepatology and NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patrick F van Rheenen
- University of Groningen, University Medical Centre Groningen - Beatrix Children's Hospital, Department of Paediatric Gastroenterology Hepatology and Nutrition, Groningen, The Netherlands
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14
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Tan JL, Stam J, van den Berg AP, van Rheenen PF, Dekkers BGJ, Touw DJ. Amanitin intoxication: effects of therapies on clinical outcomes - a review of 40 years of reported cases. Clin Toxicol (Phila) 2022; 60:1251-1265. [PMID: 36129244 DOI: 10.1080/15563650.2022.2098139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS Amanita phalloides poisoning causes severe liver damage which may be potentially fatal. Several treatments are available, but their effectiveness has not been systematically evaluated. We performed a systematic review to investigate the effect of the most commonly used therapies: N-acetylcysteine (NAC), benzylpenicillin (PEN), and silibinin (SIL) on patient outcomes. In addition, other factors contributing to patient outcomes are identified. METHODS We searched MEDLINE and Embase for case series and case reports that described patient outcomes after poisoning with amanitin-containing Amanita mushrooms. We extracted clinical characteristics, treatment details, and outcomes. We used the liver item from the Poisoning Severity Score (PSS) to categorize intoxication severity. RESULTS We included 131 publications describing a total of 877 unique cases. The overall survival rate of all patients was 84%. Patients receiving only supportive care had a survival rate of 59%. The use of SIL or PEN was associated with a 90% (OR 6.40 [3.14-13.04]) and 89% (OR 5.24 [2.87-9.56]) survival rate, respectively. NAC/SIL combination therapy was associated with 85% survival rate (OR 3.85 [2.04, 7.25]). NAC/PEN/SIL treatment group had a survival rate of 76% (OR 2.11 [1.25, 3.57]). Due to the limited number of cases, the use of NAC alone could not be evaluated. Additional analyses in 'proven cases' (amanitin detected), 'probable cases' (mushroom identified by mycologist), and 'possible cases' (neither amanitin detected nor mushroom identified) showed comparable results, but the results did not reach statistical significance. Transplantation-free survivors had significantly lower peak values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total serum bilirubin (TSB), and international normalized ratio (INR) compared to liver transplantation survivors and patients with fatal outcomes. Higher peak PSS was associated with increased mortality. CONCLUSION Based on data available, no statistical differences could be observed for the effects of NAC, PEN or SIL in proven poisonings with amanitin-containing mushrooms. However, monotherapy with SIL or PEN and combination therapy with NAC/SIL appear to be associated with higher survival rates compared to supportive care alone. AST, ALT, TSB, and INR values are possible predictors of potentially fatal outcomes.
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Affiliation(s)
- Jia Lin Tan
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janine Stam
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Analytical Biochemistry, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart G J Dekkers
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
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15
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Hamer HM, Mulder AHL, de Boer NK, Crouwel F, van Rheenen PF, Spekle M, Vermeer M, Wagenmakers-Huizinga L, Muller Kobold AC. Impact of Preanalytical Factors on Calprotectin Concentration in Stool: A Multiassay Comparison. J Appl Lab Med 2022; 7:1401-1411. [DOI: 10.1093/jalm/jfac057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Measuring calprotectin concentration in stool is increasingly important in monitoring disease activity and treatment response in inflammatory bowel disease. This study evaluates the impact of preanalytical storage conditions on reliability of calprotectin testing using 5 different calprotectin immunoassays.
Methods
Aliquots of homogenized fresh fecal samples in untreated or extracted form were stored at room temperature or 4°C. Calprotectin concentration was measured day 0 to 4 and 8. Five different immunoassays and accompanying extraction buffers were used (CALiaGold, Phadia EliA, Bühlmann fCal turbo, ELISA Bühlmann, Inova Quanta Flash). Repeated measurements of change from baseline calprotectin levels over time were analyzed using a mixed model analysis.
Results
Calprotectin concentrations declined over time under all preanalytical conditions with all assays, except for extracted feces stored at 4°C. The rate of decline was greatest in untreated stool kept at room temperature, reaching significant difference from baseline already after 1 day (P < 0.001). In extracted feces kept at room temperature, significant difference from baseline was reached after 2 days, and in untreated feces at 4°C, after 4 days. However, the results differed significantly between assays. After 4 days of storage at room temperature, the mean calprotectin decline from baseline differed between 30% and 60%, dependent on the assay used.
Conclusions
Fecal calprotectin concentration in stool samples declines over time, and the rate of decline is greater at higher temperatures. In extracted feces stored at 4°C, calprotectin is most stable. It is assay-dependent how long extracted feces stored at 4°C give reliable test results.
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Affiliation(s)
- Henrike M Hamer
- Department of Clinical Chemistry, AGEM Research Institute, Amsterdam UMC , Amsterdam , The Netherlands
| | - A H Leontine Mulder
- Clinical Chemistry, Medlon BV , Enschede , The Netherlands
- Clinical Laboratory, Ziekenhuisgroep Twente , Almelo , The Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam UMC, VU University , Amsterdam , The Netherlands
| | - Femke Crouwel
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam UMC, VU University , Amsterdam , The Netherlands
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Marlies Spekle
- Clinical Chemistry, Medlon BV , Enschede , The Netherlands
| | - Marloes Vermeer
- ZGT Academy, Ziekenhuisgroep Twente , Almelo , The Netherlands
| | - Lucie Wagenmakers-Huizinga
- Department of Clinical Chemistry, University of Groningen, University Medical center Groningen , Groningen , The Netherlands
| | - Anneke C Muller Kobold
- Department of Clinical Chemistry, University of Groningen, University Medical center Groningen , Groningen , The Netherlands
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16
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Jongsma MME, Aardoom MA, Cozijnsen MA, van Pieterson M, de Meij T, Groeneweg M, Norbruis OF, Wolters VM, van Wering HM, Hojsak I, Kolho KL, Hummel T, Stapelbroek J, van der Feen C, van Rheenen PF, van Wijk MP, Teklenburg-Roord STA, Schreurs MWJ, Rizopoulos D, Doukas M, Escher JC, Samsom JN, de Ridder L. First-line treatment with infliximab versus conventional treatment in children with newly diagnosed moderate-to-severe Crohn's disease: an open-label multicentre randomised controlled trial. Gut 2022; 71:34-42. [PMID: 33384335 PMCID: PMC8666701 DOI: 10.1136/gutjnl-2020-322339] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In newly diagnosed paediatric patients with moderate-to-severe Crohn's disease (CD), infliximab (IFX) is initiated once exclusive enteral nutrition (EEN), corticosteroid and immunomodulator therapies have failed. We aimed to investigate whether starting first-line IFX (FL-IFX) is more effective to achieve and maintain remission than conventional treatment. DESIGN In this multicentre open-label randomised controlled trial, untreated patients with a new diagnosis of CD (3-17 years old, weighted Paediatric CD Activity Index score (wPCDAI) >40) were assigned to groups that received five infusions of 5 mg/kg IFX at weeks 0, 2, 6, 14 and 22 (FL-IFX), or EEN or oral prednisolone (1 mg/kg, maximum 40 mg) (conventional). The primary outcome was clinical remission on azathioprine, defined as a wPCDAI <12.5 at week 52, without need for treatment escalation, using intention-to-treat analysis. RESULTS 100 patients were included, 50 in the FL-IFX group and 50 in the conventional group. Four patients did not receive treatment as per protocol. At week 10, a higher proportion of patients in the FL-IFX group than in the conventional group achieved clinical (59% vs 34%, respectively, p=0.021) and endoscopic remission (59% vs 17%, respectively, p=0.001). At week 52, the proportion of patients in clinical remission was not significantly different (p=0.421). However, 19/46 (41%) patients in the FL-IFX group were in clinical remission on azathioprine monotherapy without need for treatment escalation vs 7/48 (15%) in the conventional group (p=0.004). CONCLUSIONS FL-IFX was superior to conventional treatment in achieving short-term clinical and endoscopic remission, and had greater likelihood of maintaining clinical remission at week 52 on azathioprine monotherapy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02517684).
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Affiliation(s)
- Maria M E Jongsma
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martine A Aardoom
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martinus A Cozijnsen
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Merel van Pieterson
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Tim de Meij
- Paediatric Gastroenterology, University Medical Center Amsterdam—Location VUmc, Amsterdam, The Netherlands
| | | | | | - Victorien M Wolters
- Paediatric Gastroenterology, Utrecht Medical Center/Wilhelmina Children's Hospital, Utrecht, The The Netherlands
| | | | - Iva Hojsak
- Referral centre for Paediatric Gastroenterology and Nutrition, Children's Hospital Zagreb, Zagreb, Croatia,University JJ Strossmayer, School of Medicine Osijek, Osijek, Croatia
| | - Kaija-Leena Kolho
- Paediatric Gastroenterology, Children's Hospital, University of Tampere, Helsinki, Finland,Tampere University, Tampere, Finland
| | - Thalia Hummel
- Paediatrics, Medical Spectrum Twente, Enschede, The Netherlands
| | | | | | - Patrick F van Rheenen
- Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel P van Wijk
- Paediatric Gastroenterology, University Medical Center Amsterdam—Location VUmc, Amsterdam, The Netherlands
| | | | | | | | | | - Johanna C Escher
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Janneke N Samsom
- Laboratory of Pediatrics, Division of Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lissy de Ridder
- Paediatric Gastroenterology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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17
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Abstract
PURPOSE OF REVIEW Liver test abnormalities in children with inflammatory bowel disease (IBD) are usually insidious in onset. By the time that symptoms referable to liver disease have appeared, the liver injury may be well advanced. It is, therefore, important that children with an incidental finding of abnormal liver tests are investigated in an appropriate and timely manner. RECENT FINDINGS The most prevalent cause of liver test elevations in paediatric IBD is immune-related liver disease, including primary sclerosing cholangitis, autoimmune sclerosing cholangitis, and autoimmune hepatitis. Although less common, drugs used in the treatment of IBD can also cause liver injury. The diagnosis of drug-induced liver injury relies largely on excluding other causes of liver injury, such as viral hepatitis, nonalcoholic fatty liver disease, and biliary and vascular complications. SUMMARY This review highlights an avenue to a step-wise approach for investigating children with IBD and silent liver test elevations. Central to the timing of diagnostic actions is grading the severity of liver test elevations.
