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- Gastrointestinal symptoms and eating behavior among morbidly obese patients undergoing Roux-en-Y gastric bypass. [Journal Article]
- Medicina (Kaunas) 2014; 50(2):118-23.
Roux-en-Y gastric bypass (RYGB) changes anatomy and physiology of the gastrointestinal tract, and is followed by gastrointestinal side effects, changes in bowel function and eating behavior. The aim of the present study was to investigate the severity of gastrointestinal symptoms and changes in eating behavior preoperatively and one year after RYGB.A total of 180 morbidly obese patients who underwent RYGB were included into the prospective study. Gastrointestinal symptoms were evaluated with Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire and Gastrointestinal Symptom Rating Scale (GSRS), eating behavior with Three-Factor Eating Questionnaire before and one year after RYGB. For all patients routine gastroscopy before surgery was performed.A total of 99 patients (55%) completed one-year follow-up; 79 (43.9%) patients had no pathological findings on preoperative gastroscopy. GERD-HRQL score and GSRS scores of indigestion, constipation, abdominal pain and reflux decreased significantly after surgery. Male gender (OR=2.47, 95% CI 1.11-5.50, P=0.026), GERD-HRQL score (OR=1.28, 95% CI 1.16-1.41, P<0.001) and GSRS diarrhea score (OR=1.89, 95% CI 1.10-3.17, P=0.020) were significant predictors of pathological findings on gastroscopy. Eating behavior one year after RYGB changed significantly as compared to baseline. Cognitive Restraint postoperatively has increased from 42.6 to 55.9 (P<0.001). Uncontrolled Eating and Emotional Eating one year after surgery significantly decreased (59.1 vs. 20.6, P<0.001 and 28.2 vs. 17.2, P<0.001, respectively).In morbidly obese patients endoscopic findings correlate well with gastrointestinal complain. RYGB significantly improves gastrointestinal complains and eating behavior one year postoperatively.
- Dosing considerations with transdermal formulations of fentanyl and buprenorphine for the treatment of cancer pain. [Journal Article, Review]
- J Pain Res 2014.:495-503.
Opioids continue to be first-line pharmacotherapy for patients suffering from cancer pain. Unfortunately, subtherapeutic dosage prescribing of pain medications remains common, and many cancer patients continue to suffer and experience diminished quality of life. A large variety of therapeutic options are available for cancer pain patients. Analgesic pharmacotherapy is based on the patient's self-report of pain intensity and should be tailored to meet the requirements of each individual. Most, if not all, cancer pain patients will ultimately require modifications in their opioid pharmacotherapy. When changes in a patient's medication regimen are needed, adequate pain control is best maintained through appropriate dosage conversion, scheduling immediate release medication for withdrawal prevention, and providing as needed dosing for breakthrough pain. Transdermal opioids are noninvasive, cause less constipation and sedation when compared to oral opioids, and may improve patient compliance. A relative potency of 100:1 is recommended when converting the patient from oral morphine to transdermal fentanyl. Based on the limited data available, there is significant interpatient variability with transdermal buprenorphine and equipotency recommendations from oral morphine of 75:1-110:1 have been suggested. Cancer patients may require larger transdermal buprenorphine doses to control their pain and may respond better to a more aggressive 75-100:1 potency ratio. This review outlines the prescribing of transdermal fentanyl and transdermal buprenorphine including how to safely and effectively convert to and use them for those with cancer pain.
- Gastrointestinal symptoms: A comparison between patients undergoing peritoneal dialysis and hemodialysis. [Journal Article]
- World J Gastroenterol 2014 Aug 28; 20(32):11370-5.
