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Hasler WL, Lee AA, Moshiree B, Surjanhata BC, Rao S, Parkman HP, Nguyen LA, Sarosiek I, Wo JM, Schulman MI, McCallum RW, Kuo B. Benefits of Prokinetics, Gastroparesis Diet, or Neuromodulators Alone or in Combination for Symptoms of Gastroparesis. Clin Gastroenterol Hepatol 2024; 22:867-877.e12. [PMID: 37913936 DOI: 10.1016/j.cgh.2023.10.014] [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: 04/26/2023] [Revised: 10/05/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND & AIMS Prokinetics have limited effectiveness for treating symptoms of gastroparesis. Thus, alternative or adjunct therapies, such as gastroparesis diets or neuromodulators, are often prescribed. Their therapeutic benefits alone or in combination remain unclear. METHODS One hundred and twenty-nine patients with symptoms of gastroparesis underwent wireless motility capsule gastric emptying time and gastric emptying scintigraphy. Based on test results, changes in therapy were recommended. Changes in Gastroparesis Cardinal Symptom Index (GCSI) and individual symptom scores over 6 months were related to recommendations for prokinetics, gastroparesis diet, or neuromodulators given as solo new therapies or in dual combinations. Multivariate analyses were performed to adjust for gastric emptying and other variables. RESULTS In the whole group regardless of therapy, GCSI scores decreased by 0.53 points (interquartile range, -1.25 to 0.05; P < .0001) over 6 months. GCSI did not decrease for prokinetics as solo new therapy (P = .95). Conversely, neuromodulators as solo therapy decreased GCSI scores (P = .04) and all individual symptoms except nausea/vomiting (P = .86). Prokinetics combined with gastroparesis diets or neuromodulators improved GCSI scores (P ≤ .04) and most individual symptoms. Adjusting for gastric emptying time on multivariate analyses showed greater GCSI decreases for nondelayed emptying for neuromodulators as solo new therapy (P = .01). Gastric emptying scintigraphy, gender, diabetes, and functional dyspepsia did not influence responses to any treatment. CONCLUSIONS Initiating prokinetics as solo new therapy had little benefit for patients with symptoms of gastroparesis. Neuromodulators as the only new therapy decreased symptoms other than nausea and vomiting, especially with nondelayed gastric emptying. Adding gastroparesis diets or neuromodulators to prokinetics offered relief, suggesting that combination therapies may be more useful in managing these patients. (ClinicalTrials.gov NCT02022826.).
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Affiliation(s)
- William L Hasler
- Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona.
| | - Allen A Lee
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan
| | - Baharak Moshiree
- Atrium Health Wake Forest Baptist, Morehead Medical Plaza, Charlotte, North Carolina
| | - Brian C Surjanhata
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, Georgia
| | - Henry P Parkman
- Section of Gastroenterology, Temple University, Philadelphia, Pennsylvania
| | - Linda A Nguyen
- Division of Gastroenterology, Stanford University, Palo Alto, California
| | - Irene Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, Texas
| | - John M Wo
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | | | | | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Li F, Yano Y, Étiévant L, Daniel CR, Sharma SV, Brown EL, Li R, Loftfield E, Lan Q, Sinha R, Moshiree B, Inoue-Choi M, Vogtmann E. The Time-Dependent Association Between Irritable Bowel Syndrome and All-Cause and Cause-Specific Mortality: A Prospective Cohort Study Within the UK Biobank. Am J Gastroenterol 2024:00000434-990000000-00995. [PMID: 38275237 DOI: 10.14309/ajg.0000000000002675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders, but few studies have evaluated mortality risks among individuals with IBS. We explored the association between IBS and all-cause and cause-specific mortality in the UK Biobank. METHODS We included 502,369 participants from the UK Biobank with mortality data through 2022. IBS was defined using baseline self-report and linkage to primary care or hospital admission data. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality using multivariable Cox proportional hazards regression models within partitioned follow-up time categories (0-5, >5-10, and >10 years). RESULTS A total of 25,697 participants (5.1%) had a history of IBS at baseline. After a median follow-up of 13.7 years, a total of 44,499 deaths occurred. Having an IBS diagnosis was strongly associated with lower risks of all-cause (HR = 0.70, 95% CI = 0.62-0.78) and all-cancer (HR = 0.69, 95% CI = 0.60-0.79) mortality in the first 5 years of follow-up. These associations were attenuated over follow-up, but even after 10 years of follow-up, associations remained inverse (all-cause: HR = 0.89, 95% CI = 0.84-0.96; all-cancer: HR = 0.87, 95% CI = 0.78-0.97) after full adjustment. Individuals with IBS had decreased risk of mortality from breast, prostate, and colorectal cancers in some of the follow-up time categories. DISCUSSION We found that earlier during follow-up, having diagnosed IBS was associated with lower mortality risk, and the association attenuated over time. Additional studies to understand whether specific factors, such as lifestyle and healthcare access, explain the inverse association between IBS and mortality are needed.
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Affiliation(s)
- Fangyu Li
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Yukiko Yano
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Lola Étiévant
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Carrie R Daniel
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shreela V Sharma
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Eric L Brown
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ruosha Li
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Erikka Loftfield
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Qing Lan
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Rashmi Sinha
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Baharak Moshiree
- Division of Gastroenterology, Hepatology, and Nutrition, Atrium Health, Wake Forest University, Charlotte, North Carolina, USA
| | - Maki Inoue-Choi
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Emily Vogtmann
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
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Lembo A, Cash BD, Lu M, Terasawa E, Terreri B, Du S, Ayyagari R, Feuerstadt P, Moshiree B, Westermeyer B, Pi S, Boules M. Clinical outcomes before and after prucalopride treatment: an observational study in patients with chronic idiopathic constipation in the USA. Clin Transl Gastroenterol 2024:01720094-990000000-00238. [PMID: 38357940 DOI: 10.14309/ctg.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION This real-world US-based claims study compared constipation-related symptoms and complications 6 months before and after prucalopride initiation in adults with chronic idiopathic constipation (CIC). METHODS This observational, retrospective cohort analysis used the IBM MarketScan® Commercial Claims and Encounters and the Medicare Supplemental databases (January 2015-June 2020). Prucalopride-treated patients (≥18 years old) who had ≥1 constipation-related International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code during the baseline or study period were included. The proportions of patients with constipation-related symptoms (abdominal pain, abdominal distension [gaseous], incomplete defecation, and nausea) and constipation-related complications (anal fissure and fistula, intestinal obstruction, rectal prolapse, hemorrhoids, perianal venous thrombosis, peri-anal/peri-rectal abscess, and rectal bleeding) were examined. Constipation-related symptoms and complications were identified using ICD-10-CM, ICD-10-Procedure Coding System, or Current Procedural Terminology codes. Data were stratified by age (overall, 18-64 years, ≥65 years). RESULTS This study included 690 patients: mean (standard deviation) patient age was 48.0 (14.7) years and 87.5% were women. The proportions of patients overall with constipation-related symptoms decreased 6 months after prucalopride initiation (abdominal pain [50.4% vs 33.3%, P<0.001]; abdominal distension [gaseous] [23.9% vs 13.3%, P<0.001]; and nausea [22.6% vs 17.7%, P<0.01]; no improvements observed for incomplete defecation). Similarly, the proportions of patients overall with constipation-related complications decreased 6 months after prucalopride initiation (intestinal obstruction [4.9% vs 2.0%, P<0.001]; hemorrhoids [10.7% vs 7.0%, P<0.05]; and rectal bleeding [4.1% vs 1.7%, P<0.05]). DISCUSSION This study suggests that prucalopride may be associated with improved constipation-related symptoms and complications 6 months after treatment initiation.
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Affiliation(s)
- Anthony Lembo
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brooks D Cash
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mei Lu
- Takeda Pharmaceuticals USA, Inc., Lexington, MA, USA
| | | | - Brian Terreri
- Takeda Pharmaceuticals USA, Inc., Lexington, MA, USA
| | - Shawn Du
- Analysis Group, Inc., New York, NY, USA
| | | | - Paul Feuerstadt
- PACT Gastroenterology Center, Hamden, CT, USA
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Baharak Moshiree
- Atrium Health Wake Forest University School of Medicine, Charlotte, NC, USA
| | | | - Selina Pi
- Analysis Group, Inc., New York, NY, USA
| | - Mena Boules
- Takeda Pharmaceuticals USA, Inc., Lexington, MA, USA
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Li F, Ramirez Y, Yano Y, Daniel CR, Sharma SV, Brown EL, Li R, Moshiree B, Loftfield E, Lan Q, Sinha R, Inoue-Choi M, Vogtmann E. The association between inflammatory bowel disease and all-cause and cause-specific mortality in the UK Biobank. Ann Epidemiol 2023; 88:15-22. [PMID: 38013230 PMCID: PMC10842122 DOI: 10.1016/j.annepidem.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/05/2023] [Accepted: 10/26/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE Inflammatory bowel disease (IBD) has a rising global prevalence. However, the understanding of its impact on mortality remains inconsistent so we explored the association between IBD and all-cause and cause-specific mortality. METHODS This study included 502,369 participants from the UK Biobank, a large, population-based, prospective cohort study with mortality data through 2022. IBD was defined by baseline self-report or from primary care or hospital admission data. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality in multivariable Cox proportional hazards regression models. RESULTS A total of 5799 (1.2%) participants had a history of IBD at baseline. After a median follow-up of 13.7 years, 44,499 deaths occurred. Having IBD was associated with an increased risk of death from all causes (HR = 1.16, 95% CI = 1.07-1.24) and cancer (HR = 1.16, 95% CI = 1.05-1.30), particularly colorectal cancer (CRC) (HR = 1.56, 95% CI = 1.17-2.09). We observed elevated breast cancer mortality rates for individuals with Crohn's disease, and increased CRC mortality rates for individuals with ulcerative colitis. In stratified analyses of IBD and all-cause mortality, mortality risk differed by individuals' duration of IBD, age at IBD diagnosis, body mass index (BMI) (PHeterogeneity = 0.03) and smoking status (PHeterogeneity = 0.01). Positive associations between IBD and all-cause mortality were detected in individuals diagnosed with IBD for 10 years or longer, those diagnosed before the age of 50, all BMI subgroups except obese individuals, and in never or current, but not former smokers. CONCLUSIONS We found that having IBD was associated with increased risks of mortality from all causes, all cancers, and CRC. This underscores the importance of enhanced patient management strategies and targeted prevention efforts in individuals with IBD.
