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Dibba P, Ludwig E, Calo D, Gerdes H, Markowitz A, Shike M, Schattner M, Mendelsohn R. Bevacizumab does not increase risk of perforation in patients undergoing percutaneous endoscopic gastrostomy or jejunostomy placement. Surg Endosc 2021; 35:2976-2980. [PMID: 32583069 PMCID: PMC9488627 DOI: 10.1007/s00464-020-07738-7] [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: 03/28/2020] [Accepted: 06/12/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Bevacizumab is a humanized anti-vascular endothelial growth factor monoclonal antibody used in the treatment of cervical cancer, ovarian cancer, colorectal cancer, lung cancer, renal cell cancer, and recurrent glioblastomas. Its approval by US FDA was issued with a black box warning that its use has been associated with a risk of gastrointestinal (GI) tract perforation and that it should be discontinued in patients who have experienced such. The reported incidence of GI perforation in those receiving bevacizumab is as high as 3%. However, the incidence of GI perforation in those receiving bevacizumab undergoing GI endoscopic procedures has not been well studied. METHODS A retrospective, single-center observational study was conducted at Memorial Sloan Kettering Cancer Center (MSKCC) between 2011 and 2018. All patients who underwent upper GI endoscopy with percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) tube placement and received bevacizumab within 6 months of their endoscopic procedure were included. RESULTS We identified 176 patients who underwent PEG or PEJ tube placement and received bevacizumab within 6 months. Eighty-one percent of patients were female (n = 144) and the median age was 61 years. Prior to endoscopic procedures, patients received a median of seven doses of bevacizumab. Patients received bevacizumab from 170 days before to 170 days after their endoscopic procedures (median 44 days). No GI perforations were observed during or after the time of the endoscopic procedures. CONCLUSION Our study demonstrated that receiving bevacizumab within 6 months prior to their endoscopic procedure was not associated with an increased risk of GI tract perforation and thus not an absolute contraindication to proceeding with PEG and PEJ tube placement in these patients.
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Affiliation(s)
- Pratima Dibba
- New York Presbyterian Brooklyn Methodist Hospital, New York, NY, USA
| | - Emmy Ludwig
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Delia Calo
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Hans Gerdes
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Arnold Markowitz
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Moshe Shike
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Mark Schattner
- Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Robin Mendelsohn
- Gastroenterology, Hepatology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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Dibba P, Li AA, Cholankeril G, Ali Khan M, Kim D, Ahmed A. Potential Mechanisms Influencing the Inverse Relationship Between Cannabis and Nonalcoholic Fatty Liver Disease: A Commentary. Nutr Metab Insights 2019; 12:1178638819847480. [PMID: 31308686 PMCID: PMC6612909 DOI: 10.1177/1178638819847480] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 11/23/2018] [Indexed: 12/12/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) develops when the liver is unable to
oxidize or export excess free fatty acids generated by adipose tissue lipolysis,
de novo lipogenesis, or dietary intake. Although treatment has generally been
centered on reversing metabolic risk factors that increase the likelihood of
NAFLD by influencing lifestyle modifications, therapeutic modalities are being
studied at the cellular and molecular level. The endocannabinoid system has been
of recent focus. The agonism and antagonism of cannabinoid receptors play roles
in biochemical mechanisms involved in the development or regression of NAFLD.
Exocannabinoids and endocannabinoids, the ligands which bind cannabinoid
receptors, have been studied in this regard. Exocannabinoids found in cannabis
(marijuana) may have a therapeutic benefit. Our recent study demonstrated an
inverse association between marijuana use and NAFLD among adults in the United
States. This commentary combines knowledge on the role of the endocannabinoid
system in the setting of NAFLD with the findings in our article to hypothesize
different potential mechanisms that may influence the inverse relationship
between cannabis and NAFLD.