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Affiliation(s)
- Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen - Beatrix Children's Hospital, Groningen, The Netherlands
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18
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Haisma S, Weersma RK, Joosse ME, de Koning BAE, de Meij T, Koot BGP, Wolters V, Norbruis O, Daly MJ, Stevens C, Xavier RJ, Koskela J, Rivas MA, Visschedijk MC, Verkade HJ, Barbieri R, Jansen DBH, Festen EAM, van Rheenen PF, van Diemen CC. Exome sequencing in patient-parent trios suggests new candidate genes for early-onset primary sclerosing cholangitis. Liver Int 2021; 41:1044-1057. [PMID: 33590606 PMCID: PMC8252477 DOI: 10.1111/liv.14831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 01/29/2021] [Accepted: 02/07/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is a rare bile duct disease strongly associated with inflammatory bowel disease (IBD). Whole-exome sequencing (WES) has contributed to understanding the molecular basis of very early-onset IBD, but rare protein-altering genetic variants have not been identified for early-onset PSC. We performed WES in patients diagnosed with PSC ≤ 12 years to investigate the contribution of rare genetic variants to early-onset PSC. METHODS In this multicentre study, WES was performed on 87 DNA samples from 29 patient-parent trios with early-onset PSC. We selected rare (minor allele frequency < 2%) coding and splice-site variants that matched recessive (homozygous and compound heterozygous variants) and dominant (de novo) inheritance in the index patients. Variant pathogenicity was predicted by an in-house developed algorithm (GAVIN), and PSC-relevant variants were selected using gene expression data and gene function. RESULTS In 22 of 29 trios we identified at least 1 possibly pathogenic variant. We prioritized 36 genes, harbouring a total of 54 variants with predicted pathogenic effects. In 18 genes, we identified 36 compound heterozygous variants, whereas in the other 18 genes we identified 18 de novo variants. Twelve of 36 candidate risk genes are known to play a role in transmembrane transport, adaptive and innate immunity, and epithelial barrier function. CONCLUSIONS The 36 candidate genes for early-onset PSC need further verification in other patient cohorts and evaluation of gene function before a causal role can be attributed to its variants.
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Affiliation(s)
- Sjoukje‐Marije Haisma
- Department of Paediatric Gastroenterology Hepatology and NutritionUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Rinse K. Weersma
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Maria E. Joosse
- Department of Paediatric GastroenterologyErasmus University Medical CenterSophia Children's HospitalRotterdamThe Netherlands
| | - Barbara A. E. de Koning
- Department of Paediatric GastroenterologyErasmus University Medical CenterSophia Children's HospitalRotterdamThe Netherlands
| | - Tim de Meij
- Department of Pediatric GastroenterologyVU University Medical CenterAmsterdamThe Netherlands
| | - Bart G. P. Koot
- Pediatric GastroenterologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Victorien Wolters
- Department of Pediatric GastroenterologyUniversity Medical Center Utrecht – Wilhelmina Children's HospitalUtrechtThe Netherlands
| | - Obbe Norbruis
- Department of PediatricsIsala HospitalZwolleThe Netherlands
| | - Mark J. Daly
- Broad Institute of Harvard and Massachusetts Institute of TechnologyBostonMAUSA
| | - Christine Stevens
- Broad Institute of Harvard and Massachusetts Institute of TechnologyBostonMAUSA
| | | | - Jukka Koskela
- Massachusetts General Hospital, GastroenterologyBostonMAUSA,Institute for Molecular Medicine Finland (FIMM)University of HelsinkiHelsinkiFinland,Clinic of Gastroenterology HelsinkiHelsinki University and Helsinki University HospitalHelsinkiFinland
| | | | - Marijn C. Visschedijk
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Henkjan J. Verkade
- Department of Paediatric Gastroenterology Hepatology and NutritionUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Ruggero Barbieri
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Dianne B. H. Jansen
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Eleonora A. M. Festen
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Patrick F. van Rheenen
- Department of Paediatric Gastroenterology Hepatology and NutritionUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Cleo C. van Diemen
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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19
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Bouhuys M, Armbrust W, van Rheenen PF. Case Report: Systemic Small-Vessel Vasculitis in an Adolescent With Active Ulcerative Colitis. Front Pediatr 2021; 9:617312. [PMID: 33643972 PMCID: PMC7902498 DOI: 10.3389/fped.2021.617312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/21/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Small-vessel vasculitis (SVV) is a rare immunological disease that affects arterioles, capillaries and venules. It causes purpura, but can also manifest in other organs, including the gastrointestinal tract. SVV and inflammatory bowel disease (IBD) co-occur more frequently than would be expected by chance. Case description: A 16-year-old girl, who had been diagnosed with ulcerative colitis (UC) 2 years earlier at a general hospital, developed purpura, progressive abdominal pain with frequent bloody diarrhea and frontotemporal headache and swelling while on azathioprine and mesalamine maintenance therapy. Serology was positive for perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) without antiprotease- or myeloperoixidase antibodies. Endoscopy revealed active left-sided UC and atypical ulcerations in the ascending colon. Biopsies of these ulcerations and of affected skin revealed leukocytoclastic vasculitis. Initially this was interpreted as an extraintestinal manifestation of UC that would subside when remission was induced, consequently infliximab was started. Over the next 3 weeks she developed severe burning pain in her right lower leg that progressed to a foot drop with numbness and the purpura progressed to bullous lesions. The diagnosis was adjusted to ANCA-associated vasculitis with involvement of skin, bowel and peripheral nerves. Infliximab was discontinued and induction treatment with high-dose prednisolone and cyclophosphamide was given until remission of SVV and UC was achieved. Subsequently, infliximab induction and maintenance was re-introduced in combination with methotrexate. Remission has been maintained successfully for over 2 years now. The foot drop only partly resolved and necessitated the use of an orthosis. Conclusion: Pediatric patients with IBD who present with purpuric skin lesions and abdominal pain should be evaluated for systemic involvement of SVV, which includes endoscopic evaluation of the gastrointestinal tract. We discuss a practical approach to the diagnosis, evaluation and management of systemic SVV with a focus on prompt recognition and early aggressive therapy to improve outcome.
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Affiliation(s)
- Marleen Bouhuys
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Wineke Armbrust
- Department of Pediatric Rheumatology and Immunology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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20
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van den Brink DA, de Meij T, Brals D, Bandsma RHJ, Thitiri J, Ngari M, Mwalekwa L, de Boer NKH, Wicaksono A, Covington JA, van Rheenen PF, Voskuijl WP. Prediction of mortality in severe acute malnutrition in hospitalized children by faecal volatile organic compound analysis: proof of concept. Sci Rep 2020; 10:18785. [PMID: 33154417 PMCID: PMC7645771 DOI: 10.1038/s41598-020-75515-6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 09/08/2020] [Indexed: 11/08/2022] Open
Abstract
Children with severe acute malnutrition (SAM) display immature, altered gut microbiota and have a high mortality risk. Faecal volatile organic compounds (VOCs) reflect the microbiota composition and may provide insight into metabolic dysfunction that occurs in SAM. Here we determine whether analysis of faecal VOCs could identify children with SAM with increased risk of mortality. VOC profiles from children who died within six days following admission were compared to those who were discharged alive using machine learning algorithms. VOC profiles of children who died could be separated from those who were discharged with fair accuracy (AUC) = 0.71; 95% CI 0.59-0.87; P = 0.004). We present the first study showing differences in faecal VOC profiles between children with SAM who survived and those who died. VOC analysis holds potential to help discover metabolic pathways within the intestinal microbiome with causal association with mortality and target treatments in children with SAM.Trial Registration: The F75 study is registered at clinicaltrials.gov/ct2/show/NCT02246296.
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Affiliation(s)
- Deborah A van den Brink
- Department of Paediatrics, Centre for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands.
| | - Tim de Meij
- Department of Paediatric Gastroenterology, Emma, Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Daniella Brals
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Robert H J Bandsma
- Department of Paediatrics, Centre for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Division of Gastroenterology, Hepatology and Nutrition and Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- KEMRI/Welcome Trust Research Programme, Kilifi, Kenya
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- KEMRI/Welcome Trust Research Programme, Kilifi, Kenya
| | | | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | | | | | - Patrick F van Rheenen
- Department of Paediatrics, Centre for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Wieger P Voskuijl
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands.
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands.
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.
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21
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van Rheenen PF, Aloi M, Assa A, Bronsky J, Escher JC, Fagerberg UL, Gasparetto M, Gerasimidis K, Griffiths A, Henderson P, Koletzko S, Kolho KL, Levine A, van Limbergen J, Martin de Carpi FJ, Navas-López VM, Oliva S, de Ridder L, Russell RK, Shouval D, Spinelli A, Turner D, Wilson D, Wine E, Ruemmele FM. The Medical Management of Paediatric Crohn's Disease: an ECCO-ESPGHAN Guideline Update. J Crohns Colitis 2020; 15:jjaa161. [PMID: 33026087 DOI: 10.1093/ecco-jcc/jjaa161] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE We aimed to provide an evidence-supported update of the ECCO-ESPGHAN guideline on the medical management of paediatric Crohn's disease [CD]. METHODS We formed 10 working groups and formulated 17 PICO-structured clinical questions [Patients, Intervention, Comparator, and Outcome]. A systematic literature search from January 1, 1991 to March 19, 2019 was conducted by a medical librarian using MEDLINE, EMBASE, and Cochrane Central databases. A shortlist of 30 provisional statements were further refined during a consensus meeting in Barcelona in October 2019 and subjected to a vote. In total 22 statements reached ≥ 80% agreement and were retained. RESULTS We established that it was key to identify patients at high risk of a complicated disease course at the earliest opportunity, to reduce bowel damage. Patients with perianal disease, stricturing or penetrating behaviour, or severe growth retardation should be considered for up-front anti-tumour necrosis factor [TNF] agents in combination with an immunomodulator. Therapeutic drug monitoring to guide treatment changes is recommended over empirically escalating anti-TNF dose or switching therapies. Patients with low-risk luminal CD should be induced with exclusive enteral nutrition [EEN], or with corticosteroids when EEN is not an option, and require immunomodulator-based maintenance therapy. Favourable outcomes rely on close monitoring of treatment response, with timely adjustments in therapy when treatment targets are not met. Serial faecal calprotectin measurements or small bowel imaging [ultrasound or magnetic resonance enterography] are more reliable markers of treatment response than clinical scores alone. CONCLUSIONS We present state-of-the-art guidance on the medical treatment and long-term management of children and adolescents with CD.
