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Epidemiology of vitamin D deficiency in children with inflammatory bowel disease presenting to a tertiary care center in the UK
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Abstracts / Digestive and Liver Disease 45 (2013) e263–e311
expression in DCs. Altogether those data suggest that gliadin could influence the immune system of healthy subjects, potentially contributing to the development of gluten related disorders.
PO12 WEB NETWORK FOR DIAGNOSIS AND FOLLOW-UP OF COELIAC PATIENTS: A PILOT PROJECT OF THE DEPARTMENT OF PEDIATRICS, USL 2 UMBRIA L. Ferraro 1 , E. Carosati 2 , V. Dominijanni 1 , E. Gerardini 1 , R. Cozzali 1 , C. Catassi 3 , G. Castellucci 1 1 Department of Pediatrics, USL 2 Umbria, Foligno, Italy 2 Department of Chemistry, Biology and Biotecnology, Perugia University, Perugia, Italy 3 Department of Pediatrics, Marche Polytechnic, Ancona, Italy
Introduction: Data regarding diagnosis and follow-up of coeliac patients, according to recent recommendation, are collected in our department in a single doc file for each patient. Data collected over more than 10 years with the current storage mechanism are of limited use for research because they does not fit in a single database. Aim of the project is to replace the current storage strategy and management of such data with a single software product of client/server accessible via web from multiple locations concurrently. Material and method: Patient card. The patient card is made up of a registry that lists the personal data (name, social security number, address, telephone number), the center of expertise for diagnosis, date of diagnosis. There can also be one or more links with other cards and for each link the degree of parental relationships (father/mother, son, brother, etc.) can be selected. The patient card also reports on the: (a) age at diagnosis in months; (b) symptoms at onset (chosen from a list); (c) parameters of follow-up (according to ministerial regulations); (d) result of the biopsy classification according to Marsh-Villanacci; (e) result of the endoscopy with text description (report). Parameters of follow-up and symptoms. These data are managed by the software in such a way that the operator is guided in inserting data relating to follow-up. Import of data. You can import your personal data via csv file prepared according to a pre-established scheme while the result of laboratory data files are imported via HL7. It is also possible to enter the data manually. Export of the data. It is possible at any time an export of all data except than personal data in CSV text format Results: With the development of web client server all medical personnel involved in the management of celiac patient has access to a computer system that ensures the application of the most recent guidelines in terms of diagnosis and follow-up. The data for each individual patient will be stored in a single corporate database to be used for research purposes. Among the most immediate implications, it is possible to obtain accurate data of local incidence. It is hoped that in the future the software will also be used in adult gastroenterology centers, both on a regional and national level. Acknowledgement: This project has been funded by Associazione Italiana Celiachia (AIC) Umbria.
PO13 EPIDEMIOLOGY OF VITAMIN D DEFICIENCY IN CHILDREN WITH INFLAMMATORY BOWEL DISEASE PRESENTING TO A TERTIARY CARE CENTER IN THE UK S. Gatti, F. Penagini, F. Torrente, G. Noble-Jamieson, M. Zilbauer, R. Heuschkel Department of Paediatric Gastroenterology, Hepatol, Addenbrooke’s Hospital, Cambridge, UK Objectives: The aim of the study was to determine the epidemiology of vitamin D deficiency in a large cohort of paediatric IBD patients presenting to a tertiary care center in the UK. Methods: This was a retrospective observational study of patients who presented to the Paediatric IBD service at Addenbrooke’s