Search

Objectives: To determine the association between inflammatory bowel disease (IBD) and rural/urban household at the time of diagnosis, or within the first 5 years (y) of life. Methods: Population-based cohorts of residents of four Canadian provinces were created using health administrative data. Rural/urban status was derived from postal codes based on population density and distance to metropolitan areas. Validated algorithms identified all incident IBD cases from administrative data (Alberta: 1999–2008, Manitoba and Ontario: 1999–2010, and Nova Scotia: 2000–2008). We determined sex-standardized incidence (per 100,000 patient-years) and incident rate ratios (IRR) using Poisson regression. A birth cohort was created of children in whom full administrative data were available from birth (Alberta 1996–2010, Manitoba 1988–2010, and Ontario 1991–2010). IRR was calculated for residents who lived continuously in rural/urban households during each of the first 5 years of life. Results: There were 6,662 rural residents and 38,905 urban residents with IBD. Incidence of IBD per 100,000 was 33.16 (95% CI 27.24–39.08) in urban residents, and 30.72 (95% CI 23.81–37.64) in rural residents (IRR 0.90, 95% CI 0.81–0.99). The protective association was strongest in children

Background The use of fecal calprotectin (FCal) as a marker of intestinal inflammation, in the management of inflammatory bowel disease (IBD) is increasing. The aim of this study was to examine the impact of FCal measurements on decision-making and clinical care of children with IBD. Materials and methods In a retrospective cohort study, FCal, clinical activity indices, and blood markers were measured in children with established diagnoses of IBD. Pearson correlation coefficient analysis was performed to examine association between FCal and other markers. Decisions based on FCal measurements were prospectively documented and participants were evaluated 3–6 months later. Results A total of 115 fecal samples were collected from 77 children with IBD [median age 14, interquartile range (IQR) 11–15.6 years, 42 females, 37 with Crohn’s disease]. FCal positively correlated with clinical activity indices (r = 0.481, P

There are limited data on the natural history of primary sclerosing cholangitis (PSC) in children. We aimed to describe the disease characteristics and long-term outcomes of pediatric PSC. We retrospectively collected all pediatric PSC cases from 36 participating institutions and conducted a survival analysis from the date of PSC diagnosis to dates of diagnosis of portal hypertensive or biliary complications, cholangiocarcinoma, liver transplantation, or death. We analyzed patients grouped by disease phenotype and laboratory studies at diagnosis to identify objective predictors of long-term outcome. We identified 781 patients, median age 12 years, with 4,277 person-years of follow-up; 33% with autoimmune hepatitis, 76% with inflammatory bowel disease, and 13% with small duct PSC. Portal hypertensive and biliary complications developed in 38% and 25%, respectively, after 10 years of disease. Once these complications developed, median survival with native liver was 2.8 and 3.5 years, respectively. Cholangiocarcinoma occurred in 1%. Overall event-free survival was 70% at 5 years and 53% at 10 years. Patient groups with the most elevated total bilirubin, gamma-glutamyltransferase, and aspartate aminotransferase-to-platelet ratio index at diagnosis had the worst outcomes. In multivariate analysis PSC–inflammatory bowel disease and small duct phenotypes were associated with favorable prognosis (hazard ratios 0.6, 95% confidence interval 0.5-0.9, and 0.7, 95% confidence interval 0.5-0.96, respectively). Age, gender, and autoimmune hepatitis overlap did not impact long-term outcome. Conclusion: PSC has a chronic, progressive course in children, and nearly half of patients develop an adverse liver outcome after 10 years of disease; elevations in bilirubin, gamma-glutamyltransferase, and aspartate aminotransferase-to-platelet ratio index at diagnosis can identify patients at highest risk; small duct PSC and PSC–inflammatory bowel disease are more favorable disease phenotypes. (Hepatology 2017;66:518–527).

