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Mahapatra SJ, Olesen SS. Guideline adherence in acute pancreatitis: Still a long way to go. Pancreatology 2024; 24:325-326. [PMID: 38448347 DOI: 10.1016/j.pan.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/01/2024] [Indexed: 03/08/2024]
Affiliation(s)
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
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Cook ME, Bruun NH, Davidsen L, Vestergaard P, Drewes AM, Olesen SS. Metabolic Sequelae and All-Cause Mortality in Chronic Pancreatitis With and Without Prior Acute Pancreatitis: A Nationwide Population-Based Cohort Study. Am J Gastroenterol 2024:00000434-990000000-01106. [PMID: 38587288 DOI: 10.14309/ajg.0000000000002799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVES To investigate the risk of metabolic sequelae and all-cause mortality in a population-based cohort of chronic pancreatitis (CP) patients with and without prior acute pancreatitis (AP). METHODS We used nationwide health registries to identify all Danish residents (>18 years) with incident CP from 2000-2018. Information on AP/CP diagnoses, metabolic sequelae (post-pancreatitis diabetes mellitus (PPDM), exocrine pancreatic dysfunction (EPD), and osteoporosis), and all-cause mortality were obtained from Danish national health registries. CP cases were stratified based on the presence of AP prior to CP diagnosis. The risk of metabolic sequelae and all-cause mortality was expressed as hazard ratios (HRs) with 95% confidence intervals (CIs), calculated using multivariate Cox proportional hazards models. RESULTS A total of 9655 CP patients were included. Among CP patients, 3913 (40.5%) had a prior AP diagnosis. Compared to patients without a history of AP, patients with prior AP had a decreased risk of death (HR 0.79 (95% CI, 0.74-0.84)), which was largely confined to the initial period after CP diagnosis. Patients with prior AP had an increased risk of PPDM (HR 1.53 (95% CI, 1.38-1.69)), which persisted for up to a decade after CP diagnosis. No overall differences in risk were observed for EPD (HR 0.97 (95% CI, 0.87-1.07)) and osteoporosis (HR 0.87 (95% CI, 0.74-1.02)). CONCLUSIONS This nationwide study revealed that the majority of CP patients have no prior episode(s) of AP, indicating that an attack of AP sensitizing the pancreas is not essential for CP development. CP patients with and without prior AP have different risk profiles of PPDM and all-cause mortality.
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Affiliation(s)
- Mathias Ellgaard Cook
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niels Henrik Bruun
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Line Davidsen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Steno Diabetes Centre North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Pandanaboyana S, Knoph CS, Olesen SS, Jones M, Lucocq J, Samanta J, Talukdar R, Capurso G, de‐Madaria E, Yadav D, Siriwardena AK, Windsor J, Drewes AM, Nayar M. Opioid analgesia and severity of acute pancreatitis: An international multicentre cohort study on pain management in acute pancreatitis. United European Gastroenterol J 2024; 12:326-338. [PMID: 38439202 PMCID: PMC11017759 DOI: 10.1002/ueg2.12542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/05/2023] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND The effect of analgesic modalities on short-term outcomes in acute pancreatitis remains unknown. However, preclinical models have raised safety concerns regarding opioid use in patients with acute pancreatitis. OBJECTIVE This study aimed to assess the association between analgesics, particularly opioids, and severity and mortality in hospitalised patients with acute pancreatitis. METHODS This prospective multicentre cohort study recruited consecutive patients admitted with a first episode of acute pancreatitis between April 1 and 30 June 2022, with a 1-month follow-up. Data on aetiology, clinical course, and analgesic treatment were collected. The primary outcome was the association between opioid analgesia and acute pancreatitis severity, which was analysed using univariate and multivariate analyses. RESULTS Among a total of 1768 patients, included from 118 centres across 27 countries, 1036 (59%) had opioids administered on admission day, and 167 (9%) received opioids after admission day. On univariate analysis, moderately severe or severe acute pancreatitis was associated with male sex, Asian ethnicity, alcohol aetiology, comorbidity, predicted severe acute pancreatitis, higher pain scores, longer pain duration and opioid treatment (all p < 0.001). On multivariate analysis, comorbidity, alcohol aetiology, longer pain duration and higher pain scores increased the risk of moderately severe or severe acute pancreatitis (all p < 0.001). Furthermore, opioids administered after admission day (but not on admission day) doubled the risk of moderately severe or severe disease (OR 2.07 (95% CI, 1.29-3.33); p = 0.003). Opioid treatment for 6 days or more was an independent risk factor for moderately severe or severe acute pancreatitis (OR 3.21 (95% CI, 2.16-4.79; p < 0.001). On univariate analysis, longer opioid duration was associated with mortality. CONCLUSION Opioid treatment increased the risk of more severe acute pancreatitis only when administered after admission day or for 6 days or more. Future randomised studies should re-evaluate whether opioids might be safe in acute pancreatitis.
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Affiliation(s)
- Sanjay Pandanaboyana
- HPB and Transplant UnitFreeman HospitalNewcastle Upon TyneUK
- Population Health Sciences InstituteNewcastle UniversityNewcastle Upon TyneUK
| | - Cecilie Siggaard Knoph
- Centre for Pancreatic Diseases, Department of Gastroenterology & HepatologyAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology & HepatologyAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Michael Jones
- HPB and Transplant UnitFreeman HospitalNewcastle Upon TyneUK
| | - James Lucocq
- Department of HPB SurgeryRoyal Infirmary of EdinburghEdinburghUK
| | - Jayanta Samanta
- Department of GastroenterologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | | | - Gabriele Capurso
- Pancreatico‐Biliary Endoscopy DivisionVita‐Salute San Raffaele UniversityMilanItaly
| | - Enrique de‐Madaria
- Gastroenterology DepartmentDr. Balmis General University HospitalAlicanteSpain
| | - Dhiraj Yadav
- Division of Gastroenterology & HepatologyUniversity of Pittsburgh Medical CentrePittsburghPennsylvaniaUSA
| | | | - John Windsor
- Surgical and Translational Research CentreUniversity of AucklandAucklandNew Zealand
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology & HepatologyAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Manu Nayar
- HPB and Transplant UnitFreeman HospitalNewcastle Upon TyneUK
- Population Health Sciences InstituteNewcastle UniversityNewcastle Upon TyneUK
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Phillips AE, Afghani E, Akshintala VS, Benos PY, Das R, Drewes AM, Easler J, Faghih M, Gabbert C, Halappa V, Khashab MA, Olesen SS, Saloman JL, Sholosh B, Slivka A, Wang T, Yadav D, Singh VK. Pancreatic quantitative sensory testing to predict treatment response of endoscopic therapy or surgery for painful chronic pancreatitis with pancreatic duct obstruction: study protocol for an observational clinical trial. BMJ Open 2024; 14:e081505. [PMID: 38514147 PMCID: PMC10961514 DOI: 10.1136/bmjopen-2023-081505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION Treatment for abdominal pain in patients with chronic pancreatitis (CP) remains challenging in the setting of central nervous system sensitisation, a phenomenon of remodelling and neuronal hyperexcitability resulting from persistent pain stimuli. This is suspected to render affected individuals less likely to respond to conventional therapies. Endotherapy or surgical decompression is offered to patients with pancreatic duct obstruction. However, the response to treatment is unpredictable. Pancreatic quantitative sensory testing (P-QST), an investigative technique of standardised stimulations to test the pain system in CP, has been used for phenotyping patients into three mutually exclusive groups: no central sensitisation, segmental sensitisation (pancreatic viscerotome) and widespread hyperalgesia suggestive of supraspinal central sensitisation. We will test the predictive capability of the pretreatment P-QST phenotype to predict the likelihood of pain improvement following invasive treatment for painful CP. METHODS AND ANALYSIS This observational clinical trial will enrol 150 patients from the University of Pittsburgh, Johns Hopkins and Indiana University. Participants will undergo pretreatment phenotyping with P-QST. Treatment will be pancreatic endotherapy or surgery for clearance of painful pancreatic duct obstruction. PRIMARY OUTCOME average pain score over the preceding 7 days measured by Numeric Rating Scale at 6 months postintervention. Secondary outcomes will include changes in opioid use during follow-up, and patient-reported outcomes in pain and quality of life at 3, 6 and 12 months after the intervention. Exploratory outcomes will include creation of a model for individualised prediction of response to invasive treatment. ETHICS AND DISSEMINATION The trial will evaluate the ability of P-QST to predict response to invasive treatment for painful CP and develop a predictive model for individualised prediction of treatment response for widespread use. This trial was approved by the University of Pittsburgh Institutional Review Board. Data and results will be reported and disseminated in conjunction with National Institutes of Health policies. TRIAL REGISTRATION NUMBER NCT04996628.
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Affiliation(s)
- Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Elham Afghani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
| | | | - Panayiotis Y Benos
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Rohit Das
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
| | - Charles Gabbert
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Vivek Halappa
- Division of Radiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jami L Saloman
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Biatta Sholosh
- Division of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tianxiu Wang
- Center for Research on Healthcare Data, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institute, Baltimore, Maryland, USA
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Cook ME, Bruun NH, Olesen SS. Reply. Gastroenterology 2024:S0016-5085(24)00243-9. [PMID: 38431207 DOI: 10.1053/j.gastro.2024.02.036] [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: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Mathias Ellgaard Cook
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niels Henrik Bruun
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Cichosz SL, Jensen MH, Hejlesen O, Henriksen SD, Drewes AM, Olesen SS. Prediction of pancreatic cancer risk in patients with new-onset diabetes using a machine learning approach based on routine biochemical parameters. Comput Methods Programs Biomed 2024; 244:107965. [PMID: 38070389 DOI: 10.1016/j.cmpb.2023.107965] [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] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/16/2023] [Accepted: 11/30/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVE To develop a machine-learning model that can predict the risk of pancreatic ductal adenocarcinoma (PDAC) in people with new-onset diabetes (NOD). METHODS From a population-based sample of individuals with NOD aged >50 years, patients with pancreatic cancer-related diabetes (PCRD), defined as NOD followed by a PDAC diagnosis within 3 years, were included (n = 716). These PCRD patients were randomly matched in a 1:1 ratio with individuals having NOD. Data from Danish national health registries were used to develop a random forest model to distinguish PCRD from Type 2 diabetes. The model was based on age, gender, and parameters derived from feature engineering on trajectories of routine biochemical variables. Model performance was evaluated using receiver operating characteristic curves (ROC) and relative risk scores. RESULTS The most discriminative model included 20 features and achieved a ROC-AUC of 0.78 (CI:0.75-0.83). Compared to the general NOD population, the relative risk for PCRD was 20-fold increase for the 1 % of patients predicted by the model to have the highest cancer risk (3-year cancer risk of 12 % and sensitivity of 20 %). Age was the most discriminative single feature, followed by the rate of change in haemoglobin A1c and the latest plasma triglyceride level. When the prediction model was restricted to patients with PDAC diagnosed six months after diabetes diagnosis, the ROC-AUC was 0.74 (CI:0.69-0.79). CONCLUSION In a population-based setting, a machine-learning model utilising information on age, sex and trajectories of routine biochemical variables demonstrated good discriminative ability between PCRD and Type 2 diabetes.
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Affiliation(s)
- Simon Lebech Cichosz
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | | | - Ole Hejlesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Stine Dam Henriksen
- Department of Gastrointestinal Surgery and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark; Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark; Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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7
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Cichosz SL, Jensen MH, Olesen SS. Development and Validation of a Machine Learning Model to Predict Weekly Risk of Hypoglycemia in Patients with Type 1 Diabetes Based on Continuous Glucose Monitoring. Diabetes Technol Ther 2024. [PMID: 38215207 DOI: 10.1089/dia.2023.0532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
AIM The aim of this study was to develop and validate a prediction model based on CGM data to identify a week-to-week risk profile of excessive hypoglycemia. METHODS We analyzed, trained, and internally tested two prediction models using CGM data from 205 type 1 diabetes patients with long-term CGM monitoring. A binary classification approach (XGBoost) combined with feature engineering deployed on the CGM signals was utilized to predict excessive hypoglycemia risk defined by two targets (TBR > 4% and the upper TBR 90th percentile limit) of time below range (TBR) the following week. The models were validated in two independent cohorts with a total of 253 additional patients. RESULTS A total of 61,470 weeks of CGM data were included in the analysis. The XGBoost models had a ROC-AUC of 0.83-0.87 (95% confidence interval [CI]; 0.83-0.88) in the test dataset. The external validation showed ROC-AUCs of 0.81-0.90. The most discriminative features included the low blood glucose index (LBGI), the glycemic risk assessment diabetes equation (GRADE), hypoglycemia, the TBR, waveform length, the CV and mean glucose during the previous week. This highlights that the pattern of hypoglycemia combined with glucose variability during the past week contains information on the risk of future hypoglycemia. CONCLUSION Prediction models based on real-world CGM data can be used to predict the risk of hypoglycemia in the forthcoming week. The models showed good performance in both the internal and external validation cohorts.