Hospital (Cambridge, UK) between January 2008 and July 2012. We retrospectively recorded 25-hydroxyvitamin D (25-OHD) serum concentration measured in these patients. The first recorded value of 25-OHD for each patient was used in the analysis. Information on age, sex, ethnicity, diagnosis and date/season of sample collection were also obtained. Serum 25-OH D concentration was classified as optimal (>75 nmol/l), suboptimal (50–75 nmol/l), insufficient (25–50 nmol/l) and deficient (<25 nmol/l). Results: A total of 123 children (71 male, 52 female) underwent at least one 25-OHD level measurement. Overall a total of 503 25OHD levels were recorded. Twenty % of patients had 25-OHD levels measured at diagnosis. Regarding diagnosis, 85 patients were found to have Crohn’s disease (CD), 27 Ulcerative Colitis (UC) and 12 were IBD-indeterminate (IBD-U). Patients’ characteristics and main findings are presented in Table 1. Overall 55 patients (45%) were found to be vitamin D deficient or insufficient, 33% had suboptimal levels and only 22% of the patients had optimal levels. There was no significant difference in the prevalence of vitamin D deficiency between CD and UC patients (40% vs 41%). Patients with vitamin D deficiency tended to be older (13.4 vs 12.3, p = 0.0217) and had a longer disease duration (20.5 vs 10.6 months, p = 0.0158) than those who were not deficient. Vitamin D deficiency was found to be statistically (p = 0.003) more common in spring (53%) and winter (54%) than in summer (34%) and autumn (37%). Conclusions: In our study we observed a higher than previously reported prevalence of vitamin D deficiency amongst children with IBD (45%). Our report is the first attempt to clarify the epidemiology of vitamin D deficiency in children with IBD in the UK. Interestingly, vitamin D deficiency was found to be more common in autumn and winter as well as strongly associated with disease duration of disease. Taken together out data lends further support for a potential role of vitamin D in IBD disease pathogenesis and indicates that supplements should be considered particularly in patients with longstanding disease during the autumn and winter months.
Abstracts / Digestive and Liver Disease 45 (2013) e263–e311 Mean ± SD or N (%) All IBD patients (n = 123)
UC (n = 27)
Age, y 12.7 ± 1.66 12 ± 2.79 F/M 0.73 2.8 Ethnicity White 107 (86) 24 (89) Asiatic 4 (3) 0 (0) Other 12 (11) 3 (11) Disease duration (months) 15.6 16.7 Serum 25-OHD levels, nmol/l, 57.6 57.3 Serum 25-OHD levels < 50 nmol/l 55 (45) 39 (41) Serum 25-OHD levels < 25 nmol/l 5 (4) 0 25-OHD < 50 nmol/l according to the season of measurement Winter 18 (54) 4 (28) Spring 9 (24) 1 (20) Summer 13 (34) 3 (75) Autumn 9 (37) 3 (75)
CD (n = 85)
12.9 ± 2.63 0.44 87 (72) 3 (4) 6 (9) 16 57.6 11 (40) 5 (6) 14 (70) 8 (61) 10 (32) 6 (30)
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(IQR: 2.75). Regarding the school attendance only 38.1% (CI 95%: 23.3–52.9) achieved the average national school attendance (95%). Only 33.3% of patients reported their well-being as “very good or excellent” in the previous 3 months with 70.7% reporting their health as being much better or better compared to the previous year. The reported well-being was found to correlate significantly with disease activity index (r = −0.4133, p = 0.0007). The awareness of own disease status was found to be significantly higher (p = 0.042) in patient in remission (72.4%) compared to those not in remission (36.9%). Conclusions: This study represents the first effort to test a set of proposed outcome and quality measures in the management of children with IBD. We found the vast majority of the tested measures to be useful for assessing the quality of care delivered to children with IBD in a local setting. Further studies are now required to be performed in other UK centers ultimately allowing to set a national standard and thereby continuing to improve the quality of care.
