Efficacy and safety of linaclotide in treating functional constipation in paediatric patients: a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial

BACKGROUND

Linaclotide, a guanylate cyclase C agonist, has been approved in the USA for the treatment of chronic idiopathic constipation and irritable bowel syndrome with predominant constipation in adults. We aimed to assess the efficacy and safety of linaclotide in paediatric patients aged 6-17 years with functional constipation.

METHODS

This randomised, double-blind, placebo-controlled, multicentre, phase 3 study was done at 64 clinic or hospital sites in seven countries (USA, Canada, Israel, Italy, the Netherlands, Ukraine, and Estonia). Patients aged 6-17 years who met modified Rome III criteria for functional constipation were randomly assigned (1:1), with a block size of four and stratified by age (6-11 years and 12-17 years), to receive either oral linaclotide 72 μg or placebo once daily for 12 weeks. Participants, investigators, and data assessors were masked to assignment. The primary efficacy endpoint was change from baseline (CFB) in the 12-week frequency rate of spontaneous bowel movements (SBMs; occurring in the absence of rescue medication on the calendar day of or before the bowel movement) per week and the secondary efficacy endpoint was CFB in stool consistency over the 12-week treatment period; efficacy and safety were analysed in all patients in the randomised population who received at least one dose of study intervention (modified intention-to-treat population and safety population, respectively). The study is registered with ClinicalTrials.gov, NCT04026113, and the functional constipation part of the study is complete.

FINDINGS

Between Oct 1, 2019, and March 21, 2022, 330 patients were enrolled and randomly assigned to linaclotide (n=166) or placebo (n=164). Two patients in the linaclotide group did not receive any treatment; thus, efficacy and safety endpoints were assessed in 328 patients (164 patients in each group). 293 (89%) patients completed the 12-week treatment period (148 in the linaclotide group and 145 in the placebo group). 181 (55%) of 328 patients were female and 147 (45%) were male. At baseline, the mean frequency rate for SBMs was 1·28 SBMs per week (SD 0·87) for placebo and 1·16 SBMs per week (0·83) for linaclotide, increasing to 2·29 SBMs per week (1·99) for placebo and 3·41 SBMs per week (2·76) for linaclotide during intervention. Compared with placebo (least-squares mean [LSM] CFB 1·05 SBMs per week [SE 0·19]), patients treated with linaclotide showed significant improvement in SBM frequency (LSM CFB 2·22 SBMs per week [0·19]; LSM CFB difference 1·17 SBMs per week [95% CI 0·65-1·69]; p<0·0001). Linaclotide also significantly improved stool consistency over placebo (LSM CFB 1·11 [SE 0·08] vs 0·69 [0·08]; LSM CFB difference 0·42 [95% CI 0·21-0·64]; p=0·0001). The most reported treatment-emergent adverse event (TEAE) by patients treated with linaclotide was diarrhoea (seven [4%] of 164 vs three [2%] of 164 patients in the placebo group) and by patients treated with placebo was COVID-19 (five [3%] vs four [2%] in the linaclotide group). The most frequent treatment-related TEAE was diarrhoea (linaclotide: six [4%] patients; placebo: two [1%] patients). One serious adverse event of special interest (treatment-related severe diarrhoea resulting in dehydration and hospitalisation) occurred in a female patient aged 17 years in the linaclotide group; this case resolved without sequelae after administration of intravenous fluids. No deaths occurred during the study.

INTERPRETATION

Linaclotide is an efficacious and well tolerated treatment for functional constipation in paediatric patients and has subsequently been approved by the US Food and Drug Administration for this indication.

FUNDING

AbbVie and Ironwood Pharmaceuticals.

Improving anthropometric measurements in hospitalized children: A quality-improvement project

BACKGROUND

The objective of this quality-improvement project was to increase documentation rates of anthropometrics (measured weight, length/height, and body mass index [BMI], which are critical to identify patients at malnutrition (undernutrition) risk) from <50% to 80% within 24 hours of hospital admission for pediatric patients.

METHODS

Multidisciplinary champion teams on surgical, cardiac, and intensive care (ICU) pilot units were established to identify and iteratively test interventions addressing barriers to documentation from May 2016 to June 2018. Percentage of patients with documented anthropometrics <24 h of admission was assessed monthly by statistical process control methodology. Percentage of patients at malnutrition (undernutrition) risk by anthropometrics was compared by χ2 for 4 months before and after intervention.

RESULTS

Anthropometric documentation rates significantly increased (P < 0.001 for all): BMI, from 11% to 89% (surgical), 33% to 57% (cardiac), and 16% to 51% (ICU); measured weight, from 24% to 88% (surgical), 69% to 83% (cardiac), and 51% to 67% (ICU); and length/height, from 12% to 89% (surgical), 38% to 57% (cardiac), and 26% to 63% (ICU). Improvement hospital-wide was observed (BMI, 42% to 70%, P < 0.001) with formal dissemination tactics. For pilot units, moderate/severe malnutrition (undernutrition) rates tripled (1.2% [24 of 2081] to 3.4% [81 of 2374], P < 0.001).

CONCLUSION

Documentation of anthropometrics on admission substantially improved after establishing multidisciplinary champion teams. Goal rate (80%) was achieved within 26 months for all anthropometrics in the surgical unit and for weight in the cardiac unit. Improved documentation rates led to significant increase in identification of patients at malnutrition (undernutrition) risk.

Randomized clinical trial: A phase 2b controlled study of the efficacy and safety of trazpiroben (TAK-906) for idiopathic or diabetic gastroparesis

BACKGROUND

Previous clinical studies of trazpiroben, a dopamine D2 /D3 receptor antagonist for long-term treatment of moderate-to-severe idiopathic and diabetic gastroparesis, have shown improved symptoms of fullness. This study assessed trazpiroben efficacy, safety, and tolerability in adults with idiopathic and diabetic gastroparesis versus placebo.

