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Pfeiffer-Jensen M, Liao D, Tarp U, Deleuran B, Stengaard-Pedersen K, Venborg J, Brock B, Brock C. Reduced prescription of TNF-inhibitors in chronic arthritis based on therapeutic drug monitoring: A randomized controlled trial. Scand J Rheumatol 2023; 52:468-480. [PMID: 36315419 DOI: 10.1080/03009742.2022.2121081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Dosing of tumour necrosis factor-α inhibitors (TNFis) is not personalized causing interindividual variation in serum drug levels; however, dose optimization is not widely implemented. We hypothesized that some patients are overdosed; thus, drug prescription could be reduced by therapeutic drug monitoring (TDM). METHOD Independent of disease activity, 239 adults treated for rheumatoid arthritis (n = 99), psoriatic arthritis 15 (n = 48), or spondyloarthritis (n = 92) were recruited for a 48-week prospective, randomized open-label trial. Standard care alone or plus TDM was applied in chronic arthritis patients treated with infliximab (IFX), (n = 81), etanercept (ETN) (n = 79), or adalimumab (ADA) (n = 79). Serum TNFi trough levels assessed at inclusion and every 4 months determined patients within/outside predefined therapeutic intervals, supporting change in prescription or drug switch. The primary endpoint was reduced drug prescription. RESULTS Compared to standard care, TDM reduced prescribed IFX [-12% (95% confidence interval -20, -3); p = 0.001] and ETN (-15% (-29, 1); p = 0.01], and prolonged the interdosing intervals of ETN [+235% (38, 432); p = 0.02] and ADA [+28% (6, 51); p = 0.04]. Time to drug switch was accelerated (χ2 = 6.03, p = 0.01). No group differences in adverse events, disease activity, or self-reported outcomes were shown, indicating equally sustained remission. CONCLUSIONS TDM reduced prescription of IFX, ETN, and ADA and identified patients benefiting from accelerated drug switch, thereby minimizing treatment failure, risk of toxicity, and unnecessary adverse events.
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Affiliation(s)
- M Pfeiffer-Jensen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
| | - D Liao
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - U Tarp
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - B Deleuran
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | | | - J Venborg
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - B Brock
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
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2
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Papanna R, Agarwal N, Bergh EP, Brock C, Espinoza J, Johnson A. Fetoscopic laser ablation in pregnancies with Type-II vasa previa. Ultrasound Obstet Gynecol 2023; 61:779-781. [PMID: 36609872 DOI: 10.1002/uog.26153] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/30/2022] [Accepted: 12/16/2022] [Indexed: 06/03/2023]
Affiliation(s)
- R Papanna
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, TX, USA
| | - N Agarwal
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, TX, USA
| | - E P Bergh
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, TX, USA
| | - C Brock
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, TX, USA
| | - J Espinoza
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, TX, USA
| | - A Johnson
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, TX, USA
- Midwest Fetal Center, Minneapolis, MN, USA
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Fadel MG, Walters U, Smith A, Bedi N, Davies C, Brock C, Dinneen M. Splenogonadal fusion: aiding detection and avoiding radical orchidectomy. Ann R Coll Surg Engl 2022; 104:32-34. [PMID: 35100848 DOI: 10.1308/rcsann.2021.1170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Splenogonadal fusion is a rare benign congenital anomaly in which there is an abnormal connection between the gonad and the spleen. It was first described over 100 years ago with limited reports in the literature since then. Its similarity in presentation to testicular neoplasia poses a significant challenge in diagnosis and management, often resulting in radical orchidectomy. We present the case of a 31-year-old man who presented with a rapidly growing left-sided testicular mass and suspicious ultrasound findings; histology from the subsequent radical inguinal orchidectomy showed findings consistent with splenogonadal fusion. We describe points for consideration in the clinical history, examination and imaging that could suggest splenogonadal fusion, including preoperative technetium-99m-sulfur colloid imaging and intraoperative frozen section evaluation, which may confirm the diagnosis and prevent unnecessary orchidectomy.
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Affiliation(s)
- M G Fadel
- Chelsea and Westminster Hospital, London, UK
| | - U Walters
- Chelsea and Westminster Hospital, London, UK
| | - A Smith
- Imperial College London, London, UK
| | - N Bedi
- Chelsea and Westminster Hospital, London, UK
| | - C Davies
- Chelsea and Westminster Hospital, London, UK
| | - C Brock
- Chelsea and Westminster Hospital, London, UK
| | - M Dinneen
- Chelsea and Westminster Hospital, London, UK
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Buskmiller C, Bergh EP, Brock C, Miller J, Baschat A, Galan H, Behrendt N, Habli M, Peiro JL, Snowise S, Fisher J, Macpherson C, Thom E, Pedroza C, Johnson A, Blackwell S, Papanna R. Interventions to prevent preterm delivery in women with short cervix before fetoscopic laser surgery for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2022; 59:169-176. [PMID: 34129709 DOI: 10.1002/uog.23708] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Preoperative short cervical length (CL) remains a major risk factor for preterm birth after laser surgery for twin-twin transfusion syndrome (TTTS), but the optimal intervention to prolong pregnancy remains elusive. The objective of this study was to compare secondary methods for the prevention of preterm birth in twin pregnancies with TTTS undergoing fetoscopic laser photocoagulation (FLP), in the setting of a short cervix at the time of FLP, in five North American Fetal Treatment Network (NAFTNet) centers. METHODS This was a secondary analysis of data collected prospectively at five NAFTNet centers, conducted from January 2013 to March 2020. Inclusion criteria were a monochorionic diamniotic twin pregnancy complicated by TTTS, undergoing FLP, with preoperative CL < 30 mm. Management options for a short cervix included expectant management, vaginal progesterone, pessary (Arabin, incontinence or Bioteque cup), cervical cerclage or a combination of two or more treatments. Patients were not included if the intervention was initiated solely on the basis of having a twin gestation rather than at the diagnosis of a short cervix. Demographics, ultrasound characteristics, operative data and outcomes were compared. The primary outcome was FLP-to-delivery interval. Propensity-score matching was performed, with each treatment group matched (1:1) to the expectant-management group for CL, in order to estimate the effect of each treatment on the FLP-to-delivery interval. RESULTS A total of 255 women with a twin pregnancy complicated by TTTS and a short cervix undergoing FLP were included in the study. Of these, 151 (59%) were managed expectantly, 32 (13%) had vaginal progesterone only, 21 (8%) had pessary only, 21 (8%) had cervical cerclage only and 30 (12%) had a combination of treatments. A greater proportion of patients in the combined-treatment group had had a prior preterm birth compared with those in the expectant-management group (33% vs 9%; P = 0.01). Mean preoperative CL was shorter in the pessary, cervical-cerclage and combined-treatment groups (14-16 mm) than in the expectant-management and vaginal-progesterone groups (22 mm for both) (P < 0.001). There was no significant difference in FLP-to-delivery interval between the groups, nor in gestational age at delivery or the rate of live birth or neonatal survival. Vaginal progesterone was associated with a decrease in the risk of delivery before 28 weeks' gestation compared with cervical cerclage and combined treatment (P = 0.03). Using propensity-score matching for CL, cervical cerclage was associated with a reduction in FLP-to-delivery interval of 13 days, as compared with expectant management. CONCLUSIONS A large proportion of pregnancies with TTTS and a short maternal cervix undergoing FLP were managed expectantly for a short cervix, establishing a high (62%) risk of delivery before 32 weeks in this condition. No treatment that significantly improved outcome was identified; however, there were significant differences in potential confounders and there were also likely to be unmeasured confounders. Cervical cerclage should not be offered as a secondary prevention for preterm birth in twin pregnancies with TTTS and a short cervix undergoing FLP. A large randomized controlled trial is urgently needed to determine the effects of treatments for the prevention of preterm birth in these pregnancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Buskmiller
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - E P Bergh
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - C Brock
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - J Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - H Galan
- Department of Obstetrics and Gynecology, University of Colorado Denver, Colorado Fetal Care Center, Children's Hospital of Colorado, Denver, CO, USA
| | - N Behrendt
- Department of Obstetrics and Gynecology, University of Colorado Denver, Colorado Fetal Care Center, Children's Hospital of Colorado, Denver, CO, USA
| | - M Habli
- Cincinnati Children's Fetal Care Center, Cincinnati, OH, USA
| | - J L Peiro
- Cincinnati Children's Fetal Care Center, Cincinnati, OH, USA
| | - S Snowise
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, MN, USA
| | - J Fisher
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, MN, USA
| | - C Macpherson
- The Biostatistics Center, George Washington University, Rockville, MD, USA
| | - E Thom
- The Biostatistics Center, George Washington University, Rockville, MD, USA
| | - C Pedroza
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - S Blackwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth The University of Texas McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
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Fadel MG, Walters U, Smith A, Bedi N, Davies C, Brock C, Dinneen M. Splenogonadal fusion: aiding detection and avoiding radical orchidectomy. Ann R Coll Surg Engl 2021; 104:e32-e34. [PMID: 33739169 DOI: 10.1308/rcsann.2021.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Splenogonadal fusion is a rare benign congenital anomaly in which there is an abnormal connection between the gonad and the spleen. It was first described over 100 years ago with limited reports in the literature since then. Its similarity in presentation to testicular neoplasia poses a significant challenge in diagnosis and management, often resulting in radical orchidectomy. We present the case of a 31-year-old man who presented with a rapidly growing left-sided testicular mass and suspicious ultrasound findings; histology from the subsequent radical inguinal orchidectomy showed findings consistent with splenogonadal fusion. We describe points for consideration in the clinical history, examination and imaging that could suggest splenogonadal fusion, including preoperative technetium-99m-sulfur colloid imaging and intraoperative frozen section evaluation, which may confirm the diagnosis and prevent unnecessary orchidectomy.
