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Walters AS, Li Y, Koo BB, Ondo WG, Weinstock LB, Champion D, Afrin LB, Karroum EG, Bagai K, Spruyt K. Review of the role of the endogenous opioid and melanocortin systems in the restless legs syndrome. Brain 2024; 147:26-38. [PMID: 37633259 PMCID: PMC10796165 DOI: 10.1093/brain/awad283] [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: 03/07/2023] [Revised: 07/23/2023] [Accepted: 08/01/2023] [Indexed: 08/28/2023] Open
Abstract
Restless legs syndrome (RLS) is responsive to opioid, dopaminergic and iron-based treatments. Receptor blocker studies in RLS patients suggest that the therapeutic efficacy of opioids is specific to the opioid receptor and mediated indirectly through the dopaminergic system. An RLS autopsy study reveals decreases in endogenous opioids, β-endorphin and perhaps Met-enkephalin in the thalamus of RLS patients. A total opioid receptor knock-out (mu, delta and kappa) and a mu-opioid receptor knock-out mouse model of RLS show circadian motor changes akin to RLS and, although both models show sensory changes, the mu-opioid receptor knock mouse shows circadian sensory changes closest to those seen in idiopathic RLS. Both models show changes in striatal dopamine, anaemia and low serum iron. However, only in the total receptor knock-out mouse do we see the decreases in serum ferritin that are normally found in RLS. There are also decreases in serum iron when wild-type mice are administered a mu-opioid receptor blocker. In addition, the mu-opioid receptor knock-out mouse also shows increases in striatal zinc paralleling similar changes in RLS. Adrenocorticotropic hormone and α-melanocyte stimulating hormone are derived from pro-opiomelanocortin as is β-endorphin. However, they cause RLS-like symptoms and periodic limb movements when injected intraventricularly into rats. These results collectively suggest that an endogenous opioid deficiency is pathogenetic to RLS and that an altered melanocortin system may be causal to RLS as well.
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Affiliation(s)
- Arthur S Walters
- Sleep Division, Department of Neurology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Yuqing Li
- Norman Fixel Institute for Neurological Diseases, Department of Neurology, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Brian B Koo
- Sleep Medicine Laboratory, VA Connecticut Health Care System, West Haven, CT 06516, USA
- Yale Center for Restless Legs Syndrome, Yale School of Medicine, New Haven, CT 06520, USA
| | - William G Ondo
- Department of Neurology, Methodist Hospital, Weill Cornell Medical School, Houston, TX 77030, USA
| | - Leonard B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St.Louis, MO 63130, USA
| | - David Champion
- Sydney Children's Hospital, Department of Pain Medicine, Randwick, NSW 2031, Australia
| | - Lawrence B Afrin
- Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, NY 10577, USA
| | - Elias G Karroum
- Department of Neurology and Rehabilitation Medicine, The George Washington University School of Medicine and Health Sciences, George Washington University, Washington, D.C. 20052, USA
| | - Kanika Bagai
- Sleep Division, Department of Neurology, Vanderbilt University Medical Center, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Karen Spruyt
- Université Paris Cité, NeuroDiderot Inserm, Paris 75019, France
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Weinstock LB, Nelson RM, Blitshteyn S. Neuropsychiatric Manifestations of Mast Cell Activation Syndrome and Response to Mast-Cell-Directed Treatment: A Case Series. J Pers Med 2023; 13:1562. [PMID: 38003876 PMCID: PMC10672129 DOI: 10.3390/jpm13111562] [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: 09/10/2023] [Revised: 10/19/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
Mast cell activation syndrome (MCAS) is an immune disease with an estimated prevalence of 17%. Mast cell chemical mediators lead to heterogeneous multisystemic inflammatory and allergic manifestations. This syndrome is associated with various neurologic and psychiatric disorders, including headache, dysautonomia, depression, generalized anxiety disorder, and many others. Although MCAS is common, it is rarely recognized, and thus, patients can suffer for decades. The syndrome is caused by aberrant mast cell reactivity due to the mutation of the controller gene. A case series is presented herein including eight patients with significant neuropsychiatric disorders that were often refractory to standard medical therapeutics. Five patients had depression, five had generalized anxiety disorder, and four had panic disorder. Other psychiatric disorders included attention-deficit hyperactivity disorder, obsessive compulsive disorder, phobias, and bipolar disorder. All eight patients were subsequently diagnosed with mast cell activation syndrome; six had comorbid autonomic disorders, the most common being postural orthostatic tachycardia syndrome; and four had hypermobile Ehlers-Danlos syndrome. All patients experienced significant improvements regarding neuropsychiatric and multisystemic symptoms after mast-cell-directed therapy. In neuropsychiatric patients who have systemic symptoms and syndromes, it is important to consider the presence of an underlying or comorbid MCAS.
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Affiliation(s)
- Leonard B. Weinstock
- Independent Researcher, Specialists in Gastroenterology, St. Louis, MO 63141, USA
| | - Renee M. Nelson
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA; (R.M.N.); (S.B.)
| | - Svetlana Blitshteyn
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY 14203, USA; (R.M.N.); (S.B.)
- Dysautonomia Clinic, Williamsville, NY 14221, USA
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Zienkiewicz T, Homann J, Mücke M, Seidel H, Hertfelder HJ, Weinstock LB, Afrin LB, Molderings GJ. Evaluation of a tryptase depletion index for better pathologic identification of mast cell activation syndrome. Z Gastroenterol 2023; 61:268-274. [PMID: 35576976 DOI: 10.1055/a-1833-9226] [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] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Laboratory evidence supporting diagnosis of the prevalent condition of mast cell activation syndrome (MCAS) currently includes elevated levels in blood or urine of mediators relatively specific to mast cells (MCs) and/or increased numbers of MCs in luminal gastrointestinal (GI) tract tissues. However, identification of elevated mediators is technically challenging and expensive, and controversy persists regarding the normal ranges of numbers/counts of MCs in various GI tract segments, let alone challenges in determining how many of the visualized MCs are activated. To aid diagnosis of MCAS, we developed a potential new approach for the pathologist to identify the extent of GI tract MC activation easily and inexpensively. PARTICIPANTS AND METHODS Visualization of MCs in gastrointestinal biopsies from 251 patients vs. 95 controls using antibodies against CD117 and tryptase; MC counting per mm2; calculation of the difference between the CD117-positive MCs (identifying all MCs) vs. tryptase-positive MCs (identifying non-activated tryptase-containing MCs), which we define as the tryptase depletion index (TDI). RESULTS Mean total MC counts did not differ significantly between patients and controls, but mean TDIs differed significantly. Non-overlapping confidence intervals at the 99.9% level identified cut-offs of TDIs between patients vs. controls of 26, 45 and 32 MCs/mm2 in gastric antrum, duodenum, and colon, respectively. CONCLUSIONS The TDI may discriminate between MCAS patients vs. controls. If this preliminary work can be independently confirmed, the TDI may become a useful additional minor diagnostic criterion for MCAS.
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Affiliation(s)
| | - Jürgen Homann
- Division of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - Martin Mücke
- Institute for Digitalization in General Practice and Center for Rare Diseases Aachen (ZSEA), University Hospital Aachen, Aachen, Germany
| | - Holger Seidel
- Center for Bleeding Disorders and Transfusion Medicine (CBT), Bonn, Germany
| | | | - Leonard B Weinstock
- Departments of Medicine, Missouri Baptist Medical Center and Washington University School of Medicine, St. Louis, MO, United States
| | - Lawrence B Afrin
- AIM Center for Personalized Medicine, Purchase, NY, United States
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Walters AS, Li Y, Karroum EG, Champion D, Weinstock LB, Bagai K, Afrin LB, Spruyt K. Exploring the role of the endogenous opiate system in the pathogenesis of anemia in an opiate receptor knock-out model of Restless Legs Syndrome. Med Hypotheses 2022; 167:110941. [PMID: 36505961 PMCID: PMC9731170 DOI: 10.1016/j.mehy.2022.110941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Restless Legs Syndrome (RLS) is characterized by bothersome leg discomfort accompanied by an urge to move to obtain relief and symptoms are worse at night and on lying down. There is at least partial and temporary relief with activity. It is also an opioid responsive disorder, often accompanied by iron deficiency with or without anemia, and inflammation may be a precipitating factor in some cases. We created two in-vivo opiate receptor knock out mouse models of RLS - a triple opiate receptor knock-out mouse and a mu opiate receptor knock-out mouse. Both sets of animals were restless during the sleep period as is also true of RLS. Both of our knockout models showed statistically significantly decreased Hemoglobin and Hematocrit indicating anemia and both models showed statistically significant decreases in serum iron suggestive of either iron deficiency anemia or inflammatory anemia. The rest of the hematologic studies were not consistent enough to determine which of these two types of anemia was present in either model. An additional experiment in normal wild type mice showed a statistically significant decrease in serum iron when an opiate receptor blocker was used. To our knowledge this is the first demonstration that deficiency of endogenous opioids might play a role in the production of anemia. Our hypothesis is that an intact endogenous opiate system is necessary for red cell homeostasis. The presence of opioid receptors both on red blood cells and on various immunologically based white blood cells suggest mechanisms by which deficiency in the endogenous opiate system could cause anemia of either the iron deficiency or inflammatory types. The administration of opioid agonists or antagonists to iron deficient cultures of red blood cell precursors is a next step in determining the role of the endogenous opiate system in the maintenance of red cell homeostasis and in the possible prevention of iron deficiency or inflammatory anemia where iron dysregulation is key.