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Affiliation(s)
- Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Beatrix Children's Hospital, Groningen, The Netherlands
| | - Marina Aloi
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Amit Assa
- Department of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Petach Tikvah, Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Jiri Bronsky
- Paediatric Gastroenterology Unit, Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ulrika L Fagerberg
- Department of Pediatrics/Centre for Clinical Research, Västmanland Hospital, Västeras and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marco Gasparetto
- Department of Paediatric Gastroenterology, Barts Health Trust, The Royal London Children's Hospital, London, UK
| | | | - Anne Griffiths
- Department of Paediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Henderson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Sibylle Koletzko
- Department of Pediatrics, Division of Gastroenterology and Hepatology, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland
| | - Kaija-Leena Kolho
- Department of Paediatrics, Children´s Hospital, University of Helsinki and Tampere University, Tampere, Finland
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Tel Aviv University, Israel
| | - Johan van Limbergen
- Division of Pediatric Gastroenterology and Nutrition, Amsterdam UMC - location AMC, Amsterdam, The Netherlands
| | | | - Víctor Manuel Navas-López
- Pediatric Gastroenterology and Nutrition Unit, IBIMA, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Lissy de Ridder
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Richard K Russell
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
| | - Dror Shouval
- Pediatric Gastroenterology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Antonino Spinelli
- Department of Colon and Rectal Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Dan Turner
- Paediatric Gastroenterology, Shaare Zedek Medical Centre, the Hebrew University of Jerusalem, Israel
| | - David Wilson
- Child Life and Health, University Of Edinburgh, Edinburgh, UK
| | - Eytan Wine
- Division of Pediatric Gastroenterology, Edmonton Pediatric IBD Clinic (EPIC), Departments of Pediatrics & Physiology, University of Alberta, Edmonton, Canada
| | - Frank M Ruemmele
- Assistance Publique- Hôpitaux de Paris, Hôpital Necker Enfants Malades, Pediatric Gastroenterology, Paris, France
- Faculté de Médecine, Université Sorbonne Paris Cité, Paris Descartes, Paris, France
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22
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Van de Vijver E, Heida A, Ioannou S, Van Biervliet S, Hummel T, Yuksel Z, Gonera-de Jong G, Schulenberg R, Muller Kobold A, Verkade HJ, van Rheenen PF. Test Strategies to Predict Inflammatory Bowel Disease Among Children With Nonbloody Diarrhea. Pediatrics 2020; 146:peds.2019-2235. [PMID: 32694147 DOI: 10.1542/peds.2019-2235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We evaluated 4 diagnostic strategies to predict the presence of inflammatory bowel disease (IBD) in children who present with chronic nonbloody diarrhea and abdominal pain. METHODS We conducted a prospective cohort study including 193 patients aged 6 to 18 years who underwent a standardized diagnostic workup in secondary or tertiary care hospitals. Each patient was assessed for symptoms, C-reactive protein (>10 mg/L), hemoglobin (<-2 SD for age and sex), and fecal calprotectin (≥250 μg/g). Patients with rectal bleeding or perianal disease were excluded because the presence of these findings prompted endoscopy regardless of their biomarkers. Primary outcome was IBD confirmed by endoscopy or IBD ruled out by endoscopy or uneventful clinical follow-up for 6 months. RESULTS Twenty-two of 193 (11%) children had IBD. The basic prediction model was based on symptoms only. Adding blood or stool markers increased the AUC from 0.718 (95% confidence interval [CI]: 0.604-0.832) to 0.930 (95% CI: 0.884-0.977) and 0.967 (95% CI: 0.945-0.990). Combining symptoms with blood and stool markers outperformed all other strategies (AUC 0.997 [95% CI: 0.993-1.000]). Triaging with a strategy that involves symptoms, blood markers, and calprotectin will result in 14 of 100 patients being exposed to endoscopy. Three of them will not have IBD, and no IBD-affected child will be missed. CONCLUSIONS Evaluating symptoms plus blood and stool markers in patients with nonbloody diarrhea is the optimal test strategy that allows pediatricians to reserve a diagnostic endoscopy for children at high risk for IBD.
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Affiliation(s)
- Els Van de Vijver
- Department of Paediatric Gastroenterology, Hepatology, and Nutrition, University Hospital Antwerp, Edegem, Belgium;
| | | | | | - Stephanie Van Biervliet
- Department of Paediatric Gastroenterology, Hepatology, and Nutrition, University Hospital Ghent, Ghent, Belgium
| | - Thalia Hummel
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Zehre Yuksel
- Department of Paediatrics, Ziekenhuis Groep Twente, Almelo-Hengelo, the Netherlands
| | | | - Renate Schulenberg
- Department of Paediatrics, Ommelander Ziekenhuis Groningen, Winschoten, the Netherlands
| | | | - Henkjan J Verkade
- Paediatric Gastroenterology, Hepatology, and Nutrition, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Patrick F van Rheenen
- Paediatric Gastroenterology, Hepatology, and Nutrition, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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23
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Joosse ME, Haisma SM, Sterk MFM, van Munster KN, Ponsioen CIJ, Houwen RHJ, Koot BGP, de Meij T, van Rheenen PF, de Koning BAE. Disease progression in paediatric- and adult-onset sclerosing cholangitis: Results from two independent Dutch registries. Liver Int 2019; 39:1768-1775. [PMID: 31152478 DOI: 10.1111/liv.14159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Sclerosing cholangitis (SC) is a severe liver disease leading to destruction of bile ducts. It is believed to run a milder course in children than in adults. To test this assumption, we evaluated time-to-complication curves in two independent paediatric-onset cohorts from the same geographical area. METHODS Short-term disease outcomes were evaluated with an online clinical registry that was filled with data on children with SC diagnosed between 2000 and 2017 and who were followed bi-annually thereafter. Long-term disease outcomes were evaluated in a paediatric-onset subcohort derived from a previously published population-based study from the Netherlands. Time-to-complication in the first cohort was defined as the time from diagnosis until portal hypertension, biliary obstructions and infections, development of malignancy, or liver transplantation, whichever came first. In the second cohort time-to-complication was defined as the time until liver transplantation or PSC-related death. RESULTS Median age at diagnosis in the first cohort (n = 86) was 12.3 years. In the first 5 years post-diagnosis 23% of patients developed complications. The patients in the population-based study (n = 683) were stratified into those diagnosed before the age of 18 years ('paediatric-onset' subcohort, n = 43) and those diagnosed after the age of 18 years ('adult-onset' subcohort, n = 640). Median age at diagnosis was 14.6 and 40.2 years, respectively. Median time-to-complication in the paediatric-onset and adult-onset subcohorts was not statistically different. CONCLUSION Paediatric and adult-onset SC run a similar long-term disease course. Paediatricians who treat children with SC should monitor them closely to recognize early complications and control long-term sequelae.
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Affiliation(s)
- Maria E Joosse
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sjoukje M Haisma
- University of Groningen, University Medical Center Groningen, Pediatric Gastroenterology Hepatology and Nutrition, Groningen, the Netherlands
| | - Marlou F M Sterk
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Kim N van Munster
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Cyriel I J Ponsioen
- Department of Gastroenterology & Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roderick H J Houwen
- Department of Pediatric Gastroenterology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart G P Koot
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tim de Meij
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands
| | - Patrick F van Rheenen
- University of Groningen, University Medical Center Groningen, Pediatric Gastroenterology Hepatology and Nutrition, Groningen, the Netherlands
| | - Barbara A E de Koning
- Department of Pediatric Gastroenterology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
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24
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Bandsma RHJ, Voskuijl W, Chimwezi E, Fegan G, Briend A, Thitiri J, Ngari M, Mwalekwa L, Bandika V, Ali R, Hamid F, Owor B, Mturi N, Potani I, Allubha B, Muller Kobold AC, Bartels RH, Versloot CJ, Feenstra M, van den Brink DA, van Rheenen PF, Kerac M, Bourdon C, Berkley JA. A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial. PLoS Med 2019; 16:e1002747. [PMID: 30807589 PMCID: PMC6390989 DOI: 10.1371/journal.pmed.1002747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 01/18/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Children with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase. METHODS AND FINDINGS In a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2-5 days), which was similar between randomized groups (0.23 [95% CI -0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite. CONCLUSIONS Empirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM. TRIAL REGISTRATION ClinicalTrials.gov NCT02246296.