Objectives. The current number of healthcare providers (HCP) caring for children with inflammatory bowel disease (IBD) across Canadian tertiary-care centres is underinvestigated. The aim of this survey was to assess the number of healthcare providers (HCP) in ambulatory pediatric IBD care across Canadian tertiary-care centres. Methods. Using a self-administered questionnaire, we examined available resources in academic pediatric centres within the Canadian Children IBD Network. The survey evaluated the number of HCP providing ambulatory care for children with IBD. Results. All 12 tertiary pediatric gastroenterology centres participating in the network responded. Median full-time equivalent (FTE) of allied health professionals providing IBD care at each site was 1.0 (interquartile range (IQR) 0.6–1.0) nurse, 0.5 (IQR 0.2–0.8) dietitian, 0.3 (IQR 0.2–0.8) social worker, and 0.1 (IQR 0.02–0.3) clinical psychologists. The ratio of IBD patients to IBD physicians was 114 : 1 (range 31 : 1–537 : 1), patients to nurses/physician assistants 324 : 1 (range 150 : 1–900 : 1), dieticians 670 : 1 (range 250 : 1–4500 : 1), social workers 1558 : 1 (range 250 : 1–16000 : 1), and clinical psychologists 2910 : 1 (range 626 : 1–3200 : 1). Conclusions. There was a wide variation in HCP support among Canadian centres. Future work will examine variation in care including patients’ outcomes and satisfaction across Canadian centres.

Aims The aim was to systematically review the evidence on the clinical usefulness of thiopurine metabolite and white blood count (WBC) monitoring in the assessment of clinical outcomes in children with inflammatory bowel disease (IBD). Methods Medline, Embase, Cochrane Central Register of controlled trials and http://www.clinicaltrials.gov were screened in adherence to the PRISMA statement by two independent reviewers for identification of eligible studies. Eligible studies were randomized controlled trials (RCTs), cohort studies and large case series of children with inflammatory bowel disease (IBD) (

BACKGROUND: An important target in the management of pediatric inflammatory bowel disease (IBD) is normal linear growth and pubertal development. Greater awareness of IBD and more effective therapies are anticipated to reduce the prevalence of linear growth impairment as a complication of chronic intestinal inflammation. AIMS: To evaluate the current magnitude of linear growth impairment at diagnosis in pediatric Crohn’s disease (CD) and ulcerative colitis (UC). METHODS: Since April 2014, the Canadian Children IBD Network (CIDsCANN) inception cohort study prospectively enrolled patients aged

BACKGROUND: Transitioning inflammatory bowel disease (IBD) patients from pediatric to adult care is a challenging and complex process. Knowledge of the potential factors influencing transition readiness is limited, especially in this unique population. AIMS: To evaluate potential factors including patient and parent psychosocial wellbeing, self-management, self-advocacy skills and geographical location of medical care, and to explore their effects on transition readiness in patients with IBD. METHODS: An ongoing cross-sectional multicentre study evaluating transition readiness in IBD patients 16 to 19 years of age who have been enrolled from pediatric and adult gastroenterology clinics in Western Canada (Vancouver, Calgary, Edmonton and Winnipeg). Questionnaires include the OnTRAC Readiness Assessment Questionnaire, the Screen for Child Anxiety Related Disorders (SCARED), the Patient Health Questionnaire (PHQ-8) to screen for depression and the Generalized Anxiety Disorder (GAD-7) to screen for parental anxiety. The patient, parent and physician also score the child and parent’s readiness to transition on a scale of 1–10 (1=not ready and 10=completely ready). RESULTS: To date, 31 patients have been enrolled from participating Vancouver sites, 24 with Crohn’s disease, 4 with ulcerative colitis and 3 with indeterminate colitis. Questionnaires indicated scores consistent with an anxiety disorder in 38% of those with IBD (only 20% of parents suggested anxiety in their child), and mild to severe depression in 23% of those with IBD. In addition, 24% of the parents themselves had GAD-7 scores consistent with mild to severe anxiety. Patients reported a mean readiness to transition score of 7.4. The physicians’ evaluations of readiness to transition was similar to the patient group (mean 7), while the parent group gave a lower score (mean 5.8). Indeed, 77% of patients never or rarely saw the physician on their own at visits, 59% of parents indicated that they call the healthcare team with disease-related questions or concerns for their child and 46% of patients need reminders from parents to take medications. CONCLUSIONS: Survey data from initial recruited patients suggest that a large proportion of transitioning youth continue to have behaviours that reflect a lack of self-advocacy and independence. In addition, depression and anxiety scores are high in this population which could impact the level of preparation for transition to adult care. Further data will be collected in this ongoing multi-centre study to assess the impact of youth and parental factors on transition readiness and to evaluate possible site to site variability. FUNDING AGENCIES: Janssen Pharmaceuticals