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Affiliation(s)
| | - Morten Hasselstrøm Jensen
- Aalborg Universitet, 1004, Dept of Health Science and Technology, Aalborg, Denmark
- Aalborg University Hospital, 53141, Steno Diabetes Center North Denmark, Aalborg, Denmark;
| | - Søren Schou Olesen
- Aalborg University Hospital, 53141, Aalborg, North Denmark Region, Denmark;
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Nauser S, Steinkohl E, Olesen SS, Drewes AM, Frøkjær JB. Co-existence of hepatic and pancreatic fibrosis in chronic pancreatitis patients including associated risk factors: a magnetic resonance elastography study. Scand J Gastroenterol 2024; 59:100-107. [PMID: 37615331 DOI: 10.1080/00365521.2023.2250496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES To investigate the co-existence of hepatic and pancreatic fibrosis using magnetic resonance elastography (MRE) in chronic pancreatitis (CP), including the association between hepatic and pancreatic MRE-derived stiffness and exploration of potential etiological risk factors. MATERIALS AND METHODS Fifty-four CP patients and 35 healthy controls underwent hepatic and pancreatic MRE with measurements of tissue stiffness. Clinical parameters including stage (probable or definite CP), etiology of CP, the presence of diabetes or exocrine insufficiency, and previous history of common bile duct stenosis were assessed. Uni- and multivariate regression models were used to investigate risk factors associated with hepatic fibrosis/stiffness in CP patients. RESULTS Fifteen percent of CP patients and none of the controls had abnormal liver stiffness (>2.5 kPa), p = 0.02. 5.6% of CP patients had liver stiffness indicating F1 fibrosis (>2.93 kPa). However, hepatic stiffness was not higher in patients than in healthy controls (2.20 ± 0.41 vs 2.08 ± 0.21 kPa, p = 0.10). In patients, a positive association was seen between hepatic and pancreatic stiffness (r = 0.270, p = 0.048). In the multivariate analysis (adjusted for age, gender and BMI), liver stiffness was significantly associated with alcoholic etiology of CP (p = 0.029). In contrast, stage of CP, history of common bile duct stenosis, and the presence of diabetes or exocrine insufficiency were not associated with liver stiffness (all p > 0.14). CONCLUSIONS Only a modest co-existence of hepatic and pancreatic fibrosis was observed in CP. However, the positive association between hepatic and pancreatic stiffness indicates some level of common pathophysiology. Especially, alcoholic etiology of CP was related to increased hepatic stiffness.
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Affiliation(s)
- Serena Nauser
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Emily Steinkohl
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
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Cook ME, Bruun NH, Davidsen L, Drewes AM, Olesen SS. Multistate Model of the Natural History of Inflammatory Pancreatic Diseases: A Nationwide Population-based Cohort Study. Gastroenterology 2023; 165:1547-1557.e4. [PMID: 37659669 DOI: 10.1053/j.gastro.2023.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/18/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND & AIMS Understanding the nature of inflammatory pancreatic diseases is essential for planning health care system requirements and interventions. The aim of this study was to quantify the trajectories of inflammatory pancreatic diseases and their association with pancreatic cancer in a population-based setting. METHODS National health registries were used to identify all Danish residents (18 years or older) in the period from 2000 through 2018 with incident cases of acute pancreatitis (AP), recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), and pancreatic cancer. We used a multistate model to examine transitions from a healthy state to intermediate states of acute pancreatic inflammation (AP and RAP) to chronic states (CP and pancreatic cancer) and, ultimately, death. Results were reported as transition incidence rates per 1000 person-years with 95% CIs. RESULTS There were 4,663,864 individuals included (mean age, 46 years; 51% were women). During a mean follow-up of 16.8 years, 31,396 individuals were diagnosed with incident AP, 5546 with RAP, 8898 with CP, and 18,182 with pancreatic cancer. The cumulative incidence of pancreatitis (acute and chronic) during the study period was 0.80% (95% CI, 0.79%-0.80%). The transition incidence rates to CP were 12.1 (95% CI, 8.1-18.1) from AP, 46.8 (95% CI, 31.6-69.3) from RAP, and 0.07 (95% CI, 0.04-0.13) from a healthy state. Similar patterns were observed for transitions to pancreatic cancer. Most patients diagnosed with CP (64.2%) and pancreatic cancer (96.4%) transitioned directly from a healthy state. Among patients with pancreatitis, 41.0% (95% CI, 40.5%-41.5%) died during follow-up. CONCLUSIONS The study findings revealed an increased risk of CP and pancreatic cancer in patients with a history of AP. However, most patients with CP and pancreatic cancer transitioned directly from a healthy state.
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Affiliation(s)
- Mathias Ellgaard Cook
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niels Henrik Bruun
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Line Davidsen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Eder P, Verstock B, Culver E, Dragoni G, Kredel LI, Wypych J, de Paredes AGG, Kaniewska M, Leibovitzh H, Lobaton T, Truyens M, Oracz G, Giuseppe Ribaldone D, Starzyńska T, Badaoui A, Rahier JF, Bezzio C, Bossuyt P, Falloon K, Pugliese D, Frakes Vozzo C, Jess T, Larsen L, Olesen SS, Pal P, Chaparro M, Dror D, Ellul P, Gromny I, Janiak M, Maciejewska K, Peleg N, Bar-Gil Shitrit A, Szwed Ł, Talar-Wojnarowska R, Snir Y, Weisshof R, Zittan E, Miechowicz I, Goren I. Autoimmune Pancreatitis in Patients with Inflammatory Bowel Disease: A Real-World Multicentre Collaborative ECCO CONFER Study. J Crohns Colitis 2023; 17:1791-1799. [PMID: 37283545 PMCID: PMC10673810 DOI: 10.1093/ecco-jcc/jjad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/05/2023] [Accepted: 06/06/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Autoimmune pancreatitis [AIP] is rarely associated with inflammatory bowel disease [IBD]. The long-term outcomes of AIP and IBD in patients with coexisting AIP-IBD and predictors of complicated AIP course have rarely been reported. METHODS An ECCO COllaborative Network For Exceptionally Rare case reports project [ECCO-CONFER] collected cases of AIP diagnosed in patients with IBD. Complicated AIP was defined as a composite of endocrine and/or exocrine pancreatic insufficiency, and/or pancreatic cancer. We explored factors associated with complicated AIP in IBD. RESULTS We included 96 patients [53% males, 79% ulcerative colitis, 72% type 2 AIP, age at AIP diagnosis 35 ± 16 years]. The majority of Crohn's disease [CD] cases [78%] had colonic/ileocolonic involvement. In 59%, IBD preceded AIP diagnosis, whereas 18% were diagnosed simultaneously. Advanced therapy to control IBD was used in 61% and 17% underwent IBD-related surgery. In total, 82% of patients were treated with steroids for AIP, the majority of whom [91%] responded to a single course of treatment. During a mean follow-up of 7 years, AIP complications occurred in 25/96 [26%] individuals. In a multivariate model, older age at AIP diagnosis was associated with a complicated AIP course (odds ratio [OR] = 1.05, p = 0.008), whereas family history of IBD [OR = 0.1, p = 0.03], and CD diagnosis [OR = 0.2, p = 0.04] decreased the risk of AIP complications. No IBD- or AIP-related deaths occurred. CONCLUSIONS In this large international cohort of patients with concomitant AIP-IBD, most patients have type 2 AIP and colonic IBD. AIP course is relatively benign and long-term outcomes are favourable, but one-quarter develop pancreatic complications. Age, familial history of IBD, and CD may predict uncomplicated AIP course.
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Affiliation(s)
- Piotr Eder
- Department of Gastroenterology, Dietetics, and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Bram Verstock
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Emma Culver
- Translational Gastroenterology Unit, John Radcliffe Hospital and Oxford, NIHR BRC, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gabriele Dragoni
- Department of Gastroenterology, Careggi University Hospital, Florence, Italy
| | - Lea Isabell Kredel
- Division of Gastroenterology, Infectiology and Rheumatology, Medical Department, Charité-Universitätsmedizin, Berlin, Germany
| | - Joanna Wypych
- Department of Gastroenterology, Surgery and Nutrition, Copernicus Hospital, Gdansk, Poland
| | - Ana Garcia Garcia de Paredes
- Gastroenterology and Hepatology Department. Hospital Universitario Ramon y Cajal. Universidad de Alcala, IRYCIS, Madrid, Spain
| | - Magdalena Kaniewska
- Department of Gastroenterology with IBD Subdivision, National Medical Institute of Ministry of Inferior and Administration, Warsaw, Poland
| | - Haim Leibovitzh
- Zane Cohen Centre for Digestive Diseases, Division of Gastroenterology & Hepatology, Temerty Faculty of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Department of Gastroenterology, Ghent University, Ghent, Belgium
| | - Marie Truyens
- Department of Internal Medicine and Pediatrics, Department of Gastroenterology, Ghent University, Ghent, Belgium
| | - Grzegorz Oracz
- Department of Gastroenterology, Hepatology, Feeding Disorder and Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland; Pediatric Gastroenterology Faculty, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - Teresa Starzyńska
- Department of Gastroenterology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Abdenor Badaoui
- Department of Gastroenterology, Université Catholique de Louvain, Yvoir, Belgium
| | - Jean-Francois Rahier
- Department of Gastroenterology, Université Catholique de Louvain, Yvoir, Belgium
| | - Cristina Bezzio
- Gastroenterology Unit, Rho Hospital, Rho (MI), ASST Rhodense, Garbagnate Milanese, Italy
| | - Peter Bossuyt
- Imelda GI Clinical Research Center, Imelda General Hospital, Bonheiden, Belgium
| | - Katherine Falloon
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniela Pugliese
- CEMAD, IBD UNIT, Unità Operativa Complessa di Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy
| | - Catherine Frakes Vozzo
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tine Jess
- Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Lone Larsen
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Center for Molecular Prediction of Inflammatory Bowel Disease – PREDICT, Department of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Partha Pal
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - María Chaparro
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Dikla Dror
- Department of Gastroenterology, Galilee Medical Center, Nahariyya, Israel
| | - Pierre Ellul
- Division of Gastroenterology, Mater dei Hospital, Malta
| | - Iga Gromny
- Division of Dietetics, Department of Gastroenterology and Hepatology, Wroclaw Medical University, Wroclaw, Poland
| | - Maria Janiak
- Department of Gastroenterology and Hepatology, Medical University of Gdańsk, Gdańsk, Poland
| | - Katarzyna Maciejewska
- Department of Gastroenterology with IBD Subdivision, National Medical Institute of Ministry of Inferior and Administration, Warsaw, Poland
| | - Noam Peleg
- The Division of Gastroenterology, Rabin Medical Center, Petach Tikva, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariella Bar-Gil Shitrit
- IBD MOM Unit, Digestive Diseases Institute, The Hebrew University of Jerusalem, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Łukasz Szwed
- Private Gastroenterology Practice, Nowy Dwór Mazowiecki, Poland
| | | | - Yifat Snir
- Gastroenterology Department, Clalit Health Services, Tel Aviv District, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Weisshof
- Gastroenterology Institute at Rambam Health Care Campus in Haifa, Haifa, Israel
| | - Eran Zittan
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases, IBD Unit, Emek Medical Center, Afula, Israel
| | - Izabela Miechowicz
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Idan Goren
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Jensen MH, Cichosz SL, Hejlesen O, Henriksen SD, Drewes AM, Olesen SS. Risk of pancreatic cancer in people with new-onset diabetes: A Danish nationwide population-based cohort study. Pancreatology 2023; 23:642-649. [PMID: 37422338 DOI: 10.1016/j.pan.2023.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/29/2023] [Accepted: 07/01/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND New onset diabetes (NOD) in people 50 years or older may indicate underlying pancreatic ductal adenocarcinoma (PDAC). The cumulative incidence of PDAC among people with NOD remains uncertain on a population-based level. METHODS This was a nationwide population-based retrospective cohort study based on the Danish national health registries. We investigated the 3-year cumulative incidence of PDAC in people 50 years or older with NOD. We further characterised people with pancreatic cancer-related diabetes (PCRD) in relation to demographic and clinical characteristics, including trajectories of routine biochemical parameters, using people with type 2 diabetes (T2D) as a comparator group. RESULTS During a 21-year observation period, we identified 353,970 people with NOD. Among them, 2105 people were subsequently diagnosed with pancreatic cancer within 3 years (0.59%, 95% CI [0.57-0.62%]). People with PCRD were older than people with T2D at diabetes diagnosis (median age 70.9 vs. 66.0 years (P < 0.001) and had a higher burden of comorbidities (P = 0.007) and more prescriptions of medications used to treat cardiovascular diseases (all P < 0.001). Distinct trajectories of HbA1c and plasma triglycerides were observed in PCRD vs. T2D, with group differences observed for up to three years prior to NOD diagnosis for HbA1c and up to two years for plasma triglyceride levels. CONCLUSIONS The 3-year cumulative incidence of PDAC is approximately 0.6% among people 50 years or older with NOD in a nationwide population-based setting. Compared to T2D, people with PCRD are characterised by distinct demographic and clinical profiles, including distinctive trajectories of plasma HbA1c and triglyceride levels.
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Affiliation(s)
- Morten Hasselstrøm Jensen
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark; Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Simon Lebech Cichosz
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Ole Hejlesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Stine Dam Henriksen
- Department of Gastrointestinal Surgery and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark; Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark; Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark; Centre for Pancreatic Diseases and Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
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12
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Knoph CS, Nedergaard RB, Olesen SS, Kuhlmann L, Drewes AM. Spinal Excitability in Patients with Painful Chronic Pancreatitis. J Pain Res 2023; 16:2287-2298. [PMID: 37431436 PMCID: PMC10329835 DOI: 10.2147/jpr.s408523] [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: 03/04/2023] [Accepted: 06/10/2023] [Indexed: 07/12/2023] Open
Abstract
Purpose Abdominal pain is common in patients with chronic pancreatitis (CP), but management is challenging - possibly due to altered pain processing within the central nervous system rendering conventional treatments ineffective. We hypothesized that many patients with painful CP have generalized hyperalgesia correlating with central neuronal hyperexcitability. Patients and Methods Seventeen CP patients with pain and 20 matched healthy controls underwent experimental pain testing, including repeated pain stimuli (temporal summation), pressure algometry performed in dermatomes with same spinal innervation as the pancreatic gland (pancreatic areas) and remote dermatomes (control areas), a cold pressor test and a conditioned pain modulation paradigm. To probe central neuronal excitability, the nociceptive withdrawal reflex was elicited by electrical stimulation of the plantar skin, and electromyography was obtained from the ipsilateral anterior tibial muscle together with somatosensory evoked brain potentials. Results Compared to healthy controls, patients with painful CP had generalized hyperalgesia as evidenced by 45% lower pressure pain detection thresholds (P<0.05) and decreased cold pressor endurance time (120 vs 180 seconds, P<0.001). In patients, reflex thresholds were lower (14 vs 23 mA, P=0.02), and electromyographic responses were increased (16.4 vs 9.7, P=0.04) during the withdrawal reflex, reflecting predominantly spinal hyperexcitability. Evoked brain potentials did not differ between groups. A positive correlation was found between reflex thresholds and cold pressor endurance time (ρ=0.71, P=0.004). Conclusion We demonstrated somatic hyperalgesia in patients with painful CP associated with spinal hyperexcitability. This highlights that management should be directed at central mechanisms using, eg, gabapentinoids or serotonin-noradrenaline reuptake inhibitors.