METHODS

This global, multicenter, double-blind, parallel-group, phase 2b study (NCT03544229) enrolled eligible adults aged 18-85 years with symptomatic idiopathic or diabetic gastroparesis. Randomized participants received either oral placebo or trazpiroben 5, 25, or 50 mg, administered twice daily over 12 weeks, and completed the American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index-Daily Diary. Change in weekly composite score from baseline to week 12 (primary endpoint) and treatment-emergent adverse events were assessed. Data were summarized descriptively.

KEY RESULTS

Overall, 242 participants were enrolled (mean [standard deviation] age 55.7 [14.2] years; 75.6% female); 193 completed the study. No significant differences in change from baseline in weekly average of the daily diary composite score occurred at week 12 between placebo (least-squares mean [standard error] -1.19 [0.12]) and trazpiroben (5, 25, and 50 mg: -1.11 [0.22], -1.17 [0.12], and -1.21 [0.12], respectively). Overall, 41.4% of participants receiving trazpiroben reported treatment-emergent adverse events (placebo, 39.7%). No serious events were considered trazpiroben-related; no life-threatening or fatal events were reported.

CONCLUSIONS & INFERENCES

There was no clinically meaningful difference in efficacy between trazpiroben and placebo in treating gastroparesis, based on the primary endpoint analysis. Trazpiroben was well tolerated with no new safety concerns identified, strengthening evidence supporting its favorable safety profile. NCT number: NCT03544229.

Clinical Presentations of Drug-Induced Hyperprolactinaemia: A Literature Review

Screening for drug-induced hyperprolactinaemia, a condition characterised by higher-than-normal levels of serum prolactin induced by drug treatments, requires a comprehensive understanding of the clinical presentations and long-term complications of the condition. Using two databases, Embase and MEDLINE, we summarised the available evidence on the clinical presentations and long-term complications of drug-induced hyperprolactinaemia. Clinical and observational studies reporting on drug treatments known or suspected to induce hyperprolactinaemia were included. Database searches were limited to the English language; no date or geographic restrictions were applied. Fifty studies were identified for inclusion, comprising a variety of study designs and patient populations. Most data were reported in patients treated with antipsychotics, but symptoms were also described among patients receiving other drugs, such as prokinetic drugs and antidepressants. Notably, the diagnosis of drug-induced hyperprolactinaemia varied across studies since a standard definition of elevated prolactin levels was not consistently applied. Frequent clinical presentations of hyperprolactinaemia were menstrual cycle bleeding, breast or lactation disorders, and sexual dysfunctions, described in 80% (40/50), 74% (37/50), and 42% (21/50) of the included studies, respectively. In the few studies reporting such symptoms, the prevalence of vaginal dryness impacted up to 53% of females, and infertility in both sexes ranged from 15 to 31%. Clinicians should be aware of these symptoms related to drug-induced hyperprolactinaemia when treating patients with drugs that can alter prolactin levels. Future research should explore the long-term complications of drug-induced hyperprolactinaemia and apply accepted thresholds of elevated prolactin levels (i.e., 20 ng/mL for males and 25 ng/mL for females) to diagnose hyperprolactinaemia as a drug-induced adverse event.Trial Registration PROSPERO International Prospective Register Of Systematic Reviews (CRD42021245259).

Health-care resource use and costs associated with diabetic and idiopathic gastroparesis: A claims analysis of the first 3 years following the diagnosis of gastroparesis

BACKGROUND

Due to limited treatment options, many patients with diabetic gastroparesis (DG) or idiopathic gastroparesis (IG) experience inadequate symptom control resulting in increased health-care resource utilization (HRU) and associated costs. We compared all-cause HRU and health-care costs over the 3 years after patients' first gastroparesis diagnosis with that of matched controls without gastroparesis.

METHODS

Newly diagnosed adults with DG or IG were identified in Optum's de-identified Clinformatics^® Data Mart Database (Q1-2007 to Q1-2019). Patients with DG/IG were matched 1:1 to controls using a mixed approach of exact matching and propensity score matching. The index date was the first gastroparesis diagnosis for cases or randomly selected for controls. All-cause HRU and direct health-care costs per person-year (PPY) were compared between DG/IG cases and controls in Years 1-3 post-index.

KEY RESULTS

Demographics and comorbidities were balanced between patients with gastroparesis (n = 18,015 [DG]; n = 14,305 [IG]) and controls. In each of the Years 1-3 post-index, patients with DG or IG had significantly higher annual HRU and costs versus controls (mean total cost differences PPY: DG Year 1 $34,885, Year 2 $28,071, Year 3 $25,606; IG Year 1 $23,176, Year 2 $16,627, Year 3 $14,396) (all p < 0.05). Across all 3 years, DG/IG cohorts had approximately twice the costs of controls. HRU and costs were highest in Year 1 post-index for both DG and IG.

CONCLUSIONS & INFERENCES

The economic burden of gastroparesis remains high several years after diagnosis, emphasizing the need for chronic treatment to effectively manage symptoms and consequently reduce the burden of this disorder.

