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Hiremath G, Sun L, Collins MH, Bonis PA, Arva NC, Capocelli KE, Chehade M, Davis CM, Falk GW, Gonsalves N, Gupta SK, Hirano I, Leung J, Khoury P, Mukkada VA, Martin LJ, Spergel JM, Wechsler JB, Yang GY, Aceves SS, Furuta GT, Rothenberg ME, Koyama T, Dellon ES. Esophageal Epithelium and Lamina Propria Are Unevenly Involved in Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2023; 21:2807-2816.e3. [PMID: 36967100 PMCID: PMC10518022 DOI: 10.1016/j.cgh.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/28/2023] [Accepted: 03/13/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND & AIMS The nature of the involvement of esophageal tissue in eosinophilic esophagitis (EoE) is unclear. We estimated the intrabiopsy site agreements of the EoE Histologic Scoring System (EoEHSS) scores for the grade (degree) and stage (extent) of involvement of the esophageal epithelial and lamina propria and examined if the EoE activity status influenced the intrabiopsy site agreement. METHODS Demographic, clinical, and EoEHSS scores collected as part of the prospective Outcome Measures for Eosinophilic Gastrointestinal Diseases Across Ages study were analyzed. A weighted Cohen's kappa agreement coefficient (k) was used to calculate the pairwise agreements for proximal:distal, proximal:middle, and middle:distal esophageal biopsy sites, separately for grade and stage scores, for each of the 8 components of EoEHSS. A k > 0.75 was considered uniform involvement. Inactive EoE was defined as fewer than 15 eosinophils per high-powered field. RESULTS EoEHSS scores from 1263 esophageal biopsy specimens were analyzed. The k for the stage of involvement of the dilated intercellular spaces across all 3 sites in inactive EoE was consistently greater than 0.75 (range, 0.87-0.99). The k for lamina propria fibrosis was greater than 0.75 across some of the biopsy sites but not across all 3. Otherwise, the k for all other features, for both grade and stage, irrespective of the disease activity status, was 0.75 or less (range, 0.00-0.74). CONCLUSIONS Except for the extent of involvement of dilated intercellular spaces in inactive EoE, the remaining epithelial features and lamina propria are involved unevenly across biopsy sites in EoE, irrespective of the disease activity status. This study enhances our understanding of the effects of EoE on esophageal tissue pathology.
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Affiliation(s)
- Girish Hiremath
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Lili Sun
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital at Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carla M Davis
- Immunology, Allergy, and Retrovirology Division, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - John Leung
- Boston Specialists/Boston Food Allergy Center, Boston, Massachusetts
| | - Paneez Khoury
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Vincent A Mukkada
- Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine Department of Pediatrics, Cincinnati, Ohio
| | - Lisa J Martin
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy-Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Pennsylvania
| | - Joshua B Wechsler
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Guang-Yu Yang
- Division of Anatomical Pathology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Seema S Aceves
- Division of Rheumatology, Allergy & Immunology, Rady Children's Hospital, San Diego, San Diego, California
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology and Hepatology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, University of Colorado School of Medicine, Colorado
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, University of Cincinnati College of Medicine, Ohio
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, the University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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Arnim UV, Biedermann L, Aceves SS, Bonis PA, Collins MH, Dellon ES, Furuta GT, Gonsalves N, Gupta S, Hirano I, Lucendo AJ, Miehlke S, Oliva S, Schlag C, Schoepfer A, Straumann A, Vieth M, Bredenoord AJ. Monitoring Patients With Eosinophilic Esophagitis in Routine Clinical Practice - International Expert Recommendations. Clin Gastroenterol Hepatol 2023; 21:2526-2533. [PMID: 36572109 DOI: 10.1016/j.cgh.2022.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND & AIMS There are no studies or recommendations on optimal monitoring strategies for patients with eosinophilic esophagitis (EoE). Our objective was to develop guidance on how to monitor patients with EoE in routine clinical practice, on the basis of available clinical evidence and expert opinion. METHODS A multidisciplinary, international group of EoE experts identified the following important 3 questions during several consensus meetings: why, by what means, and when to monitor patients with EoE. A steering committee was named, and 3 teams were formed to review literature and to formulate statements for each topic. In a Delphi survey, a level of agreement of ≥75% was defined as threshold value for acceptance. In a final conference, results were presented, critical points and comments on the statements were discussed, and statements were rephrased/rewritten if necessary. RESULTS Eighteen EoE experts (14 adult and pediatric gastroenterologists, 2 pathologists and 2 allergists) with a median of 21.7 years in clinical practice, mostly academic or university-based, completed the Delphi survey, which included 11 statements and a proposed algorithm for monitoring patients with EoE. Each statement attained ≥75% agreement. Participants discussed and debated mostly about the statement concerning surveillance intervals for EoE patients with stable disease. CONCLUSIONS It was concluded that effective maintenance treatment probably reduces the development of EoE complications, and regular, structured, and, under certain conditions, individualized clinical follow-up is recommended to assess disease activity while opening a window to monitoring side effects, adjusting therapy, and encouraging adherence to treatment. Follow-up should comprise symptom assessment and periodic or repeated endoscopy with histological assessment in specific EoE settings.
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Affiliation(s)
- Ulrike von Arnim
- Department of Gastroenterology, Hepatology, and Infectious Diseases, University Hospital, Magdeburg, Germany.
| | - Luc Biedermann
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Seema S Aceves
- Eosinophilic Gastrointestinal Disorders Clinic, Division of Allergy Immunology, Rady Children's Hospital, San Diego University of California, San Diego, California
| | | | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Glenn T Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Diseases Program, Department of Pediatrics, Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University - Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep Gupta
- Community Hospital Network, Division of Pediatric Gastroenterology/Hepatology/Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Vereda de Socuéllamos s/n, Tomelloso, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Stephan Miehlke
- Centre for Digestive Diseases, Internal Medicine Centre Eppendorf, Hamburg, Germany
| | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza - University of Rome, Rome, Italy
| | - Christoph Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zurich, Switzerland
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Netherlands
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3
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Kliewer KL, Gonsalves N, Dellon ES, Katzka DA, Abonia JP, Aceves SS, Arva NC, Besse JA, Bonis PA, Caldwell JM, Capocelli KE, Chehade M, Cianferoni A, Collins MH, Falk GW, Gupta SK, Hirano I, Krischer JP, Leung J, Martin LJ, Menard-Katcher P, Mukkada VA, Peterson KA, Shoda T, Rudman Spergel AK, Spergel JM, Yang GY, Zhang X, Furuta GT, Rothenberg ME. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial. Lancet Gastroenterol Hepatol 2023; 8:408-421. [PMID: 36863390 PMCID: PMC10102869 DOI: 10.1016/s2468-1253(23)00012-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Empirical elimination diets are effective for achieving histological remission in eosinophilic oesophagitis, but randomised trials comparing diet therapies are lacking. We aimed to compare a six-food elimination diet (6FED) with a one-food elimination diet (1FED) for the treatment of adults with eosinophilic oesophagitis. METHODS We conducted a multicentre, randomised, open-label trial across ten sites of the Consortium of Eosinophilic Gastrointestinal Disease Researchers in the USA. Adults aged 18-60 years with active, symptomatic eosinophilic oesophagitis were centrally randomly allocated (1:1; block size of four) to 1FED (animal milk) or 6FED (animal milk, wheat, egg, soy, fish and shellfish, and peanut and tree nuts) for 6 weeks. Randomisation was stratified by age, enrolling site, and gender. The primary endpoint was the proportion of patients with histological remission (peak oesophageal count <15 eosinophils per high-power field [eos/hpf]). Key secondary endpoints were the proportions with complete histological remission (peak count ≤1 eos/hpf) and partial remission (peak counts ≤10 and ≤6 eos/hpf) and changes from baseline in peak eosinophil count and scores on the Eosinophilic Esophagitis Histology Scoring System (EoEHSS), Eosinophilic Esophagitis Endoscopic Reference Score (EREFS), Eosinophilic Esophagitis Activity Index (EEsAI), and quality of life (Adult Eosinophilic Esophagitis Quality-of-Life and Patient Reported Outcome Measurement Information System Global Health questionnaires). Individuals without histological response to 1FED could proceed to 6FED, and those without histological response to 6FED could proceed to swallowed topical fluticasone propionate 880 μg twice per day (with unrestricted diet), for 6 weeks. Histological remission after switching therapy was assessed as a secondary endpoint. Efficacy and safety analyses were done in the intention-to-treat (ITT) population. This trial is registered on ClinicalTrials.gov, NCT02778867, and is completed. FINDINGS Between May 23, 2016, and March 6, 2019, 129 patients (70 [54%] men and 59 [46%] women; mean age 37·0 years [SD 10·3]) were enrolled, randomly assigned to 1FED (n=67) or 6FED (n=62), and included in the ITT population. At 6 weeks, 25 (40%) of 62 patients in the 6FED group had histological remission compared with 23 (34%) of 67 in the 1FED group (difference 6% [95% CI -11 to 23]; p=0·58). We found no significant difference between the groups at stricter thresholds for partial remission (≤10 eos/hpf, difference 7% [-9 to 24], p=0·46; ≤6 eos/hpf, 14% [-0 to 29], p=0·069); the proportion with complete remission was significantly higher in the 6FED group than in the 1FED group (difference 13% [2 to 25]; p=0·031). Peak eosinophil counts decreased in both groups (geometric mean ratio 0·72 [0·43 to 1·20]; p=0·21). For 6FED versus 1FED, mean changes from baseline in EoEHSS (-0·23 vs -0·15; difference -0·08 [-0·21 to 0·05]; p=0·23), EREFS (-1·0 vs -0·6; difference -0·4 [-1·1 to 0·3]; p=0·28), and EEsAI (-8·2 vs -3·0; difference -5·2 [-11·2 to 0·8]; p=0·091) were not significantly different. Changes in quality-of-life scores were small and similar between the groups. No adverse event was observed in more than 5% of patients in either diet group. For patients without histological response to 1FED who proceeded to 6FED, nine (43%) of 21 reached histological remission; for patients without histological response to 6FED who proceeded to fluticasone propionate, nine (82%) of 11 reached histological remission. INTERPRETATION Histological remission rates and improvements in histological and endoscopic features were similar after 1FED and 6FED in adults with eosinophilic oesophagitis. 6FED had efficacy in just less than half of 1FED non-responders and steroids had efficacy in most 6FED non-responders. Our findings indicate that eliminating animal milk alone is an acceptable initial dietary therapy for eosinophilic oesophagitis. FUNDING US National Institutes of Health.