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Affiliation(s)
- Arthur S. Walters
- Sleep Division, Dept of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yuqing Li
- Norman Fixel Institute for Neurological Diseases, Dept of Neurology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Elias G. Karroum
- Department of Neurology & Rehabilitation Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC., USA
| | - David Champion
- Sydney Children’s Hospital, Randwick, NSW 2031, Australia
| | - Leonard B. Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Kanika Bagai
- Sleep Division, Dept of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lawrence B. Afrin
- Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, New York
| | - Karen Spruyt
- Université de Paris, NeuroDiderot Inserm, France
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Weinstock LB, Brook JB, Molderings GJ. Efficacy and toxicity of hydroxyurea in mast cell activation syndrome patients refractory to standard medical therapy: retrospective case series. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:1441-1447. [PMID: 35982335 PMCID: PMC9388361 DOI: 10.1007/s00210-022-02282-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/11/2022] [Indexed: 12/04/2022]
Abstract
Determine efficacy and adverse events (AEs) of hydroxyurea (HU) in mast cell activation syndrome (MCAS) patients who were refractory to standard medical therapy. An electronic chart review was performed to find MCAS patients who received HU in a MCAS medical practice. Diagnosis of MCAS was established on the basis of mast cell (MC) activation symptoms in ≥ 5 systems plus ≥ 1 abnormal MC mediators and/or ≥ 20 MC/high power field on duodenal biopsies. Medicines not providing significant clinical improvement prior to HU were tabulated. The following symptoms were evaluated by patients on a 0–10 scale prior to and at the study conclusion: bone pain, abdominal pain, diarrhea, bloating, and nausea. Safety labs were obtained on a regular basis. Twenty out of three hundred ten (8.4%) MCAS patients received HU. Patients included 22 females, average age 42.4 years. Dysautonomia was present in 60%. An average of 10.6 (SD 1.7, range 8–13) medications were used prior to adding HU to various concomitant medications. Average dose of HU was 634 mg. In 20 patients who continued therapy for ≥ 2 months, there was statistically significant reduction of bone pain, abdominal pain, diarrhea, bloating, and nausea. Fourteen patients noted prolonged success with therapy. Six patients stopped HU within 6 weeks owing to AEs. Four patients treated ≥ 2 months had AEs and 2 led to HU cessation. All AEs were reversible. Refractory MCAS patients showed clear significant improvement in bone pain and gastrointestinal symptoms on HU. Systematic monitoring was effective in preventing the occurrence of severe HU-induced adverse events.
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Affiliation(s)
- Leonard B Weinstock
- Clinical Medicine, Department of Medicine, Washington University School of Medicine, President, Specialists in Gastroenterology, 11525 Olde Cabin Road, St. Louis, MO, 63141, USA
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Campbell AW, Weinstock LB. Molds, Mycotoxins, the Brain, the Gut and Misconceptions. Altern Ther Health Med 2022; 28:8-12. [PMID: 35353713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Molds are present in homes and other indoor places that are water damaged and they produce mycotoxins. One mold species can produce several different mycotoxins and one mycotoxin can come from several different molds. Even small amounts of mold growth in an air conditioner or in ducts will result in the occupants being chronically exposed, constantly breathing mold spores and mycotoxins, causing illness.
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Weinstock LB, Brook JB, Walters AS, Goris A, Afrin LB, Molderings GJ. Restless legs syndrome is associated with long-COVID in women. J Clin Sleep Med 2022; 18:1413-1418. [PMID: 35484639 PMCID: PMC9059584 DOI: 10.5664/jcsm.9898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sleep disturbance is common in long-COVID (LC). Restless legs syndrome (RLS) is characterized by sleep disturbance and has been reported after viral infections. Therefore, we evaluated RLS symptoms cross-sectionally in individuals with LC at both current and pre-coronavirus disease 2019 (pre-COVID-19) time points. METHODS Adults on LC-focused Facebook pages were recruited for an online assessment of symptoms before COVID-19 infection and during their present LC state in a cross-sectional manner. The LC group documented baseline symptoms retrospectively. Questions were included about the presence/severity of RLS symptoms and assessments of fatigue, quality of life, and sleep apnea. A control group was recruited and included individuals ≥ 18 years of age who never had overt symptoms of COVID-19. Pregnancy was an exclusion criterion for both groups. RESULTS There were 136 participants with LC (89.7% females, age 46.9 ± 12.9 years) and 136 controls (65.4% females, age 49.2 ± 15.5). RLS prevalence in females with LC was 5.7% pre-COVID-19 and 14.8% post-COVID-19 (P < .01) vs 6.7% in control females. Severity of RLS was moderate in both groups. Logistic regression predicting post-COVID-19 RLS among females with LC failed to find significant effects of hospitalization, sleep apnea, neuropathic pain severity, or use of antihistamines and antidepressants. CONCLUSIONS The baseline prevalence of RLS in females with LC was similar to the general population group as well as to patients in epidemiological studies. The prevalence significantly increased in the LC state. Postinfectious immunological mechanisms may be at play in the production for RLS symptoms. CITATION Weinstock LB, Brook JB, Walters AS, Goris A, Afrin LB, Molderings GJ. Restless legs syndrome is associated with long-COVID in women. J Clin Sleep Med. 2022;18(5):1413-1418.
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Affiliation(s)
- Leonard B. Weinstock
- Departments of Medicine, Missouri Baptist Medical Center and Washington University School of Medicine, St. Louis, MO
| | | | - Arthur S. Walters
- Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Ashleigh Goris
- Infection Prevention & Control and Clinical Quality, Missouri Baptist Medical Center, St. Louis, MO
| | - Lawrence B. Afrin
- Department of Mast Cell Studies, Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, NY
| | - Gerhard J. Molderings
- Molecular Geneticist, Immunologist, Institute of Human Genetics, University Hospital Bonn, Bonn, Germany
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Afrin LB, Dempsey TT, Weinstock LB. Post-HPV-Vaccination Mast Cell Activation Syndrome: Possible Vaccine-Triggered Escalation of Undiagnosed Pre-Existing Mast Cell Disease? Vaccines (Basel) 2022; 10:127. [PMID: 35062788 PMCID: PMC8779641 DOI: 10.3390/vaccines10010127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 01/27/2023] Open
Abstract
For nearly a decade, case reports and series have emerged regarding dysautonomias-particularly postural orthostatic tachycardia syndrome (POTS)-presenting soon after vaccination against human papilloma virus (HPV). We too have observed a number of such cases (all following vaccination with the Gardasil product), and have found several to have detectable mast cell activation syndrome (MCAS) as well as histories suggesting that MCAS was likely present long before vaccination. We detail 11 such cases here, posing a hypothesis that HPV vaccination (at least with the Gardasil product) may have triggered or exacerbated MCAS in teenagers previously not recognized to have it. Only recently recognized, MCAS is being increasingly appreciated as a prevalent and chronic multisystem disorder, often emerging early in life and presenting with inflammatory ± allergic phenomena following from known mast cell (MC) mediator effects. There is rising recognition, too, of associations of MCAS with central and peripheral neuropathic disorders, including autonomic disorders such as POTS. Given the recognized potential for many antigens to trigger a major and permanent escalation of baseline MC misbehavior in a given MCAS patient, we hypothesize that in our patients described herein, vaccination with Gardasil may have caused pre-existing (but not yet clinically recognized) MCAS to worsen to a clinically significantly degree, with the emergence of POTS and other issues. The recognition and management of MCAS prior to vaccinations in general may be a strategy worth investigating for reducing adverse events following HPV vaccinations and perhaps even other types of vaccinations.
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Affiliation(s)
- Lawrence B. Afrin
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Tania T. Dempsey
- AIM Center for Personalized Medicine, Purchase, New York, NY 10577, USA;
| | - Leonard B. Weinstock
- Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
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Weinstock LB, Brook JB, Walters AS, Goris A, Afrin LB, Molderings GJ. Mast cell activation symptoms are prevalent in Long-COVID. Int J Infect Dis 2021; 112:217-226. [PMID: 34563706 PMCID: PMC8459548 DOI: 10.1016/j.ijid.2021.09.043] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/17/2021] [Accepted: 09/19/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives Hyper-inflammation caused by COVID-19 may be mediated by mast cell activation (MCA) which has also been hypothesized to cause Long-COVID (LC) symptoms. We determined prevalence/severity of MCA symptoms in LC. Methods Adults in LC-focused Facebook support groups were recruited for online assessment of symptoms before and after COVID-19. Questions included presence and severity of known MCA and LC symptoms and validated assessments of fatigue and quality of life. General population controls and mast cell activation syndrome (MCAS) patients were recruited for comparison if they were ≥18 years of age and never had overt COVID-19 symptoms. Results There were 136 LC subjects (89.7% females, age 46.9 ±12.9 years), 136 controls (65.4% females, age 49.2 ±15.5), and 80 MCAS patients (85.0% females, age 47.7 ±16.4). Pre-COVID-19 LC subjects and controls had virtually identical MCA symptom and severity analysis. Post-COVID-19 LC subjects and MCAS patients prior to treatment had virtually identical MCA symptom and severity analysis. Conclusions MCA symptoms were increased in LC and mimicked the symptoms and severity reported by patients who have MCAS. Increased activation of aberrant mast cells induced by SARS-CoV-2 infection by various mechanisms may underlie part of the pathophysiology of LC, possibly suggesting routes to effective therapy.