BACKGROUND: The Paris classification of pediatric IBD divides “pediatric-onset” IBD (A1, Montreal classification) into A1a (diagnosis

Background: this study compared the efficacy of an elemental formula (EF) to a polymeric formula (PF) in inducing remission for pediatric Crohn's disease (CD). Methods: newly diagnosed CD children were randomized to EF or PF for 6 weeks. Change in the Pediatric Crohn's Disease Activity Index (PCDAI), fecal calprotectin, and plasma fatty acids were measured at 0 and 6 weeks. Patients were followed up for 2 years. Time and treatment choice for first relapse were documented. Results: thirty-four children completed the study; EF: 15 (7 M, 8 F), PF: 19 (13 M, 6 F). The mean age was (years) EF: 12.6, PF: 11.7. Ninety-three percent of children (14/15) achieved remission in the EF group and 79% (15/19) in the PF group. One-third of patients maintained remission for 2 years. Mean time to relapse (days); EF: 183 (63-286), PF: 162 (53-301). Most children who relapsed used feed as a treatment for that relapse (EF: 9/10 and PF: 8/13). With PF, an increase of eicosapentanoic acid (EPA) and alpha linolenic acid was found with a reciprocal decrease in arachidonic acid (AA). With EF, AA and EPA levels were reduced with a significant decrease in docosahexaenoic acid. Fecal calprotectin measurements decreased significantly but did not normalize at the end of week 6. Conclusions: there was no significant difference between EF and PF in inducing remission. One-third of children maintained remission. Changes in plasma polyunsaturated fatty acid status were subtle and may be relevant; however, further evaluation is recommended

Aliment Pharmacol Ther 2011; 34: 1282–1294 Summary Background Several published studies have evaluated the efficacy of tacrolimus in the management of Crohn’s disease with variable conclusions. Aim To review systematically the evidence examining the efficacy and safety of tacrolimus in treating Crohn’s disease. Methods The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PUBMED) and EMBASE (1984 to January 2011) were searched. Also, references from selected articles were examined. Case series (five or more patients), cohort and randomised controlled trials were eligible for inclusion, incorporating oral, intravenous or topical tacrolimus therapy. The primary outcome was induction of remission of active Crohn’s disease. Results Eleven studies met the inclusion criteria which included 163 patients, of which 127 received tacrolimus therapy. In patients with luminal Crohn’s disease, the crude pooled remission rate for tacrolimus was 44.3% (range, 7–69%) and the crude pooled response rate was 37.1% (range, 14–57%). For patients with perianal disease using systemic tacrolimus, crude pooled remission rate was 28.6% (range, 0–64%) and crude pooled response rate was 38.8% (range, 0–57%). Combining data from two studies using topical tacrolimus, 35.7% of patients achieved remission and 28.6% partial response. Nonserious adverse effects are common, particularly tremor, paraesthesia and headache. Reversible nephrotoxity occurred in 16% of patients. Conclusions The current evidence; although of a poor quality, appears to support the use of tacrolimus in Crohn’s disease. High quality randomised controlled trials are needed.