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Affiliation(s)
- Fangyu Li
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Yesenia Ramirez
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Yukiko Yano
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Carrie R Daniel
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shreela V Sharma
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston
| | - Eric L Brown
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston
| | - Ruosha Li
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston
| | - Baharak Moshiree
- Division of Gastroenterology, Hepatology, and Nutrition, Atrium Health, Wake Forest University, Charlotte, NC
| | - Erikka Loftfield
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Qing Lan
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Rashmi Sinha
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Maki Inoue-Choi
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Emily Vogtmann
- Metabolic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD.
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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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6
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Davidson EA, Holingue C, Jimenez-Gomez A, Dallman JE, Moshiree B. Gastrointestinal Dysfunction in Genetically Defined Neurodevelopmental Disorders. Semin Neurol 2023; 43:645-660. [PMID: 37586397 PMCID: PMC10895389 DOI: 10.1055/s-0043-1771460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Gastrointestinal symptoms are common in most forms of neurodevelopment disorders (NDDs) such as in autism spectrum disorders (ASD). The current patient-reported outcome measures with validated questionnaires used in the general population of children without NDDS cannot be used in the autistic individuals. We explore here the multifactorial pathophysiology of ASD and the role of genetics and the environment in this disease spectrum and focus instead on possible diagnostics that could provide future objective insight into the connection of the gut-brain-microbiome in this disease entity. We provide our own data from both humans and a zebrafish model of ASD called Phelan-McDermid Syndrome. We hope that this review highlights the gaps in our current knowledge on many of these profound NDDs and that it provides a future framework upon which clinicians and researchers can build and network with other interested multidisciplinary specialties.
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Affiliation(s)
| | - Calliope Holingue
- Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore, Maryland
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andres Jimenez-Gomez
- Neuroscience Center, Joe DiMaggio Children’s Hospital, Hollywood, Florida
- Department of Child Neurology, Florida Atlantic University Stiles - Nicholson Brain Institute, Jupiter, Florida
| | - Julia E. Dallman
- Department of Biology, University of Miami, Coral Gables, Miami, Florida
| | - Baharak Moshiree
- Atrium Health, Wake Forest Medical University, Charlotte, North Carolina
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7
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Srivastava S, Sahin M, Buxbaum JD, Berry-Kravis E, Soorya LV, Thurm A, Bernstein JA, Asante-Otoo A, Bennett WE, Betancur C, Brickhouse TH, Passos Bueno MR, Chopra M, Christensen CK, Cully JL, Dies K, Friedman K, Gummere B, Holder JL, Jimenez-Gomez A, Kerins CA, Khan O, Kohlenberg T, Lacro RV, Levy LA, Levy T, Linnehan D, Loth E, Moshiree B, Neumeyer A, Paul SM, Phelan K, Persico A, Rapaport R, Rogers C, Saland J, Sethuram S, Shapiro J, Tarr PI, White KM, Wickstrom J, Williams KM, Winrow D, Wishart B, Kolevzon A. Updated consensus guidelines on the management of Phelan-McDermid syndrome. Am J Med Genet A 2023; 191:2015-2044. [PMID: 37392087 PMCID: PMC10524678 DOI: 10.1002/ajmg.a.63312] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/04/2023] [Accepted: 05/18/2023] [Indexed: 07/02/2023]
Abstract
Phelan-McDermid syndrome (PMS) is a genetic condition caused by SHANK3 haploinsufficiency and characterized by a wide range of neurodevelopmental and systemic manifestations. The first practice parameters for assessment and monitoring in individuals with PMS were published in 2014; recently, knowledge about PMS has grown significantly based on data from longitudinal phenotyping studies and large-scale genotype-phenotype investigations. The objective of these updated clinical management guidelines was to: (1) reflect the latest in knowledge in PMS and (2) provide guidance for clinicians, researchers, and the general community. A taskforce was established with clinical experts in PMS and representatives from the parent community. Experts joined subgroups based on their areas of specialty, including genetics, neurology, neurodevelopment, gastroenterology, primary care, physiatry, nephrology, endocrinology, cardiology, gynecology, and dentistry. Taskforce members convened regularly between 2021 and 2022 and produced specialty-specific guidelines based on iterative feedback and discussion. Taskforce leaders then established consensus within their respective specialty group and harmonized the guidelines. The knowledge gained over the past decade allows for improved guidelines to assess and monitor individuals with PMS. Since there is limited evidence specific to PMS, intervention mostly follows general guidelines for treating individuals with developmental disorders. Significant evidence has been amassed to guide the management of comorbid neuropsychiatric conditions in PMS, albeit mainly from caregiver report and the experience of clinical experts. These updated consensus guidelines on the management of PMS represent an advance for the field and will improve care in the community. Several areas for future research are also highlighted and will contribute to subsequent updates with more refined and specific recommendations as new knowledge accumulates.
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Affiliation(s)
- Siddharth Srivastava
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Rosamund Stone Zander Translational Neuroscience Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Rosamund Stone Zander Translational Neuroscience Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph D. Buxbaum
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth Berry-Kravis
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
- Department of Biochemistry, Rush University Medical Center, Chicago, IL, USA
| | | | - Audrey Thurm
- Neurodevelopmental and Behavioral Phenotyping Service, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | | | - Afua Asante-Otoo
- Rehabilitation Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | - William E. Bennett
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Catalina Betancur
- Sorbonne Université, INSERM, CNRS, Neuroscience Paris Seine, Institut de Biologie Paris Seine, Paris, France
| | - Tegwyn H. Brickhouse
- Department of Dental Public Health & Policy, School of Dentistry, Virginia Commonwealth University, Richmond, VA, USA
| | - Maria Rita Passos Bueno
- Departamento de Genética e Biologia Evolutiva, Centro de Estudos do Genoma Humano e Células-tronco, Instituto de Biociências, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maya Chopra
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Rosamund Stone Zander Translational Neuroscience Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Celanie K. Christensen
- Division of Developmental Medicine, Department of Pediatrics, Riley Children’s Health, Indianapolis, IN, USA
- Division of Child Neurology, Department of Neurology, Riley Children’s Health, Indianapolis, IN, USA
| | - Jennifer L. Cully
- Department of Pediatrics, College of Medicine and Division of Dentistry and Orthodontics, University of Cincinnati, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kira Dies
- Department of Neurology, Boston Children’s Hospital, Boston, MA, USA
- Rosamund Stone Zander Translational Neuroscience Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kate Friedman
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - J. Lloyd Holder
- Department of Pediatrics-Neurology, Baylor College of Medicine, Houston, TX, USA
| | | | - Carolyn A. Kerins
- Department of Pediatric Dentistry, School of Dentistry, Texas A&M University, Dallas, TX, USA
| | - Omar Khan
- National Institute of Neurological Disease and Stroke, Bethesda, MD, USA
| | | | - Ronald V. Lacro
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Tess Levy
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Eva Loth
- Kings College London, London, UK
| | - Baharak Moshiree
- Department of Medicine, Wake Forest/Atrium Health, Charlotte, NC, USA
| | - Ann Neumeyer
- Lurie Center for Autism, Massachusetts General Hospital, Lexington MA, USA, Harvard Medical School, Boston, MA USA
| | - Scott M. Paul
- Rehabilitation Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | - Katy Phelan
- Genetics Laboratory, Florida Cancer Specialists and Research Institute, Fort Myers, FL, USA
| | - Antonio Persico
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Robert Rapaport
- Department of Pediatrics, Kravis Children’s Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Jeffrey Saland
- Department of Pediatrics, Kravis Children’s Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Swathi Sethuram
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | - Phillip I. Tarr
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kerry M. White
- Division of Developmental Medicine, Department of Pediatrics, Riley Children’s Health, Indianapolis, IN, USA
- Department of Medical and Molecular Genetics, Riley Children’s Health, Indianapolis, IN, USA
| | - Jordan Wickstrom
- Sinai Rehabilitation Center, Lifebridge Health, Baltimore, MD, USA
| | - Kent M. Williams
- Department of Pediatrics, The Ohio State University School of Medicine, Columbus, OH, USA
| | | | | | - Alexander Kolevzon
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Kravis Children’s Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Ramprasad C, Mgbako O, Sampson M, Passaretti C, Moshiree B. Reply. Dis Colon Rectum 2023; 66:e311. [PMID: 36940302 DOI: 10.1097/dcr.0000000000002869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Affiliation(s)
- Chethan Ramprasad
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ofole Mgbako
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Mindy Sampson
- Division of Infectious Disease, Wake Forest Medical University Atrium Health, Charlotte, North Carolina
| | - Catherine Passaretti
- Division of Infectious Disease, Wake Forest Medical University Atrium Health, Charlotte, North Carolina
| | - Baharak Moshiree
- Division of Gastroenterology, Wake Forest Medical University Atrium Health, Charlotte, North Carolina
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Ramprasad C, Mgbako O, Sampson M, Passaretti C, Moshiree B. Perianal and Rectal Lesions in the Monkeypox Outbreak: Diagnosis and Proposed Management. Dis Colon Rectum 2022; 65:1422-1424. [PMID: 36037261 DOI: 10.1097/dcr.0000000000002590] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Chethan Ramprasad
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ofole Mgbako
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Mindy Sampson
- Division of Infectious Disease, Wake Forest Medical University Atrium Health, Charlotte, North Carolina
| | - Catherine Passaretti
- Division of Infectious Disease, Wake Forest Medical University Atrium Health, Charlotte, North Carolina
| | - Baharak Moshiree
- Division of Gastroenterology, Wake Forest Medical University Atrium Health, Charlotte, North Carolina
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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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Lee AA, Rao K, Parkman HP, McCallum RW, Sarosiek I, Nguyen LA, Wo JM, Schulman MI, Moshiree B, Rao S, Kuo B, Hasler WL. Baseline Predictors of Longitudinal Changes in Symptom Severity and Quality of Life in Patients With Suspected Gastroparesis. Clin Gastroenterol Hepatol 2022; 20:e407-e428. [PMID: 32971231 PMCID: PMC8719906 DOI: 10.1016/j.cgh.2020.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 07/21/2020] [Revised: 09/12/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Whether gastric emptying tests predict longitudinal outcomes in patients with symptoms of gastroparesis is unclear. We aimed to determine whether baseline gastric emptying tests and gut motility parameters could impact longitudinal symptom(s) and quality of life (QOL) in a prospective, observational cohort study of patients with symptoms of gastroparesis. METHODS One hundred fifty patients with gastroparesis symptoms underwent simultaneous scintigraphy (GES) and wireless motility capsule (WMC) measurement of gastric emptying and other motility parameters. Patient Assessment of Upper Gastrointestinal Symptoms and Quality of Life were administered at baseline, and 3 and 6 months after testing. Multivariable generalized linear marginal models were fit to determine which baseline parameters predict longitudinal changes in symptoms and QOL. RESULTS Overall upper GI symptoms and QOL scores were moderate in severity at baseline and significantly improved over 6 months. Clinical variables, including female gender, harder stools by Bristol stool form score, and presence of functional dyspepsia (FD) by Rome III criteria, were predictive of more severe upper GI symptoms. Even after controlling for these clinical factors, delayed gastric emptying by GES or WMC was associated with worse symptom severity and QOL scores. Low gastric and elevated small bowel contractile parameters by WMC were also independently associated with more severe upper GI symptoms and worse QOL scores. CONCLUSIONS Baseline features, including demographic and clinical variables, delayed gastric emptying and abnormal gastrointestinal contractility, were independent predictors of more severe longitudinal symptoms and worse quality of life outcomes. These factors may help to risk stratify patients and guide treatment decisions. ClinicalTrials.gov no: NCT02022826.