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Affiliation(s)
- Leonard B Weinstock
- Associate Professor of Clinical Medicine, Departments of Medicine, Missouri Baptist Medical Center and Washington University School of Medicine, President, Specialists in Gastroenterology, 11525 Olde Cabin Road, St. Louis, MO, USA 63141, TEL 314-997-4627, FAX 314-997-5086.
| | - Jill B Brook
- Biostatistics, Private Practice, 13285 Roundhill, Truckee, CA, USA 96161, TEL 626-375-6725.
| | - Arthur S Walters
- Professor of Neurology, Division of Sleep Medicine, Vanderbilt University School of Medicine, Medical Center North A-0118, 1161 21(st) Ave South, Nashville, TN, USA 37232-2551, TEL 615-322-0283, FAX 615- 936-5663.
| | - Ashleigh Goris
- Manager, Infection Prevention & Control and Clinical Quality, Missouri Baptist Medical Center, Mailstop: 95, 3015 N. Ballas Road, St. Louis, MO, USA 63131, TEL 314-996-5421, FAX 314-996-5909.
| | - Lawrence B Afrin
- Department of Mast Cell Studies, Hematology/Oncology, AIM Center for Personalized Medicine, Purchase, NY, USA 10577, TEL 914-730-7390, FAX 914-730-7391.
| | - Gerhard J Molderings
- Associate Professor of Pharmacology and Toxicology, Molecular Geneticist, Immunologist, Institute of Human Genetics, University Hospital Bonn, D53127 Bonn, Germany, TEL ++49 1623322001, FAX ++49 2225 9984911.
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Afrin LB, Ackerley MB, Bluestein LS, Brewer JH, Brook JB, Buchanan AD, Cuni JR, Davey WP, Dempsey TT, Dorff SR, Dubravec MS, Guggenheim AG, Hindman KJ, Hoffman B, Kaufman DL, Kratzer SJ, Lee TM, Marantz MS, Maxwell AJ, McCann KK, McKee DL, Menk Otto L, Pace LA, Perkins DD, Radovsky L, Raleigh MS, Rapaport SA, Reinhold EJ, Renneker ML, Robinson WA, Roland AM, Rosenbloom ES, Rowe PC, Ruhoy IS, Saperstein DS, Schlosser DA, Schofield JR, Settle JE, Weinstock LB, Wengenroth M, Westaway M, Xi SC, Molderings GJ. Diagnosis of mast cell activation syndrome: a global "consensus-2". Diagnosis (Berl) 2021; 8:137-152. [PMID: 32324159 DOI: 10.1515/dx-2020-0005] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [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: 01/05/2020] [Accepted: 02/15/2020] [Indexed: 02/06/2023]
Abstract
The concept that disease rooted principally in chronic aberrant constitutive and reactive activation of mast cells (MCs), without the gross MC neoplasia in mastocytosis, first emerged in the 1980s, but only in the last decade has recognition of "mast cell activation syndrome" (MCAS) grown significantly. Two principal proposals for diagnostic criteria have emerged. One, originally published in 2012, is labeled by its authors as a "consensus" (re-termed here as "consensus-1"). Another sizable contingent of investigators and practitioners favor a different approach (originally published in 2011, newly termed here as "consensus-2"), resembling "consensus-1" in some respects but differing in others, leading to substantial differences between these proposals in the numbers of patients qualifying for diagnosis (and thus treatment). Overdiagnosis by "consensus-2" criteria has potential to be problematic, but underdiagnosis by "consensus-1" criteria seems the far larger problem given (1) increasing appreciation that MCAS is prevalent (up to 17% of the general population), and (2) most MCAS patients, regardless of illness duration prior to diagnosis, can eventually identify treatment yielding sustained improvement. We analyze these proposals (and others) and suggest that, until careful research provides more definitive answers, diagnosis by either proposal is valid, reasonable, and helpful.
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Affiliation(s)
| | | | - Linda S Bluestein
- Department of Anesthesiology, Medical College of Wisconsin, Wausau, WI, USA
| | | | - Jill B Brook
- Alaska Internal Medicine and Pediatrics, Anchorage, AK, USA
| | | | - Jill R Cuni
- Division of Pediatrics, Beaver Medical Group, Banning, CA, USA
| | - William P Davey
- Department of Dermatology, University of Kentucky, Lexington, KY, USA
| | | | | | | | - Alena G Guggenheim
- Comprehensive Pain Center, Oregon Health and Science University, Portland, OR, USA
| | | | - Bruce Hoffman
- Hoffman Centre for Integrative and Functional Medicine, Calgary, Alberta, Canada
| | | | | | | | | | | | | | | | - Laurie Menk Otto
- Helfgott Research Institute, National College of Natural Medicine, Portland, OR, USA
| | - Laura A Pace
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, UT, USA
| | | | | | | | | | | | - Mark L Renneker
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | - William A Robinson
- Division of Hematology/Oncology, University of Colorado, Denver, CO, USA
| | - Aaron M Roland
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Jill R Schofield
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Janet E Settle
- Department of Psychiatry, University of Colorado, Denver, CO, USA
| | | | - Martina Wengenroth
- Institute of Neuroradiology, University Hospital Lübeck, Lübeck, Germany
| | | | - Shijun Cindy Xi
- Section of Allergy and Immunology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Walters AS, Paueksakon P, Adler CH, Moussouttas M, Weinstock LB, Spruyt K, Bagai K. Restless Legs Syndrome Shows Increased Silent Postmortem Cerebral Microvascular Disease With Gliosis. J Am Heart Assoc 2021; 10:e019627. [PMID: 33998250 PMCID: PMC8483539 DOI: 10.1161/jaha.120.019627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Patients with restless legs syndrome (RLS) have increased silent microvascular disease by magnetic resonance imaging. However, there has been no previous autopsy confirmation of these magnetic resonance imaging findings. RLS is also frequently associated with inflammatory and immunologically mediated medical disorders. The postmortem cortex in patients with RLS was therefore evaluated for evidence of microvascular and immunological changes. Methods and Results Ten microvascular injury samples of precentral gyrus in 5 patients with RLS (3 men, 2 women; mean age, 81 years) and 9 controls (2 men, 7 women; mean age, 90 years) were studied by hematoxylin and eosin stains in a blinded fashion. None of the subjects had a history of stroke or neurologic insults. In a similar manner, the following immunohistochemistry stains were performed: (1) glial fibrillary acidic protein (representing gliosis, reactive change of glial cells in response to damage); (2) CD3 (a T‐cell marker); (3) CD19 (a B‐cell marker); (4) CD68 (a macrophage marker); and (5) CD117 (a mast cell marker). Patients with RLS had significantly greater silent microvascular disease (P=0.015) and gliosis (P=0.003). T cells were increased in RLS compared with controls (P=0.009) and tended to colocalize with microvascular disease (P=0.003). Other markers did not differ. There was no correlation between microvascular lesion load and RLS severity or duration. Conclusions Patients with RLS had statistically significantly more silent cerebral microvascular disease and gliosis than controls compatible with previous magnetic resonance imaging studies and with studies showing a link between RLS and hypertension, clinical stroke, and cardiovascular disease. T‐cell invasion may be a secondary phenomenon.
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Affiliation(s)
- Arthur S Walters
- Sleep Division Department of Neurology Vanderbilt University Medical Center Nashville TN
| | - Paisit Paueksakon
- Department of Pathology, Microbiology, and Immunology Vanderbilt University Medical Center Nashville TN
| | - Charles H Adler
- Department of Neurology Mayo Clinic College of Medicine Scottsdale AZ
| | - Michael Moussouttas
- Cerebrovascular Division Department of Neurology Rutgers Medical School New Brunswick NJ
| | | | | | - Kanika Bagai
- Sleep Division Department of Neurology Vanderbilt University Medical Center Nashville TN
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12
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Dodson C, Bagai K, Weinstock LB, Thompson E, Okamoto LE, Peltier A, Raj SR, Walters AS. Restless legs syndrome is increased in postural orthostatic tachycardia syndrome. J Clin Sleep Med 2021; 17:791-795. [PMID: 33231164 DOI: 10.5664/jcsm.9020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Postural orthostatic tachycardia syndrome (POTS) and restless legs syndrome (RLS) are both characterized by sleep disturbance along with autoimmune/inflammatory features and autonomic dysfunction. However, to our knowledge, there has been no direct study looking at the prevalence of RLS in patients with POTS patients compared with healthy participants (controls). METHODS Ninety-six physician-diagnosed patients with POTS (89 female and 7 male) and 130 controls (99 female and 31 male) were administered the Cambridge Hopkins questionnaire. Participants who were diagnosed with probable or definite RLS on the Cambridge Hopkins questionnaire were then contacted to determine the severity of RLS with the International Restless Legs Scale. RESULTS More patients with POTS (15 of 96; 15.6%) than controls (6 of 130; 4.6%) were diagnosed with probable or definite RLS on the Cambridge Hopkins questionnaire (P = .0048). A sensitivity analysis with only female respondents yielded similar results. RLS severity was in the moderate range (12.23 ± 9.22). CONCLUSIONS There is a higher prevalence of RLS in patients with POTS patients compared with controls. This association may have to do with shared increased inflammatory/autoimmune load and autonomic dysfunction.
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Affiliation(s)
- Caroline Dodson
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kanika Bagai
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Emily Thompson
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Luis E Okamoto
- Clinical Pharmacology Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda Peltier
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Arthur S Walters
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Weinstock LB, Pace LA, Rezaie A, Afrin LB, Molderings GJ. Mast Cell Activation Syndrome: A Primer for the Gastroenterologist. Dig Dis Sci 2021; 66:965-982. [PMID: 32328892 DOI: 10.1007/s10620-020-06264-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
Mast cell activation syndrome is thought to be a common, yet under-recognized, chronic multi-system disorder caused by inappropriate mast cell activation. Gastrointestinal symptoms are frequently reported by these patients and are often mistaken by physicians as functional gastrointestinal disorders. This syndrome can be diagnosed by the medical history and measurable biomarkers. Gastroenterologists manage diseases associated with active inflammatory cells including neutrophils, lymphocytes, macrophages, and eosinophils. The mast cell has only recently been recognized as a major player in our specialty. Gastrointestinal disorders from mast cell mediators often present with apparent irritable bowel syndrome, dyspepsia, chronic or cyclical nausea, and heartburn. Individuals with mast cell activation syndrome experience significant delays in diagnosis. The gastrointestinal symptoms are often refractory to symptom-targeted prescription medications. Beyond avoiding triggers, the best therapy is directed at modulating mast cell activation and the effects of the mediators. Many of these therapies are simple over-the-counter medications. In this article, we review mast cell function and dysfunction and the gastrointestinal symptoms, comorbid conditions, diagnosis, and management of mast cell activation syndrome. Gastroenterologists who become aware of this syndrome can dramatically improve the quality of life for their patients who previously have been labeled with a functional gastrointestinal disorder.