PO14 Reference OUTCOME MEASURES IN PAEDIATRIC IBD: DATA FROM A TERTIARY LEVEL CENTER IN UK S. Gatti, M. Brennan, F. Torrente, M. Zilbauer, R. Heuschkel Department of Paediatric Gastroenterology, Hepatol, Addenbrooke’s Hospital, Cambridge, UK Background: Quality of care research is less robust for paediatric Inflammatory Bowel Disease (IBD) than for other chronic illness, with no established measures available across Europe. Given the costs, resource utilization, morbidity associated with IBD and the evidence of a gap between recommended and delivered care, efforts to define IBD standards, measure performance are becoming increasingly important. Objectives: Evaluation of a proposed outcome panel including self-reported outcome in a tertiary paediatric IBD setting. Evaluation of patient’s perception of health. Methods: The panel of outcome measures was designed based on a detailed literature review of currently available quality measures both within IBD and related immune mediated diseases. Patients, consecutively enrolled between November 2012 and February 2013, were asked to fill in a patient’ satisfaction questionnaire (adapted from QUOTE-IBD1) [1]. Data were collected from medical notes and electronic records (e-MR) and the selfreported outcomes were extrapolated from the questionnaire. The project was registered as an audit. Eighty-one questionnaires were handed out, 76 patients returned the questionnaire (96%) and were prospectively included in the study (mean age: 12.89 ± 2.5; M/F: 1.1/1). The following measures (% of children) were considered: (1) six months steroid free remission; (2) satisfactory growth and nutritional status; (3) unplanned admissions in the last 12 months; (4) school attendance in the last 12 months; (5) self reported health status. Results: Forty-three patients (63%) had Crohn’s disease (CD), 17% had Ulcerative Colitis (UC) and 20% had Inflammatory Bowel Disease Unclassified (IBDU). Overall 39% (CI 95%: 28–50) were found to be in remission, with 31.66% being in 6 months steroid free remission (CI 95%: 19.9–43.4). No differences were observed between CD, UC and IBDU patients. Patients with a satisfactory growth status (height > 10◦ percentile) were 83.4% (CI 95%: 74–92.8) and those with satisfactory nutritional status (BMI > 10◦ percentile) were 93.6% (CI 95%: 87.4–99.8). A quarter of the IBD patients (23.8%; CI 95%: 11–36.6) had at least one unplanned admission in the previous year, with a median length of stay of 2.5 days
[1] van der Eijk I, Sixma H, Smeets T, et al. Quality of health care in inflammatory bowel disease: development of a reliable questionnaire (QUOTE-IBD) and first results. Am J Gastroenterol 2001;96:3329–36.
PO15 GROWTH PATTERN IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS S. Ghione, M. Segreto, G. Rossi, E. Dati, F. Vierucci, G. Palla, S. Bertelloni, G. Maggiore Department of Pediatrics, University of Pisa, Pisa Background and aims: About 25% of diagnosis of inflammatory bowel diseases (IBD) are made in childhood, the majority of them around the pubertal growth spurt. Unique to pediatric patients is the potential risk for linear growth impairment as a complication of chronic intestinal inflammation. The aim of this study was to describe the growth pattern of a group of IBD patients and to compare it with the growth of general pubertal population. We also look to relationships between growth impairment, delayed diagnosis and high levels of inflammatory indices. Differences between ulcerative colitis (UC) and Crohn’s disease (CD) were also assessed. Patients and methods: Growth records of 42 patients (UC, n = 24; CD, n = 18) using a Harpender Stadiometer with a mean follow up of 4.8 (±3.6) years were reviewed. Age at onset of symptoms, age at diagnosis, height and weight at the diagnosis and at the last visit were registered, as we did for inflammatory indices (C-reactive protein, RCP and erythrocyte sedimentation rate, ESR). Results: The 42 patients (20 F; 22 M) showed no significant differences between age at onset of symptoms and age at diagnosis (11.8 years and 12.0 years respectively). At diagnosis, height was −0.2 ± 1.2 SDS and body mass index (BMI) −1.2 ± 1.1 SDS; both values were not significantly different from general adolescent population. At last visit (age 16.7 ± 3.6 years) a significant improvement of BMI (−0.7 SDS ± 1.2 vs −1.2 SDS ± 1.1 p < 0,05) was found; height also improved although not significantly (0.0 SDS ± 1.0). Analyzing the different factors involved in a growth impairment a negative correlation between delayed diagnosis and height at final visit was observed (r −0.53, p = 0.003). Comparing UC patients and CD patients, a significant increase of delayed diagnoses in Crohn’s patients (p < 0.006) and significant higher levels of RCP in these patients (p < 0.02) were found. Conclusions: Delayed diagnosis represents an important factors that can negatively influence growth pattern in patients with IBD.
