functional brain-gut issue 39, fall 2007 research group 39.pdf · investigator. within the academic...

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PresidentG. Richard Locke, MDRochester, MN

Vice PresidentEmeran Mayer, MDLos Angeles, CA

Secretary/TreasurerLin Chang, MDLos Angeles, CA

Executive DirectorDeb Geno

FBG President’s Letter

Election season is upon us. No, I am not talking about the U.S. national elections. The time has come for the FBG Officer and Councilor elections. Every two years, we elect new officers to the organization. You will find included with this newsletter the ballot for President-Elect and Secretary/Treasurer. We elect Councilors every year. We thought that two years was too short of a term for a person to really become involved in the FBG. We recently ratified a bylaws change and we are now electing three councilors for three years. Our efforts are limited by the time our members can provide us. We are hoping that expansion of the council will allow us to accomplish even more than we currently do. I am thankful to all of the nominees for their willingness to serve the organiza-tion. Now I ask the members to take an active role and to vote. Historically, our voting percentages have been very small.

Since our annual meeting at DDW, the FBG has been active in several ways. First of all, plans are underway for our annual fellow’s meeting. Carlo DiLorenzo and Ronnie Fass have kindly agreed to serve as the chairs of this year’s meeting. Joyce Fried will once again help us organize this meeting, which will be held in San Diego on April 11-13, 2008. We rely on our members to encourage fellows to attend this conference. The vast majority of the attendees have worked with a mentor in our organization. The feedback from the fellows has been fabulous. Please give some thought as to who in your laboratory or division might be appropriate for this meeting. Further information will be mailed out in the next couple of months.

Functional Brain-GutResearch Group

Message from the President

The mission of the Functional Brain-Gut Research Group is to support, promote and advance multidisciplinary research and education in the basic

science, clinical and behavioral aspects of brain-gut interactions.

Office

1820 Spruce Meadows DriveRochester, MN 55904USA

Phone: 507-538-0367Fax: 507-266-9081E mail: [email protected]

www.fbgweb.org

Founded 1989

Richard Locke, MDPresident

CouncilCarlo DiLorenzo, MDColumbus, OH

Ronnie Fass, MDTucson, AZ

Lesley Houghton, PhDManchester, UK

Tony Lembo, MDBoston, MA

Nancy Norton (ad-hoc member)Milwaukee,WI

Past-Presidents1989 - 1994 — Douglas A. Drossman, MD1994 - 1996 — William E. Whitehead, PhD1996 - 1998 — Kenneth L. Koch, MD1998 - 2000 — Nicholas J. Talley, MD, PhD2000 - 2002 — W. Grant Thompson, MD2002 - 2004 — Kevin Olden, MD2004 - 2006 — George F. Longstreth, MD

Newsletter EditorDouglas A. Drossman, MDNewsletter Managing EditorKirsten NyropNewsletter DesignJohn Herr


Editor’s Column

Member Spotlight

Ray E. Clouse, MDGuest Column

Book Review

Noncardiac Chest Pain: A Growing Medical ProblemIFFGD Spring 2007 Update

Cross-Cultural Column

FBG Awards

Announcements

Special Reports

Rome Foundation

FBG News

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Table of Contents

Functional Brain GutResearch Group




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I also would like to highlight NGM 2008 to be sure that people have this on their calendars. This is the next joint international meeting and will be held in Lucerne, Switzerland November 6-9, 2008. As an organization we have taken an active role in the planning of this meeting. I thank Doug Drossman and Carlo DiLorenzo for their efforts in planning the scientific content of this meeting. I think everyone will find this meeting informative and hopefully fun.

While talking about the joint international meeting, plans are de-veloping for NGM 2009. The FBG will be the host of this meeting. The scientific content will be planned by a joint committee chaired by Emeran Mayer. Brian Lacy, Ronnie Fass and Max Schmulson will all be involved in developing the content for this meeting. We also had our first meeting of the planning committee. I wish to thank Lin Chang, Enrico Corazziari, Mike Crowell, Leslie Houghton, Paul Hyman, Mike Jones, Rona Levy, Yehuda Ringel, Max Schmulson, Elena Verdu, and Bry Wyman for their willingness to participate to help plan the 2009 meeting.