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Affiliation(s)
- Leonard B Weinstock
- Specialists in Gastroenterology, 11525 Olde Cabin Rd, St. Louis, MO, 63141, USA.
| | - Laura A Pace
- Division of Gastroenterology, Department of Internal Medicine, University of Utah, 30 N 1900 E, SOM 4R118, Salt Lake City, UT, 84132, USA
| | - Ali Rezaie
- Cedars-Sinai Medical Center, Gastroenterology, 8730 Alden Dr., Suite 204E, Los Angeles, CA, 90048, USA
| | - Lawrence B Afrin
- Armonk Integrative Medicine, Hematology/Oncology, 3010 Westchester Avenue, Suite 401, Armonk, NY, 10577, USA
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14
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Afrin LB, Weinstock LB, Molderings GJ. Covid-19 hyperinflammation and post-Covid-19 illness may be rooted in mast cell activation syndrome. Int J Infect Dis 2020; 100:327-332. [PMID: 32920235 PMCID: PMC7529115 DOI: 10.1016/j.ijid.2020.09.016] [Citation(s) in RCA: 171] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES One-fifth of Covid-19 patients suffer a severe course of Covid-19 infection; however, the specific causes remain unclear. Mast cells (MCs) are activated by SARS-CoV-2. Although only recently recognized, MC activation syndrome (MCAS), usually due to acquired MC clonality, is a chronic multisystem disorder with inflammatory and allergic themes, and an estimated prevalence of 17%. This paper describes a novel conjecture explaining how MCAS might cause a propensity for severe acute Covid-19 infection and chronic post-Covid-19 illnesses. METHODS Observations of Covid-19 illness in patients with/without MCAS were compared with extensive clinical experience with MCAS. RESULTS The prevalence of MCAS is similar to that of severe cases within the Covid-19-infected population. Much of Covid-19's hyperinflammation is concordant with manners of inflammation which MC activation can drive. Drugs with activity against MCs or their mediators have preliminarily been observed to be helpful in Covid-19 patients. None of the authors' treated MCAS patients with Covid-19 suffered severe infection, let alone mortality. CONCLUSIONS Hyperinflammatory cytokine storms in many severely symptomatic Covid-19 patients may be rooted in an atypical response to SARS-CoV-2 by the dysfunctional MCs of MCAS rather than a normal response by normal MCs. If proven, this theory has significant therapeutic and prognostic implications.
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Affiliation(s)
- Lawrence B Afrin
- Department of Mast Cell Studies, AIM Center for Personalized Medicine, Purchase, New York, USA.
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15
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Molderings GJ, Dumoulin FL, Homann J, Sido B, Textor J, Mücke M, Qagish GJ, Barion R, Raithel M, Klingmüller D, Schäfer VS, Hertfelder HJ, Berdel D, Tridente G, Weinstock LB, Afrin LB. Adrenal insufficiency is a contraindication for omalizumab therapy in mast cell activation disease: risk for serum sickness. Naunyn Schmiedebergs Arch Pharmacol 2020; 393:1573-1580. [PMID: 32377770 PMCID: PMC7419348 DOI: 10.1007/s00210-020-01886-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
Omalizumab is an effective therapeutic humanized murine IgE antibody in many cases of primary systemic mast cell activation disease (MCAD). The present study should enable the clinician to recognize when treatment of MCAD with omalizumab is contraindicated because of the potential risk of severe serum sickness and to report our successful therapeutic strategy for such adverse event (AE). Our clinical observations, a review of the literature including the event reports in the FDA AE Reporting System, the European Medicines Agency Eudra-Vigilance databases (preferred search terms: omalizumab, Xolair®, and serum sickness) and information from the manufacturer’s Novartis database were used. Omalizumab therapy may be more likely to cause serum sickness than previously thought. In patients with regular adrenal function, serum sickness can occur after 3 to 10 days which resolves after the antigen and circulating immune complexes are cleared. If the symptoms do not resolve within a week, injection of 20 to 40 mg of prednisolone on two consecutive days could be given. However, in MCAD patients whose adrenal cortical function is completely suppressed by exogenous glucocorticoid therapy, there is a high risk that serum sickness will be masked by the MCAD and evolve in a severe form with pronounced damage of organs and tissues, potentially leading to death. Therefore, before the application of the first omalizumab dose, it is important to ensure that the function of the adrenal cortex is not significantly limited so that any occurring type III allergy can be self-limiting.
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Affiliation(s)
- G J Molderings
- Institute of Human Genetics, University Hospital Bonn, Venusberg-Campus 1, D-53127, Bonn, Germany.
| | - F L Dumoulin
- Department of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - J Homann
- Department of Internal Medicine, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - B Sido
- Department of General and Visceral Surgery, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - J Textor
- Department of Radiology, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | - M Mücke
- Center for Rare Diseases, University Hospital Bonn, Bonn, Germany
| | - G J Qagish
- Medical Office for Internal Medicine, Meckenheim, Germany
| | - R Barion
- Medical Office for Diabetology, Niederkassel, Rheidt, Germany
| | - M Raithel
- Malteser Waldkrankenhaus St. Marien, Medical Clinic II, Erlangen, Germany
| | - D Klingmüller
- Department of Endocrinology, University Hospital Bonn, Bonn, Germany
| | - V S Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic for Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - H J Hertfelder
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - D Berdel
- Marien Hospital Wesel, Wesel, Germany
| | | | - L B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, 63141, USA
| | - L B Afrin
- Armonk Integrative Medicine, Hematology/Oncology, Purchase, New York, NY, 10577, USA
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16
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Weinstock LB, Cottel J, Aldridge L, Egeberg A. Low-dose Naltrexone Therapy for Psoriasis. Int J Pharm Compd 2020; 24:94-96. [PMID: 32196470] [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
Safe, inexpensive, and convenient psoriasis therapy is desirable. Two recent case reports suggested that low-dose naltrexone is effective. Cases from our practice are presented in order to further the evidence of efficacy and safety of low-dose naltrexone in the treatment of psoriasis. Patients included 13 females, 2 males; mean age 57 years; mean psoriasis duration 16 years. Of the patients, 8 had psoriatic arthritis. In the past, 5 had completely failed and 10 had partially responded to =1 topical therapies. Patients used a self-assessed Likert scale on the effect of low-dose naltrexone on their psoriasis: 1 - worse; 2 - unchanged; 3 - slightly improved; 4 - somewhat improved; 5 - marked improvement. The response to 4.5 mg of oral naltrexone was as follows: 8/15 marked improvement; 2/15 somewhat improved; and 5/15 unchanged. Three adverse events included insomnia, diarrhea, and self-limited headache. Marked improvement was seen by 53% of the 15 patients. Low-dose naltrexone regulates lymphocyte responses, reduces cytokine production, and likely reduces mast cell activity. Low-dose naltrexone is safe, inexpensive, and appears be effective in this open-label study.
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17
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Weinstock LB, Walters AS, Brook JB, Kaleem Z, Afrin LB, Molderings GJ. Restless legs syndrome is associated with mast cell activation syndrome. J Clin Sleep Med 2020; 16:401-408. [PMID: 31994488 DOI: 10.5664/jcsm.8216] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 01/01/2023]
Abstract
STUDY OBJECTIVES Mast cell activation syndrome (MCAS) is an inflammatory and allergic disorder. We determined the prevalence of restless legs syndrome (RLS) in MCAS because each common syndrome may be inflammatory in nature and associated with dysautonomia. METHODS Individuals with MCAS were evaluated for RLS by two standard questionnaires. Prevalence comparisons included spouse control patients and two prevalence publications. MCAS diagnosis required mast cell (MC) symptoms in ≥ 2 organs plus ≥ 1 elevated MC mediators, improvement with MC therapy, and/or increased intestinal MC density. Clinical variables were studied. RESULTS There were 174 patients with MCAS (146 female, 28 male, mean age 44.8 years) and 85 spouse control patients (12 female, 73 male, mean age 50.9 years). Patients with MCAS as a whole had a higher prevalence of RLS (40.8%) than spouse control (12.9%) (P < .0001) Male patients with MCAS had a higher prevalence of RLS (32.1%) than male controls (12.3%, odds ratio [OR] 3.4, confidence interval [CI] 1.2-9.7, P = .025), American men (8.4%, OR 5.2, CI 2.2-12.0, P < .001), and French men (5.8%, OR 7.7, CI 3.4-17.1, P < .001). Female patients with MCAS also had a higher prevalence of RLS (42.5%) than female controls (16.7%) but this did not reach statistical significance perhaps because of the sample size of the female controls. However, female patients with MCAS had a statistically higher prevalence of RLS than American women (10.0%, OR 6.7, CI 4.5-9.7, P < .0001) and French women (10.8%, OR 6.1, CI 4.4-8.6, P < .0001). CONCLUSIONS RLS appears to be associated with MCAS. Effects of mast cell mediators, inflammation, immune mechanisms, dysautonomia, or hypoxia may theoretically activate RLS in MCAS.
