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Sayuk GS, Kanuri N, Gyawali CP, Gott BM, Nix BD, Rosenheck RA. Opioid medication use in patients with gastrointestinal diagnoses vs unexplained gastrointestinal symptoms in the US Veterans Health Administration. Aliment Pharmacol Ther 2018; 47:784-791. [PMID: 29327358 DOI: 10.1111/apt.14503] [Citation(s) in RCA: 14] [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: 07/13/2017] [Revised: 08/05/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND While opioid prescriptions have increased alarmingly in the United States (US), their use for unexplained chronic gastrointestinal (GI) pain (eg, irritable bowel syndrome) carries an especially high risk for adverse effects and questionable benefit. AIM To compare opioid use among US veterans with structural GI diagnoses (SGID) and those with unexplained GI symptoms or functional GI diagnoses (FGID), a group for whom opioids have no accepted role. METHODS Veterans Health Administration (VHA) administrative data from fiscal year 2012 were used to identify veterans with diagnostic codes recorded for SGID and FGID. This cohort study examined VHA pharmacy data to compare groups receiving ≥ 1 opioid prescription during the year and number of prescriptions filled. Bivariate and multiple logistic regression analyses adjusted for potential confounding factors (demographics, medical diagnoses, social factors) and identified potential mediators (service use, psychiatric comorbidity) of opioid use in these groups. RESULTS A greater proportion of veterans with FGID received an opioid prescription during fiscal year 2012 (36.0% of 272 431) compared to only 28.9% of 1 223 744 in the SGID group (Relative Risk [RR] = 1.25). In multivariate logistic regression, personality disorders and drug abuse (OR 1.23 for each group), recent homelessness (OR 1.22), psychotropic medication fills (OR 1.55) and emergency department encounters (OR 1.21) were independently associated with opioid prescription use. CONCLUSIONS Despite the potential for adverse consequences, opioids more often are prescribed for veterans with chronic, unexplained GI symptoms compared to those with structural diagnoses. Psychiatric comorbidities and frequent healthcare encounters mediate some of the opioid use risk.
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Affiliation(s)
- G S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.,Gastroenterology Section, John Cochran Veterans Affairs Medical Center, St. Louis, MO, USA
| | - N Kanuri
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - B M Gott
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - B D Nix
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - R A Rosenheck
- Department of Veterans Affairs, New England Mental Illness Research, Education, and Clinical Center, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Iskandar H, Gray DM, Vu H, Mirza F, Rude MK, Regan K, Abdalla A, Gaddam S, Almaskeen S, Mello M, Marquez E, Meyer C, Bolkhir A, Kanuri N, Sayuk G, Gyawali CP. Coeliac disease screening is suboptimal in a tertiary gastroenterology setting. Postgrad Med J 2017; 93:472-475. [PMID: 28069744 DOI: 10.1136/postgradmedj-2016-134005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 12/13/2016] [Accepted: 12/16/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Coeliac disease (CD) is widely prevalent in North America, but case-finding techniques currently used may not be adequate for patient identification. We aimed to determine the adequacy of CD screening in an academic gastroenterology (GI) practice. METHODS Consecutive initial visits to a tertiary academic GI practice were surveyed over a 3-month period as a fellow-initiated quality improvement project. All electronic records were reviewed to look for indications for CD screening according to published guidelines. The timing of screening was noted (before or after referral), as well as the screening method (serology or biopsy). Data were analysed to compare CD screening practices across subspecialty clinics. RESULTS 616 consecutive patients (49±0.6 years, range 16-87 years, 58.5% females, 94% Caucasian) fulfilled inclusion criteria. CD testing was indicated in 336 (54.5%), but performed in only 145 (43.2%). The need for CD screening was highest in luminal GI and inflammatory bowel disease clinics, followed by biliary and hepatology clinics (p<0.0001); CD screening rate was highest in the luminal GI clinic (p=0.002). Of 145 patients screened, 4 patients (2.4%) had serology consistent with CD, of which 2 were proven by duodenal biopsy. Using this proportion, an additional 5 patients might have been diagnosed in 191 untested patients with indications for CD screening. CONCLUSIONS More than 50% of patients in a tertiary GI clinic have indications for CD screening, but <50% of indicated cases are screened. Case-finding techniques therefore are suboptimal, constituting a gap in patient care and an important target for future quality improvement initiatives.