Aim. To compare serum vitamin and mineral levels at diagnosis in children with inflammatory bowel disease (IBD) versus a control group without. Methods. In a retrospective cohort study, serum levels of iron, zinc, folate, selenium, vitamin B 12, vitamin A, and vitamin E in children with IBD at diagnosis were compared with gender- and age-matched controls. Results. A total of 154 patients with IBD (mean age 11.27 ± 3.74 years, 83 boys, 80 with Crohn’s disease) were recruited. The mean duration of symptoms prior to diagnosis was 5.4 ± 3.2 months for patients with Crohn’s disease and 4.6 ± 2.9 months for patients with ulcerative colitis. A control group of 64 children was recruited. The mean serum zinc levels were 11.33 ± 4.16 µmol/L for ulcerative colitis, 8.74 ± 2.08 µmol/L for Crohn’s disease and 11.49 ± 1.63 µmol/L for controls ( P < .001). Conclusions. In newly diagnosed children with IBD, serum zinc levels are significantly lower compared with children without IBD.

Managing infants and children with difficult feeding problems, such as intractable vomiting and dysmotility, can be challenging. Maintaining sufficient enteral feeding is the ultimate goal. However, the options for establishing this goal may be limited. One option is gastrojejunostomy tube feeding, a technique developed in 1984. This review discusses indications and limitations of gastrojejunostomy tube feeding in children. It also discusses alternative options for gastrojejunostomy tube feeding in view of the available evidence.

BACKGROUND: Although gastrostomy tube insertion – whether endoscopic or open – is generally safe, procedure-related complications have been reported.OBJECTIVE: To compare gastrostomy tube insertion-related complications between percutaneous endoscopic gastrostomy and open gastrostomy at a single pediatric centre.METHODS: The charts of children (younger than 17 years of age at the time of tube insertion) who underwent endoscopic or open gastrostomy tube insertion from January 2005 to December 2007 at the Stollery Children’s Hospital (Edmonton, Alberta) were examined.RESULTS: A total of 298 children underwent gastrostomy tube insertion over a period of three years. After excluding patients with incomplete charts, 160 children (91 boys, mean [± SD] age 3.18±4.73 years) were included. Eighty-five children (mean age 4.50±5.40 years) had their gastrostomy tube inserted endoscopically, while the remaining 75 (mean age 1.68±3.27 years; PCONCLUSION: Although the rate of major complications was similar between the endoscopic and open tube insertion groups, major infections were more common among children who underwent endoscopic gastrostomy. The decision for gastrostomy tube insertion was primarily based on clinical background.

BACKGROUND:The aim of this study was to determine the proportion of patients' caregivers willing to participate in clinical research and examine the possible barriers against recruitment to clinical research in children with inflammatory bowel disease. METHODS:In a cross-sectional study, caregivers and children with inflammatory bowel disease were surveyed via a questionnaire that addressed parents' willingness to participate in clinical studies and factors influencing their willingness to participate. RESULTS:A total of 118 caregivers to children with inflammatory bowel disease [median age 14.5, IQR: 12.0-15.8 years, 60 boys, 61 (52%) with Crohn's disease] who were followed for a median duration of 1.73 years (IQR 0.4-3.6 years) completed the survey. One hundred and four (88.2%) caregivers answered "Definitely" or "Probably" to participate in clinical research while 14 (11.8%) were "Neutral" or "Probably" unwilling to participate (P

