Factors related to the readiness of Brazilian chronic pediatric patients to transition to care in adult clinics

Abstract Objective Advances in medicine have increased the life expectancy of pediatric patients with chronic illnesses, and challenges with the guided transition of adolescents and young adults from pediatric clinics to adult clinics have grown. The aim of this study was to better understand readiness and factors related to this transition process in Brazil. Method In this cross-sectional study of 308 patients aged from 16 to 21 years under follow-up in pediatric specialties, the degree of readiness for transition was assessed using the Transition Readiness Assessment Questionnaire (TRAQ) and its domains. Associations with demographic data, clinical data, socio-economic level, medication adherence, family functionality, and parental satisfaction with health care were evaluated. Results The median TRAQ score was 3.7 (3.2 - 4.2). Better readiness was associated with female patients, socio-economic class A-B, current active employment, higher level of education, not failing any school year, attending medical appointments alone, functional family, and a good knowledge of disease and medications. A low correlation was observed between TRAQ and age. TRAQ presented good internal consistency (alpha-Cronbach 0.86). In the multiple linear regression, TRAQ score showed a significant association with female gender, advanced age, socio-economic class A-B, better knowledge of disease and medications, and independence to attend appointments alone. Conclusion TRAQ instrument can guide healthcare professionals to identify specific areas of approach, in order to support adolescents with chronic disease to set goals for their own personal development and improve their readiness to enter into the adult healthcare system. In this study, some factors were related to better TRAQ scores.

BRAZILIAN CONSENSUS ON THE MANAGEMENT OF INFLAMMATORY BOWEL DISEASES IN PEDIATRIC PATIENTS: A CONSENSUS OF THE BRAZILIAN ORGANIZATION FOR CROHN'S DISEASE AND COLITIS (GEDIIB).

BACKGROUND: Approximately 25% of patients with inflammatory bowel disease (IBD) develop the disease during childhood or adolescence and treatment aims to control active symptoms and prevent long-term complications. The management of Crohn's disease (CD) and ulcerative colitis (UC) can be especially challenging in children and adolescents, related to particularities that may affect growth, development, and puberty. OBJECTIVE: This consensus aims to provide guidance on the most effective medical and surgical management of pediatric patients with CD or UC. METHODS: Experts in Pediatric IBD representing Brazilian gastroenterologists (Brazilian Organization for Crohn's Disease and Colitis [GEDIIB]) developed this consensus. A rapid review was performed to support the recommendations/statements. Medical and surgical recommendations were structured and mapped according to the disease type, disease activity, and indications and contraindications for medical and surgical treatment. After structuring the statements, the modified Delphi Panel methodology was used to conduct the voting. The process took place in three rounds: two using a personalized and anonymous online voting platform and one face-to-face. Whenever participants did not agree with a specific recommendation, an option to explain why was offered to enable free-text responses and provide the opportunity for the experts to elaborate or explain disagreement. The consensus of recommendations in each round was accepted when reached ≥80% agreement. RESULTS AND CONCLUSION: The recommendations are presented according to the stage of treatment and severity of the disease in three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/ patient monitoring after initial treatment, follow-up/ patient monitoring after initial treatment. Surgical recommendations were grouped according to disease type and recommended surgery. The target audience for this consensus was general practitioners, gastroenterologists, and surgeons interested in the treatment and management of pediatric CD and UC. Additionally, the consensus aimed to support the decision-making of health insurance companies, regulatory agencies, and health institutional leaders and/or administrators.

Consenso brasileiro de manejo das doenças inflamatórias intestinais em pacientes pediátricos: Consenso da Organização Brasileira para doença de Crohn e colite (GEDIIB) / Brazilian consensus on the management of inflammatory bowel diseases in pediatric patients: a consensus of the brazilian organization for crohn's disease and colitis (gediib)

ABSTRACT Background: Approximately 25% of patients with inflammatory bowel disease (IBD) develop the disease during childhood or adolescence and treatment aims to control active symptoms and prevent long-term complications. The management of Crohn's disease (CD) and ulcerative colitis (UC) can be especially challenging in children and adolescents, related to particularities that may affect growth, development, and puberty. Objective: This consensus aims to provide guidance on the most effective medical and surgical management of pediatric patients with CD or UC. Methods: Experts in Pediatric IBD representing Brazilian gastroenterologists (Brazilian Organization for Crohn's Disease and Colitis [GEDIIB]) developed this consensus. A rapid review was performed to support the recommendations/statements. Medical and surgical recommendations were structured and mapped according to the disease type, disease activity, and indications and contraindications for medical and surgical treatment. After structuring the statements, the modified Delphi Panel methodology was used to conduct the voting. The process took place in three rounds: two using a personalized and anonymous online voting platform and one face-to-face. Whenever participants did not agree with a specific recommendation, an option to explain why was offered to enable free-text responses and provide the opportunity for the experts to elaborate or explain disagreement. The consensus of recommendations in each round was accepted when reached ≥80% agreement. Results and conclusion: The recommendations are presented according to the stage of treatment and severity of the disease in three domains: management and treatment (drug and surgical interventions), criteria for evaluating the effectiveness of medical treatment, and follow-up/ patient monitoring after initial treatment, follow-up/ patient monitoring after initial treatment. Surgical recommendations were grouped according to disease type and recommended surgery. The target audience for this consensus was general practitioners, gastroenterologists, and surgeons interested in the treatment and management of pediatric CD and UC. Additionally, the consensus aimed to support the decision-making of health insurance companies, regulatory agencies, and health institutional leaders and/or administrators.

