Tumour necrosis factor inhibitors (TNFi) are effective in treating children with moderately to severely active ulcerative colitis (UC) and Crohn’s disease (CD). However, nonresponse or loss of response to therapy may lead to sequential biologic treatment. Factors associated with TNFi discontinuation in children are not well known. The aim of this study was to assess for clinical factors associated with first and subsequent TNFi discontinuation in a large paediatric inflammatory bowel disease (IBD) cohort. We performed a retrospective study using data from ImproveCareNow (ICN), a multicentre, prospective paediatric IBD registry. Patients with CD and UC who were treated with their first TNFi after enrolment into ICN were identified at 39 participating ICN sites. Clinical information was obtained from the ICN database and chart review. The association of factors with TNFi discontinuation was assessed with Cox regression analysis. Eight hundred and forty-six patients (678 CD, 168 UC) who fulfilled inclusion criteria were identified. Infliximab (IFX) was used first in 89% of CD patients, while 11% received adalimumab (ADA) first. On univariate analysis, discontinuation of the first TNFi in CD was associated with colonic only vs. ileocolonic disease location (hazard ratio (HR), 1.94; 95% confidence interval (CI), 1.28–2.94, p = 0.002) and higher shortPCDAI (HR, 1.01 per 1 unit increase in shortPCDAI; 95% CI 1.00–1.02, p = 0.032) and prednisone use (HR, 1.49; 95% CI 1.07–2.08, p = 0.017) at the time of TNFi initiation. Concomitant immunomodulator therapy was not shown to be associated with first TNFi discontinuation (p = 0.23) (Figure 1). Kaplan–Meier analysis of the effect of immunomodulator use within the first 6 months of first TNF inhibitor treatment on TNF inhibitor durability in paediatric Crohn’s disease, p = 0.23. Discontinuation of the second TNFi (86% ADA, 14% IFX) in CD was associated with abnormal C-reactive protein (HR 3.33; 95% CI 1.05–10.55, p = 0.041), lower albumin (p = 0.006) and haematocrit (p = 0.032) at the time of second biologic initiation, and the presence of upper gastrointestinal (GI) tract CD (HR, 3.25; 95% CI 1.13–9.35, p = 0.029). IFX was used first in 94% of UC patients, while 6% received ADA first. Discontinuation of the first TNFi in UC was more common with ADA compared with IFX (HR, 2.43; 95% CI 1.02–5.80, p = 0.045). None of these clinical variables were significant in multivariable analysis. Multiple factors associated with TNFi discontinuation in paediatric IBD patients were identified, including colonic only and upper GI tract CD location as well as markers of more severe CD. Prospective studies are needed to confirm these findings.

Background: Inflammatory bowel diseases (IBD) are chronic gastrointestinal diseases requiring medical therapy to maintain clinical remission. Adherence to medications is recognized to improve disease outcomes, yet it is a challenging task for patients, furthermore non-adherence is not well recognized by health care providers. The aim of this study was to evaluate adherence in pediatric IBD patients using a recently validated adherence scale and to compare the results to physician perception of adherence. Methods: IBD patients, ages 11 to 21 years were asked to fill 8-item Morisky Medication Adherence Scale (MMAS-8). Physicians who were blinded to the instrument results completed a routine electronic medical note that included their perception of patient's adherence recorded as adherent or non adherent. We retrospectively reviewed charts and compared physician adherence evaluation vs. patient's MMAS-8 results. Results: Out of 64 patients, 41 had a diagnosis of Crohn's disease and 23 had ulcerative colitis with mean disease duration of 28.9 months. The mean age was 16.7; 46.8% were female. Hispanics comprised 51.4% of our patients and African Americans comprised 25% of our patients. Fifty-six patients had both MMAS-8 and a physician adherence evaluation. Using the MMAS-8, 26/56 (46%) of IBD patients were identified to have low adherence, 21 (36%) had medium adherence and only 11 (18%) had high adherence. Physicians classified correctly all patients with high adherence but only 50% of patients with low adherence and 25% of patients with medium adherence. Conclusions: Adherence to medications is challenging for IBD patients. Screening for medication adherence is important in identifying patients at risk of non- adherence, who might benefit from interventions that will improve patient care and outcome. Identifying non-adherence is challenging for physicians and using MMAS-8 is a reliable validated survey that can be incorporated into routine use.

