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  1. San Diego Convention Center Digestive Disease Week opening reception The social media meetup (Jeffrey Roberts is in the back row, 2nd from left with glasses) The awesome and talented Kate Scarlata, RD with Jeffrey Roberts MS, BSc Dr. Mark Pimentel and Jeffrey Roberts MS, BSc podcast recording Erica Dermer (@CeliacBeast) Gluten Free and Celiac Patient Influencer and Jeffrey Roberts MS, BSc DDW 50th Anniversary Sign The Rome Foundation Leadership Dr. Max Schmulson, Dr. Lin Chang, Dr. Jan Tack, Dr. Magnus Simrén, Dr. Douglas Drossman Johannah Ruddy, MS, Executive Director Rome Foundation Celebrating World IBD Day The wonderful Patsy Catsos MS, RD, LDN The DDW19 Sign with Erica Dermer @CeliacBeast and Pam Emmer @LifeafterSibo Matt Mitcho, CEO Gemelli Biotech maker of the IBS-Smart blood test Interviewed by Dr. Neil Nandi for Healio Gut Feelings series Dynamic Dietitian meet-up! Claire Shortt, PhD, Chief Scientist with FoodMarble @ibspatient Twitter account made the top 20 list of tweeters at #DDW19
  2. Chey: Small Intestinal Bacterial Overgrowth: Fact or Fiction? Chey: Small bowel Aspiration & Culture - an imperfect gold standard. Chey: Breath Testing has pros and cons based on the test used, ie: glucose or lactulose Chey: Which test is right? We don’t know. Exciting data coming from Mark Pimentel MD and Cedar-Sinai about this. Chey: Antibiotic regiment for SIBO with Rifaximin is recommended with a positive breath test Chey: Regardless of antibiotic employed for SIBO, a positive breath test seems to return Chey: Probiotics for SIBO - not statistically significant. Note that side effects were present from the probiotic treatment. Not entirely benign. Chey: Rifaximin vs herbal for SIBO. Results are similar and surprising. Need good research. Chey: IBS and SIBO? Cause and Effect? We don’t know. Chey: 50% of patients will have recurrence of SIBO 9 months after treatment Chey: Maybe we should be using a diet which provides essential prebiotics that have the benefits of a probiotic for IBS patients instead of an actual probiotic.
  3. Chey: Congenital sucrase-isomaltase deficiency may be under-diagnosed as it is generally not on the adult GI's radar Chey: CSID signs and symptoms are similar to IBS-D symptoms Chey: CSID could be considered for low FODMAP diet failures Chey: Sucrase-isomaltese deficiency could be seen in as high as 8% of patients. Gold standard for diagnosis is via assay; however, other less invasive testing could be considered. CSID has been associated with IBS symptoms. Chey: An FDA-approved product for #CSID is Sucraid (sacrosidase) Oral Solution enzyme from QOL Medical
  4. Olorinab for Abdominal Pain Associated with Crohn's Disease MD MagazinePreston Klassen, MD, head of research and development at Arena Pharmaceuticals, discusses olorinab's efficacy and safety for the treatment of abdominal pain ... View the full article
  5. FECAL MICROBIOTA TRANSPLANTATION (FMT) FOR IRRITABLE BOWEL SYNDROME (IBS): A SYSTEMATIC REVIEW AND META-ANALYSIS AuthorBlock: Dhruvan Patel1, Anisha Daxini2, Ramkaji Baniya3, Neilanjan Nandi1, Asyia S. Ahmad1 1Gastroenterology, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States; 2Internal Medicine, Mercy Nazareth Hospital, Philadelphia, Pennsylvania, United States; 3Internal Medicine, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana, United States; Background: In recent years, the role of FMT in the treatment of IBS has been receiving increased attention from researchers. However, there are limited randomized controlled trials (RCTs) on the effectiveness of FMT in IBS. On extensive literature search, there is no meta-analysis performed on FMT effectiveness in IBS. We thus performed this systematic review and meta-analysis assessing the effectiveness of FMT in IBS patients. Methods: PubMed, Cochrane Library, Scopus, Clinicaltrials.gov, Clinicalkey, Ovid Medline and CINAHL databases were searched for all studies published up to December 2018 assessing the use of FMT in IBS. Primary outcome was clinical improvement in IBS symptoms at 3 months after FMT (50 or 75 points reduction in IBS-SSS score or self-reported). Secondary outcome was change in quality of life (QoL) at 3 months after FMT based on IBS-QoL scores. Non-RCT studies and RCTs with no clinical outcome data were excluded. Pooled effect sizes