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Robbins NM, Peltier A, Baker JR. Comment to the article "Standing tests lack reliability to diagnose all adolescents who have postural tachycardia syndrome". Clin Auton Res 2024; 34:203-204. [PMID: 38072868 DOI: 10.1007/s10286-023-01007-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 03/17/2024]
Affiliation(s)
- N M Robbins
- Department of Neurology, Geisel School of Medicine at Dartmouth, Hanover, NH, 03756, USA.
| | - A Peltier
- Department of Neurology, Vanderbilt University, Nashville, TN, USA
| | - J R Baker
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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2
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Rao SSC, Ahuja NK, Bharucha AE, Brenner DM, Chey WD, Deutsch JK, Kunkel DC, Moshiree B, Neshatian L, Reveille RM, Sayuk GS, Shapiro JM, Shah ED, Staller K, Wexner SD, Baker JR. Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations. Clin Gastroenterol Hepatol 2023; 21:2727-2739.e1. [PMID: 37302444 PMCID: PMC10542660 DOI: 10.1016/j.cgh.2023.05.025] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/13/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings. METHODS Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations. RESULTS ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices. CONCLUSIONS Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.
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Affiliation(s)
- Satish S C Rao
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia.
| | - Nitin K Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Darren M Brenner
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - William D Chey
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, Connecticut
| | - David C Kunkel
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Baharak Moshiree
- Division of Gastroenterology and Hepatology, Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, California
| | - Robert M Reveille
- Division of Gastroenterology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gregory S Sayuk
- Division of Gastroenterology, Washington University School of Medicine, Veterans Affairs Medical Center, St. Louis, Missouri
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, Florida
| | - Jason R Baker
- Department of Gastroenterology and Hepatology, Atrium Health, University of North Carolina, Charlotte, North Carolina
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3
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Shah ED, Pelletier EA, Greeley C, Sieglinger EE, Sanchez JD, Northam KA, Perrone JA, Curley MA, Navas CM, Ostler TL, Burnett Greeley AR, Martinez-Camblor P, Baker JR, Chey WD. Utility of Anorectal Testing to Predict Outcomes With Pelvic Floor Physical Therapy in Chronic Constipation: Pragmatic Trial. Clin Gastroenterol Hepatol 2023; 21:1070-1081. [PMID: 35640864 DOI: 10.1016/j.cgh.2022.05.014] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/30/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a clinical trial that aimed to inform the clinical utility of anorectal manometry (ARM) and balloon expulsion time (BET) as up-front tests to predict outcomes with community-based pelvic floor physical therapy as the next best step to address chronic constipation after failing an empiric trial of soluble fiber supplementation or osmotic laxatives. METHODS We enrolled 60 treatment-naïve patients with Rome IV functional constipation failing 2 weeks of soluble fiber supplementation or osmotic laxatives. All patients underwent ARM/BET (London protocol) followed by community-based pelvic floor physical therapy. Outcomes were assessed at baseline and 12 weeks. The primary end point was clinical response (Patient Assessment of Constipation-Symptoms instrument). RESULTS Fifty-three patients completed pelvic rehabilitation and the post-treatment questionnaire. Contemporary frameworks define dyssynergia on balloon expulsion time and dyssynergic patterns (ARM), but these parameters did not inform clinical outcomes (area under the curve [AUC], <0.6). Squeeze pressure (>192.5 mm Hg on at least 1 of 3 attempts; sensitivity, 47.6%; specificity, 83.9%) and limited squeeze duration (inability to sustain 50% of squeeze pressure for >20 seconds; sensitivity, 71.4%; specificity, 58.1%) were the strongest predictors of clinical outcomes. Combining BET with squeeze duration (BET greater than 6.5 seconds and limited squeeze duration) improved predictive accuracy (AUC, 0.75; 95% CI, 0.59-0.90). BET poorly predicted outcomes as a single test (AUC, 0.54; 95% CI, 0.38-0.69). CONCLUSIONS Using ARM to evaluate squeeze profiles, rather than dyssynergia, appears useful to screen patients with chronic constipation for up-front pelvic floor physical therapy based on likelihood of response. BET appears noninformative as a single screening test (ClinicalTrials.gov: NCT04159350).
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Elizabeth A Pelletier
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Carol Greeley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily E Sieglinger
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jamie D Sanchez
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kayla A Northam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jessica A Perrone
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Navas
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Baker
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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4
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Shah ED, Pelletier EA, Greeley C, Sieglinger EE, Sanchez JD, Northam KA, Perrone JA, Curley MA, Navas CM, Ostler TL, Burnett Greeley AR, Martinez-Camblor P, Baker JR, Harris A, Siegel CA, Chey WD. An Office-Based, Point-of-Care Test Predicts Treatment Outcomes With Community-Based Pelvic Floor Physical Therapy in Patients With Chronic Constipation. Clin Gastroenterol Hepatol 2023; 21:1082-1090. [PMID: 35341952 DOI: 10.1016/j.cgh.2022.03.022] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/02/2022] [Accepted: 03/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Rectal evacuation disorders are common among constipated patients. We aimed to evaluate the accuracy of an investigational point-of-care test (rectal expulsion device [RED]) to predict outcomes with community-based pelvic floor physical therapy. METHODS We enrolled patients meeting Rome IV criteria for functional constipation failing fiber/laxatives for more than 2 weeks. RED was inserted and self-inflated, and then time-to-expel was measured in a left lateral position. All patients underwent empiric community-based pelvic floor physical therapy in routine care with outcomes measured at 12 weeks. The primary end point was global clinical response (Patient Assessment of Constipation Symptoms score reduction, >0.75 vs baseline). Secondary end points included improvement in health-related quality-of-life (Patient Assessment of Constipation Quality of Life score reduction, >1.0) and complete spontaneous bowel movement frequency (Food and Drug Administration complete spontaneous bowel movement responder definition). RESULTS Thirty-nine patients enrolled in a feasibility phase to develop the use-case protocol. Sixty patients enrolled in a blinded validation phase; 52 patients (mean, 46.9 y; 94.2% women) were included in the intention-to-treat analysis. In the left lateral position, RED predicted global clinical response (generalized area under the curve [gAUC], 0.67; 95% CI, 0.58-0.76]), health-related quality-of-life response (gAUC, 0.67; 95% CI, 0.58-0.77; P < .001), and complete spontaneous bowel movement response (gAUC, 0.63; 95% CI, 0.57-0.71; P < .001). As a screening test, a normal RED effectively rules out evacuation disorders (expected clinical response, 8.9%; P = .042). Abnormal RED in the left lateral position (defined as expulsion within 5 seconds or >120 seconds) predicted 48.9% clinical response to physical therapy. A seated maneuver enhanced the likelihood of clinical response (71.1% response with seated RED retained >13 seconds) but likely is unnecessary in most settings. CONCLUSIONS RED offers an opportunity to disrupt the paradigm by offering a personalized approach to managing chronic constipation in the community (Clinicaltrials.gov: NCT04159350).
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Affiliation(s)
- Eric D Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Elizabeth A Pelletier
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Carol Greeley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily E Sieglinger
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jamie D Sanchez
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kayla A Northam
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jessica A Perrone
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Michael A Curley
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Navas
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy L Ostler
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jason R Baker
- Division of Gastroenterology, Atrium Health, Charlotte, North Carolina
| | | | - Corey A Siegel
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
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5
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Teshale AB, Htun HL, Hu J, Dalli LL, Lim MH, Neves BB, Baker JR, Phyo AZZ, Reid CM, Ryan J, Owen AJ, Fitzgerald SM, Freak-Poli R. The relationship between social isolation, social support, and loneliness with cardiovascular disease and shared risk factors: A narrative review. Arch Gerontol Geriatr 2023; 111:105008. [PMID: 37003026 DOI: 10.1016/j.archger.2023.105008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the greatest contributor to global morbidity and mortality. Poor social health plays a critical role in CVD incidence. Additionally, the relationship between social health and CVD may be mediated through CVD risk factors. However, the underlying mechanisms between social health and CVD are poorly understood. Certain social health constructs (social isolation, low social support and loneliness) have complicated the characterisation of a causal relationship between social health and CVD. AIM To provide an overview of the relationship between social health and CVD (and its shared risk factors). METHOD In this narrative review, we examined published literature on the relationship between three social health constructs (social isolation, social support, and loneliness) and CVD. Evidence was synthesised in a narrative format, focusing on the potential ways in which social health affects CVD, including shared risk factors. RESULTS The current literature highlights an established relationship between social health and CVD with a likelihood for bi-directionality. However, there is speculation and varied evidence regarding how these relationships may be mediated through CVD risk factors. CONCLUSIONS Social health can be considered an established risk factor for CVD. However, the potential bi-directional pathways of social health with CVD risk factors are less established. Further research is needed to understand whether targeting certain constructs of social health may directly improve the management of CVD risk factors. Given the health and economic burdens of poor social health and CVD, improvements to addressing or preventing these interrelated health conditions would have societal benefits.
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Affiliation(s)
| | - Htet Lin Htun
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Jessie Hu
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lachlan L Dalli
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.
| | - Michelle H Lim
- Prevention Research Collaboration, School of Public Health, The University of Sydney, New South Wales, Australia.
| | | | - J R Baker
- School of Health, Southern Cross University, Australia; Primary & Community Care Limited, Australia.
| | - Aung Zaw Zaw Phyo
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; School of Population Health, Curtin University, Perth, Western Australia, Australia.
| | - Joanne Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Alice J Owen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Sharyn M Fitzgerald
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Rosanne Freak-Poli
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.
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6
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Koo E, Chey WD, Ezell G, Baker JR, Armstrong M, Nojkov B. Can a Defecation Posture Modifying Device Correct an Abnormal Balloon Expulsion Test in Chronically Constipated Patients? Clin Gastroenterol Hepatol 2023; 21:847-848.e2. [PMID: 34998994 DOI: 10.1016/j.cgh.2021.12.048] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023]
Abstract
Evacuation disorders are common among chronically constipated (CC) patients who fail to respond to laxatives and are typically diagnosed by anorectal manometry (ARM) and/or balloon expulsion testing (BET).1,2 Recently, there has been emerging interest in the use of defecation posture-modifying devices (DPMDs) to improve constipation symptoms, presumably by replicating the physiologic benefits of squatting on stool evacuation, such as straightening of the anorectal angle and relaxing the pelvic floor. However, the ability of DPMDs to normalize anorectal function in adult patients with CC has not been studied.
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Affiliation(s)
- Eden Koo
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan; John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Gabrielle Ezell
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Moira Armstrong
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Borko Nojkov
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan.
