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PURPOSE OF REVIEW: Over the last few decades, there have been remarkable strides in endoscopy and radiological imaging that have advanced gastroenterology. However, the management of neurogastroenterological disorders has lagged behind, in part handicapped by the use of catheter-based manometry that is both non-physiological and uncomfortable. The advent of capsule technology has been a game changer for both diagnostic and therapeutic applications. RECENT FINDINGS: Here, we discuss several capsule devices that are available or under investigation. There are three technologies that are FDA approved. Wireless motility capsule measures pH and pressure and provides clinically impactful information regarding gastric, small intestine and colonic transit, without radiation that has been demonstrated to guide management of gastroparesis, dyspepsia and constipation. Wireless ambulatory pH monitoring capsule is currently the gold standard for assessing gastroesophageal acid reflux. In the therapeutics arena, an orally ingested vibrating capsule has been recently FDA approved for the treatment of chronic constipation, supported by a robust phase 3 clinical trial which showed significant improvement in constipation symptoms and quality of life. There are several capsules currently under investigation. Smart capsule bacterial detection system and Capscan® are capsules that can sample fluid in the small or large bowel and provide microbiome analysis for detection of small intestinal bacterial (SIBO) or fungal overgrowth (SIFO). Another investigational gas sensing capsule analyzing hydrogen, CO2, volatile fatty acids and capsule orientation, can measure regional gut transit time and luminal gas concentrations and assess gastroparesis, constipation or SIBO. Therapeutically, other vibrating capsules are in development. Innovations in capsule technology are poised to transform our ability to investigate gut function physiologically, and non-invasively deliver targeted treatment(s), thereby providing both accurate diagnostic information and luminally-directed, safe therapy.
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Endoscopia por Cápsula , Gastroenteropatias , Motilidade Gastrointestinal , Humanos , Gastroenteropatias/diagnóstico , Gastroenteropatias/terapia , Gastroenteropatias/fisiopatologia , Endoscopia por Cápsula/métodos , Motilidade Gastrointestinal/fisiologia , Constipação Intestinal/terapia , Constipação Intestinal/diagnóstico , Constipação Intestinal/fisiopatologiaRESUMO
OBJECTIVES: Chronic idiopathic constipation (CIC) is characterized by unsatisfactory defecation and difficult or infrequent stools. CIC affects 9%-20% of adults in the United States, and although prevalent, gaps in knowledge remain regarding CIC healthcare seeking and medication use in the community. We recruited a population-based sample to determine the prevalence and predictors of (i) individuals having discussed their constipation symptoms with a healthcare provider and (ii) the use of constipation therapies. METHODS: We recruited a representative sample of Americans aged 18 years or older who had experienced constipation. Those who met the Rome IV criteria for irritable bowel syndrome and opioid-induced constipation were excluded. The survey included questions on constipation severity, healthcare seeking, and the use of constipation medications. We used multivariable regression methods to adjust for confounders. RESULTS: Overall, 4,702 participants had experienced constipation (24.0% met the Rome IV CIC criteria). Among all respondents with previous constipation, 37.6% discussed their symptoms with a clinician (primary care provider 87.6%, gastroenterologist 26.0%, and urgent care/emergency room physician 7.7%). Age, sex, race/ethnicity, marital status, employment status, having a source of usual care, insurance status, comorbidities, locus of control, and constipation severity were associated with seeking care (P < 0.05). Overall, 47.8% of respondents were taking medication to manage their constipation: over-the-counter medication(s) only, 93.5%; prescription medication(s) only, 1.3%; and both over-the-counter medication(s) and prescription medication(s), 5.2%. DISCUSSION: We found that 3 of 5 Americans with constipation have never discussed their symptoms with a healthcare provider. Furthermore, the use of prescription medications for managing constipation symptoms is low because individuals mainly rely on over-the-counter therapies.
