C4B gene influences intestinal microbiota through complement activation in patients with paediatric-onset inflammatory bowel disease.

Complement C4 genes are linked to paediatric inflammatory bowel disease (PIBD), but the mechanisms have remained unclear. We examined the influence of C4B gene number on intestinal microbiota and in-vitro serum complement activation by intestinal microbes in PIBD patients. Complement C4A and C4B gene numbers were determined by genomic reverse transcription-polymerase chain reaction (RT-PCR) from 64 patients with PIBD (Crohn's disease or ulcerative colitis). The severity of the disease course was determined from faecal calprotectin levels. Intestinal microbiota was assessed using the HITChip microarray. Complement reactivity in patients was analysed by incubating their sera with Yersinia pseudotuberculosis and Akkermansia muciniphila and determining the levels of C3a and soluble terminal complement complex (SC5b-9) using enzyme immunoassays. The microbiota diversity was wider in patients with no C4B genes than in those with one or two C4B genes, irrespective of intestinal inflammation. C4B and total C4 gene numbers correlated positively with soluble terminal complement complex (TCC, SC5b-9) levels when patient serum samples were stimulated with bacteria. Our results suggest that the C4B gene number associates positively with inflammation in patients with PIBD. Multiple copies of the C4B gene may thus aggravate the IBD-associated dysbiosis through escalated complement reactivity towards the microbiota.

Human leucocyte antigens B*08, DRB1*03 and DRB1*13 are significantly associated with autoimmune liver and biliary diseases in Finnish children.

AIM: The human leucocyte antigen (HLA) allele and haplotype frequencies of the Finnish population are unique because of the restricted and homogenous gene population. There are no published data on HLA genotype associations in paediatric autoimmune liver diseases in Scandinavia. This study characterised the HLA genotypes of children with autoimmune liver or biliary disease in Finland. METHODS: The study cohort comprised 19 paediatric patients (13 female) aged three years to 15 years treated for autoimmune liver or biliary disease at the Children's Hospital, Helsinki University Hospital, between 2000 and 2011, and followed up for four years and three months to 14.6 years. We genotyped HLA-B and HLA-DRB1 in the children, and the HLA antigen frequencies were compared with 19 807 records from the Finnish Bone Marrow Donor Registry. RESULTS: All paediatric patients with autoimmune liver or biliary disease had either autoimmune HLA haplotype B*08;DRB1*03 or DRB1*13. These were significantly more common among patients with autoimmune hepatitis, primary sclerosing cholangitis and autoimmune hepatitis/primary sclerosing cholangitis overlap syndrome than the Finnish control population. HLA RB1*04 was not found in the study cohort. CONCLUSION: Our study found that B*08, DRB1*03 and DRB1*13 were significantly associated with autoimmune liver and biliary diseases in Finnish paediatric patients.

Rapid test for fecal calprotectin levels in children with Crohn disease.

Assessment of fecal calprotectin, a surrogate marker of mucosal inflammation, is a promising means to monitor therapeutic response in pediatric inflammatory bowel disease, especially if the result is readily available. We tested the performance of a novel calprotectin rapid test, Quantum Blue, versus the conventional enzyme-linked immunosorbent assay in 134 stool samples from 56 pediatric patients with Crohn disease. The intraclass correlation coefficient analysis reflected good agreement (intraclass correlation coefficient 0.97 [95% confidence interval 0.95-0.98]) but agreement was better in lower values, where dilutions were not required. Using a cutoff of 100 µg/g for normal values, the percentage agreement between the 2 tests was 87%. The optimal cutoff values to guide clinical decisions in the therapy of inflammatory bowel disease have yet to be determined.

Parent-adolescent agreement on psychosocial symptoms and somatic complaints among adolescents with inflammatory bowel disease.