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Affiliation(s)
- Kara L Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Juan P Abonia
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Seema S Aceves
- Division of Allergy and Immunology, University of California at San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - Nicoleta C Arva
- Department of Pathology and Laboratory, Ann and Robert H Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John A Besse
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Julie M Caldwell
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Antonella Cianferoni
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey P Krischer
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | | | - Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, Hepatology and Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Tetsuo Shoda
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Amanda K Rudman Spergel
- Division of Allergy, Immunology and Transplantation, National Institutes of Allergy and Infectious Disease, NIH, Bethesda, MD, USA
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Xue Zhang
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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4
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Dellon ES, Gonsalves N, Abonia JP, Alexander JA, Arva NC, Atkins D, Attwood SE, Auth MKH, Bailey DD, Biederman L, Blanchard C, Bonis PA, Bose P, Bredenoord AJ, Chang JW, Chehade M, Collins MH, Di Lorenzo C, Dias JA, Dohil R, Dupont C, Falk GW, Ferreira CT, Fox AT, Genta RM, Greuter T, Gupta SK, Hirano I, Hiremath GS, Horsley-Silva JL, Ishihara S, Ishimura N, Jensen ET, Gutiérrez-Junquera C, Katzka DA, Khoury P, Kinoshita Y, Kliewer KL, Koletzko S, Leung J, Liacouras CA, Lucendo AJ, Martin LJ, McGowan EC, Menard-Katcher C, Metz DC, Miller TL, Moawad FJ, Muir AB, Mukkada VA, Murch S, Nhu QM, Nomura I, Nurko S, Ohtsuka Y, Oliva S, Orel R, Papadopoulou A, Patel DA, Pesek RD, Peterson KA, Philpott H, Putnam PE, Richter JE, Rosen R, Ruffner MA, Safroneeva E, Schreiner P, Schoepfer A, Schroeder SR, Shah N, Souza RF, Spechler SJ, Spergel JM, Straumann A, Talley NJ, Thapar N, Vandenplas Y, Venkatesh RD, Vieira MC, von Arnim U, Walker MM, Wechsler JB, Wershil BK, Wright BL, Yamada Y, Yang GY, Zevit N, Rothenberg ME, Furuta GT, Aceves SS. International Consensus Recommendations for Eosinophilic Gastrointestinal Disease Nomenclature. Clin Gastroenterol Hepatol 2022; 20:2474-2484.e3. [PMID: 35181570 PMCID: PMC9378753 DOI: 10.1016/j.cgh.2022.02.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/28/2022] [Accepted: 02/07/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Substantial heterogeneity in terminology used for eosinophilic gastrointestinal diseases (EGIDs), particularly the catchall term "eosinophilic gastroenteritis," limits clinical and research advances. We aimed to achieve an international consensus for standardized EGID nomenclature. METHODS This consensus process utilized Delphi methodology. An initial naming framework was proposed and refined in iterative fashion, then assessed in a first round of Delphi voting. Results were discussed in 2 consensus meetings, and the framework was updated and reassessed in a second Delphi vote, with a 70% threshold set for agreement. RESULTS Of 91 experts participating, 85 (93%) completed the first and 82 (90%) completed the second Delphi surveys. Consensus was reached on all but 2 statements. "EGID" was the preferred umbrella term for disorders of gastrointestinal (GI) tract eosinophilic inflammation in the absence of secondary causes (100% agreement). Involved GI tract segments will be named specifically and use an "Eo" abbreviation convention: eosinophilic gastritis (now abbreviated EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC). The term "eosinophilic gastroenteritis" is no longer preferred as the overall name (96% agreement). When >2 GI tract areas are involved, the name should reflect all of the involved areas. CONCLUSIONS This international process resulted in consensus for updated EGID nomenclature for both clinical and research use. EGID will be the umbrella term, rather than "eosinophilic gastroenteritis," and specific naming conventions by location of GI tract involvement are recommended. As more data are developed, this framework can be updated to reflect best practices and the underlying science.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing and Center for Gastrointestinal Biology and Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J Pablo Abonia
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Nicoleta C Arva
- Department of Pathology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dan Atkins
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Stephen E Attwood
- Department of Health Services Research, Durham University, Durham, United Kingdom
| | - Marcus K H Auth
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Alder Hey Children's NHS Foundation Trust and University of Liverpool, Liverpool, United Kingdom
| | - Dominique D Bailey
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York; Division of Digestive and Liver Disease, Department of Medicine, Columbia University Irving Medical Center, New York, New York; Columbia Center for Human Development, Columbia University Irving Medical Center, New York, New York
| | - Luc Biederman
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Carine Blanchard
- Department of Gastro-Intestinal Health, Immunology group, Nestlé Institute of Health Sciences, Nestlé Research, Société des Produits Nestlé S.A., Lausanne, Switzerland
| | - Peter A Bonis
- Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Paroma Bose
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children and Community Health Network, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MichiganI
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Ranjan Dohil
- Division on Pediatric Gastroenterology, Rady's Children's Hospital, University of California, San Diego, San Diego, California
| | - Christophe Dupont
- Ramsay Group, Marcel Sembat Clinic, Paris Descartes University, Paris, France
| | - Gary W Falk
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania Philadelphia, Pennsylvania
| | - Cristina T Ferreira
- Hospital Santo Antônio, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Adam T Fox
- Paediatric Allergy, Guy's & St. Thomas' Hospitals NHS Foundation Trust, London, United Kingdom
| | - Robert M Genta
- Division of Gastroenterology, Department of Pathology and Medicine, Baylor College of Medicine, Houston, Texas; Inform Diagnostics, Irving, Texas
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland; Division of Gastroenterology and Hepatology, University Hospital Lausanne, Lausanne, Switzerland
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Riley Hospital for Children and Community Health Network, Indiana University School of Medicine, Indianapolis, Indianapolis
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Girish S Hiremath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Shunji Ishihara
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Shimane, Japan
| | - Norihisa Ishimura
- Department of Internal Medicine II, Shimane University Faculty of Medicine, Shimane, Japan
| | - Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, University Hospital Puerta de Hierro Majadahonda, Autonomous University of Madrid, Majadahonda, Spain
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic Rochester, Minnesota
| | - Paneez Khoury
- Human Eosinophil Section, National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, Maryland
| | | | - Kara L Kliewer
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sibylle Koletzko
- Department of Pediatrics, 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
| | - John Leung
- Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Chris A Liacouras
- Center for Pediatric Eosinophilic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Instituto de Investigación Sanitaria Princesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Tomelloso, Spain
| | - Lisa J Martin
- Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Emily C McGowan
- Division of Allergy and Immunology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - David C Metz
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania Philadelphia, Pennsylvania
| | | | - Fouad J Moawad
- Division of Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California
| | - Amanda B Muir
- Center for Pediatric Eosinophilic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Simon Murch
- Warwick University Medical School, Coventry, United Kingdom
| | - Quan M Nhu
- Division of Gastroenterology and Hepatology, Scripps Clinic, La Jolla, California; Department of Molecular Medicine, Scripps Research Institute, San Diego, California; Division of Allergy and Immunology, University of California, San Diego, La Jolla, California
| | - Ichiro Nomura
- Division of Eosinophilic Gastrointestinal Disorders, Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts
| | - Yoshikazu Ohtsuka
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Salvatore Oliva
- Pediatric Digestive Endoscopy, Pediatric Gastroenterology and Liver Unit, Maternal and Child Health Department, University Hospital, University of Rome, Rome, Italy
| | - Rok Orel
- University Children's Hospital Ljubljana, Faculty of Medicine, University of Ljubljana, Slovenia
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, Children's Hospital Agia Sofia, First Department of Pediatrics, University of Athens, Athens, Greece
| | - Dhyanesh A Patel
- Center for Esophageal Disorders, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert D Pesek
- Division of Allergy and Immunology, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Hamish Philpott
- Department of Gastroenterology, Lyell McEwin Hospital, University of Adelaide, Adelaide, Australia
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joel E Richter
- Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Rachel Rosen
- Aerodigestive Center, Boston Children's Hospital, Boston, Massachusetts
| | - Melanie A Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Philipp Schreiner
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, University Hospital Lausanne, Lausanne, Switzerland
| | - Shauna R Schroeder
- Division of Gastroenterology, Hepatology, and Nutrition, Phoenix Children's Hospital, Phoenix, Arizona
| | - Neil Shah
- Portland Hospital, London, United Kingdom; Reckitt Healthcare, Slough, United Kingdom
| | - Rhonda F Souza
- Division of Gastroenterology and Center for Esophageal Diseases, Baylor Scott & White Center for Esophageal Research, Baylor University Medical Center, Baylor Scott & White Research Institute, Dallas, Texas
| | - Stuart J Spechler
- Division of Gastroenterology and Center for Esophageal Diseases, Baylor Scott & White Center for Esophageal Research, Baylor University Medical Center, Baylor Scott & White Research Institute, Dallas, Texas
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alex Straumann
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Nicholas J Talley
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia; National Health and Medical Research Council Centre of Research Excellence on Digestive Health, Newcastle, Australia; Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, School of Medicine, University of Queensland, Brisbane, Australia; Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Yvan Vandenplas
- KidZ Health Castle, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rajitha D Venkatesh
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio
| | - Mario C Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Marjorie M Walker
- Department of Pathology, College of Health, Medicine and Wellbeing, Faculty of Health and Medicine, University of Newcastle Callaghan, Australia
| | - Joshua B Wechsler
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Barry K Wershil
- Division of Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Benjamin L Wright
- Division of Allergy, Asthma, and Clinical Immunology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona; Section of Allergy and Immunology, Division of Pulmonology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Yoshiyuki Yamada
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noam Zevit
- Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel-Aviv University, Petah-Tikva, Israel
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Division of Allergy, Immunology, and Rheumatology, Departments of Pediatrics and Medicine, Rady Children's Hospital, University of California San Diego, San Diego, California
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5
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Schreiner P, Safroneeva E, Schoepfer A, Greuter T, Biedermann L, Schlag C, Labenz J, Auth MKH, Bredenoord AJ, Chang JW, Bonis PA, Rothenberg ME, Collins MH, Hirano I, Gupta SK, Katzka DA, Dellon ES, Straumann A, Furuta GT, Gonsalves N. Management of eosinophilic esophagitis associated food impaction in Europe and the United States. Dis Esophagus 2022; 35:6516224. [PMID: 35088073 DOI: 10.1093/dote/doac003] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 12/11/2022]
Abstract
Eosinophilic esophagitis (EoE) is the most common cause of esophageal food impaction (EFI). Approaches to management of EFI due to EoE have not been well characterized. We conducted a web-based survey to understand approaches to management of EFI due to EoE among endoscopists. Questions focused on management of patients from presentation to post-endoscopy follow-up. The survey was administered to a list of eligible candidates provided by societies of gastroenterology. A total of 308 endoscopists completed the questionnaire. The majority (83%) practiced in Europe and treated adults (78%). Most agreed patients should be advised to seek emergency care (66%) within 1 to 2 hours (41% agreement). There was agreement that medications to induce vomiting should be avoided (84%) and that blood tests or imaging studies were usually not required before endoscopy. By contrast, there was more variability in the type of sedation recommended and the need for endotracheal intubation, especially when comparing more experienced with less experienced EoE-endoscopists. Overall, fewer than half (43%) respondents recommended obtaining esophageal biopsies during the initial endoscopy. However, there were significant differences in the proportion who recommended biopsies based on level of EoE-experience (25, 52, 77%, P < 0.001; less vs. moderate vs. very experienced) and comparing pediatric and adult endoscopists (32, vs. 79%, P < 0.001; adult vs. pediatric). There exists heterogeneity among endoscopists in recommendations to manage EFI in patients with EoE. These findings support development of clinical guidelines and new studies to clarify the rationale for best practices. Key summary: Established knowledge-The optimal management of patients with esophageal food impaction due to eosinophilic esophagitis from presentation at the emergency department to postendoscopy care is unclear. New findings-Considerable recommendation variation exists in the management of EFI in patients with EoE. Our findings provide a rationale for the creation of consensus practice guidelines and further study into best practices.
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Affiliation(s)
- Philipp Schreiner
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Luc Biedermann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Schlag
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Joachim Labenz
- Department of Medicine, Diakonie Hospital Jung- Stilling, Siegen, Germany
| | - Marcus K H Auth
- Alder Hey Children's NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Peter A Bonis
- Division of Gastroenterology, Tufts University School of Medicine, Boston, MA, USA
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University/Community Health Network, Indianapolis, IN, USA
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Alex Straumann
- Department of Gastroenterology & Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
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6
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. Gastroenterology 2022; 163:59-76. [PMID: 35606197 PMCID: PMC9233087 DOI: 10.1053/j.gastro.2022.03.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Bob Geng
- University of California San Diego, San Diego, California; Rady Children's Hospital, San Diego, California
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock, Arkansas; Arkansas Children's Hospital, Little Rock, Arkansas
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven, Connecticut; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden, Connecticut
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis, Indiana; Riley Hospital for Children, Indianapolis, Indiana; Community Health Network, Indianapolis, Indiana
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain; Instituto de Investigación Sanitaria La Princesa, Madrid, Spain
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville, Virginia
| | - Fouad J Moawad
- Division of Gastroenterology, Scripps Clinic, La Jolla, California
| | - Kathryn A Peterson
- Division of Gastroenterology, University of Utah Health, Salt Lake City, Utah
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Seema S Aceves
- Rady Children's Hospital, San Diego, California; Division of Allergy, Immunology, University of California-San Diego, San Diego, California
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7
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Dellon ES, Khoury P, Muir AB, Liacouras CA, Safroneeva E, Atkins D, Collins MH, Gonsalves N, Falk GW, Spergel JM, Hirano I, Chehade M, Schoepfer AM, Menard-Katcher C, Katzka DA, Bonis PA, Bredenoord AJ, Geng B, Jensen ET, Pesek RD, Feuerstadt P, Gupta SK, Lucendo AJ, Genta RM, Hiremath G, McGowan EC, Moawad FJ, Peterson KA, Rothenberg ME, Straumann A, Furuta GT, Aceves SS. A Clinical Severity Index for Eosinophilic Esophagitis: Development, Consensus, and Future Directions. J Allergy Clin Immunol 2022; 150:33-47. [PMID: 35606166 PMCID: PMC9549868 DOI: 10.1016/j.jaci.2022.03.015] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/13/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND & AIMS Disease activity and severity of eosinophilic esophagitis (EoE) dictate therapeutic options and management, but the decision-making process for determining severity varies among practitioners. To reduce variability in practice patterns and help clinicians monitor the clinical course of the disease in an office setting, we aimed to create an international consensus severity scoring index for EoE. METHODS A multidisciplinary international group of adult and pediatric EoE researchers and clinicians, as well as non-EoE allergy immunology and gastroenterology experts, formed 3 teams to review the existing literature on histology, endoscopy, and symptoms of EoE in the context of progression and severity. A steering committee convened a 1-day virtual meeting to reach consensus on each team's opinion on salient features of severity across key clinicopathologic domains and distill features that would allow providers to categorize disease severity. RESULTS Symptom features and complications and inflammatory and fibrostenotic features on both endoscopic and histologic examination were collated into a simplified scoring system-the Index of Severity for Eosinophilic Esophagitis (I-SEE)-that can be completed at routine clinic visits to assess disease severity using a point scale of 0-6 for mild, 7-14 for moderate, and ≥15 for severe EoE. CONCLUSIONS A multidisciplinary team of experts iteratively created a clinically usable EoE severity scoring system denominated "I-SEE" to guide practitioners in EoE management by standardizing disease components reflecting disease severity beyond eosinophil counts. I-SEE should be validated and refined using data from future clinical trials and routine clinical practice to increase its utilization and functionality.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill.