RESUMO Contexto: Aproximadamente 25% dos pacientes desenvolvem doença inflamatória intestinal (DII) durante a infância ou adolescência, e o tratamento visa controlar os sintomas ativos e prevenir complicações a longo prazo. O tratamento da doença de Crohn (DC) e retocolite ulcerativa (RCU) pode ser especialmente desafiador em crianças e adolescentes, relacionado a particularidades que podem afetar o crescimento, o desenvolvimento e a puberdade. Objetivo: Este consenso visa fornecer orientações sobre o tratamento clínico e cirúrgico mais eficaz de pacientes pediátricos com DC ou RCU. Métodos: Gastroenterologistas brasileiros especialistas em DII Pediátrico membro da Organização Brasileira para Doença de Crohn e Colite (GEDIIB) desenvolveram este consenso. Uma revisão rápida foi realizada para apoiar as recomendações/declarações. As recomendações médicas e cirúrgicas foram estruturadas e mapeadas de acordo com o tipo de doença, atividade da doença e indicações e contraindicações para tratamento médico e cirúrgico. Após a estruturação das declarações, foi utilizada a metodologia modificada do Painel Delphi para conduzir a votação. O processo ocorreu em três rodadas: duas por meio de uma plataforma de votação online personalizada e anônima e uma presencial. Sempre que os participantes não concordavam com a recomendação específica, uma opção para explicar o motivo era oferecida para permitir respostas em texto livre e dar a oportunidade para os especialistas elaborarem ou explicarem a discordância. O consenso das recomendações em cada rodada foi aceito quando houve concordância ≥80%. Resultados e conclusão: As recomendações são apresentadas de acordo com o estágio de tratamento e gravidade da doença em três domínios: manejo e tratamento (intervenções medicamentosas e cirúrgicas), critérios para avaliar a eficácia do tratamento médico, acompanhamento/monitoramento do paciente após tratamento. As recomendações cirúrgicas foram agrupadas de acordo com o tipo de doença e cirurgia recomendada. O público-alvo deste consenso foram clínicos gerais, gastroenterologistas e cirurgiões interessados no tratamento e manejo da RCU e DC pediátrica. Além disso, o consenso visava apoiar a tomada de decisão das operadoras de planos de saúde, agências reguladoras e líderes e/ou administradores de instituições de saúde.

Celiac Disease and Sensitization to Wheat, Rye, and Barley: Should We Be Concerned?

BACKGROUND: Concomitance of celiac disease (CD) and IgE-mediated wheat allergy is described in some case reports. The objective was to evaluate the frequency of sensitization to wheat, rye, barley, and malt in children and adolescents with CD. METHODS: Measurement of serum levels of specific IgE to wheat, rye, barley, and malt (ImmunoCAP; sensitization IgE ≥0.35 kUA/L) in CD patients followed in specialized clinics to verify allergy history, general characteristics, small bowel biopsy characteristics, compliance with gluten-free diet (GFD), and occurrence of symptoms in case of noncompliance. RESULTS: We evaluated 74 patients; the median of age and age at diagnosis of CD were 8.6 years (5.0-12.8) and 3.6 years (1.6-7.0), respectively. Median time of GFD was 3.5 years (1.4-5.8). History of asthma occurred in 17.3% of subjects, allergic rhinitis in 13.5%, and AD in 5.4%. Frequency of sensitization was 4% for wheat, 10.8% for rye, 5.4% for barley, and 2.7% for malt. There was no association between wheat sensitization and age at diagnosis, time of GFD, small bowel biopsy characteristics, allergy history, and gluten consumption. There was no relationship between sensitization to wheat and occurrence of immediate symptoms when not complying with GFD. CONCLUSION: In conclusion, the frequency of sensitization to wheat, rye, barley, and malt in CD patients was 4, 10.8, 5.4, and 2.7%, respectively. Therefore, to ensure that cutaneous and respiratory contact with wheat is safe, we advise patients with CD to investigate their sensitivity to wheat, rye, and barley because not all patients with CD are allergic to these cereals.