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Affiliation(s)
- Cecilie Siggaard Knoph
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rasmus Bach Nedergaard
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Louise Kuhlmann
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Center for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Phillips AE, Faghih M, Singh VK, Bick B, Yadav D, Drewes AM, Olesen SS. Widespread Hyperalgesia by Pancreatic Quantitative Sensory Testing Is Associated With Reduced Pain Response in Chronic Pancreatitis. Pancreas 2023; 52:e257-e258. [PMID: 37967828 DOI: 10.1097/mpa.0000000000002247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
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14
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Becker U, Timmermann A, Ekholm O, Grønbæk M, Drewes AM, Novovic S, Nøjgaard C, Olesen SS, Tolstrup JS. Alcohol Drinking Patterns and Risk of Developing Acute and Chronic Pancreatitis. Alcohol Alcohol 2023. [PMID: 36864550 DOI: 10.1093/alcalc/agad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
AIM The aim was to analyze the effects of drinking pattern and type of alcohol on risk of acute and chronic pancreatitis. METHODS Prospective cohort study based on data from 316,751 men and women participating in the Danish National Health Surveys 2010 and 2013. Self-reported questionnaire-based alcohol parameters and information on pancreatitis was obtained from national health registers. Cox regression models were used adjusting for baseline year, gender, age, smoking, Body Mass Index, diet and education. RESULTS Development of acute and chronic pancreatitis increased with alcohol intake with a significant increase among abstainers and those drinking >14 drinks per week compared with individuals drinking 1-7 drinks per week. Frequent binge drinking and frequent drinking (every day) was associated with increased development of acute and chronic pancreatitis compared with those drinking 2-4 days per week. Problematic alcohol use according to the CAGE-C questionnaire was associated with increased development of acute and chronic pancreatitis.Intake of more than 14 drinks of spirits per week was associated with increased development of acute and chronic pancreatitis, and more than 14 drinks of beer per week were associated with increased development of chronic pancreatitis, whereas drinking wine was not associated with development of pancreatitis. CONCLUSION This large prospective population study showed a J-shaped association between alcohol intake and development of pancreatitis. Drinking every day, frequent binge drinking and problematic alcohol use were associated with increased development of pancreatitis and drinking large amounts of beer and spirits might be more harmful than drinking wine.
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Affiliation(s)
- Ulrik Becker
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Copenhagen DK-1455, Denmark
| | - Amalie Timmermann
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Copenhagen DK-1455, Denmark
| | - Ola Ekholm
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Copenhagen DK-1455, Denmark
| | - Morten Grønbæk
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Copenhagen DK-1455, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Mølleparkvej 4, Aalborg DK-9000, Denmark.,Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, Aalborg DK-9000, Denmark
| | - Srdan Novovic
- Gastrounit, Hvidovre University Hospital, Kettegaard Alle 30, Hvidovre DK-2650, Denmark
| | - Camilla Nøjgaard
- Gastrounit, Hvidovre University Hospital, Kettegaard Alle 30, Hvidovre DK-2650, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Mølleparkvej 4, Aalborg DK-9000, Denmark.,Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, Aalborg DK-9000, Denmark
| | - Janne Schurmann Tolstrup
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Copenhagen DK-1455, Denmark
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15
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Steinkohl E, Olesen SS, Hansen TM, Drewes AM, Frøkjær JB. Quantification of parenchymal fibrosis in chronic pancreatitis: relation to atrophy and pancreatic function. Acta Radiol 2023; 64:936-944. [PMID: 35915988 DOI: 10.1177/02841851221114772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Non-invasive modalities for assessing chronic pancreatitis (CP) are needed in clinical practice. PURPOSE To investigate the correlation between magnetic resonance elastography (MRE)-derived stiffness and T1 relaxation times (as proxies of fibrosis) and explore their relationships to gland volume and pancreatic functions in patients with CP and healthy controls (HCs). MATERIAL AND METHODS In 49 patients with CP and 35 HCs, pancreatic stiffness, T1 relaxation times, and gland volume were assessed. Fecal elastase and the presence of diabetes were used to evaluate pancreatic exocrine and endocrine functions. Uni- and multivariable linear regression models were used to analyze correlations between imaging parameters. RESULTS There was a positive correlation between MRE-derived stiffness and T1 relaxation times in patients with CP (R2 = 0.42; P < 0.001) and HCs (R2 = 0.14; P = 0.028). There was no correlation between MRE-derived stiffness and gland volume in patients (R2 = 0.007; P = 0.065) or HCs (R2 = 0.010; P = 0.57). T1 relaxation time was correlated to gland volume (R2 = 0.19; P = 0.002) in patients with CP but not in the HCs (P = 0.056). Severity of pancreatic functional impairment was reflected by increased fibrosis-related parameters in patients without functional impairment, followed by a further increase in fibrosis-related parameters and reduction in gland volume in patients with pancreatic functional impairments. CONCLUSION Pancreatic MRE-derived stiffness and T1 relaxation times might reflect early pathophysiological changes in CP. The dynamic correlation with pancreatic function suggests that these parameters may be useful for the non-invasive and early identification of CP.
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Affiliation(s)
- Emily Steinkohl
- Mech-Sense, Department of Radiology, 53141Aalborg University Hospital, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, 53141Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, 1004Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, 53141Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, 1004Aalborg University, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, 53141Aalborg University Hospital, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, 53141Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, 53141Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, 1004Aalborg University, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, 53141Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, 1004Aalborg University, Aalborg, Denmark
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16
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Bouça-Machado T, Bouwense SAW, Brand M, Demir IE, Frøkjær JB, Garg P, Hegyi P, Löhr JM, de-Madaria E, Olesen SS, Pandanaboyana S, Pedersen JB, Rebours V, Sheel A, Singh V, Smith M, Windsor JA, Yadav D, Drewes AM. Position statement on the definition, incidence, diagnosis and outcome of acute on chronic pancreatitis. Pancreatology 2023; 23:143-150. [PMID: 36746714 DOI: 10.1016/j.pan.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/09/2023] [Accepted: 01/23/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute on chronic pancreatitis (ACP) is a relatively common condition, but there are significant gaps in our knowledge on the definition, incidence, diagnosis, treatment and prognosis. METHODS A systematic review that followed PICO (Population; Intervention; Comparator; Outcome) recommendation for quantitative questions and PICo (Population, Phenomenon of Interest, Context) for qualitative research was done to answer 10 of the most relevant questions about ACP. Quality of evidence was judged by the GRADE criteria (Grades of Recommendation, Assessment, Development and Evaluation). The manuscript was sent for review to 12 international experts from various disciplines and continents using a Delphi process. RESULTS The quality of evidence, for most statements, was low to very low, which means that the recommendations in general are only conditional. Despite that, it was possible to reach strong levels of agreement by the expert panel for all 10 questions. A new consensus definition of ACP was reached. Although common, the real incidence of ACP is not known, with alcohol as a major risk factor. Although pain dominates, other non-specific symptoms and signs can be present. Serum levels of pancreatic enzymes may be less than 3 times the upper limit of normal and cross-sectional imaging is considered more accurate for the diagnosis in many cases. It appears that it is less severe and with a lower mortality risk than acute pancreatitis. CONCLUSIONS Although the evidence base is poor, this position statement provides a foundation from which to advance management of ACP.
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Affiliation(s)
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Martin Brand
- Department of Surgery, University of Pretoria, Pretoria, South Africa
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Pramod Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary. Centre for Translational Medicine, Division of Pancreatic Diseases, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - J-Matthias Löhr
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital, ISABIAL, Alicante, Spain
| | - Søren Schou Olesen
- Mech-Sense & Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Jan Bech Pedersen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Vinciane Rebours
- Pancreatology Department and Digestive Oncology, Beaujon Hospital, AP-HP, Clichy, Paris-Cité University, Paris, France
| | - Andrea Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - Vikesh Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Martin Smith
- Department of Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, Gauteng, South Africa
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, USA
| | - Asbjørn Mohr Drewes
- Mech-Sense & Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
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17
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Kuhlmann L, Olesen SS, Drewes AM. Assessment of visceral pain with special reference to chronic pancreatitis. Front Pain Res (Lausanne) 2022; 3:1067103. [PMID: 36606031 PMCID: PMC9807876 DOI: 10.3389/fpain.2022.1067103] [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] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
A thorough pain assessment is of utmost importance when managing pain in clinical practice as it is the foundation for defining pain in need of treatment, either interventional or pharmacological. Pain characteristics can also guide interventional strategies and help evaluate the effect of treatment. In research settings, standardized pain assessment is crucial to improve comparability across studies and facilitate meta-analysis. Due to the importance of thorough visceral pain assessment, this manuscript describes the key elements of pain evaluation focusing on chronic pancreatitis. Most studies in pain assessment have focused on somatic pain, and although chronic pain often shares characteristics between etiologies, some differences must be addressed when assessing visceral pain. Especially differences between somatic and visceral pain are apparent, where visceral pain is diffuse and difficult to localize, with referred pain aspects and often autonomic symptoms dominating the clinical picture. These aspects need to be incorporated into the pain assessment instrument. The manuscript will discuss the different ways of assessing pain, including unidimensional measurement scales, multidimensional questionnaires, and quantitative sensory testing. The advantages and challenges linked to the different methods will be evaluated.
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Affiliation(s)
- Louise Kuhlmann
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark,Correspondence: Louise Kuhlmann
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Muthulingam JA, Olesen SS, Hansen TM, Drewes AM, Frøkjær JB. White matter brain changes in chronic pancreatitis: A 7-year longitudinal follow-up study. Pancreatology 2022; 22:871-879. [PMID: 36031507 DOI: 10.1016/j.pan.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The progression of cerebral white matter changes over time has not been explored in chronic pancreatitis (CP). We aimed to characterize such alterations in individuals with CP at baseline and after 7-years as compared with controls and to explore associations to risk factors and clinical parameters. METHODS Diffusion tensor imaging was used to evaluate 20 individuals with CP and 13 healthy controls at baseline and after 7-years (CP: n = 9, controls: n = 11). Tract-based spatial statistics were used to assess whole-brain white matter structure, extract significant fractional anisotropy (FA) clusters between groups, mean FA skeleton, mean FA and mean diffusivity (MD). FA of the extracted significant clusters between groups were used for regression analyses with risk factors and clinical parameters, including duration of CP, smoking, and diabetes. RESULTS At baseline, widespread reductions in FA were found in CP compared to controls involving corpus callosum, the anterior, posterior thalamic radiation, and superior and posterior corona radiata (cluster volume: 49,431 mm3, all P < 0.05). At baseline, also the mean FA (P = 0.004) and FA skeleton (P = 0.002) were reduced in CP compared to controls. FA of the extracted significant cluster was associated with the daily tobacco use (P = 0.001) and duration of CP (P = 0.010). At follow-up, the whole-brain FA skeleton was reduced by 1.7% for both CP individuals and controls (P = 0.878). CONCLUSION Individuals with CP had widespread cerebral white matter alterations at baseline that can likely be explained by the CP disease and exposure to toxic substances. Otherwise, further progression resembles that in healthy controls.
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Affiliation(s)
- Janusiya Anajan Muthulingam
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark; Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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19
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Knoph CS, Kamronn TM, Drewes AM, Nielsen LP, Olesen SS. Varenicline for Smoking Cessation in Patients With Chronic Pancreatitis. Pancreas 2022; 51:e117-e118. [PMID: 37099794 DOI: 10.1097/mpa.0000000000002201] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
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20
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Larsen IM, Holten-Rossing S, Mark EB, Poulsen JL, Krogh K, Scott SM, Olesen SS, Drewes AM. Regional gastrointestinal transit times in patients with chronic pancreatitis. Medicine (Baltimore) 2022; 101:e31141. [PMID: 36253998 PMCID: PMC9575730 DOI: 10.1097/md.0000000000031141] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The mechanisms behind disrupted gastrointestinal (GI) motor function in patients with chronic pancreatitis (CP) have not been fully elucidated. We compared regional transit times in patients with CP to those in healthy controls, and investigated whether they were associated with diabetes mellitus, exocrine dysfunction, opioid treatment or quality of life. Twenty-eight patients with CP and 28 age- and gender-matched healthy controls were included. Regional GI transit times were determined using the 3D-Transit system, which consists of an ingestible electromagnetic capsule and a detector worn in an abdominal belt for 5 days. Exocrine function was assessed using the fecal elastase-1 test, and quality of life was assessed using the European Organization for Research and Treatment of Cancer questionnaire. Transit times were analyzed for associations with diabetes mellitus, exocrine pancreatic insufficiency (EPI), opioid treatment and quality of life. Compared with healthy controls, patients with CP had prolonged transit times in the small intestine (6.6 ± 1.8 vs 4.8 ± 2.2 hours, P = .006), colon (40 ± 23 vs 28 ± 26 hours, P = .02), and total GI tract (52 ± 26 vs 36 ± 26 hours, P = .02). There was no difference in gastric emptying time (4.8 ± 5.2 vs 3.1 ± 1.3 hours, P = .9). No associations between transit times and diabetes, EPI, or opioid consumption were found (all P > .05). Quality of life and associated functional and symptom subscales were not associated with transit times, except for diarrhea (P = .03). Patients with CP have prolonged small intestinal and colonic transit times. However, these alterations do not seem to be mediated by diabetes, EPI, or opioid consumption.