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Affiliation(s)
- Heba Iskandar
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,Digestive Diseases Division, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Darrell M Gray
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hongha Vu
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Faiz Mirza
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Mary Katherine Rude
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Kara Regan
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Adil Abdalla
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Srinivas Gaddam
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Sami Almaskeen
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Michael Mello
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Evelyn Marquez
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Claire Meyer
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Ahmed Bolkhir
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Navya Kanuri
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - Gregory Sayuk
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA.,John Cochran Veterans Affairs Medical Center, St Louis, Missouri, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Department of Medicine, Washington University in St Louis, St Louis, Missouri, USA
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Gaddam S, Reddy CA, Munigala S, Patel A, Kanuri N, Almaskeen S, Rude MK, Abdalla A, Gyawali CP. The learning curve for interpretation of oesophageal high-resolution manometry: a prospective interventional cohort study. Aliment Pharmacol Ther 2017; 45:291-299. [PMID: 27859421 PMCID: PMC5148725 DOI: 10.1111/apt.13855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/18/2016] [Accepted: 10/15/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND High-resolution manometry has become the preferred choice of oesophagologists for oesophageal motor assessment, but the learning curve among trainees remains unclear. AIM To determine the learning curve of high-resolution manometry interpretation. METHODS A prospective interventional cohort study was performed on 18 gastroenterology trainees, naïve to high-resolution manometry (median age 32 ± 4.0 years, 44.4% female). An intake questionnaire and a 1-h standardised didactic session were performed at baseline. Multiple 1-h interpretation sessions were then conducted periodically over 15 months where 10 studies were discussed; 5 additional test studies were provided for interpretation, and results were compared to gold standard interpretation by the senior author. Hypothetical management decisions based on trainee interpretation were separately queried. Accuracy was compared across test interpretations and sessions to determine the learning curve, with a goal of 90% accuracy. RESULTS Baseline accuracy was low for abnormal body motor patterns (53.3%), but higher for achalasia/outflow obstruction (65.9%). Recognition of achalasia reached 90% accuracy after six sessions (P = 0.01), while overall accurate management decisions reached this threshold by the 4th session (P < 0.001). Based on our data, the threshold of 90% accuracy for recognition of any abnormal from normal pattern was reached after 30 studies (3rd session) but fluctuated. Diagnosis of oesophageal body motor patterns remained suboptimal; accuracy of advisability of fundoplication improved, but did not reach 90%. CONCLUSIONS High-resolution manometry has a steep learning curve among trainees. Achalasia recognition is achieved early, but diagnosis of other abnormal motor patterns and management decisions require further supervised training.
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Affiliation(s)
- S Gaddam
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - C A Reddy
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Munigala
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - A Patel
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - N Kanuri
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Almaskeen
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - M K Rude
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - A Abdalla
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
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Kanuri N, Cassell B, Bruce SE, White KS, Gott BM, Gyawali CP, Sayuk GS. The impact of abuse and mood on bowel symptoms and health-related quality of life in irritable bowel syndrome (IBS). Neurogastroenterol Motil 2016; 28:1508-17. [PMID: 27151081 PMCID: PMC5042818 DOI: 10.1111/nmo.12848] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [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: 11/17/2015] [Accepted: 04/11/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a common abdominal pain disorder without an organic explanation. Abuse histories (physical, sexual, emotional) are prevalent in IBS. While abuse relates to mood disorders (depression and anxiety) also common in IBS, the influence of abuse on gastrointestinal (GI) symptoms and health-related quality of life (HRQOL) and its independence from psychological symptom comorbidity has not been studied. METHODS Consecutive GI outpatients completed the ROME III Research Diagnostic Questionnaire and questionnaires on trauma (Life-Stress Questionnaire), mood (Beck Depression/Anxiety Inventories), somatic symptoms (PHQ-12), and HRQOL (SF-36). Current GI symptom severity and bother were assessed using 10-cm Visual Analog Scales. KEY RESULTS 272 ROME-defined IBS (47.6 ± 0.9 years, 81% female) and 246 non-FGID (51.6 ± 1.0 years, 65% female) subjects participated. IBS patients reported greater rates of physical, sexual, and emotional abuse (p < 0.006 each), and higher depression, anxiety, and somatic symptoms (p < 0.001). Greater bowel symptom bother (7.4 ± 0.2 vs 6.7 ± 0.2, p = 0.040), severity (7.7 ± 0.2 vs 6.5 ± 0.2, p < 0.001), recent symptomatic days (9.8 ± 0.4 vs 8.5 ± 0.3, p = 0.02), and poorer HRQOL (40.9 ± 2.3 vs 55.5 ± 1.7, p < 0.001) were noted in IBS with abuse. Abuse effects were additive, with greater IBS symptom severity and poorer HRQOL noted in cases with multiple forms of abuse. Mediation analyses suggested that abuse effects on GI symptoms and HRQOL were partially mediated by mood. CONCLUSIONS & INFERENCES Abuse experiences common among IBS sufferers are associated with reports of greater GI symptoms and poorer HRQOL, particularly in those with multiple forms of abuse; this relationship may be partially mediated by concomitant mood disturbances.