To compare the prevalence and diversity of gastrointestinal (GI) symptoms in patients undergoing peritoneal dialysis (PD) and hemodialysis (HD).Two hundred and ninety-four end-stage renal disease patients participated in the study, including 182 HD and 112 PD patients. Dimension scores were calculated from a modified gastrointestinal symptom rating scale (GSRS) 18-item questionnaire, including items concerning eating dysfunction, and were used for measuring GI symptoms. Information on patient age, condition contributing to end-stage renal disease and the most recent dialysis adequacy assessment (serum Kt/V urea value) was obtained from the follow-up database and by interviewing patients and/or reviewing the medical records. Differences between the HD and PD groups were evaluated using Student's t, Pearson's χ(2) or Fisher's exact tests.The overall prevalence of GI symptoms, defined by a GSRS > 1, in end-stage renal disease patients was 70.7% (208/294), which differed between HD and PD patients (76.4% vs 61.6%, P < 0.01). HD patients had a higher prevalence of constipation, abdominal pain and diarrhea compared to PD patients (36.3% vs 17.9%, 32.4% vs 5.4%, 17.6% vs 4.5%, respectively, P < 0.05). PD patients had a higher prevalence of reflux compared to HD patients (32.1% vs 24.2%, P < 0.05). Additionally, reflux and eating dysfunction were more severe in PD patients (GSRS: 1.71 ± 1.15 vs 1.30 ± 0.67, 1.57 ± 0.84 vs 1.39 ± 0.61, respectively, P < 0.05), whereas HD patients had greater abdominal pain, diarrhea and constipation (GSRS: 1.22 ± 0.39 vs 1.04 ± 0.19, 1.19 ± 0.53 vs 1.07 ± 0.35, 1.51 ± 0.83 vs 1.23 ± 0.58, respectively, P < 0.05). Finally, 14.8% (27/182) of HD patients presented with more than three GI symptoms, compared to 7.2% (8/112) of PD patients (P < 0.01).HD and PD patients differ in prevalence, severity and diversity of GI symptoms.
- FDA Approval Summary: Crizotinib for the Treatment of Metastatic Non-Small Cell Lung Cancer With Anaplastic Lymphoma Kinase Rearrangements. [JOURNAL ARTICLE]
- Oncologist 2014 Aug 28.
On August 26, 2011, crizotinib received accelerated approval for the treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) that is ALK-positive as detected by a test approved by the U.S. Food and Drug Administration (FDA). Approval was based on two single-arm trials demonstrating objective response rates (ORRs) of 50% and 61% and median response durations of 42 and 48 weeks. On November 20, 2013, crizotinib received regular approval based on confirmation of clinical benefit in study A8081007, a randomized trial in 347 patients with ALK-positive advanced NSCLC who had previously received one platinum-containing regimen. Patients were assigned (1:1) to receive crizotinib 250 mg orally twice daily or standard of care (docetaxel or pemetrexed). The primary endpoint was progression-free survival (PFS) determined by independent radiology review; secondary endpoints were ORR and overall survival (OS). PFS was significantly longer in the crizotinib arm, with median PFS of 7.7 and 3.0 months in the crizotinib and chemotherapy arms, respectively, and a 46% absolute increase in ORR but no difference in OS between treatment arms at the interim analysis. The most common adverse drug reactions (>25%) in crizotinib-treated patients were vision disorders, nausea, diarrhea, vomiting, constipation, edema, elevated transaminases, and fatigue. The most serious toxicities of crizotinib were hepatotoxicity, interstitial lung disease or pneumonitis, and QT-interval prolongation. Crizotinib's rapid clinical development program (6 years from identification of ALK rearrangements in a subset of NSCLC to full FDA approval) is a model of efficient drug development in this new era of molecularly targeted oncology therapy.
- Long-term Follow-up of Sigmoid Bladder Augmentation for Low-compliance Neurogenic Bladder. [Journal Article]
- Urology 2014 Sep; 84(3):697-701.
To assess the clinical and urodynamic outcomes of patients with low-compliance neurogenic bladder who were treated with sigmoid bladder augmentation (SBA) over a long-term follow-up.We retrospectively reviewed 52 patients with low-compliance neurogenic bladder who underwent SBA alone or with antireflux techniques in our hospital from 2006 to 2014. Clinical outcomes regarding bladder function, incontinence, medications, catheterization schedules, subsequent interventions, bowel function, and patient satisfaction were addressed.The mean follow-up was 49 months. All patients experienced significant increases in safe cystometric capacity from 113.8 ± 65.9 mL to 373.1 ± 66.7 mL (P <.001), bladder compliance from 2.96 ± 1.55 mL/cm H2O to 14.07 ± 5.45 mL/cm H2O (P <.001), and decreases in creatinine from 88.1 ± 38.6 μmol/L to 77.1 ± 30.4 μmol/L (P <.001) compared with those before surgery. Six patients (11.5%) required anticholinergic medicine to control neurogenic detrusor overactivity, and 11 (21.1%) had recurrent febrile urinary tract infections after SBA. Among 47 prehydronephrosis patients (grade I-II in 10 and III-V in 37), 16 still had minor hydronephrosis after SBA, but the hydronephrosis had been improved significantly (all posthydronephroses were grade I-II instead). All patients reported significant improvements in constipation, and no patient had obvious metabolic acidosis or bladder perforation after SBA. All patients expressed extreme satisfaction with the operation.SBA provided durable clinical and urodynamic improvement for patients with low-compliance neurogenic bladder and constipation. SBA alone, without ureteral reimplantation, seemed sufficient for neurogenic bladder. Furthermore, there was a high level of patient satisfaction with SBA.