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Affiliation(s)
- Robert H. J. Bandsma
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutrition Sciences, University of Toronto, Toronto, Canada
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - Wieger Voskuijl
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Emmanuel Chimwezi
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Greg Fegan
- Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
- University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
| | | | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Victor Bandika
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Rehema Ali
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Fauzat Hamid
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Betty Owor
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Isabel Potani
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Benjamin Allubha
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Anneke C. Muller Kobold
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - Rosalie H. Bartels
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Christian J. Versloot
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marjon Feenstra
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Deborah A. van den Brink
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Patrick F. van Rheenen
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marko Kerac
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - James A. Berkley
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
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van der Doef HPJ, van Rheenen PF, van Rosmalen M, Rogiers X, Verkade HJ. Wait-list mortality of young patients with Biliary atresia: Competing risk analysis of a eurotransplant registry-based cohort. Liver Transpl 2018; 24:810-819. [PMID: 29377411 DOI: 10.1002/lt.25025] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 09/19/2017] [Revised: 01/13/2018] [Accepted: 01/17/2018] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is the standard treatment for biliary atresia (BA) patients with end-stage liver disease. The prognosis after LT has steadily improved, but overall prognosis of BA patients is also determined by mortality before LT. We aimed to quantify mortality in young BA patients on the Eurotransplant waiting list and to determine the effect of disease severity and age at time of listing on pretransplant mortality. We used a cohort study design, which incorporated data from the Eurotransplant registry. Participants were 711 BA patients who were below 5 years of age from 5 countries and listed for LT between 2001 and 2014. We applied a competing risk analysis to evaluate simultaneously the outcomes death, LT, and still waiting for a suitable organ. We used Cox proportional hazards regression to assess 2-year mortality. In a subcohort of 416 children, we performed multivariate analyses between 2-year mortality and disease severity or age, each at listing. Disease severity at listing was quantified by the Model for End-Stage Liver Disease (MELD) score, which assesses bilirubin, creatinine, albumin, and international normalized ratio as continuous variables. Two-year wait-list mortality was 7.9%. Age below 6 months and MELD score above 20 points, each at listing, were strongly and independently associated with 2-year mortality (each P < 0.001). A total of 21% of infants who fulfilled both criteria did not survive the first 6 months on the waiting list. In conclusion, our findings quantify mortality among young BA patients on the waiting list and the relative importance of risk factors (age and severity of disease at listing). Our results provide both an evidence base to rationally address high mortality in subgroups and a methodology to assess effects of implemented changes, for example, in allocation rules. Liver Transplantation 24 810-819 2018 AASLD.
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Affiliation(s)
- Hubert P J van der Doef
- Department of Pediatric Gastroenterology Hepatology and Nutrition, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology Hepatology and Nutrition, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Henkjan J Verkade
- Department of Pediatric Gastroenterology Hepatology and Nutrition, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Heida A, Dijkstra A, Muller Kobold A, Rossen JW, Kindermann A, Kokke F, de Meij T, Norbruis O, Weersma RK, Wessels M, Hummel T, Escher J, van Wering H, Hendriks D, Mearin L, Groen H, Verkade HJ, van Rheenen PF. Efficacy of Home Telemonitoring versus Conventional Follow-up: A Randomized Controlled Trial among Teenagers with Inflammatory Bowel Disease. J Crohns Colitis 2018; 12:432-441. [PMID: 29228230 DOI: 10.1093/ecco-jcc/jjx169] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/07/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Conventional follow-up of teenagers with inflammatory bowel diseases [IBD] is done during scheduled outpatient visits regardless of how well the patient feels. We designed a telemonitoring strategy for early recognition of flares and compared its efficacy with conventional follow-up. METHODS We used a multicentre randomized trial in patients aged 10-19 years with IBD in clinical remission at baseline. Participants assigned to telemonitoring received automated alerts to complete a symptom score and send a stool sample for measurement of calprotectin. This resulted in an individual prediction for flare with associated treatment advice and test interval. In conventional follow-up the health check interval was left to the physician's discretion. The primary endpoint was cumulative incidence of disease flares. Secondary endpoints were percentage of participants with a positive change in quality-of-life and cost-effectiveness of the intervention. RESULTS We included 170 participants [84 telemonitoring; 86 conventional follow-up]. At 52 weeks the mean number of face-to-face visits was significantly lower in the telemonitoring group compared to conventional follow-up [3.6 vs 4.3, p < 0.001]. The incidence of flares [33 vs 34%, p = 0.93] and the proportion of participants reporting positive change in quality-of-life [54 vs 44%, p = 0.27] were similar. Mean annual cost-saving was €89 and increased to €360 in those compliant to the protocol. CONCLUSIONS Telemonitoring is as safe as conventional follow-up, and reduces outpatient visits and societal costs. The positive impact on quality-of-life was similar in the two groups. This strategy is attractive for teenagers and families, and health professionals may be interested in using it to keep teenagers who are well out of hospital and ease pressure on overstretched outpatient services. TRIAL REGISTRATION NTR3759 [Netherlands Trial Registry].
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Affiliation(s)
- Anke Heida
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Alie Dijkstra
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Anneke Muller Kobold
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - John W Rossen
- Department of Microbiology, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Angelika Kindermann
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital Academic Medical Centre, Meibergdreef, Amsterdam, The Netherlands
| | - Freddy Kokke
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Wilhelmina Children's Hospital, Lundlaan, Utrecht, The Netherlands
| | - Tim de Meij
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, VU Medical Centre, De Boelelaan, Amsterdam, The Netherlands
| | - Obbe Norbruis
- Department of Paediatrics, Isala Clinic, Dokter van Heesweg, Zwolle, The Netherlands
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Margreet Wessels
- Department of Paediatrics, Rijnstate Hospital, Wagnerlaan, Arnhem, The Netherlands
| | - Thalia Hummel
- Department of Paediatrics, Medisch Spectrum Twente, Koningsplein, Enschede, The Netherlands
| | - Johanna Escher
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Erasmus Medical Center-Sophia Children's Hospital, Wytemaweg, Rotterdam, The Netherlands
| | - Herbert van Wering
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Amphia Hospital, Langendijk, Breda, The Netherlands
| | - Daniëlle Hendriks
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Juliana Children's Hospital/Haga, Els Borst-Eilersplein, The Hague, The Netherlands
| | - Luisa Mearin
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Leiden University Medical Centre, Albinusdreef, Leiden, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Hanzeplein, The Netherlands
| | - Henkjan J Verkade
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
| | - Patrick F van Rheenen
- Paediatric Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Groningen, University Medical Center Groningen, Hanzeplein, Groningen, The Netherlands
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Heida A, Kobold ACM, Wagenmakers L, van de Belt K, van Rheenen PF. Reference values of fecal calgranulin C (S100A12) in school aged children and adolescents. Clin Chem Lab Med 2017; 56:126-131. [PMID: 28708568 DOI: 10.1515/cclm-2017-0152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/25/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Calgranulin C (S100A12) is an emerging marker of inflammation. It is exclusively released by activated neutrophils which makes this marker potentially more specific for inflammatory bowel disease (IBD) compared to established stool markers including calprotectin and lactoferrin. We aimed to establish a reference value for S100A12 in healthy children and investigated whether S100A12 levels can discriminate children with IBD from healthy controls. METHODS In a prospective community-based reference interval study we collected 122 stool samples from healthy children aged 5-19 years. Additionally, feces samples of 41 children with suspected IBD (who were later confirmed by endoscopy to have IBD) were collected. Levels of S100A12 were measured with a sandwich enzyme-linked immunosorbent assay (ELISA) (Inflamark®). The limit of detection was 0.22 μg/g. RESULTS The upper reference limit in healthy children was 0.75 μg/g (90% confidence interval: 0.30-1.40). Median S100A12 levels were significantly higher in patients with IBD (8.00 μg/g [interquartile range (IQR) 2.5-11.6] compared to healthy controls [0.22 μg/g (IQR<0.22); p<0.001]). The best cutoff point based on receiver operating characteristic curve was 0.33 μg/g (sensitivity 93%; specificity 97%). CONCLUSIONS Children and teenagers with newly diagnosed IBD have significantly higher S100A12 results compared to healthy individuals. We demonstrate that fecal S100A12 shows diagnostic promise under ideal testing conditions. Future studies need to address whether S100A12 can discriminate children with IBD from non-organic disease in a prospective cohort with chronic gastrointestinal complaints, and how S100A12 performs in comparison with established stool markers.
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Norbruis OF, Escher JC, Walhout LC, Kindermann A, de Rijke YB, van Rheenen PF, Berger MY. Diagnostic test strategies in children at increased risk of inflammatory bowel disease in primary care. PLoS One 2017; 12:e0189111. [PMID: 29211800 PMCID: PMC5718464 DOI: 10.1371/journal.pone.0189111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 11/09/2016] [Accepted: 11/20/2017] [Indexed: 01/13/2023] Open
Abstract
Background In children with symptoms suggestive of inflammatory bowel disease (IBD) who present in primary care, the optimal test strategy for identifying those who require specialist care is unclear. We evaluated the following three test strategies to determine which was optimal for referring children with suspected IBD to specialist care: 1) alarm symptoms alone, 2) alarm symptoms plus c-reactive protein, and 3) alarm symptoms plus fecal calprotectin. Methods A prospective cohort study was conducted, including children with chronic gastrointestinal symptoms referred to pediatric gastroenterology. Outcome was defined as IBD confirmed by endoscopy, or IBD ruled out by either endoscopy or unremarkable clinical 12 month follow-up with no indication for endoscopy. Test strategy probabilities were generated by logistic regression analyses and compared by area under the receiver operating characteristic curves (AUC) and decision curves. Results We included 90 children, of whom 17 (19%) had IBD (n = 65 from primary care physicians, n = 25 from general pediatricians). Adding fecal calprotectin to alarm symptoms increased the AUC significantly from 0.80 (0.67–0.92) to 0.97 (0.93–1.00), but adding c-reactive protein to alarm symptoms did not increase the AUC significantly (p > 0.05). Decision curves confirmed these patterns, showing that alarm symptoms combined with fecal calprotectin produced the diagnostic test strategy with the highest net benefit at reasonable threshold probabilities. Conclusion In primary care, when children are identified as being at high risk for IBD, adding fecal calprotectin testing to alarm symptoms was the optimal strategy for improving risk stratification.
