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Pearson J, Khan A, Bhogal T, Wong H, Law A, Mills S, Santamaria N, Bishop J, Cliff J, Errington D, Hall A, Hart C, Malik Z, Sripadam R, Innes H, Flint H, Langton G, Ahmed E, Jackson R, Palmieri C. A comparison of the efficacy of trastuzumab deruxtecan in advanced HER2-positive breast cancer: active brain metastasis versus progressive extracranial disease alone. ESMO Open 2023; 8:102033. [PMID: 37866031 PMCID: PMC10774880 DOI: 10.1016/j.esmoop.2023.102033] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/29/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Trastuzumab deruxtecan (T-DXd) has demonstrated efficacy in patients with brain metastasis (BM), a group historically with poor outcomes. The prevalence of BMs in patients commencing T-DXd is currently unknown. No direct comparisons have been made of the activity of T-DXd in patients with active BM versus those with extracranial progression alone. This real-world study explored the prevalence of BMs in patients commencing T-DXd, the efficacy of T-DXd in active BM versus extracranial progression alone and the safety of T-DXd. PATIENTS AND METHODS Patients with human epidermal growth factor receptor 2-positive advanced breast cancer treated with T-DXd between June 2021 and February 2023 at our specialist cancer hospital were identified and notes reviewed. Clinicopathological information, prior treatment, the presence or absence of central nervous system (CNS) disease, outcomes and treatment-emergent adverse events (TEAEs) were recorded. RESULTS Twenty-nine female patients, with a median age of 52 years (interquartile range 44-62 years), were identified; the prevalence of BM was 41%. Median number of lines of prior therapy was 2 (range 2-6). At a median follow-up of 13.8 months, median progression-free survival (PFS) for the overall population was 13.9 months [95% confidence interval (CI) 12.4 months-not estimable (NE)], 16.1 months (95% CI 15.1 months-NE) for active BMs and 12.4 months (95% CI 8.3 months-NE) for progressive extracranial disease alone. The 12-month overall survival (OS) rate was 74% (95% CI 59% to 95%) in the overall population, and 83% (95% CI 58% to 100%) and 66% (95% CI 45% to 96%) for active BMs and extracranial disease only, respectively. Most common TEAEs were fatigue, alopecia, and constipation. In nine patients (31%, including two deaths), pneumonitis occurred. CONCLUSION In this real-world population, we demonstrate T-DXd to be effective in patients with active BMs and those with progressive extracranial disease alone. PFS and OS were numerically longer in those with active BMs. These data demonstrate that patients with active BM treated with T-DXd have at least comparable outcomes to those with extracranial disease alone. The high rate of pneumonitis warrants further consideration.
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Affiliation(s)
- J Pearson
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool; Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool
| | - A Khan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - T Bhogal
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool; Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool
| | - H Wong
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - A Law
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - S Mills
- The Walton NHS Foundation Trust, Liverpool, UK
| | - N Santamaria
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - J Bishop
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - J Cliff
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - D Errington
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - A Hall
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - C Hart
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - Z Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - R Sripadam
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - H Innes
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - H Flint
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - G Langton
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - E Ahmed
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - R Jackson
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool
| | - C Palmieri
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool; Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool.
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Parkman HP, Wilson LA, Silver P, Maurer AH, Sarosiek I, Bulat RS, Kuo B, Grover M, Farrugia G, Chumpitazi BP, Shulman RJ, Malik Z, Miriel LA, Tonascia J, Hamilton F, Abell TL, Pasricha PJ, McCallum RW, Koch KL. Relationships among intragastric meal distribution during gastric emptying scintigraphy, water consumption during water load satiety testing, and symptoms of gastroparesis. Am J Physiol Gastrointest Liver Physiol 2023; 325:G407-G417. [PMID: 37552206 PMCID: PMC10887845 DOI: 10.1152/ajpgi.00065.2023] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/09/2023]
Abstract
Gastric emptying scintigraphy (GES) measures total gastric retention after a solid meal and can assess intragastric meal distribution (IMD). Water load satiety test (WLST) measures gastric capacity. Both IMD immediately after meal ingestion [ratio of proximal gastric counts after meal ingestion to total gastric counts at time 0 (IMD0)] and WLST (volume of water ingested over 5 min) are indirect measures of gastric accommodation. In this study, IMD0 and WLST were compared with each other and to symptoms of gastroparesis to gauge their clinical utility for assessing patients with symptoms of gastroparesis. Patients with symptoms of gastroparesis underwent GES to obtain gastric retention and IMD0, WLST, and filled out patient assessment of upper GI symptoms. A total of 234 patients with symptoms of gastroparesis were assessed (86 patients with diabetes, 130 idiopathic, 18 postfundoplication) and 175 (75%) delayed gastric emptying. Low IMD0 <0.568 suggesting initial rapid transit to the distal stomach was present in 8% and correlated with lower gastric retention, less heartburn, and lower volumes consumed during WLST. Low WLST volume (<238 mL) was present in 20% and associated with increased severity of early satiety, postprandial fullness, loss of appetite, and nausea. Low IMD0 is associated with less gastric retention and less heartburn. Volume of water consumed during WLST, while associated with IMD0, has associations with early satiety, postprandial fullness, loss of appetite, and nausea. Thus, IMD0 and WLST appear to overlap somewhat in their assessment of gastric physiology in adults with symptoms of gastroparesis but relate to different dyspeptic symptoms.NEW & NOTEWORTHY IMD0 and WLST were assessed for their clinical utility in assessing patients with symptoms of gastroparesis. Low IMD0 is associated with less gastric retention and less heartburn. Volume of water consumed during WLST, while associated with IMD0, has associations with early satiety, postprandial fullness, loss of appetite, and nausea. IMD0 and WLST appear to overlap somewhat in their assessment of gastric physiology in adults with symptoms of gastroparesis but relate to different dyspeptic symptoms.
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Affiliation(s)
- Henry P Parkman
- Gastroenterology Section, Temple University, Philadelphia, Pennsylvania, United States
| | - Laura A Wilson
- Gastroenterology Section, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Paul Silver
- Gastroenterology Section, Temple University, Philadelphia, Pennsylvania, United States
| | - Alan H Maurer
- Gastroenterology Section, Temple University, Philadelphia, Pennsylvania, United States
| | - Irene Sarosiek
- Gastroenterology Section, Texas Tech University Health Sciences Center, El Paso, Texas, United States
| | - Robert S Bulat
- Gastroenterology Section, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Braden Kuo
- Gastroenterology Section, Harvard Medical School, Boston, Massachusetts, United States
| | - Madhusudan Grover
- Gastroenterology Department, Mayo Clinic, Rochester, Minnesota, United States
| | - Gianrico Farrugia
- Gastroenterology Department, Mayo Clinic, Rochester, Minnesota, United States
| | - Bruno P Chumpitazi
- Gastroenterology Section, Baylor College of Medicine, Children's Nutrition Research Center, Houston, Texas, United States
| | - Robert J Shulman
- Gastroenterology Section, Baylor College of Medicine, Children's Nutrition Research Center, Houston, Texas, United States
| | - Zubair Malik
- Gastroenterology Section, Temple University, Philadelphia, Pennsylvania, United States
| | - Laura A Miriel
- Gastroenterology Section, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - James Tonascia
- Gastroenterology Section, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Frank Hamilton
- Gastroenterology Section, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, United States
| | - Thomas L Abell
- Gastroenterology Section, University of Louisville, Louisville, Kentucky, United States
| | - Pankaj J Pasricha
- Gastroenterology Section, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States
| | - Richard W McCallum
- Gastroenterology Section, Texas Tech University Health Sciences Center, El Paso, Texas, United States
| | - Kenneth L Koch
- Section of Gastroenterology, Wake Forest University, Winston-Salem, North Carolina, United States
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Khatri R, Patel J, Song J, Malik Z, Smith MS, Parkman HP. Esophageal Inlet Patch: Association with Barrett's Esophagus. Dig Dis Sci 2023; 68:3671-3678. [PMID: 37452980 DOI: 10.1007/s10620-023-08030-z] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Esophageal inlet patch (IP) with heterotopic gastric mucosa is an incidental finding on esophagogastroduodenoscopy (EGD). Although IP is thought to be embryologic in nature, IP has been associated with Barrett's esophagus (BE). AIMS The aim of this study was to compare prevalence, symptoms, demographic factors, and esophageal testing in patients with IP and BE. METHODS We retrospectively analyzed endoscopic findings of EGDs, high-resolution esophageal manometry and esophageal pH impedance studies from January 2010 to January 2021 at a single academic medical center. Patients were grouped by presence or absence of IP and BE. RESULTS Of 27,498 patients evaluated, 1.3% had endoscopic evidence of IP and 4.9% had BE. Of 362 patients with IP, 17.1% had BE; of 1356 patients with BE, 4.6% had IP. Both IP and BE patients presented primarily with heartburn and/or regurgitation. Patients with BE and/or IP were older and had higher BMI than those without (p < 0.001). Mean lower esophageal sphincter pressure was lower and mean acid exposure time (AET) was higher in patients with IP and/or BE than those without (p < 0.05). CONCLUSIONS Our study reports an IP prevalence of 1.3%, with 17.1% patients having concomitant BE; and a BE prevalence of 4.9%, with 4.6% also having IP. Patients with IP alone presented with similar symptoms to patients with concomitant BE. Esophageal function testing showed that patients with either IP or BE had decreased LES pressures and increased esophageal AET. During endoscopy, patients found to have one of these findings should be carefully examined for the other.
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Affiliation(s)
- Rishabh Khatri
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA.
- Gastroenterology Section, Temple University School of Medicine, Parkinson Pavilion, 8th Floor, Philadelphia, PA, 19140, USA.
| | - Jay Patel
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Jun Song
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Zubair Malik
- Department of Gastroenterology, Temple University Health System, Philadelphia, PA, USA
| | - Michael S Smith
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai West & Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Health System, Philadelphia, PA, USA
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Tanner SE, Kurin M, Shahsavari D, Malik Z, Parkman HP. Trends in Gastroparesis Management: A United States Population-based Study From 2010 to 2020. J Clin Gastroenterol 2023; 57:789-797. [PMID: 36227007 DOI: 10.1097/mcg.0000000000001766] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 08/23/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND There is little consensus on the medical management of gastroparesis, a disorder characterized by delayed gastric emptying with symptoms of early satiety, nausea, vomiting, and upper abdominal pain. GOALS We utilized population-level data to: (1) describe the prevalence of different pharmacological and nonpharmacological therapies in patients with gastroparesis; and (2) trend the prevalence of these therapies from 2010 to 2020. STUDY More than 59 million unique medical records across 26 US-based major health care systems were surveyed using the Explorys platform to identify a cohort of adults with gastroparesis who completed both a gastric emptying study and upper endoscopy or upper gastrointestinal tract imaging. Prevalence of antiemetic, prokinetic, neuromodulator prescriptions, and surgical therapies for gastroparesis were searched within this cohort and trended annually from 2010 to 2020. RESULTS Antiemetics (72% of patients), prokinetics (47%), and neuromodulators (75% of patients, 44% of patients without a concomitant psychiatric or diabetic peripheral neuropathy diagnosis) were all commonly used in the treatment of patients with gastroparesis. From 2010 to 2020, there was an increase in the prevalence of antiemetic and neuromodulator prescriptions (36.4% to 57.6%, P <0.001 and 47.0% to 66.9%, P <0.001, respectively), whereas the prevalence of prokinetics remained relatively constant (31.8% to 31.6%, P =0.52). Procedural and surgical treatments were used in 5% of gastroparesis patients. CONCLUSIONS Treatments for gastroparesis have changed over the last decade: antiemetic and neuromodulator use has increased whereas prokinetic use has remained constant. This practice pattern may reflect the growing number and availability of antiemetics and neuromodulators and the small number and known side effects of prokinetics.
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Affiliation(s)
| | - Michael Kurin
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Dariush Shahsavari
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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5
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Parkman HP, Yates KP, Sarosiek I, Bulat RS, Abell TL, Koch KL, Kuo B, Grover M, Farrugia G, Silver P, Abdullah A, Maurer AH, Malik Z, Miriel LA, Tonascia J, Hamilton F, Pasricha PJ, McCallum RW. Buspirone for early satiety and symptoms of gastroparesis: A multi-centre, randomised, placebo-controlled, double-masked trial (BESST). Aliment Pharmacol Ther 2023; 57:1272-1289. [PMID: 37052334 DOI: 10.1111/apt.17479] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/18/2023] [Accepted: 03/10/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Patients with gastroparesis and related disorders have symptoms including early satiety, postprandial fullness and bloating. Buspirone, a 5-HT1 receptor agonist, may improve fundic accommodation. AIM To determine if buspirone treatment improves early satiety and postprandial fullness in patients with symptoms of gastroparesis. METHODS This 4-week multi-centre clinical trial randomised patients with symptoms of gastroparesis and moderate-to-severe symptoms of fullness (Gastroparesis Cardinal Symptom Index [GCSI] early satiety/postprandial fullness subscore [ES/PPF]) to buspirone (10 mg orally) or placebo three times per day. The primary outcome was a change in the ES/PPF from baseline to 4 weeks. The primary analysis was per protocol intention-to-treat ANCOVA of between-group baseline vs. 4-week differences (DoD) in ES/PPF adjusted for baseline ES/PPF. Results are reported using both nominal and Bonferroni (BF) p values. RESULTS AND CONCLUSIONS Ninety-six patients (47 buspirone, 49 placeboes; 92% female, 50% delayed gastric emptying, 39% diabetic) were enrolled. There was no between-groups difference in the 4-week ES/PPF primary outcome: -1.16 ± 1.25 (SD) on buspirone vs -1.03 ± 1.29 (SD) on placebo (mean DoD: -0.11 [95% CI: -0.68, 0.45]; p = 0.69). Buspirone performed better than placebo in patients with severe-to-very severe bloating at baseline compared to patients with none to moderate: (ES/PPF DoD = -0.65 vs. 1.58, pTX*GROUP = 0.003; pBF = 0.07). Among individual GCSI symptoms, only bloating appeared to improve with buspirone vs. placebo. CONCLUSIONS Patients with moderate-to-severe early satiety/postprandial fullness and other symptoms of gastroparesis did not benefit from buspirone treatment to improve the ES/PPF primary outcome compared with placebo. There was a suggestion of the benefit of buspirone in patients with more severe bloating. TRIAL REGISTRATION ClinicalTrials.gov NCT0358714285.
