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Clin J Gastroenterol ; 12(6): 530-533, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31077082


Eosinophilic gastrointestinal disorders (EGID) comprise a spectrum of inflammatory diseases that can affect any segment of the gastrointestinal tract. The pathogenesis of these conditions is complex; differentiating between primary and secondary forms of these disorders can be clinically challenging. We report a case of primary EGID in a patient with remote parasite exposure, whose symptoms were initially attributed to irritable bowel syndrome. Endoscopy revealed the rare finding of EGID involving the entire gastrointestinal tract; symptoms improved with an elimination diet. This case raises the possibility of a link between prior parasite exposure and development of EGID, and underscores the necessity of exploring alternative diagnoses in patients with presumed IBS who present with severe symptoms.

Colite/parasitologia , Enterite/parasitologia , Eosinofilia/parasitologia , Esofagite Eosinofílica/parasitologia , Gastrite/parasitologia , Toxocaríase , Colite/diagnóstico , Colite/dietoterapia , Laticínios , Enterite/diagnóstico , Enterite/dietoterapia , Eosinofilia/diagnóstico , Eosinofilia/dietoterapia , Esofagite Eosinofílica/diagnóstico , Esofagite Eosinofílica/dietoterapia , Gastrite/diagnóstico , Gastrite/dietoterapia , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
Expert Rev Gastroenterol Hepatol ; 13(3): 229-239, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30791761


INTRODUCTION: Many of the therapeutic options for patients with inflammatory bowel disease (IBD) suppress the immune system, which increases the risk of certain infections in these patients. Effective vaccines exist and offer protection against a number of infectious diseases. However, data has shown that IBD patients are inadequately vaccinated and, as a result, are at risk of developing certain preventable infections. Furthermore, gastroenterologists' knowledge regarding the appropriate immunizations to administer to their IBD patients is suboptimal. Areas covered: Over the past several years, there has been a considerable amount of research contributing to our knowledge regarding vaccination of patients with IBD. Expert opinion: This updated review article focuses on the current immunization schedule for the IBD patient and stresses the important role of the gastroenterologist as an active participant in the health maintenance of their IBD patients.

Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Doenças Inflamatórias Intestinais/tratamento farmacológico , Infecções Oportunistas/prevenção & controle , Vacinação , Vacinas/administração & dosagem , Humanos , Doenças Inflamatórias Intestinais/diagnóstico , Doenças Inflamatórias Intestinais/imunologia , Infecções Oportunistas/diagnóstico , Infecções Oportunistas/imunologia , Fatores de Risco , Viagem , Resultado do Tratamento , Vacinação/efeitos adversos , Vacinas/efeitos adversos , Vacinas/imunologia
Lancet Oncol ; 19(6): 758-767, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29706374