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Affiliation(s)
- Isabelle M. Larsen
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Sidse Holten-Rossing
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Esben Bolvig Mark
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Lykke Poulsen
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
- Clinical Institute, Aarhus University, Aarhus Denmark
| | - S. Mark Scott
- Neurogastroenterology Group (GI Physiology Unit), Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Søren Schou Olesen
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense and Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
- *Correspondence: Asbjørn Mohr Drewes, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark (e-mail: )
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21
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Erchinger F, Tjora E, Nordaas IK, Dimcevski G, Olesen SS, Jensen N, Dahl EE, Borch A, Nøjgaard C, Novovic S, Barauskas G, Ignatavicius P, Vujasinovic M, Lőhr M, Laukkarinen J, Parhiala M, Drewes AM, Engjom T. Pancreatic enzyme treatment in chronic pancreatitis: Quality of management and adherence to guidelines-A cross-sectional observational study. United European Gastroenterol J 2022; 10:844-853. [PMID: 35981311 PMCID: PMC9557959 DOI: 10.1002/ueg2.12276] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/17/2022] [Indexed: 12/01/2022] Open
Abstract
Objectives Pancreatic exocrine insufficiency (PEI) is a common complication in patients with chronic pancreatitis (CP), leading to increased morbidity and mortality if not treated adequately. Pancreatic enzyme replacement therapy|pancreas enzyme replacement therapy (PERT) is the cornerstone in treatment of patients with PEI. In the present study, we use data from the Scandinavian Baltic Pancreatic Club database to examine adherence of PERT according to United European Gastroenterology evidence‐based guidelines treatment of CP. Patients and methods Patients with definitive or probable CP according to M‐ANNHEIM diagnostic criteria were included. We collected information on exposures, exocrine function, intake of pancreatic enzymes, and markers of nutrition. Fecal elastase <200 μg/g was defined as a marker for PEI. Enzyme replacement therapy of 100,000 lipase units or more was defined as adequate treatment. Results We included 1006 patients from 8 centers in five countries. Sixty‐four percent of the patients were correctly treated. Twenty‐five per cent of PEI patients were not taking enzymes at all, and 20% of PEI patients were undertreated with insufficient PERT doses according to the guidelines. Fourteen percent of patients with sufficient pancreatic function were receiving enzymes despite normal exocrine pancreatic function. There were center differences. Current smoking was associated with lack of treatment and alcohol abuse was associated with under‐treatment. There were no associations between “no treatment” or “under‐treatment” for underweight or vitamin D deficiency. Conclusion In our CP expert centers, the adherence to guidelines for enzyme treatment is insufficient. Both patient factors and center differences have influence on treatment adherence.
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Affiliation(s)
| | - Erling Tjora
- Pediatric Department, Haukeland University Hospital, Bergen, Norway
| | | | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Søren Schou Olesen
- Department of Gastroenterology and Hepatology, Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Nanna Jensen
- Department of Gastroenterology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Eva Efsen Dahl
- Department of Gastroenterology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Anders Borch
- Department of Gastroenterology, Herlev University Hospital, Herlev, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre University Hospital, Herlev, Denmark
| | - Srdan Novovic
- Department of Gastroenterology, Hvidovre University Hospital, Herlev, Denmark
| | - Giedrus Barauskas
- Department of Gastrointestinal Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Ignatavicius
- Department of Gastrointestinal Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Matthias Lőhr
- Department of Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, University Hospital, Tampere, Finland
| | - Mikael Parhiala
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, University Hospital, Tampere, Finland
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Trond Engjom
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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22
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Tuck NL, Teo K, Kuhlmann L, Olesen SS, Johnson M, Bean DJ, Rashid U, MacCormick AD, Srikumar G, Drewes AM, Windsor JA. Pain patterns in chronic pancreatitis and chronic primary pain. Pancreatology 2022; 22:572-582. [PMID: 35562269 DOI: 10.1016/j.pan.2022.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/12/2022] [Accepted: 04/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Abdominal pain is the most distressing symptom of chronic pancreatitis (CP), and current treatments show limited benefit. Pain phenotypes may be more useful than diagnostic categories when planning treatments, and the presence or absence of constant pain in CP may be a useful prognostic indicator. AIMS This cross-sectional study examined dimensions of pain in CP, compared pain in CP with chronic primary pain (CPP), and assessed whether constant pain in CP is associated with poorer outcomes. METHODS Patients with CP (N = 91) and CPP (N = 127) completed the Comprehensive Pancreatitis Assessment Tool. Differences in clinical characteristics and pain dimensions were assessed between a) CP and CPP and b) CP patients with constant versus intermittent pain. Latent class regression analysis was performed (N = 192) to group participants based on pain dimensions and clinical characteristics. RESULTS Compared to CPP, CP patients had higher quality of life (p < 0.001), lower pain severity (p < 0.001), and were more likely to use strong opioids (p < 0.001). Within CP, constant pain was associated with a stronger response to pain triggers (p < 0.05), greater pain spread (p < 0.01), greater pain severity, more features of central sensitization, greater pain catastrophising, and lower quality of life compared to intermittent pain (all p values ≤ 0.001). Latent class regression analysis identified three groups, that mapped onto the following patient groups 1) combined CPP and CP-constant, 2) majority CPP, and 3) majority CP-intermittent. CONCLUSIONS Within CP, constant pain may represent a pain phenotype that corresponds with poorer outcomes. CP patients with constant pain show similarities to some patients with CPP, potentially indicating shared mechanisms.
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Affiliation(s)
- N L Tuck
- The Health and Rehabilitation Research Institute, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology (AUT), Auckland, New Zealand; The Auckland Regional Pain Service (TARPS), Auckland District Health Board (ADHB), Auckland, New Zealand; The Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Waitematā District Health Board (WDHB), Auckland, New Zealand.
| | - K Teo
- Department of Surgery, School of Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - L Kuhlmann
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - S S Olesen
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - M Johnson
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - D J Bean
- The Health and Rehabilitation Research Institute, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology (AUT), Auckland, New Zealand; The Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Waitematā District Health Board (WDHB), Auckland, New Zealand
| | - U Rashid
- The Health and Rehabilitation Research Institute, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology (AUT), Auckland, New Zealand
| | - A D MacCormick
- Department of Surgery, School of Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand; Department of General Surgery, Counties Manukau District Health Board (CMDHB), Auckland, New Zealand
| | - G Srikumar
- Department of General Surgery, Counties Manukau District Health Board (CMDHB), Auckland, New Zealand
| | - A M Drewes
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - J A Windsor
- Department of Surgery, School of Medicine, Faculty of Medical and Health Science, University of Auckland, New Zealand
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23
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Nordaas IK, Tjora E, Dimcevski G, Haldorsen IS, Olesen SS, Drewes AM, Zviniene K, Barauskas G, Bayram BK, Nørregaard P, Borch A, Nøjgaard C, Jensen AB, Kardasheva SS, Okhlobystin A, Hauge T, Waage A, Frøkjaer JB, Engjom T. Structural imaging findings are related to clinical complications in chronic pancreatitis. United European Gastroenterol J 2022; 10:385-395. [PMID: 35396813 PMCID: PMC9103373 DOI: 10.1002/ueg2.12228] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 03/12/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/OBJECTIVES Structural pancreatic changes and complications related to chronic pancreatitis are well described, but little is known about their relationship. We aimed to explore the associations between pancreatic morphology and clinical complications in a large chronic pancreatitis cohort. METHODS The Scandinavian Baltic Pancreatic Club database collects registrations on patients with definite or probable chronic pancreatitis according to the M-ANNHEIM diagnostic criteria. In this cross-sectional study, we used multivariate logistic regression analyses to evaluate whether imaging-based structural pancreatic changes were associated with common clinical complications. We adjusted for sex, age, disease duration, current alcohol abuse and current smoking. RESULTS We included 742 patients with a mean age of 55 years. Among these, 68% were males, 69% had pancreatic exocrine insufficiency, 35% had diabetes, 12% were underweighted and 68% reported abdominal pain. Main pancreatic duct obstruction, severe (i.e. more than 14) calcifications, pancreatic atrophy and parenchymal changes throughout the entire pancreas (continuous organ involvement) were positively associated with pancreatic exocrine insufficiency. Continuous organ involvement and pseudocysts were positively and negatively associated with diabetes, respectively. Pancreatic atrophy and severe calcifications were positively associated with underweight, and severe calcifications were negatively associated with pain. CONCLUSIONS This study shows independent associations between distinct structural changes on pancreatic imaging and clinical complications in chronic pancreatitis. Pancreatic atrophy, severe calcifications and continuous organ involvement may be of particular clinical relevance, and these findings should motivate monitoring of pancreatic function and nutritional status.
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Affiliation(s)
- Ingrid Kvåle Nordaas
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erling Tjora
- Department of Pediatrics and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Center for Diabetes Research, University of Bergen, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ingfrid S Haldorsen
- Department of Radiology, Mohn Medical Imaging and Visualization Centre, Haukeland University Hospital, Bergen, Norway
| | - Søren Schou Olesen
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kristina Zviniene
- Department of Radiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Giedrius Barauskas
- Department of Gastrointestinal Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Berivan Kyed Bayram
- Department of Gastroenterology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Peter Nørregaard
- Department of Gastroenterology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Anders Borch
- Department of Gastroenterology, Herlev University Hospital, Herlev, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | | | - Svetlana S Kardasheva
- Department of Internal Disease, Propaedeutic, Gastroenterology and Hepatology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Alexey Okhlobystin
- Department of Internal Disease, Propaedeutic, Gastroenterology and Hepatology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Anne Waage
- Department of Surgery, Oslo University Hospital, Oslo, Norway
| | - Jens Brøndum Frøkjaer
- Department of Radiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Trond Engjom
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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24
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Erchinger F, Engjom T, Dimcevski G, Drewes AM, Olesen SS, Vujasinovic M, Löhr JM, Nøjgaard C, Novovic S, Laukkarinen J, Parhiala M, Björn L, Waage A, Hauge T, Pukitis A, Ozola-Zalite I, Kalaitzakis E, Okhlobystin A, Barauskas G, Eva Efsen D, Tjora E. Exocrine pancreas insufficiency in chronic pancreatitis - Risk factors and associations with complications. A multicentre study of 1869 patients. Pancreatology 2022; 22:374-380. [PMID: 35216905 DOI: 10.1016/j.pan.2022.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/18/2022] [Accepted: 02/10/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES There is scarce information about risk factors for exocrine pancreas insufficiency (EPI) in chronic pancreatitis (CP), and how it associates with other complications. The aim of the present study was to examine risk factors for EPI and associations to procedures and other CP related complications in a large, Northern European cohort. PATIENTS AND METHODS We retrieved cross-sectional data on demographics, status on EPI, aetiological risk factors for CP, CP related complications as well as surgical and endoscopic treatment from the Scandinavian Baltic Pancreatic Club Database. Associations were assessed by univariate and multivariate logistic regression analyses. Results are presented as odds ratios (OR) with 95% confidence intervals. RESULTS We included 1869 patients with probable or definitive CP in the study. Exocrine pancreas insufficiency was present in 849 (45.4%) of patients. In multivariate analyses, EPI associated with smoking aetiology (OR 1.47 (1.20-1.79), p < 0.001), and nutritional/metabolic aetiology (OR 0.52 (0.31-0.87), p = 0.01) to CP. Pancreatic or common bile duct stenting procedure and pancreatic resection were both associated with EPI (ORs 1.44 (1.15-1.80), p = 0.002 and 1.54 (1.02-2.33), p = 0.04, respectively). The presence of diabetes mellitus (OR 2.45 (1.92-3.15), p < 0.001), bile duct stenosis (OR 1.48 (1.09-2.00), p = 0.02) and underweight (2.05 (OR 1.40-3.02), p < 0.001) were all associated with presence of EPI. CONCLUSIONS Smoking, bile duct stenosis, previous stenting and resection procedures are all associated with EPI in patients with CP. Presence of EPI were also associated with malnutrition and diabetes mellitus. Hence, intensive nutritional surveillance is needed in these patients.
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Affiliation(s)
| | - Trond Engjom
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Medical Department, Haukeland University Hospital, Bergen, Norway
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | - Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Srdan Novovic
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Mikael Parhiala
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Lindkvist Björn
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anne Waage
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Aldis Pukitis
- Centre of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Imanta Ozola-Zalite
- Centre of Gastroenterology, Hepatology and Nutrition, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Evangelos Kalaitzakis
- Copenhagen University Hospital/Herlev, University of Copenhagen, Copenhagen, Denmark
| | - Alexey Okhlobystin
- Department of Internal Diseases Propedeutics, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Giederius Barauskas
- Department of Gastrointestinal Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dahl Eva Efsen
- Department of Gastroenterology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Erling Tjora
- Paediatric Department, Haukeland University Hospital, Bergen, Norway.
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25
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Kuhlmann L, Teo K, Olesen SS, Phillips AE, Faghih M, Tuck N, Afghani E, Singh VK, Yadav D, Windsor JA, Drewes AM. Development of the Comprehensive Pain Assessment Tool Short Form for Chronic Pancreatitis: Validity and Reliability Testing. Clin Gastroenterol Hepatol 2022; 20:e770-e783. [PMID: 34089847 DOI: 10.1016/j.cgh.2021.05.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/23/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND & AIMS Pain is the foremost complication to chronic pancreatitis (CP), but no validated questionnaires for assessment exist. The COMPAT questionnaire includes all relevant pain dimensions in CP, but a short form is needed to make it usable in clinical practice. METHODS The full COMPAT questionnaire was completed by 91 patients and systematically reduced to 6 questions. Pain severity and analgesic use were merged, leaving 5 pain dimensions. The pain dimension ratings were normalized to a 0-100 scale, and the weighted total score was calculated, where 3 dimensions were weighted double. Reliability of the short form was tested in a test-retest study in 76 patients, and concurrent validity tested against the Brief Pain Inventory and Izbicki pain questionnaire. Convergent validity was verified using confirmatory factor analysis, and criterion validity tested against quality-of-life and hospitalization rates. RESULTS The COMPAT-SF questionnaire consisted of the following pain dimensions: a) pain severity, b) pain pattern, c) factors provoking pain, d) widespread pain, and e) a qualitative pain-describing dimension. Quality of life correlated with the total score and all pain dimensions (P <.05). The total score, pain severity, pain pattern, and factors provoking pain were correlated with hospitalization rates (P <.05). The total score correlated with the Izbicki and Brief Pain Inventory scores (P <.0001). The reliability of the questionnaire in patients in a stable phase was good with an interclass correlation coefficient of 0.89. CONCLUSION The COMPAT-SF questionnaire includes the most relevant aspects of pain in CP and is a feasible, reliable, and valid pain assessment instrument recommended to be used in future trials.