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Affiliation(s)
- Pratima Dibba
- Division of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Andrew A Li
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, CA, USA
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Li AA, Kim D, Kim W, Dibba P, Wong K, Cholankeril G, Jacobson IM, Younossi ZM, Ahmed A. Disparities in mortality for chronic liver disease among Asian subpopulations in the United States from 2007 to 2016. J Viral Hepat 2018; 25:1608-1616. [PMID: 30112849 PMCID: PMC6709979 DOI: 10.1111/jvh.12981] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022]
Abstract
The Asian American population is characterized by remarkable diversity. Studying Asians as an aggregate group may obscure clinically meaningful heterogeneity. We performed a population-based study using data from the US National Vital Statistics System. We determined the trends in age-standardized mortality rates for chronic liver disease stratified by aetiology among the most populous US-based Asian subgroups (Asian Indians, Chinese, Filipino, Japanese, Korean and Vietnamese) and compared it to non-Hispanic whites. Annual percentage change was calculated to determine temporal mortality patterns using joinpoint analysis. Hepatitis C virus-related mortality rates were higher in non-Hispanic whites compared to individual Asian subgroups, but a sharp decline in mortality rates was noted in 2014 among non-Hispanic whites and all Asian subgroups. Age-standardized hepatitis B virus-related mortality rates were higher in all Asian subgroups as compared to non-Hispanic whites in 2016, with the highest mortality among Vietnamese followed by Chinese. Mortality rates for alcoholic liver disease have been steadily trending upwards in all Asian subgroups, with the highest mortality in Japanese. Overall, age-standardized cirrhosis-related mortality rates were highest in non-Hispanic whites, followed by Japanese, and more distantly by Vietnamese and other subgroups. However, hepatocellular carcinoma-related mortality rates were higher in most Asian subgroups led by Vietnamese, Japanese and Koreans compared to non-Hispanic whites. In this population-based study utilizing a nationally representative database, we demonstrated a marked heterogeneity in the mortality rates of aetiology-specific chronic liver disease among Asian subgroups in the United States.
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Affiliation(s)
- Andrew A. Li
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - Pratima Dibba
- Division of Gastroenterology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Katherine Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Ira M. Jacobson
- Department of Medicine, New York University School of Medicine, New York, New York
| | - Zobair M. Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Virginia
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
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Dibba P, Li AA, Cholankeril G, Iqbal U, Gadiparthi C, Khan MA, Kim D, Ahmed A. The Role of Cannabinoids in the Setting of Cirrhosis. Medicines 2018; 5:E52. [PMID: 29890719 PMCID: PMC6023500 DOI: 10.3390/medicines5020052] [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] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 12/18/2022]
Abstract
Although the mortality rates of cirrhosis are underestimated, its socioeconomic burden has demonstrated a significant global impact. Cirrhosis is defined by the disruption of normal liver architecture after years of chronic insult by different etiologies. Treatment modalities are recommended primarily in decompensated cirrhosis and specifically tailored to the different manifestations of hepatic decompensation. Antifibrogenic therapies are within an active area of investigation. The endocannabinoid system has been shown to play a role in liver disease, and cirrhosis specifically, with intriguing possible therapeutic benefits. The endocannabinoid system comprises cannabinoid receptors 1 (CB1) and cannabinoid receptor 2 (CB2) and their ligands, endocannabinoids and exocannabinoids. CB1 activation enhances fibrogenesis, whereas CB2 activation counteracts progression to fibrosis. Conversely, deletion of CB1 is associated with an improvement of hepatic fibrosis and steatosis, and deletion of CB2 results in increased collagen deposition, steatosis, and enhanced inflammation. CB1 antagonism has also demonstrated vascular effects in patients with cirrhosis, causing an increase in arterial pressure and vascular resistance as well as a decrease in mesenteric blood flow and portal pressure, thereby preventing ascites. In mice with hepatic encephalopathy, CB1 blockade and activation of CB2 demonstrated improved neurologic score and cognitive function. Endocannabinoids, themselves also have mechanistic roles in cirrhosis. Arachidonoyl ethanolamide (AEA) exhibits antifibrogenic properties by inhibition of HSC proliferation and induction of necrotic death. AEA induces mesenteric vasodilation and hypotension via CB1 induction. 2-arachidonoyl glycerol (2-AG) is a fibrogenic mediator independent of CB receptors, but in higher doses induces apoptosis of HSCs, which may actually show antifibrotic properties. 2-AG has also demonstrated growth-inhibitory and cytotoxic effects. The exocannabinoid, THC, suppresses proliferation of hepatic myofibroblasts and stellate cells and induces apoptosis, which may reveal antifibrotic and hepatoprotective mechanisms. Thus, several components of the endocannabinoid system have therapeutic potential in cirrhosis.
