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Management of acute food protein-induced enterocolitis syndrome emergencies at home and in a medical facility.
Leonard, SA, Miceli Sopo, S, Baker, MG, Fiocchi, A, Wood, RA, Nowak-Węgrzyn, A
Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2021;(5):482-488.e1
Abstract
OBJECTIVE Acute food protein-induced enterocolitis syndrome (FPIES) is characterized by delayed repetitive vomiting after ingestion of a trigger food, and severe reactions may lead to dehydration, hypotension, and shock. We provide recommendations on management of FPIES emergencies in a medical facility and at home. DATA SOURCES This review summarizes the literature on clinical context, pathophysiology, presentation, and treatment of FPIES emergencies. STUDY SELECTIONS We referred to the 2017 International Consensus Guidelines for the Diagnosis and Management of FPIES and performed a literature search identifying relevant recent primary articles and review articles on clinical management. RESULTS Management of FPIES emergencies in a medical facility is based on severity of symptoms and involves rehydration, ondansetron, and corticosteroids. A proactive approach for reactions occurring at home involves prescribing oral ondansetron and providing an individualized treatment plan based on the evolution of symptoms and severity of past reactions. A better understanding of the pathophysiology of FPIES and randomized trials on ondansedron and cocorticosteroid use could lead to more targeted treatments. CONCLUSION Children with FPIES are at risk for severe symptoms constituting a medical emergency. Management of FPIES emergencies is largely supportive, with treatment tailored to the symptoms, severity of the patient's condition, location of reaction, and reaction history.
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[Gastrointestinal symptoms revealing COVID-19 in Malian breast cancer patient undergoing chemotherapy].
Sidibe, FM, Bathily, M, Diarra, B, Kone, AS, Diabate, K, Konate, M, Cisse, HL, Guindo, I, Kone, AA, Kone, J, et al
Bulletin du cancer. 2020;(10):1019-1023
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In this review, we report a case of a bone's metastatic breast cancer in Malian patient treated by chemotherapy in whom SRAS-COV-2's diagnosis was made 9days after the onset gastrointestinal symptoms. Patient quickly died before any COVID-19's treatment. According to the poor outcomes of cancer patients with COVID-19, authors emphasize to an intensive attention to such patients in order to find the best therapeutic balance between the two pathologies during this pandemic.
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Proposed characterization of the syndrome of epidural pneumatosis (pneumorrhachis) in patients with forceful vomiting from diabetic ketoacidosis as a clinico-radiologic pentad based on systematic literature review & an illustrative case report.
Gill, I, Edhi, AI, Cappell, MS
Medicine. 2020;(35):e21001
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BACKGROUND Previous literature on epidural pneumatosis (pneumorrhachis, or air in epidural cavity) associated with forceful vomiting in a patient with diabetic ketoacidosis (DKA) has consisted of individual case reports without comprehensive syndrome characterization due to syndromic rarity, with the largest previous literature review comprising 6 cases. Presumed pathophysiology is air escaping from alveolar rupture from forceful vomiting via tissue planes to cause epidural pneumatosis. AIM: Systematically review literature to facilitate syndromic diagnosis, evaluation, and treatment. A new illustrative case is reported. METHODS Systematic review of literature using 2 independent readers, 2 computerized databases, and the following medical terms/keywords: ["epidural pneumatosis" OR "pneumorrhachis"] AND ["diabetes" OR "diabetic ketoacidosis" or "DKA"]. Discrepancies between 2 readers were resolved by consensus using prospectively developed study inclusion criteria. Two readers independently abstracted case report. Prospective review protocol and patients, problems, intervene, comparison group, outcomes discussed in Methods section of paper. RESULTS-SYSTEMATIC-LITERATURE-REVIEW Revealed 10 previously reported cases plus 1 new case (see below) that shows this syndrome presents rather stereotypically with the tentatively proposed following pentad (% of patients fulfilling individual criterion): 1-forceful vomiting (100%), 2-during DKA (100%), 3-pneumomediastinum from forceful alveolar rupture (100%), 4-epidural pneumatosis from air escape from pneumomediastinum (100%), and 5-no complications of Boerhaave syndrome or of focal neurological deficits (100%). Pentad is pathophysiologically reasonable because forceful vomiting can cause alveolar rupture, pneumomediastinum, and air entry into epidural space. RESULTS-ILLUSTRATIVE-CASE-REPORT Epidural pneumatosis occurred in a 33-year-old-male with poorly controlled diabetes mellitus type 1 who presented with forceful vomiting while in DKA. Radiologic findings also included subcutaneous emphysema, pneumomediastinum, and small pneumothorax. The patient rapidly improved while receiving acute therapy for DKA, and was discharged after 2 hospital days. STUDY LIMITATIONS Limited number of analyzed, retrospectively reported cases. Case reports subject to reporting bias. Specificity, positive predictive value, and negative predictive value not meaningfully analyzed in this homogeneous population. CONCLUSIONS Based on systematic review, syndrome is tentatively proposed as a pentad with: 1-forceful vomiting, 2-during DKA, 3- pneumomediastinum, 4-epidural pneumatosis, and 5-no complications of Boerhaave syndrome or focal neurological deficits. Proposed pentad should be prospectively tested in a larger population including patients with this versus closely related syndromes.