and 95% confidence intervals (CI) were obtained using the random effects model. We calculated odds ratios (ORs) for categorical variables and mean differences for continuous variables. The Mantel-Haenszel method and random effect models were used to analyze the data. Results: A total of 18 studies (6 RCTs, 4 open label studies, 3 retrospective studies, 4 case series, 1 case report) were identified assessing the effectiveness of FMT in IBS (Table 1). Only 4 RCTs met the inclusion criteria and total 246 IBS patients were included. A total of 142 IBS patients received FMT and 97 IBS patients received the placebo treatments, of which 74 (52%) in FMT and 50 (51.5%) in the placebo group achieved IBS symptoms improvement at 3 months. In the meta-analysis, no significant difference was noted between the placebo and FMT group. [OR:0.89 (95% CI:0.22-3.62), p=0.87] with high heterogeneity (I2= 84%) (Figure 1). Heterogeneity was noted because of diversity in the mode of FMT administration, different IBS-SSS score criteria as outcomes, and different population with inconsistency in IBS phenotypes. Sub-analysis demonstrated significant IBS symptoms improvement at 3 months in non-capsule FMT group compared to placebo. [OR:2.94 (95% CI:1.42-6.08),p=0.004] with no heterogeneity (I2= 0%). Interestingly, the QoL scores were higher at 3 months in the placebo groups compared to FMT groups. [mean difference in score from baseline: 6.70 (95% CI:13.52 to 0.13,p=0.05)] with moderate heterogeneity (I2= 39%) (Figure 1). Most adverse events were transient gastrointestinal complains. Conclusion: FMT does not appear to be more effective than placebo for the treatment of IBS. However, FMT utilizing non-capsule routes of administration appears to significantly reduce IBS symptoms at 3 months compared to placebo. Future studies assessing the effectiveness of FMT in IBS should consider not to use the capsule as a mode of delivery. Table 1. Systematic review on the effectiveness of FMT in IBS patients Study type Author Patients FMT vs Placebo Route Dose Frequency Improvement in IBS symptoms Improvement in IBS-QoL score from baseline RCT Aroniadis et al (2018) USA 48 (IBS-D) 24 vs 24 Capsule 25 cap/d containing 50gm feces 3 days 10/24 (48%) vs 15/24 (63%) (p=0.32) IBS-SSS score reduction >50 points at 3 months from baseline 12±5 vs 14±5 (p=0.62) at 3 months RCT Halkjaer et al (2018) DENMARK 51 (all types of IBS) 25 vs 26 Capsule 25 cap/d containing 50gm feces 12 days 8/22 (36%) vs 19/24 (79%) (p=0.008) IBS-SSS score reduction >50 points at 3 months from baseline 7±10 vs 16±10 (p=0.003) at 3 months RCT Holvent et al (2018) BELGIUM 64 IBS with bloating 42 vs 22 Naso-jejunal N/A Once 20/41(49%) vs 6/21(29%) (P=0.004) Self-reported improvements in IBS/bloating symptoms at 3 months 16% in FMT group, no data for placebo at 3 months RCT Johnsen et al (2018) NORWAY 83 (IBS-M, IBS-D) 55 vs 28 Colonoscopy 50-80 gm of feces in 200 ml saline Once 36/55 (65%) vs 12/28 (43%) (P=0.049) IBS-SSS score reduction >75 points at 3 months from baseline N/A RCT Holster et al (2018) SWEDEN 16 (all types of IBS) 8 vs 8 Colonoscopy N/A Once in IBS-SSS score 63.3±43 at 2 months in FMT group, no data in placebo 10.0 ± 6.3 in FMT group (at 2 months), no data in placebo RCT Bruno et al (2018) ITALY 3 (IBS-D, IBS-U) 3 vs 0 Enema N/A at 0 and 3 weeks 2/3 (66%) at 6weeks in FMT group N/A Open label study Beurden et al (2017) 10 (antibiotic as well as post-infectious IBS) N/A Naso- Duodenal 198 ml donor feces Once 4/10 (40%) (IBS-SSS score reduction >30% at 2 months from baseline 15% in FMT group (at 2 months) Open label study Holvent et al (2016) 12 IBS-D, bloating N/A Colonoscopy 300 ml donor feces Once 9/12(75%) at 3 months 13% in FMT group (at 3 months) Open label study Mizuno et al (2017) 10 All types of IBS N/A Colonoscopy 100 gm feces in 200 ml NS Once 6/10 (60%) at 1 month N/A Open label study Cruz et al (2015) 9 (IBS-C and IBS-D) N/A Colonoscopy and enema N/A Once 6/9 (66%) at 3 months N/A Retrospective study Pinn et al (2014) 13 All type of IBS N/A Jejunal or Duodenal 50-100 ml donor feces Once 9/13 (70%) at 11 months N/A Retrospective study Li et al (2017) 15 N/A N/A N/A N/A 11/15 (73.3%) N/A Case report Andrews et al (1992) 1 IBS-C N/A Enema N/A 2 days 1/1 (100%) at 18 months N/A Case series Borody et al (2004) 3 IBS-C N/A Enema N/A 5 days 3/3 (100%) at 8-28 months N/A Case series Hong et al (2016) 10 N/A N/A N/A N/A 8/10 (80%) patients at 1 month N/A Case series Syzneko et al (2016) 12 all type of IBS N/A Colonoscopy N/A Once 9/12 (75%) at 1 month N/A Case series Mazzawi et al (2016) 9 IBS-D N/A N/A N/A N/A Reduction in IBS-SSS score (p=0.0002) and Bristol stool scale (p=0.02) at 3 weeks N/A Retrospective study Vivekanandrajah et al (2017) 15 IBS-D, IBS-C N/A Colonoscopy or enema N/A N/A Reduction in daily BM post-treatment in IBS-D (p<0.05) N/A