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Constipação Intestinal/tratamento farmacológico , Laxantes/uso terapêutico , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Fatores Etários , Bisacodil/uso terapêutico , Doença Crônica , Colonoscopia/estatística & dados numéricos , Constipação Intestinal/fisiopatologia , Fibras na Dieta/uso terapêutico , Ácido Dioctil Sulfossuccínico/uso terapêutico , Serviço Hospitalar de Emergência , Emprego , Etnicidade/estatística & dados numéricos , Feminino , Gastroenterologistas , Fármacos Gastrointestinais/uso terapêutico , Agonistas da Guanilil Ciclase C/uso terapêutico , Humanos , Seguro Saúde/estatística & dados numéricos , Controle Interno-Externo , Lactulose/uso terapêutico , Masculino , Estado Civil/estatística & dados numéricos , Pessoa de Meia-Idade , Medicamentos sem Prescrição/uso terapêutico , Peptídeos/uso terapêutico , Médicos de Atenção Primária , Polietilenoglicóis/uso terapêutico , Senosídeos/uso terapêutico , Índice de Gravidade de Doença , Fatores Sexuais , Tensoativos/uso terapêutico , Inquéritos e Questionários , Estados UnidosRESUMO
OBJECTIVES: National societies provide little guidance regarding which colonoscopy bowel preps are best tolerated and most effective; this reflects a lack of comparative effectiveness studies that directly evaluate the available preps in a "real-world" setting. To address this gap, we conducted a prospective, commercially unfunded comparative effectiveness study of currently available bowel preps and measured their impact on bowel cleansing. METHODS: We included patients aged ≥18 years, who presented for an outpatient colonoscopy at a large medical center serving more than 70 academic and community-based endoscopists who are free to prescribe the bowel prep of their choice. The primary outcome was bowel cleansing quality as measured by the Boston Bowel Preparation Scale. We performed regression models with random effects on the outcomes to adjust for confounding. RESULTS: Approximately 4,339 colonoscopies were performed by 75 endoscopists. Magnesium citrate, MiraLAX with Gatorade, MoviPrep, OsmoPrep, Prepopik/Clenpiq, and Suprep all had significantly higher prep tolerability compared with GoLYTELY (all P < 0.05). For bowel cleansing, Suprep (7.28 ± 1.66; P < 0.001), MoviPrep (7.11 ± 1.62; P = 0.004), and MiraLAX with Gatorade (7.09 ± 1.64; P < 0.001) had higher total Boston Bowel Preparation Scale scores compared with GoLYTELY (6.67 ± 1.87); there were no significant differences among the remaining preps. Split-prep dosing was associated with better cleansing; however, men, opioid and tricyclic antidepressent users, and patients with diabetes and cirrhosis had worse cleansing (all P < 0.05). CONCLUSIONS: In this prospective, real-world comparative effectiveness study of available bowel preps, we found that MiraLAX with Gatorade, MoviPrep, and Suprep were prospectively associated with superior tolerability and bowel cleansing.
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Catárticos/uso terapêutico , Colonoscopia/métodos , Adolescente , Adulto , Idoso , Ácido Cítrico , Eletrólitos , Feminino , Humanos , Soluções Isotônicas , Masculino , Pessoa de Meia-Idade , Compostos Organometálicos , Polietilenoglicóis , Estudos Prospectivos , Adulto JovemRESUMO
BACKGROUND: Irritable bowel syndrome (IBS) is a common chronic disorder of the gastrointestinal tract. Several treatments have been developed, including rifaximin for the treatment of IBS without constipation (non-IBS-C), but no studies have evaluated the effect of these therapies on patient referral rates to tertiary care gastroenterology clinics. AIM: To assess referral patterns for IBS patients at a tertiary motility clinic over a 10-year period. METHODS: Data from consecutive patients referred to the clinic during 2006-2016 were analyzed. Trends in the proportion of referrals and prior rifaximin use in IBS-C versus non-IBS-C groups were compared. RESULTS: A total of 814 adult patients were referred to a single physician panel for IBS-related symptoms. Of these, 776 were included in the study [528 females (68%), average age 45.7 ± 15.9 years), comprising 431 IBS-C (55.5%) and 345 non-IBS-C (44.5%) patients. The proportion of non-IBS-C referrals declined significantly from 53.0% in 2006 to 27.3% in 2016 (Chi-square, p < 0.0001, Cochran-Armitage trend test p = 0.0001), and the proportion of IBS-C referrals increased significantly from 46.9% in 2006 to 72.7% in 2016 (Chi-square, p < 0.0001, Cochran-Armitage trend test p = 0.0004). Non-IBS-C referrals with prior rifaximin use significantly increased from 22.7% in 2006 to 66.7% in 2016 (Cochran-Armitage trend test, p = 0.008). CONCLUSIONS: The results indicate a significantly declining tertiary care referral rate for non-IBS-C over the past decade. While not directly linked, there has been an increase in rifaximin use in the same population during the same time interval.
