Transitions of care for adolescents with disorders of gut-brain interaction.

OBJECTIVES: Little is known about the experience of adolescents and young adults (AYA) with disorders of gut-brain interaction (DGBI) who transition from pediatric to adult gastroenterology care. In this two-part study, we used quantitative and qualitative methods to: (1) assess incidence of optimal versus suboptimal transitions of care for AYA with DGBI, (2) characterize health and quality of life effects of the transition, and (3) identify barriers and facilitators for optimal transition of care. METHODS: In Part 1, we conducted a retrospective review of AYA referrals to our adult neurogastroenterology clinic who had transitioned from pediatric gastroenterology care (N = 109, 17-23 years, 72% female). We collected demographic, psychosocial, and healthcare utilization data to determine rate and risk factors for suboptimal transitions. In Part 2, we recruited 24 AYA and parents (n = 19 AYA, n = 5 parents) for completion of a survey and semistructured interview, which was analyzed using validated rapid qualitative analysis method. RESULTS: In Part 1, 20% (22/109) of AYA met the criteria for suboptimal transition of care, which was associated with treatment adherence concern and functional impairment. In Part 2, we identified two principal themes: (1) AYA's health and quality of life are impacted during the transition, and (2) parental involvement and collaboration with pediatric gastrointestinal (GI) are facilitators to successful transitions, whereas access to care and practice style change are barriers. CONCLUSION: AYA with DGBI have high rates of suboptimal care transitions, affecting their health and quality of life. Our study highlights the need for a comprehensive approach that incorporates parents and pediatric providers.

The Role of the Advanced Practice Provider in a Subspecialty Practice: Satisfaction and Professionalism, Including COVID-19 Impacts.

The advanced practice provider collaborates with other clinicians and works to educate, advocate, and increase access for patients in the clinical setting. Research has shown that advanced practice providers working collaboratively with physicians yield improved quality of care and outcomes; however, the current level of understanding of this role in gastroenterology has not been explored in detail. Across two academic institutions, we conducted 16 semi-structured interviews to examine how the environment of the gastroenterology department aligns with the professional satisfaction of its advanced practice providers. Thematic saturation was achieved, revealing four themes: (1) productivity of the working relationship; (2) inconsistent understandings of the advanced practice provider role in clinical care; (3) mixed advanced practice provider experience relating to colleague support; and (4) autonomy impacts satisfaction. These themes highlight not only a reasonable degree of advanced practice provider satisfaction, but also the need to engage with colleagues regarding the advanced practice provider role in care to allow for better integration into the overall gastroenterology healthcare team. The results from different institutions suggest the need to interview gastroenterology advanced practice providers in different settings to better understand whether similar themes exist.

Factors Associated With Chronic De Novo Post-Coronavirus Disease Gastrointestinal Disorders in a Metropolitan US County.

The first coronavirus disease 2019 (COVID-19) pandemic surge harshly impacted the medically underserved populations of the urbanized northeastern United States. SARS-CoV-2 virions infect the gastrointestinal (GI) tract, and GI symptoms are common during acute infection.1 Post-COVID syndromes increasingly are recognized as important public health considerations.2 Postinfectious disorders of gut-brain interaction (DGBIs; formerly known as functional gastrointestinal disorders) can occur after enteric illness; the COVID-19 pandemic is anticipated to provoke DGBI development3 within a rapidly evolving post-COVID framework of illness. Here, we evaluate factors associated with DGBI-like post-COVID gastrointestinal disorders (PCGIDs) in our hospital's surrounding communities comprised predominantly of racial/ethnic minorities and those of reduced socioeconomic status.

Digestive Health in Sexual and Gender Minority Populations.

It has been over 50 years since the Stonewall Inn Riots in June 1969, a seminal event for the lesbian, gay, bisexual, transgender, queer, intersex, and other sexual and gender-diverse minorities (LGBTQI+, or lesbian, gay, bisexual, transgender, queer, intersex, and everyone else) rights movement. However, sexual and gender minority (SGM) individuals still face discrimination and harassment due to their sexual orientation or gender identity. As such, the National Institute on Minority Health and Health Disparities has identified SGM communities as a "health disparity population." Broadly, there are higher rates of sexually transmitted infections, substance use and abuse, mental health conditions, obesity and eating disorders, certain cancers (breast, cervical, and anorectal), and cardiovascular disease in SGM communities. Transgender patients, especially those of color, are more likely to be uninsured, experience discrimination, and be denied health care than cisgender patients. In addition, SGM individuals have twice the risk of lifetime exposure to emotional, physical, and sexual trauma compared with heterosexuals. It is expected all these factors would negatively affect digestive health as well. This review summarizes the effects of social determinants of health and discrimination on health care access, highlights important digestive diseases to consider in the SGM population, and offers solutions to improve and prioritize the health of these communities. We aim to draw attention to SGM-specific issues that affect gastrointestinal health and spur research that is desperately lacking.

