Publications by authors named "George F Longstreth"

43 Publications

An Evolutionary Medicine Perspective on Treatment of Pediatric Functional Abdominal Pain.

Am J Gastroenterol 2020 12;115(12):1979-1980

Department of Gastroenterology, Kaiser Permanente Southern California, San Diego, California, USA.

In a recent issue, Kovacic et al. analyze data from a randomized sham-controlled trial and show that pretreatment vagal efficiency, an index related to respiratory sinus arrhythmia, is a predictor of pain improvement in adolescents with functional abdominal pain when treated with auricular percutaneous electrical nerve field stimulation. The underlying premise is the polyvagal hypothesis, an explanatory framework for the evolution of the mammalian autonomic nervous system, which proposes that functional gastrointestinal disorders can result from a chronic maladaptive state of autonomic neural control mechanisms after traumatic stress. This is an opportunity for us to stimulate physicians' interest in evolutionary medicine.
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http://dx.doi.org/10.14309/ajg.0000000000001024DOI Listing
December 2020

Foot Torture (Falanga): Ten Victims with Chronic Plantar Hyperpigmentation.

Am J Med 2021 02 15;134(2):278-281. Epub 2020 Sep 15.

Survivors of Torture, International. San Diego, Calif.

Background: Falanga is a widespread form of torture, but details of the chronic skin sequelae on physical examination are unreported.

Methods: In an organization dedicated to the care of torture victims, we prospectively documented examination findings in 10 consecutive, black African falanga victims.

Results: Ten individuals (8 men) suffered 1 or more episodes of falanga, most recently 9 to 29 months (9 cases) or 10 years (1 case) earlier. Examination revealed 3 to 50 or more pigmented macules, most greater than or equal to 0.5 cm in size, on both soles of all 10 victims. The degree of pigmentation and border distinctness of the lesions varied. Two cases had plantar tenderness.

Conclusions: Plantar hyperpigmentation was present in all cases 9 months to 10 years after suffering falanga. This physical sign can support victims' legal requests for political asylum, and its recognition can aid physicians who care for torture victims.
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http://dx.doi.org/10.1016/j.amjmed.2020.08.016DOI Listing
February 2021

Misdiagnosis of Diverticulitis After a Prior Diagnosis of Irritable Bowel Syndrome (IBS).

J Am Board Fam Med 2020 Jul-Aug;33(4):549-560

From the Department of Gastroenterology, Kaiser Permanente-Southern California, San Diego (GFL, CW); Department of Research & Evaluation, Kaiser Permanente-Southern California, Pasadena (QC).

Introduction: Irritable bowel syndrome (IBS) and diverticulitis share clinical features. Misdiagnosed diverticulitis can cause unnecessary antibiotic therapy. Among IBS and non-IBS patients, we compared outpatient, clinically diagnosed (no computed tomography) diverticulitis rates. Among primary-care, diverticulitis-diagnosed IBS patients, we assessed imaged diverticulosis and probable misdiagnosed diverticulitis.

Methods: Among 3836-patient IBS and 67,827-patient non-IBS cohorts identified from 2000 to 2002, we retrospectively compared the frequency of outpatient, clinically diagnosed, antibiotic-treated diverticulitis from 2003 to endpoints of December 31, 2017, disenrollment, or death. In IBS patients, we reviewed records of initial, primary care-managed episodes for misdiagnosis.

Results: In 3836 clinically diagnosed IBS and 63,991 non-IBS cohorts, followup (median [interquartile range]) was 12.4 (3.9 to 15.0) years versus 10.2 (3.0 to 15.0) years, respectively ( < .001). The incidence rate/1000 patient-years (95% CI) of diagnosed diverticulitis was 14.0 (12.1 to 16.3) and 4.2 (4.0 to 4.5), respectively, (crude incidence rate ratio, 3.3 [2.8-3.9]; < .001). Of examined features, the diagnosis of IBS was most strongly associated with clinically diagnosed diverticulitis (adjusted incidence rate ratio [95% CI]; 2.64 [2.21-3.15], < .001). Of initial diverticulitis diagnoses in 189 IBS patients, objective evidence-based diagnosis revision or exclusion occurred in 12 (6.3%), including 6 hospitalized; 29 (15.3%) had colon imaging before and/or afterward without diverticulosis reported; 143 (75.1%) had image-documented diverticulosis; and 6 (3.2%) had no imaging.