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Fármacos Gastrointestinais/uso terapêutico , Síndrome do Intestino Irritável/tratamento farmacológico , Padrões de Prática Médica/tendências , Encaminhamento e Consulta/tendências , Rifaximina/uso terapêutico , Centros de Atenção Terciária/tendências , Adulto , Idoso , Revisão de Uso de Medicamentos/tendências , Feminino , Humanos , Síndrome do Intestino Irritável/diagnóstico , Síndrome do Intestino Irritável/epidemiologia , Los Angeles/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoAssuntos
Divertículo Esofágico/cirurgia , Transtornos da Motilidade Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Esofagoscopia , Miotomia , Idoso , Divertículo Esofágico/complicações , Divertículo Esofágico/fisiopatologia , Transtornos da Motilidade Esofágica/complicações , Transtornos da Motilidade Esofágica/fisiopatologia , Esfíncter Esofágico Inferior/fisiopatologia , Feminino , Humanos , ManometriaRESUMO
Using data from the National Longitudinal Study of Adolescent Health, this study examines the impact of high school cohort composition on the educational and labor market outcomes of individuals during their early 20s and again during their late 20s and early 30s. We find that the positive effects of having more high school classmates with a college educated mother on college attendance in the years immediately following high school decline as students reach their later 20s and early 30s, and are not followed by comparable effects on college completion and labor market outcomes. The results suggest that factors that increase college attendance are not always sufficient to improve college graduation rates and longer term outcomes.
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Background: Malnutrition has been linked to adverse health economic outcomes. There is a paucity of data on malnutrition in patients admitted with COVID-19. Methods: This is a retrospective cohort study consisting of 4311 COVID-19 adult (18 years and older) inpatients at 5 Johns Hopkins-affiliated hospitals between 1 March and 3 December 2020. Malnourishment was identified using the malnutrition universal screening tool (MUST), then confirmed by registered dietitians. Statistics were conducted with SAS v9.4 (Cary, NC, USA) software to examine the effect of malnutrition on mortality and hospital length of stay among COVID-19 inpatient encounters, while accounting for possible covariates in regression analysis predicting mortality or the log-transformed length of stay. Results: COVID-19 patients who were older, male, or had lower BMIs had a higher likelihood of mortality. Patients with malnutrition were 76% more likely to have mortality (p < 0.001) and to have a 105% longer hospital length of stay (p < 0.001). Overall, 12.9% (555/4311) of adult COVID-19 patients were diagnosed with malnutrition and were associated with an 87.9% increase in hospital length of stay (p < 0.001). Conclusions: In a cohort of COVID-19 adult inpatients, malnutrition was associated with a higher likelihood of mortality and increased hospital length of stay.
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COVID-19 , Desnutrição , Adulto , Hospitais , Humanos , Pacientes Internados , Tempo de Internação , Masculino , Desnutrição/diagnóstico , Estudos RetrospectivosRESUMO
Irritable bowel syndrome (IBS) is a common disorder requiring complex, multidisciplinary management. Antidepressants are commonly used and recommended in guidelines for the treatment of patients with IBS. We assessed randomized controlled trials (RCTs) on antidepressants in patients with IBS, with specific attention to study design and data quality/reporting characteristics. Following a comprehensive search, data and RCT characteristics were systematically summarized. Fragility index, representing the number of positive "events" that the study relies on for its significance, was calculated. Eighteen RCTs were included. Overall, tricyclic antidepressants (TCAs), but not selective serotonin reuptake inhibitors (SSRIs), appeared to be efficacious in IBS. Eight studies reported on adverse events (AEs), which were significantly greater in patients receiving antidepressants versus placebo. The median (mean) fragility index of TCA trials was 0 (1.5). RCTs with positive results had significantly lower placebo rates (20.8%) versus negative studies (45.7%; p < 0.0001). RCTs exhibited limitations related to study design (sample size and blinding), data analysis (outcomes and placebo response), and data reporting (selective reporting of AEs and publication bias). Careful consideration of limitations of RCTs on antidepressants in IBS is warranted to formulate a safe and beneficial treatment regimen for patients with IBS.
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There is no clear study identifying the microbiome of the appendix. However, in other diverticular conditions, such as diverticulosis, methanogens appear important. We investigated whether patients who had undergone appendectomies had decreased levels of exhaled methane (CH4). Consecutive patients who underwent breath testing (BT) from November 2005 to October 2013 were deterministically linked to electronic health records. The numbers of patients with CH4 ≥ 1 ppm (detectable) and ≥ 3 and ≥ 10 ppm (excess) were compared between patients who did and did not undergo appendectomy using a multivariable model adjusted for age and sex. Of the 4977 included patients (48.0 ± 18.4 years, 30.1% male), 1303 (26.2%) had CH4 ≥ 10 ppm, and 193 (3.9%) had undergone appendectomy. Appendectomy was associated with decreased odds of CH4 ≥ 1, ≥ 3, and ≥ 10 ppm (ORs (95% CI) = 0.67 (0.47-0.93), p = 0.02; 0.65 (0.46-0.92), p = 0.01; and 0.66 (0.46-0.93), p = 0.02, respectively). Additionally, the percentage of CH4 producers increased 4-fold from the first to ninth decade of life. This is the first study to report that appendectomy is associated with decreased exhaled CH4. The appendix may play an active physiologic role as a reservoir of methanogens.