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Affiliation(s)
- M G Fadel
- Chelsea and Westminster Hospital, London, UK
| | - U Walters
- Chelsea and Westminster Hospital, London, UK
| | - A Smith
- Imperial College London, London, UK
| | - N Bedi
- Chelsea and Westminster Hospital, London, UK
| | - C Davies
- Chelsea and Westminster Hospital, London, UK
| | - C Brock
- Chelsea and Westminster Hospital, London, UK
| | - M Dinneen
- Chelsea and Westminster Hospital, London, UK
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6
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Donepudi R, Brock C, Schulte S, Bundock E, Fletcher S, Johnson A, Papanna R, Chauhan S, Tsao K. Trend in ventricle size during pregnancy and its use for prediction of ventriculoperitoneal shunt in fetal open neural tube defect. Ultrasound Obstet Gynecol 2020; 56:678-683. [PMID: 31763720 DOI: 10.1002/uog.21928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 11/03/2019] [Accepted: 11/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Fetal surgery for repair of open neural tube defect (ONTD) typically results in decreased need for a ventriculoperitoneal shunt (VPS). Our objectives were to determine the trend in ventricle size (VS) during pregnancy and whether VS and change in VS, as assessed by ultrasound, were predictive of the need for VPS in pregnancy with ONTD. METHODS This was a retrospective analysis of prospectively collected data of consecutive pregnancies with ONTD, evaluated in a single center from January 2012 to May 2018. Two groups were identified: the first consisted of pregnancies that underwent in-utero repair (IUR) and the second those that had postnatal repair (PNR). Penalized B splines were used to determine the trend in VS, across 2-week gestational-age (GA) epochs, between 24 and 36 weeks of gestation. VS at each GA epoch and the change in VS between each GA epoch were compared between the IUR and PNR groups. To determine whether VS at any GA was predictive of VPS, receiver-operating-characteristics (ROC) curves were used and the optimal cut-off at each GA epoch was identified. Univariate analysis and multiple logistic regression were used for further analysis. RESULTS ONTD was diagnosed in 110 fetuses, of whom 69 underwent IUR and 41 had PNR. Fetuses in the IUR group were more likely to have Chiari II malformation (100.0% vs 82.9%; P < 0.01), lower GA at delivery (34.9 ± 3.2 vs 37.1 ± 2.1 weeks; P < 0.01) and lower rates of VPS within the first year postpartum (36.2% vs 61.0%; P = 0.02) compared with the PNR group. In both groups, VS increased steadily with GA from the initial evaluation to delivery. In the IUR group, there was a significant change in VS between the 24 + 0 to 25 + 6-week and the 26 + 0 to 27 + 6-week epochs (2.3 (95% CI, 0.4-4.1) mm; P = 0.02). There was a positive trend in the change in VS at later GAs, but this was not significant. Although there was no significant change in VS in the PNR group before 30 weeks, there was a positive trend after that time. On multivariate analysis, each week of advancing GA was associated with a mean increase of 0.74 mm in VS (P < 0.0001) in both groups. VS was not associated with the level or type of lesion, but presence of Chiari II malformation was associated with a mean increase of 5.88 mm (P < 0.0001) in VS in both the IUR and PNR groups. VS was modestly predictive of need for VPS in both groups, with area under ROC curves between 0.68 and 0.76 at the different GA epochs. Change in VS between the first and last measurements was also modestly predictive of the need for VPS, with better performance in the PNR group. CONCLUSIONS VS increased with advancing GA in all fetuses with ONTD, although in the IUR group this increase occurred immediately after fetal surgery and in the PNR group it occurred after 30 weeks of gestation. In-utero surgery was associated with a decreased rate of VPS and was more predictive of need for VPS than was VS. Postnatal factors resulting in increased need for VPS in the PNR group need to be assessed further. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Donepudi
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - C Brock
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Schulte
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - E Bundock
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Fletcher
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Pediatric Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - A Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - R Papanna
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - S Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - K Tsao
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
- Department of Pediatric Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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7
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Drewes AM, Brock C, Rasmussen SE, Møller HJ, Brock B, Deleuran BW, Farmer AD, Pfeiffer-Jensen M. Short-term transcutaneous non-invasive vagus nerve stimulation may reduce disease activity and pro-inflammatory cytokines in rheumatoid arthritis: results of a pilot study. Scand J Rheumatol 2020; 50:20-27. [PMID: 33047630 DOI: 10.1080/03009742.2020.1764617] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: Rheumatoid arthritis (RA) is a chronic, autoimmune, inflammatory disease. Studies suggest that pro-inflammatory cytokines may be attenuated by the vagus nerve through the cholinergic anti-inflammatory pathway. We aimed to evaluate the anti-inflammatory effects of short-term transcutaneous non-invasive vagus nerve stimulation (n-VNS) applied to the cervical vagus nerve in patients with RA. Method: We conducted a single-centre, open-label, preliminary proof-of-concept study of n-VNS in two cohorts of participants with RA: one with high disease activity (n = 16) and one with low disease activity (n = 20). Disease Activity Score based on 28-joint count-C-reactive protein (DAS28-CRP), cardiac vagal tone, and pro-inflammatory cytokines were measured at baseline and after 1 and 4 days of n-VNS. Results: In the high disease activity group, n-VNS resulted in reductions in DAS28-CRP (4.1 to 3.8, p = 0.02), CRP (8.2 to 6 mg/mL, p = 0.01), and interferon-γ (29.8 to 22.5 pg/mL, p = 0.02). In the low disease activity group, there was no effect on DAS28-CRP, and n-VNS was associated with a decrease in cardiac vagal tone (p = 0.03) and a reduction in interleukin-10 (0.8 to 0.6 pg/mL, p = 0.02). Participants with high disease activity had lower baseline cardiac vagal tone than those with low disease activity (3.6 ± 2 vs 4.9 ± 3 linear vagal scale, p = 0.03). Cardiac vagal tone was negatively associated with DAS28-CRP (r = -0.37, p = 0.03). Overall, n-VNS was well tolerated. Conclusion: This study provides preliminary support for an anti-inflammatory effect of n-VNS in patients with RA. These findings warrant further investigation in larger placebo-controlled trials.
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Affiliation(s)
- A M Drewes
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital , Aalborg, Denmark
| | - S E Rasmussen
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
| | - H J Møller
- Department of Clinical Biochemistry, Aarhus University Hospital , Aarhus, Denmark
| | - B Brock
- Steno Diabetes Center Copenhagen , Gentofte, Denmark
| | - B W Deleuran
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
| | - A D Farmer
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital , Aalborg, Denmark.,Centre for Trauma and Neuroscience, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London , London, UK.,Institute of Applied Clinical Sciences, University of Keele , Stoke on Trent, UK
| | - M Pfeiffer-Jensen
- Department of Rheumatology, Aarhus University Hospital , Aarhus, Denmark
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Affiliation(s)
| | | | | | - Jason Denney
- University of Missouri–Columbia Columbia, Missouri
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9
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Haas S, Faaborg PM, Gram M, Lundby L, Brock C, Drewes AM, Laurberg S, Krogh K, Christensen P. Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy. Tech Coloproctol 2020; 24:721-730. [PMID: 32323098 DOI: 10.1007/s10151-020-02210-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers. METHODS Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing. RESULTS Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers. CONCLUSIONS Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.
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Affiliation(s)
- S Haas
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark. .,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark.
| | - P M Faaborg
- Department of Surgery, Vejle Hospital, Vejle, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - L Lundby
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - P Christensen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
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Wegeberg AML, Brock C, Brock B, Farmer AD, Hobson AR, Semler JR, Scott SM. Regional gastrointestinal pH profile is altered in patients with type 1 diabetes and peripheral neuropathy. Neurogastroenterol Motil 2018; 30:e13407. [PMID: 30062823 DOI: 10.1111/nmo.13407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/12/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal (GI) symptoms, such as nausea and bloating, are common in people with type 1 diabetes (T1DM). Autonomic dysfunction can lead to changes in the GI secreto-motor function which can be associated with GI symptom development. We hypothesized that regional pH profiles in T1DM differs from health and would be associated with objective physiological/clinical markers. METHODS Forty-seven T1DM with confirmed diabetic sensory peripheral neuropathy and 41 healthy age-matched subjects underwent standardized wireless motility capsule testing. T1DM completed the gastroparesis cardinal symptom index (GCSI) and the gastrointestinal symptom rating scale. Disease duration, glycemic control, insulin usage, and 24-hour heart rate variability testing were evaluated. KEY RESULTS In comparison to healthy subjects, gastric, and large bowel median pH were lower in T1DM (1.8 ± 1.6 vs 2.9 ± 1.5, P = 0.001 and 6.7 ± 0.6 vs 7.0 ± 0.5, P = 0.003, respectively). Additionally, change in pH across the pylorus was lower while change in pH across the ileocecal junction was higher in T1DM (5.2 ± 1.5 vs 5.8 ± 0.5, P = 0.003 and 1.8 ± 0.4 vs 1.3 ± 0.4, P < 0.0001, respectively). No difference was found in small bowel median pH. Gastric median pH was associated with small bowel transit time (r = 0.30, P = 0.049). Change in pH across the pylorus was negatively associated with fasting glycose (r = -0.35, P = 0.027). Small bowel median pH was associated with nausea (r = 0.42, P = 0.005) and small bowel transit time (r = 0.48, P = 0.0007). Large bowel median pH was associated with nausea (r = 0.35, P = 0.018) and the total GCSI score (r = 0.34, P = 0.023). CONCLUSIONS AND INFERENCES The GI pH profile in T1DM with DSPN is different from healthy subjects. Changes in pH profile may have important therapeutic implications and influence pharmacotherapeutic bioavailability.
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Affiliation(s)
- A-M L Wegeberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg and Clinical Institute, Aalborg University, Aalborg, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg and Clinical Institute, Aalborg University, Aalborg, Denmark.,Department of Pharmacotherapy and Development, University of Copenhagen, Copenhagen, Denmark
| | - B Brock
- Steno Diabetes Centre, Copenhagen, Denmark
| | - A D Farmer
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg and Clinical Institute, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK.,Academic Surgical Unit & Neurogastroenterology Group, Centre for Neuroscience and Trauma Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | | | - S M Scott
- Academic Surgical Unit & Neurogastroenterology Group, Centre for Neuroscience and Trauma Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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11
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Farmer AD, Wegeberg AML, Brock B, Hobson AR, Mohammed SD, Scott SM, Bruckner-Holt CE, Semler JR, Hasler WL, Hellström PM, Drewes AM, Brock C. Regional gastrointestinal contractility parameters using the wireless motility capsule: inter-observer reproducibility and influence of age, gender and study country. Aliment Pharmacol Ther 2018; 47:391-400. [PMID: 29210098 DOI: 10.1111/apt.14438] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 09/26/2017] [Accepted: 11/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND The wireless motility capsule concurrently measures temperature, pH and pressure as it traverses the gastrointestinal tract. AIMS To describe normative values for motility/contractility parameters across age, gender and testing centres. METHODS Healthy participants underwent a standardised wireless motility capsule assessment following an overnight fast and consumption of a meal of known nutritional content. Traces were divided into regions of interest and analysed using 2 software packages (MotiliGI and GIMS Data Viewer). Inter-observer agreement was independently assessed by 2 investigators. RESULTS Normative data for motility/contractility parameters (maximum amplitude, mean peak amplitude, contraction frequency and motility index) are presented for 107 individuals (62 male, median age 40 years, range 18-78). MotiliGI-Gastric, small bowel and colonic maximal contraction amplitude correlated with age (r = .24, P = .01; r = .22, P = .02; and r = .2, P = .04 respectively). Small bowel motility index was higher in females than males (150.4 ± 12 vs 122 ± 7.6, P = .04). Inter-observer agreement was excellent for transit times, pH and contractility/motility parameters. GIMS Data viewer-Gastric, small bowel and colonic loge motility index correlated with the respective area under the contraction curve, total contractions, sum of amplitudes and contraction frequency (all r>.35, P < .0003) but not with transit times. CONCLUSIONS Our analysis provides normative data for motility/contractility parameters. Log motility index summarises a number of measures. In future, the measurement of contractile activity with the wireless motility capsule may potentially aid in the diagnosis of disease states such as visceral myopathic disorders.