AIM: To investigate parent-adolescent agreement on psychosocial and somatic symptoms in adolescents with inflammatory bowel disease (IBD). METHODS: A questionnaire-based postal survey comprising Finnish adolescents aged 10-18 years with IBD (n = 156) and their parents. Emotional, behavioural and somatic symptoms were measured using the Child Behaviour Checklist (parent report) and the Youth Self-Report. RESULTS: In paediatric IBD, adolescents and parents agreed on the presence of a psychosocial problem (in subclinical/clinical range) in 5% of the cases but disagreed in 21%. In 74% of the dyads, respondents agreed that no problems existed. Agreement in reporting psychosocial or somatic symptoms was poor to low (κ = 0.00-0.38). The lowest agreement was on anxious/depressed mood (κ = 0.02) and thought problems (κ = 0.00) and the highest on social problems. The parents reported more somatic symptoms in their adolescents than the adolescents themselves (p < 0.001). CONCLUSION: Young IBD patients and their parents disagree in reporting psychosocial and somatic symptoms of the patients. The adolescents as well as their parents need to be involved; otherwise, many symptoms of clinical significance would go unnoticed.

Magnetic resonance enterography guiding treatment in children with Crohn's jejunoileitis.

AIM: To determine the usefulness of magnetic resonance enterography (MRE) in treatment for paediatric patients with Crohn's disease. METHODS: To evaluate small bowel involvement, 45 children with Crohn's disease were scheduled for MRE. Two radiologists blinded to the patient data independently re-evaluated the images. Findings in images were compared to macroscopic findings at surgery or endoscopy. RESULTS: The terminal ileum was visualized in all with a completed procedure (43/45). The treatment remained conservative in 74% after imaging. In all 13 patients who underwent ileocolonoscopy within 3 months of MRE, the MRE findings were comparable with the macroscopic findings or revealed a more extensive disease. Bowel resection was performed in 26% after imaging. The macroscopic findings in the bowel corresponded to the MRE findings in 73%. In three MRE suggested a more severe disease than was verified intraoperatively. CONCLUSIONS: Magnetic resonance enterography identifies disease involvement in the small bowel in young patients with Crohn's disease and may guide decisions on the need for intestinal surgery or adjustment of medication.

Intra-articular corticoid injection induces circulating glucocorticoid bioactivity and systemic immune activation in juvenile idiopathic arthritis.

OBJECTIVE: To study the systemic effects of intra-articular (IA) glucocorticoid (GC) injections in juvenile idiopathic arthritis (JIA). METHODS: The study group comprised 21 JIA patients being treated with IA methylprednisolone [MP (n = 15) or MP plus triamcinolone hexacetonide (THA) (n = 6)] prescribed on clinical indications. The systemic effect of MP was assessed by measuring circulating glucocorticoid bioactivity (GBA) with a recombinant cell transactivation assay 7 and 24 h after the IA injections, and after 2 months. The systemic immunological responses were studied with a novel assay for testing patient serum-induced changes in the secretion of interferon (IFN)-γ and interleukin (IL)-5 from target cells. RESULTS: Administration of IA GC induced serum GBA (p = 0.001) and suppressed circulating cortisol levels (p = 0.002) 7 h after the injection. Serum withdrawn 24 h after the IA injection induced less IL-5 secretion from mitogen-activated target cells when compared with pre-treatment sera (p = 0.036). This decrease in target cell T helper (Th)2 response (IL-5) was MP dose related (r = -0.550, p = 0.018). High IL-5 secretion from target cells prior to the IA injections was associated with good clinical outcome at 2 months, seen as a low number of active (p = 0.044) and restricted joints (p = 0.049). CONCLUSION: IA GC injections have systemic effects that are reflected in the serum as an immediate elevation of GBA, a decrease of endogenous cortisol as well as a suppressive effect of patient serum on target cell IL-5 secretion. These systemic effects may play a role in the attenuation of disease activity.

Clinics of coeliac disease in children in the 2000s.