  6. Healio Gastroenterology In this video Dr. Chey, professor of medicine, and director of the GI Physiology Laboratory at University of Michigan Health System, discusses a state-of-the-art lecture he gave during the conference that highlighted how gastroenterologists, and even physicians, can keep to time and in turn, keep patients happy. https://www.healio.com/gastroenterology/practice-management/news/online/{c1e38310-a030-4a81-a36c-73dad8aa055a}/video-physicians-words-guide-patients-from-hopeless-to-hopeful
  7. Caterina Carco: The gut microbiome is thought to play a role in the mechanisms underlying gastrointestinal comfort and function.
  8. M. Pimentel: Second generation IBS blood test. Anti-CdtB and anti-vinculin using epitope optimization increases post-test probability of IBS to >98% (the basis for IBS-smart). M. Pimentel: Reduces unnecessary testing in IBS AND IBS is not in your head SECOND GENERATION ANTI-CDTB AND ANTI-VINCULIN TESTING PRODUCES GREATER DIAGNOSTIC ACCURACY FOR IBS-D COMPARED TO IBD Presentation Number: Sa1680 AuthorBlock: Walter Morales1, Ali Rezaie1,2, Stacy Weitsman1, Gillian Barlow1, Mark Pimentel1,2 1Medically Associated Science and Technology (MAST) Program, Cedars-Sinai Medical Center, Los Angeles, California, United States; 2Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, California, United States; ELISA testing for anti-CdtB and anti-vinculin distinguishes patients with irritable bowel syndrome with diarrhea (IBS-D) from those with inflammatory bowel disease (IBD). Epitope instability can create problems for testing with these antigens. We have resolved this problem using a new epitope stabilization. In this study, we assess the test characteristics of second generation anti-CdtB and anti-vinculin testing in diagnosing IBS-D subjects and distinguishing them from subjects with IBD. Methods Plasma samples from IBS-D subjects from a large-scale trial and subjects with endoscopically active IBD and no concurrent immunomodulator therapy were assessed. After proprietary epitope stabilization (Gemelli Biotech), CdtB and vinculin were used as substrates in ELISA testing. Optical density (OD) readings were compared between IBS-D and IBD subjects and used to determine the ability to diagnose IBS-D versus IBD. Results Samples from 84 IBS-D and 31 IBD (22 UC and 9 CD) subjects were tested. IBS-D subjects had higher anti-CdtB titers (P=0.0001) and higher anti-vinculin titers (P=0.004) than IBD subjects. The specificities of anti-CdtB and anti-vinculin to differentiate IBS-D from IBD were 93.6 and 90.9 respectively, with sensitivities of 40.5 and 47.7, respectively. This second generation test produced positive likelihood ratios of identifying IBS-D with anti-CdtB and anti-vinculin at 6.3 and 5.3, respectively. Based on the published pre-test probability of 57% for diagnosis of IBS-D in patients with abdominal pain and change in bowel habits, testing positive for both antibodies resulted in a post-test probability of 98%. Conclusions In this second generation test, performing epitope stabilization for CdtB and vinculin enhances the test characteristics of ELISAs for anti-CdtB and anti-vinculin in discriminating IBS-D from IBD. With a post-test probability of IBS-D as high as 98%, this may more confidently identify patients with IBS-D as a diagnosis of inclusion. Table 1. Sensitivity and specificity of anti-CdtB and anti-vinculin in diagnosing IBS-D Test Sensitivity Specificity PPV NPV LR+ LR- Anti-CdtB (OD>1.56) 40.5 93.6 94.4 36.7 6.3 0.64 Anti-vinculin (OD>1.60) 47.7 90.9 91.3 46.5 5.3 0.6 PPV=positive predictive value, NPV=negative predictive value, LR+=positive likelihood ratio
  9. Maya Pimentel (Cedar-Sinai): Elevated levels of Campylobacter jejuni in appendicitis (females n=50) seen in microbial DNA analysis. May support the use of antibiotics in a subgroup of patients with appendicitis.