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Affiliation(s)
| | | | - Irene Sarosiek
- Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | | | | | - Kenneth L Koch
- Wake Forest University, Winston-Salem, North Carolina, USA
| | - Braden Kuo
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Paul Silver
- Temple University, Philadelphia, Pennsylvania, USA
| | | | | | - Zubair Malik
- Temple University, Philadelphia, Pennsylvania, USA
| | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
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Parkman HP, Blackford AL, Murray HB, Yates KP, Grover M, Malik Z, Schey R, Bulat RS, Koch KL, Sarosiek I, Kuo B, Shulman RJ, Chumpitazi BP, Farrugia G, Miriel L, Tonascia J, Hamilton F, Pasricha PJ, McCallum RW, Abell TL. Characteristics and outcomes of patients with gastroparesis using enteral and/or exclusive parenteral nutrition. JPEN J Parenter Enteral Nutr 2023; 47:541-549. [PMID: 36871132 PMCID: PMC10164106 DOI: 10.1002/jpen.2493] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/21/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Patients with gastroparesis (Gp) may need enteral nutrition (EN) or exclusive parenteral nutrition (PN). Among patients with Gp, we aimed to (1) identify the frequency of EN and exclusive PN use and (2) explore characteristics of patients using EN and/or exclusive PN compared with those using oral nutrition (ON), including changes over 48 weeks. METHODS Patients with Gp underwent history and physical examination, gastric emptying scintigraphy, water load satiety testing (WLST), and questionnaires assessing gastrointestinal symptoms and quality of life (QOL). Patients were observed 48 weeks. RESULTS Of 971 patients with Gp (idiopathic, 579; diabetic, 336; post-Nissen fundoplication, 51), 939 (96.7%) were using ON only, 14 (1.4%) using exclusive PN, and 18 (1.9%) using EN. Compared with patients receiving ON, patients receiving exclusive PN and/or EN were younger, had lower body mass index, and had greater symptom severity. Patients receiving exclusive PN and/or EN had lower physical QOL but not mental QOL or Gp-related QOL scores. Patients receiving exclusive PN and/or EN ingested less water during WLST but did not have worse gastric emptying. Of those who had been receiving exclusive PN and/or EN, 50% and 25%, respectively, resumed ON at 48-week follow-up. CONCLUSIONS This study describes patients with Gp requiring exclusive PN and/or EN for nutrition support, who represent a small (3.3%) but important subset of patients with Gp. Unique clinical and physiological parameters are associated with this subset and provide insight into the use of nutrition support in Gp.
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Affiliation(s)
- Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Amanda L Blackford
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Katherine P Yates
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Madhusudan Grover
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Ron Schey
- Gastroenterology Section, Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Robert S Bulat
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kenneth L Koch
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Irene Sarosiek
- Department of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Braden Kuo
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Shulman
- Department of Medicine, Baylor School of Medicine, Houston, Texas, USA
| | | | - Gianrico Farrugia
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Laura Miriel
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - James Tonascia
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Pankaj J Pasricha
- Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Richard W McCallum
- Department of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Thomas L Abell
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
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7
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Tanner SE, Burton Murray H, Brown TA, Malik Z, Parkman HP. Gastrointestinal-Specific symptom anxiety in patients with gastroparesis: Relationships to symptom severity and quality of life. Neurogastroenterol Motil 2023; 35:e14534. [PMID: 36740788 DOI: 10.1111/nmo.14534] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal (GI)-specific anxiety has been identified as a treatment target in irritable bowel syndrome. However, GI-specific anxiety has been understudied in other GI functional/motility disorders. Among adults with gastroparesis, we aimed to: (1) initially validate a measure of GI-specific anxiety, the Visceral Sensitivity Index (VSI); and (2) evaluate the relationship between GI-specific anxiety and gastroparesis symptom severity and quality of life, compared to measures of anxiety, depression, and somatization. METHODS Consecutive adult patients (N = 100) with gastroparesis presenting for initial consultation completed a series of self-report measures including the VSI. We conducted a confirmatory factor analysis of the VSI one-factor structure and tested internal consistency and convergent validity. We then performed hierarchical linear regression analyses to explore associations between VSI and gastroparesis symptom severity and overall quality of life. KEY RESULTS Confirmatory factor analysis revealed that the original VSI one-factor structure overall fit well [χ2 (90) = 220.1, p < 0.0001; SRMR = 0.08; RMSEA = 0.12; CFI = 0.96]. The VSI also had excellent internal consistency (α = 0.99) and convergent validity (r = 0.29-0.56; all p < 0.01). Higher GI-specific anxiety was significantly associated with greater gastroparesis symptom severity, including nausea/vomiting, fullness/satiety, and upper abdominal pain scores beyond depression, anxiety, or somatization (all p = <0.01-0.01). Additionally, higher GI-specific anxiety was significantly associated with lower mental health-related quality of life, beyond gastroparesis symptom severity, depression, anxiety, or somatization (p = 0.01). CONCLUSIONS & INFERENCES The VSI is an adequate measure of GI-specific anxiety in patients with gastroparesis. Higher GI-specific anxiety was associated with increased patient-reported gastroparesis symptom severity and decreased quality of life, beyond depression/anxiety.
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Affiliation(s)
- Samuel E Tanner
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Helen Burton Murray
- Department of Medicine, Center for Neurointestinal Health, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Tiffany A Brown
- Department of Psychological Sciences, Auburn University, Auburn, Alabama, USA
| | - Zubair Malik
- Department of Medicine, Gastroenterology Section, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Henry P Parkman
- Department of Medicine, Gastroenterology Section, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Attard G, Murphy L, Clarke N, Cross W, Gillessen S, Amos C, Brawley C, Jones R, Pezaro C, Malik Z, Montazeri A, Millman R, Cook A, Gilbert D, Langley R, Parker C, Sydes M, Brown L, Parmar M, James N. LBA62 Comparison of abiraterone acetate and prednisolone (AAP) or combination enzalutamide (ENZ) + AAP for metastatic hormone sensitive prostate cancer (mHSPC) starting androgen deprivation therapy (ADT): Overall survival (OS) results of 2 randomised phase III trials from the STAMPEDE protocol. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.08.065] [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] Open
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Shahsavari D, Thomas R, Ehrlich AC, Feinstein LH, Malik Z, Parkman HP. Demographics of Gastroparesis Hospitalizations Through the Age Spectrum Using National Inpatient Databases: Children Compared With Adults. J Clin Gastroenterol 2022; 56:679-687. [PMID: 34653068 DOI: 10.1097/mcg.0000000000001617] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/24/2021] [Indexed: 12/10/2022]
Abstract
GOAL The goal of this study was to characterize the etiology and demographics of hospitalized patients with gastroparesis (Gp) across different age groups. BACKGROUND Gp is a chronic condition associated with increasing hospitalizations and costs. The gender and etiology distributions of Gp throughout the age spectrum are unknown. MATERIALS AND METHODS Nationwide Inpatient Sample (NIS) and Kid's Inpatient Database (KID) were used to identify patients using International Classification of Diseases (ICD)-10 codes for Gp as a primary diagnosis or as secondary diagnosis with the first diagnosis a GI-related symptom. RESULTS There were a total of 15,790 admissions (75.6% female, age: 46.2±18.0 y). After age 6, female admissions percentage increased: ages 2 to 5: 45.0%, ages 6 to 12: 62.8%, ages 13 to 20: 76.7% ( P <0.001), with a distinct increase at age 12. Diabetic gastroparesis (DG) was seen in 3995 (25.3%) of all Gp admissions but in only 1.1% of children under the age of 20. Overall, 68% of DG admissions were female, but a higher percentage of DG was seen among male admissions for Gp compared with female admissions for Gp between ages 21 and 64 (38.3% vs. 23%, P <0.001). The most common races were white (63.2%), African American (20.6%), and Hispanic (8.7%). DG was more often present in Native American (61.9%), Hispanic (39.1%), and African American (38.2%) admissions than in white patients (17.8%; P <0.05). CONCLUSIONS This study using large inpatient databases shows that the gender, race, and etiology of Gp admissions is age-dependent. The female predominance of Gp admissions is more prominent from the second decade of life. DG, although uncommon in children, is seen more often in nonwhite admissions.
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Affiliation(s)
| | | | | | - Laurence H Feinstein
- Department of Pediatrics, Saint Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
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Shahsavari D, Smith MS, Malik Z, Parkman HP. Hiatal hernias associated with acid reflux: size larger than 2 cm matters. Dis Esophagus 2022; 35:6513901. [PMID: 35066592 DOI: 10.1093/dote/doac001] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 11/11/2021] [Accepted: 12/17/2021] [Indexed: 01/05/2023]
Abstract
Hiatal hernia (HH) is associated with gastroesophageal reflux disease (GERD); the effect of HH size on GERD is not well defined. To evaluate the relationship between HH size as measured by high-resolution esophageal manometry (HREM) and reflux parameters on esophageal pH-impedance testing (multichannel intraluminal impedance-pH [MII-pH]) to define HH sizes associated with GERD. HREM and MII-pH studies were reviewed. The relationship of HH size to other parameters was analyzed with multivariable logistic regression. Correlation coefficients were determined using Spearman and Pearson's tests. A total of 897 patients underwent both HREM and MII-pH. There were 529 (58.9%) patients with HH size <1 cm, 203 (22.6%) with HH 1.0-1.9 cm, and 165 (18.4%) with HH ≥2 cm. Larger HH size was associated with lower esophageal sphincter (LES) basal and residual pressures (r = -0.43 and r = -0.48, p < 0.01), higher acid exposure time (AET) (r = 0.17, p < 0.01), number of acidic refluxes (r = 0.16, p < 0.05), and number of reflux episodes detected by impedance (total r = 0.22, p < 0.01). HH ≥ 2 cm compared with smaller size HH was associated with higher proximal AET%, acidic refluxes, and reflux episodes detected by impedance (p < 0.05). Increasing HH size was associated with older age, higher AET, and number of reflux episodes. HH ≥2 cm was associated with multiple worsened GERD parameters. Low LES pressure was weakly associated with an increase in the number of reflux episodes. Larger HHs, particularly >2 cm, are associated with more severe GERD parameters.
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Affiliation(s)
- Dariush Shahsavari
- Department of Gastroenterology and Hepatology, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Michael S Smith
- Division of Gastroenterology and Hepatology, Mount Sinai West & Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zubair Malik
- Section of Gastroenterology, Temple University, Philadelphia, PA, USA
| | - Henry P Parkman
- Section of Gastroenterology, Temple University, Philadelphia, PA, USA
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Parkman HP, Van Natta ML, Maurer AH, Koch KL, Grover M, Malik Z, Sarosiek I, Abell TL, Bulat R, Kuo B, Shulman RJ, Farrugia G, Miriel L, Tonascia J, Hamilton F, Pasricha PJ, McCallum RW. Postprandial symptoms in patients with symptoms of gastroparesis: roles of gastric emptying and accommodation. Am J Physiol Gastrointest Liver Physiol 2022; 323:G44-G59. [PMID: 35502871 PMCID: PMC9236865 DOI: 10.1152/ajpgi.00278.2021] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Patients often are evaluated for gastroparesis because of symptoms occurring with meals. Gastric emptying scintigraphy (GES) is used for gastroparesis diagnosis, although results are not well correlated with gastroparesis symptoms. The aim of this study is to assess relationships between gastroparesis symptoms, gastric emptying (GE), and gastric accommodation (GA). Patients with symptoms of gastroparesis completed the Patient Assessment of Upper GI Symptoms (PAGI-SYM) and recorded symptoms during GES and water load satiety test (WLST), an indirect assessment for GA. A total of 109 patients with gastroparesis symptoms were assessed. Symptom severity increased after GES meal for stomach fullness, belching, nausea, abdominal burning, and abdominal pain. There was no difference in symptoms after meal between patients with delayed (n = 66) and normal (n = 42) GE. Diabetic patients (n = 26) had greater gastric retention than idiopathic patients (n = 78), but idiopathic patients had greater postprandial nausea, stomach fullness, and abdominal pain. Water consumed during WLST averaged 421 ± 245 mL. Idiopathic patients had greater nausea scores during WLST than diabetic patients. In comparison to those with normal water consumption (≥238 mL; n = 80), patients with impaired water ingestion (<238 mL; n = 26) had increased stomach fullness, early satiety, postprandial fullness, and loss of appetite on PAGI-SYM. Patients with delayed and normal GE had similar symptom profiles during GES and WLST. Idiopathic patients had less gastric retention but more symptoms after GES meal and after WLST compared with diabetic patients. Patients with impaired water consumption during WLST had increased symptoms by PAGI-SYM. These data suggest that impaired GA, rather than GE, may be important in explaining postprandial symptoms in patients with symptoms of gastroparesis.NEW & NOTEWORTHY Patients with delayed and normal gastric emptying (GE) had similar symptom profiles during gastric emptying scintigraphy (GES). Idiopathic patients with symptoms of gastroparesis had less gastric retention by GES; but more symptoms after GES meal and after water load satiety test (WLST) compared with diabetic patients. In patients with symptoms of gastroparesis, symptoms after WLST increased with decreasing water consumption. Early satiety and loss of appetite were associated with decreased water consumption during WLST. Thus, impaired accommodation and perhaps visceral hypersensitivity are important in explaining postprandial symptoms in gastroparesis.