| | - Paneez Khoury
- Human Eosinophil Section, Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia
| | - Chris A Liacouras
- Division of Gastroenterology, Hepatology, and Nutrition, Perelman School of Medicine, University of Pennsylvania, Philadelphia; The Children's Hospital of Philadelphia, Philadelphia; Center for Pediatric Eosinophilic Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora; Children's Hospital Colorado, Aurora
| | - Margaret H Collins
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati; Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Nirmala Gonsalves
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Gary W Falk
- The Children's Hospital of Philadelphia, Philadelphia; Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jonathan M Spergel
- The Children's Hospital of Philadelphia, Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Ikuo Hirano
- Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York
| | - Alain M Schoepfer
- Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne
| | - Calies Menard-Katcher
- Department of Pediatrics, University of Colorado School of Medicine, Aurora; Digestive Health Institute, Children's Hospital Colorado, Aurora
| | | | | | - Albert J Bredenoord
- Department of Gastroenterology, Amsterdam University Medical Center, Amsterdam
| | - Bob Geng
- University of California San Diego, San Diego; Rady Children's Hospital, San Diego
| | - Elizabeth T Jensen
- Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem
| | - Robert D Pesek
- Division of Allergy/Immunology, University of Arkansas for Medicine Sciences, Little Rock; Arkansas Children's Hospital, Little Rock
| | - Paul Feuerstadt
- Division of Gastroenterology, Yale-New Haven Hospital, New Haven; Physicians Alliance of Connecticut, Gastroenterology Center, Hamden
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology/Hepatology/Nutrition, Indiana University School of Medicine, Indianapolis; Riley Hospital for Children, Indianapolis; Community Health Network, Indianapolis
| | - Alfredo J Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Ciudad Real; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid; Instituto de Investigación Sanitaria La Princesa, Madrid
| | | | - Girish Hiremath
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Emily C McGowan
- Allergy and Clinical Immunology, University of Virginia, Charlottesville
| | | | | | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati
| | | | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora; Department of Pediatrics, Gastrointestinal Eosinophilic Diseases Program and Mucosal Inflammation Program, University of Colorado School of Medicine, Aurora
| | - Seema S Aceves
- Rady Children's Hospital, San Diego; Division of Allergy, Immunology, University of California-San Diego, San Diego
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8
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Safroneeva E, Pan Z, King E, Martin LJ, Collins MH, Yang GY, Capocelli KE, Arva NC, Abonia JP, Atkins D, Bonis PA, Dellon ES, Falk GW, Gonsalves N, Gupta SK, Hirano I, Leung J, Menard-Katcher PA, Mukkada VA, Schoepfer AM, Spergel JM, Wershil BK, Rothenberg ME, Aceves SS, Furuta GT. Long-Lasting Dissociation of Esophageal Eosinophilia and Symptoms After Dilation in Adults With Eosinophilic Esophagitis. Clin Gastroenterol Hepatol 2022; 20:766-775.e4. [PMID: 34062314 PMCID: PMC8628021 DOI: 10.1016/j.cgh.2021.05.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Esophageal dilation improves dysphagia but not inflammation in eosinophilic esophagitis (EoE) patients. We investigated if dilation modifies the association between symptoms and peak esophageal eosinophils per high-power field (eos/hpf). METHODS Adults enrolled in a multisite prospective Consortium of Gastrointestinal Eosinophilic Disease Researchers Outcome Measures for Eosinophilic Gastrointestinal Diseases Across Ages observational study (NCT02523118) completed the symptom-based EoE activity index (EEsAI) patient-reported outcome instrument and underwent endoscopy with biopsy specimens. Patients were stratified based on dilation status as absent, performed 1 year or less before endoscopy, and performed more than 1 year before endoscopy. Assessments included Spearman correlations of the relationship between symptoms and eos/hpf and linear regression with EEsAI as the outcome, eos/hpf as predictor, and interaction for dilation and eos/hpf. RESULTS Among 100 patients (n = 61 males; median age, 37 y), 15 and 40 patients underwent dilation 1 year or less and more than 1 year before index endoscopy, respectively. In nondilated patients, the association between eos/hpf and symptoms was moderate (ρ = 0.49; P < .001); for a 10-eos/hpf increase, the predicted EEsAI increased by 2.69 (P = .002). In patients dilated 1 or less and more than 1 year before index endoscopy, this association was abolished (ρ = -0.38; P = .157 for ≤1 y and ρ = 0.02; P = .883 >1 y); for a 10-eos/hpf increase, the predicted EEsAI changed by -1.64 (P = .183) and 0.78 (P = .494), respectively. Dilation modified the association between symptoms and eos/hpf (P = .005 and P = .187 for interaction terms of eos/hpf and dilation 1 or less years before and more than 1 year before index endoscopy, respectively). CONCLUSIONS In nondilated EoE adults, eos/hpf correlate modestly with symptoms; this correlation was no longer appreciated in dilated patients, and the dilation effects lasted longer than 1 year. Dilation status should be considered in studies evaluating EoE treatment and for clinical follow-up evaluation.
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Affiliation(s)
- Ekaterina Safroneeva
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
| | - Zhaoxing Pan
- Pediatric Gastroenterology, Pediatric Allergy and Immunology, Aurora, Colorado
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati, Ohio
| | | | | | | | | | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Chicago, Illinois
| | - J Pablo Abonia
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati, Ohio
| | - Dan Atkins
- Section of Allergy, Immunology, Aurora, Colorado
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Gary W Falk
- Division of Gastroenterology, Philadelphia, Pennsylvania
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children/Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts
| | - Paul A Menard-Katcher
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alain M Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Jonathan M Spergel
- Department of Allergy and Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Barry K Wershil
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati, Ohio
| | - Seema S Aceves
- Division of Allergy Immunology, University of California, San Diego, Rady Children's Hospital, San Diego, California
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Aurora, Colorado
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Shoda T, Wen T, Caldwell JM, Ben-Baruch Morgenstern N, Osswald GA, Rochman M, Mack LE, Felton JM, Abonia JP, Arva NC, Atkins D, Bonis PA, Capocelli KE, Collins MH, Dellon ES, Falk GW, Gonsalves N, Gupta SK, Hirano I, Leung J, Menard-Katcher PA, Mukkada VA, Putnam PE, Rudman Spergel AK, Spergel JM, Wechsler JB, Yang GY, Aceves SS, Furuta GT, Rothenberg ME. Loss of Endothelial TSPAN12 Promotes Fibrostenotic Eosinophilic Esophagitis via Endothelial Cell-Fibroblast Crosstalk. Gastroenterology 2022; 162:439-453. [PMID: 34687736 PMCID: PMC8792211 DOI: 10.1053/j.gastro.2021.10.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [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: 01/22/2021] [Revised: 09/16/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis (EoE) can progress to fibrostenosis by unclear mechanisms. Herein, we investigated gene dysregulation in fibrostenotic EoE, its association with clinical parameters and specific pathways, and the functional consequences. METHODS Esophageal biopsies from subjects with EoE were collected across 11 Consortium of Eosinophilic Gastrointestinal Disease Researchers sites (n = 311) and 2 independent replication cohorts (n = 83). Inclusion criteria for fibrostenotic EoE were endoscopic rings, stricture, and/or a history of dilation. Endoscopic, histologic, and molecular features were assessed by the EoE Endoscopic Reference Score, EoE Histology Scoring System, EoE Diagnostic Panel, and RNA sequencing. Esophageal endothelial TSPAN12 expression and functional effects on barrier integrity and gene expression were analyzed in vitro. RESULTS TSPAN12 was the gene most correlated with fibrostenosis (r = -0.40, P < .001). TSPAN12 was lower in fibrostenotic EoE and correlated with EoE Endoscopic Reference Score, EoE Diagnostic Panel, and EoE Histology Scoring System (r = 0.34-0.47, P < .001). Lower TSPAN12 associated with smaller esophageal diameter (r = 0.44, P = .03), increased lamina propria fibrosis (r = -0.41, P < .001), and genes enriched in cell cycle-related pathways. Interleukin (IL)-13 reduced TSPAN12 expression in endothelial cells. Conversely, anti-IL-13 therapy increased TSPAN12 expression. TSPAN12 gene silencing increased endothelial cell permeability and dysregulated genes associated with extracellular matrix pathways. Endothelial cell-fibroblast crosstalk induced extracellular matrix changes relevant to esophageal remodeling. CONCLUSIONS Patients with fibrostenotic EoE express decreased levels of endothelial TSPAN12. We propose that IL-13 decreases TSPAN12, likely contributing to the chronicity of EoE by promoting tissue remodeling through fibroblast-endothelial cell crosstalk.
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Affiliation(s)
- Tetsuo Shoda
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ting Wen
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Julie M Caldwell
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Netali Ben-Baruch Morgenstern
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Garrett A Osswald
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Rochman
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lydia E Mack
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer M Felton
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - J Pablo Abonia
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nicoleta C Arva
- Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dan Atkins
- Section of Pediatric Allergy and Immunology, Children's Hospital Colorado, Aurora, Colorado
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts
| | | | - Margaret H Collins
- Division of Pathology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts
| | - Paul A Menard-Katcher
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amanda K Rudman Spergel
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jonathan M Spergel
- Division of Allergy and Immunology, University of Pennsylvania Perelman School of Medicine/Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joshua B Wechsler
- Gastroenterology, Hepatology and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Guang-Yu Yang
- Department of Pathology and Laboratory Medicine, Northwestern University, Chicago, Illinois
| | - Seema S Aceves
- Division of Allergy Immunology, Departments of Pediatrics and Medicine, University of California, San Diego, Rady Children's Hospital, San Diego, California
| | - Glenn T Furuta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Digestive Health Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Marc E Rothenberg
- Division of Allergy and Immunology, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Bonis PA. Clinical Decision Support Improves Decision-Making and Leads to Better Outcomes. ACTA MEDICA PORT 2019; 32:677. [PMID: 31625883 DOI: 10.20344/amp.12688] [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: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Peter A Bonis
- Chief Medical Officer. Division of Clinical Effectiveness. Wolters Kluwer. Aldeia de Juzo. Portugal; Adjunct Professor of Medicine. School of Medicine. Tufts University. Boston. USA
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11
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Van Vleck TT, Chan L, Coca SG, Craven CK, Do R, Ellis SB, Kannry JL, Loos RJF, Bonis PA, Cho J, Nadkarni GN. Augmented intelligence with natural language processing applied to electronic health records for identifying patients with non-alcoholic fatty liver disease at risk for disease progression. Int J Med Inform 2019; 129:334-341. [PMID: 31445275 PMCID: PMC6717556 DOI: 10.1016/j.ijmedinf.2019.06.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/20/2019] [Accepted: 06/28/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Electronic health record (EHR) systems contain structured data (such as diagnostic codes) and unstructured data (clinical documentation). Clinical insights can be derived from analyzing both. The use of natural language processing (NLP) algorithms to effectively analyze unstructured data has been well demonstrated. Here we examine the utility of NLP for the identification of patients with non-alcoholic fatty liver disease, assess patterns of disease progression, and identify gaps in care related to breakdown in communication among providers. MATERIALS AND METHODS All clinical notes available on the 38,575 patients enrolled in the Mount Sinai BioMe cohort were loaded into the NLP system. We compared analysis of structured and unstructured EHR data using NLP, free-text search, and diagnostic codes with validation against expert adjudication. We then used the NLP findings to measure physician impression of progression from early-stage NAFLD to NASH or cirrhosis. Similarly, we used the same NLP findings to identify mentions of NAFLD in radiology reports that did not persist into clinical notes. RESULTS Out of 38,575 patients, we identified 2,281 patients with NAFLD. From the remainder, 10,653 patients with similar data density were selected as a control group. NLP outperformed ICD and text search in both sensitivity (NLP: 0.93, ICD: 0.28, text search: 0.81) and F2 score (NLP: 0.92, ICD: 0.34, text search: 0.81). Of 2281 NAFLD patients, 673 (29.5%) were believed to have progressed to NASH or cirrhosis. Among 176 where NAFLD was noted prior to NASH, the average progression time was 410 days. 619 (27.1%) NAFLD patients had it documented only in radiology notes and not acknowledged in other forms of clinical documentation. Of these, 170 (28.4%) were later identified as having likely developed NASH or cirrhosis after a median 1057.3 days. DISCUSSION NLP-based approaches were more accurate at identifying NAFLD within the EHR than ICD/text search-based approaches. Suspected NAFLD on imaging is often not acknowledged in subsequent clinical documentation. Many such patients are later found to have more advanced liver disease. Analysis of information flows demonstrated loss of key information that could have been used to help prevent the progression of early NAFLD (NAFL) to NASH or cirrhosis. CONCLUSION For identification of NAFLD, NLP performed better than alternative selection modalities. It then facilitated analysis of knowledge flow between physician and enabled the identification of breakdowns where key information was lost that could have slowed or prevented later disease progression.