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Apêndice/metabolismo , Apêndice/cirurgia , Metano/metabolismo , Adulto , Fatores Etários , Idoso , Apendicectomia , Testes Respiratórios , Estudos de Coortes , Feminino , Humanos , Modelos Lineares , Masculino , Metano/análise , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: To compare the appendiceal microbiomes and examine the prevalence of Campylobacter species in the appendices of adult subjects with confirmed acute non-perforated appendicitis and controls with healthy appendices. DESIGN: Archived samples of formalin-fixed paraffin-embedded appendiceal tissues were obtained from 50 consecutive female subjects who underwent appendectomy for acute, non-perforated appendicitis, and 35 consecutive female controls who underwent incidental appendectomy during gynaecological surgery. RESULTS: 16S rRNA gene sequencing revealed that the relative abundances (RAs) of the major phyla in appendiceal tissues (Firmicutes, Proteobacteria, Bacteroidetes, and Actinobacteria) were similar in both groups. Beta diversity was significantly different due to differences in Bacteroidetes and Proteobacteria (p<0.0001). Within Proteobacteria, RAs of classes Alphaproteobacteria (~21%, fold change (FC)=1.31, false discovery rate (FDR) p value=0.03) and Epsilonproteobacteria (~1%, FC=0.25, FDR p value>0.05) were increased in acute appendicitis samples. RAs of unknown genera from families Burkholderiaceae and Enterobacteriaceae were decreased in appendicitis samples, and 14 genera were increased, including Neisseria, Acinetobacter and Campylobacter. Quantitative PCR revealed that levels of Campylobacter jejuni DNA, but not other Campylobacter species or pathogens tested, were significantly higher in appendicitis samples than in controls (p=0.013). Using a cut-off of 0.31 pg/µL, 40% of appendicitis cases and 6% of controls were positive for C. jejuni, indicating specificity of 93.7% (95% Cl 79.2 to 99.2), sensitivity of 40.9% (95% Cl 24.7 to 54.5), and OR of 10.38 (Fisher's p value=0.0006, 95% Cl 2.3 to 47.4). CONCLUSIONS: Our findings indicate that Campylobacter jejuni may be a significant cause of acute appendicitis. This supports earlier studies and suggests that targeted antibiotic therapies could be an alternative treatment for a subset of non-complicated acute appendicitis cases.
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Apendicite/microbiologia , Apêndice/microbiologia , Infecções por Campylobacter/microbiologia , Campylobacter jejuni/genética , Microbiota/genética , Doença Aguda , Adulto , Apendicectomia/métodos , Apendicite/diagnóstico , Apendicite/cirurgia , Apêndice/imunologia , Infecções por Campylobacter/epidemiologia , Campylobacter jejuni/isolamento & purificação , Estudos de Casos e Controles , DNA Bacteriano/genética , Feminino , Humanos , Microbiota/imunologia , Pessoa de Meia-Idade , Prevalência , RNA Ribossômico 16S/genéticaRESUMO
Objectives To define characteristics that influence patient perceptions of thyroidectomy scar cosmesis. Study Design Prospective cohort study. Setting Tertiary endocrine surgery practice in an academic medical center. Subjects and Methods Institutional review board-approved trial in which 136 subjects were recruited from a population of patients being seen for either thyroid or sinus surgery and evaluated standardized photographs, superimposed with computer-generated thyroidectomy scars of varying lengths (2, 4, and 6 cm) and widths (1 and 2 mm), and graded their perception of the scars using the observer scar assessment scale (OSAS) domains of the patient and observer scar assessment scale. Results There were 69 subjects in the thyroid group and 67 in the nonthyroid group. Controlling for width, longer scars were perceived as worse than shorter scars; controlling for length, thicker scars were perceived as worse than thinner scars ( P < .01). Beyond 2 cm, thick scars were judged to be worse than thin scars, even when they were shorter. There was no difference in the mean overall OSAS scores between surgery, sex, or age groups. Nonwhites tended to judge scars as being worse than whites did ( P < .01). Conclusion As expected, patients of all demographics prefer shorter scars compared with longer scars and thinner scars over thick scars. Ethnic differences in scar perception were identified and deserve additional study. Surgeons should endeavor to perform thyroid surgery through the smallest incision that allows the operation to be performed safely to minimize the cosmetic impact of the operation.