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Affiliation(s)
- Allen A. Lee
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI,Division of Gastroenterology, University of Vermont, Burlington, VT
| | - Krishna Rao
- Division of Infectious Diseases, University of Michigan, Ann Arbor, MI
| | - Henry P. Parkman
- Section of Gastroenterology, Temple University, Philadelphia, PA
| | | | - Irene Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, TX
| | - Linda A. Nguyen
- Division of Gastroenterology, Stanford University, Stanford, CA
| | - John M. Wo
- Division of Gastroenterology, Indiana University, Indianapolis, IN
| | | | | | - Satish Rao
- Division of Gastroenterology, Augusta University, Augusta, GA
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA
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12
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Moshiree B, Freeman J, Vu P, Khan U, Heltshe S, Goss C, Schwarzenberg S, Freedman S, Sathe M. 206: Gastrointestinal symptoms are common in people with cystic fibrosis regardless of gastrointestinal medication usage: Results from GALAXY. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01631-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Saboori S, Jarvis M, Baker J, Seminara B, Vickers D, Pacicco T, Moshiree B. Hard to Swallow Results. Dysphagia 2021; 37:863-867. [PMID: 34297152 DOI: 10.1007/s00455-021-10344-x] [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] [Received: 09/17/2020] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
The American Neurogastroenterology and Motility Society (ANMS) proposed quality measures (QMs) for performance and interpretation of esophageal manometry (EM). We implemented a quality improvement (QI) study at a large community hospital to assess and improve procedural adherence and interpretation of EM studies based on the ANMS QMs using the Chicago Classification 3.0 (CC) Guidelines. For pre-intervention, three motility independent reviewers reinterpreted 60 EM studies conducted by community gastroenterologists without Tier II-III motility training from October to December 2018 for compliance with pre-procedural, procedural, and data interpretation ANMS QMs. In December 2018, we developed a pre-procedural form, educated nurses on EM procedural compliance, and provided preliminary pre-intervention results to gastroenterologists along with literature utilizing the CC 3.0 Guidelines. For post-intervention, we reinterpreted 54 EM studies from January to August 2019 and investigated whether they met QMs for data interpretation with respect to the CC Guidelines and resulted in appropriate treatment. We found a statistically significant improvement in procedural compliance among nursing staff for 30 s of swallows (76% post-intervention versus 12% pre-intervention, p < 0.001) and 7 evaluable swallows (94% post-intervention versus 53% pre-intervention, p < 0.001). However, quality metrics within data interpretation by physicians post-intervention showed mixed results. An incorrect diagnosis was made in 50% (n = 27)) of studies with 72% (n = 39) having at least one missing item based on the CC. The most missed diagnosis was fragmented peristalsis (30%, n = 29). Among the 39% (n = 21) of surgery referrals, 24% (n = 5) were incorrectly referred. Our study shows poor data interpretation by community gastroenterologists without formal motility training despite adequate performance by nursing staff. This further supports the need for a national ANMS certification process for formal HRM education.
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Affiliation(s)
- S Saboori
- Department of Internal Medicine at Atrium Health's Carolinas Medical Center, 5th Floor Medical Education Building, 1000 Blythe Blvd, Charlotte, NC, 28203, USA.
| | - M Jarvis
- Department of Internal Medicine at Atrium Health's Carolinas Medical Center, Atrium Health Gastroenterology and Hepatology, Charlotte, USA
| | - J Baker
- Department of Internal Medicine and Surgery at Atrium Health's Carolinas Medical Center, Charlotte, USA
| | - B Seminara
- Atrium Health Gastroenterology and Hepatology, Charlotte, USA
| | - D Vickers
- Atrium Health Gastroenterology and Hepatology, Charlotte, USA
| | - T Pacicco
- Atrium Health Gastroenterology and Hepatology, Charlotte, USA
| | - B Moshiree
- UNC School of Medicine-Charlotte Campus, Atrium Health Gastroenterology and Hepatology, Charlotte, USA
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James DM, Davidson EA, Yanes J, Moshiree B, Dallman JE. The Gut-Brain-Microbiome Axis and Its Link to Autism: Emerging Insights and the Potential of Zebrafish Models. Front Cell Dev Biol 2021; 9:662916. [PMID: 33937265 PMCID: PMC8081961 DOI: 10.3389/fcell.2021.662916] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/15/2021] [Indexed: 12/22/2022] Open
Abstract
Research involving autism spectrum disorder (ASD) most frequently focuses on its key diagnostic criteria: restricted interests and repetitive behaviors, altered sensory perception, and communication impairments. These core criteria, however, are often accompanied by numerous comorbidities, many of which result in severe negative impacts on quality of life, including seizures, epilepsy, sleep disturbance, hypotonia, and GI distress. While ASD is a clinically heterogeneous disorder, gastrointestinal (GI) distress is among the most prevalent co-occurring symptom complex, manifesting in upward of 70% of all individuals with ASD. Consistent with this high prevalence, over a dozen family foundations that represent genetically distinct, molecularly defined forms of ASD have identified GI symptoms as an understudied area with significant negative impacts on quality of life for both individuals and their caregivers. Moreover, GI symptoms are also correlated with more pronounced irritability, social withdrawal, stereotypy, hyperactivity, and sleep disturbances, suggesting that they may exacerbate the defining behavioral symptoms of ASD. Despite these facts (and to the detriment of the community), GI distress remains largely unaddressed by ASD research and is frequently regarded as a symptomatic outcome rather than a potential contributory factor to the behavioral symptoms. Allowing for examination of both ASD's impact on the central nervous system (CNS) as well as its impact on the GI tract and the associated microbiome, the zebrafish has recently emerged as a powerful tool to study ASD. This is in no small part due to the advantages zebrafish present as a model system: their precocious development, their small transparent larval form, and their parallels with humans in genetics and physiology. While ASD research centered on the CNS has leveraged these advantages, there has been a critical lack of GI-centric ASD research in zebrafish models, making a holistic view of the gut-brain-microbiome axis incomplete. Similarly, high-throughput ASD drug screens have recently been developed but primarily focus on CNS and behavioral impacts while potential GI impacts have not been investigated. In this review, we aim to explore the great promise of the zebrafish model for elucidating the roles of the gut-brain-microbiome axis in ASD.
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Affiliation(s)
- David M. James
- Department of Biology, University of Miami, Coral Gables, FL, United States
| | | | - Julio Yanes
- Department of Biology, University of Miami, Coral Gables, FL, United States
| | - Baharak Moshiree
- Department of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, United States
| | - Julia E. Dallman
- Department of Biology, University of Miami, Coral Gables, FL, United States
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Moshiree B, Rao S. Up-to-Date Diagnosis and Management of IBS and Chronic Constipation in Primary Care. J Fam Pract 2021; 70:S2-S15. [PMID: 33755039 DOI: 10.12788/jfp.0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The goal of this monograph will focus on emerging treatment updates, reviewing current treatment guidelines, and advances in the management of irritable bowel syndrome (IBS).
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Affiliation(s)
- Baharak Moshiree
- University of North Carolina, Department of Medicine Atrium Health Gastroenterology and Hepatology, Charlotte, NC, USA
| | - Satish Rao
- Augusta University Medical Center, Augusta, GA, USA
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16
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Sendzischew Shane MA, Moshiree B. Esophageal and Gastric Motility Disorders in the Elderly. Clin Geriatr Med 2020; 37:1-16. [PMID: 33213764 DOI: 10.1016/j.cger.2020.08.002] [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
The elderly are particularly prone to developing upper gastrointestinal disturbances. Changes are due to the aging process, diabetes, cardiovascular risk factors, and neurologic issues. Medications used to treat these underlying conditions can cause gastrointestinal symptoms. Dysphagia is common and can be oropharyngeal and/or esophageal. Gastroparesis is due to either medications such opiates, or due to neurologic sequala of diabetes, cerebrovascular accidents, or neurologic diseases such as Parkinson's disease. Given limitations in many commonly used prokinetics with a wide range of side effect profiles including neurologic and cardiac, the focus of treatment should be on symptom management with dietary changes.