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Association Between Vomiting and QT Hysteresis: Data from a TQT Study with the Endothelin A Receptor Antagonist Clazosentan.
Juif, PE, Dingemanse, J, Voors-Pette, C, Ufer, M
The AAPS journal. 2020;(5):103
Abstract
This study investigated the potential QT liability of the selective endothelin-1 A receptor antagonist clazosentan at a therapeutic (20 mg/h) and supratherapeutic (60 mg/h) intravenous (i.v.) dose. A randomized, placebo- and moxifloxacin-controlled, double-blind, 3-period, crossover study was conducted in 36 healthy subjects receiving clazosentan (20 mg/h followed by 60 mg/h i.v. for 3 h each), placebo (i.v. for 6 h), and moxifloxacin (single oral dose of 400 mg concomitantly with placebo i.v. for 6 h). At least three replicate ECGs were extracted from Holter recordings at predefined time points from 1 h pre-dose to 24 h after end of infusion. Pharmacokinetic blood sampling was performed for concentration/QT analysis (primary endpoint). For moxifloxacin, the lower bound of the 90% confidence interval (CI) of baseline- and placebo-corrected QTcF (ΔΔQTcF) was > 5 ms at its maximum plasma concentration together with a positive slope of the concentration/QT regression line demonstrating assay sensitivity. For clazosentan, time of peak exposure preceded maximum ΔΔQTcF by 4 h indicating delayed QT-prolonging effects leading to invalidity of the concentration/QT analysis. The secondary by-time-point analysis revealed QT liability of clazosentan (i.e., upper bound of 90% CI ∆∆QTcF > 10 ms). Delayed QT prolongation (i.e., hysteresis) was predominantly observed in subjects with nausea and vomiting, potentially caused by vagal reaction and/or decreases in potassium concentration. By contrast, there was no association with other adverse events, food intake, or concomitant medication. In conclusion, clazosentan at therapeutic and supratherapeutic doses has QT liability with hysteresis effects being associated with nausea and vomiting.
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Masked bolus gluten challenge low in FODMAPs implicates nausea and vomiting as key symptoms associated with immune activation in treated coeliac disease.