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Affiliation(s)
- Gea A. Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Boudewijn J. Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Obbe F. Norbruis
- Department of Pediatrics, Isala Hospital, Zwolle, The Netherlands
| | - Johanna C. Escher
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Laurence C. Walhout
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children’s Hospital ⁄ Academic Medical Center, Amsterdam, the Netherlands
| | - Yolanda B. de Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Patrick F. van Rheenen
- Department of Pediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marjolein Y. Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Heida A, Knol M, Kobold AM, Bootsman J, Dijkstra G, van Rheenen PF. Agreement Between Home-Based Measurement of Stool Calprotectin and ELISA Results for Monitoring Inflammatory Bowel Disease Activity. Clin Gastroenterol Hepatol 2017; 15:1742-1749.e2. [PMID: 28606846 DOI: 10.1016/j.cgh.2017.06.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/21/2017] [Accepted: 06/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS An increasing number of physicians use repeated measurements of stool calprotectin to monitor intestinal inflammation in patients with inflammatory bowel diseases (IBDs). A lateral flow-based rapid test allows patients to measure their own stool calprotectin values at home. The test comes with a software application (IBDoc; Bühlmann Laboratories AG, Schönenbuch, Switzerland) that turns a smartphone camera into a results reader. We compared results from this method with those from the hospital-based reader (Quantum Blue; Bühlmann Laboratories AG) and enzyme-linked immunosorbent assay (ELISA) analysis. METHODS In a single-center comparison study, we asked 101 participants (10 years of age or older) in the Netherlands to perform the IBDoc measurement on stool samples collected at home, from June 2015 to October 2016. Participants then sent the residual extraction fluid and a fresh specimen from the same bowel movement to our pediatric and adult IBD center at the University Medical Center Groningen, where the level of calprotectin was measured by the Quantum Blue reader and ELISA analysis, respectively. The primary outcome was the agreement of results between IBDoc and the Quantum Blue and ELISA analyses, determined by Bland-Altman plot analysis. RESULTS We received 152 IBDoc results, 138 samples of residual extraction fluid for Quantum Blue analysis, and 170 fresh stool samples for ELISA analysis. Spearman's rank correlation coefficient was 0.94 for results obtained by IBDoc vs Quantum Blue and 0.85 for results obtained by IBDoc vs ELISA. At the low range of calprotectin level (<500 μg/g), 91% of IBDoc-Quantum Blue results were within the predefined limits of agreement (±100 μg/g), and 71% of IBDoc-ELISA results were in agreement. At the high range of calprotectin level (≥500 μg/g), 81% of IBDoc-Quantum Blue results were within the predefined limits of agreement (±200 μg/g) and 64% of IBDoc-ELISA results were in agreement. CONCLUSIONS Measurements of fecal levels of calprotectin made with home-based lateral flow method were in agreement with measurements made by Quantum Blue and ELISA, as long as concentrations were <500 μg/g. For patients with concentrations of fecal calprotectin above this level, findings from IBDoc should be confirmed by another method. (Netherlands Trial Registration Number: NTR5133).
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Affiliation(s)
- Anke Heida
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Mariska Knol
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Anneke Muller Kobold
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Josette Bootsman
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.
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Holtman GA, Lisman-van Leeuwen Y, Day AS, Fagerberg UL, Henderson P, Leach ST, Perminow G, Mack D, van Rheenen PF, van de Vijver E, Wilson DC, Reitsma JB, Berger MY. Use of Laboratory Markers in Addition to Symptoms for Diagnosis of Inflammatory Bowel Disease in Children: A Meta-analysis of Individual Patient Data. JAMA Pediatr 2017; 171:984-991. [PMID: 28806445 PMCID: PMC5710621 DOI: 10.1001/jamapediatrics.2017.1736] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/19/2017] [Indexed: 02/05/2023]
Abstract
Importance Blood markers and fecal calprotectin are used in the diagnostic workup for inflammatory bowel disease (IBD) in pediatric patients. Any added diagnostic value of these laboratory markers remains unclear. Objective To determine whether adding laboratory markers to evaluation of signs and symptoms improves accuracy when diagnosing pediatric IBD. Data Sources A literature search of MEDLINE and EMBASE from inception through September 26, 2016. Studies were identified using indexing terms and free-text words related to child, target condition IBD, and diagnostic accuracy. Study Selection Two reviewers independently selected studies evaluating the diagnostic accuracy of more than 1 blood marker or fecal calprotectin for IBD, confirmed by endoscopy and histopathology or clinical follow-up, in pediatric patients with chronic gastrointestinal symptoms. Studies that included healthy controls and/or patients with known IBD were excluded. Data Extraction and Synthesis Individual patient data from each eligible study were requested from the authors. In addition, 2 reviewers independently assessed quality with Quality Assessment of Diagnostic Accuracy Studies-2. Mean Outcomes and Measures Laboratory markers were added as a single test to a basic prediction model based on symptoms. Outcome measures were improvement of discrimination by adding markers as a single test and improvement of risk classification of pediatric patients by adding the best marker. Results Of the 16 eligible studies, authors of 8 studies (n = 1120 patients) provided their data sets. All blood markers and fecal calprotectin individually significantly improved the discrimination between pediatric patients with and those without IBD, when added to evaluation of symptoms. The best marker-fecal calprotectin-improved the area under the curve of symptoms by 0.26 (95% CI, 0.21-0.31). The second best marker-erythrocyte sedimentation rate-improved the area under the curve of symptoms by 0.16 (95% CI, 0.11-0.21). When fecal calprotectin was added to the model, the proportion of patients without IBD correctly classified as low risk of IBD increased from 33% to 91%. The proportion of patients with IBD incorrectly classified as low risk of IBD decreased from 16% to 9%. The proportion of the total number of patients assigned to the intermediate-risk category decreased from 55% to 6%. Conclusions and Relevance In a hospital setting, fecal calprotectin added the most diagnostic value to symptoms compared with blood markers. Adding fecal calprotectin to the diagnostic workup of pediatric patients with symptoms suggestive of IBD considerably decreased the number of patients in the group in whom challenges in clinical decision making are most prevalent.
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Affiliation(s)
- Gea A. Holtman
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Andrew S. Day
- Department of Paediatric Gastroenterology, Sydney Children’s Hospital, Randwick, Australia
- University of Otago (Christchurch), Christchurch, New Zealand
| | - Ulrika L. Fagerberg
- Centre for Clinical Research, Department of Paediatrics, Västmanlands Hospital, Västerås, Sweden
- Karolinska Institutet, Stockholm, Sweden
| | - Paul Henderson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, Scotland
- Child Life and Health, University of Edinburgh, Edinburgh, Scotland
| | - Stevan T. Leach
- School of Women’s and Children’s Health, Sydney Children’s Hospital, Randwick, Australia
| | - Gøri Perminow
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway
| | - David Mack
- Deparment of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Patrick F. van Rheenen
- Department of Paediatric Gastroenterology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Els van de Vijver
- Department of Paediatric Gastroenterology, Antwerp University Hospital, Edegem, Belgium
| | - David C. Wilson
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, Scotland
- Child Life and Health, University of Edinburgh, Edinburgh, Scotland
| | - Johannes B. Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marjolein Y. Berger
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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van Rheenen PF, Aloi M, Biron IA, Carlsen K, Cooney R, Cucchiara S, Cullen G, Escher JC, Kierkus J, Lindsay JO, Roma E, Russell RK, Sieczkowska-Golub J, Harbord M. European Crohn's and Colitis Organisation Topical Review on Transitional Care in Inflammatory Bowel Disease. J Crohns Colitis 2017; 11:1032-1038. [PMID: 28158494 DOI: 10.1093/ecco-jcc/jjx010] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND This European Crohn's and Colitis Organisation [ECCO] topical review focuses on the transition of adolescents with inflammatory bowel disease [IBD] from child-centred to adult-oriented care. The aim was to provide evidence-supported, expert consensus for health professionals taking part in the transition. METHODS An online survey determined the areas of importance for health professionals involved in the transition of adolescents with IBD. Thereafter an expert panel of nine paediatric and five adult gastroenterologists was formed to identify the critical elements of the transition programme, and to prepare core messages defined as 'current practice points'. There is limited literature about transition, therefore this review is mainly based on expert opinion and consensus, rather than on specific evidence. RESULTS A total of 21 practice points were generated before the first [online] voting round. Practice points that reached >80% agreement were accepted, while those that did not reach 80% agreement were refined during a consensus meeting and subjected to voting. Ultimately, 14 practice points were retained by this review. CONCLUSION We present a consensus-based framework for transitional care in IBD that provides a guidance for clinical practice.
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Affiliation(s)
- Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen,Groningen, The Netherlands
| | - Marina Aloi
- Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, University Hospital Umberto I, Rome, Italy
| | - Irit Avni Biron
- Department of Gastroenterology, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
| | - Katrine Carlsen
- Department of Paediatrics, Hvidovre University Hospital, Hvidovre, Denmark
| | - Rachel Cooney
- Department of Gastroenterology, Queen Elizabeth Hospital,Birmingham, UK
| | - Salvatore Cucchiara
- Paediatric Gastroenterology and Liver Unit, Sapienza University of Rome, University Hospital Umberto I, Rome, Italy
| | - Garret Cullen
- Department of Gastroenterology, Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus University Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jaroslaw Kierkus
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | - James O Lindsay
- Department of Gastroenterology, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Eleftheria Roma
- First Department of Paediatrics, Gastroenterology Unit, University of Athens, Athens, Greece
| | - Richard K Russell
- Department of Paediatric Gastroenterology, The Royal Hospital for Children, Glasgow, UK
| | - Joanna Sieczkowska-Golub
- Department of Gastroenterology, Hepatology, Feeding Disorders and Paediatrics, Children's Memorial Health Institute, Warsaw, Poland
| | - Marcus Harbord
- Imperial College, London; and Chelsea and Westminster Hospital, London, UK
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Holtman GA, Lisman-van Leeuwen Y, van Rheenen PF, Kollen BJ, Escher JC, Kindermann A, de Rijke YB, Berger MY. Evaluation of point-of-care test calprotectin and lactoferrin for inflammatory bowel disease among children with chronic gastrointestinal symptoms. Fam Pract 2017; 34:400-406. [PMID: 27535331 DOI: 10.1093/fampra/cmw079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 12/29/2022] Open
Abstract
BACKGROUND Faecal calprotectin is considered to be a valid test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms in specialist care. In contrast, faecal lactoferrin has higher specificity. The recent availability of both as point-of-care tests (POCTs) makes them attractive for use in primary care. OBJECTIVE To evaluate the test characteristics of calprotectin and lactoferrin POCTs for diagnosing IBD in symptomatic children. METHODS We defined two prospective cohorts of children with chronic gastrointestinal symptoms: (i) children presenting to primary care (primary care cohort); (ii) children referred for specialist care (referred cohort). Baseline POCT results were compared with the outcome of either endoscopic assessment or 12 months follow-up. Clinicians were blinded to the POCT results. RESULTS In the primary care cohort, none of the 114 children had IBD, and the calprotectin and lactoferrin POCTs had specificities of 0.95 (0.89-0.98) and 0.98 (0.93-0.99), respectively. In the referred cohort, 17 of the 90 children had IBD: the sensitivity of POCT calprotectin and POCT lactoferrin were both 0.94 (0.72-0.99); and the specificity was 0.93 (0.84-0.97) and 0.99 (0.92-1.00), respectively. The POCT calprotectin could reduce the referral rate by 76% and POCT lactoferrin by 81%, while missing one child with IBD (6%). CONCLUSION A diagnostic test strategy in primary care using a simple POCT calprotectin or lactoferrin has the potential to reduce the need for referral for further diagnostic work-up in specialist care, with a low risk of missing a child with IBD.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Boudewijn J Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
| | - Johanna C Escher
- Department of Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Angelika Kindermann
- Department of Paediatric Gastroenterology, Emma Children's Hospital/Academic Medical Center, PO Box 22700, 1100 DE Amsterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus MC, University Medical Centre, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands
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Versloot CJ, Voskuijl W, van Vliet SJ, van den Heuvel M, Carter JC, Phiri A, Kerac M, Heikens GT, van Rheenen PF, Bandsma RHJ. Effectiveness of three commonly used transition phase diets in the inpatient management of children with severe acute malnutrition: a pilot randomized controlled trial in Malawi. BMC Pediatr 2017; 17:112. [PMID: 28446221 PMCID: PMC5406940 DOI: 10.1186/s12887-017-0860-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 04/05/2017] [Indexed: 11/26/2022] Open
Abstract
Background The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75). Methods In this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6–60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ≤ 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates. Results The proportion of children with acidic stool (pH ≤5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p < 0.05). There was no significant difference in mortality (n = 6) between diets during the transition phase nor were there any differences in other secondary outcomes. Conclusions This pilot trial does not demonstrate that a particular transition phase diet is significantly better or worse since biochemical and clinical outcomes in children with SAM did not differ. However, larger and more tightly controlled efficacy studies are needed to confirm these findings. Trial registration ISRCTN13916953 Registered: 14 January 2013.