Prevalence of genetic susceptibility for celiac disease in blood donors in são paulo, brazil / Prevalência da predisposição genética para doença celíaca nos doadores de sangue em São Paulo, Brasil

ABSTRACT Background Celiac disease is a permanent intolerance induced by gluten, which is expressed by T-cell mediated enteropathy, and has a high prevalence in the general population. There is evidence of a strong genetic predisposition to celiac disease. Objective To determine the prevalence of genetic markers HLA-DQ2 and HLA-DQ8 in blood donors from São Paulo and measure human recombinant tissue transglutaminase antibody IgA class in HLA-DQ2 and HLA-DQ8 positive donors. Methods A total of 404 blood donors from São Paulo city and Jundiaí were included in the study and signed the informed consent form. Information regarding diarrhea, constipation and abdominal pain in the last 3 months was collected. Determination of HLADQ2 and HLADQ8 alleles was performed in all participants and human recombinant tissue transglutaminase antibody class IgA was measured only in blood donors who presentedDQ2 and/or DQ8. Results HLADQ2 and/or HLADQ8 were positive in 49% (198/404) of subjects. Positive samples were associated with alleles DR3, DR4, DR7, DR11 and DR12. The most frequent genotype was DR4-DQ8, which was present in 13.6% of samples, followed by genotypes DR3-DQ2 and DR7-DQ2 with DQB1*02 in heterozygous, which were present in 10.4% and 8.7%, respectively. Eleven out of 198 positive donors (5%) were positive to human tissue transglutaminase test. Conclusion We observed a high prevalence of genetic markers for celiac disease, HLA-DQ2 and HLA-DQ8, in blood donors from São Paulo, similar to prevalence described in Europe. These findings show that the prevalence of celiac disease should not be rare in our country, but underdiagnosed.

RESUMO Contexto A doença celíaca é uma enteropatia imuno mediada causada pela intolerância permanente induzida pelo glúten, que se expressa por enteropatia mediada por linfócitos T, e possui uma alta prevalência na população geral. Há evidências de forte predisposição genética para doença celíaca. Objetivo Determinar a prevalência dos marcadores genéticos HLA-DQ2 e HLA-DQ8 em doadores de sangue da cidade de São Paulo e realizar rastreamento sorológico para doença celíaca com anticorpo antitransglutaminase tissular recombinante humana de classe IgA naqueles doadores de sangue com genotipagem HLA-DQ2 e HLA-DQ8 positivos. Métodos Estudo transversal prospectivo em que participaram 404 doadores de sangue, residentes na cidade de São Paulo e Jundiaí. A determinação dos alelos HLADQ2 e HLADQ8 foi realizada por PCR multiplex e alelo específico em todos os participantes do estudo e o anticorpo antitransglutaminase tissular recombinante humana de classe IgA e dosagem sérica de IgA foi realizada apenas nos doadores de sangue que possuíam DQ2 e/ou DQ8 positivo. Resultados O HLADQ2 e/ou DQ8 foi positivo em 49% (198/404) dos indivíduos, destes, 11 (5%) apresentaram anticorpo antitransglutaminase tissular humana positivo. Conclusão Podemos concluir que a prevalência dos marcadores genéticos para doença celíaca, HLA-DQ2 e DQ8 em São Paulo, mostrou-se elevada e similar à encontrada na Europa, assim como foi elevada a soroprevalênca para doença celíaca nos doadores de sangue com presença HLA-DQ2 e DQ8. Estes achados permitem afirmar que a prevalência da doença celíaca não deve ser rara em São Paulo, mas sim subdiagnosticada.

Gastroesophageal reflux disease: exaggerations, evidence and clinical practice / Doença do refluxo gastroesofágico: exageros, evidências e a prática clínica

OBJECTIVE: there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children. DATA SOURCE: a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013. DATA SYNTHESIS: abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects. CONCLUSIONS: there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected. .

OBJETIVO: há muitas dúvidas e poucas evidências para o diagnóstico e tratamento da doença do refluxo gastroesofágico (DRGE) na criança. A relação entre a DRGE e a alergia às proteínas do leite de vaca (APLV), o uso exagerado da ultrassonografia abdominal para diagnóstico da DRGE e o excesso de medicamentos, especialmente dos inibidores de bomba de prótons (IBP), são alguns aspectos que necessitam esclarecimentos. Esta revisão tem como objetivo estabelecer as evidências científicas atuais para o diagnóstico e tratamento da DRGE em pediatria. FONTES DOS DADOS: foram pesquisadas nas bases de dados eletrônicos do Medline, Pubmed, Lilacs, Cochrane Library e Scielo, nas diferentes faixas etárias da pediatria, até maio de 2013, as seguintes palavras-chave: refluxo gastroesofágico, doença do refluxo gastroesofágico, inibidores da bomba de prótons e procinéticos. SíNTESE DOS DADOS: a ultrassonografia de abdome não deve ser recomendada para pesquisa de refluxo gastroesofágico (RGE). O tratamento simultâneo da DRGE e da APLV induz, muitas vezes, ao uso desnecessário de medicação ou dieta de exclusão. Não existem evidências suficientes para prescrição de procinéticos em todos os portadores de RGE/DRGE. Poucas evidências fornecem suporte para a supressão ácida, no primeiro ano de vida, para tratamento de sintomas inespecíficos, sugestivos de DRGE. O tratamento conservador traz muitos benefícios e poucos gastos, sem efeitos colaterais. CONCLUSÕES: existem poucos estudos controlados e randomizados que avaliam a DRGE na criança e nenhum exame pode considerado padrão-ouro para o seu diagnóstico. Por esses motivos, ocorrem exageros no diagnóstico e no tratamento dessa doença, e que necessitam ...

Gastroesophageal reflux disease: exaggerations, evidence and clinical practice.