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7
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Chey WD, Baker JR, Watts L, Harris A, Shah ED. Development of a Simple, Point-of-Care Device to Test Anorectal Function in Patients with Constipation: Randomized Clinical Trial. Clin Gastroenterol Hepatol 2023; 21:832-834. [PMID: 34864156 PMCID: PMC9160215 DOI: 10.1016/j.cgh.2021.11.034] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 02/07/2023]
Abstract
Functional constipation (FC) is one of the most frequently encountered gastrointestinal conditions in practice.1 Practice guidelines universally recommend that patients with typical constipation symptoms and no alarm features be treated empirically with dietary/lifestyle interventions and laxative therapy.2,3 Unfortunately, by the time a patient reaches a gastroenterologist, these treatments frequently have already been tried. Anorectal function testing (anorectal manometry [ARM] and balloon expulsion test [BET]) is the next best step in management guidelines in this all-too-common scenario, because treatment can then be targeted toward pelvic floor dysfunction or colon transit abnormalities. Unfortunately, more than 95% of patients continue to take only over-the-counter laxatives and receive empirical dietary advice, whereas fewer than 2% undergo physiologic evaluation to ascertain the cause of their symptoms.4 Indeed, more than 90% of patients desire more effective treatment options. These observations call into question the wisdom of a management strategy that fails to recognize the intrinsic diversity of the constipation universe and reinforces the misguided "one size fits all" empirical treatment strategy.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Lydia Watts
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | | | - Eric D Shah
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan; Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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8
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Nojkov B, Baker JR, Chey WD, Saad R, Watts L, Armstrong M, Collins K, Ezell G, Phillips C, Menees S. Age- and Gender-Based Differences in Anorectal Function, Gastrointestinal Symptoms, and Constipation-Specific Quality of Life in Patients with Chronic Constipation. Dig Dis Sci 2022; 68:1403-1410. [PMID: 36173584 DOI: 10.1007/s10620-022-07709-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: 04/12/2022] [Accepted: 09/21/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND The effect of age and gender differences on anorectal function, symptoms severity, and quality of life (QoL) in patients with chronic constipation (CC) is not well studied. This study examines the impact of age and gender on anorectal function testing (AFT) characteristics, symptoms burden, and QoL in patients with CC. METHODS This is a retrospective analysis of prospectively collected data from 2550 adults with CC who completed AFT. Collected data include demographics, sphincter response to simulated defecation during anorectal manometry (ARM), balloon expulsion testing (BET), and validated surveys assessing constipation symptoms and QoL. DD was defined as both the inability to relax the anal sphincter during simulated defecation and an abnormal BET. RESULTS 2550 subjects were included in the analysis (mean age = 48.6 years). Most patients were female (81.6%) and Caucasian (82%). 73% were < 60 years old (mean = 41) vs. 27% ≥ 60 years old (mean = 69). The prevalence of impaired anal sphincter relaxation on ARM, abnormal BET, and DD in patients with CC was 48%, 42.1%, and 22.9%, respectively. Patients who were older and male were significantly more frequently diagnosed with DD and more frequently had impaired anal sphincter relaxation on ARM, compared to patients who were younger and female (p < 0.05). Conversely, CC patients who were younger and female reported greater constipation symptoms severity and more impaired QoL (p ≤ 0.004). CONCLUSION Among patients with CC referred for anorectal function testing, men and those older than 60 are more likely to have dyssynergic defecation, but women and patients younger than 60 experience worse constipation symptoms and QoL.
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Affiliation(s)
- Borko Nojkov
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA.
| | - Jason R Baker
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - William D Chey
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Richard Saad
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Lydia Watts
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Moira Armstrong
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Kristen Collins
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Gabrielle Ezell
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Cari Phillips
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
| | - Stacy Menees
- Division of Gastroenterology, Department of Internal Medicine, Michigan Medicine, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr. SPC 5362, Ann Arbor, MI, 48109, USA
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Dingle GA, Sharman LS, Hayes S, Chua D, Baker JR, Haslam C, Jetten J, Haslam SA, Cruwys T, McNamara N. A controlled evaluation of the effect of social prescribing programs on loneliness for adults in Queensland, Australia (protocol). BMC Public Health 2022; 22:1384. [PMID: 35854258 PMCID: PMC9295098 DOI: 10.1186/s12889-022-13743-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 06/17/2022] [Accepted: 07/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In social prescribing, link workers support individuals whose persistent health problems are exacerbated by loneliness by connecting them to community-based social activities. This approach is well established in the UK and is gaining attention in Australia. However, a major limitation of research to date has been a lack of theoretically informed and rigorous evaluations of social prescribing. We will address these points in this study, applying a social identity framework to examine the effects of group-based social prescribing (SP) activity compared to primary care treatment as usual (TAU). METHODS Ninety participants experiencing loneliness recruited from primary care services and community centres across five sites in Southeast Queensland will be assigned to one of two conditions (SP, TAU) and assessed at two timepoints (baseline, + 8 weeks). Individuals will be aged 18 years and over, have sufficient English language skills to provide consent, and at the time of recruitment they will not be experiencing acute symptoms or social issues that require urgent intervention. Primary outcomes are loneliness, mental well-being, and health service use (total number of GP, hospital, and allied health visits in the past 3 months). Secondary outcomes will assess social group processes, including number of important social groups, new group identification, multiple identity compatibility, and group-based support and emotion regulation. DISCUSSION This study will provide comprehensive data about the extent to which, and how, social prescribing to community-based group activities may help people to feel less lonely, more socially integrated, and healthy over the first 8 weeks. If effective, this social identity-informed model of social prescribing can be disseminated in communities across Australia. TRIAL REGISTRATION ANZCTR, Registered 8 June 2022 - Retrospectively registered, https://www.anzctr.org.au/ACTRN12622000801718.aspx.
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Affiliation(s)
- G A Dingle
- School of Psychology, The University of Queensland, St Lucia QLD, Brisbane, 4072, Australia.
| | - L S Sharman
- School of Psychology, The University of Queensland, St Lucia QLD, Brisbane, 4072, Australia
| | - S Hayes
- School of Psychology, The University of Queensland, St Lucia QLD, Brisbane, 4072, Australia
| | - D Chua
- School of Psychology, The University of Queensland, St Lucia QLD, Brisbane, 4072, Australia.,Inala Primary Care, Brisbane, Australia
| | - J R Baker
- Primary & Community Care Services, Gold Coast, Australia
| | - C Haslam
- School of Psychology, The University of Queensland, St Lucia QLD, Brisbane, 4072, Australia
| | - J Jetten
- School of Psychology, The University of Queensland, St Lucia QLD, Brisbane, 4072, Australia
| | - S A Haslam
- School of Psychology, The University of Queensland, St Lucia QLD, Brisbane, 4072, Australia
| | - T Cruwys
- Australian National University, Canberra, Australia
| | - N McNamara
- Nottingham Trent University, Nottingham, UK
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Baker JR, Curtin BF, Moshiree B, Rao SSC. Organizing and Developing a GI Motility Lab in Community Practice: Challenges and Rewards. Curr Gastroenterol Rep 2022; 24:73-87. [PMID: 35674875 DOI: 10.1007/s11894-022-00838-5] [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: 02/07/2023]
Abstract
PURPOSE OF REVIEW Neurogastroenterology and motility is a rapidly evolving subspecialty that encompasses over 33% of gastroenterological disorders, and up to 50% of referrals to gastroenterology practice. It includes common problems such as dysphagia, gastroesophageal reflux disease, irritable bowel syndrome, chronic constipation, gastroparesis, functional dyspepsia, gas/bloating, small intestinal bacterial overgrowth, food intolerance and fecal incontinence Standard diagnostic tests such as endoscopy or imaging are normal in these conditions. To define the underlying mechanism(s)/etiology of these disorders, diagnostic motility tests are often required. These are best performed by well-trained personnel in a dedicated motility laboratory. Our purpose is to provide an up-to-date overview on how to organize and develop a motility laboratory based on our collective experiences in setting up such facilities in academia and community practice. RECENT FINDINGS A lack of knowledge, training and facilities for providing diagnostic motility tests has led to suboptimal patient care. A motility laboratory is the hub for diagnostic and therapeutic motility procedures. Common procedures include esophageal function tests such as esophageal manometry and pH monitoring, anorectal function tests suchlike anorectal manometry, neurophysiology and balloon expulsion, dysbiosis and food intolerance tests such as hydrogen/methane breath tests, and gastrointestinal transit assessment. These tests provide an accurate diagnosis and guide clinical management including use of medications, biofeedback therapy, neuromodulation, behavioral therapies, evidence-based dietary interventions and endoscopic or surgical procedures. Further, there have been recent developments in billing and coding of motility procedures and training requirements that are not well known. This review provides a stepwise approach on how to set-up a motility laboratory in the community or academic practice and includes the rationale, infrastructure, staffing needs, commonly performed motility tests and their clinical utility, billing and coding strategies, training needs and economic considerations for setting up this service.
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Affiliation(s)
- Jason R Baker
- Atrium Health, Charlotte, NC, USA.,Neurogastroenterology and Motility Laboratory, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28209, USA
| | - Bryan F Curtin
- Division of Neurogastroenterology, The Institute for Digestive and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | | | - Satish S C Rao
- Division of Neurogastroenterology/Motility, Augusta University Medical Center, Augusta, GA, USA.
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Reddy CA, Wenzke K, Watts LS, Armstrong M, Chen VL, Baker JR, Chen JW. Phenotyping patients with borderline elevated esophageal acid exposure. Dis Esophagus 2022; 35:6381246. [PMID: 34607359 DOI: 10.1093/dote/doab071] [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: 04/12/2021] [Revised: 07/16/2021] [Accepted: 09/18/2021] [Indexed: 01/05/2023]
Abstract
Acid exposure time (AET) <4% on ambulatory reflux monitoring definitively rules out pathologic gastroesophageal acid reflux, while AET >6% indicates pathologic reflux per the Lyon Consensus, leaving AET of 4-6% as borderline. We aimed to elucidate the borderline AET population and identify metrics that could help differentiate this group. A total of 50 subjects in each group, AET <4, 4-6, and >6% on pH-impedance monitoring between 2015 and 2019, were retrospectively reviewed. In addition to demographic and clinical information, the extracted data included mean nocturnal baseline impedance (MNBI) on reflux study and high-resolution manometry (HRM) parameters and diagnosis. After excluding patients with prior foregut surgery, major esophageal motility disorder, or unreliable impedance testing, a total of 89 subjects were included in the analysis (25 with normal AET < 4%, 38 with borderline 4-6%, 26 with abnormal >6%). MNBI in borderline AET patients was significantly lower compared to normal AET (1607.7 vs. 2524.0 ohms, P < 0.01), and higher than abnormal AET (951.5 ohms, P < 0.01). Borderline subjects had a greater frequency of ineffective esophageal motility (IEM) diagnosis per Chicago classification v3.0 (42.1 vs. 8.0%, P = 0.01), but did not demonstrate any differences compared to abnormal subjects (34.6%, P = 0.56). Patients with borderline AET had an average MNBI that was in between normal AET and abnormal AET. Borderline AET patients also commonly demonstrate IEM on HRM, similar to those with abnormal AET. Our findings can be potentially useful in assigning higher clinical significance for patients found to have borderline AET with concomitant low MNBI and IEM on manometry.
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Affiliation(s)
- Chanakyaram A Reddy
- Center for Esophageal Diseases, Baylor University Medical Center, Dallas, TX, USA
| | - Kevin Wenzke
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Lydia S Watts
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Moira Armstrong
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Vincent L Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - Jason R Baker
- Atrium Health, University of North Carolina, Charlotte, NC, USA
| | - Joan W Chen
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
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12
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Read AJ, Rice MD, Baker JR, Waljee AK, Saini SD. Diffusion of an innovation: growth in video capsule endoscopy in the U.S. Medicare population from 2003 to 2019. BMC Health Serv Res 2022; 22:425. [PMID: 35361221 PMCID: PMC8969398 DOI: 10.1186/s12913-022-07780-2] [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] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 03/15/2022] [Indexed: 11/12/2022] Open
Abstract
Background Video capsule endoscopy (VCE), approved by the U.S. Food and Drug Administration (FDA) in 2001, represented a disruptive technology that transformed evaluation of the small intestine. Adoption of this technology over time and current use within the U.S. clinical population has not been well described. Methods To assess the growth of capsule endoscopy within the U.S. Medicare provider population (absolute growth and on a population-adjusted basis), characterize the providers performing VCE, and describe potential regional differences in use. Medicare summary data from 2003 to 2019 were used to retrospectively analyze capsule endoscopy use in a multiple cross-sectional design. In addition, detailed provider summary files were used from 2012 to 2018 to characterize provider demographics. Results VCE use grew rapidly from 2003 to 2008 followed by a plateau from 2008 to 2019. There was significant variation in use of VCE between states, with up to 10-fold variation between states (14.6 to 156.1 per 100,000 enrollees in 2018). During this time, the adjusted VCE use on a population-adjusted basis declined, reflecting saturation of growth. Conclusions Growth of VCE use over time follows an S-shaped diffusion of innovation curve demonstrating a successful diffusion of innovation within gastroenterology. The lack of additional growth since 2008 suggests that current levels of use are well matched to overall population need within the constraints of reimbursement. Future studies should examine whether this lack of growth has implications for access and healthcare inequities. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07780-2.