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Affiliation(s)
- A D Farmer
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark.,Neurogastroenterology Group, Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - A-M L Wegeberg
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark.,School of Medicine and Health, Aalborg University, Aalborg, Denmark
| | - B Brock
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | | | - S D Mohammed
- Neurogastroenterology Group, Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - S M Scott
- Neurogastroenterology Group, Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - C E Bruckner-Holt
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | | | - W L Hasler
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | - P M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg and Clinical Institute, Aalborg University Hospital, Aalborg University, Denmark.,Department of Pharmacotherapy and Development, University of Copenhagen, Copenhagen, Denmark
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12
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Brock C, Jessen N, Brock B, Jakobsen PE, Hansen TK, Rantanen JM, Riahi S, Dimitrova YK, Dons-Jensen A, Aziz Q, Drewes AM, Farmer AD. Cardiac vagal tone, a non-invasive measure of parasympathetic tone, is a clinically relevant tool in Type 1 diabetes mellitus. Diabet Med 2017; 34:1428-1434. [PMID: 28703868 DOI: 10.1111/dme.13421] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 12/19/2022]
Abstract
AIMS To compare a novel index of parasympathetic tone, cardiac vagal tone, with established autonomic variables and to test the hypotheses that (1) cardiac vagal tone would be associated with established time and frequency domain measures of heart rate and (2) cardiac vagal tone would be lower in people with Type 1 diabetes than in a matched healthy cohort and lower still in people with established neuropathy. METHODS Cardiac vagal tone is a validated cardiometrically derived index of parasympathetic tone. It is measured using a standard three-lead electrocardiogram which connects, via Bluetooth, to a smartphone application. A 5-min resting recording of cardiac vagal tone was undertaken and observational comparisons were made between 42 people with Type 1 diabetes and peripheral neuropathy and 23 without peripheral neuropathy and 65 healthy people. In those with neuropathy, 24-h heart rate variability values were compared with cardiac vagal tone. Correlations between cardiac vagal tone and clinical variables were also made. RESULTS Cardiac vagal tone was lower in people with established neuropathy and Type 1 diabetes in comparison with healthy participants [median (interquartile range) linear vagal scale 3.4 (1.6-5.5 vs 7.0 (5.5-9.6); P < 0.0001]. Cardiac vagal tone was positively associated with time (r = 0.8, P < 0.0001) and frequency domain markers of heart rate variability (r = 0.75, P < 0.0001), representing established measures of parasympathetic function. Cardiac vagal tone was negatively associated with age (r=-0.32, P = 0.003), disease duration (r=-0.43, P < 0.0001) and cardiovascular risk score (r=-0.32, P = 0.006). CONCLUSIONS Cardiac vagal tone represents a convenient, clinically relevant method of assessing parasympathetic nervous system tone, potentially facilitating the earlier identification of people with Type 1 diabetes who should undergo formal autonomic function testing.
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Affiliation(s)
- C Brock
- Department of Mech-Sense, Department of Gastroenterology and Hepatology and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
- Department of Pharmacotherapy and Development, University of Copenhagen, Copenhagen
- Department of Rheumatology, Aarhus University Hospital, Aarhus
| | - N Jessen
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus
- Department of Biomedicine, Aarhus University Hospital, Aarhus
| | - B Brock
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus
- Department of Biochemistry, Aarhus University Hospital, Aarhus
| | - P E Jakobsen
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - T K Hansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus
| | - J M Rantanen
- Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - S Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Y K Dimitrova
- Department of Mech-Sense, Department of Gastroenterology and Hepatology and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - A Dons-Jensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus
| | - Q Aziz
- Centre for Neuroscience and Trauma, Wingate Institute of Neurogastroenterology, Blizard Institute, London School of Medicine and Dentistry, Queen Mary University of London, London
| | - A M Drewes
- Department of Mech-Sense, Department of Gastroenterology and Hepatology and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - A D Farmer
- Department of Mech-Sense, Department of Gastroenterology and Hepatology and Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
- Centre for Neuroscience and Trauma, Wingate Institute of Neurogastroenterology, Blizard Institute, London School of Medicine and Dentistry, Queen Mary University of London, London
- Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK
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13
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Kentley J, Brock C, Ramamurthy K, Laird A, Linhares B, Bewley A. Western herbal medicine is a useful adjunct to traditional dermatological practice. Clin Exp Dermatol 2017; 43:58-60. [PMID: 28940683 DOI: 10.1111/ced.13229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2017] [Indexed: 11/29/2022]
Affiliation(s)
- J Kentley
- Department of Dermatology, Whipps Cross University Hospital, Whipps Cross Road, London, E11 1NR, UK
| | - C Brock
- Department of Life Sciences Research, School of Life Sciences, University of Westminster, London, UK
| | - K Ramamurthy
- Department of Dermatology, Whipps Cross University Hospital, Whipps Cross Road, London, E11 1NR, UK
| | - A Laird
- Department of Dermatology, Whipps Cross University Hospital, Whipps Cross Road, London, E11 1NR, UK
| | - B Linhares
- Department of Dermatology, Whipps Cross University Hospital, Whipps Cross Road, London, E11 1NR, UK
| | - A Bewley
- Department of Dermatology, Whipps Cross University Hospital, Whipps Cross Road, London, E11 1NR, UK
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14
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Brock C, Drewes AM, Farmer AD. Multiregional dysmotility in diabetes mellitus assessed using the wireless motility capsule. Neurogastroenterol Motil 2017; 29. [PMID: 28782196 DOI: 10.1111/nmo.13135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/22/2017] [Indexed: 02/08/2023]
Affiliation(s)
- C Brock
- Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - A M Drewes
- Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - A D Farmer
- Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, UK
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15
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Rasmussen SE, Pfeiffer-Jensen M, Drewes AM, Farmer AD, Deleuran BW, Stengaard-Pedersen K, Brock B, Brock C. Vagal influences in rheumatoid arthritis. Scand J Rheumatol 2017; 47:1-11. [PMID: 28766392 DOI: 10.1080/03009742.2017.1314001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic immune-mediated inflammatory disease with a prevalence of 0.5-1% in Western populations. Conventionally, it is treated with therapeutic interventions that include corticosteroids, disease-modifying anti-rheumatic drugs, and biological agents. RA exerts a significant socio-economic burden and despite the use of existing treatments some patients end up with disabling symptoms. The autonomic nervous system (ANS) is a brain-body interface that serves to regulate homeostasis by integrating the external environment with the internal milieu. The main neural substrate of the parasympathetic branch of the ANS is the vagus nerve (VN). The discovery of the role of the ANS and the VN in mediating and dampening the inflammatory response has led to the proposal that modulation of neural circuits may serve as a valuable therapeutic tool. Recent studies have explored the role of the VN in this inflammatory reflex and have provided evidence that stimulation may represent a novel new therapeutic intervention. Accumulating evidence suggests that modulation of the parasympathetic tone results in a broad physiological multi-level response, including decreased pro-inflammatory cytokine response in terms of tumour necrosis factor-α, interleukin-1 (IL-1), and IL-6, and may result in an enhanced macrophage switch from M1 to M2 cells and potentially an increased level of the anti-inflammatory cytokine IL-10. Therefore, therapeutic electrical modulation of the VN may serve as an alternative, non-pharmacological, neuroimmunomodulatory intervention in RA in the future. This review gives a focused introduction to the mechanistic link between the ANS and the immune system.
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Affiliation(s)
- S E Rasmussen
- a Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - M Pfeiffer-Jensen
- a Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - A M Drewes
- a Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - A D Farmer
- b Department of Gastroenterology , University Hospitals of North Midlands , Stoke on Trent , UK.,c Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology , Barts and the London School of Medicine and Dentistry, Queen Mary University of London , London , UK.,d Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital, and Clinical Institute, Aalborg University , Aalborg , Denmark
| | - B W Deleuran
- a Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | | | - B Brock
- e Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark
| | - C Brock
- a Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark.,d Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital, and Clinical Institute, Aalborg University , Aalborg , Denmark.,f Department of Drug Design and Pharmacology , University of Copenhagen , Copenhagen , Denmark
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16
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Grønlund D, Olesen A, Poulsen J, Brock C, Drewes A. The impact of naloxegol treatment on gastrointestinal transit and colonic volume. Scand J Pain 2017. [DOI: 10.1016/j.sjpain.2017.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Aims
Opioid treatment is associated with gastrointestinal (GI) side effects, known as opioid-induced bowel dysfunction (OIBD). Symptoms of OIBD are caused by opioid receptor activation in the enteric nervous system, which results in increased GI transit time and increased faecal volume in the colon. OIBD can be experimentally induced in healthy participants through oral oxycodone treatment. The aim of this study was to investigate whether administration of naloxegol, a peripherally restricted opioid antagonist, could reduce GI symptoms, GI transit time, and colorectal volume, using an experimental model of OIBD.
Methods
In a double blind crossover trial, twenty-five healthy males were randomly assigned to a six day treatment of oral oxycodone in combination with either oral naloxegol or placebo. At baseline and at day six, participants filled in the Patient Assessment of Constipation Symptom questionnaire, and colorectal volume was quantified with a magnetic resonance imaging method. Participants swallowed a small electromagnetic capsule, which allowed determination of total and segmental GI transit times, using the 3D-Transit system.
Results
In the established model of oxycodone induced OIBD, fewer GI symptoms were observed during naloxegol treatment, compared to placebo (P <0.01). Naloxegol decreased median total transit time by 27% (56 vs 71 h, P < 0.05) and decreased colorectal transit time by 33% (45 vs 59 h, P < 0.01), compared to placebo. No difference in colorectal volume was found between the two treatments.
Conclusions
In an experimental model of OIBD, GI symptoms and GI transit time were reduced during treatment with naloxegol, compared to placebo. However, naloxegol treatment did not reduce colorectal volume. These findings add information on the potential of naloxegol to be used in prevention and treatment of OIBD.