OBJECTIVE: there are many questions and little evidence regarding the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children. The association between GERD and cow's milk protein allergy (CMPA), overuse of abdominal ultrasonography for the diagnosis of GERD, and excessive pharmacological treatment, especially proton-pump inhibitors (PPIs) are some aspects that need clarification. This review aimed to establish the current scientific evidence for the diagnosis and treatment of GERD in children. DATA SOURCE: a search was conducted in the MEDLINE, PubMed, LILACS, SciELO, and Cochrane Library electronic databases, using the following keywords: gastroesophageal reflux; gastroesophageal reflux disease; proton-pump inhibitors; and prokinetics; in different age groups of the pediatric age range; up to May of 2013. DATA SYNTHESIS: abdominal ultrasonography should not be recommended to investigate gastroesophageal reflux (GER). Simultaneous treatment of GERD and CMPA often results in unnecessary use of medication or elimination diet. There is insufficient evidence for the prescription of prokinetics to all patients with GER/GERD. There is little evidence to support acid suppression in the first year of life, to treat nonspecific symptoms suggestive of GERD. Conservative treatment has many benefits and with low cost and no side-effects. CONCLUSIONS: there have been few randomized controlled trials that assessed the management of GERD in children and no examination can be considered the gold standard for GERD diagnosis. For these reasons, there are exaggerations in the diagnosis and treatment of this disease, which need to be corrected.

Avaliação nutricional e consumo alimentar de pacientes com doença celíaca com e sem transgressão alimentar / Nutritional evaluation and food intake of celiac disease patients compliant or not with a gluten-free diet

OBJETIVO: Avaliar o estado nutricional e a ingestão de energia e de macronutrientes de pacientes com diagnóstico de doença celíaca que transgrediam ou não a dieta isenta de glúten. MÉTODOS: Foram estudados 63 pacientes com doença celíaca: 34 crianças e 29 adolescentes. Transgressão à dieta isenta de glúten foi caracterizada por meio da dosagem sérica do anticorpo antitransglutaminase tissular recombiante humana. O estado nutricional foi avaliado com base nos escores-Z de peso/idade, estatura/idade e no índice de massa corporal. A ingestão alimentar foi avaliada por meio do inquérito alimentar de 24 horas. RESULTADOS: A transgressão à dieta sem glúten foi constatada em 41,2% das crianças e em 34,5% dos adolescentes. Nas crianças com transgressão alimentar, a média do escore-Z de estatura/idade foi inferior à das crianças do grupo que não transgredia (p=0,024). Todavia, o grupo com transgressão apresentou maior escore-Z do índice de massa corporal em relação aos que não transgrediam (p=0,021). Os adolescentes que não transgrediam apresentaram maior índice de massa corporal quando comparados aos que transgrediam a dieta (p=0,037). Em relação à ingestão alimentar, não se observou diferença estatística entre os grupos. Todavia, cerca de 70,0% das crianças e adolescentes apresentaram consumo de energia acima de 120,0% da recomendação. CONCLUSÃO: As crianças que transgrediam a dieta apresentaram menor escore-Z de estatura/idade e maior escore-Z para índice de massa corporal do que crianças que seguem sem transgressões alimentares. Os adolescentes que não transgrediam a dieta apresentaram maior média de índice de massa corporal quando comparados aos que transgrediam a dieta. Consumo energético elevado foi observado tanto nas crianças quanto nos adolescentes.

OBJECTIVE: This study evaluated the nutritional status and intakes of energy and macronutrients of celiac disease patients compliant or not with a gluten-free diet. METHODS: We studied 63 patients with celiac disease, 34 children and 29 adolescents. Noncompliance with a gluten-free diet was characterized by detection of antibodies to tissue transglutaminase in serum by recombinant human tissue transglutaminase antigen. Nutritional status was classified according to the weight-for-age, height-for-age, and body mass index Z-scores. Dietary intake was assessed by a 24-hour recall. RESULTS: The percentages of children and adolescents noncompliant with a gluten-free diet were 41.2% and 34.5%, respectively. Noncompliant children had a lower mean height-for-age Z-score than compliant children (p=0.024). However, noncompliant children had higher mean body mass index Z-score than compliant children (p=0.021). On the other hand, compliant adolescents had higher BMI than noncompliant adolescents (p=0.037). The food intake between the groups did not differ, but the energy intakes of 70.0% of the children and adolescents exceeded 120.0% of their requirements. CONCLUSION: Children who do not comply with a gluten-free diet have lower height-for-age Z-scores and higher body mass index Z-scores than children who comply. Compliant adolescents have a higher mean body mass index than noncompliant adolescents. High energy intake was observed in both children and adolescents.