Esophageal foreign body (FB) impaction is a common emergency in children. The goal of this study was to compare rigid versus flexible endoscopy in esophageal FB extraction in children.In a retrospective cohort study with consecutive data, children with esophageal FB impaction who were admitted between January 2005 and December 2008 to the Stollery Children's Hospital, Edmonton, Canada, were included. Nature of the procedure for FB removal (flexible vs. rigid endoscopy), duration of the procedure, complications, and associated pathology were documented.A total of 140 children were included (81 boys; mean age, 59.8 ± 48.6 (range, 4-203) months). More than half (54%) of patients were aged 3 years or younger. Coins were the most common foreign body (77.9%). Flexible endoscopy was used in 89 patients, rigid in 49, and both in 2 patients. The mean duration of the endoscopic procedure was 10.50 ± 12.2 minutes for FE (95% confidence interval (CI), 7.94-13.08) and 16.49 ± 21.1 minutes for RE (95% CI, 13.75-22.45; p = 0.04). Biopsies were taken in 19% of patients undergoing FE and in 6% of RE (p = 0.04).Both rigid and flexible endoscopy techniques appear to be equally safe and effective in esophageal foreign body extraction. However, performing flexible endoscopy for esophageal foreign body takes a substantial shorter duration compared with rigid endoscopy. Flexible endoscopy would probably allow a better and more thorough examination and, hence, biopsying esophageal mucosa compared with rigid endoscopy.

The aim of this study was to examine bone mineral density and serum 25-hydroxy vitamin D in relation to disease activity in children newly diagnosed with IBD. In a cross-sectional analytic study, 60 children newly diagnosed with IBD (39 with Crohn’s disease [CD], mean age 12.2 ± 2.1 years; and 21 with ulcerative colitis [UC], mean age 12.4 ± 3.7 years) were recruited. Fifty-six age- and sex-matched children without IBD were invited as controls (mean age 11.3 ± 4.2 years). Serum 25-hydroxy vitamin D for patients and controls was measured at diagnosis. Patients’ adjusted lumbar spine bone mineral density (BMD) z scores were measured. Activity indices for both CD and UC were calculated. The serum level of 25-hydroxy vitamin D was significantly lower in children with IBD compared to the control group (P = 0.04). BMD was significantly lower in patients with CD compared to those with UC (P = 0.039). There was no correlation between vitamin D levels, BMD z scores or disease activity indices for both CD and UC. Serum vitamin D level is significantly lower in children with newly diagnosed IBD compared to those without. However, vitamin D levels are not affected by disease severity. It seems that BMD status may not be affected by vitamin D levels or disease severity in this cohort. Larger prospective controlled studies are needed to confirm these findings.

Nutrition therapy of Crohn's disease is considered the first-line of treatment for Crohn's disease in children, especially in Europe. This article discusses the role, mechanism, and the available updated evidence supporting use of this treatment to induce and maintain remission of Crohn's disease. It also highlights the importance of the team approach in achieving success using this treatment. Future research-related topics are briefly summarized.

BACKGROUND: Patients with inflammatory bowel disease (IBD) often do not take their medications as prescribed.OBJECTIVE: To examine self-reported adherence rates in IBD patients at the Stollery Children’s Hospital (Edmonton, Alberta) and to determine predictors of medication adherence.METHODS: A survey was mailed to 212 pediatric IBD patients of the Stollery Children’s Hospital. A chart review was completed for those who returned the survey.RESULTS: A total of 119 patients completed the survey. The nonresponders were significantly older than responders (14.5 years versus 13.2 years; P=0.032). The overall adherence rate was 80%. Nonadherence was associated with older age (14.6 years versus 13.0 years; P=0.04), longer disease duration (5.0 years versus 3.1 years; P=0.004) and reported use of herbal medications (40.0% versus 13.6%; P=0.029). The most common reasons reported for missing medications were forgetfulness, feeling better and too many medications. In addition, patients reported being more likely to take anti-inflammatory medications and less likely to take herbal medicines.CONCLUSION: Identified predictors of nonadherence such as age, disease duration and use of herbal treatments may enable the development of specific strategies to improve adherence in adolescents with IBD.