The foregut in cystic fibrosis.

The aerodigestive organs share a kindred embryologic origin that allows for a more complete explanation as to how the foregut can remain a barrier to normalcy in people with cystic fibrosis (pwCF). The structures of the aerodigestive tract include the nasopharynx, the oropharynx, the hypopharynx, the esophagus, the stomach, as well as the supraglottic, glottic, and subglottic tubular airways (including the trachea). Additional gastrointestinal (GI) luminal/alimentary organs of the foregut include the duodenum. Extraluminal foregut structures include the liver, the gall bladder, the biliary tree, and the pancreas. There are a variety of neurologic controls within these complicated anatomic compartments to separate the transit of food and liquid from air. These structures share the same origin from the primitive foregut/mesenchyme. The vagus nerve is a critical structure that unites respiratory and digestive functions. This article comments on the interconnected nature of cystic fibrosis and the GI tract. As it relates to the foregut, this has been typically treated as simple "reflux" as the cause of worsened lung function in pwCF. That terms like gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), heartburn, and regurgitation are used interchangeably to reflect pathology further complicates matters; we offer a more physiologically accurate term called "GI-related aspiration" or "GRASP." Broadly, this term reflects that aspiration of foregut contents from the duodenum through the stomach to the esophagus, into the pharynx and the respiratory tree in pwCF. As a barrier to normalcy in pwCF, GRASP is fundamentally two disease processes-GERD and gastroparesis-that likely contribute most to the deterioration of lung disease in pwCF. In the modulator era, successful GRASP management will be critical, particularly in those post-lung transplantation (LTx), only through successful management of both GERD and gastroparesis. Standardization of clinical management algorithms for GRASP in CF-related GRASP is a key clinical and research gap preventing normalcy in pwCF; what exists nearly exclusively addresses surgical evaluations or offers guidance for the management of GI symptoms alone (with unclear parameters for respiratory disease considerations). We begin first by describing the result of GRASP damage to the lung in various stages of lung disease. This is followed by a discussion of the mechanisms by which the digestive tract can injure the lungs. We summarize what we anticipate future research directions will be to reduce the impact of GRASP as a barrier to normalcy in pwCF.

The current state of gastrointestinal motility evaluation in cystic fibrosis: a comprehensive literature review.

Background and Objective: As life expectancy in cystic fibrosis (CF) has increased over the years, a shift in focus toward extra-pulmonary comorbidities such as gastrointestinal (GI) disease has become a topic of particular importance. Although not well-defined in the current literature, GI dysmotility is thought to significantly contribute to GI symptomatology in the CF population. The objective of this article was to provide a comprehensive review of diagnostic modalities at the disposal of the clinician in the evaluation of patients with CF (pwCF) presenting with GI complaints. Furthermore, we aimed to highlight the available literature regarding utilization of these modalities in CF, in addition to their shortcomings, and emphasize areas within the motility literature where further research is essential. Methods: A comprehensive review of all available literature in the English language through December 1, 2022 utilizing PubMed was conducted. Our search was limited to GI motility/transit and dysmotility in pwCF. Two researchers independently screened references for applicable articles and extracted pertinent data. Key Content and Findings: Several diagnostic imaging and manometry options exist in the evaluation of dysmotility; however, the literature is lacking in high-quality, prospective studies to validate such testing in pwCF. Common symptoms experienced and diagnostic motility tools available based on segment of the GI tract as related to pwCF are explored in the current review. Shortcomings in the current literature are identified and future direction to enhance research efforts within the field of CF-related dysmotility is provided. Conclusions: The influence of CF on GI integrity and motility is far-reaching. Despite improvements in longevity and advancement of pulmonary-specific treatment strategies, further high-quality research targeting the evaluation and management of GI dysmotility in pwCF is needed.

Factors associated with receiving an obesity diagnosis and obesity-related treatment for patients with obesity class II and III within a single integrated health system.