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Affiliation(s)
- Tielman T Van Vleck
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Lili Chan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Catherine K Craven
- Institute for Healthcare Delivery Science, Dept. of Pop. Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, USA; Clinical Informatics Group, IT Department, Mount Sinai Health System, New York, USA
| | - Ron Do
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Stephen B Ellis
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Joseph L Kannry
- Information Technology, Mount Sinai Medical Center, New York, USA
| | - Ruth J F Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, USA
| | - Judy Cho
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, USA; Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, USA; Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Girish N Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, USA; Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
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12
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Dellon ES, Liacouras CA, Molina-Infante J, Furuta GT, Spergel JM, Zevit N, Spechler SJ, Attwood SE, Straumann A, Aceves SS, Alexander JA, Atkins D, Arva NC, Blanchard C, Bonis PA, Book WM, Capocelli KE, Chehade M, Cheng E, Collins MH, Davis CM, Dias JA, Di Lorenzo C, Dohil R, Dupont C, Falk GW, Ferreira CT, Fox A, Gonsalves NP, Gupta SK, Katzka DA, Kinoshita Y, Menard-Katcher C, Kodroff E, Metz DC, Miehlke S, Muir AB, Mukkada VA, Murch S, Nurko S, Ohtsuka Y, Orel R, Papadopoulou A, Peterson KA, Philpott H, Putnam PE, Richter JE, Rosen R, Rothenberg ME, Schoepfer A, Scott MM, Shah N, Sheikh J, Souza RF, Strobel MJ, Talley NJ, Vaezi MF, Vandenplas Y, Vieira MC, Walker MM, Wechsler JB, Wershil BK, Wen T, Yang GY, Hirano I, Bredenoord AJ. Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the AGREE Conference. Gastroenterology 2018; 155:1022-1033.e10. [PMID: 30009819 PMCID: PMC6174113 DOI: 10.1053/j.gastro.2018.07.009] [Citation(s) in RCA: 642] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/21/2018] [Accepted: 07/03/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Over the last decade, clinical experiences and research studies raised concerns regarding use of proton pump inhibitors (PPIs) as part of the diagnostic strategy for eosinophilic esophagitis (EoE). We aimed to clarify the use of PPIs in the evaluation and treatment of children and adults with suspected EoE to develop updated international consensus criteria for EoE diagnosis. METHODS A consensus conference was convened to address the issue of PPI use for esophageal eosinophilia using a process consistent with standards described in the Appraisal of Guidelines for Research and Evaluation II. Pediatric and adult physicians and researchers from gastroenterology, allergy, and pathology subspecialties representing 14 countries used online communications, teleconferences, and a face-to-face meeting to review the literature and clinical experiences. RESULTS Substantial evidence documented that PPIs reduce esophageal eosinophilia in children, adolescents, and adults, with several mechanisms potentially explaining the treatment effect. Based on these findings, an updated diagnostic algorithm for EoE was developed, with removal of the PPI trial requirement. CONCLUSIONS EoE should be diagnosed when there are symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (or approximately 60 eosinophils per mm2) on esophageal biopsy and after a comprehensive assessment of non-EoE disorders that could cause or potentially contribute to esophageal eosinophilia. The evidence suggests that PPIs are better classified as a treatment for esophageal eosinophilia that may be due to EoE than as a diagnostic criterion, and we have developed updated consensus criteria for EoE that reflect this change.
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Affiliation(s)
- Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Chris A Liacouras
- Center for Pediatric Eosinophilic Diseases, Division of Gastroenterology and Hepatology & Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Javier Molina-Infante
- Department of Gastroenterology, Hospital Universitario San Pedro de Alcántara, Cáceres, Spain and Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Glenn T Furuta
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Jonathan M Spergel
- Center for Pediatric Eosinophilic Diseases, Division of Allergy-Immunology, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noam Zevit
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Stuart J Spechler
- Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas
| | - Stephen E Attwood
- Department of Health Services Research, Durham University, Durham, UK
| | | | - Seema S Aceves
- Division of Allergy, Immunology, Departments of Pediatrics and Medicine, University of California-San Diego and Rady Children's Hospital, San Diego, La Jolla, California
| | | | - Dan Atkins
- Allergy & Immunology Section, Children's Hospital Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Nicoleta C Arva
- Department of Pathology and Laboratory Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Carine Blanchard
- Institute of Nutritional Science, Nestlé Research Center, Vevey, Switzerland
| | - Peter A Bonis
- Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Wendy M Book
- American Partnership for Eosinophilic Disorders, Atlanta, Georgia
| | - Kelley E Capocelli
- Department of Pediatric Pathology, Children's Hospital Colorado, Aurora, Colorado
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Edaire Cheng
- Departments of Pediatrics and Internal Medicine, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Margaret H Collins
- Division of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carla M Davis
- Allergy and Immunology Section of the Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jorge A Dias
- Pediatric Gastroenterology, Centro Hospitalar S. João, Porto, Portugal
| | - Carlo Di Lorenzo
- Division of Gastroenterology and Hepatology & Nutrition, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Ranjan Dohil
- Division of Gastroenterology and Hepatology, University of California-San Diego, Rady Children's Hospital, San Diego, California
| | | | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Cristina T Ferreira
- Federal University of Health Sciences of Porto Alegre, Hospital Santo Antônio, Porto Alegre, RS, Brazil
| | - Adam Fox
- Department of Paediatric Allergy, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Nirmala P Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
| | - Sandeep K Gupta
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Illinois, University of Illinois, Peoria, Illinois
| | - David A Katzka
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Yoshikazu Kinoshita
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, Izumo, Japan
| | - Calies Menard-Katcher
- Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado and Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, Colorado
| | - Ellyn Kodroff
- Campaign Urging Research for Eosinophilic Diseases, Lincolnshire, Illinois
| | - David C Metz
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stephan Miehlke
- Centre for Digestive Diseases, Internal Medicine Center, Eppendorf, Hamburg, Germany
| | - Amanda B Muir
- Center for Pediatric Eosinophilic Diseases, Division of Gastroenterology and Hepatology & Nutrition, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Simon Murch
- Department of Paediatrics, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, Massachusetts
| | - Yoshikazu Ohtsuka
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Rok Orel
- University of Ljubljana, Faculty of Medicine, University Children's Hospital, Ljubljana, Slovenia
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, University of Athens, Children's Hospital Agia Sofia, Athens, Greece
| | | | - Hamish Philpott
- Northern Adelaide Local Health Network, Department of Gastroenterology, University of Adelaide, South Australia
| | - Philip E Putnam
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joel E Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Rachel Rosen
- Aerodigestive Center, Boston Children's Hospital, Boston, Massachusetts
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alain Schoepfer
- Division of Gastroenterology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | | | - Neil Shah
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Javed Sheikh
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Rhonda F Souza
- Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas
| | - Mary J Strobel
- American Partnership for Eosinophilic Disorders, Atlanta, Georgia
| | | | - Michael F Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yvan Vandenplas
- KidZ Health Castle, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mario C Vieira
- Department of Pediatrics, Pontifical University of Paraná and Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Brazil
| | - Marjorie M Walker
- Anatomical Pathology University of Newcastle Faculty of Health and Medicine School of Medicine and Public Health Callaghan, New South Wales, Australia
| | - Joshua B Wechsler
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Barry K Wershil
- Eosinophilic Gastrointestinal Diseases Program, Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
| | - Albert J Bredenoord
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
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13
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Aceves SS, King E, Collins MH, Yang GY, Capocelli KE, Abonia JP, Atkins D, Bonis PA, Carpenter CL, Dellon ES, Eby MD, Falk GW, Gonsalves N, Gupta SK, Hirano I, Kocher K, Krischer JP, Leung J, Lipscomb J, Menard-Katcher P, Mukkada VA, Pan Z, Spergel JM, Sun Q, Wershil BK, Rothenberg ME, Furuta GT. Alignment of parent- and child-reported outcomes and histology in eosinophilic esophagitis across multiple CEGIR sites. J Allergy Clin Immunol 2018; 142:130-138.e1. [PMID: 29852258 DOI: 10.1016/j.jaci.2018.05.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/22/2018] [Accepted: 05/22/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patient-reported outcome metrics for eosinophilic esophagitis (EoE) have been developed and validated but not used in a multicenter pediatric population or systematically aligned with histology. OBJECTIVE We sought to understand (1) the potential of caregiver report to predict patient self-reported symptoms and (2) the correlation of patient-reported outcome domains with histology. METHODS Patients with EoE (n = 310) and their parents participating in the Consortium of Gastrointestinal Eosinophilic Disease Researchers (CEGIR) observational clinical trial were queried for baseline patient symptoms and quality of life (QOL) by using the Pediatric Eosinophilic Esophagitis Symptom Score, version 2 (PEESSv2.0), and the Pediatric QOL EoE module (PedsQL-EoE), and biopsy specimens were analyzed by using the EoE Histology Scoring System. RESULTS PEESSv2.0 parental and child reports aligned across all domains (r = 0.68-0.73, P < .001). PedsQL-EoE reports correlated between parents and children across ages and multiple domains (r = 0.48-0.79, P < .001). There was a tight correlation between symptoms on PEESSv2.0 and their effects on QOL both on self-report and parental report (P < .001). Self-reported symptoms on PEESSv2.0 (positively) and PedsQL-EoE (inversely) showed a weak correlation with proximal, but not distal, peak eosinophil counts and features and architectural tissue changes on the EoE Histology Scoring System (P < .05). CONCLUSIONS Parents of children with EoE aged 3 to 18 years accurately reflected their children's disease symptoms and QOL. Self- and parent-reported symptoms correlate with proximal esophageal histology. Our data suggest that parental report in young children can function as an adequate marker for self-reported symptoms and that self-reported symptoms can reflect changes in tissue histology in the proximal esophagus. These findings should be considered during clinical trials for drug development.
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Affiliation(s)
- Seema S Aceves
- Division of Allergy Immunology, University of California, San Diego, Rady Children's Hospital, San Diego, Calif
| | - Eileen King
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Margaret H Collins
- Division of Pathology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Guang-Yu Yang
- Division of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | | | - J Pablo Abonia
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dan Atkins
- Section of Allergy, Immunology, Children's Hospital Colorado, Aurora, Colo
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, Mass
| | - Christina L Carpenter
- Health Informatics Institute, Departments of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Evan S Dellon
- Department of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Michael D Eby
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gary W Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Sandeep K Gupta
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine, Chicago, Ill
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
| | - Kendra Kocher
- Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Jeffrey P Krischer
- Health Informatics Institute, Departments of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, Mass
| | - Jessi Lipscomb
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Paul Menard-Katcher
- Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Zhaoxing Pan
- Pediatric Gastroenterology, Pediatric Allergy and Immunology, Children's Hospital of Colorado, Aurora, Colo
| | - Jonathan M Spergel
- Department of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Qin Sun
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Barry K Wershil
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, Ill
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Glenn T Furuta
- Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
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14
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Shoda T, Wen T, Aceves SS, Abonia JP, Atkins D, Bonis PA, Caldwell JM, Capocelli KE, Carpenter CL, Collins MH, Dellon ES, Eby MD, Gonsalves N, Gupta SK, Falk GW, Hirano I, Menard-Katcher P, Kuhl JT, Krischer JP, Leung J, Mukkada VA, Spergel JM, Trimarchi MP, Yang GY, Zimmermann N, Furuta GT, Rothenberg ME. Eosinophilic oesophagitis endotype classification by molecular, clinical, and histopathological analyses: a cross-sectional study. Lancet Gastroenterol Hepatol 2018; 3:477-488. [PMID: 29730081 DOI: 10.1016/s2468-1253(18)30096-7] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/15/2018] [Accepted: 03/15/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eosinophilic oesophagitis is understood in terms of quantifiable histological, endoscopic, and molecular features. Data are scant for inter-relations of these features and their potential to identify distinct disease endotypes. We aimed to identify clinical-pathological correlations between endoscopic and histological disease variables by transcription profiling of the oesophagus of patients with eosinophilic oesophagitis of varying severity and disease activity states. METHODS We did a cross-sectional study across ten hospital sites in the USA associated with the Consortium of Eosinophilic Gastrointestinal Disease Researchers. We analysed oesophageal biopsy specimens taken from paediatric and adult patients with eosinophilic oesophagitis (discovery cohort), using the eosinophilic oesophagitis diagnostic panel (EDP), a set of 96 informative transcripts. Histological and endoscopic features were assessed by quantification of oesophageal eosinophils and use of the eosinophilic oesophagitis histology scoring system (HSS) and the eosinophilic oesophagitis endoscopic reference score (EREFS). Associations among the various histological, endoscopic, and molecular features were analysed by Spearman correlation. Results were replicated in a biologically independent, single-centre, validation cohort of patients with active eosinophilic oesophagitis. FINDINGS The discovery cohort contained 185 samples and the validation cohort comprised 100 specimens. In the discovery cohort, EDP showed intersite consistency, significant correlation with oesophageal eosinophils (p<0·0001), and similar findings between paediatric and adult patients. Of eight HSS domains, basal zone hyperplasia correlated with the EDP (median Spearman ρ 0·47 [IQR 0·36-0·60]). Of five EREFS features, distal furrows correlated with the EDP (median Spearman ρ 0·42 [0·32-0·50]). By analysing active eosinophilic oesophagitis in the discovery cohort, the EDP identified three clusters associated with distinct endotypes (termed EoEe1-3) despite similar eosinophil levels. EoEe1 was associated with a normal-appearing oesophagus (risk ratio [RR] 3·27, 95% CI 1·04-10·27; p=0·0443), an inverse association with a history of oesophageal dilation (0·27, 0·09-0·82; p=0·0105) and showed relatively mild histological, endoscopic, and molecular changes. EoEe2 showed an inflammatory and steroid-refractory phenotype (RR 2·77, 95% CI 1·11-6·95; p=0·0376) and had the highest expression of inflammatory cytokines and steroid-responding genes. EoEe3 was associated with a narrow-calibre oesophagus (RR 7·98, 95% CI 1·84-34·64; p=0·0013) and adult onset (2·22, 1·19-4·12; p=0·0155), and showed the highest degree of endoscopic and histological severity and the lowest expression of epithelial differentiation genes. These endotypes were replicated in the validation cohort by clustering and with an eosinophilic oesophagitis endotype-prediction algorithm. INTERPRETATION Our new disease classification stratifies patients with eosinophilic oesophagitis into subgroups with potential clinical and therapeutic significance and provides a framework for a precision medicine approach to eosinophilic oesophagitis. FUNDING National Institutes of Health.