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Affiliation(s)
- D. Grønlund
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - A.E. Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- Department of Drug Design and Pharmacology , University of Copenhagen , Copenhagen , Denmark
| | - J.L. Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| | - C. Brock
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
- Department of Drug Design and Pharmacology , University of Copenhagen , Copenhagen , Denmark
| | - A.M. Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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17
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Brock C, Brock B, Aziz Q, Møller HJ, Pfeiffer Jensen M, Drewes AM, Farmer AD. Transcutaneous cervical vagal nerve stimulation modulates cardiac vagal tone and tumor necrosis factor-alpha. Neurogastroenterol Motil 2017; 29. [PMID: 27957782 DOI: 10.1111/nmo.12999] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 10/27/2016] [Indexed: 12/13/2022]
Abstract
The vagus nerve is a central component of cholinergic anti-inflammatory pathways. We sought to evaluate the effect of bilateral transcutaneous cervical vagal nerve stimulation (t-VNS) on validated parameters of autonomic tone and cytokines in 20 healthy subjects. 24 hours after t-VNS, there was an increase in cardiac vagal tone and a reduction in tumor necrosis factor-α in comparison to baseline. No change was seen in blood pressure, cardiac sympathetic index or other cytokines. These preliminary data suggest that t-VNS exerts an autonomic and a subtle antitumor necrosis factor-α effect, which warrants further evaluation in larger controlled studies.
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Affiliation(s)
- C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - B Brock
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Q Aziz
- Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - H J Møller
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - M Pfeiffer Jensen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - A D Farmer
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Centre for Neuroscience and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, UK
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18
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Jørgensen D, Poulsen J, Olesen A, Brock C, Sandberg T, Krogh K, Drewes A. The impact of opioid treatment on regional gastrointestinal transit. Scand J Pain 2016. [DOI: 10.1016/j.sjpain.2016.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Abstract
Aims
To employ a human experimental model of opioid-induced bowel dysfunction (OIBD) in healthy volunteers, and evaluate the impact of opioid treatment compared to placebo on gastrointestinal (GI) symptoms and motility, assessed by questionnaires and regional GI transit times.
Methods
Twenty-five healthy males were randomly assigned to oxycodone or placebo for five days in a double-blind, crossover design. Adverse GI effects were measured with bowel function index, gastrointestinal symptom rating scale, patient assessment of constipation symptoms questionnaire, and bristol stool form scale. Regional GI transit times were determined using the 3D-Transit system and segmental colonic transit times were determined using a custom Matlab® graphical user interface.
Results
GI symptom scores increased significantly across all applied questionnaires during opioid treatment. Oxycodone increased median total GI transit time from 22.2 to 43.9 h (P< 0.01), segmental transit times in the cecum and ascending colon from 5.7 to 9.9 h (P<0.05), rectosigmoid transit time from 2.7 to 9.0 h (P<0.05), and colorectal transit time from 18.6 to 38.6 h (P<0.01). No association between questionnaire scores and segmental transit times were detected.
Conclusions
Self-assessed adverse GI effects and increased GI transit times in different segments were induced during oxycodone treatment. This detailed information about segmental changes in motility has great potential for future interventional head-to-head trials of different laxative regimes for prevention and treatment of OIBD.
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Affiliation(s)
- D. Jørgensen
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
| | - J.L. Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
| | - A.E. Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Drug Design and Pharmacology , University of Copenhagen , Copenhagen , Denmark
| | - C. Brock
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Drug Design and Pharmacology , University of Copenhagen , Copenhagen , Denmark
| | - T.H. Sandberg
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
| | - K. Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology , Aarhus University Hospital , Aarhus , Denmark
| | - A.M. Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology , Aalborg University Hospital , Aalborg , Denmark
- Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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19
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Frøkjaer JB, Bergmann S, Brock C, Madzak A, Farmer AD, Ellrich J, Drewes AM. Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity. Neurogastroenterol Motil 2016; 28:592-8. [PMID: 26728182 DOI: 10.1111/nmo.12760] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/27/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The parasympathetic nervous system, whose main neural substrate is the vagus nerve, exerts a fundamental antinociceptive role and influences gastrointestinal sensori-motor function. Our research question was to whether combined electrical and physiological modulation of vagal tone, using transcutaneous electrical vagal nerve stimulation (t-VNS) and deep slow breathing (DSB) respectively, could increase musculoskeletal pain thresholds and enhance gastroduodenal motility in healthy subjects. METHODS Eighteen healthy subjects were randomized to a subject-blinded, sham-controlled, cross-over study with an active protocol including stimulation of auricular branch of the vagus nerve, and breathing at full inspiratory capacity and forced full expiration. Recording of cardiac derived parameters including cardiac vagal tone, moderate pain thresholds to muscle, and bone pressure algometry, conditioned pain modulation using a cold pressor test and a liquid meal ultrasonographic gastroduodenal motility test were performed. KEY RESULTS Cardiac vagal tone increased during active treatment with t-VNS and DSB compared to sham (p = 0.009). In comparison to sham, thresholds to bone pain increased (p = 0.001), frequency of antral contractions increased (p = 0.004) and gastroduodenal motility index increased (p = 0.016) with active treatment. However, no effect on muscle pain thresholds and conditioned pain modulation was seen. CONCLUSIONS & INFERENCES This experimental study suggests that this noninvasive approach with combined electrical and physiological modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity. These findings warrant further investigation in patients with disorders characterized with chronic pain and gastrointestinal dysmotility such as functional dyspepsia and irritable bowel syndrome.
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Affiliation(s)
- J B Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - S Bergmann
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - A Madzak
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - A D Farmer
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Gastroenterology, University Hospitals of North Midlands, Stoke on Trent, UK.,Centre for Digestive Diseases, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - J Ellrich
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - A M Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
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Martel M, Olesen A, Jørgensen D, Nielsen L, Brock C, Edwards R, Drewes A. Does catastrophic thinking enhance oesophageal pain sensitivity? An experimental investigation. Eur J Pain 2016; 20:1214-22. [DOI: 10.1002/ejp.845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2015] [Indexed: 12/12/2022]
Affiliation(s)
- M.O. Martel
- Department of Anesthesiology & Pain Medicine; Brigham & Women's Hospital; Harvard Medical School; Boston USA
| | - A.E. Olesen
- Mech-Sense; Department of Gastroenterology & Hepatology; Aalborg University Hospital; Denmark
- Department of Drug Design and Pharmacology; Faculty of Health and Medical Sciences; University of Copenhagen; Denmark
| | - D. Jørgensen
- Mech-Sense; Department of Gastroenterology & Hepatology; Aalborg University Hospital; Denmark
- Center for Sensory-Motor Interaction (SMI); Department of Health Science and Technology; Aalborg University; Denmark
| | - L.M. Nielsen
- Mech-Sense; Department of Gastroenterology & Hepatology; Aalborg University Hospital; Denmark
- Department of Drug Design and Pharmacology; Faculty of Health and Medical Sciences; University of Copenhagen; Denmark
| | - C. Brock
- Mech-Sense; Department of Gastroenterology & Hepatology; Aalborg University Hospital; Denmark
- Department of Drug Design and Pharmacology; Faculty of Health and Medical Sciences; University of Copenhagen; Denmark
| | - R.R. Edwards
- Department of Anesthesiology & Pain Medicine; Brigham & Women's Hospital; Harvard Medical School; Boston USA
| | - A.M. Drewes
- Mech-Sense; Department of Gastroenterology & Hepatology; Aalborg University Hospital; Denmark
- Department of Clinical Medicine; Aalborg University; Denmark
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Nilsson M, Sandberg TH, Poulsen JL, Gram M, Frøkjaer JB, Østergaard LR, Krogh K, Brock C, Drewes AM. Quantification and variability in colonic volume with a novel magnetic resonance imaging method. Neurogastroenterol Motil 2015; 27:1755-63. [PMID: 26598050 DOI: 10.1111/nmo.12673] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 08/13/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Segmental distribution of colorectal volume is relevant in a number of diseases, but clinical and experimental use demands robust reliability and validity. Using a novel semi-automatic magnetic resonance imaging-based technique, the aims of this study were to describe: (i) inter-individual and intra-individual variability of segmental colorectal volumes between two observations in healthy subjects and (ii) the change in segmental colorectal volume distribution before and after defecation. METHODS The inter-individual and intra-individual variability of four colorectal volumes (cecum/ascending colon, transverse, descending, and rectosigmoid colon) between two observations (separated by 52 ± 10) days was assessed in 25 healthy males and the effect of defecation on segmental colorectal volumes was studied in another seven healthy males. KEY RESULTS No significant differences between the two observations were detected for any segments (All p > 0.05). Inter-individual variability varied across segments from low correlation in cecum/ascending colon (intra-class correlation coefficient [ICC] = 0.44) to moderate correlation in the descending colon (ICC = 0.61) and high correlation in the transverse (ICC = 0.78), rectosigmoid (ICC = 0.82), and total volume (ICC = 0.85). Overall intra-individual variability was low (coefficient of variance = 9%). After defecation the volume of the rectosigmoid decreased by 44% (p = 0.003). The change in rectosigmoid volume was associated with the true fecal volume (p = 0.02). CONCLUSIONS & INFERENCES Imaging of segmental colorectal volume, morphology, and fecal accumulation is advantageous to conventional methods in its low variability, high spatial resolution, and its absence of contrast-enhancing agents and irradiation. Hence, the method is suitable for future clinical and interventional studies and for characterization of defecation physiology.
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Affiliation(s)
- M Nilsson
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - T H Sandberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - J L Poulsen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - J B Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - L R Østergaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Haas S, Brock C, Krogh K, Gram M, Lundby L, Drewes AM, Laurberg S. Abnormal neuronal response to rectal and anal stimuli in patients with idiopathic fecal incontinence. Neurogastroenterol Motil 2015; 27:954-62. [PMID: 25903483 DOI: 10.1111/nmo.12567] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/16/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The pathophysiology behind idiopathic fecal incontinence (IFI) is poorly understood. We hypothesized abnormal sensory pathways along the brain-gut axis as a key player in this disease, reflected in cortical evoked potentials (CEP) from mechanical stimuli of the rectum and the anal canal. METHODS CEPs were recorded during repeated rapid balloon distensions of the rectum and anal canal in 19 women with IFI (mean age: 60 ± 14, mean Wexner score: 14.7 ± 2.9) and in 19 healthy women (mean age: 56 ± 11, mean Wexner score: 1.1 ± 1.3). Latencies, amplitudes and topography of CEPs elicited by rectal distension were compared between the groups. CEPs from both rectal and anal distensions were examined using spectral band analysis of single sweeps determining the relative amplitude of five spectral bands as a proxy of neuronal processing. KEY RESULTS Compared to controls IFI patients had prolonged latency of CEPs from rectal distension by up to 27% (p < 0.001) while amplitudes and topography were similar (all p > 0.7 and all p > 0.23). Spectral analysis of CEPs from rectal distensions showed no difference (all p > 0.1) between groups. However, analysis of CEPs following distension of the anal canal resulted in abnormally low activity in beta (8-12 Hz; p < 0.001) band and high activity in the gamma (32-70 Hz; p = 0.04) band in patients. CONCLUSIONS & INFERENCES IFI seems to be associated with impaired ano-rectal sensory functions in both the afferent fibers to the brain and the cortical processing of anal sensory pathways. This may play a central role for the pathogenesis of IFI.