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Affiliation(s)
- Leonard B Weinstock
- Washington University School of Medicine, Specialists in Gastroenterology, LLC, St. Louis, Missouri
| | - Arthur S Walters
- Division of Sleep Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Zahid Kaleem
- Specialists in Gastroenterology, LLC, St. Louis, Missouri
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18
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Affiliation(s)
- Leonard B Weinstock
- Specialists in Gastroenterology, LLC, St. Louis, MO, USA. Department of Gastroenterology, Cedar Sinai, Los Angeles, CA, USA. Hematology and Oncology, Armonk Integrative Medicine, Armonk, NY, USA
| | - Ali Rezaie
- Specialists in Gastroenterology, LLC, St. Louis, MO, USA. Department of Gastroenterology, Cedar Sinai, Los Angeles, CA, USA. Hematology and Oncology, Armonk Integrative Medicine, Armonk, NY, USA
| | - Lawrence B Afrin
- Specialists in Gastroenterology, LLC, St. Louis, MO, USA. Department of Gastroenterology, Cedar Sinai, Los Angeles, CA, USA. Hematology and Oncology, Armonk Integrative Medicine, Armonk, NY, USA
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Abstract
Epiploic appendagitis is as an acute painful condition of the fat on the outside of the intestine. Thus far, there have been no publications to our knowledge that appendagitis can be caused by mast cells or can be associated with chronic pain. A patient with multisystemic disorders suffered with both chronic and acute attacks of abdominal pain for a year. The worst attack led to surgical resection of an enlarged sigmoid colon epiploic appendage. Careful review of her complex medical history and mast cell stains of gastrointestinal biopsies led to the diagnosis of mast cell activation syndrome. Re-examination of the resected appendage using an immunohistochemical stain demonstrated a high mast cell density which is a new histopathological finding. Treatment of mast cell activation syndrome and other related syndromes led to marked improvement in her health, including all types of chronic abdominal pain.
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Affiliation(s)
- Leonard B Weinstock
- Gastroenterology, GI, Washington University, Saint Louis, Missouri, USA.,Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Zahid Kaleem
- Gastroenterology, GI, Washington University, Saint Louis, Missouri, USA
| | - Dale Selby
- Department of Pathology, Missouri Baptist Medical Center, Saint Louis, Missouri, USA
| | - Lawrence B Afrin
- Internal Medicine, Armonk Integrative Medicine, Armonk, New York, USA
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20
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Rice AD, Patterson K, Reed ED, Wurn BF, Robles K, Klingenberg B, Weinstock LB, Pratt JSA, King CR, Wurn LJ. Decreasing recurrent bowel obstructions, improving quality of life with physiotherapy: Controlled study. World J Gastroenterol 2018; 24:2108-2119. [PMID: 29785079 PMCID: PMC5960816 DOI: 10.3748/wjg.v24.i19.2108] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/03/2018] [Accepted: 05/05/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare (1) quality of life and (2) rate of recurrent small bowel obstructions (SBO) for patients treated with novel manual physiotherapy vs no treatment.
METHODS One hundred and three subjects (age 19-89) with a history of recurrent adhesive SBO were treated with a manual physiotherapy called the Clear Passage Approach (CPA) which focused on decreasing adhesive crosslinking in abdominopelvic viscera. Pre- and post-therapy data measured recurring obstructions and quality of life, using a validated test sent 90 d after therapy. Results were compared to 136 untreated control subjects who underwent the same measurements for subjects who did not receive any therapy, which is the normal course for patients with recurring SBO. Comparison of the groups allowed us to assess changes when the physiotherapy was added as an adjunct treatment for patients with recurring SBO.
RESULTS Despite histories of more prior hospitalizations, obstructions, surgeries, and years impacted by bowel issues, the 103 CPA-treated subjects reported a significantly lower rate of repeat SBO than 136 untreated controls (total obstructions P = 0.0003; partial obstructions P = 0.0076). Subjects treated with the therapy demonstrated significant improvements in five of six total domains in the validated Small Bowel Obstruction Questionnaire (SBO-Q). Domains of diet, pain, gastrointestinal symptoms, quality of life (QOL) and pain severity when compared to post CPA treatment were significantly improved (P < 0.0001). The medication domain was not changed in the CPA treated group (P = 0.176).
CONCLUSION CPA physical therapy was effective for patients with adhesive SBO with significantly lower recurrence rate, improvement in reported symptoms and overall quality of life of subjects.
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Affiliation(s)
- Amanda D Rice
- Department of Internal Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, United States
| | | | - Evette D Reed
- Clear Passage Therapies, Gainesville, FL 32606, United States
| | - Belinda F Wurn
- Clear Passage Therapies, Gainesville, FL 32606, United States
| | - Kristen Robles
- Clear Passage Therapies, Gainesville, FL 32606, United States
| | - Bernhard Klingenberg
- Department of Mathematics and Statistics, Williams College, Williamstown, MA 01267, United States
| | - Leonard B Weinstock
- Clinical Medicine and Surgery, Washington University School of Medicine, Specialists in Gastroenterology, LLC, St. Louis, MO 63141, United States
| | - Janey SA Pratt
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94035, United States
| | - C Richard King
- College of Medicine, University of Florida, Gainesville, FL 32607, United States
| | - Lawrence J Wurn
- Clear Passage Therapies, Gainesville, FL 32606, United States
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21
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Weinstock LB, Brook JB, Myers TL, Goodman B. Successful treatment of postural orthostatic tachycardia and mast cell activation syndromes using naltrexone, immunoglobulin and antibiotic treatment. BMJ Case Rep 2018; 2018:bcr-2017-221405. [PMID: 29326369 PMCID: PMC5778345 DOI: 10.1136/bcr-2017-221405] [Citation(s) in RCA: 15] [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] [Indexed: 12/26/2022] Open
Abstract
A patient with severe postural orthostatic tachycardia syndrome (POTS) and mast cell activation syndrome (MCAS) received immunotherapy with low-dose naltrexone (LDN) and intravenous immunoglobulin (IVIg) and antibiotic therapy for small intestinal bacterial overgrowth (SIBO). A dramatic and sustained response was documented. The utility of IVIg in autoimmune neuromuscular diseases has been published, but clinical experience with POTS is relatively unknown and has not been reported in MCAS. As a short-acting mu-opioid antagonist, LDN paradoxically increases endorphins which then bind to regulatory T cells which regulate T-lymphocyte and B-lymphocyte production and this reduces cytokine and antibody production. IVIg is emerging as a promising therapy for POTS. Diagnosis and treatment of SIBO in POTS is a new concept and appears to play an important role.
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Affiliation(s)
- Leonard B Weinstock
- Medicine, Washington University, Saint Louis, Missouri, USA.,Gastroenterology, Specialists in Gastroenterology, Saint Louis, MO, USA
| | - Jill B Brook
- Biostatistics, Private Practice, Anchorage, Alaska, USA
| | - Trisha L Myers
- Gastrointestinal Department, Specialists in Gastroenterology, Saint Louis, Missouri, USA
| | - Brent Goodman
- Department of Neurology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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22
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Jørgensen AHR, Egeberg A, Gideonsson R, Weinstock LB, Thyssen EP, Thyssen JP. Rosacea is associated with Helicobacter pylori: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2017; 31:2010-2015. [PMID: 28543746 DOI: 10.1111/jdv.14352] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 05/09/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Rosacea is a common skin disease characterized by facial erythema, telangiectasia, papules and pustules. Helicobacter pylori infection has been suggested to play a role in the etiopathogenesis of rosacea. OBJECTIVE To systematically review and meta-analyse the relationship between rosacea and infection with Helicobacter pylori. METHODS A literature search was performed using PubMed, EMBASE and Web of Science. Data extraction and analyses were performed on descriptive data. Study quality was assessed using the Newcastle-Ottawa Scale. Random-effects models with DerSimonian-Laird methods were utilized to estimate pooled odds ratios (ORs), with 95% confidence intervals (95% CIs). Heterogeneity of results was assessed using I² statistics. RESULTS A total of 454 articles were identified and 42 full-text articles were chosen for further review. Fourteen studies were included in the quantitative meta-analysis, comprising a total of 928 rosacea patients and 1527 controls. The overall association between Helicobacter pylori infection and rosacea was non-significant (OR 1.68, 95% CI 1.00-2.84, P = 0.052), but analysis restricted to C-urea breath test showed a significant association (OR 3.12, 95% CI 1.92-5.07, P < 0.0001). Effect of eradication treatment on rosacea symptoms was assessed in seven studies, but without significant effect (RR 1.28, 95% CI 0.98-1.67, P = 0.069). CONCLUSION This meta-analysis found weak associations between rosacea and Helicobacter pylori infection as well as an effect of Helicobacter pylori therapy on rosacea symptoms, albeit that these did not reach statistical significance. Whether a pathogenic link between the two conditions exists, or whether Helicobacter pylori infection represents a proxy for other factors remains unknown.
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Affiliation(s)
- A-H R Jørgensen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - A Egeberg
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - R Gideonsson
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | | | - E P Thyssen
- Specialists in Gastroenterology, St Louis, MO, USA
| | - J P Thyssen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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23
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Weinstock LB, Myers TL, Walters AS, Schwartz OA, Younger JW, Chopra PJ, Guarino AH. Identification and Treatment of New Inflammatory Triggers for Complex Regional Pain Syndrome: Small Intestinal Bacterial Overgrowth and Obstructive Sleep Apnea. ACTA ACUST UNITED AC 2017; 6:272-6. [PMID: 26867023 DOI: 10.1213/xaa.0000000000000292] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Complex regional pain syndrome (CRPS) is evoked by conditions that may be associated with local and/or systemic inflammation. We present a case of long-standing CRPS in a patient with Ehlers-Danlos syndrome in which prolonged remission was attained by directing therapy toward concomitant small intestinal bacterial overgrowth, obstructive sleep apnea, and potential increased microglia activity. We theorize that cytokine production produced by small intestinal bacterial overgrowth and obstructive sleep apnea may act as stimuli for ongoing CRPS symptoms. CRPS may also benefit from the properties of low-dose naltrexone that blocks microglia Toll-like receptors and induces production of endorphins that regulate and reduce inflammation.