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Affiliation(s)
- Henry P. Parkman
- 1Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Mark L. Van Natta
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Alan H. Maurer
- 1Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Kenneth L. Koch
- 3Department of Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Madhusudan Grover
- 4Department of Gastroenterology, School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Zubair Malik
- 1Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Irene Sarosiek
- 5Department of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Thomas L. Abell
- 6Department of Medicine, University of Louisville, Louisville, Kentucky
| | - Robert Bulat
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Braden Kuo
- 7Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Robert J. Shulman
- 8Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Gianrico Farrugia
- 4Department of Gastroenterology, School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Laura Miriel
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James Tonascia
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Frank Hamilton
- 9Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Pankaj J. Pasricha
- 2Departments of Epidemiology and Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard W. McCallum
- 5Department of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
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Song J, Patel J, Khatri R, Nadpara N, Malik Z, Parkman HP. Gastrointestinal symptoms in patients hospitalized with COVID-19: Prevalence and outcomes. Medicine (Baltimore) 2022; 101:e29374. [PMID: 35758370 PMCID: PMC9276248 DOI: 10.1097/md.0000000000029374] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 05/10/2022] [Indexed: 01/09/2023] Open
Abstract
To characterize outcomes in patients hospitalized with coronavirus disease 2019 (COVID-19) who present with gastrointestinal (GI) symptoms.Clinical outcomes in patients with COVID-19 associated with GI symptoms have been inconsistent in the literature.The study design is a retrospective analysis of patients, age 18 years or older, admitted to the hospital after testing positive for COVID-19. Clinical outcomes included intensive care unit requirements, rates of discharges to home, rates of discharges to outside facilities, and mortality.Seven hundred fifty patients met the inclusion criteria. Three hundred seventy three (49.7%) patients presented with at least one GI symptom and 377 (50.3%) patients presented with solely non-GI symptoms. Patients who presented with at least one GI symptom had significantly lower ICU requirements (17.4% vs 20.2%), higher rates of discharges home (77.2% vs 67.4%), lower rates of discharges to other facilities (16.4% vs 22.8%), and decreased mortality (6.4% vs 9.8%) compared with patients with non-GI symptoms. However, patients who presented with solely GI symptoms had significantly higher ICU requirements (23.8% vs 17.0%), lower rates of discharges home (52.4% vs 78.7%), higher rates of discharges to facilities (28.6% vs 15.6%), and higher mortality (19.0% vs 5.7%) compared with those with mixed GI and non-GI symptoms.Although patients with COVID-19 requiring hospitalization with GI symptoms did better than those without GI symptoms, those with isolated GI symptoms without extra-GI symptoms had worse clinical outcomes. COVID-19 should be considered in patients who present with new onset or worsening diarrhea, nausea, vomiting, and abdominal pain even without pulmonary symptoms.
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Affiliation(s)
- Jun Song
- Temple University Hospital, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA
| | - Jay Patel
- Temple University Hospital, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA
| | - Rishabh Khatri
- Temple University Hospital, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA
| | - Neil Nadpara
- Temple University Hospital, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA
| | - Zubair Malik
- Temple University Hospital, Department of Medicine, Section of Gastroenterology and Hepatology, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA
| | - Henry P. Parkman
- Temple University Hospital, Department of Medicine, Section of Gastroenterology and Hepatology, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA
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13
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Parkman HP, Van Natta ML, Makol A, Grover M, McCallum RW, Malik Z, Koch KL, Sarosiek I, Kuo B, Shulman RJ, Farrugia G, Miriel L, Tonascia J, Hamilton F, Pasricha PJ, Abell TL. Prevalence and clinical correlates of antinuclear antibody in patients with gastroparesis. Neurogastroenterol Motil 2022; 34:e14270. [PMID: 34595805 PMCID: PMC8971139 DOI: 10.1111/nmo.14270] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/21/2021] [Accepted: 08/31/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autoimmunity may play a role in the pathogenesis of gastroparesis in a subset of patients. Antinuclear antibody (ANA) testing is often used to screen for autoimmune disorders. AIMS 1) Determine prevalence of a positive ANA in patients with gastroparesis; 2) Describe characteristics of idiopathic gastroparesis patients with positive ANA. METHODS Patients were assessed with gastric emptying scintigraphy (GES), symptom assessment via Patient Assessment of Upper GI Symptoms [PAGI-SYM], and blood tests-ANA, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP). RESULTS Positive ANA was seen in 148 of 893 (17%) patients with gastroparesis, being similar in idiopathic (16% of 536 patients), T1DM (16% of 162), T2DM (18% of 147), and postfundoplication (19% of 48 patients) gastroparesis. Among 536 patients with idiopathic gastroparesis, ANA titer 1:40-1:80 was seen in 33 (6%) patients, 1:160-1:320 in 36 (7%) patients, and ≥1:640 in 17 (3%) patients. Increasing ANA titer was associated with female gender (p = 0.05), Hispanic ethnicity (p = 0.02), comorbid rheumatoid arthritis (p = 0.02), systemic sclerosis (p = 0.004), and elevated ESR (p = 0.007). ANA positivity was associated with lower total GCSI (p = 0.007) and lower nausea/vomiting subscale (p = 0.0005), but not related to gastric emptying. CONCLUSIONS The prevalence of a positive ANA in patients with gastroparesis was high at ~17% and did not differ significantly based on etiology. In idiopathic patients, ANA positivity was associated with rheumatoid arthritis, systemic sclerosis, and elevated ESR. ANA-positive gastroparesis represents a subset who often have other autoimmune symptoms or disorders, but less severe nausea and vomiting.
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Affiliation(s)
| | | | | | | | | | | | | | - Irene Sarosiek
- Texas Tech University Health Sciences Center, El Paso, TX
| | | | | | | | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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14
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Khan S, Malik Z, Khan N, Mojai SA, Rehman AU, Khan A, Khan MI, Ullah N, Jan HTU, Ahmed T. Frequency of Acute Ischemic Stroke in Patient with Type-II Diabetes Mellitus: Descriptive Cross Sectional Study. JPRI 2021. [DOI: 10.9734/jpri/2021/v33i48b33274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Aim: To evaluate the frequency of acute ischemic stroke in patients with type-II diabetes mellitus.
Study Design: Descriptive Cross sectional Study
Place & Duration of Study: The study was carried out at Department of Medicine, DHQ Teaching Hospital, Dera Ismail Khan for the period of 06 months from 06 Feb, 2018 to 06 Aug, 2018.
Methodology: All patients admitted through OPD presented with type-II diabetes mellitus and having acute ischemic stroke after radiological confirmation using non-contrast enhanced CT scan brain with type-II diabetes (as per operational definitions above) were enrolled in study. Informed written consent was taken by the researcher with detailed history followed by detailed clinical examination and all patients who was give their consent to participate in the study was questioned about their medical history and was examined in detail for their neurological deficits. All the laboratory investigation was done from single hospital laboratory and all the radiological investigations were done from hospital radiology department.
Results: As per frequencies and percentages for acute ischemic stroke, 215 (74.65%) patients were found having acute ischemic stroke.
Conclusion: In this study, we concluded that there is a significant age difference between the diabetes-stroke co-morbid patient and non-diabetic stroke patient. Therefore, health education on preventive measures for type 2 DM, adequate regulation of blood pressure and blood sugar level through compliance to medical advice and medication, regular clinic attendance and periodic measurement of blood pressure and blood sugar level.
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15
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Meltzer AC, Limkakeng AT, Gentile NT, Freeman JQ, Hall NC, Vargas NM, Fleischer DE, Malik Z, Kallus SJ, Borum ML, Ma Y, Kumar AB. Risk stratification with video capsule endoscopy leads to fewer hospital admissions in emergency department patients with low-risk to moderate-risk upper gastrointestinal bleed: A multicenter clinical trial. J Am Coll Emerg Physicians Open 2021; 2:e12579. [PMID: 34723247 PMCID: PMC8544929 DOI: 10.1002/emp2.12579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/01/2021] [Accepted: 10/01/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE In US emergency departments (EDs), the physician has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Although many bleeding lesions are self-limited, the majority of these patients require emergency hospitalization for upper endoscopy (EGD). We conducted a clinical trial to determine if ED risk stratification with video capsule endoscopy (VCE) reduces hospitalization rates for low-risk to moderate-risk patients with suspected upper GI bleeding. METHODS We conducted a randomized controlled trial at 3 urban academic EDs. Inclusion criteria included signs of upper GI bleeding and a Glasgow Blatchford score <6. Patients were randomly assigned to 1 of the following 2 treatment arms: (1) an experimental arm that included VCE risk stratification and brief ED observation versus (2) a standard care arm that included admission for inpatient EGD. The primary outcome was hospital admission. Patients were followed for 7 and 30 days to assess for rebleeding events and revisits to the hospital. RESULTS The trial was terminated early as a result of low accrual. The trial was also terminated early because of a need to repurpose all staff to respond to the coronavirus disease 2019 pandemic. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital, and in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (P = 0.012). There was no difference in safety on day 7 and day 30 after the index ED visit. CONCLUSIONS VCE is a potential strategy to decrease admissions for upper GI bleeding, though further study with a larger cohort is required before this approach can be recommended.
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Affiliation(s)
- Andrew C. Meltzer
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | | | - Nina T. Gentile
- School of MedicineTemple UniversityPhiladelphiaPennsylvaniaUSA
| | - Jincong Q. Freeman
- Milken Institute School of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Nicole C. Hall
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Nataly Montano Vargas
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | | | - Zubair Malik
- School of MedicineTemple UniversityPhiladelphiaPennsylvaniaUSA
| | - Samuel J. Kallus
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Marie L. Borum
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Yan Ma
- Milken Institute School of Public HealthGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - Anita B. Kumar
- School of Medicine and Health SciencesGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
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Meltzer A, Limkakeng A, Gentile N, Vargas N, Fleisher D, Malik Z, Kallus S, Borum M, Ma Y, Kumar A. 182 A Multi-Center Randomized Trial of Capsule Endoscopy to Reduce Admissions in Emergency Department Patients With Low Risk Upper Gastrointestinal Bleed. Ann Emerg Med 2021. [DOI: 10.1016/j.annemergmed.2021.09.193] [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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Attard G, Brown L, Clarke N, Murphy L, Cross W, Jones R, Gillessen S, Russell J, Cook A, Bowen J, Lydon A, Pedley I, Parikh O, Chowdhury S, Malik Z, Matheson D, Parker C, Sydes M, Parmar M, James N. LBA4 Abiraterone acetate plus prednisolone (AAP) with or without enzalutamide (ENZ) added to androgen deprivation therapy (ADT) compared to ADT alone for men with high-risk non-metastatic (M0) prostate cancer (PCa): Combined analysis from two comparisons in the STAMPEDE platform protocol. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.2098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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18
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Qureshi A, Jehangir A, Malik Z, Parkman HP. Rheumatologic disorders in patients undergoing esophageal manometry: prevalence, symptom characteristics, and manometric findings. Dis Esophagus 2021; 34:6131381. [PMID: 33558877 DOI: 10.1093/dote/doaa135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/19/2020] [Revised: 12/01/2020] [Accepted: 12/19/2020] [Indexed: 12/11/2022]
Abstract
Rheumatologic disorders (RDs) can have gastrointestinal (GI) manifestations. Systemic sclerosis (SSc) patients often have upper GI symptoms from absent esophageal contractility (AC). Upper GI symptom characteristics and high-resolution esophageal manometry with impedance (HREMI) findings of other RDs have not been well studied. We aimed to: (i) determine the prevalence of RD in patients undergoing HREMI and (ii) assess the symptom characteristics and manometric findings of these patients. Patients undergoing HREMI (July 2018 to March 2020) rated their GI symptoms' severity. Healthy volunteers (HVs) also underwent HREMI. Of the 1,003 patients, 90 (9%) had RD (mean age: 55.3 ± 1.4 years, 73.3% females), most commonly SSc (n = 27), rheumatoid arthritis (RA, n = 20), and systemic lupus erythematosus (SLE, n = 11). The most severe upper GI symptoms in patients with RD were heartburn, regurgitation, nausea, and dysphagia, with no significant differences in their severities between SSc, RA, and SLE. RD patients had higher upper esophageal sphincter (UES) pressures, lower distal contractile integral (DCI), lower bolus clearance, and more frequent hiatal hernia (HH) on HREMI (all P < 0.05) than HVs. Over half (61.1%) of patients with RD had esophageal motility disorders, most commonly AC (n = 25), ineffective esophageal motility (IEM; n = 18), and esophagogastric junction (EGJ) obstructive disorders (n = 11). Among patients undergoing HREMI, 9% had RD. Upper GI symptom severities did not distinguish different RDs. Patients with RD had higher UES pressures, weaker DCI, lower bolus clearance, and more frequent HH than HVs. Although AC and IEM were most common motility disorders, a considerable minority (12.2%) of our RD patients had EGJ obstructive disorders.
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Affiliation(s)
- Anam Qureshi
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Asad Jehangir
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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Jehangir A, Malik Z, Petrov RV, Parkman HP. EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty. Dig Dis Sci 2021; 66:2682-2690. [PMID: 32749636 DOI: 10.1007/s10620-020-06510-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 04/17/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms. AIMS We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation. METHODS Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. RESULTS Thirteen (ten females) patients (mean age 45.2 ± 5.1 years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p < 0.05 for both), with five (38%) patients reporting symptoms somewhat/moderately better. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml, 40 ml, and 50 ml than patients with little/no improvement (all p < 0.05). CONCLUSIONS In gastroparesis patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric distensibility on EndoFLIP suggesting incomplete myotomy, pyloric muscle regeneration, or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty.
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Affiliation(s)
- Asad Jehangir
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Roman V Petrov
- Department of Thoracic Surgery, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA.
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20
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Parkman HP, Wilson LA, Yates KP, Koch KL, Abell TL, McCallum RW, Sarosiek I, Kuo B, Malik Z, Schey R, Shulman RJ, Grover M, Farrugia G, Miriel L, Tonascia J, Hamilton F, Pasricha PJ. Factors that contribute to the impairment of quality of life in gastroparesis. Neurogastroenterol Motil 2021; 33:e14087. [PMID: 33493377 PMCID: PMC8310540 DOI: 10.1111/nmo.14087] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 08/25/2020] [Revised: 12/12/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Understanding factors that impair quality of life (QOL) in gastroparesis is important for clinical management. AIMS (a) Determine QOL in patients with gastroparesis; (b) Determine factors that impair QOL. METHODS Gastroparetic patientsAQ6 underwent history and questionnaires assessing symptoms (PAGI-SYM and Rome III), QOL (SF-36v2 and PAGI-QOL), depression (Beck Depression Inventory [BDI]), and anxiety (State Trait Anxiety InventoryAQ7). KEY RESULTS 715 gastroparesis patients (256 diabetic (DG), 459 idiopathic (IG)) were evaluated. SF-36 physical component (PC) score averaged 33.3 ± 10.5; 41% had impaired score <30. SF-36 PC scores were similar between diabetic and idiopathic gastroparesis. Impaired SF-36 PC associated with increased nausea/vomiting and upper abdominal pain subscores, acute onset of symptoms, higher number of comorbidities, use of narcotic pain medications, and irritable bowel syndrome (IBS). SF-36 mental component (MC) score averaged 38.9 ± 13.0; 26% had impaired score <30. Poor SF-36 MC associated with diabetic etiology, higher Beck depression inventory, and state anxiety scores. PAGI-QOL score averaged 2.6 ± 1.1; 50% had a score of <2.6. Low PAGI-QOL associated with higher fullness, bloating, and upper abdominal pain subscores, more depression and Trait anxiety, smoking cigarettes, need for nutritional support, progressively worsening symptoms and periodic exacerbations. CONCLUSIONS & INFERENCES Multiple measures show poor QOL present in gastroparesis. Several areas impacted on reduced QOL: (a) Symptoms of nausea, vomiting, and abdominal pain, as well as IBS; (b) Etiology and acute onset and progressively worsening symptoms; (c) Comorbidities and psychological factors such as anxiety and depression; (d) Patient-related factors such as smoking. Targeting the modifiable factors may improve patient outcomes in gastroparesis.