- Phantom Urinary Incontinence in Children With Bladder-bowel Dysfunction. [Journal Article]
- Urology 2014 Sep; 84(3):685-8.
To report a previously undescribed condition in which children present with the sensation of wetness because of presumed urinary incontinence when they are actually completely dry. We have termed this entity "phantom" urinary incontinence (PUI).Twenty children referred to our pediatric urology clinic were diagnosed with PUI between 2009 and 2013. Patient demographics, associated bladder and bowel symptoms, concomitant diagnoses, imaging, management, and treatment outcomes were evaluated.Twenty children (18 females and 2 males) were diagnosed with PUI over a 5-year interval. Mean age at diagnosis was 6.9 ± 2.5 years (range, 4-12 years). Nineteen patients (95%) had concomitant lower urinary tract symptoms, and all were also diagnosed with constipation. Urgency (75%) and frequency (50%) were the most common associated bladder symptoms. Of the 18 girls, 13 (72%) had associated vaginitis. Fourteen children (70%) carried a parent-reported diagnosis of obsessive-compulsive disorder or obsessive-compulsive disorder personality traits. Patients were managed with timed voiding, dietary modifications, and a bowel regimen. Ninety percent children experienced improvement of bladder-bowel dysfunction and resolution of PUI at a mean follow-up of 14.4 months.Children with PUI have a high incidence of obsessive-compulsive traits. Phantom incontinence as well as associated lower urinary tract symptoms resolve with adherence to a strict bladder-bowel regimen.
- A systematic review of sacral nerve stimulation mechanisms in the treatment of fecal incontinence and constipation. [Journal Article]
- Neurogastroenterol Motil 2014 Sep; 26(9):1222-37.
Sacral nerve stimulation (SNS) is now well established as a treatment for fecal incontinence (FI) resistant to conservative measures and may also have utility in the management of chronic constipation; however, mechanism of action is not fully understood. End organ effects of SNS have been studied in both clinical and experimental settings, but interpretation is difficult due to the multitude of techniques used and heterogeneity of reported findings. The aim of this study was to systematically review available evidence on the mechanisms of SNS in the treatment of FI and constipation.Two systematic reviews of the literature (performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses framework) were performed to identify manuscripts pertaining to (a) clinical and (b) physiological effects of SNS during the management of hindgut dysfunction.The clinical literature search revealed 161 articles, of which 53 were deemed suitable for analysis. The experimental literature search revealed 43 articles, of which nine were deemed suitable for analysis. These studies reported results of investigative techniques examining changes in cortical, gastrointestinal, colonic, rectal, and anal function.The initial hypothesis that the mechanism of SNS was primarily peripheral motor neurostimulation is not supported by the majority of recent studies. Due to the large body of evidence demonstrating effects outside of the anorectum, it appears likely that the influence of SNS on anorectal function occurs at a pelvic afferent or central level.
- Sonographic Evaluation of Gallbladder Motility in Children with Chronic Functional Constipation. [JOURNAL ARTICLE]
- Gut Liver 2014 Jun 18.