OBJECTIVE: To describe the clinical picture of patients with coeliac disease (CD) and the change in its presentation over the past decades. STUDY DESIGN: Patients with CD were identified and clinical data collected from hospital records over a 6-year period (2000-2005). RESULTS: Altogether 197 patients aged 0.6-15.9 (mean 7.2) years were identified. They were found amongst the child population served by the hospital, the mean number of children at age 0.5-16 years was 268 000 during 2000-2005. The presenting symptom amongst the youngest patients (<3 years) was chronic diarrhoea (in 67%), and amongst older patients, abdominal pain. At the time of diagnosis, growth was severely retarded (height <2 SD for age) in 6.6%; mean height was -0.06 SD and weight + 1% for height. After diet treatment for a mean of 6 months, both height and weight increased significantly. Anaemia and iron deficiency were present in 25% and 43% of patients respectively. Intraepithelial T-cell receptor gamma/delta cells were pathologic in all 150 specimens studied. CONCLUSIONS: The presentation of CD depends on age. Even when we found six times more patients than during years 1976-1985 in the same hospital, published data on the prevalence of CD suggest that we found only a small minority of children with CD.

Nutritional risk screening-a cross-sectional study in a tertiary pediatric hospital.

BACKGROUND: All hospitalized patients should be screened for malnutrition risk. No universal method exists for pediatric patients. METHODS: We performed a cross-sectional study comparing three published malnutrition risk screening tools (PYMS, STAMP, and STRONGkids), applying them to each inpatient aged 1 month to 17 years over a period of five consecutive weekdays in Helsinki University Hospital, Finland. RESULTS: Of the eligible patients, 67% (n = 69) participated. We found that 6.2% of the children were acutely malnourished and accurately categorized by the three tools. STRONGkids showed the highest specificity (100%) and positive predictive value (36%). Acute malnutrition seemed to be associated with longer hospital stay (p = 0.051). CONCLUSION: STRONGkids was the most accurate screening tool for detecting acute malnutrition and was therefore chosen as the screening method in our hospital. Routine screening for the risk of malnutrition in pediatric inpatients is important in detecting at-risk children who would otherwise be left without dietary intervention.

Malignancy and mortality in paediatric-onset inflammatory bowel disease: a 3-year prospective, multinational study from the paediatric IBD Porto group of ESPGHAN.

BACKGROUND: Risk benefit strategies in managing inflammatory bowel diseases (IBD) are dependent upon understanding the risks of uncontrolled inflammation vs those of treatments. Malignancy and mortality in IBD have been associated with disease-related inflammation and immune suppression, but data are limited due to their rare occurrence. AIM: To identify and describe the most common causes of mortality, types of cancer and previous or current therapy among children and young adults with paediatric-onset IBD. METHODS: Information on paediatric-onset IBD patients diagnosed with malignancy or mortality was prospectively collected via a survey in 25 countries over a 42-month period. Patients were included if death or malignancy occurred after IBD diagnosis but before the age of 26 years. RESULTS: In total, 60 patients were identified including 43 malignancies and 26 fatal cases (9 due to cancer). Main causes of fatality were malignancies (n = 9), IBD or IBD-therapy related nonmalignant causes (n = 10; including 5 infections), and suicides (n = 3). Three cases, all fatal, of hepatosplenic T-cell lymphoma were identified, all were biologic-naïve but thiopurine-exposed. No other haematological malignancies were fatal. The 6 other fatal cancer cases included 3 colorectal adenocarcinomas and 3 cholangiocarcinomas (CCAs). Primary sclerosing cholangitis (PSC) was present in 5 (56%) fatal cancers (1 colorectal carcinoma, 3 CCAs and 1 hepatosplenic T-cell lymphoma). CONCLUSIONS: We report the largest number of paediatric-onset IBD patients with cancer and/or fatal outcomes to date. Malignancies followed by infections were the major causes of mortality. We identified PSC as a significant risk factor for cancer-associated mortality. Disease-related adenocarcinomas were a commoner cause of death than lymphomas.

Declining trend in the incidence of biopsy-verified coeliac disease in the adult population of Finland, 2005-2014.