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Affiliation(s)
- Andrew J Read
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Michael D Rice
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Jason R Baker
- Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | - Akbar K Waljee
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Sameer D Saini
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,VA HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA
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13
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Menees SB, Jackson K, Baker JR, Fenner DE, Eswaran S, Nojkov B, Saad R, Lee AA, Chey WD. A Randomized Pilot Study to Compare the Effectiveness of a Low FODMAP Diet vs Psyllium in Patients With Fecal Incontinence and Loose Stools. Clin Transl Gastroenterol 2022; 13:e00454. [PMID: 35060943 PMCID: PMC8963855 DOI: 10.14309/ctg.0000000000000454] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/06/2021] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION The aim of the study was to compare the effectiveness of a low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet (LFD) vs psyllium on the frequency and severity of fecal incontinence (FI) episodes in patients with loose stools. METHODS This was a single-center, randomized pilot trial of adult patients with FI (Rome III) with at least 1 weekly FI episode associated with loose stool. Eligible patients were randomized to 4 weeks of either a dietitian-led LFD or 6 g/d psyllium treatment. RESULTS Forty-three subjects were randomized from October 2014 to May 2019. Thirty-seven patients completed the study (19 LFD and 18 psyllium). There was no statistically significant difference in the proportion of treatment responders (>50% reduction in FI episodes compared with baseline) for treatment weeks 1-4 (LFD 38.9%, psyllium 50%, P = .33). Compared with baseline, mean fecal incontinence severity index score significantly improved with LFD (39.4 vs 32.6, P = .02) but not with psyllium (35.4 vs 32.1, P = .29). Compared with baseline values, the LFD group reported improvements in fecal incontinence quality of life coping/behavior, depression/self-perception, and embarrassment subscales. The psyllium group reported improvement in incontinence quality of life coping/behavior. DISCUSSION In this pilot study, there was no difference in the proportion of patients who reported a 50% reduction of FI episodes with the LFD or psyllium. Subjects in the psyllium group reported a greater reduction in overall FI episodes, whereas the LFD group reported consistent improvements in FI severity and quality of life. Further work to understand these apparently discrepant results are warranted but the LFD and psyllium seem to provide viable treatment options for patients with FI and loose stools.
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Affiliation(s)
- Stacy B. Menees
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Kenya Jackson
- Children's Healthcare of Atlanta Aflac Blood and Cancer Disorders Center, Atlanta, Georgia, USA; and
| | - Jason R. Baker
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Dee E. Fenner
- Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, Michigan, USA.
| | - Shanti Eswaran
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Borko Nojkov
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Richard Saad
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Allen A. Lee
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan, USA
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14
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Ortengren AR, Ramkissoon RA, Chey WD, Baker JR, Staller K, Iturrino J, Shah ED. Anorectal manometry to diagnose dyssynergic defecation: Systematic review and meta-analysis of diagnostic test accuracy. Neurogastroenterol Motil 2021; 33:e14137. [PMID: 33772969 PMCID: PMC10091423 DOI: 10.1111/nmo.14137] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 11/04/2020] [Revised: 02/23/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Chronic constipation is a common condition, and dyssynergic defecation underlies up to 40% of cases. Anorectal manometry is recommended to assess for dyssynergic defecation among chronically constipated patients but remains poorly standardized. We aimed to evaluate the diagnostic accuracy of anorectal manometry and determine optimal testing parameters. METHODS We performed a systematic review with meta-analysis of diagnostic test accuracy including cohort studies of chronically constipated patients and case-control studies of patients with dyssynergic defecation or healthy controls. Meta-analysis was performed to determine summary sensitivity, specificity, and area under the curve (AUC) with 95% confidence intervals (CI). KEY RESULTS A total of 15 studies comprising 2140 patients were included. Including all studies (estimating optimal diagnostic accuracy), the AUC was 0.78 [95% CI 0.72-0.82], summary sensitivity was 79% [61%-90%], and summary specificity was 64% [44%-79%] to diagnose dyssynergic defecation. In cohort studies only (estimating real-world diagnostic accuracy), the AUC was 0.72 [0.66-0.77], summary sensitivity was 86% [64%-95%], and summary specificity was 49% [30%-68%]. Employing three consecutive simulated defecation attempts improved sensitivity to 94%. A fourth simulated defecation maneuver with air insufflation may improve accuracy. Measuring anorectal pressures to identify complex dyssynergic patterns did not improve real-world diagnostic accuracy estimates over anal pressure measurement alone. Choice of manometry system did not impact diagnostic accuracy. CONCLUSIONS & INFERENCES Following the current iteration of the London consensus protocol (three simulated defecation attempts measuring anal relaxation), the role of anorectal manometry in evaluating dyssynergic defecation appears limited. Future iterations of this protocol may improve diagnostic accuracy.
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Affiliation(s)
- Alexandra R. Ortengren
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - Resham A. Ramkissoon
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
| | - William D. Chey
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
| | - Jason R. Baker
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, MI, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachussetts General Hospital, Boston, MA, USA
| | - Johanna Iturrino
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric D. Shah
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Health, Lebanon, NH, USA
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Abstract
INTRODUCTION Increased nonacid reflux is diagnosed in a subgroup of patients with gastroesophageal reflux disease who often present with reflux symptoms refractory to proton-pump inhibitor therapy. Despite the prevalence of this condition, the management approach for patients with increased nonacid reflux can often be varied and unclear. AIMS Our primary aim was to investigate physician management patterns for patients who had received a diagnosis of increased nonacid reflux on impedance-pH studies. METHODS Reflux studies in patients with increased nonacid reflux per Lyon Consensus criteria and management approaches were retrospectively reviewed. Reflux symptom survey, manometry findings, reflux symptom association (RSA) on reflux testing, immediate posttesting management information, and managing provider information were assessed. RESULTS A total of 43 subjects in total were analyzed. Management plan after a diagnosis of increased nonacid reflux was decided by a gastroenterologist in over 95% of cases and varied greatly with no changes being the most common. Even among subjects with + RSA on reflux monitoring, no change in management was the most common action, although this occurred much less frequently compared to subjects with - RSA (28.6% vs. 78.6%, p < 0.01). When change in therapy occurred, medical treatment with baclofen was the most common choice (21.4%). Other management changes included medications for visceral hypersensitivity and antireflux surgery, although these changes occurred rarely. CONCLUSIONS Abnormally increased nonacid reflux is frequently encountered on impedance-pH studies; however, management decisions vary significantly among gastroenterologists. When treatment change is implemented, they are variable and can include lifestyle modifications, medication trials, or antireflux surgery. Future development of standardized management algorithms for increased nonacid reflux is needed.
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Affiliation(s)
- Chanakyaram A Reddy
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA.
| | - Lydia Watts
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA
| | - Jason R Baker
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA
| | - Joan W Chen
- Division of Gastroenterology, University of Michigan Hospitals-Michigan Medicine, 3912 Taubman Center, 1500 E Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA
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16
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Khashab MA, Baker JR, Roesch T. What is Missing Before Gastric Peroral Endoscopic Myotomy Can Go Mainstream for Treatment of Gastroparesis? Clin Gastroenterol Hepatol 2021; 19:662-664. [PMID: 32739570 DOI: 10.1016/j.cgh.2020.07.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jason R Baker
- Atrium Health, University of North Carolina, Charlotte, North Carolina
| | - Thomas Roesch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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17
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Augustijns P, Vertzoni M, Reppas C, Langguth P, Lennernäs H, Abrahamsson B, Hasler WL, Baker JR, Vanuytsel T, Tack J, Corsetti M, Bermejo M, Paixão P, Amidon GL, Hens B. Unraveling the behavior of oral drug products inside the human gastrointestinal tract using the aspiration technique: History, methodology and applications. Eur J Pharm Sci 2020; 155:105517. [DOI: 10.1016/j.ejps.2020.105517] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 02/08/2023]
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18
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Watts LS, Baker JR, Lee AA, Harer K, Bowers N, Law R, Hasler WL. Impact of gastric per-oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients. Neurogastroenterol Motil 2020; 32:e13892. [PMID: 32542920 DOI: 10.1111/nmo.13892] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 01/16/2020] [Revised: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Functional Lumen Imaging Probe (EndoFLIP) tests typically measure static pyloric parameters, but the pylorus exhibits phasic variations on manometry. Dynamic changes in pyloric function have not been quantified using EndoFLIP, and the impact of Gastric Per-Oral Endoscopic Myotomy (G-POEM) on static and dynamic pyloric activity in gastroparesis is unknown. METHODS EndoFLIP balloon inflation to 30, 40, and 50 mL was performed to measure mean, maximum, and minimum values and variability in pyloric diameter and distensibility before and after G-POEM in 20 patients with refractory gastroparesis. The impact of phasic contractions on these pyloric measures was compared. KEY RESULTS G-POEM increased mean (P < .0001) and maximum (P = .0002) pyloric diameters and mean (P = .02) and maximum (P = .02) pyloric distensibility on 50 mL EndoFLIP inflation but not intraballoon pressures or minimum diameters or distensibility. Temporal variability of pyloric diameter (P = .02) and distensibility (P = .02) also increased after G-POEM. Phasic coupled contractions propagating from the antrum through the pylorus were observed in 37.5% of recordings; other phasic activity including isolated pyloric contractions were seen in 23.3%. Variability of pyloric diameter and distensibility tended to be higher during recordings with phasic activity. Some pyloric responses to G-POEM were influenced by age, gastroparesis etiology, gastric emptying, and prior botulinum toxin injection. CONCLUSIONS & INFERENCES Pyloric activity exhibits dynamic changes on EndoFLIP testing in gastroparesis. G-POEM increases maximal but not minimal diameter and distensibility with increased variations, suggesting this therapy enhances pyloric opening but may not impair pyloric closure. Phasic pyloric contractions contribute to variations in pyloric activity.
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Affiliation(s)
- Lydia S Watts
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Allen A Lee
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kimberly Harer
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicole Bowers
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - William L Hasler
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
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Attari A, Chey WD, Baker JR, Ashton-Miller JA. Comparison of anorectal function measured using wearable digital manometry and a high resolution manometry system. PLoS One 2020; 15:e0228761. [PMID: 32991595 PMCID: PMC7523952 DOI: 10.1371/journal.pone.0228761] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022] Open
Abstract
There is a need for a lower cost manometry system for assessing anorectal function in primary and secondary care settings. We developed an index finger-based system (termed "digital manometry") and tested it in healthy volunteers, patients with chronic constipation, and fecal incontinence. Anorectal pressures were measured in 16 participants with the digital manometry system and a 23-channel high-resolution anorectal manometry system. The results were compared using a Bland-Altman analysis at rest as well as during maximum squeeze and simulated defecation maneuvers. Myoelectric activity of the puborectalis muscle was also quantified simultaneously using the digital manometry system. The limits of agreement between the two methods were -7.1 ± 25.7 mmHg for anal sphincter resting pressure, 0.4 ± 23.0 mmHg for the anal sphincter pressure change during simulated defecation, -37.6 ± 50.9 mmHg for rectal pressure changes during simulated defecation, and -20.6 ± 172.6 mmHg for anal sphincter pressure during the maximum squeeze maneuver. The change in the puborectalis myoelectric activity was proportional to the anal sphincter pressure increment during a maximum squeeze maneuver (slope = 0.6, R2 = 0.4). Digital manometry provided a similar evaluation of anorectal pressures and puborectalis myoelectric activity at an order of magnitude less cost than high-resolution manometry, and with a similar level of patient comfort. Digital Manometry provides a simple, inexpensive, point of service means of assessing anorectal function in patients with chronic constipation and fecal incontinence.