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Affiliation(s)
- Leonard B Weinstock
- From the Departments of *Anesthesia and †Internal Medicine, Washington University School of Medicine, St. Louis, Missouri; ‡Specialists in Gastroenterology, LLC, St. Louis, Missouri; §Department of Neurology, Vanderbilt University, Nashville, Tennessee; ‖Sleep and EEG Laboratory, Barnes Jewish West County, BJC Medical Group Center for Sleep Medicine, St. Louis, Missouri; Departments of ¶Psychology, #Anesthesiology, and **Rheumatology, Neuroinflammation, Pain and Fatigue Lab, University of Alabama, Birmingham, Alabama; ††Pain Management Center, Department of Anesthesia, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and ‡‡Department of Anesthesia, Washington University School of Medicine, St. Louis, Missouri
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Weinstock LB, Myers TL, Shetty A. Low-dose Naltrexone for the treatment of sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2017; 34:184-187. [PMID: 32476841 DOI: 10.36141/svdld.v34i2.5303] [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] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 09/06/2016] [Indexed: 11/02/2022]
Abstract
Systemic therapy is administered to 50% of patients and the need for long-term use of therapy is quite variable (1,2). Prednisone is often administered for many months with risk for multiple side effects, immunomodulators as steroid sparing agents have a delayed onset of action and have risks for infection and malignancies, and infliximab increases the risk for infection (1). In light of these issues, alternative options for therapy are desirable. We made a comparison between sarcoidosis and Crohn's disease in that in each disease there is unregulated lymphocyte activity, a common unique pathological finding of non-caseating granulomas, and a similar approach to medical therapy (3,4). Low dose naltrexone (LDN) has been utilized for many conditions (5). Efficacy has been documented in Crohn's disease with randomized controlled studies showing mucosal healing and histologic improvement (6-7). LDN is compounded in 1/10th to 1/20th the dose used for the FDA-approved indications of narcotic and alcohol dependence (8). Neuropeptides (e.g., enkephalins and endorphins) are present in the gastrointestinal tract and endocrine cells and modulate immune responses (9). Up-regulation of met-enkephelin and opioid receptors can be induced by a rebound effect by short-acting LDN (10). Higher levels of endogenous opioids and receptors inhibit cell proliferation which suppress T and B lymphocyte responses (11,12) and decrease production of pro-inflammatory interleukins-6 and -12 (13). In light of the Crohn's disease LDN literature and similar experiences with other inflammatory conditions in our clinic (14,15), LDN was administered to a sarcoidosis patient with severe fatigue, sarcoid rash, and marked radiographic evidence of gastrointestinal involvement. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 184-187).
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Affiliation(s)
- Leonard B Weinstock
- Dept. Anesthesia and Internal Medicine, Washington University, School of Medicine, St. Louis, Missouri
| | | | - Anup Shetty
- Dept. of Radiology, Washington University, School of Medicine, St. Louis, Missouri
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Lembo A, Pimentel M, Rao SS, Schoenfeld P, Cash B, Weinstock LB, Paterson C, Bortey E, Forbes WP. Repeat Treatment With Rifaximin Is Safe and Effective in Patients With Diarrhea-Predominant Irritable Bowel Syndrome. Gastroenterology 2016; 151:1113-1121. [PMID: 27528177 DOI: 10.1053/j.gastro.2016.08.003] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Few treatments have demonstrated efficacy and safety for diarrhea-predominant irritable bowel syndrome (IBS-D). A phase 3, randomized, double-blind, placebo-controlled trial was performed to evaluate the safety and efficacy of repeat treatment with the nonsystemic antibiotic rifaximin. METHODS The trial included adults with IBS-D, mean abdominal pain and bloating scores of 3 or more, and loose stool, located at 270 centers in the United States and Europe from February 2012 through June 2014. Those responding to a 2-week course of open-label rifaximin 550 mg 3 times daily, who then relapsed during an observation phase (up to 18 weeks), were randomly assigned to groups given repeat treatments of rifaximin 550 mg or placebo 3 times daily for 2 weeks. The primary end point was percentage of responders after first repeat treatment, defined as a decrease in abdominal pain of ≥30% from baseline and a decrease in frequency of loose stools of ≥50% from baseline, for 2 or more weeks during a 4-week post-treatment period. RESULTS Of 1074 patients (44.1%) who responded to open-label rifaximin, 382 (35.6%) did not relapse and 692 (64.4%) did; of these, 636 were randomly assigned to receive repeat treatment with rifaximin (n = 328) or placebo (n = 308). The percentage of responders was significantly greater with rifaximin than placebo (38.1% vs 31.5%; P = .03). The percentage of responders for abdominal pain (50.6% vs 42.2%; P = .018) was significantly greater with rifaximin than placebo, but not stool consistency (51.8% vs 50.0%; P = .42). Significant improvements were also noted for prevention of recurrence, durable response, and bowel movement urgency. Adverse event rates were low and similar between groups. CONCLUSIONS In a phase 3 study of patients with relapsing symptoms of IBS-D, repeat rifaximin treatment was efficacious and well tolerated. ClinicalTrials.gov ID: NCT01543178.
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Affiliation(s)
- Anthony Lembo
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Mark Pimentel
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Brooks Cash
- University of South Alabama, Mobile, Alabama
| | - Leonard B Weinstock
- Washington University School of Medicine, Specialists in Gastroenterology, St. Louis, Missouri
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Egeberg A, Weinstock LB, Thyssen EP, Gislason GH, Thyssen JP. Rosacea and gastrointestinal disorders: a population-based cohort study. Br J Dermatol 2016; 176:100-106. [PMID: 27501017 DOI: 10.1111/bjd.14930] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Rosacea is a common inflammatory facial skin condition. Recent genetic and epidemiological studies have suggested pathogenic links between rosacea and gastrointestinal disorders, but data are limited. OBJECTIVES The objective was to investigate the association between rosacea and coeliac disease (CeD), Crohn disease (CD), ulcerative colitis (UC), Helicobacter pylori infection (HPI), small intestinal bacterial overgrowth (SIBO) and irritable bowel syndrome (IBS), respectively. METHODS We performed a nationwide cohort study. A total of 49 475 patients with rosacea and 4 312 213 general population controls were identified using nationwide administrative registers. We established the prevalence of the aforementioned disorders, and used Cox regression analysis to obtain hazard ratios (HRs) of the risk of new-onset CeD, CD, UC, HPI, SIBO and IBS, respectively, in patients with rosacea. RESULTS The prevalence of CeD, CD, UC, HPI, SIBO and IBS, respectively, was higher among patients with rosacea when compared with the control subjects. Adjusted HRs revealed significant associations between rosacea and CeD (HR 1·46, 1·11-1·93), CD (HR 1·45, 1·19-1·77), UC (HR 1·19, 1·02-1·39), and IBS (HR 1·34, 1·19-1·50), respectively, but not HPI (HR 1·04, 0·96-1·13) or SIBO (HR 0·71, 0·18-1·86). CONCLUSIONS Rosacea is associated with certain gastrointestinal diseases, but the possible pathogenic link is unknown. Gastrointestinal complaints in patients with rosacea should warrant clinical suspicion of disease.
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Affiliation(s)
- A Egeberg
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Kildegårdsvej 28, 2900, Hellerup, Denmark
| | - L B Weinstock
- Department of Gastroenterology, Washington University School of Medicine, St Louis, MO, U.S.A
| | - E P Thyssen
- Department of Gastroenterology, Washington University School of Medicine, St Louis, MO, U.S.A
| | - G H Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, Kildegårdsvej 28, 2900, Hellerup, Denmark.,The Danish Heart Foundation, DK-1127, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, DK-1353, Copenhagen, Denmark
| | - J P Thyssen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Kildegårdsvej 28, 2900, Hellerup, Denmark
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Affiliation(s)
- Leonard B Weinstock
- Specialists in Gastroenterology, LLC, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Dayna S Early
- Washington University School of Medicine, St. Louis, Missouri, USA
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Weinstock LB, Jasion VS. Serum-Derived Bovine Immunoglobulin/Protein Isolate Therapy for Patients with Refractory Irritable Bowel Syndrome. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojgas.2014.410047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Weinstock LB, Steinhoff M. Rosacea and small intestinal bacterial overgrowth: prevalence and response to rifaximin. J Am Acad Dermatol 2013; 68:875-6. [PMID: 23602178 DOI: 10.1016/j.jaad.2012.11.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 11/13/2012] [Accepted: 11/18/2012] [Indexed: 10/26/2022]
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Affiliation(s)
- Leonard B Weinstock
- Department of Clinical Medicine and Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Weinstock LB, Walters AS, Paueksakon P. Restless legs syndrome--theoretical roles of inflammatory and immune mechanisms. Sleep Med Rev 2012; 16:341-54. [PMID: 22258033 DOI: 10.1016/j.smrv.2011.09.003] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 09/22/2011] [Accepted: 09/26/2011] [Indexed: 12/13/2022]
Abstract
Theories for restless legs syndrome (RLS) pathogenesis include iron deficiency, dopamine dysregulation and peripheral neuropathy. Increased prevalence of small intestinal bacterial overgrowth (SIBO) in controlled studies in RLS and case reports of post-infectious RLS suggest potential roles for inflammation and immunological alterations. A literature search for all conditions associated with RLS was performed. These included secondary RLS disorders and factors that may exacerbate RLS. All of these conditions were reviewed with respect to potential pathogenesis including reports of iron deficiency, neuropathy, SIBO, inflammation and immune changes. A condition was defined as highly-associated if there was a prevalence study that utilized an appropriate control group. Small case reports were recorded but not included as definite RLS-associated conditions. Fifty four diseases, syndromes and conditions have been reported to cause and/or exacerbate RLS. Of these, 38 have been reported to have a higher prevalence than age-matched controls, 9 have adequate sized reports and have general acceptance as RLS-associated conditions and 7 have been reported in case report form. Overall, 42 of the 47 RLS-associated conditions (89%) have also been associated with inflammatory and/or immune changes. In addition, 43% have been associated with peripheral iron deficiency, 40% with peripheral neuropathy and 32% with SIBO. Most of the remaining conditions have yet to be studied for these factors. The fact that 95% of the 38 highly-associated RLS conditions are also associated with inflammatory/immune changes suggests the possibility that RLS may be mediated or affected through these mechanisms. Inflammation can be responsible for iron deficiency and hypothetically could cause central nervous system iron deficiency-induced RLS. Alternatively, an immune reaction to gastrointestinal bacteria or other antigens may hypothetically cause RLS by a direct immunological attack on the central or peripheral nervous system.
