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Volume 49, Number 8, September 2015

and associated autoimmune conditions. Adv Pediatr. 2008;55:349–365. Culliford AN, Green PH. Refractory sprue. Curr Gastroenterol Rep. 2003;5:373–378. Koletzko S, Niggemann B, Arato A, et al. European Society of Pediatric Gastroenterology, Hepatology, and Nutrition. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatric Gastroenterol Nutr. 2012;55:221–229. Syrigou E, Angelakopoulou A, Merikas E, et al. Soy allergy complicating disease management in a child with coeliac disease. Pediatr Allergy Immunol. 2014;25: 826–828. Heine RG, Verstege A, Mehl A, et al. Proposal for a standardized interpretation of the atopy patch tests in children with atopic dermatitis and suspected food allergy. Pediatr Allergy Immunol. 2006;17:213–217. Kristjansson G, Venge P, Hallgren R. Mucosal reactivity to cow’s milk protein in coeliac disease. Clin Exp Immunol. 2007;147:449–455. Faulkner-Hogg KB, Selby WS, Loblay RH. Dietary analysis in symptomatic patients with coeliac disease on a gluten-free diet: the role of trace amounts of gluten and non-gluten food intolerances. Scand J Gastroenterol. 1999;34:784–789. Altschul SF, Madden TL, Schaffer AA, et al. Gapped BLAST and PSI-BLAST: a new generation of protein database search programs. Nucleic Acids Res. 1997;25:3389–3402. Sollid LM. Molecular basis of celiac disease. Annu Rev Immunol. 2000;18:53–81.

Fecal Calprotectin as a Predictor of Relapse in Patients With Inflammatory Bowel Disease To the Editor: We read with interest the article by Rocio Ferreiro-Iglesias evaluating the predictive value of a rapid fecal calprotectin (FC) test to predict flares in patients with inflammatory bowel disease (IBD) under maintenance therapy with infliximab.1 The author found that FC is a promising marker of intestinal inflammation and is able C. D., M. J., and M.-J. S. wrote the paper. C. D. and M.-J. S. had the original idea for the paper. All authors reviewed and approved the final draft of the paper. The authors declare that they have nothing to disclose.

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to predict relapse within the following 8 weeks in patients with IBD under remission with infliximab therapy. Because their findings are important to current practices, several questions deserve attention. It would indeed be attractive for patients if repetitive determination of FC could help predict flares in patients with IBD under maintenance therapy with infliximab. It will be of interest to ascertain whether FC has sufficient sensitivity to detect these lesions in patients with IBD and whether it will be able to replace endoscopy ultimately in this case. The role of FC in assessing the relapse of IBD has been debated because of inconsistent results in small studies. At the same time, the specificity of FC has been questioned, and where to set the FC baseline level is an important issue. Rocio FerreiroIglesias’s study showed that an FC level 60% over the following 8 weeks. However, Wright et al’s2 study showed that a cutoff of FC > 100 mg/g identified patients with endoscopic recurrence with 89% sensitivity and 58% specificity. In patients with IBD, there will be some degree of variability based on disease activity. The issue of intraindividual variability must be considered, and there is variability of FC concentrations within patients with IBD. To maximize utility, FC that is measured on a continuous scale should be considered along the continuum across which it is measured rather than exclusively as a dichotomous variable. There is a trade-off between sensitivity and specificity across the continuum. As such, a single cutoff point may not be optimal in all circumstances. For the low-risk patient, serial FC measurements may be sufficient. For the intermediate-risk patient, serial FC might be used but with a lower threshold for confirmatory colonoscopy. Finally, for high-risk patients, colonoscopy may remain the preferred test to assess for endoscopic recurrence. Thus, FC measurements would not replace colonoscopy but may serve as a complementary investigation. In summary, FC has a potential role in noninvasive monitoring of IBD patients under infliximab therapy. The use of FC and colonoscopy based on patient characteristics could improve the economics and feasibility. Future

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Letters to the Editor

studies are needed to evaluate whether disease activity monitoring by FC alters clinical outcomes in the long term and they should gather additional information to help us understand the optimal frequency to measure FC. Cong Dai, MD, PhD Min Jiang, MD, PhD Ming-Jun Sun, MD, PhD Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang City, Liaoning Province, China

REFERENCES 1. Ferreiro-Iglesias R, Barreiro-de Acosta M, Otero Santiago M, et al. Fecal calprotectin as predictor of relapse in patients with inflammatory bowel disease under maintenance infliximab therapy. J Clin Gastroenterol. 2015 [Epub ahead of print]. 2. Wright EK, De Cruz P, Hamilton AL, et al. Measurement of fecal calprotectin improves monitoring and detection of recurrence of Crohn’s disease after surgery. Gastroenterology. 2015;148:938–947.

Water Toxicity During Antroduodenal Manometry To the Editor: A 2-year-old boy weighing 10 kg had complex medical problems resulting from fetal valproate syndrome. He had intestinal failure secondary to intestinal dysmotility and was admitted for antroduodenal manometry. The manometry catheter (MMS 20 channels 2.5 cm apart water-perfused system, infusing 0.15 mL/min) was placed by interventional radiologists in a satisfactory position. He was started on normal maintenance intravenous fluids. Six hours into the study he had a generalized tonic-clonic seizure which was noted to resolve following 2 doses of benzodiazipine. He had a further generalized tonic-clonic seizure 2 hours later and had plasma [Na] of 108 mmol/ L; it was 139 mmol/L on admission. His urine [Na] was 52 mmol/L with an osmolality of 163 mOsm/kg, serum M.T.D. has received consultancy fees from Sandoz pharmaceuticals and payment for lectures from Novo Nordisk, Sandoz, and Ferring. The remaining authors declare that they have nothing to disclose.

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Fecal Calprotectin as a Predictor of Relapse in Patients With Inflammatory Bowel Disease.

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