Experiências internacionais da aplicação de sistemas de apoio à decisão clínica em gastroenterologia / International outcomes from attempts to implement a clinical decision support system in gastroenterology / Experiencias internacionales de la aplicación de sistemas de apoyo a la decisión clínica en gastroenterología

Objetivo: Descrever as experiências recentes com a aplicação de sistemas de apoio à decisão clínica em gastroenterologia, de forma a estabelecer o nível de desenvolvimento, testes e vantagens conferidas à prática médica com a introdução desses softwares. Métodos: Foi realizada busca nas bases de dados PubMed, LILACS e ISI Web of Knowledge, utilizando termos relacionados à sistemas de apoio à decisão e à gastroenterogia, incluindo artigos originais publicados no período entre 2005 e 2010. Foram recuperadas 104 publicações, na busca inicial e, após a aplicação dos critérios de inclusão e exclusão, foram eleitos nove estudos para leitura do texto completo. Resultados: Os sistemas de apoio à decisão clínica apresentam grande multiplicidade de problemas clínicos e investigação de doenças. Em 89% dos casos, são descritos modelos experimentais para o desenvolvimento de sistemas de apoio à decisão clínica. A descrição dos resultados obtidos por técnicas de inteligência artificial em 78% das publicações. Em dois dos estudos foram realizadas comparações com o médico e em apenas uma publicação um estudo controlado foi descrito, mostrando evidências de melhorias na prática médica. Conclusão: Os estudos mostram potenciais benefícios dos sistemas de apoio à decisão clínica à prática médica, porém, estudos controlados em ambiente real devem ser realizados para comprovar esta perspectiva.

Objective: This study aimed at describing the recent experience acquired with the implementation and use of clinical decision support system in gastroenterology in order to determine the level of development, tests used and advantages that such a system can offer to the medical practice. Methods: A search in the PubMed, LILACS and ISI Web of Knowledge databases for studies in decision-making support systems in gastroenterology including original papers produced from 2005 to 2010 was performed. A total of 104 scientific papers were retrieved initially. These were analyzed using inclusion and exclusion criteria, thus yielding nine studies for further analysis. Results: The clinical decision support system analyzed in the present study showed a great variety of clinical problems regarding the investigation of a disease and the determination of a diagnosis. Eighty-nine per cent of the studies showed experimental models for clinical decision support system development. Seventy-eight per cent of the studies described the outcomes obtained with artificial intelligence technique. Two studies compared the clinical decision support system performance with that of a doctor, and only one research work described a controlled study evidencing improvements in the medical practice. Conclusion: The studies analyzed showed evidence of potential benefits that clinical decision support system can bring to the clinical practice. However, further controlled studies performed in medical day-to-day conditions and environment should be performed in order to provide more clear evidence of the usefulness of clinical decision support system in the medical practice.

Objetivo: Describir la experiencia reciente con la aplicación de los sistemas de apoyo a la toma de decisiones clínicas en gastroenterología, y establecer el nivel de desarrollo, pruebas y beneficios concedidos a la práctica médica con la introducción de dicho software. Métodos: Se realizó una búsqueda en bases de datos PubMed, LILACS e ISI Web of Knowledge el uso de términos relacionados con los sistemas de apoyo a toma de decisiones y gastroenterología, incluyendo artículos originales publicados entre 2005 y 2010. Se recuperaron 104 publicaciones en la búsqueda inicial y después de la aplicación de criterios de inclusión y exclusión, nueve estudios fueron elegidos para leer el texto completo. Resultados: Hay una gran variedad de sistemas de apoyo a la toma de decisiones clínicas sobre los más diversos problemas clínicos y de investigación de las enfermedades. En el 89% de los casos se describen los modelos experimentales para el desarrollo de los sistemas de apoyo a la toma de decisiones clínicas. En el 78% de las publicaciones hay descripción de los resultados obtenidos por técnicas de inteligencia artificial. En dos estudios, las se hicieron comparaciones del sistema con el médico y solamente una única publicación, un estudio controlado describe la evidencia de las mejoras en la práctica médica. Conclusión: Estos estudios muestran los beneficios potenciales de los sistemas de apoyo a la toma de decisión clínica a la práctica médica, sin embargo, estudios controlados en un entorno real debe llevarse a cabo para confirmar este punto de vista.

Effectiveness of infliximab in Brazilian children and adolescents with Crohn disease and ulcerative colitis according to clinical manifestations, activity indices of inflammatory bowel disease, and corticosteroid use.

OBJECTIVE: The objective of the study was to evaluate the response to infliximab in children and adolescents with Crohn disease and ulcerative colitis up to week 22. PATIENTS AND METHODS: A total of 21 patients with inflammatory bowel disease (IBD) received 5 mg/kg of infliximab at weeks 0, 2, 6, and 14. The following parameters were evaluated: clinical manifestations; activity indices of IBD, including the Pediatric Crohn Disease Activity Index for Crohn disease, the Lightiger Colitis Activity Index and the Pediatric Ulcerative Colitis Activity Index for ulcerative colitis, and the modified Harvey-Bradshaw Index for Crohn disease and ulcerative colitis; and the reduction or suspension of corticosteroid use. RESULTS: All of the patients had improvements in clinical manifestations after the first infusion of infliximab. At week 22, 18 of 21 (85.7%) patients were categorized as being in remission, 3 of 21 (14.3%) patients were categorized as having clinical improvement, and none of the patients were categorized as having no response. There was a statistically significant difference in all of the IBD activity indices at weeks 2, 6, 14, and 22 compared with time 0. The corticosteroid use was completely discontinued in 6 of 15 patients by week 22. CONCLUSIONS: Infliximab is effective in the treatment of Crohn disease and ulcerative colitis in children and adolescents up to week 22.