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Affiliation(s)
- Navya Kanuri
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin Cassell
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Steven E. Bruce
- Center for Trauma Recovery, University of Missouri-St. Louis, Missouri, USA
| | - Kamila S. White
- Center for Trauma Recovery, University of Missouri-St. Louis, Missouri, USA
| | - Britt M. Gott
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - C. Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gregory S. Sayuk
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA,Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA,Gastroenterology Section, John Cochran Veterans Affairs Medical Center, University of Missouri-St. Louis, Missouri, USA
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Affiliation(s)
- Kelly Cushing
- Washington University, Department of Gastroenterology, 660 South Euclid Ave, St. Louis, MO 63110. Support provided by the T32DK007130 grant
| | - Navya Kanuri
- Washington University, Department of Gastroenterology, 660 South Euclid Ave, St. Louis, MO 63110
| | - Matthew Ciorba
- Washington University, Department of Gastroenterology, 660 South Euclid Ave, St. Louis, MO 63110
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Vivio EE, Kanuri N, Gilbertsen JJ, Monroe K, Dey N, Chen CH, Gutierrez AM, Ciorba MA. Vedolizumab Effectiveness and Safety Over the First Year of Use in an IBD Clinical Practice. J Crohns Colitis 2016; 10:402-9. [PMID: 26681763 PMCID: PMC4946762 DOI: 10.1093/ecco-jcc/jjv226] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Vedolizumab inhibits leucocyte vascular adhesion and migration into the gastrointestinal tract through α4β7 integrin blockade. This agent became available in mid-2014 for the treatment of moderate to severe Crohn's disease (CD) and UC (UC). The aim of this study was to assess the patterns of use, effectiveness and safety of vedolizumab in an inflammatory bowel disease (IBD) clinical practice. METHODS Patients beginning vedolizumab were enrolled with informed consent. A prospective cohort was followed with laboratory, disease activity and quality-of-life assessments made during infusion visits up to week 14. Duration of vedolizumab use, mucosal healing and safety were analysed retrospectively for all patients not captured in the prospective component of this study. RESULTS One hundred and two patients started vedolizumab, with 51 patients (30 CD, 21 UC) followed prospectively. The CD patients exhibited a significant decrease in Crohn's Disease Activity Index (p = 0.04) and Harvey-Bradshaw index (p < 0.01) by week 14. The UC patients demonstrated improved partial Mayo scores at weeks 6 (p < 0.01) and 14 (p < 0.001). Ninety percent of all CD and UC patients remained on vedolizumab up to week 14. IBD-related quality of life was improved by week 6 in CD and UC cohorts (p = 0.02 and p < 0.01 respectively). Colectomy for lack of response and systemic histoplamosis were notable reasons for early discontinuation of vedolizumab, which was otherwise well tolerated. CONCLUSIONS Vedolizumab was efficacious and a high percentage of patients continued this therapy beyond induction dosing. Observed safety signals may be attributed to the refractory IBD disease state of this early-adopting clinical cohort.
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Affiliation(s)
- Emily E Vivio
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Navya Kanuri
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Joanna J Gilbertsen
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Kelly Monroe
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Neelendu Dey
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Chien-Huan Chen
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Alexandra M Gutierrez
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
| | - Matthew A Ciorba
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO 63110, USA
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Lee A, Kanuri N, Zhang Y, Sayuk GS, Li E, Ciorba MA. Correction: IDO1 and IDO2 Non-Synonymous Gene Variants: Correlation with Crohn's Disease Risk and Clinical Phenotype. PLoS One 2015; 10:e0133098. [PMID: 26173109 PMCID: PMC4501741 DOI: 10.1371/journal.pone.0133098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Gupta NK, Thaker AI, Kanuri N, Riehl TE, Rowley CW, Stenson WF, Ciorba MA. Serum analysis of tryptophan catabolism pathway: correlation with Crohn's disease activity. Inflamm Bowel Dis 2012; 18:1214-20. [PMID: 21823214 PMCID: PMC3235239 DOI: 10.1002/ibd.21849] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 07/12/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Indoleamine 2,3 dioxygenase-1 (IDO1) is a tryptophan catabolizing enzyme with immunotolerance-promoting functions. We sought to determine if increased gut expression of IDO1 in Crohn's disease (CD) would result in detectable changes in serum levels of tryptophan and the initial IDO1 pathway catabolite, kynurenine. METHODS Individuals were prospectively enrolled through the Washington University Digestive Diseases Research Center. The Montreal Classification was used for disease phenotyping. Disease severity was categorized by the Physician's Global Assessment. Serum tryptophan and kynurenine were measured by high-pressure liquid chromatography. IDO1 immunohistochemical staining was performed on formalin-fixed tissue blocks. RESULTS In all, 25 CD patients and 11 controls were enrolled. Eight CD patients had serum collected at two different timepoints and levels of disease activity compared. Strong IDO1 expression exists in both the lamina propria and epithelium during active CD compared to controls. Suppressed serum tryptophan levels and an elevated kynurenine/tryptophan (K/T) ratio were found in individuals with active CD as compared to those in remission or the control population. K/T ratios correlated positively with disease activity as well as with C-reactive protein and erythrocyte sedimentation rate. In the subgroup of CD patients with two serum measurements, tryptophan levels were elevated while kynurenine levels and the K/T ratio lowered as the disease activity lessened. CONCLUSIONS IDO1 expression in CD is associated with lower serum tryptophan and an elevated K/T ratio. These levels may serve as a reasonable objective marker of gut mucosal immune activation and as a surrogate for CD activity.
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Affiliation(s)
- Nitin K Gupta
- Division of Gastroenterology, Washington University in Saint Louis School of Medicine, St. Louis, Missouri, USA
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