Abstracts / Digestive and Liver Disease 45 (2013) e263–e311
expression in DCs. Altogether those data suggest that gliadin could influence the immune system of healthy subjects, potentially contributing to the development of gluten related disorders.
PO12 WEB NETWORK FOR DIAGNOSIS AND FOLLOW-UP OF COELIAC PATIENTS: A PILOT PROJECT OF THE DEPARTMENT OF PEDIATRICS, USL 2 UMBRIA L. Ferraro 1 , E. Carosati 2 , V. Dominijanni 1 , E. Gerardini 1 , R. Cozzali 1 , C. Catassi 3 , G. Castellucci 1 1 Department of Pediatrics, USL 2 Umbria, Foligno, Italy 2 Department of Chemistry, Biology and Biotecnology, Perugia University, Perugia, Italy 3 Department of Pediatrics, Marche Polytechnic, Ancona, Italy
Introduction: Data regarding diagnosis and follow-up of coeliac patients, according to recent recommendation, are collected in our department in a single doc file for each patient. Data collected over more than 10 years with the current storage mechanism are of limited use for research because they does not fit in a single database. Aim of the project is to replace the current storage strategy and management of such data with a single software product of client/server accessible via web from multiple locations concurrently. Material and method: Patient card. The patient card is made up of a registry that lists the personal data (name, social security number, address, telephone number), the center of expertise for diagnosis, date of diagnosis. There can also be one or more links with other cards and for each link the degree of parental relationships (father/mother, son, brother, etc.) can be selected. The patient card also reports on the: (a) age at diagnosis in months; (b) symptoms at onset (chosen from a list); (c) parameters of follow-up (according to ministerial regulations); (d) result of the biopsy classification according to Marsh-Villanacci; (e) result of the endoscopy with text description (report). Parameters of follow-up and symptoms. These data are managed by the software in such a way that the operator is guided in inserting data relating to follow-up. Import of data. You can import your personal data via csv file prepared according to a pre-established scheme while the result of laboratory data files are imported via HL7. It is also possible to enter the data manually. Export of the data. It is possible at any time an export of all data except than personal data in CSV text format Results: With the development of web client server all medical personnel involved in the management of celiac patient has access to a computer system that ensures the application of the most recent guidelines in terms of diagnosis and follow-up. The data for each individual patient will be stored in a single corporate database to be used for research purposes. Among the most immediate implications, it is possible to obtain accurate data of local incidence. It is hoped that in the future the software will also be used in adult gastroenterology centers, both on a regional and national level. Acknowledgement: This project has been funded by Associazione Italiana Celiachia (AIC) Umbria.
PO13 EPIDEMIOLOGY OF VITAMIN D DEFICIENCY IN CHILDREN WITH INFLAMMATORY BOWEL DISEASE PRESENTING TO A TERTIARY CARE CENTER IN THE UK S. Gatti, F. Penagini, F. Torrente, G. Noble-Jamieson, M. Zilbauer, R. Heuschkel Department of Paediatric Gastroenterology, Hepatol, Addenbrooke’s Hospital, Cambridge, UK Objectives: The aim of the study was to determine the epidemiology of vitamin D deficiency in a large cohort of paediatric IBD patients presenting to a tertiary care center in the UK. Methods: This was a retrospective observational study of patients who presented to the Paediatric IBD service at Addenbrooke’s Hospital (Cambridge, UK) between January 2008 and July 2012. We retrospectively recorded 25-hydroxyvitamin D (25-OHD) serum concentration measured in these patients. The first recorded value of 25-OHD for each patient was used in the analysis. Information on age, sex, ethnicity, diagnosis and date/season of sample collection were also obtained. Serum 25-OH D concentration was classified as optimal (>75 nmol/l), suboptimal (50–75 nmol/l), insufficient (25–50 nmol/l) and deficient (<25 nmol/l). Results: A total of 123 children (71 male, 52 female) underwent at least one 25-OHD level measurement. Overall a total of 503 25OHD levels were recorded. Twenty % of patients had 25-OHD levels measured at diagnosis. Regarding diagnosis, 85 patients were found to have Crohn’s disease (CD), 27 Ulcerative Colitis (UC) and 12 were IBD-indeterminate (IBD-U). Patients’ characteristics and main findings are presented in Table 1. Overall 55 patients (45%) were found to be vitamin D deficient or insufficient, 33% had suboptimal levels and only 22% of the patients had optimal levels. There was no significant difference in the prevalence of vitamin D deficiency between CD and UC patients (40% vs 41%). Patients with vitamin D deficiency tended to be older (13.4 vs 12.3, p = 0.0217) and had a longer disease duration (20.5 vs 10.6 months, p = 0.0158) than those who were not deficient. Vitamin D deficiency was found to be statistically (p = 0.003) more common in spring (53%) and winter (54%) than in summer (34%) and autumn (37%). Conclusions: In our study we observed a higher than previously reported prevalence of vitamin D deficiency amongst children with IBD (45%). Our report is the first attempt to clarify the epidemiology of vitamin D deficiency in children with IBD in the UK. Interestingly, vitamin D deficiency was found to be more common in autumn and winter as well as strongly associated with disease duration of disease. Taken together out data lends further support for a potential role of vitamin D in IBD disease pathogenesis and indicates that supplements should be considered particularly in patients with longstanding disease during the autumn and winter months.
Abstracts / Digestive and Liver Disease 45 (2013) e263–e311 Mean ± SD or N (%) All IBD patients (n = 123)
UC (n = 27)
Age, y 12.7 ± 1.66 12 ± 2.79 F/M 0.73 2.8 Ethnicity White 107 (86) 24 (89) Asiatic 4 (3) 0 (0) Other 12 (11) 3 (11) Disease duration (months) 15.6 16.7 Serum 25-OHD levels, nmol/l, 57.6 57.3 Serum 25-OHD levels < 50 nmol/l 55 (45) 39 (41) Serum 25-OHD levels < 25 nmol/l 5 (4) 0 25-OHD < 50 nmol/l according to the season of measurement Winter 18 (54) 4 (28) Spring 9 (24) 1 (20) Summer 13 (34) 3 (75) Autumn 9 (37) 3 (75)
CD (n = 85)
12.9 ± 2.63 0.44 87 (72) 3 (4) 6 (9) 16 57.6 11 (40) 5 (6) 14 (70) 8 (61) 10 (32) 6 (30)
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(IQR: 2.75). Regarding the school attendance only 38.1% (CI 95%: 23.3–52.9) achieved the average national school attendance (95%). Only 33.3% of patients reported their well-being as “very good or excellent” in the previous 3 months with 70.7% reporting their health as being much better or better compared to the previous year. The reported well-being was found to correlate significantly with disease activity index (r = −0.4133, p = 0.0007). The awareness of own disease status was found to be significantly higher (p = 0.042) in patient in remission (72.4%) compared to those not in remission (36.9%). Conclusions: This study represents the first effort to test a set of proposed outcome and quality measures in the management of children with IBD. We found the vast majority of the tested measures to be useful for assessing the quality of care delivered to children with IBD in a local setting. Further studies are now required to be performed in other UK centers ultimately allowing to set a national standard and thereby continuing to improve the quality of care.