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Affiliation(s)
- Morgan A Sendzischew Shane
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB 1184, Miami, FL 33136, USA.
| | - Baharak Moshiree
- Atrium Health-Charlotte, UNC School of Medicine, Charlotte Campus, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204, USA
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17
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Kapnadak SG, Dimango E, Hadjiliadis D, Hempstead SE, Tallarico E, Pilewski JM, Faro A, Albright J, Benden C, Blair S, Dellon EP, Gochenour D, Michelson P, Moshiree B, Neuringer I, Riedy C, Schindler T, Singer LG, Young D, Vignola L, Zukosky J, Simon RH. Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease. J Cyst Fibros 2020; 19:344-354. [DOI: 10.1016/j.jcf.2020.02.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 12/25/2022]
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18
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Kim SB, Calmet FH, Garrido J, Garcia-Buitrago MT, Moshiree B. Sucrase-Isomaltase Deficiency as a Potential Masquerader in Irritable Bowel Syndrome. Dig Dis Sci 2020; 65:534-540. [PMID: 31493040 DOI: 10.1007/s10620-019-05780-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 04/12/2018] [Accepted: 08/07/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with irritable bowel syndrome (IBS) frequently have meal-related symptoms and can recognize specific trigger foods. Lactose intolerance is a well-established carbohydrate malabsorption syndrome that causes symptoms similar to IBS such as bloating, abdominal pain, and diarrhea. However, the prevalence of sucrase-isomaltase deficiency (SID) in this population is poorly defined. SID is a condition in which sucrase-isomaltase, an enzyme produced by brush border of small intestine to metabolize sucrose, is deficient. Just like lactase deficiency, SID causes symptoms of maldigestion syndromes including abdominal pain, bloating, gas, and diarrhea. In this study, we aim to determine the prevalence of SID in patients with presumed IBS-D/M and characterize its clinical presentation. METHODS Patients with a presumed diagnosis of IBS-D/M based on symptoms of abdominal pain, diarrhea, and/or bloating who underwent esophagogastroduodenoscopy with duodenal biopsies and testing for disaccharidase deficiency were included. Patients with a history of inflammatory bowel disease, gastrointestinal malignancy, or celiac disease were excluded. Odds ratio was calculated for abdominal pain, diarrhea, and bloating in patients with versus without SID. RESULTS A total of 31 patients with clinical suspicion for IBS-D/M were included with a median age of 46 years (IQR 30.5-60) and with 61% females. SID was present in 35% of patients. Among patients with SID, 63.6% had diarrhea, 45.4% had abdominal pain, and 36.4% had bloating. Patients with SID were less likely than controls to have abdominal pain (OR 0.16, 95% CI 0.03-0.81, p = 0.04) although no difference in diarrhea or bloating was found. Only two patients with SID underwent sucrose breath testing of which only one had a positive result. However, this patient also had a positive glucose breath test and may have had small intestinal bacterial overgrowth as a confounder. CONCLUSION SID was found in 35% of patients with presumed IBS-D/M and should be considered in the differential diagnosis of patients presenting with abdominal pain, diarrhea, or bloating. Further studies should better characterize the clinical features of SID and investigate the effects of dietary modification in this group of patients.
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Affiliation(s)
- Su Bin Kim
- Department of Gastroenterology, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Fernando H Calmet
- Division of Gastroenterology, Newton-Wellesley Hospital, 2000 Washington St, Suite 368, Newton, MA, 02462, USA
| | - Jose Garrido
- Department of Gastroenterology, University of Miami Miller School of Medicine, 1295 Northwest 14th Street, Miami, FL, 33125, USA
| | - Monica T Garcia-Buitrago
- Department of Pathology, Jackson Memorial Health System, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136, USA
| | - Baharak Moshiree
- Atrium Health, University of North Carolina, 1025 Morehead Medical Dr. Suite 300, Charlotte, NC, 28204, USA.
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Hasler WL, Rao SSC, McCallum RW, Krause RA, Nguyen LA, Schulman MI, Lee AA, Moshiree B, Wo JM, Parkman HP, Sarosiek I, Wilding GE, Kuo B. Influence of Gastric Emptying and Gut Transit Testing on Clinical Management Decisions in Suspected Gastroparesis. Clin Transl Gastroenterol 2019; 10:e00084. [PMID: 31663906 PMCID: PMC6919448 DOI: 10.14309/ctg.0000000000000084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 08/16/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Gastric emptying scintigraphy (GES) or wireless motility capsules (WMCs) can evaluate upper gastrointestinal symptoms in suspected gastroparesis; WMC tests can also investigate lower gut symptoms. We aimed to determine whether these tests impact treatment plans and needs for additional diagnostic evaluation. METHODS In a prospective, multicenter study, 150 patients with gastroparesis symptoms simultaneously underwent GES and WMC testing. Based on these results, investigators devised management plans to recommend changes in medications, diet, and surgical therapies and order additional diagnostic tests. RESULTS Treatment changes were recommended more often based on the WMC vs GES results (68% vs 48%) (P < 0.0001). Ordering of additional test(s) was eliminated more often with WMC vs GES (71% vs 31%) (P < 0.0001). Prokinetics (P = 0.0007) and laxatives (P < 0.0001) were recommended more often based on the WMC vs GES results. Recommendations for prokinetics and gastroparesis diets were higher and neuromodulators lower in subjects with delayed emptying on both tests (all P ≤ 0.0006). Laxatives and additional motility tests were ordered more frequently for delayed compared with normal WMC colonic transit (P ≤ 0.02). Multiple motility tests were ordered more often on the basis of GES vs WMC findings (P ≤ 0.004). Antidumping diets and transit slowing medications were more commonly recommended for rapid WMC gastric emptying (P ≤ 0.03). DISCUSSION WMC transit results promote medication changes and eliminate additional diagnostic testing more often than GES because of greater detection of delayed gastric emptying and profiling the entire gastrointestinal tract in patients with gastroparesis symptoms. TRANSLATIONAL IMPACT Gastric scintigraphy and WMCs have differential impact on management decisions in suspected gastroparesis.
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Affiliation(s)
- William L. Hasler
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Satish S. C. Rao
- Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta, Georgia, USA
| | | | | | - Linda A. Nguyen
- Division of Gastroenterology, Stanford University, Palo Alto, California, USA
| | | | - Allen A. Lee
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Baharak Moshiree
- Atrium Health Gastroenterology and Hepatology, Carolinas HealthCare System Digestive Health-Morehead Medical Plaza, Charlotte, North Carolina, USA
| | - John M. Wo
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Henry P. Parkman
- Section of Gastroenterology, Temple University, Philadelphia, Pennsylvania, USA
| | - Irene Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, Texas, USA
| | - Gregory E. Wilding
- Department of Biostatistics, University of Buffalo, Buffalo, New York, USA
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Lee AA, Rao S, Nguyen LA, Moshiree B, Sarosiek I, Schulman MI, Wo JM, Parkman HP, Wilding GE, McCallum RW, Hasler WL, Kuo B. Validation of Diagnostic and Performance Characteristics of the Wireless Motility Capsule in Patients With Suspected Gastroparesis. Clin Gastroenterol Hepatol 2019; 17:1770-1779.e2. [PMID: 30557741 PMCID: PMC7442471 DOI: 10.1016/j.cgh.2018.11.063] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/26/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS It is a challenge to make a diagnosis of gastroparesis. There is good agreement in results from wireless motility capsule (WMC) analysis and gastric emptying scintigraphy (GES), but the diagnostic yield of WMC is unclear and the accuracy of this method has not been validated. We compared the performance characteristics of WMC vs GES in assessing gastric emptying in patients with suspected gastroparesis. METHODS We performed a prospective study of 167 subjects with gastroparesis (53 with diabetes and 114 without) at 10 centers, from 2013 through 2016. Subjects were assessed simultaneously by GES and with a WMC to measure gastric emptying and regional transit. Delayed gastric emptying by GES was defined as more than 10% meal retention at 4 hrs whereas delayed gastric emptying by WMC was defined as more than 5 hrs for passage of the capsule into the duodenum; a severe delay in gastric emptying was defined as a gastric emptying time of more than 12 hrs by WMC or more than 35% retention at 4 hrs by GES. Rapid gastric emptying was defined as less than 38% meal retention at 1 hr based on by GES or gastric emptying times less than 1:45 hrs by WMC. We compared diagnostic and performance characteristics of GES vs WMC. RESULTS Delayed gastric emptying was detected in a higher proportion of subjects by WMC (34.6%) than by GES (24.5%) (P=.009). Overall agreement in results between methods was 75.7% (kappa=0.42). In subjects without diabetes, the WMC detected a higher proportion of subjects with delayed gastric emptying (33.3%) than GES (17.1%) (P < .001). A higher proportion of subjects with diabetes had delayed gastric emptying detected by GES (41.7%) compared with non-diabetic subjects (17.1%) (P=.002). Severe delays in gastric emptying were observed in a higher proportion of subjects by WMC (13.8%) than by GES (6.9%) (P = .02). Rapid gastric emptying was detected in a higher proportion of subjects by GES (13.8%) than by WMC (3.3%) (P < .001). Regional and generalized transit abnormalities were observed in 61.8% subjects and only detected by WMC. CONCLUSION Although there is agreement in analysis of gastric emptying by GES vs WMC, WMC provides higher diagnostic yield than GES. WMC detects delayed gastric emptying more frequently than GES and identifies extra-gastric transit abnormalities. Diabetic vs non-diabetic subjects have different results from GES vs WMC. These findings could affect management of patients with suspected gastroparesis. ClinicalTrials.gov no: NCT02022826.
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Affiliation(s)
- Allen A. Lee
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI
| | - Satish Rao
- Division of Gastroenterology, Augusta University, Augusta, GA
| | - Linda A. Nguyen
- Division of Gastroenterology, Stanford University, Stanford, CA
| | | | - Irene Sarosiek
- Section of Gastroenterology, Texas Tech University, El Paso, TX
| | | | - John M. Wo
- Division of Gastroenterology, Indiana University, Indianapolis, IN
| | - Henry P. Parkman
- Section of Gastroenterology, Temple University, Philadelphia, PA
| | | | | | | | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts.
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Barkin JA, Keihanian T, Barkin JS, Antequera CM, Moshiree B. Preferential usage of rifaximin for the treatment of hydrogen-positive smallintestinal bacterial overgrowth. Rev Gastroenterol Peru 2019; 39:111-115. [PMID: 31333225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Small intestinal bacterial overgrowth (SIBO) is challenging to treat and diagnose and is associated with diagnosis of irritable bowel syndrome (IBS). Although no FDA-approved medications exist for treatment of SIBO, rifaximin has recently received approval to treat diarrhea-predominant IBS and patients with methane-positive SIBO breath tests. The aim of this study is to evaluate patient response to rifaximin for SIBO based on breath test results. MATERIALS AND METHODS All patients underwent breath testing to evaluate for SIBO during a 42-month period. Patients were defined as having a positive glucose breath test for SIBO based on an increase of ≥ 20 ppm of hydrogen and/or ≥ 10 ppm of methane 90 minutes after ingesting glucose. Patient demographic and symptom data, antibiotic treatment regimens, symptomatic response to therapy, and repeat treatments were recorded. Institutional review board approval was obtained. RESULTS A total of 53 of 443 patients had positive breath testing for SIBO. Response rates to rifaximin (550 mg three times daily for 14 days) were 47.4% for hydrogen positivity alone and 80% for both hydrogen and methane positivity. CONCLUSIONS Rifaximin was the most commonly prescribed antibiotic regimen for SIBO therapy. Patients with hydrogen or hydrogen and methane positive breath tests responded well to rifaximin therapy. For patients with hydrogen-positive SIBO, rifaximin may prove a highly effective therapy in providing symptom relief from the effects of SIBO.