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Affiliation(s)
- S Haas
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - L Lundby
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - S Laurberg
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
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23
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Lelic D, Nissen TD, Brock C, Aziz Q, Drewes AM. Rapid balloon distension as a tool to study cortical processing of visceral sensations and pain. Neurogastroenterol Motil 2015; 27:832-40. [PMID: 26011783 DOI: 10.1111/nmo.12557] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 02/27/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The processing of discomfort and pain in the central nervous system is normally studied with experimental methods, but it is mandatory that they are reliable over time to ensure that any interventions will result in valid results. We investigated reliability of rapid balloon distension in the rectum to elicit cortical evoked potentials (CEPs) to study the reliability of central processing of visceral sensation and discomfort/pain. METHODS Eighteen healthy volunteers had two series of rectal balloon distensions performed on two separate days. Individualized balloon pressure, corresponding to pain detection threshold or to the maximum possible distension (30 psi), was used. Within- and between days reliability was measured in terms of amplitudes and latencies of the CEP global field power, topography and underlying brain networks. KEY RESULTS There were two prominent peaks in the CEP recordings at mean latencies of 157 and 322 ms. There were no differences in latencies or amplitudes (p = 0.3) and they passed the Bland-Altman test for reproducibility. There were no differences in topographies (p > 0.7). Brain source connectivity revealed the cingulate-operculum network as the most consistent network within and between subjects. There were no differences in the location of brain sources in this network (p = 0.9) and the source coordinates were reproducible. Finally, the cingulate source generally had higher strength than operculum source (p < 0.001). CONCLUSIONS & INFERENCES A reliable method to study central mechanisms underlying visceral sensation and pain was established. The method may improve our understanding of visceral pain and could be an objective method for studying efficacy of analgesics on visceral pain.
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Affiliation(s)
- D Lelic
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - T D Nissen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Q Aziz
- Centre for Digestive Diseases, Blizard Institute, The Wingate Institute of Neurogastroenterology, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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24
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Fassov J, Brock C, Lundby L, Drewes AM, Gregersen H, Buntzen S, Laurberg S, Krogh K. Sacral nerve stimulation changes rectal sensitivity and biomechanical properties in patients with irritable bowel syndrome. Neurogastroenterol Motil 2014; 26:1597-604. [PMID: 25223743 DOI: 10.1111/nmo.12426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 08/14/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sacral nerve stimulation (SNS) has been demonstrated to alleviate symptoms and improve quality of life in selected patients with irritable bowel syndrome (IBS). The mechanisms of action, however, remain unknown. The aim of the study was to evaluate the effects of SNS on rectal sensitivity and biomechanical properties in patients with IBS. METHODS Twenty patients with diarrhea-predominant (n = 11) or mixed (n = 9) IBS were treated with SNS in a controlled, randomized crossover trial. They were randomized to either 1 month of SNS (ON) or placebo (OFF) with the opposite setting for the next month. Sensory and biomechanical parameters were assessed by multimodal rectal stimulation at the end of each period. IBS-specific symptoms were evaluated at baseline and at the end of each treatment period. KEY RESULTS Cold stimuli were better tolerated in the ON period (19.9 °C[± 0.6]) compared to the OFF period (21.8 °C[± 0.6]; p = 0.03). Significantly lower cross-sectional areas were needed to elicit sensory responses in the ON period (1545 mm(2) [± 95]) compared to the OFF period (1869 mm(2) [± 92]; p = 0.015). The association between reduced sensory threshold and improvement of constipation was of borderline significance (p = 0.05). Wall stiffness was significantly lower in the ON period (192 mmHg[± 10]) compared to the OFF period (234 mmHg[± 10]; p = 0.004). Reduced wall stiffness was significantly associated with improved overall GSRS-IBS symptom score (p = 0.01). Reduced sensory threshold to stretch (p = 0.02) and reduced wall stiffness (p < 0.001) were predictors of the GSRS-IBS symptom score. CONCLUSIONS & INFERENCES SNS for diarrhea-predominant and mixed IBS relaxes the rectal wall, while making it more sensitive to stretch and less sensitive to cold. Reduced wall stiffness and increased sensitivity to stretch are associated with improved GSRS-IBS symptom score.
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Affiliation(s)
- J Fassov
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark; Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Haas S, Brock C, Krogh K, Gram M, Nissen TD, Lundby L, Laurberg S, Drewes AM. Cortical evoked potentials in response to rapid balloon distension of the rectum and anal canal. Neurogastroenterol Motil 2014; 26:862-73. [PMID: 24750321 DOI: 10.1111/nmo.12341] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 03/11/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neurophysiological evaluation of anorectal sensory function is hampered by a paucity of methods. Rapid balloon distension (RBD) has been introduced to describe the cerebral response to rectal distension, but it has not successfully been applied to the anal canal. METHODS Nineteen healthy women received 30 RBDs in the rectum and the anal canal at intensities corresponding to sensory and unpleasantness thresholds, and response was recorded as cortical evoked potentials (CEPs) in 64-channels. The anal canal stimulations at unpleasantness level were repeated after 4 min to test the within-day reproducibility. CEPs were averaged, and to overcome latency variation related to jitter the spectral content of single sweeps was also computed. KEY RESULTS Repeated stimulation of the anal canal generated CEPs with similar latencies but smaller amplitudes compared to those from the rectum. Due to latency jitter, reproducibility of averaged CEPs was lower than what was found in the rectum. The most reproducible feature was N2P2 peak-to-peak amplitude with intra-class correlation coefficient (ICC) of 0.7 and coefficient of variation (CV) of 18%. Spectral content of the single sweeps showed reproducibility with ICCs for all bands >0.8 and corresponding CVs <7%. CONCLUSIONS & INFERENCES Cortical potentials evoked from the anal canal are challenged by latency jitter likely related to variability in muscle tone due to the distensions. Using single-sweep analysis, anal CEPs proved to be reproducible and should be used in future evaluation of the anal function.
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Affiliation(s)
- S Haas
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
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26
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Lelic D, Brock C, Simrén M, Frøkjaer JB, Søfteland E, Dimcevski G, Gregersen H, Drewes AM. The brain networks encoding visceral sensation in patients with gastrointestinal symptoms due to diabetic neuropathy. Neurogastroenterol Motil 2014; 26:46-58. [PMID: 24050116 DOI: 10.1111/nmo.12222] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Increasing evidence points to association between long-term diabetes mellitus and abnormal brain processing. The aim of this study was to investigate central changes due to electrical stimulation in esophagus in patients with upper gastrointestinal (GI) symptoms due to diabetic neuropathy. METHODS Twenty-three diabetes patients with upper GI symptoms and 27 healthy controls were included. A standard ambulatory 24-h electrocardiography was carried out. 122-channel esophageal evoked brain potentials to electrical stimulation were acquired. Brain source/network analysis was performed. Gastroparesis Cardinal Symptom Index was used to evaluate upper GI symptoms and SF-36 questionnaire was utilized to assess patients' quality of life (QOL). KEY RESULTS Diabetes patients with GI symptoms showed modifications in three brain networks: (i) brainstem/operculum/frontal cortex, (ii) operculum/cingulate, and (iii) mid-cingulate/anterior-cingulate/operculum/deep limbic structures. Operculum brain source in patients was localized deeper and more anterior in all three networks. The shift of operculum source was correlated with the severity of upper GI symptoms, decreased heart beat-to-beat interval, and decreased SD of the intervals. The activation of the first network was delayed in patients. Operculum source had higher activity than cingulate in the second network in patients, and this was correlated with decreased physical QOL. Deep limbic source was localized deeper in patients, which also correlated with decreased physical QOL. CONCLUSIONS & INFERENCES This study indicates involvement of central nervous system in diabetes. Reorganization within opercular cortex was correlated with GI symptoms suggesting that operculo-cingulate cortex could contribute to development and maintenance of GI symptoms in diabetes patients.