Inflammatory bowel disease (IBD) encompasses 2 disorders of unknown etiology: Crohn disease (CD) and ulcerative colitis (UC). There has been a continuous search for markers for disease activity. Eosinophils are granulocytic leukocytes that are implicated in the pathogenesis of IBD. The aim of this study was to examine the prevalence and significance of peripheral eosinophilia (PE) at diagnosis in children with IBD.A comprehensive chart review of all children with diagnosed as having IBD between January 2006 and August 2014 was performed. Patients with PE at diagnosis were compared with those without in relation to disease clinical activity and disease course.A total of 109 children (mean age 14.6 ± 2.77, range 4.5-17.9 years, 55 boys) with IBD (68 with CD and 41 with UC) who were studied for a mean duration of 2.82 ± 1.89 (range 0.1-9.2 years) were identified. At diagnosis, 44 (40.4%) children had PE, which was more prevalent in patients with UC compared with those with CD (61.3% vs 36.3%, P 0.05). At diagnosis, PE was more common in patients with high eosinophilic count in colonic biopsy samples (P 0.01) and was significantly associated with disease activity as indicated by Pediatric CD Activity Index for children with CD (P 0.05), Pediatric UC Activity Index for children with UC (P 0.01).PE is a common finding at diagnosis in children with IBD especially in those with UC. Patients with PE at diagnosis are more likely to present with higher clinical activity indices. PE is associated with more eosinophils in colonic biopsy samples.

Aim The role of noninvasive biologic markers for disease activity is very important in children with Crohn's disease. The aim of this study was to assess an association between disease activity and quantitative serum anti-Saccharomyces cerevisiae antibody (ASCA) titres. Methods Anti-Saccharomyces cerevisiae antibody immunoglobulin (Ig) A and immunoglobulin G titres, paediatric Crohn's disease activity index (PCDAI), serum albumin and C-reactive protein (CRP) were repeatedly measured simultaneously in children with Crohn's disease. A possible association between ASCA IgA and IgG titres and changes in PCDAI was examined. Results Serial 136 measurements of ASCA IgA and IgG titres were documented in 57 children with Crohn's disease over a mean duration of 3.1 ± 2.1 years. In a univariate linear regression model, there were significant correlations between ASCA IgA titres and PCDAI (p

Idiopathic fibrosing pancreatitis, a rare cause of obstructive jaundice and abdominal pain in children, which has certain features in common with the emerging entity of autoimmune pancreatitis as described in adults, has frequently been managed surgically. We present our experience of successful conservative management of this condition in children. Three children (6–12 years; two girls, one boy) presented with a short history of abdominal pain followed by obstructive jaundice. Abdominal ultrasonographic examination in each case showed dilated intrahepatic and common bile ducts with a bulky pancreas, predominantly the head. These findings were confirmed by magnetic resonance imaging. In two cases, the diagnosis of fibrosing pancreatitis was made by exclusion after extensive investigation. The third case had a percutaneous ultrasound-guided pancreatic needle biopsy. Two patients were managed by supportive medical therapy alone, whilst the third, with symptomatic obstructive jaundice, underwent temporary endoscopic stenting of the common bile duct. Cases have been followed-up for 12–49 months. There was complete clinical and biochemical resolution of obstructive jaundice in all three cases. Plasma bilirubin concentrations decreased to normal within 3–8 weeks. Serial abdominal imaging showed a gradual resolution of biliary dilatation and abnormal pancreatic morphology with subsequent pancreatic atrophy. Two children developed steatorrhoea that responded to pancreatic enzyme supplements, and one patient developed diabetes mellitus. None of the cases needed invasive surgery for diagnosis or management. Conclusion: With careful radiological and biochemical assessment and monitoring, invasive surgery can be avoided in the management of fibrosing pancreatitis. The eventual outcome is no different from reported surgically treated cases.