We have chosen to have this meeting in Chicago on August 26-30, 2009. This may seem a long way away, but it will be here before we know it. We have engaged Lori Ennis as the meeting planner.


Lori organized the Boston 2006 meeting and so she is well expe-rienced with this. The IFFGD will be more involved in this meeting than it has been in the first two joint international symposiums. We are planning to cover the breadth of our field to make this meeting attractive and interesting to everyone.

I encourage everyone to visit our newly designed website at http://fbgweb.org/. We are hoping to move to a more internet-based ad-ministrative process. I think you will appreciate the new look and feel of the website. Over time, we are hoping the website will serve as a focal point for our organization.

As President, I have one final request which is to pay your dues. Dues to the FBG are small compared to other societies and organi-zations of which you might be a member. We have arranged for dues paying members to receive our journal, Neurogastroenterology and Motility. Funding from pharmaceutical organizations is less available than it has been in the past. Dues now represent a more important element of our budget each year. We are hoping that you find all of this to be of benefit to you. If not, please let me know what we could do to make your membership in the FBG more valuable.

See you all at DDW in San Diego in 2008, if not earlier!

Rick LockeFBG President





3Editor’s Column

On Mentoring *

Douglas A. Drossman, MDEditor

As academic clinicians and investigators working in the FGID’s, it is important for us to facilitate the training of young investigators and clinicians to help them become knowledgeable, competent and independent in their careers. The process of mentoring is actually an ancient process of facilitating learning. It began with the “oral law” or the passing down of knowledge from generation to generation in many cultures. This has occurred with African tribes, Native Americans, and within Orthodox Judaism for centuries. The process allows for the continuation of traditional values and can serve to preserve medical and scientific knowledge through apprenticeship, where the protégés later become mentors to future generations. Within academic medicine, this process has become formalized through training grants from NIH (T32 awards), preceptorships, residencies, and fellowships. What has been given limited attention is the process of mentoring. How should the mentor and mentee interact? What are the goals, benefits and challenges of mentoring? Finally, how do we judge the success of a mentoring experience? This document sets forth some suggested guidelines for trainee supervision through a mentoring relationship between a senior faculty member and a trainee in a research or clinical environment.

The value of a mentoring relationship

Mentoring is a development-enhancing relationship between a more experienced or senior investigator and a trainee or junior investigator. Within the academic environment, mentoring is a means to systematically assist trainees and junior faculty in their career development, usually by a single senior faculty member. However, this may occur with more than one mentor. Mentoring is a constantly changing iterative process that leads to professional growth for both mentor and mentee. The values of mentoring are displayed in Figure 1.

There is evidence that a mentoring relationship leads to better professional development for the protégé. Studies show that mentored faculty: (a) spend more time on research, (b) rate their research skills higher, (c) are more likely to receive grant funding, (d) rate higher support for teaching research and administration, and (e) have greater career satisfaction (1). Furthermore, successful researchers are more likely to have had mentors before, during and after their training, and they maintain these relationships with their advisors throughout their career (2).

Mentoring Values Protégé Mentor

Career gains Receives expert Guidance

Exercises higher level of dynamic teaching

Work Productivity Gains knowledge and resources

Protégé extends work productivity

Personal Gratification from expert attention, support, direction

Rejuvenation of work and enhances self-esteem viaprotégé’s enthusiasm

Interpersonal Long-term personal, and professionalrelationship

Long-term personal, and professional relationship

Figure 1 - Mentoring Values

* Reprinted from Drossman DA, American J of Gastroenterology 2007;102:1848-1852





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Expectations of the mentee

Takes greater responsibility in setting the agenda 1. over time

Seeks to initiate new ideas2. Is respectful of mentor’s time and availability3. Communicates with mentor on concerns4. Provides status of activities and projects5. Accepts new challenges 6. Seeks feedback and takes responsibility to give 7.

feedback to mentorKnows personal limits and when to ask for help8. Personally reassesses goals over time 9. Doesn’t overstep boundaries (e.g., overuse of time, 10.

dependency on mentor for answers)