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Affiliation(s)
- Christian J Versloot
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Wieger Voskuijl
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Sara J van Vliet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Meta van den Heuvel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Jane C Carter
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Ajib Phiri
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Leonard Cheshire Disability & Inclusive Development Centre, Department of Epidemiology & Public Health, University College London, London, UK
| | - Geert Tom Heikens
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Robert H J Bandsma
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
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Attia S, Versloot CJ, Voskuijl W, van Vliet SJ, Di Giovanni V, Zhang L, Richardson S, Bourdon C, Netea MG, Berkley JA, van Rheenen PF, Bandsma RH. Mortality in children with complicated severe acute malnutrition is related to intestinal and systemic inflammation: an observational cohort study. Am J Clin Nutr 2016; 104:1441-1449. [PMID: 27655441 PMCID: PMC5081715 DOI: 10.3945/ajcn.116.130518] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 08/24/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Diarrhea affects a large proportion of children with severe acute malnutrition (SAM). However, its etiology and clinical consequences remain unclear. OBJECTIVE We investigated diarrhea, enteropathogens, and systemic and intestinal inflammation for their interrelation and their associations with mortality in children with SAM. DESIGN Intestinal pathogens (n = 15), cytokines (n = 29), fecal calprotectin, and the short-chain fatty acids (SCFAs) butyrate and propionate were determined in children aged 6-59 mo (n = 79) hospitalized in Malawi for complicated SAM. The relation between variables, diarrhea, and death was assessed with partial least squares (PLS) path modeling. RESULTS Fatal subjects (n = 14; 18%) were younger (mean ± SD age: 17 ± 11 compared with 25 ± 11 mo; P = 0.01) with higher prevalence of diarrhea (46% compared with 18%, P = 0.03). Intestinal pathogens Shigella (36%), Giardia (33%), and Campylobacter (30%) predominated, but their presence was not associated with death or diarrhea. Calprotectin was significantly higher in children who died [median (IQR): 1360 mg/kg feces (2443-535 mg/kg feces) compared with 698 mg/kg feces (1438-244 mg/kg feces), P = 0.03]. Butyrate [median (IQR): 31 ng/mL (112-22 ng/mL) compared with 2036 ng/mL (5800-149 ng/mL), P = 0.02] and propionate [median (IQR): 167 ng/mL (831-131 ng/mL) compared with 3174 ng/mL (5819-357 ng/mL), P = 0.04] were lower in those who died. Mortality was directly related to high systemic inflammation (path coefficient = 0.49), whereas diarrhea, high calprotectin, and low SCFA production related to death indirectly via their more direct association with systemic inflammation. CONCLUSIONS Diarrhea, high intestinal inflammation, low concentrations of fecal SCFAs, and high systemic inflammation are significantly related to mortality in SAM. However, these relations were not mediated by the presence of intestinal pathogens. These findings offer an important understanding of inflammatory changes in SAM, which may lead to improved therapies. This trial was registered at www.controlled-trials.com as ISRCTN13916953.
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Affiliation(s)
- Suzanna Attia
- Division of Gastroenterology, Hepatology, and Nutrition
| | - Christian J Versloot
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | - Wieger Voskuijl
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, Amsterdam, Netherlands
| | - Sara J van Vliet
- University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Groningen, Netherlands
| | - Valeria Di Giovanni
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | - Ling Zhang
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | | | - Céline Bourdon
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - James A Berkley
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom; and.,Childhood Acute Illness and Nutrition Network (CHAIN)
| | - Patrick F van Rheenen
- University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Groningen, Netherlands
| | - Robert Hj Bandsma
- Division of Gastroenterology, Hepatology, and Nutrition, .,Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Groningen, Netherlands.,Childhood Acute Illness and Nutrition Network (CHAIN)
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Heida A, Dijkstra A, Dantuma SK, van Rheenen PF. A Cross-Sectional Study on the Perceptions and Practices of Teenagers With Inflammatory Bowel Disease About Repeated Stool Sampling. J Adolesc Health 2016; 59:479-81. [PMID: 27506279 DOI: 10.1016/j.jadohealth.2016.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 02/19/2016] [Revised: 06/02/2016] [Accepted: 06/15/2016] [Indexed: 01/07/2023]
Abstract
PURPOSE Repeated stool sampling to monitor disease activity is increasingly used in teenagers with inflammatory bowel disease (IBD). Knowledge about their perceptions and practices regarding collection of feces will increase the success rate of this monitoring strategy. METHODS We sent a survey to teenagers with IBD treated in an academic center. RESULTS Seventy-two of 122 invited teenagers completed the survey (response rate 59%; median age 15 years (interquartile range, 13-17). Eighty-five percent reported that stool sampling is normally initiated with help of their parents or caretakers. Seventy-eight percent of respondents say that their parents assist with the placement of stool in the container. CONCLUSIONS Teenagers do not feel embarrassed by the idea of stool sampling, but an active role of the parents or caretakers is an important prerequisite for maintaining a stool-based disease monitoring system. Autonomy in stool sampling is an essential skill required for a successful transition to adult-centered IBD care.
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Affiliation(s)
- Anke Heida
- Department of Pediatric Gastroenterology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Alie Dijkstra
- Department of Pediatric Gastroenterology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sietske K Dantuma
- Department of Pediatric Gastroenterology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Norbruis OF, Escher JC, Kindermann A, de Rijke YB, van Rheenen PF, Berger MY. Diagnostic Accuracy of Fecal Calprotectin for Pediatric Inflammatory Bowel Disease in Primary Care: A Prospective Cohort Study. Ann Fam Med 2016; 14:437-45. [PMID: 27621160 PMCID: PMC5394359 DOI: 10.1370/afm.1949] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 03/16/2016] [Indexed: 02/03/2023] Open
Abstract
PURPOSE In specialist care, fecal calprotectin (FCal) is a commonly used noninvasive diagnostic test for ruling out inflammatory bowel disease (IBD) in children with chronic gastrointestinal symptoms. The aim of this study was to evaluate the diagnostic accuracy of FCal for IBD in symptomatic children in primary care. METHODS We studied 2 prospective cohorts of children with chronic diarrhea, recurrent abdominal pain, or both: children initially seen in primary care (primary care cohort) and children referred to specialist care (referred cohort). FCal (index test) was measured at baseline and compared with 1 of the 2 reference standards for IBD: endoscopic assessment or 1-year follow-up. Physicians were blinded to FCal results, and values greater than 50 μg/g feces were considered positive. We determined specificity in the primary care cohort and sensitivity in the referred cohort. RESULTS None of the 114 children in the primary care cohort ultimately received a diagnosis of IBD. The specificity of FCal in the primary care cohort was 0.87 (95% CI, 0.80-0.92). Among the 90 children in the referred cohort, 17 (19%) ultimately received a diagnosis of IBD. The sensitivity of FCal in the referred cohort was 0.99 (95% CI, 0.81-1.00). CONCLUSIONS The findings of this study suggest that a positive FCal result in children with chronic gastrointestinal symptoms seen in primary care is not likely to be indicative of IBD. A negative FCal result is likely to be a true negative, which safely rules out IBD in children in whom a primary care physician considers referral to specialist care.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne Lisman-van Leeuwen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Boudewijn J Kollen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Obbe F Norbruis
- Department of Pediatrics, Isala Hospital, Zwolle, The Netherlands
| | - Johanna C Escher
- Department of Pediatric Gastroenterology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Angelika Kindermann
- Department of Pediatric Gastroenterology, Emma Children's Hospital ⁄ Academic Medical Center, Amsterdam, The Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Beatrix Children's Hospital ⁄ University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Bierma MJ, Coffey MJ, Nightingale S, van Rheenen PF, Ooi CY. Predicting severe acute pancreatitis in children based on serum lipase and calcium: A multicentre retrospective cohort study. Pancreatology 2016; 16:529-34. [PMID: 27161174 DOI: 10.1016/j.pan.2016.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/26/2016] [Accepted: 04/10/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aims to identify predictors of severe paediatric AP based on laboratory trends and peak/trough values on day 2 (D2) after presentation. The performance of identified predictors was first assessed and then combined with the previously validated sensitive predictor serum lipase ≥7 times the upper limit of normal (× ULN) on day 1 (D1). METHODS A retrospective review of children with AP (January 2000-July 2011) was performed at three tertiary referral hospitals (two in Australia, one in the Netherlands). Trends of candidate predictors were analysed using the percentage change from D1 to D2 or peak/trough values within 48 h after presentation. RESULTS 175 AP episodes (including 50 severe episodes [29%]) were identified. Serum lipase ≥50% decrease on D2 (sensitivity 73%, specificity 54%) and calcium trough ≤2.15 mmol/L within 48 h (sensitivity 59%, specificity 81%) were identified as statistically significant predictors for severe AP. By combining the newly identified predictors with the previously validated predictor serum lipase ≥7× ULN on D1 (sensitivity 82%, specificity 53%), specificity improved to predict severe AP on D2 with the addition of: (i) serum lipase ≥50% decrease (sensitivity 67%, specificity 79%), or (ii) trough calcium ≤2.15 mmol/L (sensitivity 46%, specificity 89%). CONCLUSIONS Serum lipase and calcium, may be helpful in predicting severity of paediatric AP. There may be a clinical role on D1 for using serum lipase ≥7× ULN (high sensitivity), and on D2 for combining D1 serum lipase ≥7× ULN with calcium trough ≤2.15 mmol/L within 48 h (high specificity) to help predict severe paediatric AP.