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Affiliation(s)
- D. Lelic
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg Hospital; Aarhus University; Aalborg Denmark
| | - C. Brock
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg Hospital; Aarhus University; Aalborg Denmark
| | - M. Simrén
- Institute of Medicine; Department of Internal Medicine; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - J. B. Frøkjaer
- Mech-Sense; Department of Radiology; Aalborg Hospital; Aarhus University Hospital; Aalborg Denmark
| | - E. Søfteland
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Institute of Medicine; University of Bergen; Bergen Norway
| | - G. Dimcevski
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Institute of Medicine; University of Bergen; Bergen Norway
| | - H. Gregersen
- Department of Medicine; GIOME and Sino-Danish Centre for Education and Research; Aarhus Denmark
| | - A. M. Drewes
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg Hospital; Aarhus University; Aalborg Denmark
- Department of Health Science and Technology; Center for Sensory-Motor Interactions (SMI); Aalborg University; Aalborg Denmark
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Nilsson M, Piasco A, Nissen T, Graversen C, Gazerani P, Lucas MF, Dahan A, Drewes A, Brock C. Reproducibility of psychophysics and electroencephalography during offset analgesia. Eur J Pain 2013; 18:824-34. [DOI: 10.1002/j.1532-2149.2013.00424.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2013] [Indexed: 12/29/2022]
Affiliation(s)
- M. Nilsson
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
- Center for Sensory-Motor Interactions (SMI); Department of Health Science and Technology; Faculty of Medicine; Aalborg University; Denmark
| | | | - T.D. Nissen
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
| | - C. Graversen
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
- Mech-Sense; Department of Radiology; Aalborg University Hospital; Denmark
- Department of Neurorehabilitation Engineering; Bernstein Center for Computational Neuroscience; University Medical Center Göttingen, Georg-August University; Göttingen Germany
| | - P. Gazerani
- Center for Sensory-Motor Interactions (SMI); Department of Health Science and Technology; Faculty of Medicine; Aalborg University; Denmark
| | | | - A. Dahan
- Department of Anaesthesiology; Leiden University Medical Center; The Netherlands
| | - A.M. Drewes
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
- Center for Sensory-Motor Interactions (SMI); Department of Health Science and Technology; Faculty of Medicine; Aalborg University; Denmark
| | - C. Brock
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
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Valeriani M, Brock C, Graversen C, Frøkjaer J, Søfteland E, Drewes A. 17. Peripheral and central nervous contribution to gastrointestinal symptoms in diabetic patients with autonomic neuropathy. Clin Neurophysiol 2013. [DOI: 10.1016/j.clinph.2013.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bartels A, Brock C, Nelson C, Denney J, Barnes S. Spontaneous rupture of a splenic hamartoma. Am Surg 2013; 79:E331-E332. [PMID: 24165240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Ashley Bartels
- University of Missouri-Columbia, Columbia, Missouri, USA
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Dizon M, Brock C, Elder R, Zite N, Klein F, White W. Robotic Sacral Colpopexy for the Treatment of Symptomatic Pelvic Organ Prolapse in the Elderly Population. J Minim Invasive Gynecol 2013. [DOI: 10.1016/j.jmig.2013.08.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Hoff DAL, Krarup AL, Lelic D, Olesen SS, Dimcevski G, Hansen TM, Brock C, Hatlebakk JG, Drewes AM. Central response to painful electrical esophageal stimulation in well-defined patients suffering from functional chest pain. Neurogastroenterol Motil 2013; 25:e718-27. [PMID: 23965033 DOI: 10.1111/nmo.12196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 07/03/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Functional chest pain (FCP) of presumed esophageal origin is considered a common cause for chest pain in which central nervous system hyperexcitability is thought to play an important role. We aimed to compare cerebral responses with painful esophageal stimuli between FCP patients and healthy subjects (HS). METHODS Thirteen patients with FCP (seven females, mean age 50.4 ± 7.5 years) and 15 HS (eight females, mean age 49.1 ± 12.9 years) were enrolled. Inclusion criteria consisted of typical chest pain, normal coronary angiogram, and normal upper gastrointestinal evaluation. Electrical stimulations evoking the pain threshold were applied in the distal esophagus, while cortical evoked potentials were recorded from the scalp. Pain scores, resting electroencephalogram (EEG), evoked potential characteristics and brain electrical sources to pain stimulation were compared between groups. KEY RESULTS No differences were seen between patients and HS regarding (i) pain thresholds (patients: 20.1 ± 7.4 mA vs HS: 22.4 ± 8.3 mA, all P > 0.05), (ii) resting-EEG (P > 0.05), (iii) evoked brain potential latencies (N2: patients 181.7 ± 25.7 mS vs HS 182.2 ± 25.8 mS, all P > 0.05) and amplitudes (N2P2: patients 8.2 ± 7.2 μV vs HS: 10.1 ± 3.4 μV, all P > 0.05), (iv) topography (P > 0.05), and (v) brain source location (P > 0.05). CONCLUSIONS & INFERENCES No differences in activation of brain areas to painful esophageal stimulation were seen in this group of well characterized patients with FCP compared with sex- and age-matched HS. The mechanism of pain in FCP and whether it originates in the esophagus remains unsolved.
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Affiliation(s)
- D A L Hoff
- Department of Medicine, Division of Gastroenterology and Hepatology, Aalesund Hospital, Aalesund, Norway
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Graversen C, Frøkjaer JB, Brock C, Drewes AM, Farina D. Support vector regression correlates single-sweep evoked brain potentials to gastrointestinal symptoms in diabetes mellitus patients. Annu Int Conf IEEE Eng Med Biol Soc 2013; 2012:5242-5. [PMID: 23367111 DOI: 10.1109/embc.2012.6347176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Diabetes mellitus (DM) is a multi-factorial and complex disease causing autonomic neuropathy and gastrointestinal symptoms in some patients. The neural mechanisms behind these symptoms are poorly understood, but it is believed that both peripheral and central mechanisms are involved. To gain further knowledge of the central mechanisms, the aim of this study was to identify biomarkers for the altered brain activity in type-1 DM patients compared to healthy volunteers (HV), and to correlate the obtained biomarkers to clinical patient scores. The study included 14 DM patients and 15 HV, with brain activity recorded as multi-channel electroencephalography evoked brain potentials (EPs) elicited by painful electrical stimulations in the esophagus. The single-sweep EPs were decomposed by an optimized discrete wavelet transform (DWT), and averaged for each channel. The DWT features from the DM patients were discriminated from the HV by a support vector machine (SVM) applied in regression mode. For the optimal DWT, the discriminative features were extracted and the SVM regression value representing the overall alteration of the EP was correlated to the clinical scores. A classification performance of 86.2% (P=0.01) was obtained by applying a majority voting scheme to the 5 best performing channels. The biomarker was identified as decreased theta band activity. The regression value was correlated to symptoms reported by the patients (P=0.04). The methodology is an improvement of the present approach to study central mechanisms in diabetes mellitus, and may provide a future application for a clinical tool to optimize treatment in individual patients.
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Affiliation(s)
- C Graversen
- Mech-Sense, Department of Gastroenterology & Radiology, Aalborg Hospital, DK-9000 Aalborg, Denmark.
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Frøkjær JB, Brock C, Søfteland E, Dimcevski G, Gregersen H, Simrén M, M Drewes A. Macrostructural brain changes in patients with longstanding type 1 diabetes mellitus - a cortical thickness analysis study. Exp Clin Endocrinol Diabetes 2013; 121:354-60. [PMID: 23757052 DOI: 10.1055/s-0033-1345120] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Longstanding diabetes mellitus (DM) is associated with the risk of complications affecting the central nervous system. The aims were to study brain volume and cortical thickness in regional brain areas in DM patients and to correlate the findings with relevant clinical data.15 patients with longstanding (average 24.6 years) type 1 DM and 20 healthy controls were studied in a 3T magnetic resonance scanner. Using an automated surface based cortical segmentation method, cortical thickness was assessed in anatomical regions including total and lobe-wise grey and white matter volumes. Also morphological changes were evaluated.No differences between patients and controls were found in regard to number of white matter lesions (P=0.50), grey and white matter volumes (P=0.25) and overall cortical thickness (P=0.64). Subanalysis revealed exclusively reduced cortical thickness of the postcentral (P=0.03) and superior parietal gyrus (P=0.008) in patients. The cortical thickness of these regions was not associated with diabetes duration, age at diabetes onset or to HbA1c (all P>0.08). Patients with peripheral neuropathy showed reduced right postcentral gyrus cortical thickness compared to patients without peripheral neuropathy (P=0.02).Patients with longstanding type 1 diabetes showed cortical thinning involving sensory related areas, even though no overall macrostructural brain alterations were detected. This could possibly have underlying functional significance since cortical thinning was associated to presence of peripheral neuropathy. The absence of universal macrostructural changes might illustrate that more pronounced brain pathology is likely to be preceded by more subtle microstructural changes as reported in other studies.
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Affiliation(s)
- J B Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.
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Olausson EA, Brock C, Drewes AM, Grundin H, Isaksson M, Stotzer P, Abrahamsson H, Attvall S, Simrén M. Measurement of gastric emptying by radiopaque markers in patients with diabetes: correlation with scintigraphy and upper gastrointestinal symptoms. Neurogastroenterol Motil 2013; 25:e224-32. [PMID: 23316944 DOI: 10.1111/nmo.12075] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Scintigraphy, the gold standard to measure gastric emptying, is expensive and not widely available. Therefore, we compared emptying of radiopaque markers (ROM) from the stomach, by use of fluoroscopy, with scintigraphy in patients with insulin-treated diabetes. METHODS On the same day we measured gastric emptying of 20 ROM using fluoroscopy and scintigraphic emptying of a standard solid meal. The subjects also completed a validated gastrointestinal (GI) symptom questionnaire. KEY RESULTS We included 115 patients with insulin-treated diabetes (median age 53, range 21-69 years; 59 women). A moderately strong correlation was demonstrated between scintigraphic (% retained at 2 h) and ROM emptying (markers retained at 6 h) (r = 0.47; P < 0.0001). Eighty-three patients had delayed gastric emptying with scintigraphy, whereas only 29 patients had delayed emptying of ROM. Of the 29 patients with delayed emptying of ROM, 28 also had delayed scintigraphic emptying. The sensitivity and specificity of the ROM test was 34% and 97%, respectively. Significant correlations were only noted between scintigraphic gastric emptying and GI symptom severity, with the strongest correlations for fullness/early satiety (r = 0.34; P < 0.001) and nausea/vomiting (r = 0.30; P < 0.001). CONCLUSIONS & INFERENCES A gastric emptying test with ROM is a widely available screening method to detect delayed gastric emptying in patients with diabetes, where a positive result seems reliable. However, a normal ROM test does not exclude delayed gastric emptying, and if the clinical suspicion of gastroparesis remains, scintigraphy should be performed. Results from scintigraphy also correlate with GI symptom severity, which ROM test did not.
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Affiliation(s)
- E A Olausson
- Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Brock C, Graversen C, Frøkjaer JB, Søfteland E, Valeriani M, Drewes AM. Peripheral and central nervous contribution to gastrointestinal symptoms in diabetic patients with autonomic neuropathy. Eur J Pain 2012; 17:820-31. [PMID: 23239083 DOI: 10.1002/j.1532-2149.2012.00254.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Long-term diabetes mellitus (DM) has been associated with neuronal changes in the enteric, peripheral and/or central nervous system. Moreover, abnormal visceral sensation and gastrointestinal (GI) symptoms are seen in up to 75% of patients. To explore the role of diabetic autonomic neuropathy (DAN) in patients with long-standing DM, we investigated psychophysical responses and neuronal activity recorded as evoked brain potentials and dipolar source modelling. METHODS Fifteen healthy volunteers and 14 type-1 DM patients with DAN were assessed with a symptom score index characterizing upper GI abnormalities. Multichannel (62) electroencephalography was recorded during painful electrical stimulation of the lower oesophagus. Brain activity to painful stimulations was modelled using Brain Electrical Source Analysis (besa). RESULTS Diabetic patients had higher stimulus intensities to evoke painful sensation (p ≤ 0.001), longer latencies of N2 and P2 components (both p ≤ 0.001), and lower amplitudes of P1-N2 and N2-P2 complexes (p ≤ 0.001; p = 0.02). Inverse modelling of brain sources showed deeper bilateral insular dipolar source localization (p = 0.002). Symptom score index was negatively correlated with the depth of insular activity (p = 0.004) and positively correlated with insular dipole strength (p = 0.03). CONCLUSION DM patients show peripheral and central neuroplastic changes. Moreover, the role of abnormal insular processing may explain the appearance and persistence of GI symptoms related to DAN. This enhanced understanding of DAN may have future clinical and therapeutical implications.