The pharmacokinetics of oral trazpiroben (TAK-906) after organic anion transporting polypeptide 1B1/1B3 inhibition: A phase I, randomized study

Trazpiroben is a dopamine D₂/D₃ receptor antagonist under development for the treatment of gastroparesis. This phase I, open‐label, randomized, two‐way crossover study (NCT04121078) evaluated the effect of single‐dose intravenous rifampin, a potent inhibitor of the organic anion transporting polypeptides (OATPs) 1B1 and 1B3, on the pharmacokinetics and safety of trazpiroben in healthy adults. The utility of coproporphyrin (CP) I and CPIII as biomarkers of OATP inhibition was also assessed. Overall, 12 participants were enrolled and randomized (1:1) into one of two treatment sequences (AB and BA). Participants received either a single oral dose of trazpiroben 25 mg (treatment A) or a single oral dose of trazpiroben 25 mg immediately after a single 30‐min intravenous infusion of rifampin 600 mg (treatment B). After a washout period of at least 7 days, participants received the other treatment. Geometric mean area under the curve from time 0 extrapolated to infinity (AUC_∞) and maximum serum concentration (C_max) of plasma trazpiroben were higher in participants receiving treatment B than those receiving treatment A (AUC_∞, 168.5 vs. 32.68 ng*h/ml; C_max, 89.62 vs. 14.37 ng/ml); corresponding geometric mean ratios (90% confidence interval) showed 5.16 (4.25–6.25) and 6.24 (4.62–8.42)‐fold increases in these parameters, respectively. In this study, trazpiroben was confirmed as a substrate of OATP1B1/1B3, and therefore co‐administration of trazpiroben with moderate to strong inhibitors of OATP1B1/1B3 is not recommended. This is also the first assessment of the utility of CPI and CPIII as endogenous biomarkers of OATP1B1/1B3 inhibition after a single intravenous dose of rifampin.

Epidemiology, Etiology, and Treatment of Gastroparesis: Real-World Evidence From a Large US National Claims Database

BACKGROUND & AIMS

Although gastroparesis carries a considerable health care and patient burden, associated epidemiological data are limited. To provide new real-world evidence for gastroparesis, we estimated disease prevalence, and investigated patient demographics and disease etiology in a large US claims database.

METHODS

This retrospective, cross-sectional analysis used de-identified, longitudinal patient-level enrollment and billing data for adults from the Optum Clinformatics Data Mart database, a large US national administrative health insurance claims database. Prevalence was age-, sex-, and geographical region-standardized using the 2018 US census. Descriptive analyses of demographic and clinical variables and underlying disease etiologies were performed.

RESULTS

The overall standardized prevalence of gastroparesis was 267.7 (95% confidence interval [CI] 264.8-270.7) per 100,000 US adults, whereas prevalence of "definite" gastroparesis (individuals diagnosed within 3 months of gastric emptying scintigraphy testing with persistent symptoms for more than 3 months) was 21.5 (95% CI 20.6-22.4) per 100,000 persons. Patients with gastroparesis had an overall Charlson Comorbidity Index score of 4.2, indicating substantial comorbidity burden. The most frequently documented comorbidities were chronic pulmonary disease (46.4%), diabetes with chronic complication (37.3%), and peripheral vascular disease (30.4%). Patients most commonly had a diabetic etiology (57.4%; type 1, 5.7% and type 2, 51.7%), followed by postsurgical (15.0%), drug-induced (11.8%), and idiopathic (11.3%) etiologies.

CONCLUSIONS

New evidence is provided regarding the prevalence, patient demographics, and etiology of gastroparesis in the US general population. Wider availability of reliable objective gastric emptying measures and further education of medical professionals in recognizing and diagnosing gastroparesis would benefit future studies and improve understanding of disease epidemiology.

Clinical characteristics and MRI-based phenotypes of perianal abscess formation in children with fistulizing Crohn's Disease

PURPOSE

The aim of this study was to explore potential correlation of the MR imaging features and clinical characteristics with formation of perianal abscess in children with Crohn's perianal fistulas (CPF).

METHODS

From 2010 to 2020, pediatric patients with CPF diagnosis on their first pelvic MRI were identified retrospectively. All patients were divided into two groups based on the presence or absence of perianal abscess. Baseline clinical and MRI characteristics were recorded for each patient. All the statistical calculations were performed using R (version 3.6.3).

RESULTS

A total of 60 patients [F:M 17:43, median age 14 years (IQR 10-15), ranging 3-18 years] were included in this study. Forty-four abscesses were identified in 36/60 children (mean volume 3 ± 8.6 ml, median 0.3 ml). In 24/60 patients with perianal disease, no abscess was detected on the MRI. Ten patients (28%) showed perianal abscess on pelvic MRI at the initial diagnosis. The rate of active disease on colonoscopy (visible ulcerations/aphthous ulcers) was similar in both groups (95% vs. 94%). With regards to disease location, the majority of patients (40/60, 66.6%) in both groups had ileocolonic CD. All patients without abscess had a single perianal fistula (n = 24; 3 simple and 21 complex fistulae), however, patients with perianal abscess tended to have >1 fistulous tracts (n = 50 fistulas; all complex, 27 single, 10 double and 1 triple). Intersphincteric fistula was the most common fistula type in both groups (79% and 66%, p = 0.1). The total length of fistula (3.8 ± 1.7 vs. 2.8 ± 0.8 cm, p = 0.006) and presence of multiple external openings (n = 25 vs. 7, p = 0.019) were significantly higher in patients with abscesses, and fistula length >3.3 cm showed 80% specificity and 83% PPV for the presence of perianal abscess. Fistulas were symptomatic (pain, bleeding or drainage) at similar rates in both groups (68% and 70%, p = 0.1).

CONCLUSION

Pediatric patients with CPF who develop perianal abscess have a distinct imaging phenotype defined by longer fistula length (>3.3 cm), multiple skin openings and multiple fistulous tracts (≥2) on MRI. Patients who have these features but does not have an abscess on imaging may merit more aggressive treatment (and close monitoring) to prevent the development of an abscess.