Conclusions: Outpatient, clinically diagnosed, antibiotic-treated diverticulitis was increased 3-fold in IBS patients. Primary care clinical misdiagnosis of initial episodes occurred in 1 of 5 patients, but additional misdiagnosis due to misattribution of IBS pain to diverticulitis is suggested.
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http://dx.doi.org/10.3122/jabfm.2020.04.190328DOI Listing
September 2019

Internists' Misconceptions About PPIs: Increasing Knowledge and Implementing Guidelines.

Am J Gastroenterol 2020 05;115(5):681-682

Department of Gastroenterology, Kaiser Permanente Southern California, San Diego, CA, USA.

Misconceptions about proton-pump inhibitor (PPI) adverse effects were common among internists, and many had changed prescribing. Among 4 scenarios representing a risk spectrum for upper gastrointestinal bleeding, 86% of physicians properly chose discontinuing PPI for a minimum-risk patient with previous gastroesophageal reflux disease, but 79% inappropriately chose discontinuing PPI for a high-risk patient with a peptic ulcer history taking low-dose aspirin. Physician self-assessment is often inaccurate. Time barriers to learning and unanswered clinical questions, especially drug issues, are common. Unscientific information can influence both physicians and patients. Strategies for increasing the guideline implementation include making scientific information available more rapidly and systematically monitoring guideline use.
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http://dx.doi.org/10.14309/ajg.0000000000000561DOI Listing
May 2020

Low Rate of Cancer Detection by Colonoscopy in Asymptomatic, Average-Risk Subjects with Negative Results From Fecal Immunochemical Tests.

Clin Gastroenterol Hepatol 2020 12 31;18(13):2929-2936.e1. Epub 2020 Jan 31.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.

Background & Aims: Screening colonoscopies are of uncertain benefit for persons with negative results from a fecal immunochemical test (FIT). We investigated detection of CRC by colonoscopy in asymptomatic, average-risk, FIT-negative subjects.

Methods: We conducted a retrospective, population-based cohort study of 96,804 subjects with an initial negative result from a FIT at ages 50-75 years, from 2008 through 2014, who then underwent colonoscopy, using the Kaiser Permanente California databases. We identified participants diagnosed with CRC from January 1, 2008 through December 31, 2015 from a cancer registry. Subjects were followed until initial colonoscopy, health plan disenrollment, death, or December 31, 2015. We reviewed records from 400 randomly selected persons without CRC (controls) for risk features to estimate the proportion who underwent screening colonoscopy. We performed logistic regression to identify variables associated with CRC detection.

Results: Of 257 subjects with a diagnosis of CRC, 102 did not have a record of CRC risk factors; 86 of these patients (84.3%) had non-advanced-stage CRC (no regional node spread/distant metastases). Of the 400 controls, 299 (74.75%; 95% CI, 70.49%-79.01%) lacked CRC risk features, enabling estimation that 72,263 (mean age, 57.5 ± 7.0 y; 54.5% female) had undergone screening colonoscopy. CRC was detected in 1.4 per 1000 persons after 1 FIT, without association with increasing FITs (P = .97). CRC was detected in 1.3 per 1000 persons in 2 y or less after the last FIT and in 4.4 per 1000 persons more than 2 y after the last FIT (P < .001). When the last FIT was 2 y earlier or less, CRC increased from 0.7 per 1000 persons age 50-59 y to 3.1 per 1000 persons older than 70 y. Age and time from the last FIT were associated with CRC, with adjusted odds ratios of 1.08 (95% CI, 1.05-1.11) and 2.76 (95% CI, 1.28-5.95), respectively.

Conclusions: In asymptomatic, average-risk persons with a negative result from a FIT, CRC is infrequent within 2 y after the last FIT (especially for persons younger than 60 y), usually non-advanced, and unrelated to the number of FITs performed.
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http://dx.doi.org/10.1016/j.cgh.2020.01.029DOI Listing
December 2020

Increased Systemic Antibiotic Use and Clostridium difficile Infection Among Outpatients With Irritable Bowel Syndrome.

Clin Gastroenterol Hepatol 2018 06 8;16(6):974-976. Epub 2017 Nov 8.

Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California.

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http://dx.doi.org/10.1016/j.cgh.2017.11.004DOI Listing
June 2018

Misdiagnosis of Diverticulitis in Patients With Irritable Bowel Syndrome.

Mayo Clin Proc 2016 11;91(11):1670-1671

Kaiser Permanente Southern California, San Diego.

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http://dx.doi.org/10.1016/j.mayocp.2016.09.001DOI Listing
November 2016

Functional Dyspepsia.

N Engl J Med 2016 03;374(9):895

Kaiser Permanente Medical Care Program, Southern California, San Diego, CA

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http://dx.doi.org/10.1056/NEJMc1515497DOI Listing
March 2016

Right-Colon Ischemia, Acute Mesenteric Ischemia, and Vascular Imaging.

Clin Gastroenterol Hepatol 2016 May 22;14(5):779-80. Epub 2015 Nov 22.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.

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http://dx.doi.org/10.1016/j.cgh.2015.11.009DOI Listing
May 2016

Clinically Diagnosed Acute Diverticulitis in Outpatients: Misdiagnosis in Patients with Irritable Bowel Syndrome.

Dig Dis Sci 2016 Feb 6;61(2):578-88. Epub 2015 Oct 6.

Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles, Second Floor, Pasadena, CA, 92201, USA.

Background: Physicians often diagnose diverticulitis and prescribe antibiotics in outpatients with abdominal pain and tenderness without other evidence.

Aim: We investigated the misattribution of irritable bowel syndrome (IBS) symptoms to diverticulitis in outpatients.

Methods: In patients diagnosed with diverticulitis and dispensed antibiotics in an integrated healthcare system, we retrospectively compared 15,846 outpatients managed without computed tomography (CT) versus 3750 emergency department/inpatients who had CT. We assessed demographics and past history, including 17 symptom-based somatic and 11 mental disorders and three somatic-mental comorbidity pairs (dyads) coded over 3 years and seven drug classes dispensed over 1 year before diagnosis.

Results: Univariate analysis showed small intergroup demographic differences. Outpatients had increases in prior diverticulitis, including outpatient-managed episodes, total somatic diagnoses (p < .0001), eight somatic and three mental disorders (p ≤ .015), all three dyads (p ≤ .05), and dispensing of three drug classes (p ≤ .016). IBS had been diagnosed in 2399 (15.1 %) outpatients versus 361 (9.6 %) emergency department/inpatients (p < .0001), the greatest increase in any comorbidity. Emergency department/inpatients had no somatic comorbidity more often but more alcohol dependence, non-dependent drug abuse, and opioid dispensing (p ≤ .05). Regression analysis revealed outpatient care was independently positively associated with younger age, non-Hispanic white race/ethnicity, less Charlson comorbidity, diverticulitis history, IBS, chest pain, dyspepsia, fibromyalgia, low back pain, migraine, acute reaction to stress, and antispasmodic and anxiolytic dispensing and negatively associated with non-dependent drug abuse and opioid dispensing (p ≤ .0226).

Conclusions: Multiple types of indirect and concordant evidence suggest misattribution of IBS pain to diverticulitis and unnecessary antibiotic therapy in outpatients.
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http://dx.doi.org/10.1007/s10620-015-3892-5DOI Listing
February 2016

Carnett's Legacy: Raising Legs and Raising Awareness of an Often Misdiagnosed Syndrome.

Dig Dis Sci 2016 Feb;61(2):337-9

Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, 2nd Floor, Pasadena, CA, 92201, USA.

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http://dx.doi.org/10.1007/s10620-015-3885-4DOI Listing
February 2016

Right-Side Colon Ischemia: Clinical Features, Large Visceral Artery Occlusion, and Long-Term Follow-Up.

Perm J 2015 5;19(4):11-6. Epub 2015 Aug 5.

Vascular Surgeon in the Department of Surgery at the San Diego Medical Center and the Chair of the San Diego Area Research Committee for the Southern California Permanente Medical Group.

Context: Large visceral artery occlusion (LVAO) could underlie right-side colon ischemia (RSCI) but is little known.

Objective: To assess patients with RSCI through long-term follow-up, including features and management of LVAO.

Main Outcome Measures: Mesenteric ischemia and mortality.

Design: Retrospective observational study in an integrated health care system.