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Affiliation(s)
- Ali Attari
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, United States of America
| | - William D. Chey
- Division of Gastroenterology and Hepatology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, United States of America
| | - Jason R. Baker
- Division of Gastroenterology and Hepatology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, United States of America
| | - James A. Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
- Institute of Gerontology, University of Michigan, Ann Arbor, MI, United States of America
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Baker JR, Moshiree B, Pandolfino J, Gyawali CP. Response to the Letter: How do we reopen our motility laboratory safely and efficiently? Neurogastroenterol Motil 2020; 32:e13969. [PMID: 32856762 PMCID: PMC7460958 DOI: 10.1111/nmo.13969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/23/2020] [Indexed: 12/27/2022]
Affiliation(s)
| | - Baha Moshiree
- Atrium HealthUniversity of North CarolinaCharlotteNCUSA
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21
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Metcalf PA, Baker JR, Scragg RK, Dryson E, Scott AJ, Wild CJ. Albuminuria in people at least 40 years old: effect of alcohol consumption, regular exercise, and cigarette smoking. Clin Chem 2019. [DOI: 10.1093/clinchem/39.9.1793] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
We investigated the relation between albuminuria and life-style factors in 5670 people, ages 40 years and over, who participated in a health screening survey of a local workforce. The degree of albuminuria showed piecewise log-linear relationships with alcohol consumption and cigarette smoking, with changes in slope (and 95% confidence interval) corresponding with 5 (2, 8) g of alcohol/day and 10 (6, 14) cigarettes/day. After adjusting for age, gender, ethnicity, and other life-style variables, relative risks (95% confidence interval) of slight albuminuria for people consuming > 32 g of alcohol/day compared with nondrinkers, and for cigarette smokers compared with nonsmokers, were 1.74 (1.02, 2.98) and 1.37 (1.01, 1.88), respectively. However, there was no significant effect of exercise. We conclude that slight albuminuria is significantly associated with cigarette smoking and heavy alcohol consumption, consistent with its role as an index of risk of cardiovascular disease.
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Affiliation(s)
- P A Metcalf
- Department of Community Health, University of Auckland, New Zealand
| | - J R Baker
- Department of Community Health, University of Auckland, New Zealand
| | - R K Scragg
- Department of Community Health, University of Auckland, New Zealand
| | - E Dryson
- Department of Community Health, University of Auckland, New Zealand
| | - A J Scott
- Department of Community Health, University of Auckland, New Zealand
| | - C J Wild
- Department of Community Health, University of Auckland, New Zealand
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Yu A, Koenigsknecht MJ, Hens B, Baker JR, Wen B, Jackson TL, Pai MP, Hasler W, Amidon GL, Sun D. Mechanistic Deconvolution of Oral Absorption Model with Dynamic Gastrointestinal Fluid to Predict Regional Rate and Extent of GI Drug Dissolution. AAPS J 2019; 22:3. [PMID: 31712917 DOI: 10.1208/s12248-019-0385-z] [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] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/23/2019] [Indexed: 12/20/2022]
Abstract
Multiple approaches such as mathematical deconvolution and mechanistic oral absorption models have been used to predict in vivo drug dissolution in the gastrointestinal (GI) tract. However, these approaches are often validated by plasma pharmacokinetic profiles, but not by in vivo drug dissolution due to the limited data available regarding the local GI environment. It is also challenging to predict and validate in vivo dissolution in different regions of the GI tract (stomach, duodenum, jejunum, and ileum). In this study, the dynamic fluid compartment absorption and transport (DFCAT) model was used to predict the in vivo dissolution profiles of ibuprofen, which was administered as an 800-mg immediate-release tablet to healthy subjects, in different regions of the GI tract. The prediction was validated with concentration time-courses of ibuprofen (BCS class 2a) in different regions of the GI tract that we have obtained over the past few years. The computational model predicted that the dissolution of ibuprofen was minimal in the stomach (2%), slightly more in the duodenum (6.3%), and primarily dissolved in the jejunum (63%) and the ileum (25%). The detailed model prediction of drug dissolution in different regions of GI can provide a quantitative reference of in vivo dissolution that may provide valuable insight in developing in vitro tests for drug product optimization and quality.
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Affiliation(s)
- Alex Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Mark J Koenigsknecht
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Bart Hens
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jason R Baker
- Department of Internal Medicine, College of Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Trachette L Jackson
- Department of Mathematics, College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - William Hasler
- Department of Internal Medicine, College of Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Gordon L Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, 48109, USA. .,North Campus Research Complex (NCRC), Room 3353, Building 520,1600 Huron Parkway, Ann Arbor, MI, 48109, USA.
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Yu JX, Baker JR, Watts L, Varban OA, Chen JW, Rubenstein JH, Schulman AR. Functional Lumen Imaging Probe Is Useful for the Quantification of Gastric Sleeve Stenosis and Prediction of Response to Endoscopic Dilation: a Pilot Study. Obes Surg 2019; 30:786-789. [DOI: 10.1007/s11695-019-04105-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Seekatz AM, Schnizlein MK, Koenigsknecht MJ, Baker JR, Hasler WL, Bleske BE, Young VB, Sun D. Spatial and Temporal Analysis of the Stomach and Small-Intestinal Microbiota in Fasted Healthy Humans. mSphere 2019; 4:e00126-19. [PMID: 30867328 PMCID: PMC6416366 DOI: 10.1128/msphere.00126-19] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [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] [Received: 02/22/2019] [Accepted: 02/23/2019] [Indexed: 02/07/2023] Open
Abstract
Although the microbiota in the proximal gastrointestinal (GI) tract have been implicated in health and disease, much about these microbes remains understudied compared to those in the distal GI tract. This study characterized the microbiota across multiple proximal GI sites over time in healthy individuals. As part of a study of the pharmacokinetics of oral mesalamine administration, healthy, fasted volunteers (n = 8; 10 observation periods total) were orally intubated with a four-lumen catheter with multiple aspiration ports. Samples were taken from stomach, duodenal, and multiple jejunal sites, sampling hourly (≤7 h) to measure mesalamine (administered at t = 0), pH, and 16S rRNA gene-based composition. We observed a predominance of Firmicutes across proximal GI sites, with significant variation compared to stool. The microbiota was more similar within individuals over time than between subjects, with the fecal microbiota being unique from that of the small intestine. The stomach and duodenal microbiota displayed highest intraindividual variability compared to jejunal sites, which were more stable across time. We observed significant correlations in the duodenal microbial composition with changes in pH; linear mixed models identified positive correlations with multiple Streptococcus operational taxonomic units (OTUs) and negative correlations with multiple Prevotella and Pasteurellaceae OTUs. Few OTUs correlated with mesalamine concentration. The stomach and duodenal microbiota exhibited greater compositional dynamics than the jejunum. Short-term fluctuations in the duodenal microbiota were correlated with pH. Given the unique characteristics and dynamics of the proximal GI tract microbiota, it is important to consider these local environments in health and disease states.IMPORTANCE The gut microbiota are linked to a variety of gastrointestinal diseases, including inflammatory bowel disease. Despite this importance, microbiota dynamics in the upper gastrointestinal tract are understudied. Our article seeks to understand what factors impact microbiota dynamics in the healthy human upper gut. We found that the upper gastrointestinal tract contains consistently prevalent bacterial OTUs that dominate the overall community. Microbiota variability is highest in the stomach and duodenum and correlates with pH.
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Affiliation(s)
- Anna M Seekatz
- Department of Internal Medicine, Division of Infectious Disease, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew K Schnizlein
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark J Koenigsknecht
- Department of Internal Medicine, Division of Infectious Disease, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason R Baker
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - William L Hasler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Barry E Bleske
- Department of Pharmacy Practice and Administrative Sciences, University of New Mexico, Albuquerque, New Mexico, USA
| | - Vincent B Young
- Department of Internal Medicine, Division of Infectious Disease, University of Michigan, Ann Arbor, Michigan, USA
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, Michigan, USA
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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Baker JR, Dickens JR, Koenigsknecht M, Frances A, Lee AA, Shedden KA, Brasseur JG, Amidon GL, Sun D, Hasler WL. Propagation Characteristics of Fasting Duodeno-Jejunal Contractions in Healthy Controls Measured by Clustered Closely-spaced Manometric Sensors. J Neurogastroenterol Motil 2019; 25:100-112. [PMID: 30646481 PMCID: PMC6326202 DOI: 10.5056/jnm18112] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/22/2018] [Accepted: 11/05/2018] [Indexed: 12/20/2022] Open
Abstract
Background/Aims High-resolution methods have advanced esophageal and anorectal manometry interpretation but are incompletely established for intestinal manometry. We characterized normal fasting duodeno-jejunal manometry parameters not measurable by standard techniques using clustered closely-spaced recordings. Methods Ten fasting recordings were performed in 8 healthy controls using catheters with 3–4 gastrointestinal manometry clusters with 1–2 cm channel spacing. Migrating motor complex phase III characteristics were quantified. Spatial-temporal contour plots measured propagation direction and velocity of individual contractions. Coupling was defined by pressure peak continuity within clusters. Results Twenty-three phase III complexes (11 antral, 12 intestinal origin) with 157 (95% CI, 104–211) minute periodicities, 6.99 (6.25–7.74) minute durations, 10.92 (10.68–11.16) cycle/minute frequencies, 73.6 (67.7–79.5) mmHg maximal amplitudes, and 4.20 (3.18–5.22) cm/minute propagation velocities were recorded. Coupling of individual contractions was 39.1% (32.1–46.1); 63.0% (54.4–71.6) of contractions were antegrade and 32.8% (24.1–41.5) were retrograde. Individual phase III contractions propagated > 35 fold faster (2.48 cm/sec; 95% CI, 2.25–2.71) than complexes themselves. Phase III complexes beyond the proximal jejunum were longer in duration (P = 0.025) and had poorer contractile coupling (P = 0.025) than proximal complexes. Coupling was greater with 1 cm channel spacing vs 2 cm (P < 0.001). Conclusions Intestinal manometry using clustered closely-spaced pressure ports characterizes novel antegrade and retrograde propagation and coupling properties which degrade in more distal jejunal segments. Coupling is greater with more closely-spaced recordings. Applying similar methods to dysmotility syndromes will define the relevance of these methods.
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Affiliation(s)
- Jason R Baker
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | | | | | - Ann Frances
- School of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Allen A Lee
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kerby A Shedden
- School of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - James G Brasseur
- Department of Aerospace Engineering Sciences, University of Colorado Boulder, Boulder, CO, USA
| | - Gordon L Amidon
- School of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Duxin Sun
- School of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - William L Hasler
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
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26
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Bermejo M, Paixão P, Hens B, Tsume Y, Koenigsknecht MJ, Baker JR, Hasler WL, Lionberger R, Fan J, Dickens J, Shedden K, Wen B, Wysocki J, Löbenberg R, Lee A, Frances A, Amidon GE, Yu A, Salehi N, Talattof A, Benninghoff G, Sun D, Kuminek G, Cavanagh KL, Rodríguez-Hornedo N, Amidon GL. Linking the Gastrointestinal Behavior of Ibuprofen with the Systemic Exposure between and within Humans-Part 1: Fasted State Conditions. Mol Pharm 2018; 15:5454-5467. [PMID: 30372084 DOI: 10.1021/acs.molpharmaceut.8b00515] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The goal of this project was to explore and to statistically evaluate the responsible gastrointestinal (GI) factors that are significant factors in explaining the systemic exposure of ibuprofen, between and within human subjects. In a previous study, we determined the solution and total concentrations of ibuprofen as a function of time in aspirated GI fluids, after oral administration of an 800 mg IR tablet (reference standard) of ibuprofen to 20 healthy volunteers in fasted state conditions. In addition, we determined luminal pH and motility pressure recordings that were simultaneously monitored along the GI tract. Blood samples were taken to determine ibuprofen plasma levels. In this work, an in-depth statistical and pharmacokinetic analysis was performed to explain which underlying GI variables are determining the systemic concentrations of ibuprofen between (inter-) and within (intra-) subjects. In addition, the obtained plasma profiles were deconvoluted to link the fraction absorbed with the fraction dissolved. Multiple linear regressions were performed to explain and quantitatively express the impact of underlying GI physiology on systemic exposure of the drug (in terms of plasma Cmax/AUC and plasma Tmax). The exploratory analysis of the correlation between plasma Cmax/AUC and the time to the first phase III contractions postdose (TMMC-III) explains ∼40% of the variability in plasma Cmax for all fasted state subjects. We have experimentally shown that the in vivo intestinal dissolution of ibuprofen is dependent upon physiological variables like, in this case, pH and postdose phase III contractions. For the first time, this work presents a thorough statistical analysis explaining how the GI behavior of an ionized drug can explain the systemic exposure of the drug based on the individual profiles of participating subjects. This creates a scientifically based and rational framework that emphasizes the importance of including pH and motility in a predictive in vivo dissolution methodology to forecast the in vivo performance of a drug product. Moreover, as no extensive first-pass metabolism is considered for ibuprofen, this study demonstrates how intraluminal drug behavior is reflecting the systemic exposure of a drug.