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Affiliation(s)
- Pratima Dibba
- Division of Gastroenterology, Women and Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Andrew A Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - Umair Iqbal
- Department of Medicine, Mary Imogene Bassett Hospital, Cooperstown, NY 13326, USA.
| | - Chiranjeevi Gadiparthi
- Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
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Dibba P, Li A, Cholankeril G, Iqbal U, Gadiparthi C, Khan MA, Kim D, Ahmed A. Mechanistic Potential and Therapeutic Implications of Cannabinoids in Nonalcoholic Fatty Liver Disease. Medicines 2018; 5:E47. [PMID: 29843404 PMCID: PMC6023518 DOI: 10.3390/medicines5020047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 05/23/2018] [Accepted: 05/24/2018] [Indexed: 04/11/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is comprised of nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). It is defined by histologic or radiographic evidence of steatosis in the absence of alternative etiologies, including significant alcohol consumption, steatogenic medication use, or hereditary disorders. NAFLD is now the most common liver disease, and when NASH is present it can progress to fibrosis and hepatocellular carcinoma. Different mechanisms have been identified as contributors to the physiology of NAFLD; insulin resistance and related metabolic derangements have been the hallmark of physiology associated with NAFLD. The mainstay of treatment has classically involved lifestyle modifications focused on the reduction of insulin resistance. However, emerging evidence suggests that the endocannabinoid system and its associated cannabinoid receptors and ligands have mechanistic and therapeutic implications in metabolic derangements and specifically in NAFLD. Cannabinoid receptor 1 antagonism has demonstrated promising effects with increased resistance to hepatic steatosis, reversal of hepatic steatosis, and improvements in glycemic control, insulin resistance, and dyslipidemia. Literature regarding the role of cannabinoid receptor 2 in NAFLD is controversial. Exocannabinoids and endocannabinoids have demonstrated some therapeutic impact on metabolic derangements associated with NAFLD, although literature regarding direct therapeutic use in NAFLD is limited. Nonetheless, the properties of the endocannabinoid system, its receptors, substrates, and ligands remain a significant arena warranting further research, with potential for a pharmacologic intervention for a disease with an anticipated increase in economic and clinical burden.
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Affiliation(s)
- Pratima Dibba
- Division of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Andrew Li
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - Umair Iqbal
- Department of Medicine, Mary Imogene Bassett Hospital, Cooperstown, NY 13326, USA.
| | - Chiranjeevi Gadiparthi
- Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
| | - Muhammad Ali Khan
- Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
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Dibba P, Cholankeril R, Li AA, Patel M, Fayek M, Dibble C, Okpara N, Hines A, Ahmed A. Hepatitis C in Pregnancy. Diseases 2018; 6:E31. [PMID: 29702563 PMCID: PMC6023348 DOI: 10.3390/diseases6020031] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [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: 03/27/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023] Open
Abstract
The prevalence of hepatitis C in pregnancy is as high as 3.6% in large cohorts. The prevalence of hepatitis C acquired by vertical transmission is 0.2% to 0.4% in the United States and Europe. Although screening is not recommended in the absence of certain risk factors, the importance of understanding hepatitis C in pregnancy lies in its association with adverse maternal and neonatal outcomes. There is potential for those infants infected by vertical transmission to develop chronic hepatitis C, cirrhosis or hepatocellular carcinoma. The risk of vertical transmission is increased when mothers are co-infected with Human Immunodeficiency Virus (HIV) or possess a high viral load. There is no clear data supporting that mode of delivery increases or reduces risk. Breastfeeding is not associated with increased risk of transmission. Premature rupture of membranes, invasive procedures (such as amniocentesis), intrapartum events, or fetal scalp monitoring may increase risk of transmission. In pregnant patients, hepatitis C is diagnosed with a positive ELISA-3 and detectable Hepatitis C Virus (HCV) RNA viral load. Infants born to HCV-infected mothers should be tested for either HCV RNA on at least two separate occasions. Although prevention is not possible, there may be a role for newer direct acting anti-viral medications in the future.
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Affiliation(s)
- Pratima Dibba
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Rosann Cholankeril
- Department of Medicine, Roger Williams Medical Center, Providence, RI 02908, USA.
| | - Andrew A Li
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
| | - Meera Patel
- Department of Hematology/Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27157, USA.
| | - Mariam Fayek
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Christy Dibble
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Nnenna Okpara
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Autumn Hines
- Department of Gastroenterology, Women & Infants Hospital/Warren Alpert School of Medicine, Brown University, Providence, RI 02905, USA.
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA 94304, USA.
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Rahman A, Dibba P, Hassan L, Cohen Z, Williams E. Revisiting Nesiritide (Natrecor) in Group 2 Pulmonary Hypertension. Chest 2016. [DOI: 10.1016/j.chest.2016.08.1316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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