Proinflammatory and anti-inflammatory cytokines present in the acute phase of experimental colitis treated with Saccharomyces boulardii.

PURPOSE: To study the proinflammatory and anti-inflammatory cytokines present in the acute phase of trinitrobenzene sulfonic acid (TNBS)-induced experimental colitis treated with Saccharomyces boulardii. METHODS: Thirty male Wistar rats were divided into three groups: (1) treated group--received Saccharomyces boulardii for 14 days; (2) non-treated group--received sodium chloride solution for 14 days; (3) control group. Colitis was induced on the seventh day of the study in the treated and the non-treated groups using TNBS (10 mg) dissolved in 50% ethanol. Quantification of cytokines, including interleukin (IL)-1beta (IL-1beta), IL-6, transforming growth factor-beta (TGF-beta), IL-10 and tumor necrosis factor-alpha (TNF-alpha), in the serum and colonic tissue collected on day 14 were carried out using an enzyme-linked immunosorbent assay (ELISA). RESULTS: The mean concentrations of TGF-beta in both the serum and the colonic tissue of the treated group were statistically higher than that of the control group. The mean concentration of TGF-beta in the colonic tissue of the non-treated group was also statistically higher than the control group. CONCLUSION: The group treated with Saccharomyces boulardii showed increased amounts of TGF-beta, an anti-inflammatory cytokine, during the acute phase of colitis. There were no differences in the amount of TNF-alpha, IL-1beta, IL-6, and IL-10 between the treated and the non-treated or the control groups during the acute phase of experimental colitis induced by TNBS.

CARD15 and IL23R influences Crohn's disease susceptibility but not disease phenotype in a Brazilian population.

BACKGROUND: Although many genetic variants are identified in association with Crohn's disease (CD), CARD15, IL23R, and ATG16L1 association with CD have been firmly confirmed in Caucasians of European ancestry. The prevalence of CD is rapidly rising in Brazil, where European ancestry is firmly admixed with natives and Africans, resulting in a heterogeneous population. We investigated the contribution of CARD15, IL23R, and ATG16L1 with CD risk in a heterogeneous Brazilian population. METHODS: Genotyping for CARD15 (R702W, G908R, 3020insC), IL23R (rs1004819, rs7517847, rs11209026, rs10889677, rs1495965), and ATG16L1 (rs2241880) was performed in 187 children and adults with CD and 255 healthy ethnically matched controls. Clinical records were systematically reviewed and detailed phenotypic information was obtained. RESULTS: At least 1 CARD15 risk allele was present in 30% of the CD patients compared with 10% of controls. Variants of CARD15 (3020insC and R702W) and IL23R (rs1004819, rs11209026, and rs1088967) were associated with CD. However, no genotype-phenotype correlations were found among the Brazilian CD population with CARD15 or IL23R variants. No significant association was achieved with ATG16L1. CONCLUSIONS: CARD15 and IL23R confer susceptibility to CD in the Brazilian population. However, the presence of these variants did not influence disease phenotype. Further research should be focused on larger sample sizes with population admixture analysis to better understand the risks and genotype-phenotype correlation in populations like Brazil where the prevalence of CD is rapidly rising.

Desempenho de pais de crianças em dieta de exclusão do leite de vaca na identificação de alimentos industrializados com e sem leite vaca / The performance of parents of children receiving cow's milk free diets at indentification of commercial food products with and without cows's milk

OBJETIVO: Investigar o desempenho de pais de crianças em dieta isenta da proteína do leite de vaca no reconhecimento de expressões e alimentos que contenham ou não proteínas do leite de vaca. MÉTODOS: Foram entrevistados 24 pais de crianças em dieta de exclusão do leite de vaca e derivados e 23 sem necessidade de nenhum tipo de dieta de exclusão. Foi questionado se reconheciam 12 expressões relacionadas ao leite de vaca. A seguir, foi solicitado que classificassem 10 produtos industrializados quanto ao conteúdo ou não de proteínas do leite de vaca. RESULTADOS:Termos iniciados com a palavra leite foram os mais reconhecidos pelos dois grupos. Os responsáveis por crianças em dieta de exclusão reconheceram mais freqüentemente as palavras proteína do leite de vaca, traços do leite e formulação ou preparação láctea (p < 0,05). Caseína, caseinato, lactoalbumina e lactoglobulina foram reconhecidas por menos de 25,0 por cento dos entrevistados. O número de identificação correta dos 10 produtos industrializados foi maior para os produtos com leite de vaca nos dois grupos. A mediana de acertos dos produtos com leite de vaca (n = 5) pelos pais em dieta de exclusão (4,0) foi maior que a do grupo controle (3,0; p = 0,005). Leitura de pelo menos um rótulo associou-se com maior chance de identificação correta de mais de cinco dos 10 produtos (razão de chance = 8,0). CONCLUSÃO:Apesar de orientados, os pais de crianças em dieta de exclusão não estão plenamente preparados para sua correta realização, indicando a necessidade de aprimoramento das orientações para essa dieta de exclusão.