Results: Of 49 patients (30 women [61.2%]; mean [standard deviation] age, 69.4 [11.9] years), 19 (38.8%) underwent surgery—that is, 5 (83.3%) of 6 who developed RSCI in hospital following surgical procedures and 14 (32.6%) of 43 who had RSCI before hospitalization (p value = 0.03); overall, 5 (10.2%) died. Among 44 survivors with a median (range) follow-up of 5.19 (0.03-14.26) years, 5 (11.4%), including 3 (20.0%) of 15 operated cases, had symptomatic LVAO and underwent angioplasty and stent placement: 2 for abdominal angina that preceded RSCI, 1 for acute mesenteric ischemia 1 week after resection of RSCI, 1 for RSCI 6 weeks after resection of left-side ischemia, and 1 for abdominal angina that began 3 years after spontaneous recovery from RSCI. None had further mesenteric ischemia until death from nonintestinal disease or the end of follow-up (1.6 to 10.2 years later). Kaplan-Meier survival estimates for all 44 survivors at 1, 3, 5, and 10 years were 88.6%, 72.3%, 57.6%, and 25.9%, respectively. Thirty-one patients (70.4%) died during follow-up, 19 (61.3%) of a known cause; the 39 patients not treated for LVAO lacked mesenteric ischemia.

Conclusion: Patients with RSCI may have symptomatic LVAO; therefore, we advise they undergo careful query for symptoms of abdominal angina and routine visceral artery imaging.
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http://dx.doi.org/10.7812/TPP/15-024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4625989PMC
August 2016

ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI).

Am J Gastroenterol 2015 Jan 23;110(1):18-44; quiz 45. Epub 2014 Dec 23.

Division of Pediatric Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.

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http://dx.doi.org/10.1038/ajg.2014.395DOI Listing
January 2015

Acute colonic diverticulitis: diagnostic evidence, demographic and clinical features in three practice settings.

J Gastrointestin Liver Dis 2014 Dec;23(4):379-86

Department of Research and Evaluation Kaiser Permanente Southern California, Pasadena, CA, USA.

Background And Aims: Diverticulitis is often diagnosed in outpatients, yet little evidence exists on diagnostic evidence and demographic/clinical features in various practice settings. We assessed variation in clinical characteristics and diagnostic evidence in inpatients, outpatients, and emergency department cases and effects of demographic and clinical variables on presentation features.

Methods: In a retrospective cohort study of 1749 patients in an integrated health care system, we compared presenting features and computed tomography findings by practice setting and assessed independent effects of demographic and clinical factors on presenting features.

Results: Inpatients were older and more often underweight/normal weight and lacked a diverticulitis past history and had more comorbidities than other patients. Outpatients were most often Hispanic/Latino. The classical triad (abdominal pain, fever, leukocytosis) occurred in 78 (38.6%) inpatients, 29 (5.2%) outpatients and 34 (10.7%) emergency department cases. Computed tomography was performed on 196 (94.4%) inpatients, 110 (9.2%) outpatients and 296 (87.6%) emergency department cases and was diagnostic in 153 (78.6%) inpatients, 62 (56.4%) outpatients and 243 (82.1%) emergency department cases. Multiple variables affected presenting features. Notably, female sex had lower odds for the presence of the triad features (odds ratio [95% CI], 0.65 [0.45-0.94], P<0.05) and increased odds of vomiting (1.78 [1.26-2.53], P<0.01). Patients in age group 56 to 65 and 66 or older had decreased odds of fever (0.67 [0.46-0.98], P<0.05) and 0.46 [0.26-0.81], P<0.01), respectively, while > / =1 co-morbidity increased the odds of observing the triad (1.88 [1.26-2.81], P<0.01).

Conclusion: There was little objective evidence for physician-diagnosed diverticulitis in most outpatients. Demographic and clinical characteristics vary among settings and independently affect presenting features.
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http://dx.doi.org/10.15403/jgld.2014.1121.234.acddDOI Listing
December 2014

Screening colonoscopy versus sigmoidoscopy: implications of a negative examination for cancer prevention and racial disparities in average-risk patients.

Gastrointest Endosc 2014 Nov 6;80(5):852-61.e1-2. Epub 2014 May 6.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA.