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Affiliation(s)
- Jodie A Barkin
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami. Miami, Florida, USA
| | - Tara Keihanian
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami. Miami, Florida, USA
| | - Jamie S Barkin
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami. Miami, Florida, USA
| | - Carol M Antequera
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami. Miami, Florida, USA
| | - Baharak Moshiree
- Division of Gastroenterology, Carolinas HealthCare System, University of North Carolina. Charlotte, North Carolina, USA
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James DM, Kozol RA, Kajiwara Y, Wahl AL, Storrs EC, Buxbaum JD, Klein M, Moshiree B, Dallman JE. Intestinal dysmotility in a zebrafish ( Danio rerio) shank3a;shank3b mutant model of autism. Mol Autism 2019; 10:3. [PMID: 30733854 PMCID: PMC6357389 DOI: 10.1186/s13229-018-0250-4] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023] Open
Abstract
Background and aims Autism spectrum disorder (ASD) is currently estimated to affect more than 1% of the world population. For people with ASD, gastrointestinal (GI) distress is a commonly reported but a poorly understood co-occurring symptom. Here, we investigate the physiological basis for GI distress in ASD by studying gut function in a zebrafish model of Phelan-McDermid syndrome (PMS), a condition caused by mutations in the SHANK3 gene. Methods To generate a zebrafish model of PMS, we used CRISPR/Cas9 to introduce clinically related C-terminal frameshift mutations in shank3a and shank3b zebrafish paralogues (shank3abΔC). Because PMS is caused by SHANK3 haploinsufficiency, we assessed the digestive tract (DT) structure and function in zebrafish shank3abΔC+/− heterozygotes. Human SHANK3 mRNA was then used to rescue DT phenotypes in larval zebrafish. Results Significantly slower rates of DT peristaltic contractions (p < 0.001) with correspondingly prolonged passage time (p < 0.004) occurred in shank3abΔC+/− mutants. Rescue injections of mRNA encoding the longest human SHANK3 isoform into shank3abΔC+/− mutants produced larvae with intestinal bulb emptying similar to wild type (WT), but still deficits in posterior intestinal motility. Serotonin-positive enteroendocrine cells (EECs) were significantly reduced in both shank3abΔC+/− and shank3abΔC−/− mutants (p < 0.05) while enteric neuron counts and overall structure of the DT epithelium, including goblet cell number, were unaffected in shank3abΔC+/− larvae. Conclusions Our data and rescue experiments support mutations in SHANK3 as causal for GI transit and motility abnormalities. Reductions in serotonin-positive EECs and serotonin-filled ENS boutons suggest an endocrine/neural component to this dysmotility. This is the first study to date demonstrating DT dysmotility in a zebrafish single gene mutant model of ASD. Electronic supplementary material The online version of this article (10.1186/s13229-018-0250-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David M James
- 1Department of Biology, University of Miami, Coral Gables, FL USA
| | - Robert A Kozol
- 1Department of Biology, University of Miami, Coral Gables, FL USA
| | - Yuji Kajiwara
- 2Seaver Autism Center for Research and Treatment, Department of Psychiatry, Friedman Brain Institute and Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA.,5Denali Therapeutics, South San Francisco, CA USA
| | - Adam L Wahl
- 1Department of Biology, University of Miami, Coral Gables, FL USA
| | - Emily C Storrs
- 1Department of Biology, University of Miami, Coral Gables, FL USA
| | - Joseph D Buxbaum
- 2Seaver Autism Center for Research and Treatment, Department of Psychiatry, Friedman Brain Institute and Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Mason Klein
- 3Department of Physics, University of Miami, Coral Gables, FL USA
| | - Baharak Moshiree
- Division of Gastroenterology, Atrium Health, University of North Carolina, Charlotte, NC USA
| | - Julia E Dallman
- 1Department of Biology, University of Miami, Coral Gables, FL USA
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Eshraghi RS, Deth RC, Mittal R, Aranke M, Kay SIS, Moshiree B, Eshraghi AA. Early Disruption of the Microbiome Leading to Decreased Antioxidant Capacity and Epigenetic Changes: Implications for the Rise in Autism. Front Cell Neurosci 2018; 12:256. [PMID: 30158857 PMCID: PMC6104136 DOI: 10.3389/fncel.2018.00256] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/27/2018] [Indexed: 12/20/2022] Open
Abstract
Currently, 1 out of every 59 children in the United States is diagnosed with autism. While initial research to find the possible causes for autism were mostly focused on the genome, more recent studies indicate a significant role for epigenetic regulation of gene expression and the microbiome. In this review article, we examine the connections between early disruption of the developing microbiome and gastrointestinal tract function, with particular regard to susceptibility to autism. The biological mechanisms that accompany individuals with autism are reviewed in this manuscript including immune system dysregulation, inflammation, oxidative stress, metabolic and methylation abnormalities as well as gastrointestinal distress. We propose that these autism-associated biological mechanisms may be caused and/or sustained by dysbiosis, an alteration to the composition of resident commensal communities relative to the community found in healthy individuals and its redox and epigenetic consequences, changes that in part can be due to early use and over-use of antibiotics across generations. Further studies are warranted to clarify the contribution of oxidative stress and gut microbiome in the pathophysiology of autism. A better understanding of the microbiome and gastrointestinal tract in relation to autism will provide promising new opportunities to develop novel treatment modalities.
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Affiliation(s)
- Rebecca S. Eshraghi
- Division of Gastroenterology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Richard C. Deth
- Department of Pharmaceutical Sciences, College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Rahul Mittal
- Department of Otolaryngology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Mayank Aranke
- Department of Otolaryngology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Sae-In S. Kay
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Baharak Moshiree
- Division of Gastroenterology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Adrien A. Eshraghi
- Department of Otolaryngology, Miller School of Medicine, University of Miami, Miami, FL, United States
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24
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Eshraghi AA, Liu G, Kay SIS, Eshraghi RS, Mittal J, Moshiree B, Mittal R. Epigenetics and Autism Spectrum Disorder: Is There a Correlation? Front Cell Neurosci 2018; 12:78. [PMID: 29636664 PMCID: PMC5881102 DOI: 10.3389/fncel.2018.00078] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/06/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Adrien A Eshraghi
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - George Liu
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Sae-In Samantha Kay
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Rebecca S Eshraghi
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jeenu Mittal
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Baharak Moshiree
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rahul Mittal
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, United States
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Abstract
Fibromyalgia (FM) has historically been associated with several diseases in gastroenterology and hepatology. The most substantiated evidence pertains to irritable bowel syndrome (IBS). The pathogeneses of FM and IBS remain unclear, but it is likely related to dysregulation within the brain-gut axis, resulting in a hyperalgesic state. IBS and FM share other similarities, including a female predominance, fatigue, insomnia, and susceptibility to psychiatric state. These common manifestations and pathogeneses serve as a foundation for overlapping, multidisciplinary treatment modalities.
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Affiliation(s)
- Richard A Schatz
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, 114 Doughty Street, STB Suite 249, Charleston, SC 29425, USA.
| | - Baharak Moshiree
- Division of Gastroenterology, Carolinas HealthCare System, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204, USA
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26
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Khushman M, Morris MI, Diaz L, Goodman M, Pereira D, Fuller K, Garcia-Buitrago M, Moshiree B, Zelaya S, Nayer A, Benjamin CL, Komanduri KV. Syndrome of Inappropriate Anti-Diuretic Hormone Secretion Secondary to Strongyloides stercoralis Infection in an Allogeneic Stem Cell Transplant Patient: A Case Report and Literature Review. Transplant Proc 2017; 49:373-377. [PMID: 28219601 DOI: 10.1016/j.transproceed.2016.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 12/06/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
Abstract
Syndrome of inappropriate anti-diuretic hormone (SIADH) has been reported to be associated with systemic Strongyloides stercoralis. Here, we report a case of a stem cell transplant (SCT) recipient who developed severe SIADH secondary to systemic S Stercoralis. The SIADH resolved quickly after treating the systemic S Stercoralis with ivermectin. A systematic review of the literature was performed by PubMed, Scopus, and Cochrane database search. Only eight cases of S Stercoralis in allogeneic SCT recipients have been previously reported. To our knowledge, ours is the first reported case of SIADH secondary to S Stercoralis infection in an allogeneic SCT recipient. Prior to transplantation, even if asymptomatic, patients from endemic regions should be screened with strongyloides immunoglobulin (Ig)G serology. Pretransplantation eosinophilia should be evaluated by screening multiple stool samples for ova and parasites. Transplant candidates with positive serology or stool tests can be treated pretransplantation to eradicate infection. Patients at risk for S Stercoralis who develop nonspecific gastrointestinal complaints, rash, pulmonary infiltrates, or gram-negative bacteremia or meningitis may have S Stercoralis hyperinfection syndrome. Our case indicates that the development of SIADH may be an additional clue to this diagnosis. Appropriate diagnostic studies, including repeat stool and other body fluid sampling, should be expedited and ivermectin therapy initiated rapidly to prevent significant morbidity and mortality.