Delivery by caesarean section and offspring adiposity and cardio-metabolic health at ages 6.5, 11.5 and 16 years: results from the PROBIT cohort in Belarus

BACKGROUND

Caesarean delivery has been associated with later adiposity, perhaps via early programming or perhaps because of residual confounding by maternal or birth characteristics.

OBJECTIVES

Examine associations of caesarean delivery with adiposity and cardio-metabolic biomarkers.

METHODS

Observational analysis of 15 069 children in the PROBIT cohort in Belarus. We examined measures of child anthropometry and blood pressure at 6.5, 11.5 and 16 years and fasting blood (11.5 years).

RESULTS

Caesarean-delivered children were slightly heavier at 6.5 (mean BMI 15.8 vs. 15.6 kg/m² ), 11.5 (18.4 vs. 18.2) and 16 years (21.5 vs. 21.3). After adjustment for prenatal characteristics including maternal third trimester BMI, however, we observed no association of caesarean versus vaginal delivery with child BMI (β 0.05 kg/m² ; 95%CI: -0.03, 0.14), sum of skinfolds (0.14 mm; -0.13, 0.42), waist circumference (-0.07 cm; -0.23, 0.10), obesity (OR 0.99; 0.76, 1.29), or systolic (-0.20 mmHg; -0.70, 0.30) or diastolic (-0.17 mmHg, -0.60, 0.26) blood pressure at 6.5 years; results were similar at 11.5 and 16 years. At 11.5 years, we observed a modest association of caesarean delivery with fasting insulin (0.33 mU/L; 0.00, 0.65).

CONCLUSIONS

Caesarean delivery had little or no association with adiposity or related cardio-metabolic biomarkers in childhood. Adjustment for maternal BMI attenuated all outcome effect estimates.

Maternal Place of Birth, Socioeconomic Characteristics, and Child Health in US-Born Latinx Children in Boston

OBJECTIVE

Among US-born children of Latina US (USB) and Latina foreign-born mothers (FBM), to determine whether 1) household and child characteristics differ; 2) child health outcomes differ; 3) these differences diminish for children of FBM with longer duration of residence in the United States; and 4) these differences can be explained by food insecurity (FI) or by Supplemental Nutrition Assistance Program (SNAP) participation.

METHODS

Cross-sectional survey of 2145 Latina mothers of publicly insured US-born children 0 to 48 months old in a Boston emergency department (ED) 2004 to 2013. Predictors were FBM versus USBM and duration of residence in the United States. Outcomes were mothers' report of child health, history of hospitalization, developmental risk, and hospital admission on the day of ED visit. Multivariable logistic regression adjusted for potential confounders and effect modification.

RESULTS

FBM versus USBM households had more household (31% vs 26%) and child (19% vs 11%) FI and lower SNAP participation (44% vs 67%). Children of FBM versus USBM were more likely to be reported in fair/poor versus good/excellent health (adjusted odds ratios 1.9, 95% confidence interval [1.4, 2.6]), with highest odds for children of FBM with shortest duration of residence, and to be admitted to the hospital on the day of the ED visit (adjusted odds ratios 1.7, 95% confidence interval [1.3, 2.2]). SNAP and FI did not fully explain these outcomes.

CONCLUSION

When providing care and creating public policies, clinicians and policymakers should consider higher rates of food insecurity, lower SNAP participation, and risk for poor health outcomes in Latinx children of FBM.

Macronutrient Analysis of Modified-Fat Breast Milk Produced by 3 Methods of Fat Removal

BACKGROUND

Infants with chylothorax after congenital heart disease surgery are commonly treated using modified-fat breast milk. The effect of fat removal on breast milk macronutrients remains unclear. We compared macronutrient content of breast milk with breast milk skimmed using 3 methods, including a novel device, a cream separator.

METHODS

Thawed frozen breast milk samples from 30 women were defatted using refrigerated centrifuge, cream separator, and manual separation after refrigeration. We used standard assays to measure energy, protein, and fat content of breast milk samples.

RESULTS

All fat removal methods yielded skimmed breast milk with substantially lower fat and energy content. Mean energy content in breast milk skimmed by centrifuge (36.7 [SD 3.6] kcal/100 mL) was similar to that from cream separator (38.8 [3.5] kcal/100 mL). Both centrifuge and cream separator methods removed almost all fat and substantially more fat than the manual fat removal method. For unprocessed milk, energy and fat content estimated by creamatocrit was similar to reference method measurements; in skimmed milk, the creamatocrit significantly overestimated fat content. Mean protein content of skimmed breast milk was similar to unprocessed breast milk (mean 1.25 [0.31] g/100 mL).

CONCLUSION

Breast milk fat removal did not significantly alter protein levels. In skimmed breast milk, the overestimation of fat content using creamatocrit method suggests a need for more accurate bedside methods to assess macronutrient content. The similar macronutrient composition of breast milk skimmed by cream separator and centrifuge suggests the potential for cream separator use as a new, portable defatting method for hospitals and families.

Risk Factors for Fractures in Children Hospitalized in Intensive and Intermediate Care Units

BACKGROUND AND OBJECTIVES

Fragility fractures are increasingly recognized in hospitalized children. Our study aim was to identify risk factors for fracture in children hospitalized in intensive and intermediate care units.

METHODS

We conducted a retrospective, case-control study comparing the clinical characteristics of children with fractures (cases) to children without fractures (controls) matched for age, sex, hospital unit, admission quarter and year, ICU length of stay, severity of illness, and resource utilization. Bivariate comparisons and matched multivariable logistic regression modeling were used to determine associations between potential risk factors and fracture.