Background: Both colonoscopy and flexible sigmoidoscopy are accepted procedures for colorectal cancer (CRC) screening in the United States.

Objective: To compare risk of CRC after negative findings on screening colonoscopy versus sigmoidoscopy and to evaluate racial/ethnic disparities in postscreening CRC.

Design: Retrospective, comparative cohort study.

Setting: Integrated community-based health-care system.

Patients: Average-risk patients 50 to 75 years of age with negative findings on an initial endoscopic screening examination from January 2000 to December 2010.

Interventions: Colonoscopy versus sigmoidoscopy as the initial screening procedure.

Main Outcome Measurements: Incident cases of CRC identified via a prospective internal cancer registry, risk of CRC determined by Cox regression adjusted for age, sex, race/ethnicity, and comorbidity.

Results: The study cohort included 138,297 patients (42,938 patients with negative findings on colonoscopy and 95,359 with negative findings on sigmoidoscopy). The median age was 57.9 years (interquartile range 53.0-64.1 years). Women comprised 51.8% of the cohort with 42.2% non-Hispanic white patients, 24.1% Hispanic patients, 10.7% non-Hispanic black patients, 9.7% Asian patients, and 13.3% other/unknown. A total of 241 cases of CRC was detected during 553,543 person-years of follow-up. The adjusted hazard ratio (HR) of postscreening CRC was 0.42 (95% confidence interval [CI], 0.28-0.64; P < .0001) for colonoscopy versus sigmoidoscopy. Risk reduction was primarily among proximal tumors (adjusted HR 0.30; 95% CI, 0.16-0.57). Non-Hispanic black patients were at higher risk of postscreening CRC compared with non-Hispanic white patients (adjusted HR 1.71; 95% CI, 1.20-2.42); however, this disparity was noted only in the sigmoidoscopy cohort.

Limitations: Retrospective study with potential selection bias and residual confounding.

Conclusions: Negative screening colonoscopy was associated with decreased incidence of subsequent CRC and a decrease in disparities compared with negative sigmoidoscopy findings in this large, community-based setting.
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http://dx.doi.org/10.1016/j.gie.2014.03.015DOI Listing
November 2014

Calcinosis, varioliform gastritis, and bleeding.

Clin Gastroenterol Hepatol 2014 Oct 1;12(10):1763. Epub 2014 Apr 1.

Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, California.

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http://dx.doi.org/10.1016/j.cgh.2014.03.024DOI Listing
October 2014

"Wherever you go, remember Africa": memories of a medical experience in Kenya.

Perm J 2013 ;17(4):e150-4

Gastroenterologist at the Garfield Specialty Center in San Diego, CA.

A short time spent volunteering in a small, rural Kenyan hospital required me to revive dormant medical skills. Much could be done despite markedly limited resources. Major contrasts with my experiences in the US, especially the harsh living conditions, types of illnesses, and more advanced disease at presentation, left indelible memories.
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http://dx.doi.org/10.7812/TPP/12-129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3854823PMC
August 2014

Ischemic colitis and bleeding.

Gastrointest Endosc 2012 Mar;75(3):697; author reply 697-8

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http://dx.doi.org/10.1016/j.gie.2011.10.023DOI Listing
March 2012

Pediatric obesity and gallstone disease.

J Pediatr Gastroenterol Nutr 2012 Sep;55(3):328-33

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.

Objectives: The aim of the present study was to investigate the association between childhood and adolescent obesity, the risk of gallstones, and the potential effect modification by oral contraceptive use in girls.

Methods: For this population-based cross-sectional study, measured weight and height, oral contraceptive use, and diagnosis of cholelithiasis or choledocholithiasis were extracted from the electronic medical records of 510,816 patients ages 10 to 19 years enrolled in an integrated health plan, 2007-2009.

Results: We identified 766 patients with gallstones. The adjusted odds ratios (95% CI) of gallstones for under-/normal-weight (reference), overweight, moderate obesity, and extreme obesity in boys were 1.00, 1.46 (0.94%-2.27%), 1.83 (1.17%-2.85%), and 3.10 (1.99%-4.83%) and in girls were 1.00, 2.73 (2.18%-3.42%), 5.75 (4.62%-7.17%), and 7.71 (6.13%-9.71%), respectively (P for interaction sex × weight class <0.001). Among girls, oral contraceptive use was associated with higher odds for gallstones (odds ratio 2.00, 95% CI 1.66%-2.40%). Girls who used oral contraceptives were at higher odds for gallstones than their counterparts in the same weight class who did not use oral contraceptives (P for interaction weight class × oral contraceptive use 0.023).