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Affiliation(s)
- Marival Bermejo
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States.,Department of Engineering, Pharmacy Section , Miguel Hernandez University , San Juan de Alicante, 03550 Alicante , Spain
| | - Paulo Paixão
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy , Universidade de Lisboa , Avenida Professor Gama Pinto , 1649-003 Lisboa , Portugal
| | - Bart Hens
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States.,Department of Pharmaceutical and Pharmacological Sciences , KU Leuven , Herestraat 49 , 3000 Leuven , Belgium
| | - Yasuhiro Tsume
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Mark J Koenigsknecht
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | | | | | - Robert Lionberger
- Office of Generic Drugs, Center for Drug Evaluation and Research , U.S. Food and Drug Administration , Silver Spring , Maryland 20993 , United States
| | - Jianghong Fan
- Office of Generic Drugs, Center for Drug Evaluation and Research , U.S. Food and Drug Administration , Silver Spring , Maryland 20993 , United States
| | | | | | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Jeffrey Wysocki
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Raimar Löbenberg
- Faculty of Pharmacy & Pharmaceutical Sciences , University of Alberta , Edmonton , Alberta , Canada T6G 2H7
| | - Allen Lee
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Ann Frances
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Gregory E Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Alex Yu
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Niloufar Salehi
- Center for the Study of Complex Systems and Department of Chemical Engineering , University of Michigan , Ann Arbor , Michigan 48109-2136 , United States
| | - Arjang Talattof
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Gail Benninghoff
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Gislaine Kuminek
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Katie L Cavanagh
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Naír Rodríguez-Hornedo
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
| | - Gordon L Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy , University of Michigan , 428 Church Street , Ann Arbor , Michigan 48109-1065 , United States
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27
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Paixão P, Bermejo M, Hens B, Tsume Y, Dickens J, Shedden K, Salehi N, Koenigsknecht MJ, Baker JR, Hasler WL, Lionberger R, Fan J, Wysocki J, Wen B, Lee A, Frances A, Amidon GE, Yu A, Benninghoff G, Löbenberg R, Talattof A, Sun D, Amidon GL. Linking the Gastrointestinal Behavior of Ibuprofen with the Systemic Exposure between and within Humans—Part 2: Fed State. Mol Pharm 2018; 15:5468-5478. [DOI: 10.1021/acs.molpharmaceut.8b00736] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paulo Paixão
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003 Lisboa, Portugal
| | - Marival Bermejo
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
- Department of Engineering, Pharmacy Section, Miguel Hernandez University, San Juan de Alicante, 03550 Alicante, Spain
| | - Bart Hens
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Yasuhiro Tsume
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | | | | | - Niloufar Salehi
- Center for the Study of Complex Systems and Department of Chemical Engineering, University of Michigan, Ann Arbor, Michigan 48109-2136, United States
| | - Mark J. Koenigsknecht
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Jason R. Baker
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - William L. Hasler
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Robert Lionberger
- Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Jianghong Fan
- Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Jeffrey Wysocki
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Allen Lee
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Ann Frances
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Gregory E. Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Alex Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Gail Benninghoff
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Raimar Löbenberg
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada T6G 2H7
| | - Arjang Talattof
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
| | - Gordon L. Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan 48109–1065, United States
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Paixão P, Bermejo M, Hens B, Tsume Y, Dickens J, Shedden K, Salehi N, Koenigsknecht MJ, Baker JR, Hasler WL, Lionberger R, Fan J, Wysocki J, Wen B, Lee A, Frances A, Amidon GE, Yu A, Benninghoff G, Löbenberg R, Talattof A, Sun D, Amidon GL. Gastric emptying and intestinal appearance of nonabsorbable drugs phenol red and paromomycin in human subjects: A multi-compartment stomach approach. Eur J Pharm Biopharm 2018; 129:162-174. [DOI: 10.1016/j.ejpb.2018.05.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/21/2018] [Accepted: 05/28/2018] [Indexed: 10/16/2022]
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Jain A, Baker JR, Chen JW. In ineffective esophageal motility, failed swallows are more functionally relevant than weak swallows. Neurogastroenterol Motil 2018; 30:e13297. [PMID: 29368366 DOI: 10.1111/nmo.13297] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 08/22/2017] [Accepted: 12/29/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Esophageal pressure topography (EPT) diagnosis of ineffective esophageal motility (IEM) can be non-specific with unclear clinical significance. AIMS To determine whether peristaltic vigor or lower esophageal sphincter (LES) integrity is associated with poor clearance and acid reflux in IEM. METHODS Bolus clearance on high-resolution impedance manometry (HRIM) and available reflux studies in patients with IEM were retrospectively reviewed. Bolus clearance was assessed using both line tracing and colored contour methods on HRIM. EPT parameters, bolus clearance, and acid reflux variables were explored. KEY RESULTS Eighty-eight patients with IEM were included. Bolus clearance occurred in 71% of all swallows, and 55.7% of patients had complete bolus transit (CBT, bolus clearance in ≥80% of swallows). Bolus clearance was impaired in swallows with distal contractile integral (DCI) <100 mmHg•cm•s compared to DCI 100-450 (0.43 vs 0.79, P < .0001). A cutoff at DCI 100 mmHg•cm•s was associated with clearance with an accuracy of 76% compared to 49% at DCI 450 (P = .0001 for both). A median DCI <100 was associated with a higher Eckardt score (9 vs 3, P = .03), and on reflux testing available in 47 patients, with abnormal acid exposure time (P = .002). Peristaltic reserve (PR) defined as (DCI of multiple rapid swallow/median DCI of wet swallows), integrated relaxation pressure, and resting lower esophageal sphincter pressure were not associated with clearance or acid exposure. CONCLUSIONS & INFERENCES Failed peristalsis, as defined by DCI <100 mmHg•cm•s, is associated with impaired bolus clearance and more severe dysphagia in IEM, and likely abnormal acid exposure.
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Affiliation(s)
- A Jain
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | - J R Baker
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
| | - J W Chen
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, MI, USA
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30
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Koenigsknecht MJ, Baker JR, Wen B, Frances A, Zhang H, Yu A, Zhao T, Tsume Y, Pai MP, Bleske BE, Zhang X, Lionberger R, Lee A, Amidon GL, Hasler WL, Sun D. In Vivo Dissolution and Systemic Absorption of Immediate Release Ibuprofen in Human Gastrointestinal Tract under Fed and Fasted Conditions. Mol Pharm 2017; 14:4295-4304. [PMID: 28937221 DOI: 10.1021/acs.molpharmaceut.7b00425] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In vivo drug dissolution in the gastrointestinal (GI) tract is largely unmeasured. The purpose of this clinical study was to evaluate the in vivo drug dissolution and systemic absorption of the BCS class IIa drug ibuprofen under fed and fasted conditions by direct sampling of stomach and small intestinal luminal content. Expanding current knowledge of drug dissolution in vivo will help to establish physiologically relevant in vitro models predictive of drug dissolution. A multilumen GI catheter was orally inserted into the GI tract of healthy human subjects. Subjects received a single oral dose of ibuprofen (800 mg tablet) with 250 mL of water under fasting and fed conditions. The GI catheter facilitated collection of GI fluid from the stomach, duodenum, and jejunum. Ibuprofen concentration in GI fluid supernatant and plasma was determined by LC-MS/MS. A total of 23 subjects completed the study, with 11 subjects returning for an additional study visit (a total of 34 completed study visits). The subjects were primarily white (61%) and male (65%) with an average age of 30 years. The subjects had a median [min, max] weight of 79 [52, 123] kg and body mass index of 25.7 [19.4, 37.7] kg/m2. Ibuprofen plasma levels were higher under fasted conditions and remained detectable for 28 h under both conditions. The AUC0-24 and Cmax were lower in fed subjects vs fasted subjects, and Tmax was delayed in fed subjects vs fasted subjects. Ibuprofen was detected immediately after ingestion in the stomach under fasting and fed conditions until 7 h after dosing. Higher levels of ibuprofen were detected in the small intestine soon after dosing in fasted subjects compared to fed. In contrast to plasma drug concentration, overall gastric concentrations remained higher under fed conditions due to increased gastric pH vs fasting condition. The gastric pH increased to near neutrality after feedingbefore decreasing to acidic levels after 7 h. Induction of the fed state reduced systemic levels but increased gastric levels of ibuprofen, which suggest that slow gastric emptying and transit dominate the effect for plasma drug concentration. The finding of high levels of ibuprofen in stomach and small intestine 7 h post dosing was unexpected. Future work is needed to better understand the role of various GI parameters, such as motility and gastric emptying, on systemic ibuprofen levels in order to improve in vitro predictive models.
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Affiliation(s)
- Mark J Koenigsknecht
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Jason R Baker
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Ann Frances
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Huixia Zhang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Alex Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Ting Zhao
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Yasuhiro Tsume
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Barry E Bleske
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico , Albuquerque, New Mexico 87120, United States
| | - Xinyuan Zhang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, Maryland 20993, United States
| | - Robert Lionberger
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, Maryland 20993, United States
| | - Allen Lee
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Gordon L Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - William L Hasler
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
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Yu A, Jackson T, Tsume Y, Koenigsknecht M, Wysocki J, Marciani L, Amidon GL, Frances A, Baker JR, Hasler W, Wen B, Pai A, Sun D. Mechanistic Fluid Transport Model to Estimate Gastrointestinal Fluid Volume and Its Dynamic Change Over Time. AAPS J 2017; 19:1682-1690. [DOI: 10.1208/s12248-017-0145-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/01/2017] [Indexed: 12/22/2022]
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Guivatchian T, Koeppe ES, Baker JR, Moisa C, Demerath M, Foor-Pessin C, Chey WD, Eswaran SL, Kolars JC, Menees SB, Rajala M, Rice MD, Rizk R, Rubenstein JH, Sharma P, Todisco A, Stoffel EM. Family history in colonoscopy patients: feasibility and performance of electronic and paper-based surveys for colorectal cancer risk assessment in the outpatient setting. Gastrointest Endosc 2017; 86:684-691. [PMID: 28174125 DOI: 10.1016/j.gie.2017.01.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 01/20/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Family history is crucial in stratifying patients' risk for colorectal cancer (CRC). Previous risk assessment tools developed for use in clinic or endoscopy settings have demonstrated suboptimal specificity for identifying patients with hereditary cancer syndromes. Our aim was to test the feasibility and performance of 2 family history surveys (paper and electronic) in individuals presenting for outpatient colonoscopy. METHODS Patients presenting for outpatient colonoscopy at a tertiary care center were asked to complete a 5-question paper risk assessment survey (short paper survey) either alone or in conjunction with a second, comprehensive electronic family risk assessment survey (comprehensive tablet survey). Each subject's survey results, along with the electronic medical record, were reviewed, and 10 high-risk criteria and PREMM1,2,6 model scores (a predictive model for carrying a Lynch syndrome-associated gene mutation) were used to identify patients warranting genetic evaluation for suspected hereditary cancer syndromes. RESULTS Six hundred patients completed the short paper survey (cohort 1), with an additional 100 patients completing both the short paper and comprehensive tablet survey (cohort 2). Using 10 high-risk criteria and/or a PREMM1,2,6 score ≥5%, we identified 10% and 9% of patients as high risk for CRC in cohorts 1 and 2, respectively. Of the 69 high-risk subjects, 23 (33%) underwent genetic evaluations and 7 (10%) carried germline mutations associated with cancer predisposition. Both patients and endoscopists reported the tools were user-friendly and helpful for CRC risk stratification. CONCLUSIONS Systematic assessment of family history in colonoscopy patients is feasible and can help endoscopists identify high-risk patients who would benefit from genetic evaluation.