The mentoring process

The mentoring process can be viewed as evolving in discrete stages. Initially, the mentor takes relatively more responsibility for the protégé’s learning and provides most of the resources. This can involve discussing goals and expectations, scheduling meetings, providing an agenda based on the needs of the mentee, and providing feedback. The mentor also identifies and addresses the mentee’s views and facilitates the acquisition of knowledge. This can be of immediate and concrete relevance, such as helping to write an abstract, providing articles and other educational resources, and helping to write grants, budgets and presentations. Through these activities, the mentor also needs to create a “need to learn” in other relevant areas (psychosocial and communication skills, biostatistics, writing skills, and creative thinking).

Positive Attributes of a Mentor (3) Knowledge and Resources

Provides expertise in areas of mutual interest1. Provides direction and guidance on professional issues 2.

(e.g., joining organizations, networking) Is willing to provide resources (e.g., research 3.

assistants, source materials, statistical assistance)Being “connected” to other resources and individuals as 4.

needed.

Teaching and SupervisionIs approachable, accessible, personable1. Is supportive and encouraging2. Provides positive and negative feedback3. Possesses good communication skills (writing, 4.

speaking, interpersonal)Seeks to improve the protégé’s knowledge, skills, 5.

productivity Promotes independence6. Challenges protégé to extend his/her abilities7. Employs a learner centered approach – recognizes/ 8.

adapts to new learning styles

Personal ValuesExhibits professional integrity1. Achieves credibility and respect among peers2. Communicates satisfaction with career3. Acknowledges and facilitates protégé’s contributions 4.

(e.g., authorship, awards)Able to tolerate challenges from protégé without 5.

reacting personally.

Editor’s Column

Mentoring - Transition Stages in Relationship

Level Protégé Mentor

I. Pedantic Learning

- Learns basic elements - Initiates Ideas- Primary task responsibility- Active teaching

II. Tutoring - Increased responsibility- Increased self-learning

- Supervises work tasks- Frequesnt tutoring

III. Androgogic Learning - Initiates/develops ideas- Primary task responsibility- Tutors when needed

- Provides feedback- Negotiates ideas

IV. Autonomy - Full responsibility for ideas and work tasks

- Feedback when needed

V. Collaboration - Shared responsibility - Shared responsibility

Figure 2 - Transitions in the mentoring process over time





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Over time, as the mentoring relationship matures, the mentor takes more of “back seat” and becomes a facilitator, thus encouraging the mentee’s professional growth and responsibility for tasks. Figure 2 illustrates the mentoring process as five levels, the most developed stage being full collaboration. The timeframe for each of these levels is determined by the parties involved, their skills and needs, and the quality of the relationship.

Clinical mentoring

Within a clinical context, mentoring is like a preceptorship where the mentor initially provides the knowledge and then the guidance for clinical decision making. While many attendings believe they need to be the purveyor of the knowledge, in modern times this is almost impossible. The rapid expansion of knowledge in medicine makes it difficult for one person to “know it all”. Instead, the mentor/attendings’ job is to teach trainees how to gather the information and to facilitate the trainees’ ability to make decisions with an abundance of information; it is the “art of medicine” that is communicated(4).

One study showed that the attributes of clinical attending role models include: (a) spending at least a quarter of the time on teaching (OR 5.1; 95%CI1.8-14.5), (b) stressing the physician-patient relationship (OR 2.6; 95%CI11.1-6.4), (c) teaching the psychosocial aspects of medicine (OR 2.3; 95%CI1.3-4.4), and (d) having served as a chief resident, presumably to gain more experience as a teacher (OR 1.1; 95%CI1.1-4.0).(5)

Survey of expectations within a mentoring relationship In a recent survey of GI fellows and faculty attending the Functional Brain-Gut Group annual fellows meeting in 2005, a group of 20 fellows and 5 faculty were surveyed regarding expectations, needs, and positive and negative attributes of mentors. The results are shown in descending order of response frequency:

Expectations:• Positive personality attributes, accessibility and approachability, technical skill/ ability to listen and provide advice, provision of honest feedback, and support for career goals.

Needs of protégé:• Career development, technical skills, feedback, and new ideas.