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Affiliation(s)
- M Khushman
- The University of South Alabama, Mitchell Cancer Institute, Mobile, Alabama, USA.
| | - M I Morris
- Infectious Diseases, The University of Miami Miller School of Medicine, Miami, Florida, USA
| | - L Diaz
- Internal Medicine, The University of Miami Miller School of Medicine, Miami, Florida, USA
| | - M Goodman
- Adult Stem Cell Transplant Program, The University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - D Pereira
- Adult Stem Cell Transplant Program, The University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - K Fuller
- Adult Stem Cell Transplant Program, The University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - M Garcia-Buitrago
- Pathology, The University of Miami Miller School of Medicine, Miami, Florida, USA
| | - B Moshiree
- Gastroenterology, The University of Miami Miller School of Medicine, Miami, Florida, USA
| | - S Zelaya
- Nephrology, The University of Miami Miller School of Medicine, Miami, Florida, USA
| | - A Nayer
- Nephrology, The University of Miami Miller School of Medicine, Miami, Florida, USA
| | - C L Benjamin
- Adult Stem Cell Transplant Program, The University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - K V Komanduri
- Adult Stem Cell Transplant Program, The University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
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Szeto W, Garcia-Buitrago MT, Abbo L, Rosenblatt JD, Moshiree B, Morris MI. Clofazimine Enteropathy: A Rare and Underrecognized Complication of Mycobacterial Therapy. Open Forum Infect Dis 2016; 3:ofw004. [PMID: 27800519 PMCID: PMC5084711 DOI: 10.1093/ofid/ofw004] [Citation(s) in RCA: 20] [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: 09/03/2015] [Accepted: 01/12/2016] [Indexed: 11/15/2022] Open
Abstract
Clofazimine-induced crystal-storing histiocytosis is a rare complication of treatment previously reported in dermatology literature as a complication of leprosy therapy. We report a case of disseminated Mycobacterium abscessus requiring treatment with high-dose oral clofazimine resulting in enteropathy in a patient who presented with abdominal pain, malnutrition, and melena.
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Affiliation(s)
| | | | | | - Joseph D Rosenblatt
- Division of Hematology and Oncology, Department of Medicine , University of Miami, Leonard M. Miller School of Medicine , Florida
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28
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Barkin JA, Czul F, Barkin JS, Klimas NG, Rey IR, Moshiree B. Gastric Enterovirus Infection: A Possible Causative Etiology of Gastroparesis. Dig Dis Sci 2016; 61:2344-2350. [PMID: 27344315 DOI: 10.1007/s10620-016-4227-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 06/09/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastroparesis (GP) is a disabling chronic gastroenterologic disorder with high morbidity that severely impacts patients' quality of life. GP can present acutely after a viral-like gastrointestinal illness resulting in speculation that in some patients, neurologic damage caused by the infection might underlie the pathogenesis of idiopathic gastroparesis (IGP). AIMS The aim of this study is to document case reports of Enterovirus (EV) infection as a possible cause of IGP. METHODS Eleven patients referred with a diagnosis of GP underwent workup to exclude known causes of GP. Those with a history of flu-like symptoms or gastroenteritis prior to onset of GP symptoms had gastric biopsies taken during upper endoscopy to assess for the presence of gastric mucosal EV infection. Data on presenting symptoms, extra-intestinal symptoms and conditions, prior nutritional support requirements, upper endoscopy findings, and response to therapy were cataloged. RESULTS Eleven patients were diagnosed as IGP. Nine had active EV infection on gastric biopsies and were included (7/9 female, mean age 43 years). Eight out of nine received EV treatment with antivirals and/or immune therapies, with a wide degree of variability in treatment regimens. Four out of eight who received EV treatment had symptomatic improvement. One patient had stable symptoms. Three patients are currently undergoing therapy. CONCLUSIONS Gastric EV infection was frequently detected (82 %) in patients undergoing investigation for IGP. Antiviral and/or immune therapies against EV seem to be favorable, as most of our patients had resolution of their GP symptoms after treatment. This is the first study to identify EV as a possible infectious etiology of IGP.
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Affiliation(s)
- Jodie A Barkin
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Clinical Research Building, Suite 1116 (D-49), Miami, FL, 33136, USA.
| | - Frank Czul
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Clinical Research Building, Suite 1116 (D-49), Miami, FL, 33136, USA
| | - Jamie S Barkin
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Clinical Research Building, Suite 1116 (D-49), Miami, FL, 33136, USA
| | - Nancy G Klimas
- Institute for Neuro-Immune Medicine, Nova Southeastern University, 3440 South University Drive, Davie, FL, 33328, USA
| | - Irma R Rey
- Institute for Neuro-Immune Medicine, Nova Southeastern University, 3440 South University Drive, Davie, FL, 33328, USA
| | - Baharak Moshiree
- Division of Gastroenterology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, 1120 NW 14th Street, Clinical Research Building, Suite 1116 (D-49), Miami, FL, 33136, USA
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29
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Corral JE, Dye CW, Mascarenhas MR, Barkin JS, Salathe M, Moshiree B. Is Gastroparesis Found More Frequently in Patients with Cystic Fibrosis? A Systematic Review. Scientifica (Cairo) 2016; 2016:2918139. [PMID: 27313953 PMCID: PMC4904114 DOI: 10.1155/2016/2918139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/06/2016] [Indexed: 05/08/2023]
Abstract
Cystic fibrosis (CF) is associated with different gastrointestinal motility disturbances and syndromes. We aim to assess gastric emptying in patients with CF compared to healthy controls by a systematic review of existing literature. Medical databases and abstracts from major gastroenterology and CF meetings were reviewed. Emptying times in CF patients were compared with healthy controls using random effects models. Subgroup analysis stratified results by age and diagnostic modality. Nineteen studies from 7 countries included 574 subjects (359 CF patients and 215 controls). Using pooled analysis frequency of gastroparesis was high (38%, 95% CI 30-45%) but results were highly dependent on the diagnostic modality. Delayed gastric emptying is more common in CF compared to general population. Scintigraphy identified rapid gastric emptying in a subgroup of CF patients, but this finding disappeared with adequate pancreatic enzyme replacement and after other diagnostic modalities were included.
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Affiliation(s)
- Juan E. Corral
- Department of Internal Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- *Juan E. Corral:
| | - Corey W. Dye
- Department of Internal Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Maria R. Mascarenhas
- Division of Gastroenterology, Hepatology and Nutrition, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jamie S. Barkin
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Matthias Salathe
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Baharak Moshiree
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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30
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Affiliation(s)
- Juan E Corral
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Seth Sclair
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Baharak Moshiree
- University of Miami Miller School of Medicine, Miami, Florida, USA
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31
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Diaz L, Hernandez-Oquet RE, Deshpande AR, Moshiree B. Upper Gastrointestinal Involvement in Crohn Disease: Histopathologic and Endoscopic Findings. South Med J 2015; 108:695-700. [DOI: 10.14423/smj.0000000000000373] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Barboza JL, Okun MS, Moshiree B. The treatment of gastroparesis, constipation and small intestinal bacterial overgrowth syndrome in patients with Parkinson's disease. Expert Opin Pharmacother 2015; 16:2449-64. [PMID: 26374094 DOI: 10.1517/14656566.2015.1086747] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Parkinson's disease (PD) affects the nerves of the entire gastrointestinal (GI) tract and may result in profound gastrointestinal (GI) dysfunction leading to poor patient outcomes. Common GI disturbances in patients with PD include gastroparesis (GP), constipation and small intestinal bacterial overgrowth syndrome (SIBO). In particular, GP is difficult to treat due to the limited options available and precautions, contraindications and adverse effects associated with the approved treatments. Moreover, some commonly used medications can worsen pre-existing PD. AREAS COVERED Our review will focus on treatment options for GP and SIBO with motilin agonists, dopamine receptor antagonists, Ghrelin agonists muscarinic agonists, 5-HT4 receptor agonists, antibiotics, probiotics and herbal formulation such as iberogast. Constipation occurs in the majority of patients with PD and fortunately many treatments are now available. Our review is based on original papers or reviews selected from PUBMED search and Cochrane reviews. EXPERT OPINION Motility disorders of the GI tract are found frequently in patients with PD and treating the underlying GI disorders caused by PD with various prokinetics and laxatives is paramount in achieving improvements in patient's motor function. Various prokinetics and laxatives are now available to provide some relief of the GI morbidity caused by PD leading even to better absorption of even the PD treatments.
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Affiliation(s)
| | - Michael S Okun
- b 2 University of Florida, Center for Movement Disorders and Neurorestoration , Gainesville, FL, UK
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Schatz RA, Zhang Q, Lodhia N, Shuster J, Toskes PP, Moshiree B. Predisposing factors for positive D-Xylose breath test for evaluation of small intestinal bacterial overgrowth: A retrospective study of 932 patients. World J Gastroenterol 2015; 21:4574-4582. [PMID: 25914466 PMCID: PMC4402304 DOI: 10.3748/wjg.v21.i15.4574] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 11/15/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate, in the largest cohort to date, patient characteristics and associated risk factors for developing small intestinal bacterial overgrowth (SIBO) using the D-Xylose breath test (XBT).
METHODS: We performed a retrospective cross-sectional study to analyze patient characteristics who underwent the XBT for evaluation of SIBO. Diagnostic testing with the XBT was performed based on a clinical suspicion for SIBO in patients with symptoms of bloating, abdominal pain, abdominal distension, weight loss, diarrhea, and/or constipation. Consecutive electronic medical records of 932 patients who completed the XBT at the University of Florida between 2005 and 2009 were reviewed. A two-way Analysis of Variance (ANOVA) was used to test for several associations including age, gender, and body mass index (BMI) with a +XBT. A two-way ANOVA was also performed to control for the differences and interaction with age and between genders. A similar analysis was repeated for BMI. Associations between medical conditions and prior surgical histories were conducted using the Mantel-Haenszel method for 2 by 2 contingency tables, stratified for gender. Reported odds ratio estimates reflect the odds of the prevalence of a condition within the +XBT group to that of the -XBT group. P values of less than 0.05 (two-sided) were considered statistically significant.
RESULTS: In the 932 consecutive eligible subjects studied, 513 had a positive XBT. A positive association was found between female gender and a positive XBT (P = 0.0025), and females with a positive test were, on average, greater than 5 years older than those with a negative test (P = 0.024). The mean BMI of positive XBT subjects was normal (24.5) and significantly lower than the subjects with a negative XBT (29.5) (P = 0.0050). A positive XBT was associated with gastroesophageal reflux disease (GERD) (OR = 1.35; 95%CI: 1.02-1.80, P = 0.04), peptic ulcer disease (PUD) (OR = 2.61; 95%CI: 1.48-4.59, P < 0.01), gastroparesis (GP) (OR = 2.04; 95%CI: 1.21-3.41, P < 0.01) and steroid use (OR = 1.35; 95%CI: 1.02-1.80, P = 0.01). Irritable bowel syndrome, independent proton-pump inhibitor (PPI) usage, or previous abdominal surgery was not significantly associated with a positive XBT. No single subdivision by gender or PPI use was associated with a significant difference in the odds ratios between any of the subsets.