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Affiliation(s)
| | | | | | | | | | | | - Irene Sarosiek
- Texas Tech University Health Sciences Center, El Paso, TX
| | | | | | | | | | | | | | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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Shahsavari D, Reznick-Lipina K, Malik Z, Weiner M, Jehangir A, Repanshek ZD, Parkman HP. Haloperidol Use in the Emergency Department for Gastrointestinal Symptoms: Nausea, Vomiting, and Abdominal Pain. Clin Transl Gastroenterol 2021; 12:e00362. [PMID: 34060494 PMCID: PMC8162512 DOI: 10.14309/ctg.0000000000000362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 04/23/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Haloperidol (HL) has successfully been used for nausea and abdominal pain in emergency departments (EDs). This study examines outcomes and predictive factors for clinical improvement of patients presenting to an ED with gastrointestinal (GI) symptoms (nausea, vomiting, and abdominal pain) who received HL. METHODS Review of patients' records who presented to our ED between August 2016 and March 2019 with GI symptoms and received HL. International Classification of Diseases, Tenth Revision codes were used to identify patients. RESULTS In all, 281 patients (410 encounters) presented to the ED with GI symptoms and received HL for their symptoms: 66% were women, 32% had diabetes, 68% used marijuana, and 27% used chronic opioids. Patients received HL 1.1 ± 0.3 times with dose 2.5 ± 3.0 mg, mostly intravenously (84.6%). Total ED length of stay was 7.5 ± 3.9 hours (3.2 ± 2.1 hours before HL and 4.4 ± 3.4 hours after). Approximately 4.4% of patients developed side effects to HL, including 2 patients with dystonia which improved with medication before discharge. Most patients (56.6%) were discharged home while 43.2% were admitted to hospital mostly because of refractory nausea or vomiting (70.1%). Receiving HL as the only medication in the ED led to lower hospital admission (odds ratio = 0.25, P < 0.05). Diabetes, cannabinoid use, anxiety, male sex, and longer ED stay were associated with increased hospital admissions. DISCUSSION Most patients treated in our ED with HL for GI symptoms, particularly nausea, vomiting, and/or abdominal pain, were successfully treated and discharged home. HL use seemed relatively safe and, when used as the only medication, led to less frequent hospital admissions.
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Affiliation(s)
- Dariush Shahsavari
- Department of Gastroenterology, Temple University, Philadelphia, Pennsylvania, USA
| | | | - Zubair Malik
- Department of Gastroenterology, Temple University, Philadelphia, Pennsylvania, USA
| | - Mark Weiner
- Weill Cornell Medical College, New York, New York, USA
| | - Asad Jehangir
- Department of Gastroenterology, Augusta University, Augusta, Georgia, USA
| | - Zachary D. Repanshek
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Henry P. Parkman
- Department of Gastroenterology, Temple University, Philadelphia, Pennsylvania, USA
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Pasricha PJ, Grover M, Yates KP, Abell TL, Bernard CE, Koch KL, McCallum RW, Sarosiek I, Kuo B, Bulat R, Chen J, Shulman R, Lee L, Tonascia J, Miriel LA, Hamilton F, Farrugia G, Parkman HP, Bulat R, Burns R, Hernandez GB, McKnight M, Kuo B, Mendez A, Staller K, Thurler A, Velez C, Silvernale C, Parkman HP, Malik Z, Maurer A, Palit A, McCallum RW, Sarosiek I, Vega N, Vasquez D, Connery S, Espino K, Friedman M, Abell T, Stocker A, Cannon B, McElmurray L, Cooper K, McBride C, Koch K, Baxter L, Brown A, Stuart P, Abdullah A, Snape W, DeVole N, Earle K, Kirkeby K, Lee C, Lin M, Troyer D, von Bakonyi A, Shulman R, Chumpitazi B, Febo-Rodriguez L, Hollier J, Bouette C, Charron H, Nurko S, Wall S, Kane M, Williams K, Yossef-Salameh L, Woodley F, Farrugia G, Grover M, Bernard C, Serrano J, Hamilton F, Hall S, James S, Torrance R, Tonascia J, Adamo M, Belt P, Dodge J, Donithan M, Isaacson M, Lee L, Meinert J, Miriel L, Sharkey E, Smith J, Smith M, Sternberg A, Van Natta M, Wagoner A, Wilson L, Yamada G, Yates K. Functional Dyspepsia and Gastroparesis in Tertiary Care are Interchangeable Syndromes With Common Clinical and Pathologic Features. Gastroenterology 2021; 160:2006-2017. [PMID: 33548234 PMCID: PMC8547190 DOI: 10.1053/j.gastro.2021.01.230] [Citation(s) in RCA: 114] [Impact Index Per Article: 38.0] [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: 06/20/2020] [Revised: 01/22/2021] [Accepted: 01/28/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The aim of this study was to clarify the pathophysiology of functional dyspepsia (FD), a highly prevalent gastrointestinal syndrome, and its relationship with the better-understood syndrome of gastroparesis. METHODS Adult patients with chronic upper gastrointestinal symptoms were followed up prospectively for 48 weeks in multi-center registry studies. Patients were classified as having gastroparesis if gastric emptying was delayed; if not, they were labeled as having FD if they met Rome III criteria. Study analysis was conducted using analysis of covariance and regression models. RESULTS Of 944 patients enrolled during a 12-year period, 720 (76%) were in the gastroparesis group and 224 (24%) in the FD group. Baseline clinical characteristics and severity of upper gastrointestinal symptoms were highly similar. The 48-week clinical outcome was also similar but at this time 42% of patients with an initial diagnosis of gastroparesis were reclassified as FD based on gastric-emptying results at this time point; conversely, 37% of patients with FD were reclassified as having gastroparesis. Change in either direction was not associated with any difference in symptom severity changes. Full-thickness biopsies of the stomach showed loss of interstitial cells of Cajal and CD206+ macrophages in both groups compared with obese controls. CONCLUSIONS A year after initial classification, patients with FD and gastroparesis, as seen in tertiary referral centers at least, are not distinguishable based on clinical and pathologic features or based on assessment of gastric emptying. Gastric-emptying results are labile and do not reliably capture the pathophysiology of clinical symptoms in either condition. FD and gastroparesis are unified by characteristic pathologic features and should be considered as part of the same spectrum of truly "organic" gastric neuromuscular disorders. CLINICALTRIALS. GOV IDENTIFIER NCT00398801, NCT01696747.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Braden Kuo
- Massachusetts General Hospital, Boston, MA
| | - Robert Bulat
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Linda Lee
- Johns Hopkins University, Baltimore, MD
| | | | | | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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Song J, Bhuta R, Baig K, Parkman HP, Malik Z. COVID-19 infection manifesting as a severe gastroparesis flare: A case report. Medicine (Baltimore) 2021; 100:e25467. [PMID: 33832159 PMCID: PMC8036087 DOI: 10.1097/md.0000000000025467] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 12/23/2022] Open
Abstract
RATIONALE Coronavirus disease 2019 (COVID-19) is a disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which commonly presents with symptoms including fever, cough, and dyspnea. More recently, however, some patients have tested positive for COVID-19 after developing gastrointestinal (GI) symptoms either solely or in conjunction with respiratory symptoms. This may be due to SARS-CoV-2 infection of the GI tract. In patients with chronic GI illnesses, COVID-19 may initially present as a flare of their underlying GI conditions as viruses have historically been implicated in exacerbations of GI disorders, including gastroparesis. PATIENT CONCERNS We report a case of a 37-year-old female with a history of diabetic gastroparesis who presented to the Emergency Department (ED) with nausea and vomiting similar to her gastroparesis flares. DIAGNOSES Her symptoms in the ED failed to improve with fluids and anti-emetic medications. After developing a fever, she was tested and found to be positive for COVID-19. INTERVENTIONS She was started on antibiotic, steroid, and antiviral medications. OUTCOMES Her symptoms improved, her fever defervesced on day 4 of hospitalization, and she was discharged on day 5 of hospitalization. The patient reported symptom improvement at a follow-up outpatient gastroenterology visit 2 months after hospitalization. LESSONS To the best of our knowledge, at the present time, this is the first report of a patient with COVID-19 presenting with signs and symptoms of a gastroparesis flare. This case illustrates that COVID-19 may present in an exacerbation of symptoms of an underlying disorder, such as a severe gastroparesis flare, in a patient with underlying gastroparesis. Initial presentation of these patients manifesting as a flare of their chronic GI disease, more severe than usual, should prompt an index of suspicion for COVID-19.
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Affiliation(s)
- Jun Song
- Temple University Hospital, Department of Medicine
| | - Rajiv Bhuta
- Section of Gastroenterology and Hepatology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Kamal Baig
- Section of Gastroenterology and Hepatology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P. Parkman
- Section of Gastroenterology and Hepatology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Section of Gastroenterology and Hepatology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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Kaul V, Gross S, Corbett FS, Malik Z, Smith MS, Tofani C, Infantolino A. Clinical utility of wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) in identifying Barrett's esophagus and associated neoplasia. Dis Esophagus 2020; 33:5865411. [PMID: 32607543 DOI: 10.1093/dote/doaa069] [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: 02/02/2020] [Revised: 05/30/2020] [Accepted: 06/05/2020] [Indexed: 12/11/2022]
Abstract
Sampling error during screening and surveillance endoscopy is a well-recognized problem. Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D), used adjunctively to forceps biopsy (FB), has been shown to increase the detection of Barrett's esophagus (BE) and BE-associated neoplasia. We evaluated the clinical utility of WATS3D and its impact on the management of patients with BE and dysplasia. Between 2013 and 2018, 432 consecutive patients who had a WATS3D positive and an accompanying FB negative result were identified. Physicians were contacted to determine if the WATS3D result impacted their decision to enroll patients in surveillance or increase the frequency of surveillance, recommend ablation, and/or initiate or increase the dose of proton pump inhibitors (PPIs). WATS3D directly impacted the management of 97.8% of 317 BE patients; 96.2% were enrolled in surveillance and 60.2% were started on PPIs or their dose was increased. WATS3D impacted the management of 94.9% and 94.1% of the 98 low-grade dysplasia and 17 high-grade dysplasia patients, respectively. As a result of WATS3D, 33.7% of low-grade dysplasia and 70.6% of high-grade dysplasia patients underwent endoscopic therapy. More than 37% of all dysplasia patients were enrolled in a surveillance program, and nearly 30% were scheduled to be surveilled more frequently. PPIs were either initiated, or the dose was increased in more than 54% of all dysplasia patients. We demonstrate that WATS3D has high clinical utility. By prompting physicians to change their clinical management in patients with negative FB results, WATS3D, used adjunctively to FB, directly impacts patient management, and improves patient outcomes.
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Affiliation(s)
- Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, New York
| | - Seth Gross
- Division of Gastroenterology, NYU Langone Medical Center, New York, New York
| | - F Scott Corbett
- Suncoast Endoscopy of Sarasota, Gastroenterology Associates of Sarasota, Sarasota, Florida
| | - Zubair Malik
- Division of Gastroenterology, Temple University, Philadelphia, Pennsylvania
| | - Michael S Smith
- Division of Gastroenterology, Temple University, Philadelphia, Pennsylvania
| | - Christina Tofani
- Department of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anthony Infantolino
- Department of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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25
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Zoll B, Jehangir A, Edwards MA, Petrov R, Hughes W, Malik Z, Parkman HP. Surgical Treatment for Refractory Gastroparesis: Stimulator, Pyloric Surgery, or Both? J Gastrointest Surg 2020; 24:2204-2211. [PMID: 31512100 DOI: 10.1007/s11605-019-04391-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 06/08/2019] [Accepted: 08/28/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several surgical options exist for refractory gastroparesis (Gp) including gastric electric stimulation (GES) and pyloric surgery (PS) such as pyloromyotomy or pyloroplasty. Few studies exist comparing the outcomes of these surgeries. AIM Compare the clinical outcomes of GES, PS, and simultaneous GES+PS for refractory Gp. METHODS Patients undergoing surgical intervention at our medical center from January 2016 to April 2019 were given pre- and post-surgery questionnaires to assess their response to intervention: Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM) grading symptoms and Clinical Patient Grading Assessment Scale (CPGAS) grading response to treatment. Results are expressed as mean ± SE. RESULTS One hundred thirty-two patients underwent surgical intervention; 12 were excluded. Mean CPGAS improvement overall was 2.8 ± 0.2 (p < 0.01): GES+PS had CPGAS score at 3.6 ± 0.5, pyloric interventions 3.1 ± 0.5, and GES 2.5 ± 0.4 (p > 0.05). Mean improvement in Gastroparesis Cardinal Symptom Index (GCSI) total score was 1.0 ± 0.1 (p < 0.01), with improvement of 1.1 ± 0.2 for GES + PS, 0.9 ± 0.2 for GES, and 0.9 ± 0.2 for PS (p > 0.05). GES and GES + PS, but not PS only, significantly improved symptoms of nausea and vomiting (p < 0.01). Among gastroparesis subtypes, patients with diabetic gastroparesis had more improvement on nausea/vomiting subscale compared with idiopathic gastroparesis (p = 0.028). CONCLUSIONS Patients with refractory symptoms of Gp undergoing GES, PS, or combined GES+PS each had significant improvement of their GCSI total score. GES and combined GES+PS significantly improved nausea/vomiting. These results suggest GES or combined GES+PS appears better for nausea/vomiting predominant refractory Gp.