BACKGROUND: The frequency of coeliac disease (CD) has been on the rise over the past decades, especially in Western Europe, but current trends are unclear. AIM: To research the recent temporal changes in the incidence of adult, biopsy-verified coeliac disease and dermatitis herpetiformis (DH) in Finland, a country with a high frequency of coeliac disease. METHODS: All coeliac disease and DH cases diagnosed at age 20-79 years during 2005-2014 were retrieved from a nationwide database documenting all applicants for monthly compensation to cover the extra cost of maintaining a gluten-free diet. This benefit is granted on the basis of histology, not socioeconomic status. Temporal trends in the annual incidences were estimated using Poisson regression analyses. RESULTS: The total incidence of coeliac disease decreased from 33/100 000 during the years 2005-2006 to 29/100 000 during 2013-2014. The mean annual incidence of coeliac disease was nearly twice as high among women as among men, 42 vs 22 per 100 000, respectively. For middle- and old-aged women, the average rate of decrease in incidence was 4.8% (95% CI 3.9-5.7) per year and for men 3.0% (1.8-4.1) (P for linear trend <.001, for both). Similarly, the annual incidence of DH declined. For young adults, the rate of change remained low and nonsignificant throughout the period 2005-2014. CONCLUSIONS: Although the awareness of coeliac disease has increased during the past decades, the incidence of biopsy-verified diagnoses is not increasing, which suggests that exposure to yet unidentified triggering factors for coeliac disease has plateaued among the Finnish adult population.

Suppression of pituitary-testis function in rats treated neonatally with a gonadotrophin-releasing hormone agonist and antagonist: acute and long-term effects.

The acute and long-term effects of pituitary-testis suppression with a gonadotrophin-releasing hormone (GnRH) agonist, D-Ser(Bu(t))6des-Gly10-GnRH N-ethylamide (buserelin; 0.02, 0.1, 1.0 or 10 mg/kg body weight per day s.c.) or antagonist, N-Ac-D-Nal(2)1,D-p-Cl-Phe2,D-Trp3,D-hArg(Et2)6,D-Ala10 -GnRH (RS 68439; 2 mg/kg body weight per day s.c.) were studied in male rats treated on days 1-15 of life. The animals were killed on day 16 (acute effects) or as adults (130-160 days; long-term effects). Acutely, the lowest dose of the agonist decreased pituitary FSH content and testicular LH receptors, but with increasing doses pituitary and serum LH concentrations, intratesticular testosterone content and weights of testes were also suppressed (P less than 0.05-0.01). No decrease was found in serum FSH or in weights of accessory sex organs even with the highest dose of the agonist, the latter finding indicating continuing secretion of androgens. The GnRH antagonist treatment suppressed pituitary LH and FSH contents and serum LH (P less than 0.05-0.01) but, as with the agonist, serum FSH remained unaltered. Testicular testosterone and testis weights were decreased (P less than 0.01) but testicular LH receptors remained unchanged. Moreover, the seminal vesicle and ventral prostate weights were reduced, in contrast to the effects of the agonists. Pituitary LH and FSH contents had recovered in all adult rats treated neonatally with agonist and there was no effect on serum LH and testosterone concentrations or on fertility.(ABSTRACT TRUNCATED AT 250 WORDS)

Suppression and recovery of pituitary gonadotrophin secretion in intact and orchidectomized rats treated neonatally with a gonadotrophin-releasing hormone antagonist.