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Affiliation(s)
- Leonard B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Weinstock LB, Geng B, Brandes SB. Chronic prostatitis and small intestinal bacterial overgrowth: effect of rifaximin. Can J Urol 2011; 18:5826-5830. [PMID: 21854715] [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: 05/31/2023]
Abstract
INTRODUCTION This pilot study determined the efficacy of rifaximin, a gut-directed antibiotic, in reducing chronic prostatitis (CP) and gastrointestinal (GI) symptoms in patients with CP type III. The prevalence of small intestinal bacterial overgrowth (SIBO) and irritable bowel syndrome (IBS) in patients with CP was also evaluated. MATERIALS AND METHODS Chronic prostatitis patients were recruited and screened for SIBO and IBS using the lactulose breath test (LBT) and Rome II criteria, respectively. Patients with a positive LBT result and Chronic Prostatitis Symptom Index (CPSI) score ≥ 15 received rifaximin 550 mg three times daily for 10 days. The CPSI score and global improvement of CP and GI symptoms were ascertained at screening (ie, 7 days before therapy), at baseline immediately before therapy (ie, day 0), and on days 14 and 28. RESULTS Fourteen of 16 CP patients (88%) had a positive LBT result and were included in this therapeutic study (mean age, 41 years). Mean CPSI score significantly decreased from screening to day 28 (ie, 18 days after rifaximin treatment; p = 0.043). Mean abdominal pain and bloating scores were also significantly reduced on day 28 versus baseline (p = 0.010 and p = 0.003, respectively). Chronic prostatitis patients with IBS and SIBO had a statistically significant response as well. CONCLUSION Data from this pilot study suggest that SIBO and IBS are common in CP and that patients with CP and SIBO may benefit from rifaximin therapy. Further studies are warranted.
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Affiliation(s)
- Leonard B Weinstock
- Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Weinstock LB, Aliperti G, Thyssen EP. Occult bleeding and anemia caused by an inflammatory polyp at a sphincterotomy/stent site. Gastrointest Endosc 2011; 73:1286-7. [PMID: 21392756 DOI: 10.1016/j.gie.2010.12.012] [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] [Received: 02/03/2010] [Accepted: 12/10/2010] [Indexed: 12/11/2022]
Affiliation(s)
- Leonard B Weinstock
- Washington University School of Medicine, Specialists in Gastroenterology, LLC, St. Louis, Missouri, USA
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Weinstock LB, Walters AS. Restless legs syndrome is associated with irritable bowel syndrome and small intestinal bacterial overgrowth. Sleep Med 2011; 12:610-3. [PMID: 21570907 DOI: 10.1016/j.sleep.2011.03.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 01/28/2011] [Accepted: 03/15/2011] [Indexed: 12/30/2022]
Abstract
BACKGROUND Restless legs syndrome (RLS) is linked to gastrointestinal disorders. The prevalence of irritable bowel syndrome (IBS) and small intestinal bacterial overgrowth (SIBO) in RLS patients was determined. METHODS RLS subjects were recruited from unbiased ads that did not mention gastrointestinal symptoms. RLS diagnosis was confirmed by a neurologist and utilized the International RLS Study Group criteria. General population controls (GPC) were spouses of gastrointestinal clinic patients and were excluded for RLS. Completely healthy controls (CHC) were excluded for RLS and gastrointestinal symptoms. IBS was diagnosed by Rome II criteria. SIBO was diagnosed by the lactulose breath test (LBT). RESULTS There were 32 RLS subjects (23F/9M; 57 yo), 25 GPC (13F/12M; 58 yo) and 30 CHC (19F/11M; 44 yo). Twenty-nine had RLS unassociated with other GI diseases, one had celiac disease, and two had gastric resections. IBS was diagnosed in 28% of RLS subjects compared to 4% GPC (p=0.0317). SIBO was diagnosed in 69% of RLS subjects compared to 28% of GPC (p=0.0033) and 10% of CHC. Using a false positive rate of 10%, 59% of positive LBT results are associated with RLS. CONCLUSIONS IBS and SIBO are common in RLS. Three hypotheses developed are (a) RLS patients are selectively immunocompromised or genetically predisposed and thus more subject to SIBO; (b) SIBO leads to autoimmune changes, and subsequent auto-antibodies attack brain and/or peripheral nerves and (c) SIBO inflammation leads to increased hepcidin and CNS iron deficiency which, in turn, leads to RLS. These hypotheses bear further investigation.
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Affiliation(s)
- Leonard B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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Abstract
PURPOSE Celiac disease may be associated with restless legs syndrome (RLS) because of an association with iron deficiency. Often, RLS negatively affects quality of life but may remain undiagnosed. This study evaluated the association between celiac disease and RLS. RESULTS The incidence of RLS among 85 patients with celiac disease was 35%, with a prevalence of 25% compared with 10% of spouses (P<0.02). In 79% of patients with RLS and celiac disease, neuromuscular symptoms began during or after onset of gastrointestinal symptoms. Iron deficiency was present in 40% of celiac patients with active RLS compared with 6% of patients without RLS (P<0.001). After 6 months of a gluten-free diet, RLS symptoms improved in 50% of 28 patients. CONCLUSION Screening for celiac disease in patients with RLS is important since this commonly overlooked silent disease may be a correctable factor for some patients with idiopathic RLS.
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Affiliation(s)
- Leonard B Weinstock
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO 63141, USA.
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Ploesser J, Weinstock LB, Thomas E. Low dose naltrexone: side effects and efficacy in gastrointestinal disorders. Int J Pharm Compd 2010; 14:171-173. [PMID: 23965429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Use of low dose naltrexone has been advocated for a variety of medical problems. Only a few articles published in peer review journals have documented side effects of low dose naltrexone. The purpose of this study was to determine the frequency of adverse effects of low dose naltrexone in patients who have been treated for a variety of gastrointestinal disorders. The secondary purpose was to determine global efficacy in a retrospective survey. Patients (206) form a single gastroenterologist's clinical practice who had been prescribed naltrexone were mailed a survey to evaluate the side effects and efficacy of naltrexone. Patients had either irritable bowel syndrome without evidence for small intestinal bacterial overgrowth, chronic idiopathic constipation, or inflammatory bowel disease. Patients with diarrhea were given 2.5 mg daily, constipation 2.5 mg twice daily, and inflammatory bowel disease 4.5 mg daily. In the patients who returned the survey, 47/121 (38.8%) had no side effects. Of the 74/121 (61.2%) patients who had side effects, 58 had one or more neurological complaints, and 32 had one or more gastrointestinal side effects. In the patients with side effects, 24/74 (32.4%) had short lived symptoms. Low dose naltrexone was terminated owing to side effects in 20/74 patients (27.0%). In 13 patients with idiopathic irritable bowel syndrome, 2 were markedly worse. In 85 patients with irritable bowel syndrome-small intestinal bacterial overgrowth, 15 were markedly improved, 32 were moderately worse, and 1 was markedly worse. In 12 patients with chronic constipation, 7 were markedly improved, 1 was moderately improved, 1 was mildly improved, and 4 were unchanged. Low dose naltrexone frequently has side effects but in most is tolerable. It appears to be helpful for a member of patients with gastrointestinal disorders.
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Weinstock LB, Bosworth BP, Scherl EJ, Li E, Iroku U, Munsell MA, Mullen GE, Walters AS, Walters AS. Crohn's disease is associated with restless legs syndrome. Inflamm Bowel Dis 2010; 16:275-9. [PMID: 19575360 PMCID: PMC3864021 DOI: 10.1002/ibd.20992] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Extraintestinal manifestations of Crohn's disease (CD) have not previously included the central nervous system (CNS). Restless legs syndrome (RLS) is a CNS disorder that is either idiopathic or secondary to a number of diseases. The aim of this study was to determine if RLS was associated with CD because both are associated with iron deficiency, inflammation, and bacterial overgrowth. METHODS Consecutive CD outpatients (N = 272) were prospectively surveyed at 4 centers for criteria for RLS. Incidence (having RLS at any point in time), prevalence (having RLS at time of survey), clinical characteristics, risk factors, and potential qualitative relationship between RLS and gastrointestinal symptoms were queried. RESULTS The incidence of RLS in patients with CD was 42.7%. Prevalence was 30.2% compared with 9% of spouses. CD patients with and without RLS had a mean age of 46.8 versus 42.6 years, small intestine involvement in 77.9% versus 66.7%, colon involvement in 39.7% versus 63.2%, and prior iron deficiency anemia in 49.3% versus 33.1%. There was no difference between the CD groups with respect to current iron deficiency, RLS family history, or rare prevalence of concomitant RLS disorders. In 91.8% of patients with RLS and CD, RLS started during or after the onset of CD diagnosis. Among 73 patients with RLS, 67 (44.5%) stated there was a relationship between qualitative RLS symptom improvement with overall CD symptom improvement. CONCLUSIONS These results demonstrate that RLS occurs frequently in CD and appears to be a possible extraintestinal manifestation. The potential relationship of RLS with CD activity warrants further investigation.