O-11 Real world outcomes of contemporary treatments in children with Crohn’s disease: observations from the pediatric IBD collaborative research group registry J. Markowitz1 *, T. Lerer2, J. Morganstern2, C. Deslandres2, G. Tomer2, M. Schaefer3, S. Kugathasan2, W. Faubion2, M. Kappelman2, B. Sudel2, M. Hitch2, D. Keljo2, A. Grossman2, R. Carvalho2, N. Leleiko2, S. Saeed2, M. Oliva-Hemker2, M. Kay2, J. Rosh2, M. Pfefferkorn2, A. Otley2, J. Rick2, D. Mack2, J. Cabrera2, A. Griffiths2, J. Hyams2. 1Cohen Children’s Medical Center of NY, Lake success, United States of America, 2The Pediatric IBD Collaborative Research Group, Hartford, United States of America, 3The Pediatric IBD Collaborative Group, Hartford, United States of America

There is evidence of significant variation in the care of pediatric Crohn disease patients. Variation in the delivery of effective therapy may reduce the likelihood of favorable outcomes. Quality Improvement (QI) methods aimed at improving systems of care delivery can reduce unwanted variation and improve patient outcomes. To determine whether participation in a quality improvement collaborative for Crohn disease was associated with improvement in process measures (e.g., documentation of growth and nutrition parameters, medication dosing) and outcome measures (e.g., improved remission rates—the proportion of children in remission). The ImproveCareNow Collaborative was formed in 2007 at 9 pediatric gastroenterology practices. Practices received training in QI, developed care algorithms, enrolled patients into a registry, and began testing small changes in systems of chronic illness care. In early 2008, additional QI tools including a pre-visit planner and population management report were implemented. Several process and outcome measures, including thiopurine dosing, growth and nutritional status, and disease activity based on Physician Global Assessment (PGA) were assessed at each visit. Results were reported monthly and compared by chi square analysis. Visits of over 1,000 Crohn disease patients were analyzed. The reliability of the assessment of growth, nutrition, disease phenotype and disease severity increased from 21% to 86% (p<0.01). The measurement of TPMT prior to the use of a thiopurine increased from 52% to 92% (p<0.01). Administration of the recommended initial dose of thiopurine increased from 44% to 63% (p= 0.07). Satisfactory nutritional status (89%) and growth status (93%) remained the same although variation among sites decreased. Through July 2009, the remission rate had increased from 49% to 67% (p<0.05). These preliminary results suggest that participation in a QI collaborative is associated with improvement in the process of care and in remission rates. Further work to confirm these findings and determine the key drivers of this improvement is underway.

Journal of Pediatric Gastroenterology and NutritionVolume 39, Issue S1 p. S296-S296 ABSTRACTS: Poster Session Abstracts P0629 CARCINOID TUMOR COMPLICATING CROHN’S DISEASE IN A CHILD WITH INTESTINAL OBSTRUCTION G. Tomer, G. Tomer Division of Pediatric Gastroenterology, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this authorS. Narwal, S. Narwal Division of Pediatric Gastroenterology, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this authorG. Bultron, G. Bultron Department of Pediatrics, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this authorG. Wetzler, G. Wetzler Division of Pediatric Gastroenterology, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this author G. Tomer, G. Tomer Division of Pediatric Gastroenterology, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this authorS. Narwal, S. Narwal Division of Pediatric Gastroenterology, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this authorG. Bultron, G. Bultron Department of Pediatrics, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this authorG. Wetzler, G. Wetzler Division of Pediatric Gastroenterology, Maimonides Medical Center, Brooklyn, United StatesSearch for more papers by this author First published: 01 June 2004 https://doi.org/10.1002/j.1536-4801.2004.tb13059.x Submitted by: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume39, IssueS1June 2004Pages S296-S296 RelatedInformation

A wide range of cholestatic liver diseases result from various primary defects in bile formation. Clinical features include jaundice, pruritus, failure to thrive, fat malabsorption, cholelithiasis, and variably progressive cirrhosis. Accurate diagnosis of these disorders is essential for determination of prognosis and selection of the most appropriate therapies. Severe genetic defects in canalicular bile acid and phospholipid excretion lead to progressive liver disease that often requires liver transplantation. Defects in bile acid biosynthesis and aminophospholipid transport may be responsive to medical or non-transplant surgical approaches.