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Affiliation(s)
- Tannaz Guivatchian
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Erika S Koeppe
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Jason R Baker
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Cristina Moisa
- Comprehensive Cancer Center, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Matthew Demerath
- Comprehensive Cancer Center, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Caitlin Foor-Pessin
- Division of Gastroenterology, Department of Internal Medicine, University of Rochester, Rochester, New York, USA
| | - William D Chey
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Shanti L Eswaran
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Joseph C Kolars
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Stacy B Menees
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Michael Rajala
- Division of Gastroenterology, Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael D Rice
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Rafat Rizk
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Joel H Rubenstein
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Pratima Sharma
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Andrea Todisco
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Elena M Stoffel
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
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Jain A, Baker JR, Rubenstein JH, Chen JW. Bolus clearance in esophagogastric junction outflow obstruction is associated with strength of peristalsis. Neurogastroenterol Motil 2017; 29. [PMID: 28466506 DOI: 10.1111/nmo.13093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 03/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND A manometric diagnosis of esophagogastric junction outflow obstruction (EGJOO) without a mechanical cause creates a therapeutic conundrum. The aim of this study was to assess esophageal bolus clearance in EGJOO and assess manometric factors associated with clearance in EGJOO. METHODS Bolus clearance was assessed using line-tracing method and contour method to determine Complete Bolus Transit (CBT) and Functional Clearance (FC), respectively, on combined High-Resolution Impedance Manometry (HRIM). HRIM studies of EGJOO patients, as well as a sample of achalasia types I-III and asymptomatic controls, were retrospectively analyzed. In EGJOO, associations between Integrated Relaxation Pressure (IRP) or Distal Contractile Integral (DCI) and clearance were assessed using receiver-operating-characteristic (ROC) curves. KEY RESULTS Seventy-five EGJOO, 28 achalasia, and 11 normal subjects were included. Agreement between CBT and FC was good (Kappa=0.75). CBT across swallows in each group was as follows: type I achalasia: 14%, type II achalasia: 8%, type III achalasia: 61%, EGJOO: 86%, and normal: 98% (p values .023, .006, and <.0001 for EGJOO vs normals, type III achalasia, and all achalasia, respectively). In idiopathic EGJOO, CBT ≥60% of swallows was seen in 96.4% of patients when mean DCI>610 mmHg-s-cm (accuracy 87.7%, P=.004). Complete Bolus Transit( CBT) across individual swallows was 97.8% when DCI>884 mmHg-s-cm (accuracy 81.9%, P<.0001). IRP was poorly associated with bolus clearance. CONCLUSIONS & INFERENCES Bolus clearance in EGJOO is impaired compared to normal, but not as severely as in achalasia. In idiopathic EGJOO, weak peristalsis is associated with poor bolus clearance. Bolus transit appears to be unimpaired when DCI>900 mmHg-s-cm.
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Affiliation(s)
- A Jain
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - J R Baker
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - J H Rubenstein
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA.,Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - J W Chen
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Hens B, Tsume Y, Bermejo M, Paixao P, Koenigsknecht MJ, Baker JR, Hasler WL, Lionberger R, Fan J, Dickens J, Shedden K, Wen B, Wysocki J, Loebenberg R, Lee A, Frances A, Amidon G, Yu A, Benninghoff G, Salehi N, Talattof A, Sun D, Amidon GL. Low Buffer Capacity and Alternating Motility along the Human Gastrointestinal Tract: Implications for in Vivo Dissolution and Absorption of Ionizable Drugs. Mol Pharm 2017; 14:4281-4294. [PMID: 28737409 DOI: 10.1021/acs.molpharmaceut.7b00426] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [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: 02/07/2023]
Abstract
In this study, we determined the pH and buffer capacity of human gastrointestinal (GI) fluids (aspirated from the stomach, duodenum, proximal jejunum, and mid/distal jejunum) as a function of time, from 37 healthy subjects after oral administration of an 800 mg immediate-release tablet of ibuprofen (reference listed drug; RLD) under typical prescribed bioequivalence (BE) study protocol conditions in both fasted and fed states (simulated by ingestion of a liquid meal). Simultaneously, motility was continuously monitored using water-perfused manometry. The time to appearance of phase III contractions (i.e., housekeeper wave) was monitored following administration of the ibuprofen tablet. Our results clearly demonstrated the dynamic change in pH as a function of time and, most significantly, the extremely low buffer capacity along the GI tract. The buffer capacity on average was 2.26 μmol/mL/ΔpH in fasted state (range: 0.26 and 6.32 μmol/mL/ΔpH) and 2.66 μmol/mL/ΔpH in fed state (range: 0.78 and 5.98 μmol/mL/ΔpH) throughout the entire upper GI tract (stomach, duodenum, and proximal and mid/distal jejunum). The implication of this very low buffer capacity of the human GI tract is profound for the oral delivery of both acidic and basic active pharmaceutical ingredients (APIs). An in vivo predictive dissolution method would require not only a bicarbonate buffer but also, more significantly, a low buffer capacity of dissolution media to reflect in vivo dissolution conditions.
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Affiliation(s)
- Bart Hens
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Yasuhiro Tsume
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Marival Bermejo
- Department of Engineering, Pharmacy Section, Miguel Hernandez University , San Juan de Alicante, 03550 Alicante, Spain
| | - Paulo Paixao
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa , Avenida Professor Gama Pinto, 1649-003 Lisboa, Portugal
| | - Mark J Koenigsknecht
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Jason R Baker
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - William L Hasler
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Robert Lionberger
- Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, Maryland 20993, United States
| | - Jianghong Fan
- Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, Maryland 20993, United States
| | - Joseph Dickens
- Department of Statistics, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Kerby Shedden
- Department of Statistics, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Jeffrey Wysocki
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Raimar Loebenberg
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta , Edmonton, Alberta, Canada T6G 2H7
| | - Allen Lee
- Department of Engineering, Pharmacy Section, Miguel Hernandez University , San Juan de Alicante, 03550 Alicante, Spain
| | - Ann Frances
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Greg Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Alex Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Gail Benninghoff
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Niloufar Salehi
- Center for the Study of Complex Systems and Department of Chemical Engineering, University of Michigan , Ann Arbor, Michigan 48109-2136, United States
| | - Arjang Talattof
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Gordon L Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
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Emery RT, Brown HL, Emery KQ, Baker JR. Pheochromocytoma: A Rare Presentation. J Ark Med Soc 2017; 113:188-190. [PMID: 30375782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Pheochromocytoma is a very rare neuroendocrine tumor usually located in one or both adrenal glands with an incidence of about 4 per 1,000,000 and about 1000 diagnosed per year. Pheochromocytomas can be located in extra-adrenal locations with about 1% being located in the urinary bladder.(1) We describe the presentation, diagnosis and treatment of one of these extremely rare tumors in the bladder.
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Chen JW, Baker JR, Compton JM, McDermott M, Rubenstein JH. Accuracy of the Air Flow Sphincter Locator system in identifying the lower esophageal sphincter for placement of pH catheters. Dis Esophagus 2017; 30:1-5. [PMID: 27862648 DOI: 10.1111/dote.12507] [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] [Indexed: 12/11/2022]
Abstract
The Air Flow Sphincter Locator (AFSL) is marketed as an alternative method to manometry for localizing the lower esophageal sphincter (LES) for pH probe placement. Such a system is desirable due to the additional time, cost, and discomfort associated with dual nasal intubation, but its accuracy has never been assessed. To assess the accuracy of the AFSL in localizing the LES. Fifty consecutive outpatients presenting for pH and manometry studies were included. The upper border of the LES was determined using HRM and the AFSL by two technicians independently. LES locations measured by technicians using AFSL versus manometry, as well as the manometrically determined LES locations by technicians versus MDs were compared. Differences in LES locations determined by HRM as read by MDs versus technicians were small; none were >3 cm, and 92% were within 2 cm. Comparison between LES locations determined by technicians using HRM versus the AFSL revealed that 52% had a difference of 2-3cm and 32% had a difference of >3 cm. Hiatal hernia was associated with a difference in LES location of >3 cm. Excluding patients with hiatal hernia, nonetheless, still produced a >3 cm difference in 24% of studies. Prior reports have suggested that a difference greater than +/-3 cm in pH probe placement is considered unacceptable for clinical studies. Based on our study, the AFSL placed the LES outside of this range in 32% of patients, and may be particularly inaccurate in the setting of a hiatal hernia. This suggests that the device may not be an acceptable alternative to manometry in determining LES location for pH probe placement.
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Affiliation(s)
- Joan W Chen
- Division of Gastroenterology and Hepatology, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - Jessica M Compton
- Division of Gastroenterology and Hepatology, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - Mark McDermott
- Division of Gastroenterology and Hepatology, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - Joel H Rubenstein
- Division of Gastroenterology and Hepatology, University of Michigan Health Systems, Ann Arbor, Michigan, USA
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37
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Dahl JU, Gray MJ, Bazopoulou D, Beaufay F, Lempart J, Koenigsknecht MJ, Wang Y, Baker JR, Hasler WL, Young VB, Sun D, Jakob U. The anti-inflammatory drug mesalamine targets bacterial polyphosphate accumulation. Nat Microbiol 2017; 2:16267. [PMID: 28112760 DOI: 10.1038/nmicrobiol.2016.267] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/12/2016] [Indexed: 01/09/2023]
Abstract
Mesalamine serves as the gold standard in treating ulcerative colitis. However, its precise mechanism(s) of action remains unclear. Here, we show that mesalamine treatment rapidly decreases polyphosphate levels in diverse bacteria, including members of the human gut microbiome. This decrease sensitizes bacteria towards oxidative stress, reduces colonization and attenuates persister cell and biofilm formation, suggesting that mesalamine aids in diminishing the capacity of bacteria to persist within chronically inflamed environments.