Positive qualities of a mentor:• Leadership and being a role model, positive personality attributes, energy and enthusiasm, facilitative style, approachability, and knowledge.

Negative qualities of a mentor:• Lack of time or availability, dominant or self-serving style, and poor communication.

In the end, the process of mentoring not only helps to “grow” academicians and clinicians, but it can also serve as a gratifying experience for mentor and mentee alike.

Douglas A. Drossman, MDEditor

Reference List

(1) Rose GL, Rukstalis MR, Schuckit MA. Informal mentoring between faculty and medical students. Acad Med. 2005;80:344-48.

(2) Palepu A, Friedman RH, Barnett RC, Carr PL, Ash AS, Szalacha L et al. Junior faculty members’ mentoring relationships and their professional development in U.S. medical schools. Acad Med. 1998;73:318-23.

(3) Berk RA, Berg J, Mortimer R, Walton-Moss B, Yeo TP. Measuring the effectiveness of faculty mentoring relationships. Acad Med. 2005;80:66-71.

(4) Greganti MA, Drossman DA, Rogers JF. The role of the attending physician. Arch Intern Med. 1982;142:698-99.

(5) Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med. 1998;339:1986-93.

Editor’s Column





6 Member Spotlight

Professor of Gastroenterologyand PsychiatryWashington University

Gregory S Sayuk, MD, C Prakash Gyawali, MD, and David H Alpers, MD

The loss of a great mentor, clinician, and friend was experienced by many with the passing of Ray E. Clouse, MD, Washington University Professor of Gastroenterology and Psychiatry, on August 31, 2007.

Ray’s remarkable career began from humble roots in Napannee, Indiana where he demonstrated a unique self-determination and motivation to excel throughout his early education. Ray’s childhood friends recall him as an exceptionally compassionate, fun-loving, and generous individual. As an adolescent, he possessed an inquisitive mind without boundaries, resulting in his (mis)-adventures in rocket construction and pyrotechnics. During his freshman year at Purdue University, his fascination with structure and design nearly led him into a career in architecture before he righted his way and chose a career in medicine. It was many of these enduring interests and attributes that not only propelled Ray into a successful career as an investigator and academician, but made him such a valued mentor and friend to those who had the fortune to interact with him.

Ray’s intellectual productivity in the realms of both gastroenterology and psychiatry was impressive. His areas of interest were diverse, yet as a common theme promoted the importance of ‘Mind-Body Research’. His work included the study of esophageal physiology and the development of high resolution manometry, elucidation of the role of the central nervous system in the pathogenesis and management of functional gastrointestinal disorders, and description of the important interface of depression and diabetes. The ability to establish a logical approach to answering clinical questions seemed almost intuitive to Ray, and resulted in more than 24 years of continuous NIH support of his investigative endeavors. Along the way, he published more than 100 original scientific papers, 50 reviews or invited publications, and over 50 book chapters.

Ray could tell a cohesive, concise and complete story in his writing, admired and adopted by those who worked with him. Ray viewed such written work as essential, but not particular to the recognition these publications yielded. Rather, he appreciated the value of such activities in strengthening one’s own expertise in one’s area of interest, while simultaneously sharing important observations and ideas with colleagues in the medical community. His success in this arena led to editorial board invitations from many high-impact journals, including Gastroenterology, Digestive Diseases and Sciences, Journal of Clinical Medicine, and Psychosomatic Medicine.

Ray’s career of 27 years resulted in many awards and recognitions for his work as an investigator and educator. He received the Foundation for Digestive Health and

IN MEMORIAMRay E. Clouse, MD





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Nutrition Award of Excellence, the Communicator Award, the Janssen Award for Basic or Clinical Science Research in Gastrointestinal Motility, and the Functional Brain-Gut Research Group Research Scientist Award, to name a few. In 2006, he was chosen as the ‘Teacher of the Year’ by the Washington University gastroenterology trainees, and was also the recipient of the American Gastroenterological Association Distinguished Educator Award. These two recent awards were particularly important to Ray, because they recognized his efforts in the aspect of his career that he perhaps enjoyed most -- education and mentorship.