OBJECTIVES:NOD2/CARD15 variants have recently been shown to be associated with Crohn's disease (CD). No analysis of NOD2/CARD15 gene variants has so far been reported in pediatric patients. Therefore, our aim was to analyze NOD2/CARD15 gene variants in children with CD and to perform genotype-phenotype analyses.METHODS:We studied 101 children with CD and 136 healthy controls. Detailed phenotypic information was obtained from each patient. Patients were genotyped for the three NOD2/CARD15 variants R702W (single nucleotide polymorphism 8 [SNP8]), G908R (SNP12), and L1007fs (SNP13), and genotype-phenotype correlations were performed.RESULTS:We found 33 NOD2/CARD15 mutations in 29 of 101 patients (29%). The frequency of NOD2 variation was 31% in white (n = 87) compared with 11% in controls (χ2= 14; p = 0.0001; OR = 3.7; 95% CI = 1.7–7.8). Four white patients but not control subjects were compound heterozygotes. NOD2/CARD15 variants were significantly associated with ileal disease (χ2= 4.5; p = 0.03; OR = 5; 95% CI = 0.9–35.9). Of the children with NOD2/CARD15 variants, 44% were ≤5th percentile for weight at diagnosis, whereas only 15% of children without mutations were ≤5th percentile (χ2= 8.7; p = 0.003; OR = 4.5; 95% CI = 1.4–14.4). Similar trends were observed for height but they did not reach statistical significance.CONCLUSIONS:Our results demonstrate that: 1) the three NOD2/CARD15 variants confer risk to CD in children; 2) NOD2/CARD15 variants are associated with ileal disease in children as in adults; and 3) NOD2/CARD15 variants are associated with lower weight percentiles at diagnosis in children and a tendency toward lower height percentile, suggesting an association between growth in children with CD.

in UC patients in this cohort was low.Conclusion: Whereas CARD15 mutations were so far only reported in CD, we now also demonstrate an increased prevalence in UC patients belonging to mixed families.Also ASCA was more frequent in these UC patients.Inversely, ASCA was less frequent in the CD patients from these mixed families.We therefore show further evidence that mixed IBD families behave differently and that they might represent a distinct entity.A yet unidentified ( genetic or environmental? ) factor must play a role in the different clinical presentations observed in these families.Table I CARDI~ % ASCA+ % Fa.NCA+ % CD Mixed 48.4 35.5 6.