RESULTS

Median age at fracture for the 35 patients was 5.0 months (interquartile range 2.0 to 10.0 months) and at a comparable interval for the 70 matched controls was 3.5 months (interquartile range 2.0 to 7.0 months). In bivariate analyses, factors associated with fracture included: primary diagnosis of tracheoesophageal fistula, esophageal atresia and stenosis; diagnosis of kidney disease; and per 5-day increase in median cumulative ICU days at risk. In the final model, a respiratory disease diagnosis (odds ratio 3.9, 95% confidence interval 1.1-13.7) and per 5-day increase in median cumulative ICU days at risk (odds ratio 1.3, 95% confidence interval 1.0-1.6) were significant independent risk factors for fracture.

CONCLUSIONS

Children prone to fracture in the hospital are young, medically complex patients who require extended periods of intensive level medical care and potentially life-sustaining treatment modalities. The children who would benefit most from fracture reduction efforts are those with respiratory disease and prolonged ICU stays.

Unpasteurized Shared Human Milk Use in Pediatric Inpatients: Health and Ethical Implications

Growing evidence supporting the health benefits of human milk, particularly in the preterm population, has led to rising demand for donor human milk in NICUs and pediatric hospitals. There are no previous reports describing the use of unpasteurized shared human milk (USHM) in the hospital setting, but the use of USHM solicited from community donors through social networks appears to be common. Many pediatric hospitals permit inpatients to receive breast milk that has been screened and pasteurized by a human milk banking organization and will provide pasteurized donor human milk (PDHM) only to infants who are preterm or have specific medical conditions. These policies are designed to minimize potential adverse effects from improperly handled or screened donor milk and to target patients who would experience the greatest benefit in health outcomes with donor milk use. We explore the ethical and health implications of 2 cases of medically complex infants who did not meet criteria in our tertiary care hospital for the use of PDHM from a regulated human milk bank and were incidentally found to be using USHM. These cases raise questions about how best to balance the ethical principles of beneficence, nonmaleficence, justice, and patient autonomy in the provision of PDHM, a limited resource. Health care staff should ask about USHM use to provide adequate counseling about the risks and benefits of various feeding options in the context of an infant's medical condition.

Clinical Trial of the Protein Farnesylation Inhibitors Lonafarnib, Pravastatin, and Zoledronic Acid in Children With Hutchinson-Gilford Progeria Syndrome

BACKGROUND

Hutchinson-Gilford progeria syndrome is an extremely rare, fatal, segmental premature aging syndrome caused by a mutation in LMNA yielding the farnesylated aberrant protein progerin. Without progerin-specific treatment, death occurs at an average age of 14.6 years from an accelerated atherosclerosis. A previous single-arm clinical trial demonstrated that the protein farnesyltransferase inhibitor lonafarnib ameliorates some aspects of cardiovascular and bone disease. This present trial sought to further improve disease by additionally inhibiting progerin prenylation.

METHODS

Thirty-seven participants with Hutchinson-Gilford progeria syndrome received pravastatin, zoledronic acid, and lonafarnib. This combination therapy was evaluated, in addition to descriptive comparisons with the prior lonafarnib monotherapy trial.

RESULTS

No participants withdrew because of side effects. Primary outcome success was predefined by improved per-patient rate of weight gain or carotid artery echodensity; 71.0% of participants succeeded (P<0.0001). Key cardiovascular and skeletal secondary variables were predefined. Secondary improvements included increased areal (P=0.001) and volumetric (P<0.001-0.006) bone mineral density and 1.5- to 1.8-fold increases in radial bone structure (P<0.001). Median carotid artery wall echodensity and carotid-femoral pulse wave velocity demonstrated no significant changes. Percentages of participants with carotid (5% to 50%; P=0.001) and femoral (0% to 12%; P=0.13) artery plaques and extraskeletal calcifications (34.4% to 65.6%; P=0.006) increased. Other than increased bone mineral density, no improvement rates exceeded those of the prior lonafarnib monotherapy treatment trial.

CONCLUSIONS

Comparisons with lonafarnib monotherapy treatment reveal additional bone mineral density benefit but likely no added cardiovascular benefit with the addition of pravastatin and zoledronic acid.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00879034 and NCT00916747.

Fractures Among Inpatients in a Pediatric Hospital

OBJECTIVE

Fractures occurring in hospitalized children may be an underrecognized preventable harm with implications for current and future bone health, but few data exist regarding the clinical characteristics of these pediatric patients. We describe the clinical characteristics of patients who sustained fractures during hospitalization over a 4.5-year period at a single tertiary care center.

METHODS

We retrospectively identified subjects who experienced inpatient fractures using a voluntary safety event reporting system and computer-assisted keyword search of the electronic medical record. We used the medical record to collect clinical characteristics, laboratory data, and survival status.

RESULTS

The safety event reporting system and keyword search identified 57% and 43% of subjects, respectively. Fifty-six subjects sustained 128 fractures while hospitalized, most frequently at the femur (33 fractures) and humerus (30 fractures). Twenty-seven subjects sustained multiple fractures. Common clinical characteristics included age ≤1 year (64%); preterm birth (53%); admission to an ICU (90%); immobilization (88%); and weight-for-age z score less than or equal to -2.0 (52%). Sixteen (29%) subjects died, and the mortality rate varied by primary diagnosis.

CONCLUSIONS

Critically ill, immobilized infants under 1 year of age and who were often born preterm sustained the majority of fractures occurring during hospitalization. A voluntary reporting system was insufficient to identify all inpatient fractures. Future studies should explore optimal fracture screening strategies and the relationship among fractures, severity of illness and mortality in hospitalized children.