BACKGROUND: The management and life expectancy of patients with cystic fibrosis have improved substantially in the past three decades, which has resulted in an increased number of these patients being diagnosed with malignancies. Our aim was to assess the risk of gastrointestinal cancers in patients with cystic fibrosis. METHODS: In this systematic review and meta-analysis, we searched PubMed, MEDLINE, Google Scholar, Scopus, Embase, and Cochrane databases with no language restrictions for studies published from inception of the databases to Aug 1, 2017, assessing the risk of gastrointestinal cancers in patients with cystic fibrosis. We also searched abstracts from scientific meetings and the bibliographies of identified articles for additional references. Studies were included if they reported the standardised incidence ratio (SIR) or incidence ratio per person-years. No exclusion criteria with regard to patient characteristics (age, sex, comorbidities, cystic fibrosis mutation type), study setting (location and time period), or method of reporting cancer diagnoses were applied. The primary outcome was risk of gastrointestinal cancer and site-specific gastrointestinal cancers in patients with cystic fibrosis compared with the general population. Pooled summary estimates were calculated using a random-effects model, and subgroup analyses were done to establish whether risk of gastrointestinal cancer varied according to patient lung transplant status. The study is registered with PROSPERO, number CRD42017075396. FINDINGS: Our search identified 95 681 records, of which six cohort studies including 99 925 patients (544 695 person-years) were eligible for the meta-analysis. The overall risk of gastrointestinal cancer was significantly higher in patients with cystic fibrosis than in the general population (pooled SIR 8·13, 95% CI 6·48-10·21; p<0·0001; log SIR 2·10, 95% CI 1·87-2·32; p<0·0001, I2=93·93%). Subgroup analyses showed that the risk of gastrointestinal cancer among patients with cystic fibrosis who had a lung transplant was increased compared with that of patients who did not receive a transplant (pooled SIR 21·13, 95% CI 14·82-30·14; p<0·0001; log SIR 3·05, 95% CI 2·70-3·41; p<0·0001, I2=28·52% vs pooled SIR 4·18, 3·10-5·62; p<0·0001; log SIR 1·43, 1·13-1·73; p<0·0001, I2=22·66%). The risk for the following site-specific cancers was also significantly increased in patients with cystic fibrosis compared with the general population: small bowel cancer (pooled SIR 18·94, 95% CI 9·37-38·27; p<0·0001; log SIR 2·94, 95% CI 2·24-3·64; p<0·0001, I2=38·61%), colon cancer (10·91, 8·42-14·11; p<0·0001; log SIR 2·39, 2·13-2·65; p<0·0001, I2=88·09%), biliary tract cancer (17·87, 8·55-37·36; p<0·0001; log SIR 2·88, 2·15-3·62; p<0·0001, I2=10·16%), and pancreatic cancer (6·18, 1·31-29·27; p=0·022; log SIR 1·82, 0·27-3·38; p<0·0001, I2=62·57%). INTERPRETATION: Our study suggests that patients with cystic fibrosis had a significantly increased risk of gastrointestinal cancer compared with the general population, including small bowel, colon, biliary tract, and pancreatic cancers. These findings highlight the need to develop individualised screening strategies for site-specific gastrointestinal cancers in patients with cystic fibrosis. FUNDING: None.

Fibrose Cística/epidemiologia , Neoplasias Gastrointestinais/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Fatores Etários , Criança , Pré-Escolar , Fibrose Cística/diagnóstico , Fibrose Cística/terapia , Feminino , Neoplasias Gastrointestinais/diagnóstico , Humanos , Expectativa de Vida , Transplante de Pulmão/efeitos adversos , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de Tempo , Adulto Jovem
Dig Dis Sci ; 62(8): 2072-2078, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28547646


INTRODUCTION: Many patients with inflammatory bowel disease (IBD) are vitamin D deficient. The purpose of our study was to identify risk factors for vitamin D deficiency in IBD and to assess the impact of vitamin D repletion on disease activity and quality of life (QOL). METHODS: Patients with at least one 25-OH vitamin D level measured between 2004 and 2011 were included. Patients with a level <30 ng/ml at baseline were followed until the time of repletion. QOL and disease activity scores were measured at baseline and repletion. RESULTS: A total of 255 patients were identified. 33, 29, and 39% had a vitamin D level of ≥30, 20-29, and <20 ng/ml, respectively. When adjusting for disease type and duration, gender, smoking, and race, non-Caucasians had 5.3 (2.3-12.3) and UC patients had a 0.59 (0.33-1.03) odds of having a vitamin D <30 ng/ml. Women were 1.7 times more likely to have a 25-OH vitamin D level <20 ng/ml than men. 55 patients underwent repletion. In CD patients, the HBI and SIBDQ prior to repletion was 5.5 ± 4.9 and 44.3 ± 16.4, respectively; these improved to 3.6 ± 3.4 and 48.6 ± 14.2 after repletion (p = 0.0154 and p = 0.0684). CONCLUSIONS: In this tertiary care IBD cohort, the majority of patients have low vitamin D levels. Non-Caucasian race and female gender are associated with low vitamin D. UC was associated with lower risk of vitamin D insufficiency. In CD, vitamin D repletion is associated with decreased disease activity and increased QOL.