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Affiliation(s)
- C Brock
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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Frøkjaer JB, Brock C, Brun J, Simren M, Dimcevski G, Funch-Jensen P, Drewes AM, Gregersen H. Esophageal distension parameters as potential biomarkers of impaired gastrointestinal function in diabetes patients. Neurogastroenterol Motil 2012; 24:1016-e544. [PMID: 22738347 DOI: 10.1111/j.1365-2982.2012.01966.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal (GI) symptoms, such as nausea, vomiting, bloating, postprandial fullness, and abdominal pain, are frequent in patients with diabetes mellitus (DM). The pathogenesis is complex and multi-factorial. To determine easy accessible and valid biomarkers for disordered GI function in DM patients, we aimed to study esophageal mechanical parameters and their relation to symptoms typically arising from the digestive tract. METHODS Seventeen patients with longstanding DM and GI symptoms and 13 healthy controls were studied using ultrasound monitored esophageal distension. The sensory response was recorded and their symptoms registered. Biomechanical parameters, such as compliance and stiffness were computed from luminal diameters during distension based on the ultrasound images and from pressure data. Biomechanical and sensory parameters were correlated with the clinical data. KEY RESULTS Diabetes patients had reduced esophageal sensitivity compared with controls (P = 0.046). The esophageal compliance was reduced (P = 0.004) and the esophageal stiffness was increased (P = 0.004) in the diabetes patients. Among patients, both postprandial fullness/early satiety and bloating correlated negatively to the esophageal compliance parameters (all P < 0.05). CONCLUSIONS & INFERENCES Patients with long-standing DM and GI symptoms had reduced esophageal sensitivity together with reduced compliance and increased stiffness, which were correlated to the patients' GI symptoms. Biomechanical parameters obtained during distension may serve as biomarker for similar pathophysiologic effects of diabetes in the stomach and small bowel. They may contribute to our understanding of the pathophysiology underlying GI dysfunction and symptoms in patients with longstanding DM.
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Affiliation(s)
- J B Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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Zhong H, Hribar LJ, Daniels JC, Feken MA, Brock C, Trager MD. Aerial ultra-low-volume application of naled: impact on nontarget imperiled butterfly larvae (Cyclargus thomasi bethunebakeri) and efficacy against adult mosquitoes (Aedes taeniorhynchus). Environ Entomol 2010; 39:1961-1972. [PMID: 22182563 DOI: 10.1603/en10089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We assessed the exposure and acute toxicity of naled, applied aerially as an ultra-low-volume spray for mosquito control, on late instar larvae of the Miami blue (Cyclargus thomasi bethunebakeri) (Comstock and Huntington 1943) (Lepidoptera: Lycaenidae), an imperiled South Florida butterfly. We concurrently evaluated the control efficacy against caged adult female salt-marsh mosquitoes (Aedes taeniorhynchus) (Wiedemann 1821) (Diptera: Culicidae). This 3-yr study was conducted in north Key Largo (Monroe County, FL) beginning in 2006. The field trials incorporated 15 sampling stations: nine in the target spray zone, three in the spray drift zone at varying distances from the target zone, and three in the control zone not subjected to naled spray drift. A total of six field spray trials were completed, three at an altitude of 30.5 m (100 feet), and three at 45.7 m (150 feet). For all trials, the ultra-low-volume application of Trumpet EC insecticide (78% naled) at a rate of 54.8 ml/ha (0.75 fl. oz/acre) was effective in killing caged adult mosquitoes in the target zone. Butterfly larvae survival was significantly reduced in the spray zone compared with drift and control zones. Analysis of insecticide residue data revealed that the mortality of the late instar butterfly larvae was a result of exposure to excess residues of naled. Additional research is needed to determine mitigation strategies that can limit exposure of sensitive butterflies to naled while maintaining mosquito control efficacy.
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Affiliation(s)
- H Zhong
- Public Health Entomology Research and Education Center/ CESTA/Florida A&M University, 4000 Frankford Avenue, Panama City, FL 32405, USA.
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Brock C, Andresen T, Frokjaer JB, Gale J, Arendt‐Nielsen L, Drewes AM. 172 CENTRAL SENSITIZATION — INDUCTION OF RECTAL HYPER‐SENSITIVITY AND ACTIVATION OF DESCENDING INHIBITION FOLLOWING OESOPHAGEAL ACID AND CAPSAICIN INFUSION. Eur J Pain 2009. [DOI: 10.1016/s1090-3801(09)60175-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- C. Brock
- Mech‐Sense, Aalborg Hospital, Aalborg, Denmark
| | - T. Andresen
- Mech‐Sense, Aalborg Hospital, Aalborg, Denmark
| | | | - J. Gale
- Pfizer, Sandwich, Kent, United Kingdom
| | - L. Arendt‐Nielsen
- Center for Sensory‐Motor Interaction, Aalborg University, Aalborg, Denmark
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Olesen SS, Krarup AL, Brock C, Drewes AM. Gastrointestinal sensations and pain: a review on basic, experimental and clinical findings. MINERVA GASTROENTERO 2009; 55:301-313. [PMID: 19829286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Painful sensations from the gastrointestinal (GI) tract are common symptoms in the clinic but the etiology is often not fully understood and underlying diseases can be difficult to diagnose and treat successfully. In clinical practice, GI pain is often diffuse and pain referral to somatic structures can be the presenting symptom. In addition, concomitant symptoms from the autonomic and enteric nervous system can be present and affect the pain experience. To examine patients suffering from GI pain, basic knowledge about the GI pain system is essential and assists to explain the often complex and diverse symptoms. Information about anatomical and physiological characteristics of the GI pain system come from basic, experimental and clinical research, which have also gained insight into pain mechanisms underlying chronic GI pain. Evidence for sensitisation at the peripheral and central level of the nervous system seems to be of importance. These findings have major implication for the evaluation and treatment of patients suffering from GI pain.
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Affiliation(s)
- S S Olesen
- Mech-Sense, Department of Gastroenterology, Aalborg Hospital, Aarhus University, Aalborg, Denmark.
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Schuh LA, London Z, Neel R, Brock C, Kissela BM, Schultz L, Gelb DJ. Education research: Bias and poor interrater reliability in evaluating the neurology clinical skills examination. Neurology 2009; 73:904-8. [PMID: 19605769 DOI: 10.1212/wnl.0b013e3181b35212] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The American Board of Psychiatry and Neurology (ABPN) has recently replaced the traditional, centralized oral examination with the locally administered Neurology Clinical Skills Examination (NEX). The ABPN postulated the experience with the NEX would be similar to the Mini-Clinical Evaluation Exercise, a reliable and valid assessment tool. The reliability and validity of the NEX has not been established. METHODS NEX encounters were videotaped at 4 neurology programs. Local faculty and ABPN examiners graded the encounters using 2 different evaluation forms: an ABPN form and one with a contracted rating scale. Some NEX encounters were purposely failed by residents. Cohen's kappa and intraclass correlation coefficients (ICC) were calculated for local vs ABPN examiners. RESULTS Ninety-eight videotaped NEX encounters of 32 residents were evaluated by 20 local faculty evaluators and 18 ABPN examiners. The interrater reliability for a determination of pass vs fail for each encounter was poor (kappa 0.32; 95% confidence interval [CI] = 0.11, 0.53). ICC between local faculty and ABPN examiners for each performance rating on the ABPN NEX form was poor to moderate (ICC range 0.14-0.44), and did not improve with the contracted rating form (ICC range 0.09-0.36). ABPN examiners were more likely than local examiners to fail residents. CONCLUSIONS There is poor interrater reliability between local faculty and American Board of Psychiatry and Neurology examiners. A bias was detected for favorable assessment locally, which is concerning for the validity of the examination. Further study is needed to assess whether training can improve interrater reliability and offset bias.
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Affiliation(s)
- L A Schuh
- Department of Neurology, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA.
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Brock C, Schou-Olesen S, Arendt-Nielsen L, Drewes A. F1 Real time source reconstruction of the cingulate activity to rectal pain: mechanisms behind activation of the inhibitory pathways. Scand J Pain 2009. [DOI: 10.1016/s1877-8860(09)70028-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Charnley N, Airley R, Du Plessis D, West C, Brock C, Barnett C, Matthews J, Symonds K, Bottomly M, Swindell R, Price P. No relationship between 18F-fluorodeoxyglucose positron emission tomography and expression of Glut-1 and -3 and hexokinase I and II in high-grade glioma. Oncol Rep 2008; 20:537-542. [PMID: 18695903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
The purpose of this study was to compare glucose metabolism, measured using 18F-fluorodeoxyglucose positron emission tomography ([18F]FDG-PET), with the expression of Glut-1 and -3 and hexokinase I (Hex I) and II in high-grade glioma. The retrospective study involved 27 patients with WHO classification grade III and IV glioma, with either newly diagnosed or recurrent tumours. Patients underwent dynamic and static [18F]FDG-PET to glucose metabolic rate (MRGlu) and standardised uptake value (SUV), respectively. Tumour biopsies were obtained and stained using immunohistochemistry for the expression of Glut-1, -3, Hex I and II. Relationships between variables were studied using Spearman's rank correlation test. Results showed that the expression of Glut-1, Glut-3, Hex I and Hex II varied between and within the tumour samples. The mean of MRGlu was 0.2 (range 0.09-0.25) micromol/min/ml and that of SUV was 4.2 (range 3.2-5.2). There were no significant relationships among the tumour expression of any of the proteins studied with either MRGlu or SUV (p>0.21 for all). In conclusion, the lack of relationship between the immunohistochemical expression of Glut-1, -3, Hex I or II and glucose metabolism measured using [18F]FDG-PET in patients with high-grade glioma may be due to the tissue heterogeneity and presence of necrosis in high-grade tumours.
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Affiliation(s)
- N Charnley
- Wolfson Molecular Imaging Centre, University of Manchester, Manchester, UK.