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Affiliation(s)
- Louise Kuhlmann
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Keith Teo
- Department of Surgery, School of Medicine, Faculty of Medicine and Health Science, University of Auckland, New Zealand
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anna Edwards Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC, Pittsburgh, Pennsylvania
| | - Mahya Faghih
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Natalie Tuck
- The Auckland Regional Pain Service, Auckland District Health Board, Auckland, New Zealand
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Vikesh K Singh
- Division of Gastroenterology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC, Pittsburgh, Pennsylvania
| | - John A Windsor
- Department of Surgery, School of Medicine, Faculty of Medicine and Health Science, University of Auckland, New Zealand
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases & Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Hansen LEM, Fjelsted CA, Olesen SS, Phillips AE, Faghih M, Wegeberg AM, Drewes AM, Brock C. Simple Quantitative Sensory Testing Reveals Paradoxical Co-existence of Hypoesthesia and Hyperalgesia in Diabetes. Front Pain Res (Lausanne) 2022; 2:701172. [PMID: 35295514 PMCID: PMC8915693 DOI: 10.3389/fpain.2021.701172] [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: 04/27/2021] [Accepted: 06/04/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Diabetic neuropathy is characterized by the paradoxical co-existence of hypo- and hyperalgesia to sensory stimuli. The literature shows consistently sensory differences between healthy and participants with diabetes. We hypothesized that due to differences in pathophysiology, advanced quantitative sensory testing (QST) might reveal sensory discrepancies between type 1 (T1D) and type 2 diabetes (T2D). Furthermore, we investigated whether vibration detection thresholds (VDT) were associated with sensory response. Method: Fifty-six adults with T1D [43 years (28–58)], 99 adults with T2D [65 years (57–71)], and 122 healthy individuals [51 years (34–64)] were included. VDT, pressure pain detection thresholds (pPDT) and tolerance (pPTT), tonic cold pain (hand-immersion in iced water), and central pain mechanisms (temporal summation and conditioned pain modulation) were tested and compared between T1D and T2D. VDT was categorized into normal (< 18 V), intermediary (18–25 V), or high (> 25 V). Results: In comparison to healthy, analysis adjusted for age, BMI, and gender revealed hypoalgesia to tibial (pPDT): p = 0.01, hyperalgesia to tonic cold pain: p < 0.01, and diminished temporal summation (arm: p < 0.01; abdomen: p < 0.01). In comparison to participants with T2D, participants with T1D were hypoalgesic to tibial pPDT: p < 0.01 and pPTT: p < 0.01, and lower VDT: p = 0.02. VDT was not associated with QST responses. Conclusion: Participants with T1D were more hypoalgesic to bone pPDT and pPTT independent of lower VDT, indicating neuronal health toward normalization. Improved understanding of differentiated sensory profiles in T1D and T2D may identify improved clinical endpoints in future trials.
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Affiliation(s)
- Line Elise Møller Hansen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Centre for Clinical Research, North Denmark Regional Hospital, Hjoerring, Denmark
| | - Camilla Ann Fjelsted
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark.,Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Anne-Marie Wegeberg
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark.,Centre of Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark.,Steno Diabetes Center Nordjylland, Aalborg, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Clinical Institute, Aalborg University, Aalborg, Denmark.,Steno Diabetes Center Nordjylland, Aalborg, Denmark
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Bouça-Machado T, Andrea-Ferreira P, Pedersen JB, Mortensen MB, Novovic S, Windsor JA, Olesen SS, Drewes AM. Confusion with the definition and diagnostic criteria for acute on chronic pancreatitis: review and recommendations. Scand J Gastroenterol 2022:1-7. [PMID: 35119346 DOI: 10.1080/00365521.2022.2035811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/12/2022] [Accepted: 01/24/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Chronic pancreatitis (CP) is a fibroinflammatory disease complicated by episodes of acute inflammation (acute on chronic pancreatitis (ACP)). This entity is common, variably defined and can reflect different pathological mechanisms that requires different interventions. The aim of this study is to conduct a systematic review of how ACP is described, defined and diagnosed in the literature. METHODS A systematic search was conducted from January 1993 to June 2020. All articles that used a term to describe ACP in adults were reviewed and definitions and diagnostic criteria were sought. RESULTS After reviewing 2271 abstracts, 848 articles included a term to describe ACP. The most common descriptions were 'acute on/in CP' (374), 'acute exacerbation of CP' (345) and 'flare(-up) of CP' (43). Among the 848 articles, 14 included a pragmatic definition of ACP, and only 2 papers stated diagnostic criteria. These covered both acute inflammation and acute exacerbation of chronic abdominal pain. CONCLUSION There is no universally accepted term, definition or diagnostic criteria for ACP. A consensus definition is needed to improve quality and comparability of future articles as well as clinical management.
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Affiliation(s)
| | | | - Jan Bech Pedersen
- Department of Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Michael Bau Mortensen
- Odense Pancreas Centre, Upper GI and HPB Section, Department of Surgery, Odense University Hospital, Odense C, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
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28
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Knoph CS, Cook ME, Fjelsted CA, Novovic S, Mortensen MB, Nielsen LBJ, Hansen MB, Frøkjær JB, Olesen SS, Drewes AM. Effects of the peripherally acting μ-opioid receptor antagonist methylnaltrexone on acute pancreatitis severity: study protocol for a multicentre double-blind randomised placebo-controlled interventional trial, the PAMORA-AP trial. Trials 2021; 22:940. [PMID: 34924020 PMCID: PMC8686628 DOI: 10.1186/s13063-021-05885-3] [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] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/26/2021] [Indexed: 12/19/2022] Open
Abstract
Background Moderate to severe acute pancreatitis (AP) is associated with a high rate of complications and increased mortality, yet no targeted pharmacologic treatment currently exists. As pain is a dominant symptom in AP, patients are exposed to excess levels of both endo- and exogenous opioids, which may have harmful effects on the course of AP. This trial investigates the effects of the peripherally acting μ-opioid receptor antagonist (PAMORA) methylnaltrexone on disease severity and clinical outcomes in patients with moderate to severe AP. Methods PAMORA-AP is a multicentre, investigator-initiated, double-blind, randomised, placebo-controlled, interventional trial, which will be conducted at four referral centres for acute pancreatitis in Denmark. Ninety patients with early-onset AP (pain onset within 48 h) as well as predicted moderate to severe disease (two or more systemic inflammatory response syndrome criteria upon admission) will be prospectively included. Subsequently, participants will be randomised (1:1) to intravenous treatment with either methylnaltrexone or matching placebo (Ringer’s lactate) during 5 days of admission. The primary endpoint will be the group difference in disease severity as defined and measured by the Pancreatitis Activity Scoring System (PASS) score 48 h after randomisation. Secondary endpoints include daily PASS scores; disease severity according to the Atlanta classification; quantification of need for analgesics, nutritional support, intravenous fluid resuscitation and antibiotics; duration of hospital admissions, readmission rates and mortality. Pain intensity and gut function will be self-reported using validated questionnaires. Exploratory endpoints include circulating levels of pro-and anti-inflammatory markers, polyethylene glycol recovery from the urine, circulating levels of blood markers of intestinal permeability, the prevalence of pancreatic complications on computed tomography (CT) scans, and colon transit time assessed using a CT-based radiopaque marker method. Discussion This trial aims to evaluate the PAMORA methylnaltrexone as a novel targeted pharmacotherapy in patients with moderate to severe AP with the potential benefit of improved patient outcomes. Trial registration ClinicalTrials.govNCT04743570. Registered on 28 January 2021. EudraCT 2020-002313-18.
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Affiliation(s)
- Cecilie Siggaard Knoph
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mathias Ellgaard Cook
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Camilla Ann Fjelsted
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Srdan Novovic
- Gastrounit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Michael Bau Mortensen
- Odense Pancreas Centre, HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Liv Bjerre Juul Nielsen
- Digestive Disease Centre K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mark Berner Hansen
- Digestive Disease Centre K, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens Brøndum Frøkjær
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Wilder-Smith C, Lee SH, Olesen SS, Low JY, Kioh DYQ, Ferraris R, Materna A, Chan ECY. Fructose intolerance is not associated with malabsorption in patients with functional gastrointestinal disorders. Neurogastroenterol Motil 2021; 33:e14150. [PMID: 33844393 DOI: 10.1111/nmo.14150] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/16/2021] [Accepted: 03/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Symptoms following fructose ingestion, or fructose intolerance, are common in patients with functional gastrointestinal disorders (FGID) and are generally attributed to intestinal malabsorption. The relationships between absorption, symptoms, and intestinal gas production following fructose ingestion were studied in patients with FGID. METHODS Thirty FGID patients ingested a single dose of fructose 35 g or water in a randomized, double-blind, crossover study. Blood and breath gas samples were collected, and gastrointestinal symptoms rated. Plasma fructose metabolites and short-chain fatty acids were quantified by targeted liquid chromatography-tandem mass spectrometry. Patients were classified as fructose intolerant or tolerant based on symptoms following fructose ingestion. KEY RESULTS The median (IQR) areas under the curve of fructose plasma concentrations within the first 2 h (AUC0-2 h ) after fructose ingestion were similar for patients with and without fructose intolerance (578 (70) µM·h vs. 564 (240) µM·h, respectively, p = 0.39), as well as for the main fructose metabolites. There were no statistically significant correlations between the AUC0-2 h of fructose or its metabolites concentrations and the AUCs of symptoms, breath hydrogen, and breath methane. However, the AUCs of symptoms correlated significantly and positively with the AUC0-2 h of hydrogen and methane breath concentrations (r = 0.73, r = 0.62, respectively), and the AUCs of hydrogen and methane concentrations were greater in the fructose-intolerant than in the fructose-tolerant patients after fructose ingestion (p ≤ 0.02). CONCLUSIONS & INFERENCES Fructose intolerance in FGID is not related to post-ingestion plasma concentrations of fructose and its metabolites. Factors other than malabsorption, such as altered gut microbiota or sensory function, may be important mechanisms.
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Affiliation(s)
- Clive Wilder-Smith
- Gastroenterology Group Practice, Brain-Gut Research Group, Bern, Switzerland
| | - Sze Han Lee
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore
| | - Søren Schou Olesen
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - Jing Yi Low
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore
| | - Dorinda Yan Qin Kioh
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore
| | - Ronaldo Ferraris
- Department of Pharmacology & Physiology, New Jersey Medical School, Newark, NJ, USA
| | - Andrea Materna
- Gastroenterology Group Practice, Brain-Gut Research Group, Bern, Switzerland
| | - Eric Chun Yong Chan
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore.,Singapore Institute of Clinical Sciences, Agency for Science, Technology and Research, Singapore City, Singapore
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30
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Steinkohl E, Olesen SS, Hansen TM, Drewes AM, Frøkjær JB. T1 relaxation times and MR elastography-derived stiffness: new potential imaging biomarkers for the assessment of chronic pancreatitis. Abdom Radiol (NY) 2021; 46:5598-5608. [PMID: 34524501 DOI: 10.1007/s00261-021-03276-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Non-invasive imaging methods to detect morphological changes of the pancreas in patients with mild chronic pancreatitis (CP) are needed. This study aimed to compare magnetic resonance imaging-based parameters, pancreatic volume, T1 mapping, magnetic resonance elastography (MRE), and proton density fat fraction between CP patients and controls, and determine the diagnostic performance for diagnosing different stages of CP. METHODS Nineteen patients with mild CP (Cambridge grade 2 or less or recurring acute pancreatitis; n = 19), 30 with moderate/severe CP (Cambridge grade 3 and 4), and 35 healthy controls underwent pancreatic magnetic resonance imaging to assess the above mentioned magnetic resonance imaging-based parameters. The diagnostic performance of each parameter for detecting any mild and moderate/severe CP was determined using receiver operating characteristic analysis. RESULTS Pancreatic volume, T1 relaxation times, MRE-derived stiffness, and proton density fat fraction differed significantly between patients with mild CP, moderate/severe CP, and healthy controls (all p < 0.05). T1 mapping and MRE showed a very high diagnostic performance for distinguishing the mild CP group from the control group (T1 mapping: receiver operating characteristic area under the curve (ROC-AUC): 0.94; sensitivity: 84%; specificity: 91%, MRE: ROC-AUC: 0.93; sensitivity: 89%; specificity: 94%). T1 mapping and MRE also had the highest performance for diagnosing the presence of any CP from the control group (ROC-AUCs of 0.98 and 0.97, respectively). CONCLUSION Quantitative assessments of T1 relaxation time and MRE-derived stiffness had high performance in detecting mild CP and could probably reflect the early fibrotic changes in CP.
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Affiliation(s)
- Emily Steinkohl
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, PO. Box 365, 9000, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000, Aalborg, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, PO. Box 365, 9000, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, PO. Box 365, 9000, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000, Aalborg, Denmark.
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Olesen SS, Svane HML, Nicolaisen SK, Kristensen JK, Drewes AM, Brandslund I, Beck-Nielsen H, Nielsen JS, Thomsen RW. Clinical and biochemical characteristics of postpancreatitis diabetes mellitus: A cross-sectional study from the Danish nationwide DD2 cohort. J Diabetes 2021; 13:960-974. [PMID: 34240829 DOI: 10.1111/1753-0407.13210] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/24/2021] [Accepted: 07/05/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postpancreatitis diabetes mellitus (PPDM) is a common metabolic sequalae of acute and chronic pancreatitis. We conducted a cross-sectional study to examine the proportion of PPDM among patients clinically diagnosed with type 2 diabetes (T2D) in Denmark and their clinical and biochemical characteristics. METHODS We identified all past diagnoses of pancreatitis among patients in the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) cohort through linkage with national health registries. Using International Classification of Diseases, Tenth Revision codes we categorized patients as PPDM and further divided them into acute/chronic subtypes (PPDM-A and PPDM-C). We assessed PPDM prevalence and examined associations with clinical and biochemical parameters using log binomial or Poisson regression to calculate age-/sex-adjusted prevalence ratios (aPRs). RESULTS Among 5564 patients with a clinical diagnosis of T2D, 78 (1.4%) had PPDM. Compared to T2D, PPDM patients were more often underweight or normal weight (body mass index ≤25.0 kg/m2 : aPR 2.3; 95% confidence interval [CI]: 1.6-3.2) and had lower waist-to-hip ratio (≤0.95/≤0.80 in men/women: aPRs 1.8; 95% CI: 1.2-2.7). PPDM patients had lower plasma amylase levels (<17 U/L: aPRs 2.2; 95% CI: 1.1-4.3), higher insulin sensitivity (homeostatic model assessment 2S [HOMA2S] >63: aPR 2.0; 95% CI: 1.2-3.2) and tended to have worse glycaemic control (HbA1c ≥8.0%: aPRs 1.4; 95% CI: 0.8-2.4). PPDM-A was largely indistinguishable from T2D, whereas PPDM-C had impaired insulin secretion, higher insulin sensitivity, and worse glycemic control. CONCLUSIONS The proportion of PPDM among patients with clinically diagnosed T2D is ~1.5% in an everyday clinical care setting. Glucose metabolism of PPDM-A is largely indistinguishable from T2D, whereas PPDM-C differs in relation to insulin secretion and sensitivity.