Daveson, AJM, Tye-Din, JA, Goel, G, Goldstein, KE, Hand, HL, Neff, KM, Williams, LJ, Truitt, KE, Anderson, RP, ,
Alimentary pharmacology & therapeutics. 2020;(2):244-252
Abstract
BACKGROUND In patients with coeliac disease, FODMAPs in gluten-containing foods, and participant anticipation of a harmful ('nocebo') effect, may contribute to acute symptoms after gluten challenge. AIM: To establish acute gluten-specific symptoms linked to immune activation in coeliac disease METHODS We included 36 coeliac disease patients on a gluten-free diet receiving placebo in the RESET CeD trial. Double-blind, bolus vital wheat gluten (~6-g gluten protein) and sham challenges low in FODMAPs were consumed 2 weeks apart. Assessments included daily Coeliac Disease Patient Reported Outcome (CeD PRO) symptom scores (0-10), adverse events and serum interleukin-2 (baseline and 4 hours). RESULTS Median CeD PRO score for nausea increased most (sham: 0 vs gluten: 5.5; P < .001). Apart from tiredness (1 vs 4, P = .005) and headache (0 vs 2, P = .002), changes in other symptoms were small or absent. Only nausea increased significantly in occurrence with gluten (11% vs 69%, P < .001). Without nausea, only tiredness and flatulence were common after gluten. Nausea (6% vs 61%, P < .001; median onset: 1:34 hours) and vomiting (0% vs 44%, P < .001; 1:51 hours) were the only adverse events more common with gluten than sham. Interleukin-2 was always below the level of quantitation (0.5 pg/mL) at baseline, and after sham. Interleukin-2 was elevated after gluten in 97% of patients (median fold-change: 20), and correlated with severity of nausea (rs = .49, P = .0025) and occurrence of vomiting (P = .0005). CONCLUSIONS Nausea and vomiting are relatively specific indicators of acute gluten ingestion, and correlate with immune activation. IBS-like symptoms without nausea are unlikely to indicate recent gluten exposure.
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Management of cyclic vomiting syndrome in adults: Evidence review.
Sharaf, RN, Venkatesan, T, Shah, R, Levinthal, DJ, Tarbell, SE, Jaradeh, SS, Hasler, WL, Issenman, RM, Adams, KA, Sarosiek, I, et al
Neurogastroenterology and motility. 2019;(Suppl 2):e13605
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BACKGROUND This evidence review was conducted to inform the accompanying clinical practice guideline on the management of cyclic vomiting syndrome (CVS) in adults. METHODS We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and focused on interventions aimed at prophylactic management and abortive treatment of adults with CVS. Specifically, this evidence review addresses the following clinical questions: (a) Should the following pharmacologic agents be used for prophylaxis of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, or mitochondrial supplements? (b) Should the following pharmacologic agents be used for abortive treatment: triptans or aprepitant? RESULTS We found very low-quality evidence to support the use of the following agents for prophylactic and abortive treatment of CVS: amitriptyline, topiramate, aprepitant, zonisamide/levetiracetam, and mitochondrial supplements. We have moderate certainty of evidence for the use of triptans as abortive therapy. We found limited evidence to support the use of ondansetron and the treatment of co-morbid conditions and complementary therapies. CONCLUSIONS This evidence review helps inform the accompanying guideline for the management of adults with CVS which is aimed at helping clinicians, patients, and policymakers, and should improve patient outcomes.
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The effect of preparative solid food status on the occurrence of nausea, vomiting and aspiration symptoms in enhanced CT examination: prospective observational study.
Li, X, Liu, H, Zhao, L, Liu, J, Cai, L, Zhang, L, Liu, L, Zhang, W
The British journal of radiology. 2018;(1090):20180198
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OBJECTIVE To evaluate the correlation between preparative solid food status and the incidence of nausea, vomiting and aspiration symptoms in contrast-enhanced CT examination, and to provide direction for standardizing the preparative dietary policies. METHODS Patients who underwent routine enhanced CT examination at our hospital between June 2015 and June 2017 (110,836 cases) were enrolled and allocated into solid food fasting group (51,807 cases) and solid food non-fasting group (59,029 cases). Fluids ingestion was not restricted for any case. The differences in the incidence of nausea, vomiting and aspiration symptoms between the two groups of patients with various basic data were compared. The risk factors for the occurrence of nausea, vomiting and aspiration symptoms were analyzed. RESULTS The total incidence of nausea and vomiting was extremely low (0.071%), and no aspiration developed. There was no significant difference in the incidence of nausea and vomiting between the two groups in all respects (p > 0.05). The incidence of nausea and vomiting in patients with an iodine adverse drug reaction (ADR) history was higher than those with other ADR history (p = 0.008) and those without ADR history (p = 0.001). CONCLUSION The occurrence of nausea and vomiting has no correlation with the preparative solid food status. Unless compulsory in clinical needs and constraints and gastrointestinal examination, solid food fasting is not a must in other examinations. Particular attention should be paid to the patients with an iodine ADR history in an effort to prevent possible ADRs. ADVANCES IN KNOWLEDGE The correlation between preparative solid food status and the incidence of nausea, vomiting and aspiration symptoms in contrast-enhanced CT examination were comprehensively analyzed in a large-scale population.
