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Coté GA, Yadav D, Abberbock JA, Whitcomb DC, Sherman S, Sandhu BS, Anderson MA, Lewis MD, Alkaade S, Singh VK, Baillie J, Banks PA, Conwell D, Guda NM, Muniraj T, Tang G, Brand R, Gelrud A, Amann ST, Forsmark CE, Wilcox MC, Slivka A, Gardner TB. Recurrent Acute Pancreatitis Significantly Reduces Quality of Life Even in the Absence of Overt Chronic Pancreatitis. Am J Gastroenterol 2018; 113:906-912. [PMID: 29867178 PMCID: PMC6136830 DOI: 10.1038/s41395-018-0087-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 03/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The impact of recurrent acute pancreatitis (RAP) on quality of life (QOL) is unknown. We hypothesized that RAP would reduce QOL even in the absence of chronic pancreatitis (CP). METHODS Data were pooled from three prospective, cross-sectional studies conducted across 27 U.S. centers (the North American Pancreatitis Studies); these included subjects with chronic pancreatitis (n = 1086), RAP alone (n = 508), and non-disease controls (n = 1025). QOL was measured using the Short Form 12 (SF-12), generating a Physical Component Summary (PCS) and the Mental Component Summary score (MCS). Multivariable regression models were developed to measure the effect of RAP on QOL, the predictors of lower QOL in those with RAP, and the differential effect QOL predictors between CP and RAP. RESULTS Compared to controls (51.0 ± 9.4), subjects with RAP (41.1 ± 11.4) and CP (37.2 ± 11.8) had lower PCS (p < 0.01). Subjects with CP had lower PCS compared to those with RAP (p < 0.01). Similarly, MCS was lower among RAP (44.6 ± 11.5) and CP (42.8 ± 12.2) subjects compared to controls (51.7 ± 9.1, p < 0.01). Subjects with CP had lower MCS compared to those with RAP (p < 0.01). After controlling for independent predictors of PCS, RAP was associated with lower PCS (estimate -8.46, p < 0.01) and MCS (estimate -6.45, p < 0.0001) compared to controls. The effect of endocrine insufficiency on PCS was differentially greater among RAP subjects (-1.28 for CP vs. -4.9 for RAP, p = 0.0184). CONCLUSIONS Even in the absence of CP, subjects with RAP have lower physical and mental QOL. This underscores the importance of identifying interventions to attenuate RAP before the development of overt CP.
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Affiliation(s)
- Gregory A Coté
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Dhiraj Yadav
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Judah A Abberbock
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - David C Whitcomb
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Stuart Sherman
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Bimaljit S Sandhu
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michelle A Anderson
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michele D Lewis
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Samer Alkaade
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Vikesh K Singh
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - John Baillie
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Peter A Banks
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Darwin Conwell
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Nalini M Guda
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Thiruvengadam Muniraj
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Gong Tang
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Randall Brand
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andres Gelrud
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Stephen T Amann
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Christopher E Forsmark
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Mel C Wilcox
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Adam Slivka
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Timothy B Gardner
- Medical university of South Carolina, Charleston, SC, USA. University of Pittsburgh Medical Center, Pittsburgh, PA, USA. Indiana university School of Medicine, Indianapolis, IN, USA. Richmond Gastroenterology Associates, Richmond, VA, USA. university of Michigan, Ann Arbor, MI, USA. Mayo Clinic, Jacksonville, FL, USA. Saint Louis university, St. Louis, MO, USA. Johns Hopkins Medical Institutions, Baltimore, MD, USA. Virginia Commonwealth university, Richmond, VA, USA. Brigham and Women's Hospital, Boston, MA, USA. Ohio State university, Columbus, OH, USA. Aurora St. Luke's Medical Center, Milwaukee, WI, USA. Yale School of Medicine, New Haven, CT, USA. University of Chicago, Chicago, IL, USA. Digestive Health Specialists, Tupelo, MS, USA. University of Florida, Gainesville, FL, USA. University of Alabama, Birmingham, AL, USA. Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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