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Affiliation(s)
- Leonard B. Weinstock
- Washington University School of Medicine, MO,Specialists in Gastroenterology, LLC, St Louis, MO
| | | | | | - Ellen Li
- Washington University School of Medicine, MO
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Weinstock LB. Antibiotic therapy may improve idiopathic restless legs syndrome: prospective, open-label pilot study of rifaximin, a nonsystemic antibiotic. Sleep Med 2009; 11:427. [PMID: 20042368 DOI: 10.1016/j.sleep.2009.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 06/03/2009] [Accepted: 06/16/2009] [Indexed: 02/06/2023]
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Weinstock LB, Fern SE, Duntley SP. Restless legs syndrome in patients with irritable bowel syndrome: response to small intestinal bacterial overgrowth therapy. Dig Dis Sci 2008; 53:1252-6. [PMID: 17934858 DOI: 10.1007/s10620-007-0021-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [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: 03/30/2007] [Accepted: 09/07/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Small intestinal bacterial overgrowth (SIBO) occurs in irritable bowel syndrome (IBS) and fibromyalgia. Since restless legs syndrome (RLS) occurs with fibromyalgia, a link between IBS, SIBO, and RLS was studied. METHODS BS patients with abnormal lactulose breath tests received rifaximin 1,200 mg day(-1) for 10 days, followed by tegaserod 3 mg, long-term, and 1 month of zinc 220 mg day(-1) and once-daily probiotic (N = 11) or rifaximin monotherapy (N = 2). IBS symptom improvement was assessed after rifaximin. RLS symptoms, IBS symptoms, and overall IBS global improvement were assessed at last posttreatment visit: 8/10 patients were followed long-term (mean, 139 days; range, 54-450 days). RESULTS Ten of 13 patients exhibited > or =80% improvement from baseline in RLS symptoms. Five maintained complete resolution of RLS symptoms. Global gastrointestinal symptom improvement was great (n = 6), moderate (n = 5), or mild (n = 2). CONCLUSION This study suggests that SIBO associated with IBS may be a factor in some RLS patients and SIBO therapy provides long-term RLS improvement.
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Weinstock LB, Klutke CG, Lin HC. Small intestinal bacterial overgrowth in patients with interstitial cystitis and gastrointestinal symptoms. Dig Dis Sci 2008; 53:1246-51. [PMID: 17932763 DOI: 10.1007/s10620-007-0022-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 09/07/2007] [Indexed: 12/30/2022]
Abstract
PURPOSE Interstitial cystitis (IC) often coexists with irritable bowel syndrome (IBS). IBS may be explained by small-intestinal bacterial overgrowth (SIBO), which increases immune activation and visceral hypersensitivity. This prospective pilot study tested hypotheses that IC patients with gastrointestinal (GI) symptoms have SIBO, that nonabsorbable antibiotic use improves symptoms, and that improvement is sustained by prokinetic therapy. METHODS Consecutive IC patients with GI symptoms had lactulose breath testing (LBT). Those with abnormal results received rifaximin 1,200-1,800 mg/day for 10 days then tegaserod 3 mg/nightly. Questionnaires addressed IC and GI global improvement. RESULTS Of 21 patients, 17 (81%) had abnormal LBTs. Of 15 patients treated, GI global improvement was moderate to great in 11 (73%) and sustained in ten (67%). IC global improvement was moderate to great in six (40%) and sustained in seven (47%). CONCLUSIONS A majority of IC patients and GI symptoms had an abnormal LBT suggesting SIBO. Rifaximin improved symptoms, which was sustained by tegaserod.
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Weinstock LB. Treatment of patients with irritable bowel syndrome. Am Fam Physician 2007; 75:31. [PMID: 17225701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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Weinstock LB, Shah RS. Review. Gastroenterol Hepatol (N Y) 2006; 2:808-809. [PMID: 28381951 PMCID: PMC5368621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
| | - Rajesh S Shah
- Washington University School of Medicine St. Louis, Mo
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Abstract
OBJECTIVES The aim of this study was to determine patient pre-examination expectations and postexamination appraisals for CT colonography, conventional colonoscopy and bowel preparation. METHODS Prospective evaluation of 120 patients at defined risk for colorectal neoplasia was performed with CT colonography followed by colonoscopy on the same day. Subjects were stratified by age and sex (67 women and 53 men) and were randomized to receive either manual air (n = 61) or CO(2) (n = 59) insufflation during CT colonography. Patients' expectations were assessed just before the two examinations, and appraisals were assessed 2 to 3 days afterward regarding pain/discomfort, embarrassment, difficulty, overall assessment, preference for future testing, and bowel preparation. RESULTS No significant differences were found in appraisals of manual air versus CO(2) insufflation techniques. For both CT colonography and colonoscopy, patients' appraisals after the procedure were significantly more positive than prior expectations. Patients expressed more favorable appraisals of colonoscopy for pain (p < 0.001) and embarrassment (p < 0.001), with most responses being "none" to "a little" for both examinations. Overall appraisals of the tests were favorable and similar between CT and colonoscopy: patients mainly expressed "not unpleasant" to "a little unpleasant" (95%, 114/120 for both examinations). Overall, appraisal of the bowel preparation was the most negative. Preferences for future testing were more favorable toward CT: of the patients, 58% (69/120) preferred CT, 14% (17/120) preferred colonoscopy, and 28% (34/120) had no preference. CONCLUSIONS Overall appraisals were similar and positive for both CT colonography and colonoscopy, with less favorable appraisals of the bowel preparation. Most patients stated that they would prefer CT for future evaluation.
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Affiliation(s)
- Stephen L Ristvedt
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri 63110-1093, USA
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McFarland EG, Pilgram TK, Brink JA, McDermott RA, Santillan CV, Brady PW, Heiken JP, Balfe DM, Weinstock LB, Thyssen EP, Littenberg B. CT colonography: multiobserver diagnostic performance. Radiology 2002; 225:380-90. [PMID: 12409570 DOI: 10.1148/radiol.2252011625] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [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] [Indexed: 02/06/2023]
Abstract
PURPOSE To prospectively evaluate multiobserver diagnostic performance and reader agreement for colorectal polyp detection in a well-characterized cohort of patients with increased number of polyps, compared with an average-risk patient, with colonoscopy as the reference standard. MATERIALS AND METHODS A cohort of 70 patients suspected of having polyps was examined with spiral computed tomographic (CT) colonography, with colonoscopy performed the same day. After air insufflation per rectum, supine and prone images were obtained with single-detector row CT (5-mm collimation, 8-mm table increment, 2-mm reconstruction interval). Images were analyzed independently by four experienced abdominal radiologists using two-dimensional multiplanar reformation followed by selective use of three-dimensional endoscopic volume-rendered images. Data were analyzed both per polyp and per patient. RESULTS Analysis per polyp demonstrated a pooled sensitivity of 0.68 for lesions 10 mm or larger (n = 40), with 75% agreement among the four readers. Analysis per patient demonstrated improved detection and agreement, with a pooled sensitivity of 0.88 for patients with polyps or cancers 10 mm or larger (n = 28), with 94% agreement. When sensitivity and receiver operating characteristic analyses were analyzed per polyp size threshold, results among readers converged and peaked at polyp diameters of approximately 10 mm. CONCLUSION In this patient cohort, diagnostic performance and interobserver agreement with single-detector row CT colonography was sufficient for detection of patients with lesions 10 mm or larger, with more variable results for smaller polyps.
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Affiliation(s)
- Elizabeth G McFarland
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110, USA.
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Affiliation(s)
- Leonard B Weinstock
- Barnes-Jewish West County Hospital and West Central Pathology, St. Louis, Missouri, USA
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Weinstock LB, Swanson PE, Bennett KJ, Van Amburg A, Wald SM, Shah NB. Jaundice caused by a clinically undetectable T-cell lymphoma infiltrating the sphincter of Oddi. Am J Gastroenterol 2001; 96:3186-9. [PMID: 11721770 DOI: 10.1111/j.1572-0241.2001.05280.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Malignant lymphoma rarely presents with jaundice. We describe a patient who had a unique etiology for painless jaundice, dilated ducts, and a normal ampulla of Vater. A Whipple's procedure was performed for the suspicion of pancreatic cancer, and initial pathological review detected only mild focal chronic pancreatitis. Seven months later, the patient developed ascites, retroperitoneal mass, and splenomegaly caused by a T-cell lymphoma. Reevaluation of the Whipple's specimen revealed previously unrecognized microscopic infiltration and fibrosis of the sphincter of Oddi by atypical T-lymphocytes. Obstructive jaundice caused by a clinically undetectable primary duodenal T-cell lymphoma has not been previously reported and is contrasted with other causes of jaundice associated with malignant lymphoma and ampullary lesions.
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Affiliation(s)
- L B Weinstock
- Department of Medicine, Barnes-Jewish Hospital, Washington University Medical Center, St. Louis, Missouri, USA
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