CONCLUSION: Female gender, lower BMI, steroid use, PUD, GERD (independent of PPI use), and GP were more prevalent in patients with SIBO, determined by a positive XBT. Increasing age was associated with SIBO in females, but not in males.
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Barkin JA, Sendzischew MA, Landy DC, Moshiree B. Upper gastrointestinal symptoms in medical professionals: a higher burden? South Med J 2015; 108:39-45. [PMID: 25580756 DOI: 10.14423/smj.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Gastroesophageal reflux disease (GERD) and dyspepsia cause significant healthcare resource utilization and greatly affect quality of life; therefore, a tendency exists to self-treat in lieu of formal diagnosis. Although their prevalence is established in the general population, their prevalence in physicians remains unknown. Our aim was to estimate the prevalence of GERD and dyspepsia symptoms in a sample of medical professionals by level of training. METHODS An anonymous, computer-based questionnaire was distributed to medical students, residents/fellows, and attending physicians at our institution. The survey included symptom-based questions for GERD (Reflux Disease Questionnaire); quality-of-life questionnaire for dyspepsia (Nepean Dyspepsia Index [NDI]), and the Gastroparesis Cardinal Symptom Index (GCSI). We calculated scores based on the validated system from each questionnaire and used appropriate statistical analysis to evaluate associations between symptomatology and training level (medical students, residents/fellows, and attending physicians). RESULTS Overall, there were 327 respondents (155 medical students, 127 residents/fellows, 45 attending physicians), of whom 52% were women, 56% were white non-Hispanic, 19% were Hispanic, and 74% were born in the United States/Canada. A total of 21% reported previously diagnosed GERD/dyspepsia, and 42% reported previously or currently using a medication for GERD/dyspepsia, with significantly higher use of proton pump inhibitors in attending physicians than in medical students and residents/fellows (P < 0.01). Higher median total scores for the NDI (P = 0.01) and GCSI (P < 0.01) in medical students exist compared with residents/fellows and attending physicians, with no significant differences for the Reflux Disease Questionnaire among groups. CONCLUSIONS Although the prevalence of diagnosed GERD/dyspepsia in our sample was comparable to the general population, medication use was higher. Self-treatment with prescription medications increased with training. Median NDI and GCSI scores were inversely related to training level, which may reflect self-treatment in medical professionals with advanced training. Further study of GERD/dyspepsia in medical professionals is warranted.
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Affiliation(s)
- Jodie A Barkin
- From the Department of Medicine, Division of Gastroenterology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Morgan A Sendzischew
- From the Department of Medicine, Division of Gastroenterology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - David C Landy
- From the Department of Medicine, Division of Gastroenterology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Baharak Moshiree
- From the Department of Medicine, Division of Gastroenterology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
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Abstract
Treatment of irritable bowel syndrome (IBS) is challenging for both primary care physicians and gastroenterologists because of the heterogeneity of the patient population and the multifactorial pathophysiologies responsible for the symptoms in IBS. This review focuses on the current and emerging pharmacological treatments for IBS. Many of the current medications used to treat this disorder have distinct properties such as efficacy for different symptoms, safety profiles, contraindications, costs, dosing regimens, treatment duration and long-term data. All of these factors, in addition to patient preference and cognitive, food and environmental triggers, must be considered prior to any medication selection. This review will focus on randomized controlled trials with a general uniformity in study design, a rigorous patient selection and appropriate treatment durations. We will also discuss other exciting emerging treatments for IBS such as the µ-opioid receptor (agonists and antagonists), selective κ-opioid receptor agonists, anti-inflammatory drugs, serotonergic agents, bile acid modulators and intestinal bile acid transporters, which may prove promising in treating our patients.
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Affiliation(s)
- Jose L Barboza
- University of South Florida College of Pharmacy, 12901 Bruce B. Downs Blvd. MDC30, Tampa, FL, 33612, USA.
| | - Nicholas J Talley
- University of Newcastle, Callaghan, NSW, 2308, Australia
- Mayo Clinic, Jacksonville, FL, USA
| | - Baharak Moshiree
- Division of Gastroenterology, University of Miami Miller School of Medicine, 1120 NW 14th Street, Miami, FL, 33136, USA
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36
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Tavakkoli A, Sayed BA, Talley NJ, Moshiree B. Acid and non-acid reflux in patients refractory to proton pump inhibitor therapy: Is gastroparesis a factor? World J Gastroenterol 2013; 19:6193-6198. [PMID: 24115816 PMCID: PMC3787349 DOI: 10.3748/wjg.v19.i37.6193] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 07/14/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine whether an increased number and duration of non-acid reflux events as measured using the multichannel intraluminal impedance pH (MII-pH) is linked to gastroparesis (GP).
METHODS: A case control study was conducted in which 42 patients undergoing clinical evaluation for continued symptoms of gastroesophageal reflux disease (both typical and atypical symptoms) despite acid suppression therapy. MII-pH technology was used over 24 h to detect reflux episodes and record patients’ symptoms. Parameters evaluated in patients with documented GP and controls without GP by scintigraphy included total, upright, and supine number of acid and non-acid reflux episodes (pH < 4 and pH > 4, respectively), the duration of acid and non-acid reflux in a 24-h period, and the number of reflux episodes lasting longer than 5 min.
RESULTS: No statistical difference was seen between the patients with GP and controls with respect to the total number or duration of acid reflux events, total number and duration of non-acid reflux events or the duration of longest reflux episodes. The number of non-acid reflux episodes with a pH > 7 was higher in subjects with GP than in controls. In addition, acid reflux episodes were more prolonged (lasting longer than 5 min) in the GP patients than in controls; however, these values did not reach statistical significance. Thirty-five patients had recorded symptoms during the 24 h study and of the 35 subjects, only 9% (n = 3) had a positive symptom association probability (SAP) for acid/non-acid reflux and 91% had a negative SAP.
CONCLUSION: The evaluation of patients with a documented history of GP did not show an association between GP and more frequent episodes of non-acid reflux based on MII-pH testing.
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Chini P, Toskes PP, Waseem S, Hou W, McDonald R, Moshiree B. Effect of azithromycin on small bowel motility in patients with gastrointestinal dysmotility. Scand J Gastroenterol 2012; 47:422-7. [PMID: 22364597 DOI: 10.3109/00365521.2012.654402] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the effect of azithromycin (AZI) on small bowel activity in patients with gastrointestinal dysmotility (GID). MATERIAL AND METHODS Manometric data on a consecutive series of 21 patients was reviewed. Only those patients with gastroparesis and small bowel dysmotility as defined by antroduodenal manometric criteria were included. Pressure profiles were recorded in three stages: baseline period, fed state and postprandial after administration of erythromycin (ERY) and AZI. The measured parameters included the number and characteristics of activity fronts and migrating motor complexes (MMCs) including duration, amplitude and frequency of contractions. The data were analyzed using repeated measures analysis of variance for comparison of each medication. RESULTS AZI induced more MMCs in the duodenum with origin of activity fronts in the antrum than did ERY (18 patients with AZI, 10 patients with ERY). No significant difference between AZI and ERY was seen with respect to the amplitude of MMCs or number of cycles per minute. The average duration of activity fronts was longer with AZI compared with ERY (AZI mean 18.5 min, ERY mean 9.7 min, p < 0.02). CONCLUSIONS AZI induces activity fronts in the antrum followed by duodenal contractions more frequently than ERY in patients with GID. AZI potentially promises to be a prokinetic for treatment of small bowel dysmotility.
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Affiliation(s)
- Payam Chini
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL 32608, USA.
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39
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Draganov PV, Chang MN, Alkhasawneh A, Dixon LR, Lieb J, Moshiree B, Polyak S, Sultan S, Collins D, Suman A, Valentine JF, Wagh MS, Habashi SL, Forsmark CE. Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps. Gastrointest Endosc 2012; 75:118-26. [PMID: 22196811 DOI: 10.1016/j.gie.2011.08.019] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 08/10/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Polypectomy with cold biopsy forceps is a frequently used technique for removal of small, sessile, colorectal polyps. Jumbo forceps may lead to more effective polypectomy because of the larger size of the forceps cup. OBJECTIVE To evaluate the efficiency of cold jumbo biopsy forceps compared with standard forceps for polypectomy of small, sessile, colorectal polyps. DESIGN Randomized, controlled trial. SETTING Outpatient endoscopy center. PATIENTS This study involved 140 patients found to have at least one eligible polyp defined as a sessile polyp measuring ≤6 mm. INTERVENTION Polypectomy with cold biopsy forceps. MAIN OUTCOME MEASUREMENTS Complete visual polyp eradication with one forceps bite. RESULTS In 140 patients, a total of 305 eligible polyps were detected (151 removed with jumbo forceps and 154 with standard forceps). Complete visual eradication of the polyp with one forceps bite was achieved in 78.8% of the jumbo forceps group and 50.7% of the standard forceps group (P < .0001). Biopsies from the polypectomy sites of adenomatous polyps thought to be visually completely eradicated with one bite showed a trend toward a higher complete histologic eradication rate with the jumbo forceps (82.4%) compared with the standard forceps (77.4%), but the difference did not reach statistical significance (P = .62). The withdrawal time for visual inspection of the colon and time to perform polypectomies were significantly shorter in the jumbo forceps group (mean 21.43 vs 18.23 minutes; P = .02). LIMITATIONS Lack of blinding to the type of forceps used. CONCLUSION The jumbo biopsy forceps is superior to the standard forceps in removing small, sessile polyps. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00855790.).
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Affiliation(s)
- Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, FL, USA
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Grundmann O, Yoon SL, Moshiree B. Current developments for the diagnosis and treatment of irritable bowel syndrome. Curr Pharm Des 2011; 16:3638-45. [PMID: 21128902 DOI: 10.2174/138161210794079227] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Accepted: 11/10/2010] [Indexed: 11/22/2022]
Abstract
Current treatment options for the chronic gastrointestinal disorder irritable bowel syndrome (IBS) have long been limited to symptomatic treatments due to lack of pathophysiologic understanding of the syndrome. Within the past 10 years, however, a number of new pharmacological targets have been identified that may aid in the treatment of irritable bowel syndrome. Although only a limited number of new drug entities have entered the market in the past years, many new potential pharmacophores are evolving. Among them, several drugs are in the pipeline that target cholecystokinin or corticotropin-releasing factor receptors, serve as inhibitors for specific tryptophan hydroxylase iso-enzymes, modulate chloride secretion, influence immune responses via monoclonal antibodies or ATP-mediated pathways, and even normalize the gastrointestinal microflora via supplementation with probiotics. While new treatments that act via chloride secretion and immune modulation present with favorable outcomes in clinical trials, other novel therapies require further evaluation. This review is intended to provide a synopsis of current and emerging pharmacotherapies for IBS.