PO14 Reference OUTCOME MEASURES IN PAEDIATRIC IBD: DATA FROM A TERTIARY LEVEL CENTER IN UK S. Gatti, M. Brennan, F. Torrente, M. Zilbauer, R. Heuschkel Department of Paediatric Gastroenterology, Hepatol, Addenbrooke’s Hospital, Cambridge, UK Background: Quality of care research is less robust for paediatric Inflammatory Bowel Disease (IBD) than for other chronic illness, with no established measures available across Europe. Given the costs, resource utilization, morbidity associated with IBD and the evidence of a gap between recommended and delivered care, efforts to define IBD standards, measure performance are becoming increasingly important. Objectives: Evaluation of a proposed outcome panel including self-reported outcome in a tertiary paediatric IBD setting. Evaluation of patient’s perception of health. Methods: The panel of outcome measures was designed based on a detailed literature review of currently available quality measures both within IBD and related immune mediated diseases. Patients, consecutively enrolled between November 2012 and February 2013, were asked to fill in a patient’ satisfaction questionnaire (adapted from QUOTE-IBD1) [1]. Data were collected from medical notes and electronic records (e-MR) and the selfreported outcomes were extrapolated from the questionnaire. The project was registered as an audit. Eighty-one questionnaires were handed out, 76 patients returned the questionnaire (96%) and were prospectively included in the study (mean age: 12.89 ± 2.5; M/F: 1.1/1). The following measures (% of children) were considered: (1) six months steroid free remission; (2) satisfactory growth and nutritional status; (3) unplanned admissions in the last 12 months; (4) school attendance in the last 12 months; (5) self reported health status. Results: Forty-three patients (63%) had Crohn’s disease (CD), 17% had Ulcerative Colitis (UC) and 20% had Inflammatory Bowel Disease Unclassified (IBDU). Overall 39% (CI 95%: 28–50) were found to be in remission, with 31.66% being in 6 months steroid free remission (CI 95%: 19.9–43.4). No differences were observed between CD, UC and IBDU patients. Patients with a satisfactory growth status (height > 10◦ percentile) were 83.4% (CI 95%: 74–92.8) and those with satisfactory nutritional status (BMI > 10◦ percentile) were 93.6% (CI 95%: 87.4–99.8). A quarter of the IBD patients (23.8%; CI 95%: 11–36.6) had at least one unplanned admission in the previous year, with a median length of stay of 2.5 days
[1] van der Eijk I, Sixma H, Smeets T, et al. Quality of health care in inflammatory bowel disease: development of a reliable questionnaire (QUOTE-IBD) and first results. Am J Gastroenterol 2001;96:3329–36.
PO15 GROWTH PATTERN IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS S. Ghione, M. Segreto, G. Rossi, E. Dati, F. Vierucci, G. Palla, S. Bertelloni, G. Maggiore Department of Pediatrics, University of Pisa, Pisa Background and aims: About 25% of diagnosis of inflammatory bowel diseases (IBD) are made in childhood, the majority of them around the pubertal growth spurt. Unique to pediatric patients is the potential risk for linear growth impairment as a complication of chronic intestinal inflammation. The aim of this study was to describe the growth pattern of a group of IBD patients and to compare it with the growth of general pubertal population. We also look to relationships between growth impairment, delayed diagnosis and high levels of inflammatory indices. Differences between ulcerative colitis (UC) and Crohn’s disease (CD) were also assessed. Patients and methods: Growth records of 42 patients (UC, n = 24; CD, n = 18) using a Harpender Stadiometer with a mean follow up of 4.8 (±3.6) years were reviewed. Age at onset of symptoms, age at diagnosis, height and weight at the diagnosis and at the last visit were registered, as we did for inflammatory indices (C-reactive protein, RCP and erythrocyte sedimentation rate, ESR). Results: The 42 patients (20 F; 22 M) showed no significant differences between age at onset of symptoms and age at diagnosis (11.8 years and 12.0 years respectively). At diagnosis, height was −0.2 ± 1.2 SDS and body mass index (BMI) −1.2 ± 1.1 SDS; both values were not significantly different from general adolescent population. At last visit (age 16.7 ± 3.6 years) a significant improvement of BMI (−0.7 SDS ± 1.2 vs −1.2 SDS ± 1.1 p < 0,05) was found; height also improved although not significantly (0.0 SDS ± 1.0). Analyzing the different factors involved in a growth impairment a negative correlation between delayed diagnosis and height at final visit was observed (r −0.53, p = 0.003). Comparing UC patients and CD patients, a significant increase of delayed diagnoses in Crohn’s patients (p < 0.006) and significant higher levels of RCP in these patients (p < 0.02) were found. Conclusions: Delayed diagnosis represents an important factors that can negatively influence growth pattern in patients with IBD.