Minocycline-induced autoimmune hepatitis and systemic lupus erythematosus-like syndrome. Andrew Gough, Stephen Chapman, Kate Wagstaff, Paul Emery, Elwyn Elias. BMJ 1996;312:169–72. Summary: Gough et al. describe seven cases of autoimmune hepatitis occurring during minocycline therapy. Six of the patients were girls, and the length of minocycline exposure was variable (6 weeks to 2 years). The clinical features of the illness included fever, polyarthralgia or polyarthritis, rash, malaise, anorexia, and jaundice. Five patients had development of severe hepatitis and were positive for antinuclear antibody. Liver biopsy specimens showed moderately severe changes of acute and chronic hepatitis. Other autoantibodies tested (DNA, smooth muscle, and mitochondrial antibodies) were negative. In addition, hepatitis viral screens were negative. All seven patients' symptoms and laboratory abnormalities returned to normal within 3 months of discontinuing minocycline. The authors also reviewed all cases of reported minocycline reactions in the United Kingdom until 1994. There were 11 cases of systemic lupus erythematosus and 16 cases of hepatitis related to minocycline use. There was a slight female preponderance, and the duration of minocycline use varied from several months to 4 years. Most patients had spontaneous recovery on drug withdrawal and recurrence of symptoms on rechallenge. However, two patients died, one of severe hepatitis and the other of pancytopenia. Comment: Minocycline is the most commonly prescribed antibiotic for acne. As its use has increased, more serious sequelae have been identified, including serum sickness–like reaction, drug-induced lupus, pneumonitis, hypersensitivity reactions, acute febrile neutrophilic syndrome, and hepatitis (Semin Arthritis Rheum 1999;28:392–7). In the past few years, after minocycline became widely available for treatment of acne, there have been more than 45 reported cases of minocycline-related autoimmune hepatitis. Autoimmune hepatitis is diagnosed by the following: (1) clinical and biochemical evidence of hepatitis, (2) absence of infection with hepatitis viruses, (3) evidence of an autoimmune reaction including presence of autoantibodies and hypergammaglobulinemia, and (4) benefit from immunosuppression. Drug-induced hepatotoxic effects are common and have been attributed to a wide variety of antibiotics such as isoniazid, sulfonamides, tetrahydrochloride, and nitrofurantoin. Although many drugs have been associated with the development of antibodies, drug-associated autoimmune hepatitis is rare and has been described with pemoline, diclofenac, and hydralazine. The exact mechanism is not clearly understood but may involve generation of autoantigens by the drug. Many antibiotics or their active metabolites can bind to cellular macromolecules, which are thereby altered, forming neoantigens that appear foreign to the immune system. The immune responses against such self components can then trigger autoreactions to their unmodified counterpart and/or other autoantigens through epitope spreading (Biomed Pharmacother 1999;53:255–63). Several forms of minocycline-induced hepatotoxicity have been recognized. There is evidence that all tetracyclines can cause direct dose-related hepatotoxic effects. In typical toxin-mediated hepatic injury, there is microvesicular steatosis, portal tract sparing, and a sparse monocellular infiltrate (Antimicrob Agents Chemother 1991;35:1434–6). A second type of minocycline-induced hepatotoxicity, fulminant hepatic failure, can occur as part of an allergic, idiosyncratic reaction (Pharmacother 1992;12:68–72). This type of drug-induced hepatitis can be reversible but can also lead to irreversible failure necessitating liver transplantation. The third type of minocycline-induced hepatic injury manifests as chronic active hepatitis detected by biopsy. The reported cases of chronic active hepatitis occurred after variable exposure to minocycline (21 days to 2 years). The clinical manifestations included jaundice, fatigue, fever, anorexia, arthralgia, arthritis, rash, and positive ANA antibodies. Other serologic markers such as anti-dsDNA, and p-ANCA may be positive. In most of the reported cases the patients' symptoms and laboratory abnormalities returned to normal within 3 months of discontinuing minocycline. Minocycline is a synthetically modified tetracycline with broad-spectrum activity against staphylococcal organisms and anaerobes. This broad activity combined with its long half-life make it an attractive choice for acne in adolescents. Although autoimmune disorders associated with this drug are rare, physicians should be aware that there have been more than 45 cases of minocycline-related autoimmune hepatitis reported in the literature, with various degrees of morbidity ranging from reversible elevation in aminotransferase levels to fulminant hepatic failure requiring liver transplantation. The incidence of abnormal liver function in patients taking minocycline has not been established prospectively. Whether some of the patients have a predisposition to autoimmune disease remains unclear. In most of the cases, resolution occurs after discontinuation of the drug. Patients should, however, be observed for at least 1 year after normalization of test results to exclude autoimmune hepatitis. If liver function does not normalize or worsens, immunosuppressive therapy should be considered. However, it has not been settled how long to wait after discontinuing the drug for liver function to normalize before initiating immunosuppressive treatment. This decision should be individualized based on the patient's clinical status and comorbidites. Pediatric gastroenterologists must be aware of minocycline's potential life-threatening effects. A careful drug history should be obtained in any patient with chronic hepatitis, because many patients may not consider minocycline as a drug but as a cosmetic medicine, and it could be overlooked. Because the reaction may be severe, early recognition and discontinuation of the drug is important to aid recovery and to avoid the need for aggressive interventions such as corticosteroids or immunosuppressants.

When challenged by DNA-damaging agents, Escherichia coli cells respond by inducing the SOS stress response, which leads to an increase in mutation frequency by two mechanisms: translesion replication, a process that causes mutations because of misinsertion opposite the lesions, and an inducible mutator activity, which acts at undamaged sites. Here we report that DNA polymerase V (pol V; UmuC), which previously has been shown to be a lesion-bypass DNA polymerase, was highly mutagenic during in vitro gap-filling replication of a gapped plasmid carrying the cro reporter gene. This reaction required, in addition to pol V, UmuD', RecA, and single-stranded DNA (ssDNA)-binding protein. pol V produced point mutations at a frequency of 2.1 x 10(-4) per nucleotide (2.1% per cro gene), 41-fold higher than DNA polymerase III holoenzyme. The mutational spectrum of pol V was dominated by transversions (53%), which were formed at a frequency of 1.3 x 10(-4) per nucleotide (1. 1% per cro gene), 74-fold higher than with pol III holoenzyme. The prevalence of transversions and the protein requirements of this system are similar to those of in vivo untargeted mutagenesis (SOS mutator activity). This finding suggests that replication by pol V, in the presence of UmuD', RecA, and ssDNA-binding protein, is the basis of chromosomal SOS untargeted mutagenesis.