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Affiliation(s)
- Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | | | | | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Gastroenterology and Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Ivan Brandslund
- Department of Biochemistry, Lillebaelt Hospital, Vejle, Denmark
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Munk T, Svendsen JA, Knudsen AW, Østergaard TB, Thomsen T, Olesen SS, Rasmussen HH, Beck AM. A multimodal nutritional intervention after discharge improves quality of life and physical function in older patients - a randomized controlled trial. Clin Nutr 2021; 40:5500-5510. [PMID: 34656032 DOI: 10.1016/j.clnu.2021.09.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/07/2021] [Accepted: 09/17/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Many older hospitalized patients are at nutritional risk or malnourished and the nutritional condition is often further impaired during hospitalization. When discharged to own home, a "Nutrition Gap" often occurs, causing inadequate dietary intake, and potentially impeded recovery. Previously, cross-sectorial studies of single component nutritional intervention have shown a limited effect on clinically relevant outcomes. We hypothesized that a multimodal nutritional intervention is necessary to elicit a beneficial effect on clinically relevant outcomes. METHODS A randomized controlled trial was performed for a period of 16 weeks. At discharge, the intervention group (IG) received dietetic counselling including a recommendation of daily training, an individual nutrition plan and a package containing foods and drinks covering dietary requirements for the next 24 h. Further, a goodie-bag containing samples of protein-rich milk-based drinks were provided. Information regarding recommendations of nutritional therapy after discharge was systematically and electronically communicated to the municipality. The dietician performed telephone follow-ups on day 4 and 30 and a home visit at 16 weeks. The control group (CG) received standard treatment. The primary outcome was readmissions within 6 month, secondary outcomes were Length of Stay (LOS), Health Related Quality of Life (EQ-5D-3L), nutritional status, physical function (30s-CST) and mortality. This trial was registered under ClinicalTrials.gov Identifier no. NCT03488329. RESULTS We included 191 patients (IG: n = 93). No significant difference was seen in readmissions within 6 month (IG: 45% vs. CG: 45%, Risk Ratio (RR): 0.96 0.71-1.31, p = 0.885). At the 16-weeks follow-up more patients in the IG reached at least 75% of energy and protein requirements (82% vs. CG: 61%, p = 0,007). The energy (kcal) and protein intake (g) per kg was significantly higher in the IG (26.4 kcal/kg (±7.4) vs. 22.6 (±7.4), p = 0.0248) (1.1 g/kg (±0.3) vs. 0.9 g/kg (±0.3). Furthermore, significant lower weight loss was seen in IG (0.7 (±4.3) vs. -1.4 (±3.6), p = 0.002). A significant and clinically relevant difference was found in the EQ-5D-3L VAS-score (IG: mean 61.6 ± 16.2 vs. CG: 53.3 ± 19.3, p = 0.011) (Δ14.3 (±15.5) vs. Δ5.6 (±17.2), p = 0.002). A significant difference in mean 30s-CST in IG was also found (7.2 (±4.3) vs. 5.3 (±4.1), p = 0.010). The improvements in physical function were of clinical relevance in both groups, but significantly higher in the IG (Δ4.2 (±4.4) vs. Δ2.2 (±2.5), p = 0.008). In fact, 86% in IG experienced improvements in the 30s-CST compared with 68% in the CG (p = 0.022). LOS was found to be lower at all time points, however not significant (30 days: -3 (-8.5 to 2.5), p = 0.276, 16 weeks: -4 (-10.2 to 2.2, p = 0.204), 6 months: -3 (-9.3 to 3.3, p = 0346)). All-cause mortality was not different between groups, however RR showed a non-significantly 47% reduction at day 30 (0.53 (0.14-2.05, p = 0.499)) and a 17% reduction at 16 weeks (0.83 (0.40-1.73, p = 1.000)) in IG. Per protocol (PP) analysis revealed a non-significant decrease of 32% in readmission at 6 months (RR: 0.68 (0.42-1.08), p = 0.105). CONCLUSION The present study, using a multimodal nutritional approach, revealed no significant effect on readmissions however a significant positive effect on nutritional status, quality of life and physical function was found. The improvements in quality of life and physical function were of clinical relevance. No significant effect was found on LOS and mortality.
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Affiliation(s)
- Tina Munk
- The Dietitians and Nutritional Research Unit, EATEN, Herlev Gentofte Hospital, University of Copenhagen, Denmark.
| | - Jonas Anias Svendsen
- The Dietitians and Nutritional Research Unit, EATEN, Herlev Gentofte Hospital, University of Copenhagen, Denmark
| | - Anne Wilkens Knudsen
- The Dietitians and Nutritional Research Unit, EATEN, Herlev Gentofte Hospital, University of Copenhagen, Denmark
| | - Tanja Bak Østergaard
- The Dietitians and Nutritional Research Unit, EATEN, Herlev Gentofte Hospital, University of Copenhagen, Denmark
| | - Thordis Thomsen
- Research Unit, Department of Anesthesiology, Herlev Gentofte University Hospital, Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Clinical Institute, Aalborg University Hospital, Denmark
| | - Henrik Højgaard Rasmussen
- The Dietitians and Nutritional Research Unit, EATEN, Herlev Gentofte Hospital, University of Copenhagen, Denmark; Centre for Nutrition and Bowel Disease & Danish Nutrition Science Centre, Aalborg University Hospital, Clinical Institute, Aalborg University, Denmark
| | - Anne Marie Beck
- The Dietitians and Nutritional Research Unit, EATEN, Herlev Gentofte Hospital, University of Copenhagen, Denmark; University College Copenhagen, Faculty of Health, Institute of Nursing and Nutrition, Copenhagen, Denmark
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Phillips AE, Faghih M, Singh VK, Olesen SS, Kuhlmann L, Novovic S, Bick B, Hart PA, Ramsey ML, Talukdar R, Garg PK, Yadav D, Drewes AM. Rationale for and Development of the Pancreatic Quantitative Sensory Testing Consortium to Study Pain in Chronic Pancreatitis. Pancreas 2021; 50:1298-1304. [PMID: 34860815 DOI: 10.1097/mpa.0000000000001912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Abdominal pain is the primary symptom of chronic pancreatitis (CP), but pain is difficult to assess, and objective methods for pain assessment are lacking. The characterization of the sensory component of pain as a surrogate for nociception can be achieved by sensory testing using standardized stimuli. Herein, we describe the rationale for and development of an international consortium to better understand and characterize CP pain. METHODS A collaboration was initially formed between the University of Aalborg, Johns Hopkins University, and the University of Pittsburgh. This group refined the protocol for pancreatic quantitative sensory testing (P-QST) and then expanded the collaboration with plans for incorporating P-QST into prospective studies. RESULTS The collaboration has successfully developed a P-QST nomogram. Chronic pancreatitis patients identified with P-QST as having widespread hyperalgesia had higher pain intensity scores, higher prevalence of constant pain, and decreased quality of life. Psychiatric comorbidities were independent of pain phenotypes. Multiple studies are underway to validate these findings and evaluate their utility in clinical trials. CONCLUSIONS Development of the P-QST Consortium will facilitate collaborative efforts to use P-QST as a means for evaluation and characterization of pain in CP patients, and optimize methods to guide individualized pain management approaches.
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Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mahya Faghih
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Srdan Novovic
- Pancreatitis Centre Copenhagen, Gastrounit, Hvidovre Hospital, Copenhagen, Denmark
| | - Benjamin Bick
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Philip A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mitchell L Ramsey
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad
| | - Pramod K Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Viggers R, Jensen MH, Laursen HVB, Drewes AM, Vestergaard P, Olesen SS. Glucose-Lowering Therapy in Patients With Postpancreatitis Diabetes Mellitus: A Nationwide Population-Based Cohort Study. Diabetes Care 2021; 44:2045-2052. [PMID: 34362812 DOI: 10.2337/dc21-0333] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Postpancreatitis diabetes mellitus (PPDM) is a type of secondary diabetes that requires special considerations for management. The main objective was to examine prescription patterns of glucose-lowering therapy among adults with PPDM compared with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS In a Danish nationwide population-based cohort study, we identified all individuals with adult-onset diabetes in the period 2000-2018 and categorized them as having type 1 diabetes, type 2 diabetes, or PPDM. We ascertained diabetes incidence rates, clinical and demographic characteristics, and classifications and prescription patterns of glucose-lowering therapy and compared these parameters across diabetes subgroups. RESULTS Among 398,456 adults with new-onset diabetes, 5,879 (1.5%) had PPDM, 9,252 (2.3%) type 1 diabetes, and the remaining type 2 diabetes (96.2%). The incidence rate of PPDM was 7.9 (95% CI 7.7-8.1) per 100,000 person-years versus 12.5 (95% CI 12.2-12.7) for type 1 diabetes (incidence rate ratio 0.6 [95% CI 0.6-0.7]; P < 0.001). A sizeable proportion of patients with PPDM were classified as having type 2 diabetes (44.9%) and prescribed sulfonylureas (25.2%) and incretin-based therapies (18.0%) that can potentially be harmful in PPDM. In contrast, 35.0% of patients never received biguanides, which are associated with a survival benefit in PPDM. Increased insulin requirements were observed for patients with PPDM compared with type 2 diabetes (hazard ratio 3.10 [95% CI 2.96-3.23]; P < 0.001) in particular for PPDM associated with chronic pancreatitis (hazard ratio 4.30 [95% CI 4.01-4.56]; P < 0.001). CONCLUSIONS PPDM is a common type of secondary diabetes in adults but is often misclassified and treated as type 2 diabetes, although PPDM requires special considerations for management.
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Affiliation(s)
- Rikke Viggers
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark .,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Morten Hasselstrøm Jensen
- Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Henrik Vitus Bering Laursen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Peter Vestergaard
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Endocrinology, Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology and Hepatology, Mech-Sense and Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
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Muthulingam JA, Hansen TM, Olesen SS, Drewes AM, Frøkjaer JB. Two-Week Cervical Vagus Nerve Stimulation in Chronic Pancreatitis Patients Induces Functional Connectivity Changes of Limbic Structures. Neuromodulation 2021; 25:471-478. [PMID: 35396075 DOI: 10.1111/ner.13482] [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: 12/02/2020] [Revised: 05/05/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Noninvasive vagus nerve stimulation (nVNS) has not only shown antinociceptive effects, but also demonstrated anti-inflammatory and antidepressant effects. These effects could be beneficial in chronic pancreatitis (CP) patients suffering from chronic abdominal pain, even though the underlying central mechanisms remain unclear. The aim was to investigate the effect of cervical nVNS in patients with painful CP on brain functional connectivity and cerebral metabolites. MATERIALS AND METHODS In a randomized double-blind, sham-controlled crossover trial, we used resting-state functional magnetic resonance imaging to investigate functional connectivity changes of limbic structures (seed-based analysis) after two weeks cervical nVNS treatment (GammaCore) as compared with two weeks sham treatment. Similarly, magnetic resonance spectroscopy was performed in the anterior cingulate cortex (ACC) with assessment of glutamate/creatine (Glu/cre) and N-acetylaspartate/creatine (NAA/cre). RESULTS Sixteen CP patients (mean age 56.6 ± 9.4 years) completed the trial. nVNS induced reduced functional connectivity compared to sham treatment between 1) bilateral thalamus and bilateral superior frontal gyrus, 2) ACC and putamen, and 3) posterior cingulate cortex and right thalamus (all p < 0.05). No changes were observed in Glu/cre (p = 0.96) and NAA/cre (p = 0.43) levels between the nVNS and sham treatments. CONCLUSION In our population of CP patients, cervical nVNS compared with sham treatment induced reduced functional connectivity of limbic structures, as also observed in other patient groups. The findings are relevant, since we have previously demonstrated an effect on pain scores in CP patients for both nVNS and sham treatment. Our results elucidate the effects in the central nervous system following nVNS treatment of CP patients, pointing at potential beneficial effects in this patient group.
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Affiliation(s)
- Janusiya Anajan Muthulingam
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Mark EB, Al-Saadi S, Olesen SS, Drewes AM, Krogh K, Frøkjær JB. Colorectal dimensions in the general population: impact of age and gender. Surg Radiol Anat 2021; 43:1431-1435. [PMID: 33903948 DOI: 10.1007/s00276-021-02756-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Constipation is among the most common gastrointestinal disorders, although, there is no generally accepted objective diagnostic criteria thereof. It has been proposed that colorectal dimensions assessed with Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) may support the diagnosis, but normative data are lacking. The aim of this study was to describe colorectal dimensions in a sample of the general population and to investigate whether the dimensions were under influence by age and gender. METHODS The maximum diameters and cross-sectional areas of the ascending colon, descending colon and rectum were determined from 119 CT scans of trauma patients (age groups from 15 to 70 years, 84 men and 35 women). A regression model was applied to explore the impact of age and gender on colorectal dimensions. RESULTS Overall, great variations were found for all colorectal diameters and cross-sectional areas (median diameter (5% percentiles; 95% percentiles): ascending 46 (26; 63) mm; descending 29 (16; 48) mm; rectum 39 (22; 67) mm. Women had larger rectal cross-sectional areas, reflecting more rectal content, compared to men (p = 0.003). Age did not affect colorectal diameters or cross-sectional areas (all p > 0.10). CONCLUSION Great variations of colorectal dimensions were found. Larger rectal cross-sectional areas in women could likely reflect the fact that women have increased prevalence of constipation. Future studies should take gender into consideration when evaluating colorectal dimensions.