OBJECTIVE: To investigate how well the parents of children on cow's milk free diets perform at recognizing whether or not expressions describe and foods contain cow's milk proteins. METHODS: Interviews were conducted with 24 parents of children on cow's milk and by-products exclusion diets and 23 parents of children with no need for any type of exclusion diet. They were asked if they recognized 12 expressions relating to cow's milk. They were then asked to classify 10 commercial food products in terms of whether or not they contained cow's milk proteins. RESULTS: Terms that included the word milk were more often recognized by both groups of parents. The parents of children on exclusion diets recognized the terms cow's milk protein, traces of milk and milk formulation or preparation most frequently (p < 0.05). Less than 25.0 percent of those interviewed recognized casein, caseinate, lactalbumin and lactoglobulin. Both groups correctly identified more of the commercial products containing cow's milk than those free from milk. The median number of products containing cow's milk (total = 5) correctly identified by the parents of children on exclusion diets (4.0) was greater than for the control group (3.0; p = 0.005). Reading at least one label was associated with a greater chance of correctly identifying more than five of the 10 products (odds ratio = 8.0). CONCLUSIONS: Despite having received guidance, the parents of children on exclusion diets were not fully prepared to manage these diets, indicating a need for improvements to the instruction provided when indicating exclusion diets.

A manometria anorretal (método do balão) no diagnóstico diferencial da doença de Hirschsprung / Effectiveness of anorectal manometry using the balloon method to identify the inhibitory recto-anal reflex for diagnosis of Hirschsprung's disease

OBJETIVO: Apresentar os resultados dos exames de manometria anorretal realizados com um aparelho brasileiro computadorizado, que utiliza o método do balão para a caracterização do reflexo inibitório reto anal na investigação diagnóstica da doença de Hirschsprung, em crianças com constipação crônica. MÉTODOS: Foram analisados os resultados de 372 manometrias anorretais realizadas consecutivamente em pacientes com constipação crônica. O equipamento utilizado (Proctosystem-Viotti) possui dois canais utilizados para registar as pressões do esfíncter anal e da ampola retal por meio de balões conectados por sonda aos transdutores de pressão. Os valores pressóricos são avaliados em computador utilizando software específico. A ausência do reflexo inibitório reto-anal foi considerada como sugestiva de doença de Hirschsprung, sendo o diagnóstico confirmado pelos métodos tradicionais. RESULTADOS: Em 14 (3,8 por cento) dos 372 exames não foi caracterizado o reflexo inibitório reto-anal. Em nove destes 14 pacientes o diagnóstico de doença de Hirschsprung foi confirmado pela caracterização de ausência de células ganglionares na avaliação anatomopatológica. Nos outros cinco pacientes não foi realizada a biópsia retal em função da evolução clínica satisfatória com o tratamento clínico da constipação, sendo que em quatro a presença de reflexo inibitório reto-anal foi caracterizada por exame de manometria anorretal realizado posteriormente. CONCLUSÃO: O equipamento utilizado foi apropriado para a realização da manometria anorretal permitindo descartar o diagnóstico de doença de Hirschsprung em 86,5 por cento dos pacientes. Foi identificado um pequeno grupo de pacientes nos quais, em mais da metade, o diagnóstico definitivo de doença de Hirschsprung foi estabelecido.

[Effectiveness of anorectal manometry using the balloon method to identify the inhibitory recto-anal reflex for diagnosis of Hirschsprung's disease]. / A manometria anorretal (método do balão) no diagnóstico diferencial da doença de Hirschsprung.

OBJECTIVE: To evaluate results of anorectal manometry performed with equipment made in Brazil for the screening of Hirschsprung's disease in children with chronic constipation. METHODS: Results of 372 anorectal manometries performed consecutively in children with chronic constipation were evaluated. The equipment (Proctosystem Viotti) has two channels for pressure registration by the balloon method and is connected to a computer using specific software. Absence of the inhibitory recto-anal reflex was considered suggestive of Hirschsprung's disease and diagnosis was confirmed by traditional diagnostic methods. RESULTS: Absence of the inhibitory recto-anal reflex was found in 14 (3.8%) of the 372 anorectal manometry examinations. Diagnosis of Hirschsprung disease was confirmed in 9 out of 14 patients by characterization of aganglionosis upon rectal biopsy. In the other 5 patients, rectal biopsy was not performed in view of a satisfactory evolution with the clinical treatment for constipation. In 4 out of the 5 patients the inhibitory recto-anal reflex was demonstrated with a second anorectal manometry examination. CONCLUSIONS: The equipment used for anorectal manometry presented a satisfactory performance. Diagnosis of Hirschsprung disease was discarded in 86.5% of the patients with chronic constipation because the inhibitory recto-anal reflex was detected. Manometric evaluation also made possible the identification of a small group of patients in which more than half had Hirschsprung's disease.