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Affiliation(s)
- Tetsuo Shoda
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ting Wen
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Seema S Aceves
- Division of Allergy Immunology, University of California at San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - J Pablo Abonia
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Dan Atkins
- Division of Pediatric Allergy and Immunology, Children's Hospital Colorado, Denver, CO, USA
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Julie M Caldwell
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Christina L Carpenter
- Health Informatics Institute, Departments of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Margaret H Collins
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Michael D Eby
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandeep K Gupta
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine, Peoria, IL, USA
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jonathan T Kuhl
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey P Krischer
- Health Informatics Institute, Departments of Pediatrics and Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Michael P Trimarchi
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nives Zimmermann
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Glenn T Furuta
- Division Digestive Health Institute, Children's Hospital Colorado, Gastrointestinal Eosinophilic Diseases Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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15
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Cheng K, Gupta SK, Kantor S, Kuhl JT, Aceves SS, Bonis PA, Capocelli KE, Carpenter C, Chehade M, Collins MH, Dellon ES, Falk GW, Gopal-Srivastava R, Gonsalves N, Hirano I, King EC, Leung J, Krischer JP, Mukkada VA, Schoepfer A, Spergel JM, Straumann A, Yang GY, Furuta GT, Rothenberg ME. Creating a multi-center rare disease consortium - the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR). Transl Sci Rare Dis 2017; 2:141-155. [PMID: 29333363 PMCID: PMC5757645 DOI: 10.3233/trd-170016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Eosinophilic gastrointestinal disorders (EGIDs) affect various segments of the gastrointestinal tract. Since these disorders are rare, collaboration is essential to enroll subjects in clinical studies and study the broader population. The Rare Diseases Clinical Research Network (RDCRN), a program of the National Center for Advancing Translational Sciences (NCATS), funded the Consortium of Eosinophilic Gastrointestinal Disease Researchers (CEGIR) in 2014 to advance the field of EGIDs. CEGIR facilitates collaboration among various centers, subspecialties, patients, professional organizations and patient-advocacy groups and includes 14 clinical sites. It has successfully initiated two large multi-center clinical studies looking to refine EGID diagnoses and management. Several pilot studies are underway that focus on various aspects of EGIDs including novel therapeutic interventions, diagnostic and monitoring methods, and the role of the microbiome in pathogenesis. CEGIR currently nurtures five physician-scholars through a career training development program and has published more than 40 manuscripts since its inception. This review focuses on CEGIR's operating model and progress and how it facilitates a framework for exchange of ideas and stimulates research and innovation. This consortium provides a model for progress on other potential clinical areas.
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Affiliation(s)
- Katherine Cheng
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sandeep K. Gupta
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Illinois College of Medicine, Peoria, IL, USA
| | - Susanna Kantor
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, Denver, CO, USA
| | - Jonathan T. Kuhl
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Seema S. Aceves
- Division of Allergy and Immunology, Department of Pediatrics and Medicine, University of California San Diego, CA, USA
| | - Peter A. Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | | | - Christina Carpenter
- Health Informatics Institute, Rare Diseases Clinical Research Network, Tampa, FL, USA
| | - Mirna Chehade
- Mount Sinai Center for Eosinophilic Disorders, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margaret H. Collins
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Evan S. Dellon
- Department of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rashmi Gopal-Srivastava
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institute of Health, Bethesda, MD, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University The Feinberg School of Medicine, Chicago, IL, USA
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern Medicine The Feinberg School of Medicine, Chicago, IL, USA
| | - Eileen C. King
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - John Leung
- Department of Gastroenterology, Tufts Medical Center, Boston, MA, USA
| | - Jeffrey P. Krischer
- Departments of Pediatrics and Medicine, Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Vincent A. Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Alain Schoepfer
- Department of Gastroenterology and Hepatology, University Hospital Lausanne/CHUV, Lausanne, Switzerland
| | - Jonathan M. Spergel
- Department of Allergy and Immunology, Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - Alex Straumann
- Department of Gastroenterology and hepatology, University Hospital Zuerich, Switzerland
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Glenn T. Furuta
- Gastrointestinal Eosinophilic Diseases Program, Children’s Hospital Colorado, Aurora, CO, USA
- Section of Gastroenterology, Hepatology, and Nutrition, Digestive Health Institute, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc E. Rothenberg
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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16
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Dellon ES, Collins MH, Bonis PA, Capocelli KE, Dohil R, Falk GW, Furuta GT, Gupta SK, Hirano I, Hiremath GS, Kagalwalla AF, Leung J, Liacouras CA, Menard-Katcher C, Muir AB, Mukkada VA, Putnam PE, Schoepfer AM, Straumann A, Wershil BK, Wo JM, Yang GY, Rothenberg ME, Gonsalves N. Substantial Variability in Biopsy Practice Patterns Among Gastroenterologists for Suspected Eosinophilic Gastrointestinal Disorders. Clin Gastroenterol Hepatol 2016; 14:1842-1844. [PMID: 27112108 PMCID: PMC5075280 DOI: 10.1016/j.cgh.2016.04.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 04/11/2016] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine; University of North Carolina School of Medicine, Chapel Hill, NC
| | - Margaret H. Collins
- Department of Pathology and Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Peter A. Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, MA
| | - Kelley E. Capocelli
- Division of Pathology and Laboratory Medicine, Children’s Hospital Colorado, Aurora, CO
| | - Ranjan Dohil
- Division of Pediatric Gastroenterology, Rady Children’s Hospital, San Diego, CA
| | - Gary W. Falk
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Glenn T. Furuta
- Digestive Health Institute, Children’s Hospital Colorado; and Section of Pediatric Gastroenterology, University of Colorado School of Medicine; Aurora, CO
| | - Sandeep K. Gupta
- Division of Pediatric Gastroenterology, Riley Hospital for Children, Indianapolis, IN
| | - Ikuo Hirano
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Girish S. Hiremath
- Division of Pediatric Gastroenterology, Vanderbilt University, Nashville, TN
| | - Amir F. Kagalwalla
- Division of Pediatric Gastroenterology, Lurie Children’s Hospital, Chicago, IL
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, MA
| | - Chris A. Liacouras
- Division of Pediatric Gastroenterology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Calies Menard-Katcher
- Digestive Health Institute, Children’s Hospital Colorado; and Section of Pediatric Gastroenterology, University of Colorado School of Medicine; Aurora, CO
| | - Amanda B. Muir
- Division of Pediatric Gastroenterology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Vincent A. Mukkada
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Philip E. Putnam
- Division of Pediatric Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Alain M. Schoepfer
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Barry K. Wershil
- Division of Pediatric Gastroenterology, Lurie Children’s Hospital, Chicago, IL
| | - John M. Wo
- Division of Gastroenterology, Indiana University, Indianapolis, IN
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Marc E. Rothenberg
- Division of Allergy and Immunology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Nirmala Gonsalves
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
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17
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Thorner AR, Cao B, Jiang T, Warner AJ, Bonis PA. Correlation Between UpToDate Searches and Reported Cases of Middle East Respiratory Syndrome During Outbreaks in Saudi Arabia. Open Forum Infect Dis 2016; 3:ofw043. [PMID: 27011953 PMCID: PMC4803184 DOI: 10.1093/ofid/ofw043] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/15/2016] [Indexed: 11/16/2022] Open
Abstract
UpToDate search activity is useful for detecting and monitoring outbreaks of Middle East respiratory syndrome in Saudi Arabia. Background. UpToDate is an online clinical decision support resource that is used extensively by clinicians around the world. Digital surveillance techniques have shown promise to aid with the detection and monitoring of infectious disease outbreaks. We sought to determine whether UpToDate searches for Middle East respiratory syndrome (MERS) could be used to detect and monitor MERS outbreaks in Saudi Arabia. Methods. We analyzed daily searches related to MERS in Jeddah and Riyadh, Saudi Arabia during 3 outbreaks in these cities in 2014 and 2015 and compared them with reported cases during the same periods. We also compared UpToDate MERS searches in the affected cities to those in a composite of 4 negative control cities for the 2 outbreaks in 2014. Results. UpToDate MERS searches during all 3 MERS outbreaks in Saudi Arabia showed a correlation to reported cases. In addition, UpToDate MERS search volume in Jeddah and Riyadh during the outbreak periods in 2014 was significantly higher than the concurrent search volume in the 4 negative control cities. In contrast, during the baseline periods, there was no difference between UpToDate searches for MERS in the affected cities compared with the negative control cities. Conclusions. UpToDate search activity seems to be useful for detecting and monitoring outbreaks of MERS in Saudi Arabia.
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Affiliation(s)
- Anna R Thorner
- UpToDate, Wolters Kluwer Health, Waltham; Brigham and Women's Hospital, Boston; Dana-Farber Cancer Institute, Boston; Harvard Medical School, Boston
| | - Bin Cao
- UpToDate, Wolters Kluwer Health , Waltham
| | | | | | - Peter A Bonis
- UpToDate, Wolters Kluwer Health, Waltham; Tufts University School of Medicine, Boston, Massachusetts
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18
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Kliewer KL, Venter C, Cassin AM, Abonia JP, Aceves SS, Bonis PA, Dellon ES, Falk GW, Furuta GT, Gonsalves N, Gupta SK, Hirano I, Kagalwalla A, Leung J, Mukkada VA, Spergel JM, Rothenberg ME. Should wheat, barley, rye, and/or gluten be avoided in a 6-food elimination diet? J Allergy Clin Immunol 2015; 137:1011-1014. [PMID: 26725190 DOI: 10.1016/j.jaci.2015.10.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/18/2015] [Accepted: 10/05/2015] [Indexed: 01/07/2023]
Abstract
Eosinophilic esophagitis (EoE), a food antigen-mediated disease, is effectively treated with the dietary elimination of 6 foods commonly associated with food allergies (milk, wheat, egg, soy, tree nuts/peanuts, and fish/shellfish). Because wheat shares homologous proteins (including gluten) with barley and rye and can also be processed with these grains, some clinicians have suggested that barley and rye might also trigger EoE as a result of cross-reaction and/or cross-contamination with wheat. In this article, we discuss the theoretical risks of cross-reactivity and cross-contamination among wheat, barley, and rye proteins (including gluten); assess common practices at EoE treatment centers; and provide recommendations for dietary treatment and future studies of EoE.
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Affiliation(s)
- Kara L Kliewer
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carina Venter
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alison M Cassin
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - J Pablo Abonia
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Seema S Aceves
- Division of Allergy and Immunology, Department of Pediatrics and Medicine, University of California, San Diego and Rady Children's Hospital, San Diego, Calif
| | - Peter A Bonis
- Division of Gastroenterology, Tufts Medical Center, Boston, Mass
| | - Evan S Dellon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Glenn T Furuta
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Sandeep K Gupta
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Ind
| | - Ikuo Hirano
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Amir Kagalwalla
- Division of Gastroenterology, Hepatology and Nutrition, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill
| | - John Leung
- Division of Gastroenterology, Tufts Medical Center, Boston, Mass
| | - Vincent A Mukkada
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jonathan M Spergel
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Marc E Rothenberg
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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19
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Abstract
A Schatzki ring is a submucosal, fibrotic thickening located at the gastroesophageal junction. Endoscopic treatment traditionally involves disruption of the ring. Many approaches have been described including bougies, balloons, biopsies, and diathermic monopolar incision. While all of these approaches are effective in the short-term, recurrence is common. The objective of our study was to evaluate the feasibility of complete excision of the ring using jumbo cold biopsy forceps. Our main outcome measurements were the feasibility, safety, and efficacy of complete obliteration of Schatzki rings using jumbo cold biopsy forceps. We designed an observational study using a standard protocol for patient management and data collection using a university hospital as our setting. We followed 10 patients with dysphagia due to a Schatzki's ring, six of whom had previously undergone bougienage or balloon dilation. Five patients were on maintenance therapy with a proton pump inhibitor and one with an H2 blocker. Complete endoscopic obliteration of the Schatzki rings with a cold jumbo biopsy forceps was achieved in all 10 patients requiring a mean of 9.8 biopsies (range 8-12). Omeprazole (20 mg twice daily) was prescribed after the procedure. All 10 patients demonstrated improvement in dysphagia after treatment, which persisted during a mean follow-up time of 379 days (range 63-496 days). There were no serious complications. The limitations of our study include lack of a control group, a small sample size, and being a single-institution study. We concluded that complete Schatzki ring obliteration with jumbo cold biopsy forceps is a safe, feasible, and effective endoscopic treatment.