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Affiliation(s)
- Bryan Zoll
- Section of Gastroenterology, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Asad Jehangir
- Section of Gastroenterology, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | | | - Roman Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - William Hughes
- Section of Gastroenterology, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Section of Gastroenterology, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Section of Gastroenterology, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
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Jehangir A, Tanner S, Malik Z, Parkman HP. Characterizing the proximal esophageal segment in patients with symptoms of esophageal dysmotility. Neurogastroenterol Motil 2020; 32:e13888. [PMID: 32485784 DOI: 10.1111/nmo.13888] [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: 01/02/2020] [Revised: 03/25/2020] [Accepted: 04/29/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Proximal esophageal striated muscle contractility may be abnormal in patients with esophageal symptoms, but is not assessed in the Chicago Classification (CC) v3.0. We aimed to (a) determine the prevalence of abnormal proximal esophageal contractility in patients with esophageal symptoms; (b) compare proximal esophageal contractility in patients with different esophageal motility disorders; (c) assess the association of abnormal proximal esophageal contractility with esophageal symptoms. METHODS Patients undergoing high-resolution esophageal manometry (HREM) from 7/2019 to 11/2019 and healthy volunteers (HVs) were studied. Measurements of the proximal esophageal segment included the vigor of contractility of the proximal esophagus (proximal contractile integral/PCI). Patients rated gastrointestinal symptoms' severity. KEY RESULTS HREM was performed on 221 patients (63.8% females, mean age 57.1 ± 1.1 years) and 19 HVs. Mean PCI in HVs was 299.5 ± 30.6 (95% CI 32.3-566.7 mm Hg. s. cm). Of all patients, 61 (27.6%) had abnormal PCI. HVs and patients with different esophageal motility disorders had significantly different PCI (P < .01). Type 1 achalasia patients had weaker PCI than patients with absent contractility (P = .02). Patients with abnormal PCI had more severe dysphagia (P = .02), nausea (P = .03), vomiting (P = .03), and lower bolus clearance (P < .01) than patients with normal PCI. CONCLUSIONS AND INFERENCES Abnormal PCI was found in a fourth of patients with esophageal symptoms. PCI may be useful to distinguish some esophageal motility disorders. Patients with abnormal PCI had a higher severity of some upper gastrointestinal symptoms than patients with normal PCI. Assessing the proximal esophageal segment on HREM may be useful in characterizing patients with esophageal symptoms.
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Affiliation(s)
- Asad Jehangir
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Samuel Tanner
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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Malik Z, Shenoy K. Esophageal Evaluation for Patients Undergoing Lung Transplant Evaluation: What Should We Do for Evaluation and Management. Gastroenterol Clin North Am 2020; 49:451-466. [PMID: 32718564 DOI: 10.1016/j.gtc.2020.04.004] [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: 02/21/2023]
Abstract
Lung transplantation is a high-risk, but lifesaving, procedure for patients with end-stage lung disease. Although 1-year survival is high, long-term survival is not nearly as high, due mainly to acute and chronic rejection. Bronchiolitis obliterans syndrome is the most common type of chronic rejection and often leads to poor outcomes. For this reason, esophageal testing in the lung transplant population has become a major issue, and this article discusses the evidence behind esophageal testing, the importance of esophageal dysmotility gastroesophageal reflux disease, both acidic and nonacidic reflux, and aspiration and the treatment of these findings.
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Affiliation(s)
- Zubair Malik
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine, Temple University, 3401 North Broad Street, 8th Floor Parkinson Pavilion, Philadelphia, PA 19140, USA.
| | - Kartik Shenoy
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, 3401 North Broad Street, 7th Floor Parkinson Pavilion, Philadelphia, PA 19140, USA
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28
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Kataria R, Rosenfeld B, Malik Z, Harrison M, Smith MS, Schey R, Parkman HP. Distal Esophageal Impedance Measured by High-resolution Esophageal Manometry With Impedance Suggests the Presence of Barrett's Esophagus. J Neurogastroenterol Motil 2020; 26:344-351. [PMID: 32325542 PMCID: PMC7329159 DOI: 10.5056/jnm19105] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/03/2019] [Accepted: 12/18/2019] [Indexed: 11/20/2022] Open
Abstract
Background/Aims Barrett's esophagus (BE) is characterized by intestinal metaplasia in the distal esophagus. The aims of this study are to: (1) Compare baseline distal esophageal impedance (DEI) using high-resolution esophageal manometry with impedance (HREMI) in patients with BE, esophagitis, and healthy volunteers and (2) Correlate length of low impedance on HREMI in patients with BE to the length of endoscopic BE. Methods Patients with BE or esophagitis who underwent HREMI were included. Ten volunteers had HREMI. Baseline DEI was calculated from HREMI using the landmark segment. In patients with BE, the impedance was plotted to measure the extent of plotted low impedance (PLI) and visual low impedance (VLI). Lengths of VLI and PLI were correlated to endoscopic length of BE by Prague score. Results Forty-five patients were included (16 BE; 19 esophagitis; 10 volunteers). BE patients had lower baseline DEI at the first, second, and third sensors above the lower esophageal sphincter (mean ± SEM: 1.37 ± 0.45, 0.97 ± 0.27, and 0.81 ± 0.20) compared to volunteers (8.73 ± 0.60, 8.20 ± 0.73, and 6.94 ± 0.99; P < 0.001). Baseline DEI was lower in BE than esophagitis patients (2.98 ± 0.65, 2.49 ± 0.56, and 2.01 ± 0.51) at the first, second, and third sensors (P < 0.052 for second and third sensors); ie, BE < esophagitis < controls. PLI and VLI had a stronger correlation to circumferential score (r2 = 0.84 and 0.83) than maximal score (r2 = 0.76 and 0.68). Conclusions Baseline DEI is lower in BE compared with esophagitis and healthy volunteers. The length of low impedance correlates to the endoscopic extent of BE. Thus, impedance values during HREMI may help suggest the presence and extent of BE or esophagitis.
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Affiliation(s)
- Rahul Kataria
- Division of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Benjamin Rosenfeld
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Zubair Malik
- Division of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Martha Harrison
- Division of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Michael S Smith
- Division of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Ron Schey
- Division of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Henry P Parkman
- Division of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
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Abstract
In the absence of dental related guidelines available in Australia specific to obesity and minimal awareness of the clinical implications on local dental practice, bariatric dental care can be perceived as a 'silent disability crisis'. This opinion piece and brief clinical note aims to question and raise awareness amongst dental professionals surrounding the current limited availability of bariatric dental chairs, difficulties in access, the safety of dental care delivery and ethical considerations for the dental management of people with obesity.
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Affiliation(s)
- Z Malik
- Department of Oral Medicine, Oral Pathology and Special Needs Dentistry, Westmead Centre for Oral Health, Westmead Hospital, Sydney, NSW, Australia
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30
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Reichenbach ZW, Stanek S, Patel S, Ward SJ, Malik Z, Parkman HP, Schey R. Botulinum Toxin A Improves Symptoms of Gastroparesis. Dig Dis Sci 2020; 65:1396-1404. [PMID: 31617132 DOI: 10.1007/s10620-019-05885-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 03/20/2019] [Accepted: 10/09/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Pyloric injections of botulinum toxin A (BoNT/A) have shown benefit in open-label studies for patients with gastroparesis but not in randomized trials. We sought to examine the effectiveness of BoNT/A injections in a prospective open-label trial of patients with gastroparesis to assess specific symptom improvements over the course of 6 months. We also wanted to determine if specific biochemical measures including creatinine kinase, lactate dehydrogenase, aldolase, and C-reactive protein suggesting muscular injection could be used to predict successful response to pyloric injections of BoNT/A. METHODS Patients with gastroparesis undergoing pyloric BoNT/A injections for the treatment of symptomatic gastroparesis were enrolled. The patients completed the Gastroparesis Cardinal Symptom Index (GCSI) at the initial encounter and at 1, 3, and 6 months. Blood samples were collected before and 1 h after BoNT/A therapy. RESULTS We enrolled 34 patients for serum analysis of which 25 patients were available for symptom follow-up. Sixty-four percent of patients had an improvement in symptoms at 1 month. Patients with improved GCSI total score at 1 month had an improvement in most individual symptoms evaluated. For patients that improved at 1 month, this improvement often extended up to 6 months (p = 0.04). Serum measures studied did not correlate with clinical outcomes. CONCLUSIONS BoNT/A therapy to the pylorus provided symptomatic improvement at 1 month in 64% of patients. For those patients initially responding, the improvement can last out to 6 months. The biochemical markers did not serve to predict the outcome of injections.
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Affiliation(s)
- Zachary Wilmer Reichenbach
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA. .,Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, 3500 N. Broad Street, Medical Education and Research Bldg., 8th Floor, Philadelphia, PA, 19140, USA.
| | - Steven Stanek
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Shyam Patel
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Sara Jane Ward
- Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, 3500 N. Broad Street, Medical Education and Research Bldg., 8th Floor, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Ron Schey
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
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Lis S, Vachhani H, Tanner S, Leopold A, Zitomer S, Bhuta R, Schey R, Malik Z, P Parkman H. Vascular pressure bands on high-resolution esophageal manometry with impedance studies. Dis Esophagus 2020; 33:5673266. [PMID: 31825486 DOI: 10.1093/dote/doz093] [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: 04/30/2019] [Revised: 07/24/2019] [Accepted: 08/03/2019] [Indexed: 12/11/2022]
Abstract
Horizontal pressure bands on high-resolution esophageal manometry with impedance (HREMI) tracings are often seen and thought to be due to cardiovascular structures compressing the esophagus. The aim of this study was to determine the prevalence and location of vascular pressure bands on HREMI studies and correlate these pressure bands to bolus clearance. HREMI studies in supine and upright positions from patients and normal volunteers were reviewed. Pressure bands were defined as bands of horizontal pressure greater than the 20 mmHg isobaric contour. Each swallow was reviewed with impedance to determine if bolus transit was impaired by the band. 38.6% of 251 patients and 36.4% of 11 normal controls had a pressure band present. There were a greater number of bands in supine versus upright position (patients: 130 vs. 25, P < 0.001 and controls: 6 vs. 1). Patients with pressure bands had similar demographics (age, gender, BMI) compared to those without. Average distal contractile integral of bands was greater in supine compared to upright (133 ± 201 vs. 60 ± 148 mmHg cm s, P < 0.05). Bands were commonly located clustered at 46 and 72% of esophageal length. Bolus transit was impaired by bands in 20.4% of supine and 14.0% of upright swallows. Vascular pressure bands can have a prominent appearance on HREMI studies, present in, being more prevalent and having greater pressure in the supine than the upright position. These vascular bands, when present, may impair esophageal transit.
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Affiliation(s)
- Steffen Lis
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Herit Vachhani
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Samuel Tanner
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Andrew Leopold
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Samantha Zitomer
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Rajiv Bhuta
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Ron Schey
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P Parkman
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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Abstract
PURPOSE OF REVIEW Nearly 4000 patients will be admitted to hospital in the US this year for hiccups. Hiccups are controlled by a complex reflex arc between peripheral receptors and the brainstem. Any disruption along this pathway may produce hiccups. Typically, hiccups resolve spontaneously but in certain pathologies symptoms may persist. Persistent hiccups may be considered a sign of underlying pathology. The most common cause involves GERD. RECENT FINDINGS Based on etiologies, studies have shown that first-line therapy should use a proton pump inhibitor (PPI) and involve appropriate gastrointestinal consultation. If symptoms persist, other etiologies such as central causes need to be explored. SUMMARY We review the pathophysiology of hiccups including multiple causes and the appropriate work up for each. We review several studies examining new treatments, both pharmacological and interventional, that may help patients. Initial therapy should still involve a PPI but several new therapies may be beneficial.
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Affiliation(s)
- Zachary Wilmer Reichenbach
- Department of Gastroenterology, Lewis Katz School of Medicine at Temple University Hospital, 3401 N. Broad St., 8th floor Parkinson Pavilion, Philadelphia, PA, 19140, USA
- Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Gregory M Piech
- Department of Gastroenterology, Lewis Katz School of Medicine at Temple University Hospital, 3401 N. Broad St., 8th floor Parkinson Pavilion, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Department of Gastroenterology, Lewis Katz School of Medicine at Temple University Hospital, 3401 N. Broad St., 8th floor Parkinson Pavilion, Philadelphia, PA, 19140, USA.