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Brock C, Nissen TD, Gravesen FH, Frøkjaer JB, Omar H, Gale J, Gregersen H, Svendsen O, Drewes AM. Multimodal sensory testing of the rectum and rectosigmoid: development and reproducibility of a new method. Neurogastroenterol Motil 2008; 20:908-18. [PMID: 18482255 DOI: 10.1111/j.1365-2982.2008.01126.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Evaluation of rectal and rectosigmoid sensation is important in basic, clinical and pharmacological studies. New methods to evoke and assess multimodal (electrical, thermal and mechanical) experimental pain of the upper gut activate distinct pathways and mimics clinical pain. The aims of the current study were to characterize the sensory response and reproducibility to multimodal stimulation of rectum and the rectosigmoid. A multimodal rectal probe was developed. Mucosal electrostimulation was delivered at the recto-sigmoid junction. In Rectum, impedance planimetry was used for measurement of cross-sectional area (CSA) during distension. Circulation of water within the bag at either 4 or 60 degrees C was applied for thermal stimulation. The method was tested in 12 healthy volunteers (six men mean age 32 years) on two subsequent days. Mechanical and sensory responses and referred pain areas were assessed. Stimulation with electrical, thermal and mechanical modalities resulted in different sensory perceptions. The relationship between stimulus intensity and sensory response was linear for all modalities. Sensory response to different modalities did not differ between investigation days (all P-values > 0.1). Approximately 75% of subjects felt referred pain in distinct skin locations. Between-days reproducibility was good for all modalities [intra-class correlation (ICC) > or = 0.6]. At sensory threshold, CSA showed best reproducibility (ICC > or = 0.9). At pain detection threshold stretch ratio, CSA and electrostimulation showed best reproducibility (ICC = 1.0; 0.9; 0.9). The present model was easily implemented, robust and showed good reproducibility. It can be used to study pathophysiology or pharmacological interventions in healthy controls and in patients with diseases involving the distal hindgut.
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Affiliation(s)
- C Brock
- Center for Visceral Biomechanics and Pain, Department of Gastroenterology, Aalborg Hospital, Aalborg, Denmark
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Liao D, Frøkjaer JB, Brock C, Andersen SD, Drewes AM, Gregersen H. Oesophageal heat transfer properties indication of segmental blood flow changes during distension. Neurogastroenterol Motil 2008; 20:298-303. [PMID: 18004987 DOI: 10.1111/j.1365-2982.2007.01031.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The pain perception to distension of the oesophagus can be explained by activation of receptors responding to mechanical deformation or to distension-induced ischaemia. The aim of this study was to develop a new method for detection of changes in segmental blood flow during distension based on measurement of heat transfer. A bag was distended in the distal oesophagus of six healthy subjects followed by cooling or heating of the bag fluid to 5 or 60 degrees C. After equilibrium, the temperature was allowed to change back to body temperature. The temperature was recorded together with intraluminal ultrasound imaging, allowing assessment of the heat transfer properties at different bag volumes. The heat transfer constants were higher after heating the bag than after cooling the bag (Tukey, P < 0.05). The heat transfer constants after heating the bag decreased as function of bag volumes whereas the heat transfer during cooling was not affected by the bag volume (F = 0.9, P = 0.4). The findings indicate that segmental blood flow can be assessed indirectly by calculating the heat transfer properties. Distension induced a drop in regional blood flow. Hence, ischaemia may contribute to distension-induced pain. Furthermore, heat increased segmental blood flow and cold decreased segmental blood flow. This method may in the future be used to explore the mechanisms behind oesophageal pain.
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Affiliation(s)
- D Liao
- Center of Excellence in Visceral Biomechanics and Pain, Aalborg Hospital, Aalborg, Denmark.
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Abstract
Over the last 130 years, patterns of land use in central Australia have altered dramatically, and so too have fire regimes and fire management objectives. Although Aboriginal people still have tenure over large parts of the landscape, their lifestyles have changed. Most Aboriginal people now live in towns and settlements and, although fire management is still culturally important, the opportunities for getting out on country to burn are constrained. Large parts of the landscape are now used for pastoral production. Under this land use the management objective is often one of fire exclusion. The other large-scale land use is for conservation. Here, fire management has a greater focus on conserving biodiversity using various burning strategies. In this paper we explore contemporary fire regimes in central Australia. Widespread fire events are found to be associated with two or more consecutive years of above-average rainfall. Although most of the fires linked with these high rainfall periods occur during the warmer months, in recent times these fires have exhibited increased activity during the cooler months. There has been a concomitant increase in the number and size of these fires and in the number of fires associated with roads. We also explored current fire management issues on Aboriginal, pastoral and conservation lands. Current fire management goals are not being wholly met on any of these land tenures in central Australia and social conflict sometimes emerges as a result. There are overlaps in management aims, issues and the under-achievement of desired outcomes across the land tenures which lead us to five key recommendations for improving fire management outcomes in central Australia. We finish with some comments on associated opportunities for livelihood enhancement based on the management of fire.
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Davidson SJ, O’Neal K, van Dellen J, Roncaroli F, Brock C, Waldman A. A study of feasibility for setting up a dedicated brain tumor registry. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12514 Background: Population-based tumor registries represent an invaluable resource for monitoring incidence and prevalence of cancer. Nevertheless, data generated is not always useful for deciding treatment protocols or running translational/clinical research. This is particularly true for rare cancers such as primary brain tumors. Moreover, benign or low grade tumors are usually excluded and information such as quality of life and efficacy of treatment not followed up. Finally, there is no agreement on the minimum dataset required. Here, we investigated the difficulties of setting up a dedicated BTR that can be supportive of research. Methods: We audited 1000 consecutive histologically proven adult cases operated between 1995–2005. This group included 734 gliomas, 246 meningiomas and 20 ependymomas. As minimum dataset, we considered demographics, presenting symptoms, site, neuroimaging findings, pathology/WHO grade, extent of surgery, post-operative treatment, relapses and cause of death. To avoid capture/recapture errors we cross-referenced four independent databases (histopathology, imaging, Cancer Specialist and hospital patient database). Results: Overall availability of data was 80% in 1995–2000 and 95% in 2000–2005 when electronic notes were introduced. Missing data were as follow: demographics: 0%; symptoms: 20%; site and neuroimaging 15%; incorrect diagnosis or grade update; 20%; extent of surgery: 5%; post-operative treatment: 15%; follow-up: 10%: cause of death: 15%. Data could not be interpreted in 20% of cases due to transcription errors and use of abbreviations. Conclusion: To fulfil requirements for clinical/translational research (GNOSIS), BTR needs i) dedicated national registries; ii) specialist and professional data collection; iii) registration at the time of pathological diagnosis. No significant financial relationships to disclose.
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Affiliation(s)
- S. J. Davidson
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - K. O’Neal
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - J. van Dellen
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - F. Roncaroli
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - C. Brock
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
| | - A. Waldman
- Imperial College, London, United Kingdom; Hammersmith NHS Trust, London, United Kingdom; Hammmersmith NHS Trust, London, United Kingdom
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Nathan P, Chao D, Brock C, Savage P, Harries M, Gore M, Eisen T. The place of VEGF inhibition in the current management of renal cell carcinoma. Br J Cancer 2006; 94:1217-20. [PMID: 16508632 PMCID: PMC2361396 DOI: 10.1038/sj.bjc.6603025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Revised: 01/31/2006] [Accepted: 02/01/2006] [Indexed: 01/18/2023] Open
Abstract
Vascular endothelial growth factor (VEGF) is overexpressed in around 80% of patients with clear cell carcinoma of the kidney owing to the inactivation of von Hippel Lindau gene activity. VEGF stimulates angiogenesis and acts as an autocrine growth factor. A number of different agents are now available which target VEGF and its signalling pathways. A significant body of evidence has accumulated demonstrating that antagonism of VEGF and its downstream pathways is clinically useful in a significant proportion of patients with metastatic clear cell carcinoma of the kidney. Enough data is now available to recommend that patients with metastatic clear cell carcinoma of the kidney should at some point during the course of their disease be offered entry into a clinical trial enabling exposure to a targeted inhibitor of VEGF or its signalling pathways. Assuming early clinical trial data is substantiated by ongoing registration studies, efforts should be made to minimise the time taken between licensing and general availability of these active agents.
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Affiliation(s)
- P Nathan
- Mount Vernon Cancer Centre, Rickmansworth Road, Northwood, Middlesex, HA6 2RN, UK.
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de Jonge MJA, Kaye S, Verweij J, Brock C, Reade S, Scurr M, van Doorn L, Verheij C, Loos W, Brindley C, Mistry P, Cooper M, Judson I. Phase I and pharmacokinetic study of XR11576, an oral topoisomerase I and II inhibitor, administered on days 1-5 of a 3-weekly cycle in patients with advanced solid tumours. Br J Cancer 2004; 91:1459-65. [PMID: 15452551 PMCID: PMC2409936 DOI: 10.1038/sj.bjc.6602178] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
XR11576 is an oral topoisomerase I and II inhibitor. The objectives of this phase I study were to assess the dose-limiting toxicities (DLTs), to determine the maximum tolerated dose (MTD) and to describe the pharmacokinetics (PKs) of XR11576 when administered orally on days 1–5 every 3 weeks to patients with advanced solid tumours. Patients were treated with escalating doses of XR11576 at doses ranging from 30 to 180 mg day−1. For PK analysis, plasma sampling was performed during the first and second courses of treatment and XR11576 concentrations were assayed using a validated high-performance liquid chromatographic assay with mass spectrometric detection. In all, 21 patients received a total of 47 courses. The MTD was reached at 180 mg day−1, with diarrhoea and fatigue as DLT. Nausea and vomiting, although not qualifying for DLT, was ubiquitous. Only in combination with an extensive prophylactic antiemetic regimen consisting of a combination of both dexamethasone and a 5HT3 antagonist was treatment with XR11576 at 120 mg day−1 tolerable. The systemic exposure of XR11576 increased more than proportionally with increasing dose, with a large interpatient variability. No objective responses were seen; four patients experienced stable disease for periods of 12–30 weeks. In this study, the DLTs of XR11576 were diarrhoea and fatigue. The recommended dose for phase II studies of XR11576 is 120 mg administered orally, on days 1–5 every 21 days. Alternative regimens are currently being explored.
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Affiliation(s)
- M J A de Jonge
- Department of Medical Oncology, Erasmus Medical Center/Daniel den Hoed Cancer Center, Groene Hilledijk 301, 3075 EA Rotterdam, The Netherlands.
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Pacey S, Rea D, Steven N, Brock C, Knowlton N, Shand N, Hazell K, Zoellner U, O'Donnell A, Judson I. Results of a phase 1 clinical trial investigating a combination of the oral mTOR-inhibitor Everolimus (E, RAD001) and Gemcitabine (GEM) in patients (pts) with advanced cancers. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.3120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- S. Pacey
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - D. Rea
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - N. Steven
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - C. Brock
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - N. Knowlton
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - N. Shand
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - K. Hazell
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - U. Zoellner
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - A. O'Donnell
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
| | - I. Judson
- Royal Marsden Hospital NHS Trust, Sutton, United Kingdom; University Birmingham Cancer Research Trials Unit, Birmingham, United Kingdom; Novartis Pharma AG, Basel, Switzerland
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