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Affiliation(s)
- A Gonzalez
- Division of Gastroenterology, Tufts Medical Center, Boston, Massachusetts, USA
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20
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Bonis PA. The epidemiology and characteristics of eosinophilic esophagitis. Gastroenterol Hepatol (N Y) 2014; 10:56-8. [PMID: 24799841 PMCID: PMC4008961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Peter A Bonis
- Adjunct Professor of Medicine Division of Gastroenterology Tufts University School of Medicine Boston, Massachusetts Chief Medical Officer, UpToDate, Inc
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21
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Sigterman KE, van Pinxteren B, Bonis PA, Lau J, Numans ME. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2013; 2013:CD002095. [PMID: 23728637 PMCID: PMC7066537 DOI: 10.1002/14651858.cd002095.pub5] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Approximately 25% of adults regularly experience heartburn, a symptom of gastro-oesophageal reflux disease (GORD). Most patients are treated empirically (without specific diagnostic evaluation e.g. endoscopy. Among patients who have an upper endoscopy, findings range from a normal appearance, mild erythema to severe oesophagitis with stricture formation. Patients without visible damage to the oesophagus have endoscopy negative reflux disease (ENRD). The pathogenesis of ENRD, and its response to treatment may differ from GORD with oesophagitis. OBJECTIVES Summarise, quantify and compare the efficacy of short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in adults with GORD, treated empirically and in those with endoscopy negative reflux disease (ENRD). SEARCH METHODS We searched MEDLINE (January 1966 to November 2011), EMBASE (January 1988 to November 2011), and EBMR in November 2011. SELECTION CRITERIA Randomised controlled trials reporting symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Participants had to be either from an empirical treatment group (no endoscopy used in treatment allocation) or from an endoscopy negative reflux disease group (no signs of erosive oesophagitis). DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS Thirty-four trials (1314 participants) were included: fifteen in the empirical treatment group, fifteen in the ENRD group and four in both. In empirical treatment of GORD the risk ratio (RR) for heartburn remission (the primary efficacy variable) in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60 to 0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87).In treatment of ENRD, the RR for heartburn remission for PPI versus placebo was 0.71 (ten trials, 95% CI 0.65 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.78 (three trials, 95% CI 0.62 to 0.97) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92). AUTHORS' CONCLUSIONS PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD, although the magnitude of benefit is greater for those treated empirically.
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Affiliation(s)
- Kirsten E Sigterman
- Technische Universität München Klinikum rechts der IsarInstitut für Allgemeinmedizin / Institute of General PracticeOrleansstrasse 47MunichGermany81667
| | | | - Peter A Bonis
- Tufts Medical Centre/Division of GastroenterologyTufts Medical Centre800 Washington StreetBox 63BostonMAUSA02111
| | - Joseph Lau
- Brown University Public Health ProgramCenter for Evidence‐based Medicine121 S. Main StreetProvidenceRIUSA02912
| | - Mattijs E Numans
- VU University Medical CenterDepartment of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, and Alzheimer CenterVan der Boechorststraat 712AmsterdamNetherlands
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Leung J, Nguyen-Traxler A, Lee EM, Yip JS, Weinstock JV, Chan WW, Ngo P, Weinstein BJ, Bonis PA. Erratum: Assessment of fractionated exhaled nitric oxide as a biomarker for the treatment of eosinophilic esophagitis. Allergy Asthma Proc 2013; 34:107. [PMID: 29165221 DOI: 10.2500/aap.2013.34.2233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Rothenberg ME, Aceves S, Bonis PA, Collins MH, Gonsalves N, Gupta SK, Hirano I, Liacouras CA, Putnam PE, Spergel JM, Straumann A, Wershil BK, Furuta GT. Working with the US Food and Drug Administration: progress and timelines in understanding and treating patients with eosinophilic esophagitis. J Allergy Clin Immunol 2012; 130:617-9. [PMID: 22935588 DOI: 10.1016/j.jaci.2012.06.051] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 02/06/2023]
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Leung J, Nguyen-Traxler A, Lee EM, Yip JS, Weinstock JV, Chan WW, Ngo P, Weinstein BJ, Bonis PA. Assessment of fractionated exhaled nitric oxide as a biomarker for the treatment of eosinophilic esophagitis. Allergy Asthma Proc 2012; 33:519-24. [PMID: 23394511 DOI: 10.2500/aap.2012.33.3606] [Citation(s) in RCA: 16] [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] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Diagnosis of eosinophilic esophagitis (EoE) and determination of response to therapy is based on histological assessment of the esophagus, which requires upper endoscopy. In children, in whom a dietary approach is commonly used, multiple endoscopies are needed, because foods are eliminated and then gradually reintroduced. Ideally, noninvasive methods could supplement or replace upper endoscopy to facilitate management. Fractionated exhaled nitric oxide (FeNO) has been proposed as a useful measure for monitoring disease activity in studies of patients with eosinophil-predominant asthma and in other atopic disorders. Thus, we evaluated whether FeNO levels could be a useful biomarker to assess the response to therapy in EoE patients. This study was designed to determine whether there is a change in FeNO levels during treatment with topical corticosteroids and whether changes correlated with clinical response. This was a prospective, multicenter study that enrolled nonasthmatic patients with established EoE. FeNO levels and symptom scores were measured at baseline, biweekly during 6-week swallowed fluticasone treatment, and 4 weeks posttreatment. Twelve patients completed the trial. We found a statistically significant difference between median pre- and posttreatment FeNO levels [20.3 ppb (16.0 -29.0 ppb) vs 17.6 ppb (11.7 -27.3 ppb), [corrected] p=0.009]. However, neither the pretreatment FeNO level, a change of FeNO level after 2 weeks of treatment, nor the FeNO level at the end of treatment confidently predicted a clinical or histological response. Although our findings suggest nitric oxide possibly has a physiological role in EoE, our observations do not support a role of FeNo determination for management of EoE.
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Affiliation(s)
- John Leung
- Department of Rheumatology, Immunology and Allergy, Harvard Medical School/Massachusetts General Hospital, Boston, USA
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Abstract
Eosinophilic esophagitis (EoE) is a chronic esophageal disease increasingly recognized in adults for its gastrointestinal manifestations. This paper discusses a young woman with EoE who presented with persistent hiccups and intermittent dyspepsia. The patient was initially treated with trials of both H(2) blocker and proton pump inhibitor. However, her hiccups resolved only after treatment with topical fluticasone. A repeat upper endoscopy while on steroid treatment demonstrated both histologic remission of EoE and resolution of esophageal trachealization. Our patient's clinical course supports an association between hiccups and EoE, suggesting that EoE be considered in the differential diagnosis of patients with refractory hiccups.
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Liacouras CA, Furuta GT, Hirano I, Atkins D, Attwood SE, Bonis PA, Burks AW, Chehade M, Collins MH, Dellon ES, Dohil R, Falk GW, Gonsalves N, Gupta SK, Katzka DA, Lucendo AJ, Markowitz JE, Noel RJ, Odze RD, Putnam PE, Richter JE, Romero Y, Ruchelli E, Sampson HA, Schoepfer A, Shaheen NJ, Sicherer SH, Spechler S, Spergel JM, Straumann A, Wershil BK, Rothenberg ME, Aceves SS. Eosinophilic esophagitis: updated consensus recommendations for children and adults. J Allergy Clin Immunol 2011; 128:3-20.e6; quiz 21-2. [PMID: 21477849 DOI: 10.1016/j.jaci.2011.02.040] [Citation(s) in RCA: 1410] [Impact Index Per Article: 108.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Accepted: 02/17/2011] [Indexed: 12/13/2022]
Abstract
Eosinophilic esophagitis (EoE) is a clinicopathologic condition of increasing recognition and prevalence. In 2007, a consensus recommendation provided clinical and histopathologic guidance for the diagnosis and treatment of EoE; however, only a minority of physicians use the 2007 guidelines, which require fulfillment of both histologic and clinical features. Since 2007, the number of EoE publications has doubled, providing new disease insight. Accordingly, a panel of 33 physicians with expertise in pediatric and adult allergy/immunology, gastroenterology, and pathology conducted a systematic review of the EoE literature (since September 2006) using electronic databases. Based on the literature review and expertise of the panel, information and recommendations were provided in each of the following areas of EoE: diagnostics, genetics, allergy testing, therapeutics, and disease complications. Because accumulating animal and human data have provided evidence that EoE appears to be an antigen-driven immunologic process that involves multiple pathogenic pathways, a new conceptual definition is proposed highlighting that EoE represents a chronic, immune/antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. The diagnostic guidelines continue to define EoE as an isolated chronic disorder of the esophagus diagnosed by the need of both clinical and pathologic features. Patients commonly have high rates of concurrent allergic diatheses, especially food sensitization, compared with the general population. Proved therapeutic options include chronic dietary elimination, topical corticosteroids, and esophageal dilation. Important additions since 2007 include genetic underpinnings that implicate EoE susceptibility caused by polymorphisms in the thymic stromal lymphopoietin protein gene and the description of a new potential disease phenotype, proton pump inhibitor-responsive esophageal eosinophila. Further advances and controversies regarding diagnostic methods, surrogate disease markers, allergy testing, and treatment approaches are discussed.
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Affiliation(s)
- Chris A Liacouras
- Center for Pediatric Eosinophilic Disorders, Division of Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Leung J, Dowling L, Obadan I, Davis J, Bonis PA, Kaplan MM, Casey D, Viveiros K. Risk of non-melanoma skin cancer in autoimmune hepatitis. Dig Dis Sci 2010; 55:3218-23. [PMID: 20165977 DOI: 10.1007/s10620-010-1145-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [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: 09/30/2009] [Accepted: 01/26/2010] [Indexed: 12/09/2022]
Abstract
BACKGROUND Most patients with autoimmune hepatitis (AIH) require long-term immunosuppressive therapy (IS). While it is well established that solid organ transplant recipients have a high risk of developing non-melanoma skin cancer (NMSC) as a result of immunosuppression, little is known about the risk of NMSC associated with IS in patients with AIH. OBJECTIVES The aim of this study is to determine the incidence and risk factors for NMSC in patients on IS for AIH. METHODS We reviewed the medical records of all patients with AIH seen at a tertiary care medical center between 1998 and 2008. We compared the incidence of NMSC to an age- and sex-matched control population and analyzed risk factors for NMSC. RESULTS A total of forty-five patients with AIH were identified. Twenty NMSC lesions were found in eight patients. Compared to the age and sex-matched general population, the risk of SCC and BCC were increased as quantified by elevated standardized incidence ratios (28.5 and 5.0, respectively). Patients who developed NMSC were on average 24 years older (78.4 vs. 54.2 years old, p < 0.0001) and had AIH diagnosed at a more advanced age (66.0 vs. 45.4 years old, p = 0.0003). CONCLUSION The risk of NMSC is significantly increased in patients with AIH on immunosuppression. Independent risk factors include current age and age at diagnosis of AIH.
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Affiliation(s)
- John Leung
- Division of Gastroenterology, Tufts Medical Center, 800 Washington Street, Boston, MA, USA.
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Bonis PA, Pickens GT, Rind DM, Foster DA. Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Int J Med Inform 2008; 77:745-53. [PMID: 18565788 DOI: 10.1016/j.ijmedinf.2008.04.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Revised: 04/15/2008] [Accepted: 04/28/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Electronic clinical knowledge support systems have decreased barriers to answering clinical questions but there is little evidence as to whether they have an impact on health outcomes. METHODS We compared hospitals with online access to UpToDate with other acute care hospitals included in the Thomson 100 Top Hospitals Database (Thomson database). Metrics used in the Thomson database differentiate hospitals on a variety of performance dimensions such as quality and efficiency. Prespecified outcomes were risk-adjusted mortality, complications, the Agency of Healthcare Research and Quality Patient Safety Indicators, and hospital length of stay among Medicare beneficiaries. Linear regression models were developed that included adjustment for hospital region, teaching status, and discharge volume. RESULTS Hospitals with access to UpToDate (n=424) were associated with significantly better performance than other hospitals in the Thomson database (n=3091) on risk-adjusted measures of patient safety (P=0.0163) and complications (P=0.0012) and had significantly shorter length of stay (by on average 0.167 days per discharge, 95% confidence interval 0.081-0.252 days, P<0.0001). All of these associations correlated significantly with how much UpToDate was used at each hospital. Mortality was not significantly different between UpToDate and non-UpToDate hospitals. LIMITATIONS The study was retrospective and observational and could not fully account for additional features at the included hospitals that may also have been associated with better health outcomes. CONCLUSIONS An electronic clinical knowledge support system (UpToDate was associated with improved health outcomes and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Additional studies are needed to clarify whether use of UpToDate is a marker for the better performance, an independent cause of it, or a synergistic part of other quality improvement characteristics at better-performing hospitals.