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Affiliation(s)
- Esben Bolvig Mark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark. .,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Sahar Al-Saadi
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Brøndum Frøkjær
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Olesen SS, Harakow A, Krogh K, Drewes AM, Handberg A, Christensen PA. Hypertriglyceridemia is often under recognized as an aetiologic risk factor for acute pancreatitis: A population-based cohort study. Pancreatology 2021; 21:334-341. [PMID: 33608229 DOI: 10.1016/j.pan.2021.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Severe hypertriglyceridemia (HTG) is a well-known risk factor for acute pancreatitis, but updated population-based estimates on incidence of HTG-associated pancreatitis are lacking. METHODS We identified all individuals with severe HTG (triglyceride level >10 mmol/L [886 mg/dL]) in a population-based sample from 2008 to 2019 and linked these with Danish nationwide health-registers to identify patients with acute pancreatitis. Pancreatitis cases were subsequently confirmed by a detailed medical chart review. Crude and standardized incidence rates were estimated and studied in relation to age, gender and time-period. In addition, aetiological classification designated during index hospitalization, severity and follow-up of individuals with HTG-associated pancreatitis were studied. RESULTS Among 2146 individuals with severe HTG during the observation period, 75 were diagnosed with acute pancreatitis (3.5%). The mean incidence rate of HTG-associated pancreatitis was 1.4 (95% CI, 1.1-1.7) per 100,000 person years for the total population, for women it was 0.7 (95% CI, 0.5-1.1) and for men 2.0 (95% CI, 1.5-2.6) per 100,000 person-years. The mean incidence rate increased from 0.7 to 1.7 per 100,000 person-years from 2008 to 2019 (ptrend = 0.01). The highest incidence rate of HTG-associated pancreatitis was observed for men in the age group 50-59 years. An elevated triglyceride level was recognized as aetiological risk factor in 35% of patients during index hospitalization. CONCLUSIONS Only a fraction of patients with severe HTG are hospitalized for acute pancreatitis, but the incidence is increasing. In more than half of patients elevated triglycerides is not recognized as a risk factor for acute pancreatitis during index hospitalization.
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Affiliation(s)
- Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
| | - Abdulkarim Harakow
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Aase Handberg
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Peter Astrup Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
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Olesen SS, Hagn-Meincke R, Drewes AM, Steinkohl E, Frøkjaer JB. Pancreatic atrophy and exocrine insufficiency associate with the presence of diabetes in chronic pancreatitis patients, but additional mediators are operative. Scand J Gastroenterol 2021; 56:321-328. [PMID: 33369483 DOI: 10.1080/00365521.2020.1867891] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Diabetes mellitus is a frequent complication of chronic pancreatitis (CP) and has traditionally been considered to develop as a consequence of pancreatic islet cell loss. However, additional mechanisms may be operative including accumulation of pancreatic fat and fibrosis. We used advanced magnetic resonance imaging (MRI) to study pancreatic morphology and exocrine function in a reference population and in CP patients with and without diabetes. METHODS This was a cross-sectional mono centre study. All subjects underwent advanced MRI including assessment of pancreatic ductal parameters (Cambridge classification and main pancreatic duct diameter), parenchymal parameters (DIXON technique and diffusion weighted imaging as proxies for pancreatic fat content and fibrosis, as well as pancreatic volume segmentation). Pancreatic exocrine function was determined as duodenal secretion following secretin stimulation and by the faecal elastase test. RESULTS The study included 76 patients with definite CP of whom 23 (30.1%) had diabetes and 23 sex- and age matched healthy volunteers. Compared to their non-diabetic counterparts, diabetic patients were characterised by a low pancreatic volume (20 vs. 36 ml; p = .02) and impaired pancreatic exocrine function (faecal elastase 19 vs. 48 µg/g; p = .008), while no difference between patients with and without diabetes were seen in relation to MRI derived proxies for fibrosis and pancreatic fat accumulation and pancreatic duct parameters. A large proportion of non-diabetic patients (49%) had similar morphological and functional characteristics as patients with diabetes. CONCLUSION Pancreatic atrophy and exocrine insufficiency are present in most CP patients with diabetes, but additional mediators seem to be operative in post pancreatitis diabetes mellitus.
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Affiliation(s)
- Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Rasmus Hagn-Meincke
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Emilie Steinkohl
- Clinical Institute, Aalborg University, Aalborg, Denmark.,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Clinical Institute, Aalborg University, Aalborg, Denmark.,Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
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Steinkohl E, Olesen SS, Drewes AM, Frøkjaer JB. Progression of pancreatic morphology in chronic pancreatitis is not associated with changes in quality of life and pain. Scand J Gastroenterol 2020; 55:1099-1107. [PMID: 32672476 DOI: 10.1080/00365521.2020.1794022] [Citation(s) in RCA: 6] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES In patients with chronic pancreatitis (CP), the aim was to explore the association between pancreatic morphological progression over four years and corresponding changes in disease characteristics, including quality of life (QOL), pain, and exocrine pancreatic function. METHODS Twenty-five patients with CP were followed by magnetic resonance imaging (MRI). Data were obtained at baseline and after 4-year follow-up, including clinical information, QOL, and pain as assessed by validated questionnaires. Morphological assessments were derived from the same MRI scanner and included pancreatic gland volume, apparent diffusion coefficient values, fat signal fraction, and main pancreatic duct diameter. RESULTS After four years, CP patients showed significant progression in morphological parameters of the pancreas, except for the ductal-related changes (p < .13). Hence, patients developed reduced pancreatic volume by 13.5% (p < .001), an increase of fibrosis by 10.8% (p < .001), and an increase of fat infiltration by 7.6% (p < .001). In contrast, the patient-reported outcomes of QOL and pain did not change significantly over four years (all p > .05). Moreover, the progression of morphological imaging findings was not related to changes in QOL, pain severity, and pain interference (all p > .05). There was, however, an association between the 4-year progression of pancreatic atrophy and the decrease in fecal elastase concentration (r = 0.61; p < .001). CONCLUSIONS Progression of gland morphology in CP did not correlate with changes in the quality of life or pain symptoms. Advanced pancreatic imaging techniques may be a highly sensitive tool for monitoring morphological disease progression, but do not directly reflect patients' disease burden.
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Affiliation(s)
- Emily Steinkohl
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology & Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology & Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Gastroenterology & Hepatology, Centre for Pancreatic Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjaer
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Detlefsen S, Olesen SS. Sialadenitis in a patient with ulcerative colitis and autoimmune pancreatitis type 2. Pathol Res Pract 2020; 216:153072. [PMID: 32825945 DOI: 10.1016/j.prp.2020.153072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 01/07/2023]
Abstract
Autoimmune pancreatitis (AIP) is a distinct form of chronic pancreatitis that has been increasingly recognised over the last decades and shows a good response to corticosteroid treatment. Two different forms of AIP have been characterized. Type 1 AIP is the pancreatic manifestation of IgG4-related disease and often affects multiple organ systems. In contrast, type 2 AIP is confined to the pancreas and involvement of extra-pancreatic organs has previously only very rarely been reported, except for an association with inflammatory bowel disease. The hallmark lesion of type 2 AIP is the granulocyte epithelial lesion (GEL), showing infiltration of neutrophilic granulocytes in the epithelium of pancreatic ducts and their accumulation in the duct lumen. We present a 61-year-old female patient who underwent pancreaticoduodenectomy with a postoperative histological diagnosis of type 2 AIP. Three months later, she underwent colectomy and was diagnosed with ulcerative colitis. One year later, she presented with swelling and pain of the right-sided submandibular salivary gland which was resected. Sialadenitis with lymphoplasmacytic inflammation, obliterative phlebitis, fibrosis and frequent accumulation of neutrophilic granulocytes in ducts, reminiscent of GELs, without IgG4-positivity or epitheloid cell granulomas, was found. Later, she presented with swelling and pain related to the left-sided submandibular gland, which resolved after steroid treatment. We describe the clinical, histological and immunohistochemical findings in this patient. It may be hypothesized that the sialadenitis may represent a rare extrapancreatic manifestation of, alternatively a rare association with, type 2 AIP or ulcerative colitis.
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Affiliation(s)
- Sönke Detlefsen
- Department of Pathology, Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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Frøkjær JB, Lisitskaya MV, Jørgensen AS, Østergaard LR, Hansen TM, Drewes AM, Olesen SS. Pancreatic magnetic resonance imaging texture analysis in chronic pancreatitis: a feasibility and validation study. Abdom Radiol (NY) 2020; 45:1497-1506. [PMID: 32266506 DOI: 10.1007/s00261-020-02512-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE This feasibility and validation study addresses the potential use of magnetic resonance imaging (MRI) texture analysis of the pancreas in patients with chronic pancreatitis (CP). METHODS Extraction of 851 MRI texture features from diffusion weighted imaging (DWI) of the pancreas was performed in 77 CP patients and 22 healthy controls. Features were reduced to classify patients into subgroups, and a Bayes classifier was trained using a tenfold cross-validation forward selection procedure. The classifier was optimized to obtain the best average m-fold accuracy, sensitivity, specificity, and positive predictive value. Classifiers were: presence of disease (CP vs. healthy controls), etiological risk factors (alcoholic vs. nonalcoholic etiology of CP and tobacco use vs. no tobacco use), and complications to CP (presumed pancreatogenic diabetes vs. no diabetes and pancreatic exocrine insufficiency vs. normal pancreatic function). RESULTS The best classification performance was obtained for the disease classifier selecting only five of the original features with 98% accuracy, 97% sensitivity, 100% specificity, and 100% positive predictive value. The risk factor classifiers obtained good performance using 9 (alcohol: 88% accuracy) and 10 features (tobacco: 86% accuracy). The two complication classifiers obtained similar accuracies with only 4 (diabetes: 83% accuracy) and 3 features (exocrine pancreatic function: 82% accuracy). CONCLUSION Pancreatic texture analysis demonstrated to be feasible in patients with CP and discriminate clinically relevant subgroups based on etiological risk factors and complications. In future studies, the method may provide useful information on disease progression (monitoring) and detection of biomarkers characterizing early-stage CP.
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Affiliation(s)
- Jens Brøndum Frøkjær
- Department of Radiology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Maria Valeryevna Lisitskaya
- Department of Radiology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | - Tine Maria Hansen
- Department of Radiology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
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Frøkjær JB, Olesen SS, Drewes AM, Collins D, Akisik F, Swensson J. Impact of age on the diagnostic performance of pancreatic ductal diameters in detecting chronic pancreatitis. Abdom Radiol (NY) 2020; 45:1488-1494. [PMID: 32296897 DOI: 10.1007/s00261-020-02522-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE In the diagnosis of chronic pancreatitis (CP), definition of main pancreatic duct (MPD) dilation is challenging due to lack of commonly accepted normal values. This study assessed the diagnostic performance of MPD diameters to detect CP including the impact of age. METHODS 274 patients with ERCP-verified CP and 262 healthy controls were included. All had magnetic resonance cholangiopancreatography (MRCP) with measurement of MPD diameters in the pancreatic head, body, and tail. CP disease stage was defined as patients with and without functional (exocrine and/or endocrine) impairment. Diagnostic performance of MPD diameter and corresponding cut-offs values to diagnose CP were determined, including an age-stratified analysis. RESULTS In healthy controls, an effect of age on MPD diameters was seen for the pancreatic head (P < 0.001), body (P = 0.006), and tail (P = 0.03). Patients with CP had increased MPD diameter compared to controls (all segments P < 0.001). Increased pancreatic head MPD diameter was seen in patients with functional pancreatic impairment compared to patients without (P = 0.03). The diagnostic performance of MPD diameter to detect CP was high (all segments ROC-AUC > 0.92). The optimal pancreatic MPD diameter cut-off values for diagnosing CP were: < 40 years: 2.0(head) and 1.8(body) mm; 40-60 years: 2.4(head) and 2.1(body) mm; > 60 years: 2.7(head) and 2.1(body) mm. CONCLUSION Age is an important factor when evaluating the diameter of the pancreatic ductal system. Our findings challenge the existing reported thresholds for defining an abnormal duct diameter and point at age-stratified assessments as an integrated part of future imaging-based diagnostic and grading systems for CP.
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Affiliation(s)
- Jens Brøndum Frøkjær
- Department of Radiology, Aalborg University Hospital, P.O. Box 365, 9100, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - David Collins
- Department of Radiology, Indiana University, Indianapolis, USA
| | - Fatih Akisik
- Department of Radiology, Indiana University, Indianapolis, USA
| | - Jordan Swensson
- Department of Radiology, Indiana University, Indianapolis, USA
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43
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Søfteland E, Poulsen JL, Starup-Linde J, Christensen TT, Olesen SS, Singh S, Vestergaard P, Drewes AM, Dimcevski G. Pancreatic exocrine insufficiency in diabetes mellitus - prevalence and characteristics. Eur J Intern Med 2019; 68:18-22. [PMID: 31402275 DOI: 10.1016/j.ejim.2019.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The prevalence of pancreatic exocrine insufficiency (PEI) in diabetes mellitus (DM) varies widely between studies, which may be explained by methodological problems. We aimed to establish the prevalence of PEI in DM using the faecal elastase-1 (FE-1) assay as a screening test, and to further investigate these patients by the mixed 13C-triglyceride (13C-MTG) breath test. METHODS One hundred and thirty-three consecutive type 1 or type 2 DM patients without known exocrine pancreatic disorders were recruited. Demographic parameters, stool consistency, stool frequency, routine laboratory tests, and the presence of DM complications were registered. An FE-1 value <200 μg/g was used as the screening cut-off for PEI, and patients with FE-1 values below this level were referred for a 13C-MTG breath test. RESULTS One hundred and two patients returned faecal samples. The prevalence of PEI as measured by low FE-1 was 13%. Insulin usage, type 1 DM, and DM duration were associated with low FE-1. Stool habits were unaffected by low FE-1. Twelve out of 13 patients with low FE-1 performed the breath test, which was normal in all cases. CONCLUSIONS The prevalence of PEI defined by FE-1 was low in our mixed cohort of type 1 and 2 DM patients. Furthermore, there was a discrepancy between FE-1 and the breath test. Hence, the role of FE-1 in evaluating pancreatic exocrine function in DM should be evaluated in larger studies in order to clarify the association between low FE-1 and clinically relevant PEI.