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Affiliation(s)
- Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, P.O. Box 100485, Gainesville, FL 32610, USA.
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41
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Sultan S, Moshiree B. ACP Journal Club. Review: Polyethylene glycol is more effective than lactulose for chronic constipation in children and adults. Ann Intern Med 2010; 153:JC6-5. [PMID: 21173406 DOI: 10.7326/0003-4819-153-12-201012210-02005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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42
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Larson JM, Tavakkoli A, Drane WE, Toskes PP, Moshiree B. Advantages of azithromycin over erythromycin in improving the gastric emptying half-time in adult patients with gastroparesis. J Neurogastroenterol Motil 2010; 16:407-13. [PMID: 21103422 PMCID: PMC2978393 DOI: 10.5056/jnm.2010.16.4.407] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 10/07/2010] [Accepted: 10/07/2010] [Indexed: 01/13/2023] Open
Abstract
Background/Aims Current therapy for gastroparesis with prokinetic agents is limited by options and side effects. One macrolide, erythromycin (ERY), is associated with possible sudden cardiac death from QT prolongation due to P450 iso-enzyme inhibition. An alternative, azithromycin (AZI), lacks P450 inhibition. We compared the effect on gastric emptying half-times (t½) between AZI and ERY in patients diagnosed with gastroparesis by gastric emptying scintigraphy. Methods Patients stopped medications known to affect gastric emptying prior to the study, and then ingested 1 scrambled egg meal labeled with 18.5-37 MBq of technetium-99m sulfur colloid followed by continuous imaging for 120 minutes, at 1 minute per frame. A simple linear fit was applied to the rate of gastric emptying, and gastric emptying t½ was calculated (normal = 45-90 minutes). At 75-80 minutes, if the stomach had clearly not emptied, patients were given either ERY (n = 60) or AZI (n = 60) 250 mg IV and a new post-treatment gastric emptying t½ was calculated. Results Comparison of gastric emptying t½ showed a similar positive effect (mean gastric emptying t½ for AZI = 10.4 ± 7.2 minutes; mean gastric emptying t½ for ERY = 11.9 ± 8.4 minutes; p = 0.30). Conclusions AZI is equivalent to ERY in accelerating the gastric emptying of adult patients with gastroparesis. Given the longer duration of action, better side effect profile and lack of P450 interaction for AZI as compared with ERY, further research should evaluate the long term effectiveness and safety of AZI as a gastroparesis treatment.
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Affiliation(s)
- Jean M Larson
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
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43
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Abstract
Gastroparesis refers to abnormal gastric motility characterized by delayed gastric emptying in the absence of mechanical obstruction. The most common etiologies include diabetes, post-surgical and idiopathic. The most common symptoms are nausea, vomiting and epigastric pain. Gastroparesis is estimated to affect 4% of the population and symptomatology may range from little effect on daily activity to severe disability and frequent hospitalizations. The gold standard of diagnosis is solid meal gastric scintigraphy. Treatment is multimodal and includes dietary modification, prokinetic and anti-emetic medications, and surgical interventions. New advances in drug therapy, and gastric electrical stimulation techniques have been introduced and might provide new hope to patients with refractory gastroparesis. In this comprehensive review, we discuss gastroparesis with emphasis on the latest developments; from the perspective of the practicing clinician.
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44
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Moshiree B, Price DD, Robinson ME, Gaible R, Verne GN. Thermal and visceral hypersensitivity in irritable bowel syndrome patients with and without fibromyalgia. Clin J Pain 2007; 23:323-30. [PMID: 17449993 DOI: 10.1097/ajp.0b013e318032e496] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder characterized by both visceral and somatic hyperalgesia, producing a similar effect seen with the central hypersensitivity mechanism in fibromyalgia (FM). OBJECTIVES The aim of the current study was to compare magnitudes of visceral and thermal hypersensitivity in IBS patients and FM patients with IBS (FM+IBS) compared with healthy controls. METHODS Female patients with IBS (n=12), FM+IBS (n=12), and control participants (n=13) rated pain intensity to hot water immersion (45 and 47 degrees C) of the hand/foot and to phasic distension of the rectum (35, 55 mm Hg) on a Mechanical Visual Analog Scale. The data were analyzed with 3 separate 1-way analyses of variance with post hoc Tukey tests. RESULTS For both thermal and visceral stimuli, the control group had lower pain ratings than either the IBS or FM+IBS groups (P<0.001). IBS patients rated rectal distension as more painful than the FM+IBS group (P=0.005). During hot water immersion of the foot, the FM+IBS group had higher pain ratings than the IBS group (P<0.001). During hand immersion, FM+IBS and IBS patients did not significantly differ in their pain intensity ratings (P=0.4). CONCLUSIONS FM+IBS patients show greater thermal hypersensitivity compared with IBS patients. However, IBS patients exhibit higher pain ratings to rectal distension compared with FM+IBS patients. This data suggests that regions of primary and secondary hyperalgesia are dependent on the primary pain complaint.
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Affiliation(s)
- Baharak Moshiree
- Department of Medicine, University of Florida Colleges of Medicine, Dentistry, Public Health and Health Professions, Gainesville, FL 32610-0214, USA
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45
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Price DD, Zhou Q, Moshiree B, Robinson ME, Verne GN. Peripheral and central contributions to hyperalgesia in irritable bowel syndrome. J Pain 2006; 7:529-35. [PMID: 16885007 DOI: 10.1016/j.jpain.2005.12.011] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Revised: 11/29/2005] [Accepted: 12/26/2005] [Indexed: 11/27/2022]
Abstract
UNLABELLED Irritable bowel syndrome (IBS) is a common gastrointestinal disorder seen by gastroenterologists. We discuss some recent evidence for potential neural mechanisms that could contribute to somatic and visceral hyperalgesia in IBS patients. The combination of research studies of human IBS patients and studies of rats with delayed rectal hypersensitivity after recovery from experimentally induced neonatal colitis strongly suggests a mechanism wherein both primary visceral hyperalgesia and secondary widespread cutaneous hyperalgesia are dynamically maintained by tonic impulse input from the noninflamed colon and/or rectum. The secondary hyperalgesia is likely to be at least partly related to sensitization of spinal cord dorsal horn neurons and in this respect might be similar to other persistent pain conditions such as fibromyalgia and complex regional pain syndrome. PERSPECTIVE Pain in irritable bowel syndrome is likely to be at least partly maintained by peripheral impulse input from the colon/rectum and central sensitization, yet it is also highly modifiable by psychological factors such as nocebo and placebo effects. A synergistic interaction might occur between psychological factors and abnormal afferent processing.
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Affiliation(s)
- Donald D Price
- Department of Oral Surgery, University of Florida College of Dentistry, Gainesville, FL 32610-0214, USA
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46
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Zhou Q, Caudle RM, Moshiree B, Price DD, Verne GN. Phosphorylation of NMDA NR1 subunits in the myenteric plexus during TNBS induced colitis. Neurosci Lett 2006; 406:250-5. [PMID: 16942839 DOI: 10.1016/j.neulet.2006.07.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Accepted: 07/21/2006] [Indexed: 01/18/2023]
Abstract
N-Methyl-d-aspartic acid (NMDA) receptors are known to function in the mediation of pain and have a significant role in the development of hyperalgesia following inflammation. Serine phosphorylation regulation of NMDA receptor function occurs in a variety of conditions. No studies have demonstrated a change in phosphorylation of enteric NMDA receptors following colonic inflammation. We examined the levels of NMDA NR1 phosphorylation in trinitrobenzene sulfonic acid (TNBS) induced colitis in rats and compared it to protein translation and the development of visceral hypersensitivity. We have previously, demonstrated an increase in the C1 cassette of NR1 mRNA expression at 14, 21, and 28 days following TNBS administration. In this study, we examined the NR1 serine phosphorylation at 14 days following TNBS injection. Male Sprague-Dawley rats (200-250 g) were treated with TNBS (20mg per rat) diluted in 50% ethanol (n=3) and vehicle controls of 50% ethanol (n=3). TNBS and vehicle controls were administered with a 24 gauge catheter inserted into the lumen of the rat colon. The animals were sacrificed at 14 days after induction of the colitis and their distal colon was retrieved for two-dimensional (2D) western blot analysis. Serine phosphorylation of the NR1 subunit with C1 cassette appears at 14 days after TNBS injection. In contrast, there was no NR1-C1 expression in the vehicle controls and untreated normal controls. These results suggest a role for colonic-NMDA receptor phosphorylation in the development of neuronal plasticity following colonic inflammation. Phosphorylation of NR1 may partially explain visceral hypersensitivity present during colonic inflammation.
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Affiliation(s)
- QiQi Zhou
- Department of Medicine, University of Florida College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Gainesville, FL 32610-0214, USA
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47
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Abstract
The concepts of visceral hyperalgesia and visceral hypersensitivity have been examined in a variety of functional gastrointestinal disorders (FGIDs). Although the pathophysiological mechanisms of pain and hypersensitivity in these disorders are still not well understood, exciting new developments in research have been made in the study of the brain-gut interactions involved in the FGIDs.
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Affiliation(s)
- B Moshiree
- Department of Medicine, University of Florida College of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, 1600 SW Archer Rd, HD 602, PO Box 100214, Gainesville, FL 32610-0214, USA
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48
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Abstract
Irritable bowel syndrome represents a common gastrointestinal disorder that significantly impacts patients' lives. It is defined by Rome II criteria and characterized by abdominal pain and bloating associated with changes in bowel habit. Visceral hypersensitivity is currently considered a biological marker for the disease. Current therapeutic treatments include the use of fiber supplements, antidiarrheal agents, laxatives, antispasmodics, tricyclic antidepressants and serotonergic agents. Through a proper understanding of the diagnostic criteria, pathophysiology and treatment options, this disorder can be treated effectively in many patients.
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Affiliation(s)
- Vishal Gupta
- University of Florida, Department of Medicine, Division of Gastroenterology, Gainesville, Florida 32608, USA
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