Doença celíaca em tratamento: avaliaçäo da densidade mineral óssea / Celiac disease under treatment: evaluation of bone mineral density

OBJETIVO: comparar a densidade mineral óssea de crianças e adolescentes com doença celíaca em tratamento com controles sadios, e avaliar exames laboratoriais relacionados com o metabolismo do cálcio. MÉTODOS: foram estudados 30 pacientes com doença celíaca em dieta isenta de glúten, 17 crianças e 13 adolescentes, e 23 indivíduos saudáveis. Todos os pacientes e controles realizaram a densidade mineral óssea (DEXA, Lunar). Os pacientes realizaram dosagem sérica de cálcio total, cálcio ionizado, fósforo, magnésio, fosfatase alcalina e paratormônio. RESULTADOS: a média de peso, estatura e densidade mineral óssea dos adolescentes com doença celíaca foi menor do que dos controles (p<0,05), enquanto que näo se observaram diferenças estatisticamente significantes destes parâmetros, comparando as crianças com doença celíaca com os controles. A proporçäo de adolescentes que iniciou dieta isenta de glúten após os dois anos de idade foi maior do que a de crianças (p<0,05). Os pacientes apresentaram níveis séricos normais de cálcio ionizado, cálcio total e paratormônio. CONCLUSÕES: a densidade mineral óssea dos adolescentes com doença celíaca em dieta isenta de glúten foi menor do que dos controles. Por outro lado, näo houve diferença entre a densidade mineral óssea de crianças com doença celíaca e controles.

Pesquisa de gliadina em medicamento: informação relevante para a orientação de pacientes com doença celíaca / Assessment of gliadin in pharmaceutical products: important information to the orientation of celiac disease patients

BACKGROUND: Some drugs might contain gliadin which can be dangerous for celiac disease patients. OBJECTIVE: Detect gliadin in pharmaceutical products commonly used in Brazil. METHODS: We analyzed 78 pharmaceutical products selected aleatory from a list of 180 products most frequently sold at Brazilian community pharmacies. The analyzed samples were analgesics (n = 9), anthelmintics (n = 3), antacids (n = 8), antibiotics (n = 13), anticholesteremics (n = 1), anticonvulsants (n = 2), antidepressants (n = 2), antiemetics (n = 3), antihypertensives (n = 3), antihistaminics (n = 3), anti-inflammatories (n = 7), antipyretics (n = 2), bronchodilators (n = 1), laxatives (n = 1), oral contraceptives (n = 5) and vitamins (n = 10). The samples were analyzed by enzyme immunoassay based on monoclonal antibodies omega-gliadins, the elected technique according to the Codex Alimentarius Commission WHO/FAO. All samples were analyzed in duplicate. The sensitivity of this test is 4 mg of gliadin/100 g of product. RESULTS: Only one (1.3%) out of 78 pharmaceutical products contained detectable amounts of gliadin (5.5 mg/100 g). The active ingredient of this drug is ranitidine. According to the Codex Alimentarius Commission WHO/FAO the intake of 10 mg of gliadin/day should not be exceeded by celiac disease patients. Considering the amount of gliadin in each capsule of ranitidine, the ingested quantity would be lower than the maximum allowed for celiac patients. CONCLUSIONS: In this study gliadin was not detected in pharmaceutical products in harmful amount for celiac disease patients

Doença celíaca: características clínicas e métodos utilizados no diagnósticos de pacientes cadastrados na Associação dos Celíacos do Brasil / Celiac disease: clinical characteristics and methods used in the diagnosis of patients registered at the Brazilian Celiac Association

Objetivo: avaliar as características clínicas e os métodos utilizados no diagnóstico dos pacientes cadastrados na Associação dos Celíacos do Brasil - Seção São Paulo. Métodos: foi enviado por correio um questionário a respeito das características clínicas e dos métodos diagnósticos da doença celíaca para 584 membros cadastrados. Resultados: foram analisados 289 questionários respondidos (49,5 por cento) dos enviados. Quanto às características clínicas da doença celíaca no momento do diagnóstico, observou-se que na amostra estudada a forma clássica foi mais frequente (88,9 por cento) do que a forma não clássica (11,1 por cento). Nos últimos cinco anos houve aumento da proporção da forma clássica tardia de 44,5 por cento para 64,2 por cento (p=0,004) e de forma não clássica de 5,2 por cento para 16,8 por cento (p=0,005). O tempo de duração dos sintomas até o estabelecimento do diagnóstico foi superior a 1 ano em 75 por cento dos pacientes com manifestação clínica não clássica. Biópsia de intestino delgado não foi realizada no momento do diagnóstico em 19 por cneto dos pacientes. Observou-se que, aos últimos 5 anos, maior número de pacientes (24,4 por cento) não realizaram biópsia de intestino delgado no momento do diagnóstico em relação aos realizados há ou mais anos (11,1 por cento) (p=0,007). Conclusões: na maostra estudada, a forma clássica continua sendo a manifestação clínica mais frequente da doença celíaca. Apesar do predomínio da forma clássica tardia, observamos aumento da proporção da forma não clássica. 19 por cento dos pacientes diagnósticados como portadores de doença celíaca não realizaram biópsia de intestino delgado no momento do diagnóstico, especialmente nos últimos 5 anos, apesar de a caracterização da atrofia vilositária subtotal da mucosa do intestino delgado ser um critério imprescindivel para o diagnóstico de doença celíaca