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Affiliation(s)
- Eirik Søfteland
- Department of Clinical Medicine, University of Bergen, Norway; Hormone Laboratory, Haukeland University Hospital, Bergen, Norway; Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Jakob Lykke Poulsen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Starup-Linde
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark
| | | | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Simran Singh
- Department of Clinical Medicine, University of Bergen, Norway
| | - Peter Vestergaard
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Norway
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Muthulingam JA, Olesen SS, Hansen TM, Brock C, Drewes AM, Frøkjær JB. Study protocol for a randomised double-blinded, sham-controlled, prospective, cross-over clinical trial of vagal neuromodulation for pain treatment in patients with chronic pancreatitis. BMJ Open 2019; 9:e029546. [PMID: 31603076 PMCID: PMC6720238 DOI: 10.1136/bmjopen-2019-029546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The management of chronic pancreatitis (CP) is challenging and requires a personalised approach focused on the individual patient's main symptoms. Abdominal pain is the most prominent symptom in CP, where central pain mechanisms, including sensitisation and impaired pain modulation, often are involved. Recent clinical studies suggest that vagal nerve stimulation (VNS) induces analgesic effects through the modulation of central pain pathways. This study aims to investigate the effect of 2 weeks transcutaneous VNS (t-VNS) on clinical pain in patients with CP, in comparison to the effect of sham treatment. METHODS AND ANALYSIS Twenty-one patients with CP will be enrolled in this randomised, double-blinded, single-centre, sham-controlled, cross-over study. The study has two treatment periods: A 2-week active t-VNS using GammaCore device and a 2-week treatment with a sham device. During both treatment periods, the patients are instructed to self-administer VNS bilaterally to the cervical vagal area, three times per day. Treatment periods will be separated by 2 weeks. During the study period, patients will record their daily pain experience in a diary (primary clinical endpoint). In addition, all subjects will undergo testing which will include MRI, quantitative sensory testing, cardiac vagal tone assessment and collecting blood samples, before and after the two treatments to investigate mechanisms underlying VNS effects. The data will be analysed using the principle of intention to treat. ETHICS AND DISSEMINATION The regional ethics committee has approved the study: N-20170023. Results of the trial will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER The study is registered at www.clinicaltrials.gov: NCT03357029.
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Affiliation(s)
- Janusiya Anajan Muthulingam
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christina Brock
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Aalborg University Hospital, Aalborg, UK
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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45
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Novovic S, Borch A, Werge M, Karran D, Gluud L, Schmidt PN, Hansen EF, Nøjgaard C, Jensen AB, Jensen FK, Frøkjær JB, Hansen MB, Jørgensen LN, Drewes AM, Olesen SS. Characterisation of the fibroinflammatory process involved in progression from acute to chronic pancreatitis: study protocol for a multicentre, prospective cohort study. BMJ Open 2019; 9:e028999. [PMID: 31439604 PMCID: PMC6707691 DOI: 10.1136/bmjopen-2019-028999] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Chronic pancreatitis (CP) is thought to present the end stage of a continuous disease process evolving from acute pancreatitis (AP), over recurrent AP, to early and end-stage CP. Due to the irreversible nature of CP, early detection and prevention is key. Prospective assessment based on advanced imaging modalities as well as biochemical markers of inflammation, fibrosis and oxidative stress may provide a better understanding of the underlying pathological processes and help identify novel biomarkers of disease with the ultimate goal of early diagnosis, intervention and prevention of disease progression. This paper describes the protocol of a prospective multicentre cohort study investigating the fibroinflammatory process involved in progression from acute to CP using state-of-the-art diagnostic imaging modalities and circulating biomarkers of inflammation, fibrosis and oxidative stress. METHODS AND ANALYSIS Adult control subjects and patients at different stages of CP according to the M-ANNHEIM system will be recruited from outpatient clinics at the participating sites and form three cohorts: controls (n=40), suspected CP (n=60) and definitive CP (n=60). Included patients will be followed prospectively for 15 years with advanced MRI and contrast-enhanced endoscopic ultrasound with elastography, assessment of endocrine and exocrine pancreatic function, biochemical and nutritional assessment, and evaluation of pain processing using quantitative sensory testing. Blood samples for a biobank will be obtained. The purpose of the biobank is to allow analyses of potential circulating biomarkers of disease progression, including markers of inflammation, fibrosis and oxidative stress. ETHICS AND DISSEMINATION Permissions from the Regional Science Ethics committee and the Regional Data Protection Agency have been obtained. We will submit the results of the study for publication in peer-reviewed journals regardless of whether the results are positive, negative or inconclusive.
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Affiliation(s)
- Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Anders Borch
- Abdominal Center K, Bispebjerg Hospital, Kobenhavn, Denmark
| | - Mikkel Werge
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - David Karran
- Abdominal Center K, Bispebjerg Hospital, Kobenhavn, Denmark
| | - Lise Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Palle Nordblad Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Erik Feldager Hansen
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology and Gastrointestinal Surgery, Hvidovre Hospital, Hvidovre, Denmark
| | | | | | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
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Drewes AM, Kempeneers MA, Andersen DK, Arendt-Nielsen L, Besselink MG, Boermeester MA, Bouwense S, Bruno M, Freeman M, Gress TM, van Hooft JE, Morlion B, Olesen SS, van Santvoort H, Singh V, Windsor J. Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons! Gut 2019; 68:1343-1351. [PMID: 31129569 PMCID: PMC6691929 DOI: 10.1136/gutjnl-2019-318742] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interactions (SMI), Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnessota Medical School, Minneapolis, Minnesota, USA
| | - Thomas M Gress
- Department of Gastroenterology, Philipps University & University Hospital of Marburg, Marburg, Germany
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart Morlion
- The Leuven Centre for Algology & Pain Management, University Hospitals Leuven, Leuven, Belgium
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Hjalmar van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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47
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Hansen TM, Muthulingam JA, Drewes AM, Olesen SS, Frøkjær JB. Cingulate glutamate levels associate with pain in chronic pancreatitis patients. Neuroimage Clin 2019; 23:101925. [PMID: 31491831 PMCID: PMC6627035 DOI: 10.1016/j.nicl.2019.101925] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/29/2019] [Accepted: 06/30/2019] [Indexed: 12/18/2022]
Abstract
Aims Emerging evidence show that patients with chronic pancreatitis (CP) and abdominal pain have structural and functional alterations in the central nervous system. The aim was to investigate cerebral metabolic signatures in CP and the associations to various risk factors/clinical characteristics and patient outcomes. Methods Magnetic resonance spectroscopy was used to measure brain metabolites in the anterior cingulate cortex (ACC), insula, prefrontal cortex and the parietal region in patients with CP and healthy controls. Subgroup analyses based on disease characteristics (alcoholic etiology of CP, diabetes and opioid treatment) were performed. Finally, relations to abdominal pain symptoms and quality of life scores were explored. Results Thirty-one patients with CP (mean age 58.5 ± 9.2 years) and 23 healthy controls (54.6 ± 7.8 years) were included. Compared to healthy controls, patients had increased glutamate/creatine (glu/cre) levels in the ACC (1.24 ± 0.17 vs. 1.13 ± 0.21, p = .045) and reduced parietal N-acetylaspartate/creatine (NAA/cre) levels (1.44 ± 0.18 vs. 1.54 ± 0.12, p = .027). Patients with alcoholic etiology of CP had significant lower levels of parietal NAA/cre as compared to patients without alcoholic etiology and healthy controls (p < .006). Patients with a high level of ACC glu/cre reported more severe abdominal pain than their counterparts with a low level of ACC glu/cre (pain score 4.1 ± 2.7 vs.1.9 ± 2.3, p = .039). Conclusions Cerebral spectroscopy revealed novel and complementary information on central pain mechanisms and alcohol mediated toxic effects in patients with CP. Our data suggest that cingulate glutamate levels associate with the patients clinical pain symptoms, while parietal NAA levels more likely associate with an alcoholic etiology of CP. Patients with chronic pancreatitis have altered brain metabolites. Increased cingulate glutamate levels associate with clinical pain symptoms. Decreased parietal N-acetylaspartate levels likely relate to alcoholic etiology.
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Affiliation(s)
- Tine Maria Hansen
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000 Aalborg, Denmark
| | - Janusiya Anajan Muthulingam
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000 Aalborg, Denmark
| | - Asbjørn Mohr Drewes
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000 Aalborg, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Søren Schou Olesen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000 Aalborg, Denmark; Centre for Pancreatic Diseases, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Mølleparkvej 4, 9000 Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Søndre Skovvej 11, 9000 Aalborg, Denmark.
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48
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Meldgaard T, Keller J, Olesen AE, Olesen SS, Krogh K, Borre M, Farmer A, Brock B, Brock C, Drewes AM. Pathophysiology and management of diabetic gastroenteropathy. Therap Adv Gastroenterol 2019; 12:1756284819852047. [PMID: 31244895 PMCID: PMC6580709 DOI: 10.1177/1756284819852047] [Citation(s) in RCA: 20] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/26/2019] [Indexed: 02/04/2023] Open
Abstract
Polyneuropathy is a common complication to diabetes. Neuropathies within the enteric nervous system are associated with gastroenteropathy and marked symptoms that severely reduce quality of life. Symptoms are pleomorphic but include nausea, vomiting, dysphagia, dyspepsia, pain, bloating, diarrhoea, constipation and faecal incontinence. The aims of this review are fourfold. First, to provide a summary of the pathophysiology underlying diabetic gastroenteropathy. Secondly to give an overview of the diagnostic methods. Thirdly, to provide clinicians with a focussed overview of current and future methods for pharmacological and nonpharmacological treatment modalities. Pharmacological management is categorised according to symptoms arising from the upper or lower gut as well as sensory dysfunctions. Dietary management is central to improvement of symptoms and is discussed in detail, and neuromodulatory treatment modalities and other emerging management strategies for diabetic gastroenteropathy are discussed. Finally, we propose a diagnostic/investigation algorithm that can be used to support multidisciplinary management.
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Affiliation(s)
| | - Jutta Keller
- Israelitic Hospital in Hamburg, Academic
Hospital University of Hamburg, Germany
| | - Anne Estrup Olesen
- Mech-Sense, Department of Gastroenterology and
Hepatology and Department of Clinical Medicine, Aalborg University Hospital,
Denmark,Department of Clinical Medicine, Aalborg
University, Denmark
| | - Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology and
Hepatology and Department of Clinical Medicine, Aalborg University Hospital,
Denmark,Department of Clinical Medicine, Aalborg
University, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology,
Aarhus University Hospital, Denmark
| | - Mette Borre
- Department of Hepatology and Gastroenterology,
Aarhus University Hospital, Denmark
| | - Adam Farmer
- Department of Gastroenterology, University
Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK,Centre for Digestive Diseases, Blizard
Institute of Cell and Molecular Science, Wingate Institute of
Neurogastroenterology, Barts and the London School of Medicine and
Dentistry, Queen Mary University of London, UK
| | - Birgitte Brock
- Department of Clinical Research, Steno Diabetes
Center Copenhagen (SDCC), Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and
Hepatology and Department of Clinical Medicine, Aalborg University Hospital,
Denmark,Department of Clinical Medicine, Aalborg
University, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and
Hepatology and Department of Clinical Medicine, Aalborg University Hospital,
Denmark,Department of Clinical Medicine, Aalborg
University, Denmark
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49
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Affiliation(s)
- Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Srdan Novovic
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
| | - Camilla Nøjgaard
- Department of Gastroenterology, Hvidovre University Hospital, Copenhagen, Denmark
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50
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Olesen SS, Krarup H, Poulsen JL, Christensen JH, Sheel ARG, Sutton R, Greenhalf W, Halloran C, Drewes AM. Pancreas-specific plasma amylase for assessment and diagnosis of chronic pancreatitis: New insights on an old topic. United European Gastroenterol J 2019; 7:955-964. [PMID: 31428420 DOI: 10.1177/2050640619846011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 04/02/2019] [Indexed: 02/06/2023] Open
Abstract
Background Pancreatic function testing and imaging are used to inform the diagnosis of chronic pancreatitis, but most of these methods are time- and cost-consuming or lack diagnostic accuracy. Objective We investigated the utility of pancreas-specific plasma amylase for assessment and diagnosis of chronic pancreatitis. Design This was a prospective study of 121 consecutive patients with chronic pancreatitis and a reference population of 94 healthy controls. Pancreas-specific plasma amylase level was determined and analysed for its association with exocrine pancreatic insufficiency, diabetes and other clinical variables. Receiver operating characteristic curve analyses were performed to determine the diagnostic utility of plasma amylase for diagnosing chronic pancreatitis and to study associations with disease severity. The findings were validated in a further cohort of 57 patients with chronic pancreatitis. Results Significant and independent associations between plasma amylase level and duration of chronic pancreatitis as well as the presence of exocrine pancreatic insufficiency and diabetes were observed (all p < 0.001). An amylase level below 17.3 U/l had a high specificity (94%) and moderate sensitivity (59%) for the diagnosis of chronic pancreatitis. Diagnostic performance was influenced by disease stage with the best performance observed for advanced disease. The findings were replicated in the validation cohort. Conclusion Pancreas-specific plasma amylase may provide a clinically useful mean for assessment and diagnosis of chronic pancreatitis.
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Affiliation(s)
- Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Henrik Krarup
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Section of Molecular Diagnostics, Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Lykke Poulsen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Jeppe Hagstrup Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Andrea Rhiannon Glynne Sheel
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK.,Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - Robert Sutton
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK.,Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - William Greenhalf
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK
| | - Christopher Halloran
- Department of Clinical Cancer Medicine, Institute of Translational Medicine, The University of Liverpool, Liverpool, UK.,Department of Pancreato-Biliary Surgery, The Royal Liverpool University Hospital, Liverpool, UK
| | - Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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