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Affiliation(s)
- Marrit J Bierma
- Department of Paediatric Gastroenterology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael J Coffey
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Scott Nightingale
- Department of Gastroenterology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia; Discipline of Paediatrics and Child Health, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Chee Y Ooi
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Department of Gastroenterology, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia.
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Degraeuwe PLJ, Beld MPA, Ashorn M, Canani RB, Day AS, Diamanti A, Fagerberg UL, Henderson P, Kolho KL, Van de Vijver E, van Rheenen PF, Wilson DC, Kessels AGH. Faecal calprotectin in suspected paediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2015; 60:339-46. [PMID: 25373864 DOI: 10.1097/mpg.0000000000000615] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The diagnostic accuracy of faecal calprotectin (FC) concentration for paediatric inflammatory bowel disease (IBD) is well described at the population level, but not at the individual level. We reassessed the diagnostic accuracy of FC in children with suspected IBD and developed an individual risk prediction rule using individual patient data. METHODS MEDLINE, EMBASE, DARE, and MEDION databases were searched to identify cohort studies evaluating the diagnostic performance of FC in paediatric patients suspected of having IBD. A standard study-level meta-analysis was performed. In an individual patient data meta-analysis, we reanalysed the diagnostic accuracy on a merged patient dataset. Using logistic regression analysis we investigated whether and how the FC value and patient characteristics influence the diagnostic precision. A prediction rule was derived for use in clinical practice and implemented in a spreadsheet calculator. RESULTS According to the study-level meta-analysis (9 studies, describing 853 patients), FC has a high overall sensitivity of 0.97 (95% confidence interval [CI] 0.92-0.99) and a specificity of 0.70 (0.59-0.79) for diagnosing IBD. In the patient-level pooled analysis of 742 patients from 8 diagnostic accuracy studies, we calculated that at an FC cutoff level of 50 μg/g there would be 17% (95% CI 15-20) false-positive and 2% (1-3) false-negative results. The final logistic regression model was based on individual data of 545 patients and included both FC level and age. The area under the receiver operating characteristic curve of this derived prediction model was 0.92 (95% CI 0.89-0.94). CONCLUSIONS In high-prevalence circumstances, FC can be used as a noninvasive biomarker of paediatric IBD with only a small risk of missing cases. To quantify the individual patients' risk, we developed a simple prediction model based on FC concentration and age. Although the derived prediction rule cannot substitute the clinical diagnostic process, it can help in selecting patients for endoscopic evaluation.
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Affiliation(s)
- Pieter L J Degraeuwe
- *Department of Paediatrics, Maastricht University Medical Centre, Maastricht, The Netherlands †Department of Paediatrics, Tampere University Hospital, Tampere, Finland ‡Department of Paediatrics and European Laboratory for the Investigation of Food Induced Diseases, University of Naples "Federico II," Naples, Italy §Paediatric Gastroenterology, Sydney Children's Hospital, Randwick, Australia ¶Hepathology, Gastroenterology and Nutrition Unit, Bambino Gesù Children's Hospital, Rome, Italy #Department of Paediatrics, Centre for Clinical Research, Västmanlands Hospital, Västerås, Karolinska Institutet, Stockholm, Sweden **Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children ‡‡Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland §§Department of Paediatrics, University Hospital Antwerp, Edegem, Belgium ||||Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen ¶¶Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
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Holtman GA, Lisman-van Leeuwen Y, Kollen BJ, Escher JC, Kindermann A, Rheenen PFV, Berger MY. Challenges in diagnostic accuracy studies in primary care: the fecal calprotectin example. BMC Fam Pract 2013; 14:179. [PMID: 24274463 PMCID: PMC4222604 DOI: 10.1186/1471-2296-14-179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 11/21/2013] [Indexed: 01/02/2023]
Abstract
Background Low disease prevalence and lack of uniform reference standards in primary care induce methodological challenges for investigating the diagnostic accuracy of a test. We present a study design that copes with these methodological challenges and discuss the methodological implications of our choices, using a quality assessment tool for diagnostic accuracy studies (QUADAS-2). Design The study investigates the diagnostic value of fecal calprotectin for detecting inflammatory bowel disease in children presenting with chronic gastrointestinal symptoms in primary care. It is a prospective cohort study including two cohorts of children: one cohort will be recruited in primary care and the other in secondary/tertiary care. Test results of fecal calprotectin will be compared to one of the two reference standards for inflammatory bowel disease: endoscopy with histopathological examination of mucosal biopsies or assessment of clinical symptoms at 1-year follow-up. Discussion According to QUADAS-2 the use of two reference standards and the recruitment of patients in two populations may cause differential verification bias and spectrum bias, respectively. The clinical relevance of this potential bias and methods to adjust for this are presented. This study illustrates the importance of awareness of the different kinds of bias that result from choices in the design phase of a diagnostic study in a low prevalence setting. This approach is exemplary for other diagnostic research in primary care.
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Affiliation(s)
- Gea A Holtman
- Department of General Practice, FA21, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD Groningen, The Netherlands.
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van Rheenen PF. Role of fecal calprotectin testing to predict relapse in teenagers with inflammatory bowel disease who report full disease control. Inflamm Bowel Dis 2012; 18:2018-25. [PMID: 22275341 DOI: 10.1002/ibd.22896] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 01/03/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND Teenagers with inflammatory bowel disease undergo regular follow-up visits to watch for symptoms that may indicate relapse. Current disease activity is frequently estimated with the use of the Pediatric Ulcerative Colitis Activity Index (PUCAI) and the Pediatric Crohn's Disease Activity Index (PCDAI). We examined the capacity of fecal calprotectin and C-reactive protein (CRP) to predict relapse in teenagers who report no symptoms. Second, we examined whether calprotectin and CRP as an "add-on test" improve the specificity of PUCAI or PCDAI to predict relapse. METHODS We collected data of 62 consecutive teenagers (31 with Crohn's disease and 31 with ulcerative colitis) who scored their degree of disease control between 90 and 100% on two successive outpatient clinic visits. Calprotectin, PUCAI or PCDAI, and CRP were measured at baseline. Primary outcome was symptomatic relapse within 3 months of baseline, necessitating the introduction of steroids, exclusive enteral nutrition, or an aminosalicylate dose escalation. RESULTS Fifteen teenagers (24%) developed symptomatic relapse within 3 months of baseline. Based on the receiver operating characteristic curve, the optimum calprotectin cutpoint to differentiate high from low risk patients was 500 μg/g. The PUCAI or PCDAI predicted relapse in 42% (11/26) of teenagers with a positive result (score ≥ 10 points), while a negative PUCAI or PCDAI result reduced the risk of relapse to 11% (4/36). Teenagers with a positive calprotectin test had a 53% (10/19) risk of progressing to symptomatic relapse within 3 months, whereas a negative calprotectin result gave a 12% (5/43) risk of symptomatic relapse. A positive CRP result (cutoff 10 mg/L) gave a 50% (4/8) risk of relapse, whereas a negative CRP result hardly reduced the risk compared with the pretest probability (from 24% to 21% (11/53)). As an add-on test after PUCAI or PCDAI, the calprotectin test limited the number of false positives and thus increased the specificity to detect gastrointestinal inflammation: 60% (9/15) of teenagers with positive concordant test results progressed to symptomatic relapse. Negative concordance reduced the risk of relapse to 10% (3/32). CRP contributed little as add-on test after PUCAI or PCDAI: two of five teenagers with positive concordant tests progressed to symptomatic relapse (40%). CONCLUSIONS Unlike CRP, fecal calprotectin as an add-on test after PUCAI or PCDAI facilitates recognition of preclinical relapse. This could help to identify teenagers who require treatment intensification at the time of minimal disease rather than at the time of clinically overt relapse. Further studies are warranted to determine the impact of fecal calprotectin testing on treatment management and outcome.
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Bandsma RHJ, Spoelstra MN, Mari A, Mendel M, van Rheenen PF, Senga E, van Dijk T, Heikens GT. Impaired glucose absorption in children with severe malnutrition. J Pediatr 2011; 158:282-7.e1. [PMID: 20843523 DOI: 10.1016/j.jpeds.2010.07.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 06/28/2010] [Accepted: 07/26/2010] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To quantify intestinal glucose absorption in children with two types of severe malnutrition, kwashiorkor and marasmus, compared with healthy children. STUDY DESIGN Children with kwashiorkor (n = 6) and marasmus (n = 9) and control subjects (n = 3) received a primed (13 mg/kg), constant infusion (0.15 mg/kg/min) of [6,6H2]glucose for 4.5 hours. Two hours after start of the infusion an oral bolus of glucose 1.75 g/kg labeled with [U-13C]glucose 10 mg/g was given and was followed by periodic blood sampling. Mathematical modeling was applied to determine oral glucose absorption. RESULTS Median total glucose absorption was 5.9 mmol/kg, interquartile range (IQR) 4.5-6.7 mmol/kg and 4.4 (IQR 2.9-5.9) mmol/kg in children with kwashiorkor and marasmus compared with 7.7 (IQR 5.8-9.0) mmol/kg in control subjects; P = .03 compared with marasmus). Children with the lowest glucose absorption were found specifically in the kwashiorkor group and marasmic children with hypoalbuminemia. Severe impairment in absorption correlated with urinary 8-hydroxydeoxyguanosine secretion (r = -0.62, P = .01). CONCLUSIONS Severe malnutrition is associated with an impaired glucose absorption and decreased glucose absorption correlates with oxidative stress in these children.