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Gastroesophageal Reflux: Regurgitation in the Infant Population.
Ferguson, TD
Critical care nursing clinics of North America. 2018;(1):167-177
Abstract
Gastroesophageal reflux (GER) is common in infancy and mainly treated through nonpharmacological interventions. Knowing the early warning signs of GER is important for nursing assessment. Untreated GER can become acute when an infant fails to gain weight and has recurrent, forceful vomiting. Further investigation of gastroesophageal reflux disease (GERD) is indicated when failure to gain weight, irritability, swallowing difficulties, regurgitation, and respiratory complications occur and should trigger referral to pediatric specialists. This article will share information about uncomplicated GER, GERD, and symptoms of these diagnoses, common screening tests, and treatment options.
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Cannabinoids for nausea and vomiting related to chemotherapy: Overview of systematic reviews.
Schussel, V, Kenzo, L, Santos, A, Bueno, J, Yoshimura, E, de Oliveira Cruz Latorraca, C, Pachito, DV, Riera, R
Phytotherapy research : PTR. 2018;(4):567-576
Abstract
Nausea and vomiting are common and distressing adverse events of chemotherapy. This review focuses on the findings and quality of systematic reviews (SRs) of cannabinoids for chemotherapy-induced nausea and vomiting (CINV). Review of SRs, a systematic literature search, was conducted in several electronic databases and included SRs evaluating cannabinoids for CINV in cancer patients. Methodological quality and quality of reporting were evaluated by AMSTAR and PRISMA, respectively. Initial search retrieved 2,206 records, and 5 SRs were included. On the basis of findings of the sole SR judged as high methodological quality, cannabinoids seem to be more effective than placebo, equal to prochlorperazine for reducing CINV, and to be preferred by patients. The response to different combinations of antiemetic agents seems to be equal to 1 antiemetic alone. The average of AMSTAR score was 5, and the average of PRISMA score was 13.2. Cannabinoids represent a valuable option for treating CINV, despite the adverse events related to treatment, such as drowsiness and cognitive impairment. There is no good quality evidence to recommend or not the use of cannabinoids for CINV. More studies are still needed to evaluate the effectiveness of cannabinoids when compared with modern antiemetics.
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[Effects of Serum Sodium Concentrations on Nausea and Vomiting after Moderately Emetogenic Chemotherapy].
Hatakeyama, S, Suzuki, N, Abe, K, Konno, N, Kaneko, T, Toyoguchi, T, Shiraishi, T
Yakugaku zasshi : Journal of the Pharmaceutical Society of Japan. 2018;(8):1095-1101
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Chemotherapy-induced nausea and vomiting (CINV) is the most unbearable adverse effect of chemotherapy. The antiemesis guidelines of the National Comprehensive Cancer Network indicate that hyponatremia is a risk factor for CINV, although the relationship between the incidence of CINV and hyponatremia has not been sufficiently studied. This two-center prospective observational study evaluated whether low serum sodium concentrations were a risk factor for CINV. The study included 34 patients who were scheduled to receive first-line carboplatin- or oxaliplatin-based chemotherapy for gynecological or colorectal cancers. Patient diaries were used to record the daily incidences of CINV events during a 5-day period. The patients were divided based on the median serum sodium concentration into a low Na+ group (<141 mEq/L) and a high Na+ group (≥141 mEq/L). The incidences of delayed nausea were 27.8% in the high Na+ group and 62.5% in the low Na+ group (p=0.042), with complete control rates (no vomiting, rescue medication, or grade 2 nausea) of 77.8% and 43.8%, respectively (p=0.042). The time to complete control failure in each group was analyzed using the Kaplan-Meier method, which revealed a significantly shorter time in the low Na+ group (p=0.03). Therefore, these results indicate that low serum sodium concentrations may increase the risk of CINV.