Colite Ulcerativa/complicações , Doença de Crohn/complicações , Suplementos Nutricionais , Deficiência de Vitamina D/etiologia , Vitamina D/administração & dosagem , Vitaminas/administração & dosagem , Adulto , Colite Ulcerativa/sangue , Grupos de Populações Continentais , Doença de Crohn/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Atenção Terciária à Saúde , Resultado do Tratamento , Vitamina D/análogos & derivados , Vitamina D/sangue , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/tratamento farmacológico
Inflamm Bowel Dis ; 22(11): E44-E45, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27755275
Inflamm Bowel Dis ; 22(6): 1391-6, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27057679


BACKGROUND: Inflammatory Bowel Disease (IBD) patients are at an increased risk of developing herpes zoster (HZ), especially when immunosuppressed. HZ may be preventable with the herpes zoster vaccine (HZV), but many patients are not offered vaccination over concern regarding efficacy and fear of adverse events. Although the Center for Disease Control and Prevention recommends that low-dose immunosuppression is not a contraindication, few IBD patients on these medications are receiving HZV. METHODS: This study was a prospective clinical trial to assess the safety and immunogenicity of HZV among 2 groups of IBD patients. Group A consisted of 14 patients on low-dose immunomodulators and group B consisted of 25 patients either on 5-aminosalicylic acid or no IBD therapy. Blood samples were obtained to measure immune responses. RESULTS: HZ specific immunoglobulin G rose significantly in both groups but the response was lower in the immunosuppressed group (P = 0.0002). Peripheral blood mononuclear cell secretion of Tumor necrosis factor-α in response to HZ antigen increased after HZV in group B, but not in group A. Interleukin-8 secretion increased in both groups, but the response was much higher in group B. There were no significant differences in adverse events between groups. No patients developed a HZ-like rash within 1 year after vaccination. CONCLUSIONS: IBD patients on low-dose immunosuppressive therapy have a blunted immune response to HZV as compared with nonimmunosuppressed subjects. Despite this, immunosuppressed IBD patients are able to mount a statistically significant immune response. There were no serious adverse events to HZV.

Anticorpos Antivirais/sangue , Vacina contra Herpes Zoster/efeitos adversos , Vacina contra Herpes Zoster/imunologia , Imunoglobulina G/sangue , Imunossupressores/administração & dosagem , Doenças Inflamatórias Intestinais/tratamento farmacológico , Idoso , Anti-Inflamatórios não Esteroides/uso terapêutico , Anticorpos Antivirais/farmacologia , Células Cultivadas , Feminino , Humanos , Doenças Inflamatórias Intestinais/sangue , Interleucina-8/metabolismo , Leucócitos Mononucleares/efeitos dos fármacos , Leucócitos Mononucleares/metabolismo , Masculino , Mesalamina/uso terapêutico , Pessoa de Meia-Idade , Estudos Prospectivos , Fator de Necrose Tumoral alfa/metabolismo
Gastroenterol Hepatol (N Y) ; 10(8): 503-509, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28845141


Adalimumab (Humira, AbbVie) has efficacy in treatment-naive and infliximab (Remicade, Janssen)-exposed patients with Crohn's disease (CD). An e-survey was sent to US gastroenterologists who were members of the American Gastroenterological Association. A total of 398 gastroenterologists (3%) completed the survey. Seventy-two percent prescribed adalimumab more than a few times yearly, 58% followed more than 50 patients with CD, and 15% followed 200 or more patients with CD. Ninety percent of gastroenterologists felt that adalimumab had a moderately significant positive impact on patient care. Eighty-two percent correctly identified the US Food and Drug Administration-approved adalimumab induction and maintenance regimens. These gastroenterologists were more likely to follow 200 or more patients with CD (P=.045) and prescribe adalimumab more than a few times per year (P=.037). Years in practice, practice setting, gender, and region did not impact prescribing. Correct dosing was associated with higher prescribing frequency (P=.014) and volume of patients with CD (P=.025). The frequency of adalimumab prescribing and volume of patients with CD were predictive of the total number of correct survey answers (P=.014 and P=.017, respectively). Only 50% of gastroenterologists always administered loading doses when switching to adalimumab from another anti-tumor necrosis factor (TNF) agent; 43.5% reported unclear loading efficacy and 24.3% reported infection concerns from excess anti-TNF as reasons. Eighteen percent of gastroenterologists reported that pharmacies had reduced their prescribed adalimumab doses. To our knowledge, this is the only study evaluating prescribing patterns of adalimumab in patients with CD in the United States. Our findings demonstrate that many gastroenterologists are not using optimal adalimumab dosing strategies, which may lead to a decreased rate of response in patients with CD. Further research is needed to confirm our findings and identify barriers to optimal adalimumab use by gastroenterologists for treatment of CD.