Conclusions: Due to the shift toward extreme childhood obesity, especially in minority children, pediatricians can expect to face increasing numbers of children and adolescents affected by gallstone disease.
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http://dx.doi.org/10.1097/MPG.0b013e31824d256fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401629PMC
September 2012

Factors that predict relief from upper abdominal pain after cholecystectomy.

Clin Gastroenterol Hepatol 2011 Oct 20;9(10):891-6. Epub 2011 May 20.

Division of Gastroenterology and Hepatology, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background & Aims: Upper abdominal pain (UAP) in patients with gallstones is often treated by cholecystectomy but it frequently persists. We aimed to identify symptoms associated with relief.

Methods: We followed 1008 patients who received cholecystectomy for gallstones and UAP at the Mayo Clinic (Rochester, Minnesota) or Kaiser Permanente (San Diego, California) for 12 months. A validated, self-completed biliary symptoms questionnaire identified features of UAP, gastroesophageal reflux disease (GERD), and irritable bowel syndrome (IBS); the questionnaire was given initially and 3 and 12 months after cholecystectomy, to identify features that predicted sustained relief of UAP.

Results: Five hundred ninety-four patients (59%) reported relief from UAP. Factors associated univariately (P < .05) with relief included frequency of UAP ≤1 per month, onset ≤1 year preoperatively, usual duration (30 minutes to 24 hours, most often in the evening or night), and severity >5/10. Compared to no features, multiple predictive features of UAP (frequency, onset, duration, or timing) were associated with increasing odds ratios (95% confidence interval) for relief: 1, 2, or 3 features (4.2 [1.1-16]; P = .03) and 4 features (6.3 [1.6-25]; P = .008). Negative univariate associations included lower abdominal pain (LAP), usual bowel pattern, nausea ≥1 per week, often feeling bloated or burpy, GERD, and/or IBS. There was an inverse association between relief and somatization; relief was not associated with postprandial UAP. Multivariable logistic regression analysis revealed independent associations (P < .05) with UAP frequency, onset, and nocturnal awakening, but inverse associations with lower abdominal pain, abnormal bowel pattern, and frequent bloated or burpy feelings.

Conclusions: UAP features and concomitant GERD, IBS, and somatization determine the odds for relief from UAP after cholecystectomy.
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http://dx.doi.org/10.1016/j.cgh.2011.05.014DOI Listing
October 2011

Ischemic colitis: important differences between kaiser and montefiore reports.

Am J Gastroenterol 2011 Feb;106(2):365; author reply 366

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http://dx.doi.org/10.1038/ajg.2010.388DOI Listing
February 2011

Do the symptom-based, Rome criteria of irritable bowel syndrome lead to better diagnosis and treatment outcomes?

Clin Gastroenterol Hepatol 2010 Feb;8(2):125-9; discussion 129-36

Nottingham Digestive Diseases Centre Biomedical Research Unit, University Hospital, Nottingham, Nottinghamshire, United Kingdom.

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http://dx.doi.org/10.1016/j.cgh.2009.12.018DOI Listing
February 2010

Effect of physician education and patient counseling on inpatient nonsurgical percutaneous feeding tube placement rate, indications, and outcome.

South Med J 2010 Feb;103(2):126-30

Division of Gastroenterology, Columbia University Presbyterian Hospital, New York City, NY 10032, USA.

Background: The decision to place a percutaneous feeding tube (PFT) in patients who are at the end of life is multidimensional and often complicated. We assessed the effect of physician education and counseling for patients and their surrogates on inpatient nonsurgical (endoscopic and radiologic) PFT placement rates, indications, complications, and mortality.

Methods: In a pre-paid group practice, a geriatrician initiated a program of physician education and patient/surrogate counseling on the ethical and nutritional aspects of long-term enteral feeding. We compared rates of nonsurgical PFT placement (excluding those for cancer therapy or gastric decompression), indications, complications, and short- and long-term mortality in adult inpatients before (2004) and after (2005) the program.