Although obesity is a frequent feature of type 2 diabetes mellitus (DM), many patients with type 1 DM are prone to high body mass index (BMI). We measured serum leptin concentrations in a cohort of children (n = 55) with type 1 diabetes mellitus (DM), as well as their anthropometric parameters including BMI, skin fold thickness at multiple sites, and midarm circumference. Glycemic control was assessed by blood glucose (BG) monitoring before meals, and measurement of glycated hemoglobin (HbA1c) and insulin dose/kg/d was recorded. Dietary evaluation and assessment of caloric intake (kg/d) was performed by an expert dietitian. In the newly diagnosed children (n = 10) before initiation of insulin therapy, circulating leptin concentration was significantly lower (1.1 +/- 0.8 ng/dL) versus 5 days after insulin therapy (1.45 +/- 0.7 ng/dL). The decreased leptin level appears to be related to insulinopenia in these patients. In 45 children with type 1 DM on conventional therapy (2 doses of insulin mixture (NPH and regular) subcutaneous (SC) before breakfast and dinner for more than 2 years), serum leptin concentration was significantly higher (2.15 +/- 1 ng/dL) compared with age-matched normal children (1.3 +/- 1 ng/dL). Diabetic children were further divided into 2 groups according to their HbA1c level: group 1 with HbA1C less than 7.5% (less than 2 SD above the mean for normal population) (n = 29) and group 2 with HbA1c greater than 7.5%. (greater than 2 SD above the mean for normal population) (n = 16). Patients with a higher HbA1c level (group 2) had a higher leptin concentration (2.3 +/- 0.8 ng/dL), higher BMI (17.8 +/- 1.7), and were receiving higher insulin dose/kg (0.92 +/- 0.2 U/kg/d) compared with group 1 (lower HbA1c) (1.78 +/- 0.8 ng/dL, 16.7 +/- 1.5, and 0.59 +/- 0.2 U/kg/d, respectively). Group 2 patients had a higher incidence of late morning hypoglycemia (9/29) versus group 1 patients (2/16). Analysis of dietary intake showed that patients with a higher HbA1c (group 2) consumed more calories (73.5 +/- 10.5 kcal/kg/d) versus patients with lower HbA1c (64.2 +/- 8.7 kcal/kg/d). These findings pointed to the unphysiologic nature of injecting a mixture of insulin twice daily. To cover the relatively big lunch meal (40% to 50% of the total caloric intake in the Arab countries) and prevent afternoon hyperglycemia, there is a great tendency to increase NPH dose before breakfast. This, in turn, induces late-morning hypoglycemia and increases appetite and food intake at that time. Multiple regression analysis showed that circulating leptin concentrations (the dependent variable) were best correlated with the mean skinfold thickness (SFT), BMI, and caloric intake/kg/d (together they explained 65% of the variability in leptin concentrations). It appears that oversubstitution by insulin and increased food intake stimulate fat synthesis and subsequently BMI. Increased appetite and BMI contribute to increased leptin secretion and explains the higher leptin levels in undercontrolled diabetic children (higher circulating HbA1c concentrations) who were oversubstituted by insulin.

Background & Aims Many first-degree relatives of patients with Crohn's disease (CD) have increased intestinal permeability. Video capsule endoscopy (VCE) is the most sensitive imaging test to identify small bowel mucosal lesions that could indicate subclinical CD. We aimed to estimate the association of increased intestinal permeability with small bowel ulcerations detectable by VCE in healthy first-degree relatives of patients with CD. Methods We conducted a cross-sectional study of 223 healthy, asymptomatic first-degree relatives of patients with CD (parents, siblings, and children; 9–45 years old) enrolled at the University of Alberta between 2009 and 2012. Patients were given the lactulose and mannitol test to measure small bowel permeability; we used high-performance liquid chromatography to measure concentrations of lactulose and mannitol in urine samples (increased permeability defined as a ratio of lactulose/mannitol 0.025 or greater). Patients with increased permeability (n = 39) and randomly selected subjects with normal permeability (n = 59) were then examined by VCE for signs of small bowel inflammation and subclinical CD. The prevalence of small bowel lesions was compared among groups. We performed logistic regression analyses to estimate odds ratios for the association of small bowel ulcerations with intestinal permeability. Results Among 223 first-degree relatives of patients with CD, 30% were found to have increased intestinal permeability; VCE examination found 24% of subjects to have 3 or more small bowel ulcers. Three or more small bowel ulcers were detected in 28% of patients with increased intestinal permeability and 20% of patients with normal intestinal permeability ( P = .37). The adjusted odds ratio for the association of 3 or more small bowel ulcers with increased intestinal permeability was 1.5 (95% confidence interval, 0.6–3.8; P = .46). Conclusions Thirty percent of healthy, asymptomatic first-degree relatives of patients with CD have increased intestinal permeability. However, a strong association of small bowel ulceration seen on VCE with increased intestinal permeability was not observed.