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Affiliation(s)
- Jan-Ulrik Dahl
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Michael J Gray
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Daphne Bazopoulou
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Francois Beaufay
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Justine Lempart
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Mark J Koenigsknecht
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Ying Wang
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Jason R Baker
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - William L Hasler
- Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Vincent B Young
- Department of Internal Medicine/Division of Infectious Diseases &Department of Microbiology and Immunology, The University of Michigan Medical School, Ann Arbor, Michigan 48109, USA
| | - Duxin Sun
- Department of Pharmaceutical Sciences, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Ursula Jakob
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109, USA
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Yu A, Baker JR, Fioritto AF, Wang Y, Luo R, Li S, Wen B, Bly M, Tsume Y, Koenigsknecht MJ, Zhang X, Lionberger R, Amidon GL, Hasler WL, Sun D. Measurement of in vivo Gastrointestinal Release and Dissolution of Three Locally Acting Mesalamine Formulations in Regions of the Human Gastrointestinal Tract. Mol Pharm 2016; 14:345-358. [PMID: 28009518 DOI: 10.1021/acs.molpharmaceut.6b00641] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [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: 12/14/2022]
Abstract
As an orally administered, locally acting gastrointestinal drug, mesalamine products are designed to achieve high local drug concentration in the gastrointestinal (GI) tract for the treatment of ulcerative colitis. The aim of this study was to directly measure and compare drug dissolution of three mesalamine formulations in human GI tract and to correlate their GI concentration with drug concentration in plasma. Healthy human subjects were orally administered Pentasa, Apriso, or Lialda. GI fluids were aspirated from stomach, duodenum, proximal jejunum, mid jejunum, and distal jejunum regions. Mesalamine (5-ASA) and its primary metabolite acetyl-5-mesalamine (Ac-5-ASA) were measured using LC-MS/MS. GI tract pH was measured from each GI fluid sample, which averaged 1.82, 4.97, 5.67, 6.17, and 6.62 in the stomach, duodenum, proximal jejunum, middle jejunum, and distal jejunum, respectively. For Pentasa, high levels of 5-ASA in solution were observed in the stomach, duodenum, proximal jejunum, mid jejunum, and distal jejunum from 1 to 7 h. Apriso had minimal 5-ASA levels in stomach, low to medium levels of 5-ASA in duodenum and proximal jejunum from 4 to 7 h, and high levels of 5-ASA in distal jejunum from 3 to 7 h. In contrast, Lialda had minimal 5-ASA levels from stomach and early small intestine. A composite appearance rate (CAR) was calculated from the deconvolution of individual plasma concentration to reflect drug release, dissolution, transit, and absorption in the GI tract. Individuals dosed with Pentasa had high levels of CAR from 1 to 10 h; individuals dosed with Apriso had low levels of CAR from 1 to 4 h and high levels of CAR from 5 to 10 h; Lialda showed minimal levels of CAR from 0 to 5 h, then increased to medium levels from 5 to 12 h, and then decreased to further lower levels after 12 h. In the colon region, Pentasa and Apriso showed similar levels of accumulated 5-ASA excreted in the feces, while Lialda showed slightly higher 5-ASA accumulation in feces. However, all three formulations showed similar levels of metabolite Ac-5-ASA in the feces. These results provide direct measurement of drug dissolution in the GI tract, which can serve as a basis for investigation of bioequivalence for locally acting drug products.
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Affiliation(s)
- Alex Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Jason R Baker
- Department of Internal Medicine, College of Medicine, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Ann F Fioritto
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Ying Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Ruijuan Luo
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Siwei Li
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Bo Wen
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Michael Bly
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Yasuhiro Tsume
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Mark J Koenigsknecht
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Xinyuan Zhang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, Maryland 20993, United States
| | - Robert Lionberger
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration , Silver Spring, Maryland 20993, United States
| | - Gordon L Amidon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - William L Hasler
- Department of Internal Medicine, College of Medicine, University of Michigan , Ann Arbor, Michigan 48109, United States
| | - Duxin Sun
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan , Ann Arbor, Michigan 48109, United States
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Baker JR, Vuppusetty C, Colley T, Papaioannou AI, Fenwick P, Donnelly L, Ito K, Barnes PJ. Oxidative stress dependent microRNA-34a activation via PI3Kα reduces the expression of sirtuin-1 and sirtuin-6 in epithelial cells. Sci Rep 2016; 6:35871. [PMID: 27767101 PMCID: PMC5073335 DOI: 10.1038/srep35871] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/07/2016] [Indexed: 12/18/2022] Open
Abstract
Sirtuin-1 (SIRT1) and SIRT6, NAD+-dependent Class III protein deacetylases, are putative anti-aging enzymes, down-regulated in patients with chronic obstructive pulmonary disease (COPD), which is characterized by the accelerated ageing of the lung and associated with increased oxidative stress. Here, we show that oxidative stress (hydrogen peroxide) selectively elevates microRNA-34a (miR-34a) but not the related miR-34b/c, with concomitant reduction of SIRT1/-6 in bronchial epithelial cells (BEAS2B), which was also observed in peripheral lung samples from patients with COPD. Over-expression of a miR-34a mimic caused a significant reduction in both mRNA and protein of SIRT1/-6, whereas inhibition of miR-34a (antagomir) increased these sirtuins. Induction of miR-34a expression with H2O2 was phosphoinositide-3-kinase (PI3K) dependent as it was associated with PI3Kα activation as well as phosphatase and tensin homolog (PTEN) reduction. Importantly, miR-34a antagomirs increased SIRT1/-6 mRNA levels, whilst decreasing markers of cellular senescence in airway epithelial cells from COPD patients, suggesting that this process is reversible. Other sirtuin isoforms were not affected by miR-34a. Our data indicate that miR-34a is induced by oxidative stress via PI3K signaling, and orchestrates ageing responses under oxidative stress, therefore highlighting miR-34a as a new therapeutic target and biomarker in COPD and other oxidative stress-driven aging diseases.
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Affiliation(s)
- J R Baker
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London SW3 6LY, U.K
| | - C Vuppusetty
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London SW3 6LY, U.K
| | - T Colley
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London SW3 6LY, U.K
| | | | - P Fenwick
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London SW3 6LY, U.K
| | - Louise Donnelly
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London SW3 6LY, U.K
| | - K Ito
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London SW3 6LY, U.K
| | - P J Barnes
- Airway Disease Section, National Heart and Lung Institute, Imperial College, London SW3 6LY, U.K
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40
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Low LF, Carroll S, Merom D, Baker JR, Kochan N, Moran F, Brodaty H. We think you can dance! A pilot randomised controlled trial of dance for nursing home residents with moderate to severe dementia. Complement Ther Med 2016; 29:42-44. [PMID: 27912955 DOI: 10.1016/j.ctim.2016.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 05/11/2016] [Accepted: 09/02/2016] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility of a dance program for people with moderate to severe dementia living in nursing homeswith regards to recruitment and retention, assessment tools, intervention safety, attendance and engagement. DESIGN Pilot randomised controlled trial with assessments at weeks 0, 16 and 32. SETTING A nursing home in Sydney, Australia. INTERVENTIONS Experienced dance teachers conducted dance groups (intervention) or music appreciation and socialisation groups (control) for 45min, three times a week for 16 weeks. MAIN OUTCOME MEASURES Descriptive statistics for recruitment and retention, adverse events and attendance and engagement. RESULTS Recruitment was smooth, attrition was17% over 32 weeks. Engagement during the sessions was high, and no serious falls or behavioural incidents occurred. Average attendance was poorer than anticipated for dance groups (67%) in comparison to music groups (89%). A ceiling effect on the Severe Impairment Battery and the logistical challenges of the Clinical Global Impression of Change meant they may not be optimal tools. CONCLUSIONS It is feasible to conduct a study of group dance for people with moderate to severe dementia in residential care. Choice of attention control condition should be reconsidered.
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Affiliation(s)
- L F Low
- Faculty of Health Sciences, University of Sydney, Australia.
| | - S Carroll
- Arts Health Institute, Newcastle, Australia
| | - D Merom
- School of Science and Health, University of Western Sydney, Australia
| | - J R Baker
- Psychiatry Research and Teaching Unit, University of New South Wales, Australia
| | - N Kochan
- Centre for Health Brain Ageing, University of New South Wales, Australia
| | - F Moran
- School of Science and Health, University of Western Sydney, Australia; The George Institute for Global Health, Australia
| | - H Brodaty
- Centre for Health Brain Ageing, University of New South Wales, Australia; Dementia Collaborative Research Centre, Assessment and Better Care, University of New South Wales, Australia
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Affiliation(s)
- M R Lawson
- Department of Clinical Chemistry, Auckland Hospital, Auckland, New Zealand
| | - R N Johnson
- Department of Clinical Biochemistry, Green Lane Hospital, Green Lane West, Auckland, New Zealand
| | - J R Baker
- Department of Clinical Biochemistry, Green Lane Hospital, Green Lane West, Auckland, New Zealand
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Pye H, Butt MA, Reinert HW, Maruani A, Nunes JPM, Marklew JS, Qurashi M, Funnell L, May A, Stamati I, Hamoudi R, Baker JR, Smith MEB, Caddick S, Deonarain MP, Yahioglu G, Chudasama V, Lovat LB. A HER2 selective theranostic agent for surgical resection guidance and photodynamic therapy. Photochem Photobiol Sci 2016; 15:1227-1238. [PMID: 27501936 DOI: 10.1039/c6pp00139d] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In many cancers early intervention involves surgical resection of small localised tumour masses. Inadequate resection leads to recurrence whereas overzealous treatment can lead to organ damage. This work describes production of a HER2 targeting antibody Fab fragment dual conjugated to achieve both real time near-infrared fluorescent imaging and photodynamic therapy. The use of fluorescence emission from a NIR-dye could be used to guide resection of tumour bulk, for example during endoscopic diagnosis for oesophago-gastric adenocarcinoma, this would then be followed by activation of the photodynamic therapeutic agent to destroy untreated localised areas of cancer infiltration and tumour infiltrated lymph nodes. This theranostic agent was prepared from the Fab fragment of trastuzumab initially by functional disulfide re-bridging and site-specific click reaction of a NIR-dye. This was followed by further reaction with a novel pre-activated form of the photosensitiser chlorin e6 with the exposed fragments' lysine residues. Specific binding of the theranostic agent was observed in vitro with a HER2 positive cell line and cellular near-infrared fluorescence was observed with flow cytometry. Specific photo-activity of the conjugates when exposed to laser light was observed with HER2 positive but not HER2 negative cell lines in vitro, this selectivity was not seen with the unconjugated drug. This theranostic agent demonstrates that two different photo-active functions can be coupled to the same antibody fragment with little interference to their independent activities.
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Affiliation(s)
- H Pye
- Department for Tissue & Energy, Division of Surgery & Interventional Science, University College London, Cruciform Building, Gower Street, London, WC1E 6AE, UK.
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43
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Jepson PD, Deaville R, Patterson IAP, Pocknell AM, Ross HM, Baker JR, Howie FE, Reid RJ, Colloff A, Cunningham AA. Acute and Chronic Gas Bubble Lesions in Cetaceans Stranded in the United Kingdom. Vet Pathol 2016; 42:291-305. [PMID: 15872375 DOI: 10.1354/vp.42-3-291] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The first evidence suggestive of in vivo gas bubble formation in cetacea, including eight animals stranded in the UK, has recently been reported. This article presents the pathologic findings from these eight UK-stranded cetaceans and two additional UK-stranded cetacean cases in detail. Hepatic gas-filled cavitary lesions (0.2-6.0 cm diameter) involving approximately 5–90% of the liver volume were found in four (two juvenile, two adult) Risso's dolphins ( Grampus griseus), three (two adult, one juvenile) common dolphins ( Delphinus delphis), an adult Blainville's beaked whale ( Mesoplodon densirostris), and an adult harbour porpoise ( Phocoena phocoena). Histopathologic examination of the seven dolphin cases with gross liver cavities revealed variable degrees of pericavitary fibrosis, microscopic, intrahepatic, spherical, nonstaining cavities (typically 50–750 μm in diameter) consistent with gas emboli within distended portal vessels and sinusoids and associated with hepatic tissue compression, hemorrhages, fibrin/organizing thrombi, and foci of acute hepatocellular necrosis. Two common dolphins also had multiple and bilateral gross renal cavities (2.0–9.0 mm diameter) that, microscopically, were consistent with acute ( n = 2) and chronic ( n = 1) arterial gas emboli-induced renal infarcts. Microscopic, bubblelike cavities were also found in mesenteric lymph node ( n = 4), adrenal ( n = 2), spleen ( n = 2), pulmonary associated lymph node ( n = 1), posterior cervical lymph node ( n = 1), and thyroid ( n = 1). No bacterial organisms were isolated from five of six cavitated livers and one of one cavitated kidneys. The etiology and pathogenesis of these lesions are not known, although a decompression-related mechanism involving embolism of intestinal gas or de novo gas bubble (emboli) development derived from tissues supersaturated with nitrogen is suspected.