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Clarke NW, Ali A, Ingleby FC, Hoyle A, Amos CL, Attard G, Brawley CD, Calvert J, Chowdhury S, Cook A, Cross W, Dearnaley DP, Douis H, Gilbert D, Gillessen S, Jones RJ, Langley RE, MacNair A, Malik Z, Mason MD, Matheson D, Millman R, Parker CC, Ritchie AWS, Rush H, Russell JM, Brown J, Beesley S, Birtle A, Capaldi L, Gale J, Gibbs S, Lydon A, Nikapota A, Omlin A, O'Sullivan JM, Parikh O, Protheroe A, Rudman S, Srihari NN, Simms M, Tanguay JS, Tolan S, Wagstaff J, Wallace J, Wylie J, Zarkar A, Sydes MR, Parmar MKB, James ND. Corrigendum to Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial: Ann Oncol 2019; 30: 1992-2003. Ann Oncol 2020; 31:442. [PMID: 32067690 PMCID: PMC8929236 DOI: 10.1016/j.annonc.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- N W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester.
| | - A Ali
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester
| | - F C Ingleby
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London; London School of Hygiene and Tropical Medicine, London
| | - A Hoyle
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester
| | - C L Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | | | - C D Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J Calvert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Chowdhury
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - A Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - W Cross
- St James University Hospital, Leeds
| | | | - H Douis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - D Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Gillessen
- Division of Cancer Sciences, The University of Manchester, Manchester
| | - R J Jones
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - R E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - A MacNair
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - Z Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | | | - D Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Wolverhampton
| | - R Millman
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - C C Parker
- Institute of Cancer Research, Sutton-London; RoyalMarsden NHS Foundation Trust, London
| | - A W S Ritchie
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - H Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J M Russell
- Institute of Cancer Sciences, Beatson West of Scotland Cancer Centre, Glasgow
| | - J Brown
- University of Sheffield, Sheffield
| | | | - A Birtle
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston
| | - L Capaldi
- Worcestershire Acute Hospitals NHS Trust, Worcester
| | - J Gale
- Portsmouth Oncology Centre, Queen Alexandra Hospital, Portsmouth
| | | | - A Lydon
- Torbay and South Devon NHS Foundation Trust, Torbay
| | | | - A Omlin
- Department of Oncology and Haematology, Kantonsspital, St Gallen, Switzerland
| | - J M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK
| | - O Parikh
- East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - A Protheroe
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Rudman
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - N N Srihari
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - M Simms
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - S Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - J Wagstaff
- Swansea University College of Medicine, Swansea, UK
| | - J Wallace
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - J Wylie
- The Christie NHS Foundation Trust, Manchester, UK
| | - A Zarkar
- Heartlands Hospital, Birmingham, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - M K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - N D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Jehangir A, Collier A, Shakhatreh M, Malik Z, Parkman HP. Caregiver Burden in Gastroparesis and GERD: Correlation with Disease Severity, Healthcare Utilization and Work Productivity. Dig Dis Sci 2019; 64:3451-3462. [PMID: 31300995 DOI: 10.1007/s10620-019-05723-2] [Citation(s) in RCA: 4] [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: 03/14/2019] [Accepted: 07/03/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Caregiver burden can be significant in chronic gastrointestinal diseases. No studies have been performed to evaluate caregiver burden in gastroparesis or gastroesophageal reflux disease (GERD). AIMS (1) Assess the caregiver burden in gastroparesis and GERD patients and healthy volunteers (HVs); (2) correlate the caregiver burden of these patients to the severity of patients' symptoms, healthcare utilization, and work productivity of the patients and the caregivers. METHODS Patients with gastroparesis and GERD, seen between June 2018 and November 2018, completed Patient Assessment of Gastrointestinal Symptoms, Work Productivity and Activity Impairment (WPAI) and healthcare utilization questionnaires. The caregivers of these patients completed Zarit Burden Interview (ZBI) and WPAI questionnaire. HVs and their potential caregivers also completed these questionnaires. RESULTS Forty-seven patients (gastroparesis = 31, GERD = 17), 12 HVs, and their caregivers completed questionnaires. Caregivers of gastroparesis patients reported high burden on ZBI (27.7 ± 2.9), greater than the caregivers of GERD (14.9 ± 2.5) and HVs (5.5 ± 1.6, p < 0.01). Among all patients, the caregiver burden had a strong correlation with patients' Gastroparesis Cardinal Symptom Index (GCSI) total score (rs = 0.63, p < 0.01) and moderate correlations with the number of patients' physician office visits (rs = 0.46, p < 0.01) and the number of work hours missed by caregivers due to patients' symptoms (rs = 0.36, p = 0.04). Using multivariable regression, both presence of gastroparesis and other comorbidities significantly predicted caregiver burden, F(2, 33) = 15.94, p < 0.0001, R2 = 0.491. CONCLUSIONS Caregivers of gastroparesis patients have high caregiver burden that strongly correlates with patients' GCSI total score. Interventions to reduce symptom severity of Gp patients may reduce the caregiver burden.
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Affiliation(s)
- Asad Jehangir
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
| | - Alexis Collier
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Mohammed Shakhatreh
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Section of Gastroenterology, Department of Medicine, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA, 19140, USA
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Clarke NW, Ali A, Ingleby FC, Hoyle A, Amos CL, Attard G, Brawley CD, Calvert J, Chowdhury S, Cook A, Cross W, Dearnaley DP, Douis H, Gilbert D, Gillessen S, Jones RJ, Langley RE, MacNair A, Malik Z, Mason MD, Matheson D, Millman R, Parker CC, Ritchie AWS, Rush H, Russell JM, Brown J, Beesley S, Birtle A, Capaldi L, Gale J, Gibbs S, Lydon A, Nikapota A, Omlin A, O'Sullivan JM, Parikh O, Protheroe A, Rudman S, Srihari NN, Simms M, Tanguay JS, Tolan S, Wagstaff J, Wallace J, Wylie J, Zarkar A, Sydes MR, Parmar MKB, James ND. Addition of docetaxel to hormonal therapy in low- and high-burden metastatic hormone sensitive prostate cancer: long-term survival results from the STAMPEDE trial. Ann Oncol 2019; 30:1992-2003. [PMID: 31560068 PMCID: PMC6938598 DOI: 10.1093/annonc/mdz396] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND STAMPEDE has previously reported that the use of upfront docetaxel improved overall survival (OS) for metastatic hormone naïve prostate cancer patients starting long-term androgen deprivation therapy. We report on long-term outcomes stratified by metastatic burden for M1 patients. METHODS We randomly allocated patients in 2 : 1 ratio to standard-of-care (SOC; control group) or SOC + docetaxel. Metastatic disease burden was categorised using retrospectively-collected baseline staging scans where available. Analysis used Cox regression models, adjusted for stratification factors, with emphasis on restricted mean survival time where hazards were non-proportional. RESULTS Between 05 October 2005 and 31 March 2013, 1086 M1 patients were randomised to receive SOC (n = 724) or SOC + docetaxel (n = 362). Metastatic burden was assessable for 830/1086 (76%) patients; 362 (44%) had low and 468 (56%) high metastatic burden. Median follow-up was 78.2 months. There were 494 deaths on SOC (41% more than the previous report). There was good evidence of benefit of docetaxel over SOC on OS (HR = 0.81, 95% CI 0.69-0.95, P = 0.009) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P = 0.827). Analysis of other outcomes found evidence of benefit for docetaxel over SOC in failure-free survival (HR = 0.66, 95% CI 0.57-0.76, P < 0.001) and progression-free survival (HR = 0.69, 95% CI 0.59-0.81, P < 0.001) with no evidence of heterogeneity of docetaxel effect between metastatic burden sub-groups (interaction P > 0.5 in each case). There was no evidence that docetaxel resulted in late toxicity compared with SOC: after 1 year, G3-5 toxicity was reported for 28% SOC and 27% docetaxel (in patients still on follow-up at 1 year without prior progression). CONCLUSIONS The clinically significant benefit in survival for upfront docetaxel persists at longer follow-up, with no evidence that benefit differed by metastatic burden. We advocate that upfront docetaxel is considered for metastatic hormone naïve prostate cancer patients regardless of metastatic burden.
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Affiliation(s)
- N W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester.
| | - A Ali
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester
| | - F C Ingleby
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London; London School of Hygiene and Tropical Medicine, London
| | - A Hoyle
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester
| | - C L Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | | | - C D Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J Calvert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Chowdhury
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - A Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - W Cross
- St James University Hospital, Leeds
| | | | - H Douis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - D Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - S Gillessen
- Division of Cancer Sciences, The University of Manchester, Manchester
| | - R J Jones
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - R E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - A MacNair
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - Z Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | | | - D Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Wolverhampton
| | - R Millman
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - C C Parker
- Institute of Cancer Research, Sutton-London; Royal Marsden NHS Foundation Trust, London
| | - A W S Ritchie
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - H Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - J M Russell
- Institute of Cancer Sciences, Beatson West of Scotland Cancer Centre, Glasgow
| | - J Brown
- University of Sheffield, Sheffield
| | | | - A Birtle
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston
| | - L Capaldi
- Worcestershire Acute Hospitals NHS Trust, Worcester
| | - J Gale
- Portsmouth Oncology Centre, Queen Alexandra Hospital, Portsmouth
| | | | - A Lydon
- Torbay and South Devon NHS Foundation Trust, Torbay
| | | | - A Omlin
- Department of Oncology and Haematology, Kantonsspital, St Gallen, Switzerland
| | - J M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast
| | - O Parikh
- East Lancashire Hospitals NHS Trust, Blackburn
| | - A Protheroe
- Oxford University Hospitals NHS Foundation Trust, Oxford
| | - S Rudman
- Guy's and Saint Thomas' NHS Foundation Trust, London
| | - N N Srihari
- Shrewsbury and Telford Hospital NHS Trust, Shrewsbury
| | - M Simms
- Hull and East Yorkshire Hospitals NHS Trust, Hull
| | | | - S Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - J Wagstaff
- Swansea University College of Medicine, Swansea
| | - J Wallace
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - J Wylie
- The Christie NHS Foundation Trust, Manchester
| | | | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - M K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London
| | - N D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham
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Clarke N, Ali A, Ingleby F, Hoyle A, Calvert J, Attard G, Chowdhury S, Dearnaley D, Douis H, Gillessen S, Jones R, Malik Z, Mason M, Millman R, Parker C, Rush H, Omlin A, Sydes M, Parmar M, James N. Docetaxel for hormone-naïve prostate cancer: Results from long-term follow-up of metastatic (M1) patients in the STAMPEDE randomised trial (NCT00268476) and sub-group analysis by metastatic burden. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz248.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Vogelzang N, Gabrail N, Malik Z, Volterra F, Nordquist L, Levin R, Zhang P, Zhou K. The extended/phase II study of safety and tolerability of proxalutamide (GT0918) in subjects with metastatic castrate resistant prostate cancer (mCRPC) who failed either abiraterone (Abi) or enzalutamide (Enza). Ann Oncol 2019. [DOI: 10.1093/annonc/mdz248.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Gastroesophageal reflux disease (GERD) is quite prevalent worldwide, especially in the western hemisphere. The pathophysiology of GERD is complex, involving an incompetent esophagogastric junction (EGJ) as an anti-reflux barrier, as well as other co-morbid conditions such as gastroparesis, hiatal herniation or hyper acid secretion. Esophageal dysmotility is also frequently encountered in GERD, further contributing to the disease in the form of fragmented peristalsis, ineffective esophageal motility (IEM) or the more severe aperistalsis. The latter is quite common in systemic connective tissue disorders such as scleroderma. The main stay treatment of GERD is pharmacologic with proton pump inhibitors (PPI), with surgical fundoplication offered to patients who are not responsive to medications or would like to discontinue them for medical or other reasons. The presence of esophageal dysmotility that can worsen or create dysphagia can potentially influence the choice of fundoplication (partial or complete), or whether it is even possible. Most of the existing literature demonstrates that fundoplication may be safe in the setting of ineffective or weak peristalsis, and that post-operative dysphagia cannot be reliably predicted by pre-operative manometry parameters. In cases of complete aperistalsis (scleroderma-like esophagus), partial fundoplication can be offered in select patients who exhibit prominent reflux symptoms after a comprehensive multidisciplinary evaluation. Roux-en-Y gastric bypass is an alternative to fundoplication in patients with this extreme form of esophageal dysmotility, after careful consideration of the nutritional status.
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Affiliation(s)
- Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Roman V Petrov
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Henry P Parkman
- Department of Medicine, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Zubair Malik
- Department of Medicine, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Medicine and Surgery, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
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Abstract
Introduction: Gastroparesis is a chronic disorder of the stomach characterized by delayed gastric emptying without mechanical obstruction. Diabetes is the most commonly known cause of gastroparesis. Management of diabetic gastroparesis involves lifestyle modifications, glycemic control, pharmacological drugs, and for refractory cases surgical treatments. Metoclopramide remains the only drug approved by the Food and Drug Administration for diabetic gastroparesis. The aim of this article is to provide a concise review of the pharmacology, clinical efficacy and tolerability of metoclopramide. Areas covered: We searched PubMed using the key words 'metoclopramide', 'diabetic gastroparesis', and 'gastric emptying'. The relevant articles and their bibliography were reviewed. Metoclopramide acts on several different receptors; primarily as a dopamine receptor antagonist, both peripherally improving gastric emptying, and centrally resulting in an anti-emetic effect. Metoclopramide side effects, mostly related to its ability to cross the blood-brain barrier, include drowsiness, restlessness, hyperprolactinemia, and tardive dyskinesia (TD), a movement disorder that may be irreversible. Expert opinion: Metoclopramide carries a black box warning for use >12 weeks due to the risk of TD. However, gastroparesis patients experience chronic symptoms often requiring prolonged treatments. Physicians and patients look forward to FDA approval of new agents for gastroparesis with better efficacy and safety profile.
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Affiliation(s)
- Mohammed Shakhatreh
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Asad Jehangir
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Zubair Malik
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Henry P Parkman
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
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Leopold A, Yu D, Bhuta R, Kataria R, Lu X, Jehangir A, Harrison M, Friedenberg F, Malik Z, Schey R, Parkman HP. Multiple Rapid Swallows (MRS) Complements Single-Swallow (SS) Analysis for High-Resolution Esophageal Manometry (HREM). Dig Dis Sci 2019; 64:2206-2213. [PMID: 30805798 DOI: 10.1007/s10620-019-05545-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 07/14/2018] [Accepted: 02/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Multiple rapid swallows (MRS) during HREM assess post-deglutitive inhibition, LES relaxation, and subsequent esophageal contraction. AIMS (1) To determine the relationship between MRS and single-swallow (SS) responses and (2) to determine if MRS provides information for symptomatic patients. METHODS Healthy volunteers (HVs) and patients underwent HREM [30-s landmark, ten 5-mL SS, MRS (5 consecutive 2-mL swallows every 2-3 s)] and were analyzed with ManoView software version 3 with CC version 3.0. RESULTS In 20 HVs, MRS response consisted of: (1) reduction in GEJ pressure; (2) absence of esophageal contractile activity during MRS; and (3) post-MRS peristaltic contraction greater than SS contractions. In 20 HVs and 403 patients, MRS IRP correlated with SS IRP (r = 0.65; p < 0.0001) and post-MRS contraction DCI correlated with SS DCI (r = 0.76; p < 0.0001). Abnormally elevated MRS IRP was seen in 68% type 2 achalasia, 50% type 3 achalasia, 47% EGJOO, and 9% jackhammer. Increased MRS DCI was seen in 53% type 2 achalasia, 92% type 3 achalasia, 10% EGJOO, 22% jackhammer, and 18% DES. Increased DCI post-MRS was seen in 38% patients with jackhammer, 8% type 3 achalasia, 12% EGJOO, and 9% DES. 14 out of 143 (10%) patients with normal or indeterminate results on SS analysis had at least one abnormality on MRS. CONCLUSIONS MRS IRP correlated with SS IRP, and post-MRS DCI correlated with SS DCI. Patients with defined CC disorders have abnormalities on MRS. There were MRS abnormalities in some patients with normal SS studies, most notably suggesting impaired LES relaxation and/or spastic esophageal motility. MRS may complement the baseline SS study analysis.