Studies in adults suggest that constipation may not be a purely colonic pathology and may be a component of a generalized gastrointestinal (GI) motor disorder in which proximal GI motility can be impaired. Pediatric data are scarce, and the natural history of the disorder remains undefined. We aimed to evaluate gallbladder motility in a subset of Asian children with chronic functional constipation.Abdominal ultrasound was performed on 105 children, including 55 patients (aged 3 to 13 years) with chronic functional constipation who met the inclusion criteria and 50 age- and gender-matched controls. The gallbladder contractility index was calculated based on the preprandial and postprandial gallbladder areas. Preprandial and postprandial values for gallbladder volume and wall thickness were evaluated.The mean value of the contractility index for the patients (15.77±24.68) was significantly lower than the mean value for the controls (43.66±11.58) (p=0.001). The mean postprandial gallbladder volumes and areas were larger in children with gallbladder hypomotility (p<0.05). The mean duration of constipation (4.8 months) was significantly higher (p=0.004) in the children with gallbladder hypomotility.Gallbladder motility is significantly impaired in children with chronic functional constipation. This study contributes to the understanding of the underlying pathophysiology, which will enable advancement in and improved management of children with chronic constipation and associated gallbladder hypomotility.
- Clinical evaluation of the efficacy of methylnaltrexone in resolving constipation induced by different opioid subtypes combined with laboratory analysis of immunomodulatory and antiangiogenic effects of methylnaltrexone. [Journal Article]
- BMC Palliat Care 2014.:42.
Opioid-induced constipation (OIC) is one of the major symptoms in palliative care with a prevalence of 30-50%. Methylnaltrexone for the treatment of OIC is significantly more effective than placebo, but only in about fifty percent of the patients regardless of dose increase. Dose increases cause increased toxicity without additional efficacy, and are therefore not recommended. While methylnaltrexone is a μ-receptor antagonist, only a few opioids are solely μ-receptor agonists. Therefore, the response to methylnaltrexone may be determined by the receptor-profile of a specific opioid. In addition, methylnaltrexone may also affect the immune system and angiogenesis as was found in pre-clinical studies. Primary aim of this study is to determine differences in the efficacy of methylnaltrexone prescribed to resolve opioid induced constipation between three commonly used opioid subtypes: morphine sulphate, oxycodone and fentanyl. Secondary aim is to explore potential immunomodulatory and antiangiogenic effects of methylnaltrexone.In this multi-center, prospective, parallel group trial we will evaluate the efficacy of methylnaltrexone in resolving OIC occurring as a side effect of the most common opioid subtypes: morphine, oxycodone and fentanyl. In total 195 patients with OIC despite prophylactic laxatives will receive methylnaltrexone every other day up to fourteen days. Patients will report its effect in a laxation diary. Group allocation is based on the opioid type the patient is using. At the start and end of the study period patients complete the Bowel Function Index questionnaire. A subgroup of the patients will donate blood for analysis of immunomodulatory- and anti-angiogenic effects of methylnaltrexone.In this study we aim to determine the efficacy of methylnaltrexone per opioid subtype to reduce constipation. We expect that the outcome of this study will improve the clinical use of methylnaltraxone.This trial is registered at clinicaltrials.gov: NCT01955213 and in the Dutch trial register: NTR4272.
- [Laparoscopy-assisted subtotal colectomy with transanal secimen extraction for slow transit constipation]. [English Abstract, Journal Article]
- Zhonghua Wei Chang Wai Ke Za Zhi 2014 Aug 25; 17(8):796-8.
To investigate the clinical application of laparoscopy-assisted subtotal colectomy with transanal specimen extraction for slow transit constipation(STC).Retrospective analysis was performed on the clinical data of 8 cases with STC undergoing the procedure mentioned above from February to November 2013. Pre-and post-opertive constipation was assessed using Wexner Constipation and Incontinence Scales, and quality of life was assessed using Gastrointestinal Quality of Life Index.All the operations were completely successful without postoperative complications, such as intestinal fistula, pelvic infection, anastomotic stricture, intestinal obstruction. The Operative time was (287.6±21.5) min, blood loss was (109.7±41.1) ml, time to first flatus was (2.5±0.9) d. The proportion of postoperative constipation symptom index improvement was(77.6±8.3)%. Postoperative quality of life score was 97.3±15.7, significantly higher than that before operation(P<0.05). Postoperative Wexner constipation score was 8.8±3.7, significantly lower than that before operation.Laparoscopy-assisted subtotal colectomy with transanal specimen extraction in the treatment of STC has good short-term efficacy with obvious improvement in quality of life.