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Affiliation(s)
- Robert H J Bandsma
- Department of Biochemistry, College of Medicine, University of Malawi, Blantyre, Malawi.
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Fennema EM, Nellensteijn DR, Nieuwenhuijs VB, van Rheenen PF, ten Duis HJ, Hulscher JBF. [Pancreatic injury in abdominal trauma in children: difficult to diagnose and treat]. Ned Tijdschr Geneeskd 2011; 155:A2406. [PMID: 21466717] [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] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Traumatic injury of the pancreas is rare in children. It is often difficult to diagnose due to the lack of signs and symptoms, and shortly after trauma laboratory values may be normal. In addition, ultrasound and CT are often not specific. The treatment of grade 1 and 2 injury is non-operative. Although there seems to be a shift towards non-operative management of grade 3-5 injuries (with injury of the pancreatic duct), this is still a matter of debate. We describe 3 children, a girl of 2.5 years-old and a boy of 7 years-old, with grade 3 pancreatic injuries and an 8-year-old boy with a grade 2 injury. We demonstrate that the diagnosis is hard to establish, while the consequences of this injury can be serious. Thinking of pancreatic injury is most important to its diagnosis. We advocate referral to or consultation of specialized centres in these cases.
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Abstract
OBJECTIVE To evaluate whether including a test for faecal calprotectin, a sensitive marker of intestinal inflammation, in the investigation of suspected inflammatory bowel disease reduces the number of unnecessary endoscopic procedures. DESIGN Meta-analysis of diagnostic accuracy studies. DATA SOURCES Studies published in Medline and Embase up to October 2009. Interventions reviewed Measurement of faecal calprotectin level (index test) compared with endoscopy and histopathology of segmental biopsy samples (reference standard). Inclusion criteria Studies that had collected data prospectively in patients with suspected inflammatory bowel disease and allowed for construction of a two by two table. For each study, sensitivity and specificity of faecal calprotectin were analysed as bivariate data to account for a possible negative correlation within studies. RESULTS 13 studies were included: six in adults (n=670), seven in children and teenagers (n=371). Inflammatory bowel disease was confirmed by endoscopy in 32% (n=215) of the adults and 61% (n=226) of the children and teenagers. In the studies of adults, the pooled sensitivity and pooled specificity of calprotectin was 0.93 (95% confidence interval 0.85 to 0.97) and 0.96 (0.79 to 0.99) and in the studies of children and teenagers was 0.92 (0.84 to 0.96) and 0.76 (0.62 to 0.86). The lower specificity in the studies of children and teenagers was significantly different from that in the studies of adults (P=0.048). Screening by measuring faecal calprotectin levels would result in a 67% reduction in the number of adults requiring endoscopy. Three of 33 adults who undergo endoscopy will not have inflammatory bowel disease but may have a different condition for which endoscopy is inevitable. The downside of this screening strategy is delayed diagnosis in 6% of adults because of a false negative test result. In the population of children and teenagers, 65 instead of 100 would undergo endoscopy. Nine of them will not have inflammatory bowel disease, and diagnosis will be delayed in 8% of the affected children. CONCLUSION Testing for faecal calprotectin is a useful screening tool for identifying patients who are most likely to need endoscopy for suspected inflammatory bowel disease. The discriminative power to safely exclude inflammatory bowel disease was significantly better in studies of adults than in studies of children.
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Affiliation(s)
- Patrick F van Rheenen
- Beatrix Children's Hospital, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, Netherlands.
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Smiers FJ, Van de Vijver E, Delsing BJP, Lankester AC, Ball LM, Rings EHHM, van Rheenen PF, Bredius RGM. Delayed immune recovery following sequential orthotopic liver transplantation and haploidentical stem cell transplantation in erythropoietic protoporphyria. Pediatr Transplant 2010; 14:471-5. [PMID: 19735434 DOI: 10.1111/j.1399-3046.2009.01233.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A nine-yr-old boy with EPP suffered from severe skin burns and liver failure caused by progressive cholestasis and fibrosis. OLT was performed without major complications. Four months following liver transplantation he underwent parental haploidentical HSCT. The myeloablative conditioning regimen was relatively well tolerated and hematological engraftment was rapid (on day 10). Protoporphyrin concentrations returned to normal following HSCT. However, immune recovery was significantly delayed. Varicella zoster virus reactivation resulted in impaired vision, prolonged hospitalization and eventually in multiorgan failure and death. Sequential liver and haploidentical HSCT proved feasible though a high risk procedure in this EPP patient. The management of post-IST after these combined transplantations remains a challenge and needs to be further established.
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Affiliation(s)
- Frans J Smiers
- Division of Immunology, Hematology, Oncology, Bone marrow transplantation and Auto-immune disease, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Mesker T, van Rheenen PF, Norbruis OF, Uitentuis J, Waalkens HJ, Gonera G, van Overbeek LAT, Butler J, Rings EHHM. Pediatric Crohn's disease activity at diagnosis, its influence on pediatrician's prescribing behavior, and clinical outcome 5 years later. Inflamm Bowel Dis 2009; 15:1670-7. [PMID: 19418567 DOI: 10.1002/ibd.20950] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND No studies have been performed in which therapeutic regimens have been compared between mild and moderate-to-severe pediatric Crohn's disease (CD) at diagnosis. The aim was to analyze pediatric CD activity at diagnosis, its influence on pediatrician's prescribing behavior, and clinical outcome 5 years later. METHODS In a retrospective multicenter study we divided pediatric CD patients at diagnosis into mild or moderate-severe disease. We compared initial therapies, duration of first remission, number of exacerbations, height-for-age and weight-for-height evolvement, and cumulative duration of systemic steroid use in a 5-year follow-up period. RESULTS Forty-three children were included (25 with mild and 18 with moderate-severe disease). Aminosalicylate monotherapy was more frequently prescribed in the mild group (40% versus 17%; P < 0.01). The median duration of systemic steroid use was 18.3 months in the mild group and 10.4 months in the moderate-severe group (P = 0.09). Duration of first remission was 15.0 months in the mild group and 23.4 months in the moderate-severe group (P = 0.16). The mean number of exacerbations was 2.2 in the mild group and 1.8 in the moderate-severe group (P = 0.28). CONCLUSIONS CD patients with mild disease were treated with aminosalicylate monotherapy more frequently. These patients, however, tend to have more exacerbations, shorter duration of first remission, and longer total duration of systemic steroid use. Our data support the concept that severity of disease at diagnosis does not reliably predict subsequent clinical course. This study suggests that there is no indication that children with mild CD should be treated differently compared to children with moderate-severe disease.
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Affiliation(s)
- Tamara Mesker
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Affiliation(s)
- Patrick F van Rheenen
- Paediatric Gastroenterology, Department of Paediatrics, University Medical Centre Groningen, PO Box 30001, 9700 RB Groningen, Netherlands.
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van Rheenen PF, Gruschke S, Brabin BJ. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. ACTA ACUST UNITED AC 2006; 26:157-67. [PMID: 16925952 DOI: 10.1179/146532806x120246] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Cheap and effective interventions are needed to reduce the risk of infant anaemia in developing countries. Delayed cord clamping (DCC) has been shown to be a simple, safe and cost-free delivery procedure that augments red cell mass in appropriate-for-gestational-age term and preterm infants. It is not known, however, whether DCC is similarly safe and effective in small-for-gestational-age (SGA) infants. We analysed the available evidence to generate a balanced inference on the use of DCC in developing countries. OBJECTIVES To examine the short- and long-term effects in SGA infants of DCC compared with immediate clamping, and to assess the relationship between time of clamping and the potential postnatal haematological complications of DCC in SGA infants. SEARCH STRATEGY PubMed (1966 to January 2006), EMBASE (1988 to January 2006) and The Cochrane Library (Issue 1, 2006) were searched. Reference lists of published trials were examined and major journals of perinatal and tropical medicine were hand-searched. SELECTION CRITERIA Randomised and quasi-randomised trials comparing delayed with immediate cord clamping in infants born between 30 and 42 completed weeks of gestation and which included a proportion of SGA infants. DATA COLLECTION AND ANALYSIS Three reviewers assessed eligibility and trial quality. MAIN RESULTS To date, no trials have specifically reported the effects of DCC in SGA infants. Three trials were included, of 190 term and 40 preterm infants, a proportion of whom were SGA. DCC was associated with higher haemoglobin levels in term infants at follow-up [two trials, 127 infants, weighted mean difference (WMD) 9.17 g/L, 95% confidence interval (CI) 5.94-12.40]. In preterm infants, the proportion who required a blood transfusion in the 1st 6 weeks after birth was lower after DCC (one trial, 38 infants, RR 0.56, 95% CI 0.34-0.94). It was not possible to infer from the available data whether SGA infants were at greater risk of adverse effects in the early neonatal period. CONCLUSIONS DCC in a group that contains both AGA and SGA infants was associated with higher haemoglobin levels at 2-3 months of age in term infants and a reduction in the number of blood transfusions needed in the 1st 4- 6 weeks of life in preterm infants. No reliable conclusions could be drawn about the potential adverse effects of DCC. The paucity of information on DCC in SGA infants justifies further research, especially in developing countries where the baseline risk for polycythaemia-hyperviscosity syndrome is likely to be lower than in industrialised countries.
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Affiliation(s)
- Patrick F van Rheenen
- Paediatrics Gastroenterology, Department of Paediatrics, University Medical Centre, Groningen, The Netherlands.
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van Rheenen PF, Brabin BJ. Effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics 2006; 118:1317-8; author reply 1318-9. [PMID: 16951036 DOI: 10.1542/peds.2006-1053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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