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Affiliation(s)
- P D Jepson
- Institute of Zoology, Zoological Society of London, Regent's Park, London NW1 4RY, UK.
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Baker JR, Hudson JL. Children with social phobia have lower quality friendships than children with other anxiety disorders. Anxiety Stress Coping 2014; 28:500-13. [PMID: 25337769 DOI: 10.1080/10615806.2014.978863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Whilst shy, socially anxious or socially withdrawn children in nonclinical community samples report lower friendship quality (FQ) than nonanxious children, no study has examined the FQ of clinically anxious children. The aim of the study was to examine the FQ of children with anxiety disorders; and whether it differs for clinical children with or without a diagnosis of social phobia (SP). DESIGN The study design was cross-sectional self-report. METHODS Clinical children - 39 anxiety-disordered children with SP and 28 anxiety-disordered children without SP (No-SP) - presented for psychological treatment, and 29 nonclinical children were recruited from the community. Same-sex close friends were invited to participate using an unrestricted nomination procedure. All children were aged between 7 and 13 years. Both target child and friend completed the Friendship Quality Questionnaire and the Spence Children's Anxiety Scale. RESULTS Using multilevel modeling within the framework of the Actor-Partner Interdependence Model, SP dyads were found to report lower overall FQ than No-SP dyads. SP dyads did not report lower overall FQ than nonclinical dyads. CONCLUSION Children with SP in their diagnostic profile may be unique in their friendship experiences relative to children with other anxiety disorders.
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Affiliation(s)
- J R Baker
- a DCRC, School of Psychiatry , University of New South Wales , Level 3, AGSM Building, Sydney , NSW 2052 , Australia
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Baker JR, Hudson JL, Taylor A. An investigation into the lower peer liking of anxious than nonanxious children. J Anxiety Disord 2014; 28:599-611. [PMID: 25016420 DOI: 10.1016/j.janxdis.2014.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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: 07/29/2013] [Revised: 03/06/2014] [Accepted: 06/07/2014] [Indexed: 11/18/2022]
Abstract
Peer dislike of anxious behaviour was investigated in 7-12 year olds. Child actors delivered an identical verbal presentation: once in an anxious manner and once confidently. The videos were rated for liking and seven potential mediators by three groups of children: 32 anxiety-disordered peers with social phobia; 16 anxiety-disordered peers without social phobia; and 48 nonclinical peers. A mediation model with moderation effects was tested within a within-subjects framework. "Anxious" actors were liked significantly less than "confident" actors. This effect differed by group rater, in that relative dislike of the anxious actor was significantly greater for the nonclinical than socially phobic raters. Physical attractiveness and friend acceptance mediated the effect for all group raters. Other identified mediators differed depending upon the group rater. The findings direct future efforts to help anxiety-disordered children circumvent an increased risk of negative peer relations, and testify to consideration of the rater in sociometric studies.
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Affiliation(s)
- J R Baker
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia.
| | - J L Hudson
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia
| | - A Taylor
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia
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Baker JR, Jeffery R, May RD, Mathies M, Spencer-Dene B, Poulsom R, Hogg N. Distinct roles for S100a8 in early embryo development and in the maternal deciduum. Dev Dyn 2012; 240:2194-203. [PMID: 22016186 DOI: 10.1002/dvdy.22709] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
S100a8 is a cytosolic protein expressed in myeloid cells where it forms a stable heterodimer with another S100 protein family member, S100a9. The S100a9(-/-) mouse is viable and phenotypically normal, whereas the S100a8(-/-) condition is embryonic lethal. We present evidence that S100a8, without S100a9, has a previously unrecognized role in embryo development between fertilization and the 8-cell stage at embryonic day (E) 2.5. S100a8 also has a second role in the maternal deciduum, where expression is associated with the vasculature from the E8.5 stage to the formation of mature placenta. Uterine natural killer cells that have a role in vascular remodelling colocalise with the S100a8 vascular expression in the metrial triangle. In inflammatory responses in peripheral tissues, S100a8 is a potent chemoattractant and also an anti-oxidant. Both roles may be important in the developing placenta. Thus we highlight two new S100a9-independent roles for S100a8 in early embryo development.
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Affiliation(s)
- J R Baker
- Leukocyte Adhesion Laboratory, Cancer Research UK London Research Institute, London, England
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47
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Stanberry LR, Simon JK, Johnson C, Robinson PL, Morry J, Flack MR, Gracon S, Myc A, Hamouda T, Baker JR. Safety and immunogenicity of a novel nanoemulsion mucosal adjuvant W805EC combined with approved seasonal influenza antigens. Vaccine 2011; 30:307-16. [PMID: 22079079 DOI: 10.1016/j.vaccine.2011.10.094] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 10/22/2011] [Accepted: 10/30/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Improving the systemic and mucosal immune response following intranasal vaccination could enhance disease protection against respiratory pathogens. We assessed the safety and immunogenicity of a novel nanoemulsion mucosal adjuvant W(80)5EC combined with approved seasonal influenza antigens. METHODS This was a first-in-human Phase I study in 199 healthy adult volunteers randomized to receive a single intranasal administration of 5%, 10%, 15% or 20% W(80)5EC, combined with 4 or 10 μg strain-specific Fluzone(®) HA, compared with intranasal PBS, intranasal Fluzone(®), or 15 ug strain-specific intramuscular Fluzone(®). Safety was evaluated by physical examination, laboratory parameters, symptom diaries, and adverse event reports. Serum HAI titers and nasal wash IgA were assessed at baseline as well as 28 and 60 days after vaccination. RESULTS W(80)5EC adjuvant combined with seasonal influenza antigens was well tolerated without safety concerns or significant adverse events. The highest dose of 20% W(80)5EC combined with 10 μg strain-specific HA elicited clinically meaningful systemic immunity based on increases in serum HAI GMT and ≥ 70% seroprotection for all 3 influenza strains, as well as a rise in antigen-specific IgA in nasal wash specimens. CONCLUSIONS W(80)5EC adjuvant was safe and well tolerated in healthy adult volunteers and elicited both systemic and mucosal immunity following a single intranasal vaccination.
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Affiliation(s)
- L R Stanberry
- Department of Pediatrics, Columbia University, New York, NY, USA
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48
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Kuo B, Maneerattanaporn M, Lee AA, Baker JR, Wiener SM, Chey WD, Wilding GE, Hasler WL. Generalized transit delay on wireless motility capsule testing in patients with clinical suspicion of gastroparesis, small intestinal dysmotility, or slow transit constipation. Dig Dis Sci 2011; 56:2928-38. [PMID: 21625964 DOI: 10.1007/s10620-011-1751-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 05/09/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND The prevalence of generalized transit delay and relation to symptoms in suspected gastroparesis, intestinal dysmotility, or slow transit constipation are unknown. AIMS The aims of this study were (1) to define prevalence of generalized dysmotility using wireless motility capsules (WMC), (2) to relate to symptoms in suspected regional delay, (3) to compare results of WMC testing to conventional transit studies to quantify new diagnoses, and (4) to assess the impact of results of WMC testing on clinical decisions. METHODS WMC transits were analyzed in 83 patients with suspected gastroparesis, intestinal dysmotility, or slow transit constipation. RESULTS Isolated regional delays were observed in 32% (9% stomach, 5% small bowel, 18% colon). Transits were normal in 32% and showed generalized delays in 35%. Symptom profiles were similar with normal transit, isolated delayed gastric, small intestinal, and colonic transit, and generalized delay (P = NS). Compared to conventional tests, WMC showed discordance in 38% and provided new diagnoses in 53%. WMC testing influenced management in 67% (new medications 60%; modified nutritional regimens 14%; surgical referrals 6%) and eliminated needs for testing not already done including gastric scintigraphy (17%), small bowel barium transit (54%), and radioopaque colon marker tests (68%). CONCLUSIONS WMC testing defines localized and generalized transit delays with suspected gastroparesis, intestinal dysmotility, or slow transit constipation. Symptoms do not predict the results of WMC testing. WMC findings provide new diagnoses in >50%, may be discordant with conventional tests, and can influence management by changing treatments and eliminating needs for other tests. These findings suggest potential benefits of this method in suspected dysmotility syndromes and mandate prospective investigation to further define its clinical role.
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Affiliation(s)
- Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
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49
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Byams VR, Kouides PA, Kulkarni R, Baker JR, Brown DL, Gill JC, Grant AM, James AH, Konkle BA, Maahs J, Dumas MM, McAlister S, Nance D, Nugent D, Philipp CS, Soucie JM, Stang E. Surveillance of female patients with inherited bleeding disorders in United States Haemophilia Treatment Centres. Haemophilia 2011; 17 Suppl 1:6-13. [PMID: 21692922 PMCID: PMC4467796 DOI: 10.1111/j.1365-2516.2011.02558.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Inherited bleeding disorders are especially problematic for affected girls and women due to the monthly occurrence of menstrual periods and the effects on reproductive health. Although heavy menstrual bleeding (HMB) is the most common manifestation, females with inherited bleeding disorders (FBD) experience other bleeding symptoms throughout the lifespan that can lead to increased morbidity and impairment of daily activities. The purpose of this article is to describe the utility of a female-focused surveillance effort [female Universal Data Collection (UDC) project] in the United States Haemophilia Treatment Centres (HTCs) and to describe the baseline frequency and spectrum of diagnoses and outcomes. All FBD aged 2 years and older receiving care at selected HTCs were eligible for enrollment. Demographic data, diagnoses and historical data regarding bleeding symptoms, treatments, gynaecological abnormalities and obstetrical outcomes were analysed. Analyses represent data collected from 2009 to 2010. The most frequent diagnoses were type 1 von Willebrand's disease (VWD) (195/319; 61.1%), VWD type unknown (49/319; 15.4%) and factor VIII deficiency (40/319; 12.5%). HMB was the most common bleeding symptom (198/253; 78.3%); however, 157 (49.2%) participants reported greater than four symptoms. Oral contraceptives were used most frequently to treat HMB (90/165; 54.5%), followed by desmopressin [1-8 deamino-D-arginine vasopressin (DDAVP)] (56/165; 33.9%). Various pregnancy and childbirth complications were reported, including bleeding during miscarriage (33/43; 76.7%) and postpartum haemorrhage (PPH) (41/109; 37.6%). FBD experience multiple bleeding symptoms and obstetrical-gynaecological morbidity. The female UDC is the first prospective, longitudinal surveillance in the US focusing on FBD and has the potential to further identify complications and reduce adverse outcomes in this population.
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Affiliation(s)
- V R Byams
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Abstract
Traumatic dental injuries are often irreversible, underscoring the need for therapies that protect dental pulp cells and enhance their regeneration. We hypothesized that generation 5 poly amido amine (PAMAM) dendrimers (G5), functionalized with fluorescein isothiocyanate (FL) and αVβ3-specific, cyclic arginine-glycine-aspartic acid (RGD) peptides, will bind to dental pulp cells (DPCs) and modulate their differentiation. Dental pulp cells and mouse odontoblast-like cells (MDPC-23) (±) treated with G5-FL-RGD were analyzed via Western blot, RT-PCR, and quantitative PCR. Transcription of dental differentiation markers was as follows: Dentin matrix protein (DMP-1), dentin sialoprotein (DSPP), and matrix extracellular phosphoglycoprotein (MEPE) as well as vascular endothelial growth factor (VEGF) all increased via the JNK pathway. Long-term G5-RGD treatment of dental pulp cells resulted in enhanced mineralization as examined via Von Kossa assay, suggesting that PAMAM dendrimers conjugated to cyclic RGD peptides can increase the odontogenic potential of these cells.
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Affiliation(s)
- J K Kim
- Department of Biologic and Materials Sciences, University of Michigan School of Dentistry, 1011 N. University, Ann Arbor, MI 48109, USA
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