Results: In 2004 and 2005, 115 and 60 inpatients underwent PFT placement, respectively. The annual number of hospital admissions was similar, but the rate of PFT placement declined (0.80% vs. 0.44%, P < 0.0001). The indications were cerebrovascular accident (42 [37%] versus 22 [37%]), dementia (15 [13%] versus 3 [5%]), other neurological disease (28 [24%] versus 16 [26%]), and miscellaneous disease (30 [26%] versus 19 [32%]); P > 0.05. Severe infectious complications occurred in 4 (3%) versus 0 (0%) patients, P > 0.05. Mortality (2004 versus 2005) at 30 days (23 [20%] versus 11 [18%]), 1 year (62 [54%] versus 29 [48%]) and 2 years (72 [63%] versus 31 [52%]) was similar, P > 0.05.

Conclusion: A pilot program of educating referring physicians and counseling patients and their surrogates reduced the rate of inpatient PFT placement by nearly 50%. Indications, severe complications and short- and long-term mortality remained unchanged.
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http://dx.doi.org/10.1097/SMJ.0b013e3181c9800fDOI Listing
February 2010

Diseases and drugs that increase risk of acute large bowel ischemia.

Clin Gastroenterol Hepatol 2010 Jan 16;8(1):49-54. Epub 2009 Sep 16.

Department of Gastroenterology, Kaiser Permanente Medical Care Plan, San Diego, California, USA.

Background & Aims: Information is limited on risk factors for acute large bowel ischemia (ALBI). We investigated diseases and drugs associated with ALBI.

Methods: We compared patients hospitalized with ALBI and controls through multivariate analysis of prior outpatient/emergency department/inpatient diagnoses and pharmacy dispensing records.

Results: There were 379 cases and 1516 controls (median age, 69 y; range, 25-97 y; 74.4% female). Disorders that were diagnosed in more cases than controls, based on univariate analysis (P < .05), included hypertension, diabetes, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, depression, asthma, coronary artery disease, dementia, rheumatoid arthritis, irritable bowel syndrome, dialysis dependency, diarrhea, and constipation. Drugs dispensed to more cases than controls were antihypertensives, opioids, statins, female hormones, potentially constipating drugs, histamine H(2)-antagonists, immunomodulators, digoxin, clopidogrel/ticlopidine, taxanes/vinca alkaloids, and antibiotics. In all cases, ALBI was associated independently with hypertension (adjusted odds ratio [AOR], 3.21, 95% confidence interval [CI]; 2.28-4.53; P < .0001), chronic obstructive pulmonary disease (AOR, 3.13; 95% CI, 2.06-4.75; P < .0001), diarrhea (AOR, 2.36; 95% CI, 1.13-4.89; P = .0218), atrial fibrillation (AOR, 2.21; 95% CI, 1.34-3.64; P = .0019), congestive heart failure (AOR, 1.94; 95% CI, 1.11-3.39; P = .0205), diabetes (AOR, 1.82; 95% CI, 1.31-2.53; P = .0004), antibiotics (AOR, 3.30; 95% CI, 2.19-4.96; P < .0001), opioids (AOR, 1.96; 95% CI, 1.43-2.67; P < .0001), and potentially constipating drugs (AOR, 1.75; 95% CI, 1.25-2.44; P = .0012). Analysis of only women revealed similar associations except for diarrhea plus rheumatoid arthritis (AOR, 3.27; 95% CI, 1.07-9.96; P = .0370), irritable bowel syndrome (AOR, 2.72; 95% CI, 1.04-7.14; P = .0424), and female hormones (AOR, 1.88; 95% CI, 1.30-2.73; P = .0009).

Conclusions: Heterogeneous diseases and drugs increase the risk of ALBI, consistent with multifactorial pathogenesis.
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http://dx.doi.org/10.1016/j.cgh.2009.09.006DOI Listing
January 2010

Passage of a large bowel cast after acute large-bowel ischemia.

Clin Gastroenterol Hepatol 2009 Oct 25;7(10):e59-60. Epub 2009 Jun 25.

Kaiser Permanente Medical Care Program, San Diego, California, USA.

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http://dx.doi.org/10.1016/j.cgh.2009.06.004DOI Listing
October 2009

Epidemiology, clinical features, high-risk factors, and outcome of acute large bowel ischemia.