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Affiliation(s)
- Peter A Bonis
- Center for Clinical Evidence Synthesis at the Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, UpToDate Inc., Waltham, MA 02453, United States.
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Bonis PA, Trikalinos TA, Chung M, Chew P, Ip S, DeVine DA, Lau J. Hereditary nonpolyposis colorectal cancer: diagnostic strategies and their implications. Evid Rep Technol Assess (Full Rep) 2007:1-180. [PMID: 17764220 PMCID: PMC4781224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES Hereditary Nonpolyposis Colorectal Cancer (HNPCC) has been defined clinically and genetically. The disorder has traditionally been recognized in kindreds with a clustering of related cancers in association with mutations in DNA mismatch repair genes. HNPCC is associated with a substantially increased risk for several forms of malignancy but particularly colorectal and endometrial cancer. There were three main objectives of this report: (1) to assess the sensitivity, specificity, and reliability of laboratory and genetic tests commonly used in evaluating patients for HNPCC (analytic validity); (2) to summarize the accuracy of commonly used clinical and laboratory characteristics for predicting the presence of HNPCC in patients with colorectal cancer (clinical validity) and use these estimates to describe the efficiency of various strategies for identifying patients with a mismatch repair mutation; (3) to describe the benefits and harms related to screening and testing patients with colorectal cancer and their family members for HNPCC. DATA SOURCES Published literature identified through an electronic search (through April 2006), review of relevant bibliographies, and suggestions from technical experts. REVIEW METHODS We evaluated studies critically and summarized the data qualitatively or by meta-analysis when studies used similar methodology and endpoints. We used decision trees to describe the efficiency of various strategies for identifying patients with HNPCC from a hypothetical population of patients with colorectal cancer. RESULTS We included a total of 104 studies of which 40 addressed issues related to clinical validity, 3 to analytic validity, and 61 to benefits and harms. We identified only three studies on analytic validity and thus there exists a major gap in the published literature with regard to the accuracy and reliability of specific tests used in the evaluation of HNPCC. Among unselected patients with colorectal cancer who fulfilled the Amsterdam I criteria, 44% (95% CI: 35, 52%) carried pathogenic mismatch repair mutations (mainly in the MLH1 and MSH2 genes). The proportion was somewhat higher (51% [95% CI: 35, 66%]) among studies that performed sequencing on all available samples. The prevalence of MMR mutation carriers may be higher when genetic testing includes evaluation for large genomic deletions/rearrangements and when testing is also performed on MSH6 and PMS2. Approximately 71% (95% CI 63, 78%) of colorectal cancers from patients who fulfilled the Amsterdam I criteria demonstrated microsatellite instability while 40% (95% CI: 28, 53%) demonstrated loss of protein expression by immunohistochemistry. Of nine clinical strategies considered for detecting the presence of mismatch repair mutations in patients with colorectal cancer, the combination of three clinical predictors (age less than 50 years old at diagnosis; or a history of colorectal or endometrial cancer in a first degree family member; or the presence of multiple, synchronous or metachronous colorectal or endometrial cancers in the proband) combined with either immunohistochemistry (IHC) or MSI testing of tumor tissue identified a similar number of patients with mismatch repair mutations as other more complex strategies. There was little published information regarding potential harms associated with screening individuals with HNPCC-related cancers using clinical criteria (e.g. the Amsterdam criteria), MSI or IHC testing. Limited data suggested that testing probands for MMR mutations was not associated with severe psychological impact following formal counseling. Pre-test genetic counseling had good efficacy in improving knowledge about HNPCC and resulted in a high likelihood of proceeding with genetic testing, satisfaction in the decision to undergo genetic testing, and decreasing depression and distress levels among family members of HNPCC probands with cancer and among asymptomatic individuals from HNPCC families. Identification of HNPCC mutations was associated with an increase in the likelihood that family members of probands with CRC would undergo cancer-screening procedures. HNPCC family members who underwent cancer-screening procedures had a lower risk of developing HNPCC-related cancers and lower mortality rates than those who did not take actions. However, all of the relevant studies suggesting these benefits had important limitations. Survival was increased among asymptomatic HNPCC family members who received colonoscopy screening, regardless of their mutation status. There was limited direct evidence related to harms of the cancer-screening procedures in family members of probands with HNPCC. However, complication rates associated with these procedures in other settings are probably similar. CONCLUSIONS This report characterizes the accuracy of clinical and laboratory predictors of MMR mutations that can be used to identify patients with an increased risk of having MMR mutations. However, the sensitivity, specificity, and reliability of the tests used to evaluate individuals for suspected HNPCC is not known confidently. Data regarding the net benefits and harms associated with predictive genetic testing in patients with HNPCC-related cancers and their families members is incomplete but suggest that such testing improves compliance with screening procedures. At-risk family members who undergo screening colonoscopy have a reduced risk of developing HNPCC-related cancers and lower mortality. However, all studies supporting these benefits had important limitations.
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van Pinxteren B, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2006:CD002095. [PMID: 16855986 DOI: 10.1002/14651858.cd002095.pub3] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately 25% of adults experience heartburn, the cardinal feature of gastro-oesophageal reflux disease (GORD), at least monthly. The evaluation and treatment of patients with suspected GORD is associated with a substantial economic burden. Most patients are treated empirically (without specific diagnostic evaluation). They include a wide range of underlying oesophageal injury. The severity of oesophageal injury can only be established in those who have undergone upper endoscopy. Patients without visible damage to the oesophagus have been referred to as having endoscopy negative reflux disease (ENRD). The pathogenesis of ENRD as well as its response to treatment may differ from GORD with oesophagitis. OBJECTIVES Summarise, quantify and compare the efficacy of the short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in adults with GORD, treated empirically and in those with endoscopy negative reflux disease (ENRD). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (January 1966 to December 2005), EMBASE (January 1988 to December 2005). SELECTION CRITERIA Randomised controlled trials focussing on symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Studies were included provided that participants could be classified in the empirical treatment group (no endoscopy used in treatment allocation) or in the endoscopy negative reflux disease group (no endoscopic signs of erosive oesophagitis). DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS Thirty-one trials (9457 participants) were included: fifteen in the empirical treatment group, twelve in the ENRD group and four in both. In empirical treatment of GORD the relative risk (RR) for heartburn remission (the primary efficacy variable) in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60 to 0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87). In treatment of ENRD, the RR for heartburn remission for PPI versus placebo was 0.69 (seven trials, 95% CI 0.62 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.78 (three trials, 95% CI 0.62 to 0.97) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92). AUTHORS' CONCLUSIONS PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD, although the magnitude of benefit is greater for those treated empirically.
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Tatsioni A, Chung M, Sun Y, Kupelnick B, Lichtenstein AH, Perrone R, Chew P, Lau J, Bonis PA. Effects of Fish Oil Supplementation on Kidney Transplantation: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials. J Am Soc Nephrol 2005; 16:2462-70. [PMID: 15958723 DOI: 10.1681/asn.2005020176] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [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: 11/03/2022] Open
Abstract
The objective of this study was to assess the effects of omega-3 fatty acid supplementation on various kidney transplant-related outcomes. A systematic review and meta-analysis was performed of published randomized, controlled trials (RCT). There were 16 kidney transplant RCT with a total of 812 patients. All trials evaluated fish oil with dosages that ranged from 1.2 to 5.4 g/d. No consistent benefits were observed for any outcome with the exception of a modest benefit on triglycerides. A meta-analysis of rejection episodes found no significant benefit on either early (<6 mo posttransplantation) or late episodes. The overall relative risk of having at least one rejection episode in those who received fish oil was 0.91 (95% confidence interval 0.74 to 1.10) in four studies with a follow-up of 1 yr. A meta-analysis of eight RCT of graft survival found no significant benefit (relative risk 1.00, 95% confidence interval 0.96 to 1.05). The available data (mostly derived from older studies with important methodologic limitations) do not demonstrate a consistent, clinically important benefit of fish oil in kidney transplantation.
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Affiliation(s)
- Athina Tatsioni
- Tufts-New England Medical Center, Evidence-Based Practice Center, Institute for Clinical Research and Health Policy Studies, 750 Washington Street, Box 63, Boston, MA 0211, USA
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Bonis PA, Chung M, Tatsioni A, Sun Y, Kupelnick B, Lichtenstein A, Perrone R, Chew P, DeVine D, Lau J. Effects of omega-3 fatty acids on organ transplantation. Evid Rep Technol Assess (Summ) 2005:1-11. [PMID: 15810864 PMCID: PMC4781309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
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van Pinxteren B, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2004:CD002095. [PMID: 15495027 DOI: 10.1002/14651858.cd002095.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Heartburn affects 25% of the adult population on a monthly basis and represents the core symptom of gastro-oesophageal reflux disease (GORD). Treatment is readily available and puts a large demand on healthcare budgets. A majority of GORD patients show no endoscopic abnormalities and in daily practice most patients are treated empirically. OBJECTIVES Summarise, quantify and compare the efficacy of the short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in adults with GORD and endoscopy negative reflux disease (ENRD). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), MEDLINE (January 1966 to December 2003), EMBASE (January 1988 to December 2003). SELECTION CRITERIA Randomised controlled trials focussing on symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Participants had to be classifiable in the empirical treatment group (no endoscopy used in treatment allocation) or in the endoscopy negative reflux disease group (no endoscopic signs of erosive oesophagitis). DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS Twenty-seven trials (8402 participants) were included: thirteen in the empirical treatment group, ten in the ENRD group and four in both. In empirical treatment of GORD the relative risk (RR) for heartburn remission in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were significantly (p < 0.05) more effective than H2RAs (five trials, RR 0.69, 95% CI 0.61 to 0.77) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87). In treatment of ENRD, RR for heartburn remission for PPI versus placebo was 0.68 (six trials, 95% CI 0.59 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.74 (three trials, 95% CI 0.53 to 1.03) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92). REVIEWERS' CONCLUSIONS The findings in this review suggest that antisecretory drugs are effective in the empirical treatment of complaints likely to originate from GORD and in treatment of ENRD and furthermore that PPIs are superior to H2RAs in empirical treatment of typical GORD symptoms.
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Numans ME, Lau J, de Wit NJ, Bonis PA. [Trial therapy with proton pump inhibitors is not a suitable test for gastroesophageal reflux disease; a meta-analysis of the diagnostic test characteristics]. Ned Tijdschr Geneeskd 2004; 148:1924-8. [PMID: 15495992] [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: 05/01/2023]
Abstract
OBJECTIVE To determine the value of successful trial therapy with proton-pump inhibitors (PPIs) as a diagnostic test for gastro-oesophageal reflux disease (GERD). DESIGN Systematic review and meta-analysis. METHOD Studies were included in which the clinical response to a short course (1-4 weeks) of PPI therapy could be related to abnormal results of 24-hr pH monitoring, gastroscopy, and/or diagnostic questionnaires. The sensitivity and specificity of the trial therapy were calculated. The ROC method was used to summarize the test characteristics across studies. RESULTS With 24-hr pH monitoring as the reference standard, the positive likelihood ratio of the diagnosis 'reflux disease' ranged from 1.63 to 1.87 and the combined estimates of sensitivity and specificity in the various studies were 0.78 (95% CI: 0.66-0.86) and 0.54 (0.44-0.65), respectively. These values were lower with the other reference standards. CONCLUSION Although there were insufficient data to determine the effect of varying dosages of PPIs and duration of therapy on the test characteristics, successful short-term treatment with PPIs in patients suspected of having GERD provides insufficient certainty as to the diagnosis.
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Affiliation(s)
- M E Numans
- Universitair Medisch Centrum Utrecht, Julius Centrum voor Patiënt-gebonden Onderzoek, Postbus 85060, 3808 AB Utrecht.
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Numans ME, Lau J, de Wit NJ, Bonis PA. Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Intern Med 2004; 140:518-27. [PMID: 15068979 DOI: 10.7326/0003-4819-140-7-200404060-00011] [Citation(s) in RCA: 205] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND A response to proton-pump inhibitors (PPIs) is commonly considered to support the diagnosis of gastroesophageal reflux disease (GERD). However, the accuracy of this diagnostic strategy has not been well established. OBJECTIVE To estimate the diagnostic test characteristics of successful PPI treatment with objective measures of GERD by performing a meta-analysis based on the published literature. DATA SOURCES English-language studies were identified by searching the Cochrane Clinical Trial Register and MEDLINE from 1 January 1980 through 1 July 2003. STUDY SELECTION Studies in which the clinical response to a short course (1 to 4 weeks) of normal- or high-dose PPI therapy could be compared with objective measures of GERD (24-hour pH monitoring, endoscopy findings, symptom questionnaires). DATA EXTRACTION Studies were screened for inclusion by 1 author. Final decisions on exclusion were made by consensus with 2 of the other authors. Two investigators independently extracted the data. Information extracted included patient characteristics, study design, setting, specific type and dose of medication, duration of treatment, and definitions of outcomes. DATA SYNTHESIS Sensitivity and specificity were determined by comparing a clinical response to PPIs with objective measures for GERD. The summary receiver-operating characteristic curve method was used to summarize test characteristics across studies. Sensitivity and specificity were also combined independently by using a random-effects model. Fifteen studies met the inclusion criteria and provided sufficient data. With 24-hour pH monitoring as the reference standard, the positive likelihood ratio ranged from 1.63 to 1.87, and combined estimates of sensitivity and specificity were 0.78 (95% CI, 0.66 to 0.86) and 0.54 (CI, 0.44 to 0.65), respectively. These values were lower with the other reference standards. LIMITATIONS Data were insufficient to determine the effect of various doses of PPIs and duration of therapy on test characteristics. CONCLUSION Successful short-term treatment with a PPI in patients suspected of having GERD does not confidently establish the diagnosis when GERD is defined by currently accepted reference standards.