Cohort profile: project viva

We established Project Viva to examine prenatal diet and other factors in relation to maternal and child health. We recruited pregnant women at their initial prenatal visit in eastern Massachusetts between 1999 and 2002. Exclusion criteria included multiple gestation, inability to answer questions in English, gestational age ≥22 weeks at recruitment and plans to move away before delivery. We completed in-person visits with mothers during pregnancy in the late first (median 9.9 weeks of gestation) and second (median 27.9 weeks) trimesters. We saw mothers and children in the hospital during the delivery admission and during infancy (median age 6.3 months), early childhood (median 3.2 years) and mid-childhood (median 7.7 years). We collected information from mothers via interviews and questionnaires, performed anthropometric and neurodevelopmental assessments and collected biosamples. We have collected additional information from medical records and from mailed questionnaires sent annually to mothers between in-person visits and to children beginning at age 9 years. From 2341 eligible women, there were 2128 live births; 1279 mother-child pairs provided data at the mid-childhood visit. Primary study outcomes include pregnancy outcomes, maternal mental and cardiometabolic health and child neurodevelopment, asthma/atopy and obesity/cardiometabolic health. Investigators interested in learning more about how to obtain Project Viva data can contact Project_Viva@hphc.org.

Fractures in hospitalized children

Hospitalized children have multiple risk factors for fragility fractures, related to disease pathophysiology, treatments, nutritional status and immobilization. Recognition and treatment of these risk factors are important to prevent morbidity associated with fractures and to promote current and future bone health. Many knowledge gaps remain regarding the ideal nutrition, physical activity, and medication regimens needed to optimize bone health and reduce the risk of fractures over the life course. This article reviews the pathogenesis, risk factors, treatment and prevention strategies for fractures in hospitalized infants and children.

Comparison of the microhardness and morphology of five different retrograde filling materials in aqueous and dry conditions

The purpose of the present study was to compare the effect of dry and aqueous conditions on the surface morphology and surface hardness of five materials 24 h after being used as fillings without initial setting time in dry condition. The five materials were ProRoot mineral trioxide aggregate (MTA), super EBA, intermediate restorative materials (IRM), zinc oxide eugenol (ZOE), and amalgam. To evaluate microhardness, the five materials were submitted to the Vickers microhardness (VHN) test. We used a scanning electron microscope (Steroscan 440, Leica Cambridge, England) to observe the microstructural morphology of the five different materials. The VHN of MTA soaked in water showed five times lower than that of MTA soaked in dry condition. On the other hand, super EBA was less influenced by the medium of storage compared with the other materials. Scanning electron microscope (SEM) images showed the similar results with microhardness tests. The surface of MTA soaked in water appeared to be unstable compared with that of dry condition while super EBA showed similarly smooth surface in both conditions (aqueous and dry). In conclusion, the physical property of MTA is reduced after storage in water; however, super EBA is less influenced by aqueous condition.

The effects of humidity and serum on the surface microhardness and morphology of five retrograde filling materials

The purpose of this study was to compare the surface morphology and surface hardness of five materials 24 h after filling, in conditions of 100% humidity, and fetal bovine serum. The five materials were ProRoot Mineral Trioxide Aggregate (MTA), Super-EBA, Intermediate Restorative Materials (IRM), Zinc Oxide Eugenol (ZOE), and Amalgam. The microhardness of these materials was evaluated by Vickers microhardness test, and their morphologies were compared by using scanning electron microscopy (SEM). To evaluate the microhardness, the mixed five materials were measured with Vickers microhardness test. Differences between the experimental groups were analyzed by two-way ANOVA and Duncan's multiple comparison tests. All analyses were performed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL). For the microstructural morphological evaluation, the cross cut and root-end cavity prepared surfaces followed by retrograde filling with five different materials were observed under a Scanning Electron Microscope (Steroscan 440; Leica, Cambridge, England) at ×500. To summarize, Super EBA was less influenced by storage medium than the other materials, especially MTA. However, further long-term studies considering other factors, such as biocompatibility (i.e. cellular toxicity) and retention, are needed to be collaborated with these findings in the clinical context.

Delivery by caesarean section and risk of obesity in preschool age children: a prospective cohort study

OBJECTIVE

To examine whether delivery by caesarean section is a risk factor for childhood obesity.

DESIGN

Prospective prebirth cohort study (Project Viva).

SETTING

Eight outpatient multi-specialty practices based in the Boston, Massachusetts area.

PARTICIPANTS

We recruited women during early pregnancy between 1999 and 2002, and followed their children after birth. We included 1255 children with body composition measured at 3 years of age.

MAIN OUTCOME MEASURES

BMI score, obesity (BMI for age and sex ≥95th percentile), and sum of triceps plus subscapular skinfold thicknesses at 3 years of age.

RESULTS

284 children (22.6%) were delivered by caesarean section. At age 3, 15.7% of children delivered by caesarean section were obese compared with 7.5% of children born vaginally. In multivariable logistic and linear regression models adjusting for maternal prepregnancy BMI, birth weight, and other covariates, birth by caesarean section was associated with a higher odds of obesity at age 3 (OR 2.10, 95% CI 1.36 to 3.23), higher mean BMI z-score (0.20 units, 95% CI 0.07 to 0.33), and higher sum of triceps plus subscapular skinfold thicknesses (0.94 mm, 95% CI 0.36 to 1.51).

CONCLUSIONS

Infants delivered by caesarean section may be at increased risk of childhood obesity. Further studies are needed to confirm our findings and to explore mechanisms underlying this association.

Plasma 25-hydroxyvitamin D during pregnancy and small-for-gestational age in black and white infants

PURPOSE

In a prospective prenatal cohort study, we examined associations of second trimester and cord plasma 25-hydroxyvitamin D (25[OH]D) with small-for-gestational age (SGA) and the extent to which vitamin D might explain black/white differences in SGA.