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Atitude Frente a Saúde , Cicatriz/psicologia , Satisfação do Paciente , Complicações Pós-Operatórias/psicologia , Tireoidectomia , Beleza , Cicatriz/etiologia , Cicatriz/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Estudos Prospectivos , Tireoidectomia/efeitos adversosRESUMO
BACKGROUND: Restoring peripheral nerve function after long gap peripheral nerve damage is challenging. Lithium chloride has demonstrated neuroprotective qualities and therefore shows great potential therapeutic benefit for some neurodegenerative diseases. This study examined the synergistic combination of glial cell line-derived neurotrophic factor and lithium chloride and its effect on peripheral nerve regeneration in a rat sciatic nerve injury model. METHODS: Polycaprolactone conduits with glial cell line-derived neurotrophic factor-loaded double-walled microspheres and local injections of lithium chloride, 1.5 or 2.5 mEq/kg body weight, were examined in a 15-mm rat sciatic nerve defect model. Eighteen Lewis male rats were divided randomly into control, 1.5-, and 2.5-mEq/kg lithium chloride injection groups. As an indicator of recovery, nerve sections were stained with S100, protein gene product 9.5 antibody, and toluidine blue. RESULTS: Nerves stained with S100 and protein gene product 9.5 antibody demonstrated a significantly increased density of Schwann cells and axons in the 2.5-mEq/kg lithium chloride injection-treated groups compared with both the control and 1.5-mEq/kg lithium chloride injection-treated groups (p<0.05). At 6 weeks, histomorphometry revealed a significantly higher fiber density in the middle of the conduit for the 2.5-mEq/kg groups compared with the 1.5-mEq/kg group or the control group. CONCLUSION: Polycaprolactone nerve guides with glial cell line-derived neurotrophic factor-loaded double-walled microspheres and local injections of lithium chloride, 2.5-mEq/kg, represent a potentially viable guiding material for Schwann cell and axon migration and proliferation for the treatment of peripheral nerve regeneration.
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Fator Neurotrófico Derivado de Linhagem de Célula Glial/farmacologia , Cloreto de Lítio/farmacologia , Regeneração Nervosa/efeitos dos fármacos , Traumatismos dos Nervos Periféricos/tratamento farmacológico , Nervo Isquiático/efeitos dos fármacos , Animais , Biópsia por Agulha , Modelos Animais de Doenças , Sinergismo Farmacológico , Imuno-Histoquímica , Masculino , Condução Nervosa/efeitos dos fármacos , Traumatismos dos Nervos Periféricos/patologia , Distribuição Aleatória , Ratos , Ratos Endogâmicos Lew , Valores de Referência , Nervo Isquiático/lesões , Nervo Isquiático/patologia , Resultado do TratamentoRESUMO
Cell sheet technology has been studied for applications such as bone, ligament and skin regeneration. There has been limited examination of adipose-derived stem cells (ASCs) for cell sheet applications. The specific aim of this study was to evaluate ASC sheet technology for wound healing. ASCs were isolated from discarded human abdominal subcutaneous adipose tissue, and ASC cell sheets were created on the surface of fibrin-grafted culture dishes. In vitro examination consisted of the histochemical characterization of the ASC sheets. In vivo experiments consisted of implanting single-layer cell sheets, triple-layer cell sheets or non-treated control onto a full-thickness wound defect (including epidermis, dermis, and subcutaneous fat) in nude mice for 3 weeks. Cell sheets were easily peeled off from the culture dishes using forceps. The single- and triple-layer ASC sheets showed complete extracellular structure via hematoxylin & eosin staining. In vivo, the injury area was measured 7, 10, 14 and 21 days post-treatment to assess wound recovery. The ASC sheet-treated groups' injury area was significantly smaller than that of the non-treated control group at all time points except day 21. The triple-layer ASC sheet treatment significantly enhanced wound healing compared to the single-layer ASC sheet at 7, 10 and 14 days. The density of blood vessels showed that ASC cell sheet treatment slightly enhanced total vessel proliferation compared to the empty wound injury treatment. Our studies indicate that ASC sheets present a potentially viable matrix for full-thickness defect wound healing in a mouse model. Consequently, our ASC sheet technology represents a substantial advance in developing various types of three-dimensional tissues.