Thiopurines are widely used for maintenance treatment of inflammatory bowel disease. Inter-individual variability in clinical response to thiopurines may be attributed to several factors including genetic polymorphisms, severity and chronicity of disease, comorbidities, duration of administration, compliance issues and use of concomitant medication, environmental factors and clinician and patient preferences. The purpose of this review is to summarise the current evidence on thiopurine safety and toxicity, to describe adverse drug events and emphasise the significance of drug interactions, and to discuss the relative safety of thiopurine use in adults, elderly patients, children and pregnant women. Thiopurines are safe to use and well tolerated, however dose adjustment or discontinuation of treatment must be considered in cases of non-response, poor compliance or toxicity. Drug safety, clinical response to treatment and short to long term risks and benefits must be balanced throughout treatment duration for different categories of patients. Treatment should be individualised and stratified according to patient requirements. Enzymatic testing prior to treatment commencement is advised. Surveillance with regular clinic follow-up and monitoring of laboratory markers is important. Data on long term efficacy, safety of thiopurine use and interaction with other disease modifying drugs are lacking, especially in paediatric inflammatory bowel disease. High quality, collaborative clinical research is required so as to inform clinical practice in the future.

Background: The impact of vitamin D on disease activity among CD patients has been studied as a modulator for autoimmune system. Since higher levels of vitamin D may significantly decrease disease activity. However, little is known about the effect of high doses of vitamin D on disease activity among CD patients. Objectives: Our aims are to determine vitamin D status and disease activity among CD cases in Canada and Saudi Arabia, and evaluate the impact of higher doses of vitamin D compared to EAR on disease activity among CD patients. Methods: This pilot study is a double-blind, randomized, control trial involving approximately 60 recent, active CD patients engaged in induction therapy. The sample size includes patients in Saskatoon, Saskatchewan, Canada (n=30) and Riyadh, Saudi Arabia (n=30). The patients have been divided into three groups to receive different oral doses of vitamin D including: 1: 400 IU/day (Control group, EAR level) 2: 2,000 IU/day 3: 10,000 IU/day. The study is expected to last betw...

UNLABELLED Colectomy and ileal pouch anal anastomosis (IPAA) is a potentially curative option for patients with ulcerative colitis (UC). A rare, postoperative complication is terminal ileitis which has been poorly documented in paediatric patients. A search of our paediatric inflammatory bowel disease (IBD) database revealed two boys with UC who were resistant to medical therapy. They each underwent colectomy with IPAA. One year later, both children represented with bloody diarrhoea and weight loss. Several endoscopies and biopsies showed acute on chronic mucosal inflammation in the pouch and up to 50 cm into the terminal ileum (TI). Biopsies revealed mixed inflammatory infiltrate with no granulomas. CONCLUSION Development of terminal ileitis after colectomy and IPAA can occur in children with UC. Although every effort should be made to exclude Crohn's disease as a cause of the terminal ileitis, this poorly defined condition should not be considered to be against the diagnosis of UC. More research is needed to develop a better understanding of the aetiopathogenesis of this uncommon condition.

Celiac disease (CD) is a common autoimmune enteropathy that occurs, in affected individuals, with exposure to gluten in the diet and improves with removal of dietary gluten. Although CD is readily considered in patients with classical presentations of the disease, atypical manifestations may be the only presenting symptoms. We present a case of CD in a 16-year-old female presenting as fever of unknown origin, which has not been reported previously. The postulated mechanism for fever in CD and the importance of clinicians having a low threshold for considering CD in the differential diagnosis of fever of unknown origin and other enigmatic clinical presentations is discussed.