Suppression of neonatal rat pituitary-testis function by gonadotrophin-releasing hormone (GnRH) antagonists results in delayed sexual maturation and infertility. Since the mechanism is not understood, the acute effects of a GnRH antagonist on gonadotrophin secretion in neonatal male rats has been studied in more detail. Treatment with a GnRH antagonist analogue, N-Ac-D-Nal(2)1,D-p-Cl-Phe2,D-Trp3,D-hArg(Et2)6,D-Ala10 -GnRH (2 mg/kg per day) on days 1-10 of life had prolonged effects on gonadotrophin secretion; serum LH and FSH recovered in 1 week, but the pituitary content took 2 weeks to recover. Likewise, LH and FSH responses to acute in-vivo stimulation with a GnRH agonist were still suppressed 1 week after the treatment. Interestingly, a rebound (86% increase) in basal serum FSH was found 16 days after treatment with the antagonist. Whether testis factors influence gonadotrophin secretion during treatment with the GnRH antagonist and/or in the subsequent recovery period was also assessed. Neonatal rats were castrated on days 1, 5 or 10 of the 10-day period of antagonist treatment. Orchidectomy on days 1 and 5 only marginally affected gonadotrophin secretion. When orchidectomy was performed at the beginning of the recovery period, no effects on pituitary recovery were seen within 1 week of castration. After 16 days, serum LH and FSH in the antagonist-treated and control castrated rats were equally increased but the pituitary contents of the antagonist-treated rats were still suppressed. Finally, the effect of testosterone treatment on the recovery of gonadotrophin secretion after antagonist suppression was studied in intact and orchidectomized animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Sexual maturation of male rats treated postnatally with a gonadotrophin-releasing hormone antagonist.

Postnatal secretion of gonadotrophin by male rats was inhibited by a potent gonadotrophin-releasing hormone (GnRH) antagonist analogue (N-Ac-4-Cl-D-Phe1,4-Cl-D-Phe2,D-Trp3,D-Phe6,des-Gly10-GnRH-D-al anylamide; Org 30039; 2 mg/kg s.c. twice daily) on days 1-5, 6-10, 11-15 or 16-20 of life. The onset of puberty was determined by monitoring the separation of the preputium from the glans penis, i.e. balano-preputial separation (BPS). Rats treated on days 1-5 matured normally, whereas all treatments between days 6 and 20 delayed BPS (P less than 0.01). In adult rats (between 110 and 160 days of age), testis weights were reduced by 21-35% (P less than 0.01) in groups treated between days 1 and 15, although weights of the accessory sex glands were normal. Testicular FSH receptors were decreased by 31-47% (P less than 0.01) in all treatment groups, whereas the LH receptor content was decreased only in rats treated between days 1 and 5 (18%; P less than 0.05) and prolactin receptor content decreased only in rats treated up to day 10 (31-33%; P less than 0.01). Concentrations of serum testosterone, LH and FSH, and pituitary contents of LH and FSH were unaffected by neonatal treatment with Org 30039. Animals treated with Org 30039 had reduced fertility which was most pronounced (88%; P less than 0.01) in rats treated between days 1 and 5. However, motile sperm were detectable in the cauda epididymis of the infertile rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric inflammation is enhanced in children with CagA-positive Helicobacter pylori infection.

BACKGROUND: Helicobacter pylori infection is likely to be acquired at an early age. The factors leading to active inflammation in childhood, however, are largely unknown. SUBJECTS AND METHODS: We determined the CagA status, the best characterized virulence factor of H. pylori, and serum antibodies of IgG and IgA classes to H. pylori in 39 infected children. RESULTS: Mononuclear cell infiltration in the antrum but not in the gastric body was more intense in CagA-positive children than in CagA-negative children. The degree of polymorphonuclear cell infiltration on the other hand was independent of the CagA status. The antibody titers of IgG and IgA classes to H. pylori were higher in CagA-positive than in CagA-negative infections (P<0.001 and P<0.01, respectively). IgG antibody titers to H. pylori correlated directly with the density of mononuclear and polymorphonuclear cell infiltration in the gastric antrum but not in the gastric body. CONCLUSION: H. pylori-infected children with CagA antibodies seem to have a more severe inflammation in the gastric antrum than CagA-negative children as shown by an increase in the density of antral mononuclear cells. A finding of higher serum antibody titers to H. pylori in CagA-positive children may be related to this enhancement of inflammation.