METHODS

We studied 1067 white and 236 black mother-infant pairs recruited from eight obstetrical offices early in pregnancy in Massachusetts. We analyzed 25(OH)D levels using an immunoassay and performed multivariable logistic models to estimate the odds of SGA by category of 25(OH)D level.

RESULTS

Mean (SD) second trimester 25(OH)D level was 60 nmol/L (SD, 21) and was lower for black (46 nmol/L [SD, 22]) than white (62 nmol/L [SD, 20]) women. Fifty-nine infants were SGA (4.5%), and more black than white infants were SGA (8.5% vs. 3.7%). The odds of SGA were higher with maternal 25(OH)D levels less than 25 versus 25 nmol/L or greater (adjusted odds ratio, 3.17; 95% confidence interval, 1.16-8.63). The increased odds of SGA among black versus white participants decreased from an odds ratio of 2.04(1.04, 4.04) to 1.68(0.82, 3.46) after adjusting for 25(OH)D.

CONCLUSIONS

Second trimester 25(OH)D levels less than 25 nmol/L were associated with higher odds of SGA. Our data raise the possibility that vitamin D status may contribute to racial disparities in SGA.

Timing of solid food introduction and risk of obesity in preschool-aged children

OBJECTIVE

To examine the association between timing of introduction of solid foods during infancy and obesity at 3 years of age.

METHODS

We studied 847 children in Project Viva, a prospective pre-birth cohort study. The primary outcome was obesity at 3 years of age (BMI for age and gender ≥ 95th percentile). The primary exposure was the timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥ 6 months. We ran separate logistic regression models for infants who were breastfed for at least 4 months ("breastfed") and infants who were never breastfed or stopped breastfeeding before the age of four months ("formula-fed"), adjusting for child and maternal characteristics, which included change in weight-for-age z score from 0 to 4 months-a marker of early infant growth.

RESULTS

In the first 4 months of life, 568 infants (67%) were breastfed and 279 (32%) were formula-fed. At age 3 years, 75 children (9%) were obese. Among breastfed infants, the timing of solid food introduction was not associated with odds of obesity (odds ratio: 1.1 [95% confidence interval: 0.3-4.4]). Among formula-fed infants, introduction of solid foods before 4 months was associated with a sixfold increase in odds of obesity at age 3 years; the association was not explained by rapid early growth (odds ratio after adjustment: 6.3 [95% confidence interval: 2.3-6.9]).

CONCLUSIONS

Among formula-fed infants or infants weaned before the age of 4 months, introduction of solid foods before the age of 4 months was associated with increased odds of obesity at age 3 years.

Prevalence of transient hyperphosphatasemia among healthy infants and toddlers

OBJECTIVE

To describe the prevalence and clinical characteristics of transient hyperphosphatasemia (TH) in a cohort of healthy infants and toddlers.

METHODS

We performed a secondary data analysis of healthy infants and toddlers enrolled in a study examining the epidemiology of vitamin D deficiency. From 2005 to 2007, children aged 8 to 24 months were enrolled during well-child visits at an urban primary care pediatric clinic. At enrollment, we collected data regarding sociodemographic and clinical characteristics. We measured serum levels of alkaline phosphatase (AP), 25-hydroxyvitamin D, parathyroid hormone (PTH), calcium, magnesium, and phosphorus. We placed participants into 1 of 3 categories on the basis of serum AP levels: normal (AP: 110-400 U/L), intermediate (AP: >400 to 1000 U/L), and TH (AP: >1000 U/L). We used Fisher's exact test and analysis of variance to evaluate differences in characteristics among the 3 groups.

RESULTS

Nine (2.8%) of 316 children had an AP level of >1000 U/L (mean: 2165 U/L). Sixteen children (5.1%) had an intermediate serum AP level (mean: 544 U/L). Mean weight-for-age, length-for-age, and weight-for-length z scores were similar across all 3 AP groups. Compared with the 291 children without TH, children in the intermediate AP and TH groups had similar mean serum levels of 25-hydroxyvitamin D, PTH, calcium, magnesium, and phosphorus.

CONCLUSIONS

TH seems to be a relatively common condition among healthy infants and toddlers. TH was not associated with anthropometric measures, vitamin D status, PTH, or serum minerals. Recognition of this benign condition is important to avoid unnecessary investigations.

Association between umbilical cord glucocorticoids and blood pressure at age 3 years

BACKGROUND

Animal data show that decreased activity of placental 11-beta-hydroxysteroid dehydrogenase type 2 (11beta-HSD2), which potently inactivates glucocorticoids (e.g. cortisol) to inert forms (cortisone), allows increased access of maternal glucocorticoids to the fetus and 'programs' hypertension. Data in humans are limited. We examined in humans the association between venous umbilical cord blood glucocorticoids, a potential marker for placental 11beta-HSD2 enzyme activity, and blood pressure at age 3 years.

METHODS

Among 286 newborns in Project Viva, a prospective pre-birth cohort study based in eastern Massachusetts, we measured cortisol (F) and cortisone (E) in venous cord blood and used the ratio of F/E as a marker for placental 11beta-HSD2 activity. We measured blood pressure (BP) when the offspring reached age 3 years. Using mixed effects regression models to control for BP measurement conditions, maternal and child characteristics, we examined the association between the F/E ratio and child BP.

RESULTS

At age 3 years, each unit increase in the F/E ratio was associated with a 1.6 mm Hg increase in systolic BP (95% CI 0.0 to 3.1). The F/E ratio was not associated with diastolic blood pressure or birth weight for gestational age z-score.

CONCLUSION

A higher F/E ratio in umbilical venous cord blood, likely reflecting reduced placental 11beta-HSD2 activity, was associated with higher systolic blood pressure at age 3 years. Our data suggest that increased fetal exposure to active maternal glucocorticoids may program later systolic blood pressure.