Objectives: The prevalence and associated adverse effects of obesity on health and healthcare cost make it a primary public health concern. However, individuals with the physiological features of obesity may be underdiagnosed and undertreated. We aimed to determine the prevalence of obesity diagnoses and obesity-related treatments in an integrated health system and determine the factors associated with receiving an obesity diagnosis and treatment for this indication. Methods: This retrospective cross-sectional study of data from the Henry Ford Health electronic health record included adult patients with a body mass index (BMI) indicating clinical evidence of class II and III (severe) obesity in 2017 and who received treatment through 2019. The primary outcome was prevalence of obesity diagnosis and obesity-related treatment. Logistic regression evaluated the patient-level factors associated with odds of having obesity diagnosis and treatment. Results: Among 64,741 patients meeting the clinical definition of definition of severe obesity, only 40.7 % were clinically diagnosed with obesity, and 23.5 % received an obesity-related intervention. Patients with BMI≥40 kg/m2 (class III) were more likely to be diagnosed with obesity than those with BMI 35-39.9 kg/m2 (class II) (odds ratio [OR] 5.84; 95 % CI, 5.62-6.07). Patients with a diagnosis of obesity (OR 2.92; 95 % CI, 2.80-3.05), Black patients (OR 1.46; 95 % CI, 1.40-1.53), and female patients (OR 1.47; 95 % CI, 1.41-1.54) were more likely to be offered obesity-related treatment. Conclusions: Severe obesity may be underdiagnosed in patients who have BMI 35-39.9 kg/m2 and 1 comorbidity.

Low Prevalence of Reporting of Participant Race and Ethnicity in Gastroenterology Research Publications.

INTRODUCTION: Empirical information on the evolution of reporting race and ethnicity information in gastroenterology research is lacking. To facilitate understanding of where improvements are needed to increase diversity, equity, and inclusion in gastroenterology research, we aimed to evaluate reporting and representation by race and ethnicity in studies published in flagship US-based gastroenterology journals over 20 years. METHODS: We manually reviewed reporting and representation by race and ethnicity in all original research articles published in the American Journal of Gastroenterology and Gastroenterology in 2000, 2010, and 2020. RESULTS: Of 1,168 publications, 24% reported information on race/ethnicity, significantly more commonly reported in US-based study samples vs non-US-based samples. While reporting significantly increased over time, reporting rates were still low as of 2020 (37% overall; 54% with US-based samples). DISCUSSION: We recommend that gastroenterology journals create standard reporting requirements for sociodemographic information, including information on race, ethnicity, and/or cultural background.

Large-Caliber Empiric Esophageal Dilation Results in Sustained Improvement for Selected Patients With Nonobstructive Dysphagia.

INTRODUCTION: Empiric esophageal dilation (EED) remains a controversial practice for managing nonobstructive dysphagia (NOD) secondary to concerns about safety and efficacy. We examine symptom response, presence of tissue disruption, and adverse events (AEs) after EED. METHODS: We examined large-caliber bougie EED for NOD at 2 tertiary referral centers: retrospectively evaluating for AEs. Esophageal manometry diagnoses were also reviewed. We then prospectively assessed EED's efficacy using the NIH Patient-Reported Outcomes Measurement Information System disrupted swallowing questionnaire to assess dysphagia at baseline, 1, 3, and 6 months after EED. Treatment success was defined by improvement in patient-reported outcome scores. RESULTS: AE rate for large-caliber dilation in the retrospective cohort of 180 patients undergoing EED for NOD was low (0.5% perforations, managed conservatively). Visible tissue disruption occurred in 18% of patients, with 47% occurring in the proximal esophagus. Obstructive motility disorders were found more frequently in patients with tissue disruption compared with those without (44% vs 14%, P = 0.05). The primary outcome, the mean disrupted swallowing T -score was 60.1 ± 9.1 at baseline, 56.1 ± 9.5 at 1 month ( P = 0.03), 57 ± 9.6 at 3 months ( P = 0.10), and 56 ± 10 at 6 months ( P = 0.02) (higher scores note more symptoms). EED resulted in a significant and durable improvement in dysphagia and specifically solid food dysphagia among patients with tissue disruption. DISCUSSION: EED is safe in solid food NOD and particularly effective when tissue disruption occurs. EED tissue disruption in NOD does not preclude esophageal dysmotility.