Mutations caused by DNA damage lead to the development of cancer. The critical step in the formation of these mutations is the replication of unrepaired lesions in DNA by DNA polymerases, a process termed translesion replication. Using a newly developed method for preparation of gapped plasmids, containing a site-specific synthetic abasic site, we analyzed translesion replication with purified mammalian DNA polymerases delta and beta. DNA polymerase delta was found to be unable to replicate through the abasic site. Addition of the sliding DNA clamp PCNA, the clamp loader RFC, and ATP caused a drastic 30-fold increase in translesion replication. Thus, similar to Escherichia coli DNA polymerase III, the processivity accessory proteins enable DNA polymerase delta to bypass blocking lesions. Under comparable conditions, DNA polymerase beta was unable to bypass the abasic site, unless its concentration was greatly increased. Analysis of translesion replication products revealed a marked difference in the specificity of bypass: whereas 90% of bypass events by DNA polymerase delta holoenzyme involved insertion of a dAMP residue opposite the abasic site, DNA polymerase beta tended to skip over the abasic site, producing mainly minus frameshifts (73%). The significance of these results for in vivo translesion replication is discussed.

DNA damage-induced mutations are formed when damaged nucleotides present in single-stranded DNA are replicated. We have developed a new method for the preparation of gapped plasmids containing site-specific damaged nucleotides, as model DNA substrates for translesion replication. Using these substrates, we show that the DNA polymerase III holoenzyme from Escherichia coli can bypass a synthetic abasic site analogue with high efficiency (30% bypass in 16 min), unassisted by other proteins. The theta and tau subunits of the polymerase were not essential for bypass. No bypass was observed when the enzyme was assayed on a synthetic 60-mer oligonucleotide carrying the same lesion, and bypass on a linear gapped plasmid was 3-4-fold slower than on a circular gapped plasmid. There was no difference in the bypass when standing-start and running-start replication were compared. A comparison of translesion replication by DNA polymerase I, DNA polymerase II, the DNA polymerase III core, and the DNA polymerase III holoenzyme clearly showed that the DNA polymerase III holoenzyme was by far the most effective in performing translesion replication. This was not only due to the high processivity of the pol III holoenzyme, because increasing the processivity of pol II by adding the gamma complex and beta subunit, did not increase bypass. These results support the model that SOS regulation was imposed on a fundamentally constitutive translesion replication reaction to achieve tight control of mutagenesis.

Error-prone DNA repair consists of replicative filling-in of DNA gaps carrying lesions. We have reconstituted E. coli SOS error-prone repair using purified DNA polymerase III holoenzyme, SSB, RecA, UmuD', a UmuC fusion protein, and a gap lesion plasmid. In the absence of UmuDC, or without SOS induction, replication skips over the lesion, forming mostly one-nucleotide deletions. These cause translational frameshifts that usually inactivate genes. UmuD' and UmuC, in the presence of RecA and SSB, stimulate translesion replication and change its mutagenic specificity such that deletions are prevented and base substitutions are increased. This results in mutagenic but nondetrimental gap repair and provides an effective mechanism for generating genetic variation in bacteria adapting to environmental stress.

The replication of damaged nucleotides that have escaped DNA repair leads to the formation of mutations caused by misincorporation opposite the lesion. In Escherichia coli, this process is under tight regulation of the SOS stress response and is carried out by DNA polymerase III in a process that involves also the RecA, UmuD' and UmuC proteins. We have shown that DNA polymerase III holoenzyme is able to replicate, unassisted, through a synthetic abasic site in a gapped duplex plasmid. Here, we show that DNA polymerase III*, a subassembly of DNA polymerase III holoenzyme lacking the beta subunit, is blocked very effectively by the synthetic abasic site in the same DNA substrate. Addition of the beta subunit caused a dramatic increase of at least 28-fold in the ability of the polymerase to perform translesion replication, reaching 52% bypass in 5 min. When the ssDNA region in the gapped plasmid was extended from 22 nucleotides to 350 nucleotides, translesion replication still depended on the beta subunit, but it was reduced by 80%. DNA sequence analysis of translesion replication products revealed mostly -1 frameshifts. This mutation type is changed to base substitution by the addition of UmuD', UmuC, and RecA, as demonstrated in a reconstituted SOS translesion replication reaction. These results indicate that the beta subunit sliding DNA clamp is the major determinant in the ability of DNA polymerase III holoenzyme to perform unassisted translesion replication and that this unassisted bypass produces primarily frameshifts.