Pancreatic secretory trypsin inhibitor from human amniotic fluid and fetal and neonatal urine: concentrations and physicochemical characterization.

The levels and physicochemical properties of the pancreatic secretory trypsin inhibitor, also known as Kazal type trypsin inhibitor, were studied in human amniotic fluid. In the second trimester, the median concentration was 160 ng/ml, which exceeds the maternal serum levels 20-fold. Towards term, the amniotic fluid levels declined about 5-fold, whereas the maternal serum values remained constant. In fetal urine, the concentration of the trypsin inhibitor was similar to that in amniotic fluid in early gestation, whereas in newborn urine, the median level was 4-to 5-fold higher than in term amniotic fluid. The physiochemical characteristics of the trypsin inhibitor in amniotic fluid, neonatal urine and cancer urine from an ovarian cancer patient were similar, as studied by gel filtration, high performance reverse phase liquid chromatography, and complete immunological identity in immunodiffusion. The physicochemical similarity and levels in various compartments suggest fetal contribution to amniotic fluid levels of the trypsin inhibitor.

Neonatal treatment of male rats with a gonadotropin-releasing hormone antagonist impairs ejaculation and fertility.

Pituitary-gonadal suppression of neonatal male rats with a gonadotropin-releasing hormone antagonist N-Ac-D-Nal(2)1,D-p-Cl-Phe2,D-Trp3,D-hArg(Et2)6,D-Ala10 -GnRH (RS 68439; Syntex; 2 mg/kg/day) during days 1-10 of life resulted in infertility of adult animals, when studied at the age of 90, 115 and 150 days. Numbers of fertile animals per rats tested at these ages were 1/10, 2/14 and 4/14, respectively, in the antagonist treated animals (vs. 8/10, 9/13 and 9/13 in controls; p less than 0.01-0.05). The numbers of mounts and intromissions were unaffected by the antagonist treatment, but none of the treated animals (n = 10) ejaculated in four subsequent behavior tests. However, if the vaginal smears were checked in a group of rats after caging the males separately with a normal female for 8 days before the behavior tests, each male had ejaculated but the females were not fertilized. When the neonatally GnRH antagonist-treated rats were followed in the long-term, fertility slowly recovered, and at the age of 220 and 350 days, the number of successful pregnancies was similar to that of age-matched controls. It is concluded that short-term neonatal pituitary-gonadal suppression with GnRH antagonist results in impaired ejaculation and infertility of adult male rats, but fertility slowly recovers within a year.

Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease.

Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.

Prevention of acute adverse events related to infliximab infusions in pediatric patients.

OBJECTIVE: To study whether premedication with an oral antifebrile agent (acetaminophen) and antihistamine (cetirizine) could decrease the frequency of acute infusion reactions in pediatric patients. METHODS: All pediatric patients scheduled for infliximab infusions at the Helsinki University Central Hospital, a tertiary care center, were prospectively introduced to a standard oral premedication of acetaminophen (20 mg/kg) and cetirizine (10 mg) prior to infliximab infusions for a period of 1 year. All acute adverse events related to infliximab infusions given according to the guidelines of pediatric rheumatologists or gastroenterologists were registered for this time period and retrospectively during the preceding year. RESULTS: During the study period, infliximab infusions with premedication were given to 64 pediatric patients (48 with rheumatic disease and l6 with inflammatory bowel disease, mean age 13 years, n = 34 boys, and n = 30 girls). Infliximab was introduced to 14 children; the rest were on maintenance therapy. Twelve infusion reactions, 4 mild and 8 severe, were observed in 8 (12.5%) of the 64 subjects, and in 1 subject 4 times. During the preceding year, 60 pediatric patients had received infliximab infusions without premedication. In this latter group, infusion reactions occurred in 5 children (8.3%; P > 0.05). The presentation of an acute infusion reaction was not related to the sex or diagnosis of the patient. CONCLUSION: In pediatric patients, acute infusion reactions related to infliximab could not be prevented with premedication with oral acetaminophen and cetirizine.