  10. Lackner: Global IBS Symptom Improvement in Cognitive Bahvioral Therapy (CBT)
  11. Robyn Rexwinkel: Long-term follow-up of gut-directed hypnotherapy self-exercises at home using CD versus individual therapy by qualified therapists in children with #IBS or FGID pain (syndrome)
  12. Mayer & Lackner: Cognitive Behavioral Therapy (CBT) increased connectivity of brain networks in IBS Mayer & Lackner: Bacteriodes is also associated with symptom improvement after CBT which suggests changes in microbiota
  13. Camilleri: Tropifexor (LJN452), a non-bile acid FXR agonist, in patients with primary bile acid diarrhea and secondary its effect on transit time with small study (n=17) - safe, well tolerated,; however an increase in cholesterol was seen Camilleri: Summary of study: further exploration of Tropifexor may be worthwhile for this non-bile acid FXR agonist for functional diarrhea or IBS-D
  14. Wong: Ketotifen (inhibitor of allergic mediators) on GI visceral hypersensitivity and reduction of mast cells (MCs) in small study (n=48) of patients M/F with IBS-D had a positive outcome in GI symptoms and reduction of mast cells
  15. Caroline Tuck: Compliance with dietary interventions like low FODMAP diet is improved with Dietician support Caroline Tuck: Connecting patients with resources is important to ensure success Dr. Bellini: Reintroduction process helped patients identify fructose, polyls and GOS as food triggers they had not been aware of at baseline. Patients need a strategy for the FODMAP reintroduction process to optimize the learning process.
  16. Magnus Simren: A biomarker is a diagnostic tool for the identification of those patients with a disease or abnormal condition Magnus Simren: The Bristol Stool chart is used to determine stool type Magnus Simren: Visceral hypersensitivity and GI symptoms are strongly associated with FGiDs; however trials are limited for a biomarker which identifies positive outcomes for a specific treatment option Magnus Simren: SeHCAT testing might be helpful for determining who may respond to bile acid binding agents Magnus Simren: Potential biomarkers for IBS include anti-CdtB and anti-vinculin antibodies (IBS-Smart Test); however its use on its own seems to be inconclusive and is also seen in healthy patients. More studies will be helpful to identify the best patient population for this test. Magnus Simren: Potentially, multiple causes for IBS-C or Functional Constipation. Magnus Simren: Functional Gastrointestinal Disorders (FGIDs) will benefit from tailored treatments by using patient biomarkers like transit times, colon volume, with focus on comorbid interactions. Magnus Simren: Gut microbiota at baseline and/or number of fecal volatile organic compounds, might indicate independently a positive response to the low FODMAP diet Magnus Simren: The Gut-Brain interaction relates to many of the symptom generation
  17. L Chang: Wide prevalence of comorbid conditions in IBS. Quality of Life (QOL) suffers with the greater number of conditions L Chang: FGiDs (Functional Gastrointestinal Disorders) and IBS comorbidities especially significant for women L Chang: Role for central neuromodulators (antidepressants) for managing FGiDs and IBS L Chang: Tricyclic antidepressants are considered first line for pain modulation. SSRI's antidepressants not as effective for GI pain. SNRI's antidepressants effective for pain. Tetracyclic antidepressants for early satiety, nausea/vomiting, weight loss and sleep disturbance L Chang: New data with pregabalin (Lyrica) for greater than 3 FGiD pain attacks per month. Could be considered for pain L Chang: Co-morbid migraine: CGRP receptor antagonist for IBS-D/M might be an option
  18. J Tack: GI Genius is a toolkit / algorithm from the Rome Foundation J Tack: Comorbidity with overlapping FGiD (Functional Gastrointestinal) conditions have more severe symptoms and seek more physician attention J Tack: FGiD (Functional Gastrointestinal) overlap is not uncommon. Sensorimotor disorders are often generalized and common mechanisms partially explain the overlap.
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