Vitamin D deficiency in children and adolescents: epidemiology, impact and treatment

Vitamin D deficiency is highly prevalent among children and adolescents worldwide. The high rates of vitamin D deficiency during childhood are of major public health relevance, given the growing evidence that vitamin D deficiency may play a key role in the pathophysiology of many chronic diseases beyond rickets, including autoimmune conditions, cardiovascular diseases, and cancer. Identification, treatment, and prevention of vitamin D deficiency in childhood may therefore have profound health effects throughout the life span. In this review, we discuss the definitions, epidemiology, clinical implications, and treatment of vitamin D deficiency in children and adolescents.

Localization of substance P-induced upregulated interleukin-8 expression in human dental pulp explants

AIM

To localize ex vivo expression of interleukin-8 (IL-8) induced by substance P (SP) in human dental pulps.

METHODOLOGY

Intact caries-free, freshly extracted third molars (n = 20) were collected from patients (15-25 years old). The teeth were split and pulpal tissue was obtained and stored in Dulbecco's modified Eagle medium. Human dental pulp tissue explants were stimulated with SP. Expression of IL-8 in pulp explants was detected and localized by immunohistochemistry.

RESULTS

Moderated IL-8 immunoreactivities were detected mainly in the cell-rich zone in pulp tissues 12 h after tumour necrosis factor alpha (TNF-alpha) stimulation (positive controls), whereas only weak IL-8 expression was observed in tissues stimulated with SP at the same time interval. These data did not differ from those in negative controls. Increased IL-8 expression in pulp explants after 24 h of SP stimulation was noted compared with negative controls and located in fibroblast-like cells, blood vessel-associated cells and extracellular matrix in the central zone and cell-rich zone of pulp explants. Tissues stimulated with TNF-alpha for 24 h (positive controls) revealed weak IL-8 immunoreactivities with altered cell morphology.

CONCLUSIONS

Substance P induces IL-8 expression and was located in fibroblast-like pulp cells, blood vessel-associated cells and extracellular matrix of human dental explants. These data support the hypothesis that neuropeptide (SP) coordinates the modulation of pulpal inflammation via up-regulating chemokine IL-8.

Associations of maternal prenatal smoking with child adiposity and blood pressure

OBJECTIVE

To examine the extent to which maternal prenatal smoking is associated with adiposity, central adiposity, and blood pressure in 3-year-old children.

RESEARCH METHODS AND PROCEDURES

We studied 746 mother-child pairs in Project Viva, a prospective cohort study, and categorized mothers as never, early pregnancy, or former smokers. Main outcome measures were overweight (BMI for age and sex > 85th percentile), BMI z-score, sum of subscapular (SS) and triceps (TR) skinfolds, SS:TR skinfold ratio, and systolic blood pressure (SBP).

RESULTS

One hundred sixty-one (22%) mothers quit smoking before pregnancy, 71 (10%) smoked in early pregnancy, and 514 (69%) never smoked. At age 3 years, 204 (27%) children were overweight. On multivariable analysis, compared with children of never smokers, children of early pregnancy smokers had an elevated risk for overweight [odds ratio (OR), 2.2; 95% confidence interval (CI), 1.2, 3.9] and higher BMI z-score (0.30 units; 95% CI, 0.05, 0.55), SS + TR (2.0 mm; 95% CI, 0.9, 3.0), and SBP (2.4 mm Hg; 95% CI, -0.1, 4.9). Children of former smokers were not more overweight (BMI z-score, 0.02 units; 95% CI, -0.15, 0.19) but had higher SBP (1.5 mm Hg; 95% CI, -0.1, 3.2). We saw no relationship of smoking with central adiposity (SS:TR).

DISCUSSION

Former and early pregnancy smokers had children with somewhat higher SBP, but only early pregnancy smokers had children who were more overweight. Mechanisms linking smoking with child adiposity and blood pressure may differ. A long-term impact of maternal smoking on offspring cardiovascular risk provides further reason to reduce smoking in women.

Maternal protein intake is not associated with infant blood pressure

BACKGROUND

Animal data show that low protein intake in pregnancy programs higher offspring blood pressure, but similar data in humans are limited. We examined the associations of first and second trimester maternal protein intake with offspring blood pressure (BP) at the age of six months.

METHODS

In a prospective US cohort study, called Project Viva, pregnant women completed validated semi-quantitative food-frequency questionnaires (FFQ) to measure gestational protein intake. Among 947 mother-offspring pairs with first trimester dietary data and 910 pairs with second trimester data, we measured systolic blood pressure (SBP) up to five times with an automated device in the offspring at the age of six months. Controlling for blood pressure measurement conditions, maternal and infant characteristics, we examined the effect of energy-adjusted maternal protein intake on infant SBP using multivariable mixed effects models.

RESULTS

Mean daily second trimester maternal protein intake was 17.6% of energy (mean 2111 kcal/day). First trimester nutrient intakes were similar. Mean SBP at age 6 months was 90.0 mm Hg (SD 12.9). Consistent with prior reports, adjusted SBP was 1.94 mm Hg lower [95% confidence interval (CI) -3.45 to -0.42] for each kg increase in birth weight. However, we did not find an association between maternal protein intake and infant SBP. After adjusting for covariates, the effect estimates were 0.14 mm Hg (95% CI 20.12 to 20.40) for a 1% increase in energy from protein during the second trimester, and 20.01 mm Hg (95% CI 20.24 to -0.23) for a 1% increase in energy from protein in the first trimester.

CONCLUSIONS

Variation in maternal total protein intake during pregnancy does not appear to program offspring blood pressure.