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Affiliation(s)
- Andrew Leopold
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Daohai Yu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Rajiv Bhuta
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Rahul Kataria
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Xiaoning Lu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Asad Jehangir
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Martha Harrison
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Frank Friedenberg
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Ron Schey
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
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Smith MS, Cash B, Konda V, Trindade AJ, Gordon S, DeMeester S, Joshi V, Diehl D, Ganguly E, Mashimo H, Singh S, Jobe B, McKinley M, Wallace M, Komatsu Y, Thakkar S, Schnoll-Sussman F, Sharaiha R, Kahaleh M, Tarnasky P, Wolfsen H, Hawes R, Lipham J, Khara H, Pleskow D, Navaneethan U, Kedia P, Hasan M, Sethi A, Samarasena J, Siddiqui UD, Gress F, Rodriguez R, Lee C, Gonda T, Waxman I, Hyder S, Poneros J, Sharzehi K, Di Palma JA, Sejpal DV, Oh D, Hagen J, Rothstein R, Sawhney M, Berzin T, Malik Z, Chang K. Volumetric laser endomicroscopy and its application to Barrett's esophagus: results from a 1,000 patient registry. Dis Esophagus 2019; 32:5481776. [PMID: 31037293 PMCID: PMC6853704 DOI: 10.1093/dote/doz029] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/08/2019] [Indexed: 12/11/2022]
Abstract
Volumetric laser endomicroscopy (VLE) uses optical coherence tomography (OCT) for real-time, microscopic cross-sectional imaging. A US-based multi-center registry was constructed to prospectively collect data on patients undergoing upper endoscopy during which a VLE scan was performed. The objective of this registry was to determine usage patterns of VLE in clinical practice and to estimate quantitative and qualitative performance metrics as they are applied to Barrett's esophagus (BE) management. All procedures utilized the NvisionVLE Imaging System (NinePoint Medical, Bedford, MA) which was used by investigators to identify the tissue types present, along with focal areas of concern. Following the VLE procedure, investigators were asked to answer six key questions regarding how VLE impacted each case. Statistical analyses including neoplasia diagnostic yield improvement using VLE was performed. One thousand patients were enrolled across 18 US trial sites from August 2014 through April 2016. In patients with previously diagnosed or suspected BE (894/1000), investigators used VLE and identified areas of concern not seen on white light endoscopy (WLE) in 59% of the procedures. VLE imaging also guided tissue acquisition and treatment in 71% and 54% of procedures, respectively. VLE as an adjunct modality improved the neoplasia diagnostic yield by 55% beyond the standard of care practice. In patients with no prior history of therapy, and without visual findings from other technologies, VLE-guided tissue acquisition increased neoplasia detection over random biopsies by 700%. Registry investigators reported that VLE improved the BE management process when used as an adjunct tissue acquisition and treatment guidance tool. The ability of VLE to image large segments of the esophagus with microscopic cross-sectional detail may provide additional benefits including higher yield biopsies and more efficient tissue acquisition. Clinicaltrials.gov NCT02215291.
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Affiliation(s)
- M S Smith
- Mount Sinai West & Mount Sinai St. Luke's Hospitals, New York, New York,Address correspondence to: Michael S. Smith, M.D., M.B.A., Chief of Gastroenterology and Hepatology, Mount Sinai West & Mount Sinai St. Luke's Hospitals, Ambulatory Care Center, Floor 13, 440 W. 114th Street, New York, NY 10025, USA.
| | - B Cash
- University of Texas Health Science Center at Houston, Houston, Texas
| | - V Konda
- Baylor University Medical Center, Dallas, Texas
| | - A J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System Manhasset, New York
| | - S Gordon
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - V Joshi
- University Medical Center at LSU, New Orleans, Louisiana
| | - D Diehl
- Geisinger Medical Center, Danville, Pennsylvania
| | - E Ganguly
- University of Vermont Medical Center, Burlington, Vermont
| | - H Mashimo
- VA Boston Health Care System, Boston, Massachusetts
| | - S Singh
- VA Boston Health Care System, Boston, Massachusetts
| | - B Jobe
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - M McKinley
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System Manhasset, New York,ProHEALTHcare Associates, Lake Success, New York, New York
| | | | - Y Komatsu
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - S Thakkar
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - R Sharaiha
- Weill Cornell Medicine, New York, New York
| | - M Kahaleh
- Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | | | - R Hawes
- Florida Hospital, Orlando, Florida
| | - J Lipham
- University of Southern California, Keck School of Medicine, Los Angeles, California
| | - H Khara
- Geisinger Medical Center, Danville, Pennsylvania
| | - D Pleskow
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - P Kedia
- Methodist Health System, Dallas, Texas
| | - M Hasan
- Florida Hospital, Orlando, Florida
| | - A Sethi
- Columbia University Medical Center, New York, New York
| | | | | | - F Gress
- Columbia University Medical Center, New York, New York
| | - R Rodriguez
- University of South Alabama, Mobile, Alabama
| | - C Lee
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System Manhasset, New York
| | - T Gonda
- Columbia University Medical Center, New York, New York
| | - I Waxman
- Chicago Medicine, Chicago, Illinois
| | - S Hyder
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - J Poneros
- Columbia University Medical Center, New York, New York
| | - K Sharzehi
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - J A Di Palma
- University of Texas Health Science Center at Houston, Houston, Texas
| | - D V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System Manhasset, New York
| | - D Oh
- University of Southern California, Keck School of Medicine, Los Angeles, California
| | - J Hagen
- University of Southern California, Keck School of Medicine, Los Angeles, California
| | - R Rothstein
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - M Sawhney
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - T Berzin
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Z Malik
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - K Chang
- UC Irvine Medical Center, Irvine, California
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Qammar M, Malik Z, Malik F, Baig T, Chaudhary AJ. Antibacterial activity of Mg1-xNixO(x=0.5) nano-solid solution; experimental and computational approach. J Mol Struct 2019. [DOI: 10.1016/j.molstruc.2018.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bhojwani A, Flint H, Hall B, Wong H, Innes H, Cliff J, Ahmed E, Malik Z, O'Hagan J, Tolan S, Hall A, Hyatt K, Errington D, Alam F, Robson P, Thorp N, O'Reilly S, Law A, Cicconi S, Jackson R, Palmieri C. Abstract P6-18-32: Profiling the early haematological dynamics and treatment modifications with palbociclib when used as first line treatment for ER-positive, HER2-negative metastatic breast cancer. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p6-18-32] [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: 11/16/2022]
Abstract
Abstract
Background: Palbociclib plus endocrine therapy (ET) significantly increases progression free survival compared to ET alone. Within PALOMA2 neutropenia was the most common AE and reason for dose reductions. No real data exists regarding dose reductions (DRs), dose interruptions (DIs), toxicities and benefits of palbociclib. Objective: To describe the early haematological dynamics, DRs/DIs with 1st line palbociclib in the context of a routine UK clinical practice. Methods: A prospective record was maintained of all patients with ER-positive, HER2-negative metastatic BC registered on the Pfizer patient programme at the Clatterbridge Cancer Centre NHS Foundation Trust. The clinical records of all patients commenced on treatment between April and December 2017 were reviewed, and clinico-pathological information, haematological data & toxicity data recorded. Data lock was 31st March 2018. Results: 48 patients received at least one cycle of treatment. The median age was 58, 29% (14/48) premenopausal & 71% (34/48) postmenopausal. 43% (21/48) had bone only disease with 42% (20/48) having visceral disease. The median number of cycles delivered 8 (range 2-11). DRs: 18/48 (38%) patients had a total of 21 DRs; 14/18 (78%) had 1 DR to 100mg; 1/18 (5%) 1 DR to 75mg; & 3/18 (17%) 2 DRs to 75mg. Reasons for DRs: 13 neutropenia, 2 leukopenia, 1 thrombocytopenia, 2 fatigue, 1 poor appetite, 1 sore mouth & 1 non-specially unwell. DIs: occurred in 24/48 patients (50%). Details of DRs/DIs by cycle will be presented. 85% (41 of 48) patients remain on treatment with 59% (24/41) on 125mg; 34% (14/41) on 100mg & 7% (3/41) on 75mg. FBC were available for 41/48 (85%) cases & dynamics considered over the first 6 cycles using FBC at the time of planned treatment delivery. Hb Baseline all patients (AP):129 (121 – 138), patients; patients with no dose reductions (NDR) 127 (123 – 139) & patient dose reduction (DR): 130 (118 – 136). Hb changes to cycles 2, 4 and 6 AP: 122 (115 – 131), 121 (116 – 127) and 125 (116 – 134); NDR:122 (110 - 135), 125 (117 - 127) and 131 (116 – 135); DR: 115 (112 - 120), 120 (115 - 124) and 122 (115 – 129). WCC Baseline AP: 6.8 (5.6 – 7.7); NDR: 7.2 (6.3 – 7.7); DR: 6.7 (5.2 – 7.7). WCC changes to cycles 2, 4 and 6 AP: 3.7 (2.9 – 4.4), 3.7 (3.1 – 4.4) and 3.3 (3 – 3.9); NDR: 3.5 (2.9 – 4.1), 3.6 (3.2 – 4.3) and 3.6 (3.1 – 4.1); DR: 2.1 (1.7 – 2.5), 4.3 (3 – 4.6) and 3.3 (2.8 – 3.5). ANC Baseline AP: 4.0 (3.2 – 5.1); NDR: 4.4 (3.4 – 5.0); DR: 3.6 (2.9 – 5.2). ANC changes to cycles 2, 4 and 6 AP: 1.5 (1.2 – 2.1), 1.7 (1.3 – 2.0) and 1.4 (1.2 – 1.9) NDR: 1.5 (1.1 – 2.1), 1.7 (1.4 – 2.0) and 1.3 (1.2 – 2.0); DR: 0.8 (0.6 – 0.8), 1.7 (1.2 – 2.3) and 1.4 (1.3 – 1.6). Plts Baseline AP: 298 (226 – 339), NDR: 252 (211 – 336); DR: 299 (253 – 339). Plt changes to cycles 2, 4 and 6 AP: 252 (198 – 310), 221 (186 – 259) and 200 (169 – 243). NDR: 249 (185 – 334), 229 (171 – 267) and 205 (177 – 263);DR: 208 (199 – 210), 216 (199 – 243) and 194 (162 -210). Conclusion: These initial real world data are consistent with the PALOMA2 data. Baseline WCC & ANC show no significant difference between NDR and DR cases. Updated data will be presented as well as outcome data for first time.
Citation Format: Bhojwani A, Flint H, Hall B, Wong H, Innes H, Cliff J, Ahmed E, Malik Z, O'Hagan J, Tolan S, Hall A, Hyatt K, Errington D, Alam F, Robson P, Thorp N, O'Reilly S, Law A, Cicconi S, Jackson R, Palmieri C. Profiling the early haematological dynamics and treatment modifications with palbociclib when used as first line treatment for ER-positive, HER2-negative metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-32.
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Affiliation(s)
- A Bhojwani
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - H Flint
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - B Hall
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - H Wong
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - H Innes
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - J Cliff
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - E Ahmed
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - Z Malik
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - J O'Hagan
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - S Tolan
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - A Hall
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - K Hyatt
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - D Errington
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - F Alam
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - P Robson
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - N Thorp
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - S O'Reilly
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - A Law
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - S Cicconi
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - R Jackson
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - C Palmieri
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, Merseyside, Switzerland; University of Liverpool, Liverpool, Merseyside, United Kingdom
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Hall B, Bhojwani A, Innes H, Ahmed E, Cliff J, Malik Z, O'Hagan J, Tolan S, Hall A, Hayat K, Errington D, Alam F, Thorp N, Flint H, Law A, Wong H, O'Reilly S, Jackson R, Cicconi S, Palmieri C. Abstract P6-17-27: Real world experience of the medical and surgical management of HER2 positive early breast cancer treated with neoadjuvant trastuzumab and pertuzumab via the NHS England cancer drug fund. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p6-17-27] [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: 11/16/2022]
Abstract
Abstract
Background: Studies of neoadjuvant (NA) dual HER2 blockade with trastuzumab (T) and pertuzumab (P) in combination with chemotherapy (CT) for early breast cancer (BC) have reported pathological complete response (pCR) rates of 39 to 62%. These studies also report manageable toxicity with diarrhoea reported in up to 73% of cases. To date no real-world studies have explored the efficacy and toxicity of this treatment. The objective of this study was to describe the medical and surgical management of women treated with neoadjuvant T-P in combination with CT (NAT-P-CT). As well as to determine the efficacy toxicity of NAT-P-CT in the context of a routine UK NHS clinical practice.
Methods: Patients with HER2+ BC treated neoadjuvantly with T-P accessed via the NHS England Cancer Drug Fund (CDF) at the Clatterbridge Cancer Centre NHS Foundation Trust between October 2016 and January 2018 were retrospectively identified. Clinico-pathological information, treatment data, nurse led toxicity review and echocardiographic were reviewed. Data lock was 19th June 2018.
Results: 78 female patients were identified with a median age of 50 years (IQR: 44.4-60.2). At diagnosis: median tumour size 30mm (23.0-47.5mm), 62% (48/78) were LN positive & 56% (44/78) ER+. CT regimens: 81% (63/78) FEC-DHP of these 30% (19/63) switched to weekly paclitaxel (wP). or nab-paclitaxel; 5% (4/78); AC/EC-DHP; 9% (8/78) TCHP with 13% (1/8) switched to wP. At time of analysis, 88% (69/78) had undergone definitive surgery. Surgical details: Breast: 52% (36/69) mastectomy & 48% (33/69) WLE, Axillary management: 51% (35/69) axillary dissection (Ax Dx) & 49% (34/69) sentinel node biopsy (4 performed prior to NA treatment). 91% (32/35) of those undergoing Ax Dx were LN+ at presentation, of these 59% (19/32) had no evidence of axillary involvement at surgery. pCR rate (ypT0/is, N0) was 46% (32/69) [pCR by HR: ER+ 43% (21/49) & ER- 55% (11/20]. pCR for 20 patients switched to wP was 60% (12/20). 7% (5/69) achieved pCR in the breast alone (in these LN status ITCx1, micrometsx3 & macrometsx1). Of the 54% (37/69) with residual breast tumour median size was 13mm (1-22mm). Toxicity Data: Ejection fraction (EF) did not decline beyond 10% of baseline in any patients. Diarrhoea (any grade) occurred in 74% of cases, and CTCAE grade 3-4 toxicity occurring in >2% of patients: diarrhoea, fatigue, and infection. Updated analysis regarding pCR rate and toxicity, as well as initial outcome data will be presented.