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Abstract
GOALS To compare the long-term outcome of medical, percutaneous, and surgical treatment of abdominal and pelvic abscesses complicating Crohn's disease. STUDY All patients with Crohn's disease and an abdominal abscess treated at one institution during a 10-year period were retrospectively identified. We reviewed hospital and outpatient records and contacted patients for telephone interviews. Outcome measures included abscess recurrence, subsequent surgery for Crohn's disease, and medications used at the time of most recent follow-up. RESULTS Fifty-one subjects were identified, with a mean follow-up of 3.75 years. Fewer patients developed recurrent abscesses after initial surgical drainage and bowel resection (12%) than patients treated with medical therapy only or percutaneous drainage (56%) (p = 0.016). One half of the patients treated nonoperatively ultimately required surgery, whereas only 12% of those treated with initial surgery required reoperation during the follow-up period (p = 0.010). Most failures of nonoperative therapy occurred within 3 months. Medication use was similar between the treatment groups at the time of most recent follow-up. CONCLUSIONS In this series, surgical management of abscesses in Crohn's disease was more effective than medical treatment or percutaneous drainage for prevention of abscess recurrence. However, nonoperative therapy prevented subsequent surgery in half of the patients and may be a reasonable treatment option for some patients.
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Affiliation(s)
- J C Garcia
- Division of Digestive Diseases and the Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Cheng SJ, Bonis PA, Lau J, Pham NQ, Wong JB. Interferon and ribavirin for patients with chronic hepatitis C who did not respond to previous interferon therapy: a meta-analysis of controlled and uncontrolled trials. Hepatology 2001; 33:231-40. [PMID: 11124841 DOI: 10.1053/jhep.2001.20675] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The efficacy of interferon (IFN) combined with ribavirin for the treatment of patients with hepatitis C who failed to respond to initial IFN therapy is not well established. The primary goal of this study was to perform a systematic review of the literature evaluating the efficacy of combination therapy in nonresponders. Studies were retrieved from MEDLINE, abstracts of scientific meetings, and review of the bibliographies of retrieved studies. Controlled trials were included in the primary analysis whereas uncontrolled trials and trials reported as abstracts were included for sensitivity analysis. The primary endpoints were biochemical and virologic response. A combined estimate of the odds ratio (OR) for each endpoint was obtained by using the random effects model. The number needed to treat (NNT) was calculated by taking the inverse of the pooled risk difference. Nine controlled trials (789 patients) were identified. Six months after treatment, the overall sustained biochemical and virologic responses to 24 weeks of combination therapy were 15.2% and 13.2% with a common OR of 3.8 (95% confidence interval [CI] 2.2-6.7) and 4.9 (95% CI 2.1-11.2) compared with patients treated with IFN monotherapy. The pooled risk difference for the sustained virologic response (SVR) to combination therapy was 7% (95% CI 2-13). The NNT was 14 (95% CI 8-50), suggesting that approximately 14 patients would need to be treated with 6 months of combination therapy for 1 patient to have a SVR. A number of variables were associated with a high response rate in individual studies. Sensitivity analysis of preliminary trials suggest a higher response rate with longer duration of therapy and non-type 1 genotypes.
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Affiliation(s)
- S J Cheng
- Division of Clinical Decision Making, Informatics and Telemedicine, Department of Medicine, New England Medical Center Hospitals, Tufts University School of Medicine, Boston, MA, USA
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van Pinxteren B, Numans ME, Bonis PA, Lau J. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2000:CD002095. [PMID: 11687139 DOI: 10.1002/14651858.cd002095] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Heartburn affects 25% of the adult population on a monthly basis and represents the core symptom of gastro-oesophageal reflux disease (GORD). Treatment is readily available and puts a large demand on healthcare budgets. Research in the past has focused largely on the treatment of oesophagitis. A majority of GORD patients show no endoscopic abnormalities and in daily practice most patients are treated empirically. OBJECTIVES Summarise, quantify and compare the efficacy of the short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in the empirical treatment of GORD and the treatment of endoscopy negative reflux disease (ENRD). SEARCH STRATEGY Electronic searches were performed of the Cochrane Controlled Trials Register, MEDLINE and EMBASE. Bibliographies were screened. SELECTION CRITERIA Included were randomised controlled trials focussing on symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Participants had to be classifiable in the empirical treatment group (no endoscopy used in treatment allocation) or in the endoscopy negative reflux disease group (no endoscopic signs of erosive oesophagitis). DATA COLLECTION AND ANALYSIS Data from included trials were extracted by two reviewers independently. The impact of interventions was expressed as relative risks (RR) together with 95% confidence intervals (95% CI). Meta-analysis was only performed if there were sufficient trials of similar comparisons reporting the same outcomes. Relative risks were combined for binary outcomes. MAIN RESULTS Twenty-one trials were included: eleven in the empirical treatment group, seven in the ENRD group and three in both. In empirical treatment of GORD the RR for heartburn remission in placebo-controlled trials for PPI was 0.35 (1 trial, 95% CI 0.26 to 0.46), for H2RAs 0.77 (2 trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (1 trial, 95% CI 0.73 to 1.01). In direct comparison PPIs were significantly (p<0.05) more effective than H2RAs (3 trials, RR 0.67, 95% CI 0.57 to 0.80) and prokinetic's (2 trials, RR 0.53, 95% CI 0.32 to 0.87). In treatment of ENRD, RR for heartburn remission for PPI versus placebo was 0.68 (4 trials, 95% CI 0.53 to 0.88) and for H2RA versus placebo was 0.84 (2 trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.69 (2 trials, 95% CI 0.39 to 1.20) and versus prokinetic 0.72 (1 trial, 95% CI 0.56 to 0.92). REVIEWER'S CONCLUSIONS The findings in this review suggest that antisecretory drugs are effective in the empirical treatment of complaints likely to originate from GORD and in treatment of ENRD and furthermore that PPIs are superior to H2RAs in empirical treatment of typical GORD symptoms.
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Affiliation(s)
- B van Pinxteren
- Department of General Practice, University Medical Center Utrecht, PO Box 80045, Utrecht, Netherlands, 3508 TA.
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Bonis PA. Clinical outcomes after hepatitis C infection from contaminated anti-D immune globulin. N Engl J Med 1999; 341:763. [PMID: 10475798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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Affiliation(s)
- P A Bonis
- UpToDate, Inc., Wellesley, Massachusetts 02481, USA.
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Abstract
BACKGROUND & AIMS Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease of presumed autoimmune etiology. Ursodeoxycholic acid (UDCA), methotrexate, and colchicine each have shown promise in its treatment. The value of combining 2 or 3 of these drugs is uncertain. The aim of this study was to determine whether addition of methotrexate to the treatment regimen improves results of liver biochemical tests in patients with antimitochondrial antibody-positive PBC who responded incompletely to treatment with UDCA and colchicine. METHODS Methotrexate was added to the treatment regimen of 10 consecutive patients with antimitochondrial antibody-positive PBC who had an incomplete response to therapy with UDCA alone or in combination with colchicine. The primary end point was biochemical response. Symptoms and histological changes were also recorded. RESULTS Addition of methotrexate to the UDCA plus colchicine regimen was associated with a significant reduction in serum alkaline phosphatase (ALP) levels beyond those found with UDCA and colchicine alone or in combination. Median ALP concentration was 389 IU (range, 247-1013 IU) at baseline, 300 IU (range, 155-467 IU) after treatment with UDCA plus colchicine, and 120 IU (range, 66-351 IU) after treatment with methotrexate. CONCLUSIONS Addition of methotrexate to a regimen of UDCA and colchicine may be beneficial for patients with PBC who respond incompletely to treatment with UDCA and colchicine.
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Affiliation(s)
- P A Bonis
- Division of Gastroenterology, Boston, Massachusetts, USA
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Bonis PA, Tong MJ, Blatt LM, Conrad A, Griffith JL. A predictive model for the development of hepatocellular carcinoma, liver failure, or liver transplantation for patients presenting to clinic with chronic hepatitis C. Am J Gastroenterol 1999; 94:1605-12. [PMID: 10364032 DOI: 10.1111/j.1572-0241.1999.01151.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Chronic infection with hepatitis C may lead to the development of cirrhosis, liver failure, and hepatocellular carcinoma. However, not all patients progress to these endpoints. Ideally, clinicians could improve their capability of stratifying the risk and the time frame within which their patients will progress to these endpoints. The purpose of the present study was to construct statistical models predicting disease progression for individual patients. METHODS Study endpoints were the development of hepatocellular carcinoma, liver transplantation, or death due to liver disease. The study cohort was 256 patients with hepatitis C acquired from either blood transfusion or use of intravenous drugs. During follow-up, 17 patients developed hepatocellular carcinoma, seven received liver transplantation, and 12 died from liver disease. RESULTS On multivariate analysis a history of decompensation (relative risk [RR] 4.321, 95% confidence interval [CI] 1.777-10.511) and the serum albumin (RR 0.253, 95% CI 0.136-0.474) were independently associated with the study endpoints. Patients without a history of decompensation and with a serum albumin > or = 4.1 mg/dl had a 3.2% chance of developing the study endpoints within 5 yr. Patients with a history of decompensation and a serum albumin < 4.1 mg/dl had a 40% chance of developing a study endpoint within 5 yr. Baseline genotype and quantitative RNA were not associated with development of the clinical endpoints, with the exception of patients coinfected with two or more genotypes. CONCLUSION Thus, the serum albumin and a history of decompensation are useful for predicting the development of hepatocellular carcinoma, liver transplantation, and death due to liver disease among patients with hepatitis C.
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Affiliation(s)
- P A Bonis
- Section of Digestive Disease, Yale University School of Medicine, New Haven, Connecticut, USA
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Bonis PA, Ioannidis JP, Cappelleri JC, Kaplan MM, Lau J. Correlation of biochemical response to interferon alfa with histological improvement in hepatitis C: a meta-analysis of diagnostic test characteristics. Hepatology 1997; 26:1035-44. [PMID: 9328332 DOI: 10.1002/hep.510260436] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The current goal of interferon treatment for chronic hepatitis C is to normalize alanine aminotransferase (ALT) and to eradicate detectable viral RNA. Many patients do not achieve this objective during treatment, and most do not sustain these outcomes after interferon is discontinued. However, biochemical or virological responses to interferon may not reflect accurately the histological consequences of therapy. The aim of this study was to determine the extent to which the biochemical measures reflect the histological outcomes in the treatment of hepatitis C with interferon alfa using a meta-analysis of diagnostic test characteristics. The data sources were English and non-English language studies retrieved from Medline (from 1966 to December 1995). The study selection included studies in which interferon alfa was used for treatment of chronic hepatitis C with liver biopsies performed before and after therapy. Data on histological and biochemical outcomes were extracted independently by two reviewers. Two separate criteria were used for defining histological response. When strict definitions of histological improvement were considered, histology improved in 28% (95% confidence interval [95% CI], 17%-43%) of patients after interferon treatment. The sensitivity and specificity of the ALT for determining histological change were 70% (95% CI, 56%-81%) and 66% (95% CI, 56%-75%), respectively. As many as 17% (95% CI, 9%-30%) of subjects with an abnormal ALT at the end of therapy may have improved histologically after interferon therapy. When less stringent definitions of histological improvement were considered, 62% (95% CI, 51%-72%) improved after therapy. The sensitivity and specificity of the ALT for determining histological change were 55% (95% CI, 44%-65%) and 75% (95% CI, 67%-81%), respectively. As many as 51% (95% CI, 38%-64%) may have improved, despite failure to normalize ALT. A substantial number of patients may improve histologically after interferon therapy. The significance of histological changes observed after interferon therapy must be weighed against the limitations of liver biopsy and the uncertain natural history of hepatitis C. Nevertheless, the ALT does not always reflect liver histology accurately after interferon alfa treatment and may underestimate histological improvement.
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Affiliation(s)
- P A Bonis
- Department of Medicine, New England Medical Center, Boston, MA, USA
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Bonis PA, Norton RA. The challenge of irritable bowel syndrome. Am Fam Physician 1996; 53:1229-36. [PMID: 8629568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Irritable bowel syndrome is a common disorder with symptom complexes that can include diarrhea, constipation, pain and bloating. After other disorders have been excluded, treatment should be directed at the predominant symptoms and gauged to their severity. A careful balance between a thoughtful investigation and the expense and dangers of overtesting must always be considered. Most patients continue to have persistent symptoms several years after the original diagnosis.
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Affiliation(s)
- P A Bonis
- New England Medical Center, Boston, Massachusetts, USA
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