Clin Gastroenterol Hepatol 2009 Oct 23;7(10):1075-80.e1-2; quiz 1023. Epub 2009 Jun 23.

Department of Gastroenterology, Kaiser Permanente Medical Care Plan, San Diego, California, USA.

Background & Aims: Only a limited amount of important information is available on acute lower bowel ischemia (ALBI). We investigated the epidemiology, clinical aspects, high-risk factors, and outcome of ALBI.

Methods: We retrospectively analyzed data collected from 401 patients with 424 hospitalizations with ALBI in a prepaid health system for 7 years.

Results: The estimated annual incidence of ALBI was 15.6/100,000 patient-years (22.6 female, 8.0 male), with a marked age-related increase. ALBI preceded 400 admissions (94%) and followed surgery or medical admission of 24 patients (6%); 307 (72%) had rectal bleeding and abdominal pain. In 417 episodes, left-sided or transverse (368, 88%) exceeded right-sided or bilateral ALBI (49, 12%). Thirty-one patients (8%) had resection; 15 died (4%). Factors that were independently associated with resection and/or death included right-sided or bilateral distribution (adjusted odds ratio [AOR], 14.64; 95% confidence interval [CI], 4.82-44.50; P < .001), onset after admission (AOR, 7.48; 95% CI, 2.19-25.54; P < .005), hypotension (AOR, 4.45; 95% CI, 1.18-16.76; P < .05), tachycardia (AOR, 4.40; 95% CI, 1.46-13.26; P < .01), warfarin use (AOR, 4.33; 95% CI, 1.21-15.47; P < .05), antibiotic therapy (AOR, 3.94; 95% CI, 1.23-12.64; P < .05), male sex (AOR, 2.65; 95% CI, 1.00-7.05; P = .05), nonsteroidal anti-inflammatory drug use (AOR, 0.15; 95% CI, 0.04-0.53; P < .005), and rectal bleeding (AOR, 0.24; 95% CI, 0.09-0.65; P < .005). During a mean of 2.6 +/- 1.9 years, no patient developed chronic colitis, and 1 (<1%) had stricture dilation. Estimated ALBI recurrence was 3%, 5%, 6%, and 10% at years 1, 2/3, 4, and 5/6, respectively.

Conclusions: ALBI is common and agerelated and predominates in female patients. Demographic and clinical variables predict severe ALBI. Chronic sequelae are rare. Recurrence is substantial.
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http://dx.doi.org/10.1016/j.cgh.2009.05.026DOI Listing
October 2009

Avoiding unnecessary surgery in irritable bowel syndrome.

Gut 2007 May;56(5):608-10

Kaiser Permanente Medical Center, 4647 Zion Avenue, San Diego, CA 92120, USA.

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http://dx.doi.org/10.1136/gut.2006.115006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1942132PMC
May 2007

Functional bowel disorders.

Gastroenterology 2006 Apr;130(5):1480-91

Kaiser Permanente Medical Care Program, San Diego, California 92120, USA.

Employing a consensus approach, our working team critically considered the available evidence and multinational expert criticism, revised the Rome II diagnostic criteria for the functional bowel disorders, and updated diagnosis and treatment recommendations. Diagnosis of a functional bowel disorder (FBD) requires characteristic symptoms during the last 3 months and onset > or =6 months ago. Alarm symptoms suggest the possibility of structural disease, but do not necessarily negate a diagnosis of an FBD. Irritable bowel syndrome (IBS), functional bloating, functional constipation, and functional diarrhea are best identified by symptom-based approaches. Subtyping of IBS is controversial, and we suggest it be based on stool form, which can be aided by use of the Bristol Stool Form Scale. Diagnostic testing should be guided by the patient's age, primary symptom characteristics, and other clinical and laboratory features. Treatment of FBDs is based on an individualized evaluation, explanation, and reassurance. Alterations in diet, drug treatment aimed at predominant symptoms, and psychotherapy may be beneficial.
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http://dx.doi.org/10.1053/j.gastro.2005.11.061DOI Listing
April 2006

Functional dyspepsia--managing the conundrum.

N Engl J Med 2006 Feb;354(8):791-3

Kaiser Permanente Medical Center, San Diego, USA.

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http://dx.doi.org/10.1056/NEJMp058326DOI Listing
February 2006