Conclusion: These results (1) confirm the efficacy of NA T-P in a real world population; (2) support the use of NA wP; (3) indicate significant proportion of patients axilla are downstaged & (4) reveal diarrhoea rates in keeping with the literature. Currently, NHS England rules do not allow wP to be used routinely in NA setting with T-P this should be reviewed in light of these data and those of the BERENICE study. Measures to identify patients who can avoid axillary dissection as well as to mitigate diarrhoea should be considered.
Citation Format: Hall B, Bhojwani A, Innes H, Ahmed E, Cliff J, Malik Z, O'Hagan J, Tolan S, Hall A, Hayat K, Errington D, Alam F, Thorp N, Flint H, Law A, Wong H, O'Reilly S, Jackson R, Cicconi S, Palmieri C. Real world experience of the medical and surgical management of HER2 positive early breast cancer treated with neoadjuvant trastuzumab and pertuzumab via the NHS England cancer drug fund [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-27.
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Affiliation(s)
- B Hall
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - A Bhojwani
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - H Innes
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - E Ahmed
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - J Cliff
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Z Malik
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - J O'Hagan
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - S Tolan
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - A Hall
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - K Hayat
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - D Errington
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - F Alam
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - N Thorp
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - H Flint
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - A Law
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - H Wong
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - S O'Reilly
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - R Jackson
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - S Cicconi
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - C Palmieri
- University of Liverpool, Liverpool, Hammersmith and Fulham, United Kingdom; Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
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Zoll B, Jehangir A, Malik Z, Edwards MA, Petrov RV, Parkman HP. Gastric Electric Stimulation for Refractory Gastroparesis. J Clin Outcomes Manag 2019; 26:27-38. [PMID: 31501641 PMCID: PMC6733037] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To outline the use and utility of gastric electric stimulation (GES) as a therapeutic intervention for gastroparesis. METHODS Review of the literature. RESULTS Gastroparesis is characterized by delayed gastric emptying, with symptoms of nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. Some patients with gastroparesis do not respond to medical intervention, and for these patients surgical intervention may be warranted. GES utilizes high-frequency gastric neurostimulation to facilitate gastric emptying and reduce symptoms of gastroparesis. It is indicated for patients with idiopathic and diabetic gastroparesis who have nausea and vomiting as their primary symptoms and who have not responded to medical therapy. GES has also been used in postsurgical and pediatric gastroparesis patients. Optimizing the outcome of this surgical treatment through proper patient selection and meticulous surgical technique is essential as there are inherent risks to the procedure. Nonblinded studies of GES for medically refractory gastroparesis have demonstrated therapeutic symptomatic benefit, whereas randomized controlled trials have not. New interventions such as pyloromyotomy and pyloroplasty are reasonable alternatives or addendums to GES. CONCLUSION GES may be considered among the therapies available for treating patients with refractory symptoms of gastroparesis. More studies, specifically those comparing GES, pyloromyotomy, GES combined with pyloromyotomy, and placebo, are needed to help guide therapy selection for refractory gastroparesis.
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Affiliation(s)
- Bryan Zoll
- Temple University School of Medicine, Philadelphia, PA
| | - Asad Jehangir
- Temple University School of Medicine, Philadelphia, PA
| | - Zubair Malik
- Temple University School of Medicine, Philadelphia, PA
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Malik Z, Pichler A, Di Lorenzo G, De Giorgi U, Hitier S, Ecstein-Fraisse E, Ozatilgan A, Carles J. Post hoc analysis of the effect of baseline characteristics on treatment duration in patients with metastatic castration-resistant prostate cancer (mCRPC) receiving cabazitaxel in the compassionate use (CUP)/expanded access programs (EAP) and CAPRISTANA registry. Ann Oncol 2018. [DOI: 10.1093/annonc/mdy284.027] [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: 11/13/2022] Open
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Malik Z, Kataria R, Modayil R, Ehrlich AC, Schey R, Parkman HP, Stavropoulos SN. Gastric Per Oral Endoscopic Myotomy (G-POEM) for the Treatment of Refractory Gastroparesis: Early Experience. Dig Dis Sci 2018; 63:2405-2412. [PMID: 29468376 DOI: 10.1007/s10620-018-4976-9] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [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: 07/12/2017] [Accepted: 02/10/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Gastric per oral endoscopic myotomy (G-POEM) of the pylorus is a technique that is recently being used to treat gastroparesis. Our aim was to report our experience in performing G-POEM for refractory gastroparesis of different etiologies and determine symptom improvement. METHODS Thirteen patients undergoing G-POEM are reported. Pre- and post-procedure gastric emptying study (GES) and PAGI-SYM for symptom severity were obtained. Patients underwent G-POEM by creating a submucosal tunnel starting in the greater curvature of the distal antrum and extending it to the beginning of the duodenal bulb, followed by a full thickness pyloromyotomy. RESULTS All 13 gastroparesis patients successfully underwent G-POEM (one diabetic [DGp], four idiopathic [IGp], eight postsurgical [PSGp]). Postsurgical patients included 4 s/p esophagectomy for esophageal cancer, 3 s/p Nissen fundoplication, and 1 s/p esophagectomy for achalasia. There were no procedure-related side effects. Of 11 patients completing follow-up questionnaires, eight were improved subjectively (four patients reported considerably better, four patients somewhat better, one unchanged, and two worse). Individual symptom severity scores tended to improve, particularly vomiting, retching, and loss of appetite. Of six patients that had post-G-POEM GES; GES improved in four, unchanged in one, and worsened in one). CONCLUSIONS G-POEM for treatment of refractory gastroparesis appears to be a feasible and safe technique that can be successfully performed in patients with a variety of etiologies including different types of postsurgical gastroparesis. Our initial experience suggests that the majority of patients report some improvement in symptoms, particularly symptoms of vomiting, retching, and loss of appetite. Further experience is needed to determine the efficacy and safety of G-POEM and predict those who best respond to this treatment.
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Affiliation(s)
- Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Rahul Kataria
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Rani Modayil
- Division of Gastroenterology, Hepatology, and Nutrition, Winthrop University Hospital, Mineola, NY, USA
| | - Adam C Ehrlich
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Ron Schey
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA.
| | - Stavros N Stavropoulos
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, 3401 N Broad Street, Parkinson Pavilion 8th floor, Philadelphia, PA, 19140, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Winthrop University Hospital, Mineola, NY, USA
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Abstract
Limited research exists regarding the relationship between small intestinal bacterial overgrowth (SIBO), small bowel transit (SBT), and colonic transit (CT). Furthermore, symptom analysis is limited between the subtypes of SIBO: hydrogen producing (H-SIBO) and methane producing (M-SIBO). The primary aims of this study are to: compare the SBT and CT in patients with a positive lactulose breath test (LBT) to those with a normal study; compare the SBT and CT among patients with H-SIBO or M-SIBO; compare the severity of symptoms in patients with a positive LBT to those with a normal study; compare the severity of symptoms among patients with H-SIBO or M-SIBO.A retrospective review was performed for 89 patients who underwent a LBT and whole gut transit scintigraphy (WGTS) between 2014 and 2016. Seventy-eight patients were included. WGTS evaluated gastric emptying, SBT (normal ≥40% radiotracer bolus accumulated at the ileocecal valve at 6 hours), and CT (normal geometric center of colonic activity = 1.6-7.0 at 24 hours, 4.0-7.0 at 48 hours, 6.2-7.0 at 72 hours; elevated geometric center indicates increased transit). We also had patients complete a pretest symptom survey to evaluate nausea, bloating, constipation, diarrhea, belching, and flatulence.A total of 78 patients (69 females, 9 males, mean age of 48 years, mean BMI of 25.9) were evaluated. Forty-seven patients had a positive LBT (H-SIBO 66%, M-SIBO 34%). Comparison of SBT among patients with a positive LBT to normal LBT revealed no significant difference (62.1% vs 58.6%, P = .63). The mean accumulated radiotracer was higher for H-SIBO compared to M-SIBO (71.5% vs 44.1%; P < .05). For CT, all SIBO patients had no significant difference in geometric centers of colonic activity at 24, 48, and 72 hours when compared to the normal group. When subtyping, H-SIBO had significantly higher geometric centers compared to the M-SIBO group at 24 hours (4.4 vs 3.1, P < .001), 48 hours (5.2 vs 3.8, P = .002), and at 72 hours (5.6 vs 4.3, P = .006). The symptom severity scores did not differ between the positive and normal LBT groups. A higher level of nausea was present in the H-SIBO group when compared to the M-SIBO group.Overall, the presence of SIBO does not affect SBT or CT at 24, 48, and 72 hours. However, when analyzing the subtypes, M-SIBO has significantly more delayed SBT and CT when compared to H-SIBO. These results suggest the presence of delayed motility in patients with high methane levels on LBT.
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Affiliation(s)
- Jaspreet Suri
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Rahul Kataria
- Gastroenterology Section, Department of Medicine
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P. Parkman
- Gastroenterology Section, Department of Medicine
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Ron Schey
- Gastroenterology Section, Department of Medicine
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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Saadi M, Yu D, Malik Z, Parkman HP, Schey R. Pyloric sphincter characteristics using EndoFLIP ® in gastroparesis. Rev Gastroenterol Mex (Engl Ed) 2018; 83:375-384. [PMID: 29709494 DOI: 10.1016/j.rgmx.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/19/2018] [Accepted: 02/02/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND AIMS Pyloric sphincter abnormalities may be detected in gastroparesis. Botulinum toxin A (BoNT/A) injection into the pylorus has been used to treat gastroparesis with varying results. The aim of the present article was to assess whether pyloric sphincter characteristics using the endoscopic functional lumen imaging probe (EndoFLIP®) with impedance planimetry in patients with gastroparesis correlated with symptoms, gastric emptying, and therapeutic response to pyloric sphincter BoNT/A injection. METHODS EndoFLIP® study was performed on patients undergoing gastroparesis treatment with BoNT/A. The gastroparesis cardinal symptom index (GCSI) was applied prior to treatment and at post-treatment weeks 2, 4, 8, and 12. RESULTS Forty-four patients were enrolled (30 with idiopathic gastroparesis, 14 with diabetic gastroparesis). Smaller pyloric diameter, cross-sectional area (CSA), and distensibility correlated with worse vomiting and retching severity at baseline. Greater gastric retention tended to correlate with decreased CSA and pyloric distensibility. BoNT/A treatment resulted in a significant decrease in the GCSI score at 2 and 4 weeks after treatment, but not at post-treatment weeks 8 or 12. Nausea, early satiety, postprandial fullness, and upper abdominal pain improved up to 12 weeks, whereas loss of appetite, stomach fullness, and stomach visibly larger improved only up to 4 weeks. Retching and vomiting failed to improve. Greater pyloric compliance at baseline correlated with greater improvement in early satiety and náusea at 8 weeks and greater pyloric distensibility correlated with improvement in upper abdominal pain. CONCLUSIONS EndoFLIP® characteristics of the pylorus provided important pathophysiologic information in patients with gastroparesis, in relation to symptoms, gastric emptying, and predicting the response to treatment directed at the pylorus.
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Affiliation(s)
- M Saadi
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - D Yu
- Temple Clinical Research Institute, Departamento de Ciencias Clínicas, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - Z Malik
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - H P Parkman
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - R Schey
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos.
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Abstract
Formation of highly organized dental hard tissues is a complex process involving sequential and ordered deposition of an extracellular scaffold, followed by its mineralization. Odontoblast and ameloblast differentiation involves reciprocal and sequential epithelial-mesenchymal interactions. Similar to early tooth development, various Bmps are expressed during this process, although their functions have not been explored in detail. Here, we investigated the role of odontoblast-derived Bmp2 for tooth mineralization using Bmp2 conditional knockout mice. In developing molars, Bmp2LacZ reporter mice revealed restricted expression of Bmp2 in early polarized and functional odontoblasts while it was not expressed in mature odontoblasts. Loss of Bmp2 in neural crest cells, which includes all dental mesenchyme, caused a delay in dentin and enamel deposition. Immunohistochemistry for nestin and dentin sialoprotein (Dsp) revealed polarization defects in odontoblasts, indicative of a role for Bmp2 in odontoblast organization. Surprisingly, pSmad1/5/8, an indicator of Bmp signaling, was predominantly reduced in ameloblasts, with reduced expression of amelogenin ( Amlx), ameloblastin ( Ambn), and matrix metalloproteinase ( Mmp20). Quantitative real-time polymerase chain reaction (RT-qPCR) analysis and immunohistochemistry showed that loss of Bmp2 resulted in increased expression of the Wnt antagonists dickkopf 1 ( Dkk1) in the epithelium and sclerostin ( Sost) in mesenchyme and epithelium. Odontoblasts showed reduced Wnt signaling, which is important for odontoblast differentiation, and a strong reduction in dentin sialophosphoprotein ( Dspp) but not collagen 1 a1 ( Col1a1) expression. Mature Bmp2-deficient teeth, which were obtained by transplanting tooth germs from Bmp2-deficient embryos under a kidney capsule, showed a dentinogenesis imperfecta type II-like appearance. Micro-computed tomography and scanning electron microscopy revealed reduced dentin and enamel thickness, indistinguishable primary and secondary dentin, and deposition of ectopic osteodentin. This establishes that Bmp2 provides an early temporal, nonredundant signal for directed and organized tooth mineralization.
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Affiliation(s)
- Z Malik
- 1 School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - M Alexiou
- 1 School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - B Hallgrimsson
- 2 Department of Cell Biology and Anatomy, Faculty of Medicine, University of Calgary, AB, Canada
| | | | - H U Luder
- 4 Institute of Oral Biology, Centre for Dental Medicine, Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - D Graf
- 1 School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,5 Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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