As a professor, Ray was involved in the training of over 100 gastroenterology fellows, many of whom are now instructing future generations of gastroenterologists at academic centers worldwide. Ray was regarded first and foremost by his fellows as an outstanding clinician whose practice they strove to emulate. His clinical skills derived in part from his keen perception and sharp decision-making, but mostly from his sincere interest in others. He was a presence at clinical case conferences and hospital rounds, during which every teaching opportunity was captured through the sophistication and depth of his ad lib remarks. In a formal teaching setting, Ray had a gift for distilling challenging topics down to a set of manageable key elements. Though precisely planned, his presentations were delivered as a seemingly effortless oration in a background of beautifully-designed (and animated) slides. Ray shared his talents as an educator with the international gastroenterology community, participating in more than 80 visiting professorships, invited lecture series, and symposia in the last two and one-half decades.

Ray had an innate ability to identify trainees’ areas of intellectual interest. His subsequent facilitation of their development into clinicians who were successful and independent in their areas of interest made him the ideal mentor. He was an inspiring advisor, promoting the pursuit of far-reaching, yet realistic goals. Ray recognized the value

of early successes in fueling an academic career, and as such he placed others’ efforts before his own, always making the time to listen, to work through struggles together, and to provide needed support and encouragement. At any given time, Ray coordinated his provision of this essential guidance for several medical students, trainees, and junior faculty members. Without question, Ray measured his own success largely by the achievements of his mentees, rather than by his own individual accomplishments.

Ray’s professional career was all the more remarkable when considered in the context of his multitude of personal interests which he pursued with equal passion. He was a fine art aficionado with an exacting eye, resulting not only in a beautiful personal collection, but also an encyclopedic knowledge of 19th and 20th century American art. An oenophile and a gourmet chef, he often shared his careful wine selections and matching menu planning with fortunate dinner guests. He enjoyed nature and the outdoors, maintaining a log cabin with splendid Missouri river views as a second home. Ray was an active member of his church where his partner of 21 years, Rev. John W. Kilgore, MD, regularly officiates at mass. As a reflection of Ray’s Episcopalian devotion, he recently was named to Knighthood within the Order of St. John Jerusalem.

Despite his remarkable achievements, Ray never lost sight of those simple, yet important principles that he embraced while growing up in Napannee, Indiana: diligence, passion, and a love for life. These lasting attributes were what made Ray such a successful person in so many areas. These same attributes also made him a great colleague and friend. Though our time with him was cut painfully short, we all will strive to continue our lives, both professionally and personally, by embracing the principles provided by the example of Ray E. Clouse, MD.





8 Guest Column

The Narcotic Bowel Syndrome The Narcotic Bowel Syndrome (NBS) is characterized as chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics. This syndrome is under recognized and may be becoming more prevalent. This may be due, in the United States, to increases in using narcotics for chronic non-malignant painful disorders, and the development of maladaptive therapeutic interactions around its use. NBS can occur in patients with no prior gastrointestinal disorder who receive high dosages of narcotics after surgery or acute painful problems. NBS is also seen among patients with functional GI disorders or other chronic gastrointestinal diseases who are managed by physicians unaware of the increased painful sensation or hyperalgesic effects of the opioid drug itself.

This review will utilize 2 case scenarios to illustrate how chronic or high dose opioids contribute to development of NBS. Further information about this entity can be found in the first reference (1).

Joseph E. Cassara, M.D. Clinical Fellow Gastroenterology & HepatologyUniversity of North Carolina Department of MedicineDivision of Gastroenterology & Hepatology

The Narcotic Bowel Syndrome

CASE # 1: A.S.

A.S. was a 29 year-old male who worked in a chemical plant. Starting in January of this year he developed the acute onset of crampy abdominal pain and diarrhea after completing a re-cent course of amoxicillin/clavulanic acid for an upper respi-ratory infection. He was diagnosed with c.difficile colitis, treat-ed with a course of metronidazole (an antibiotic that treats c.difficile). His diarrhea improved but he still had occasional loose stools. More concerning to him was the persistence of crampy abdominal pain over his lower abdomen that inter-rupted his work at the plant. He sought care at local hospitals and another tertiary care center. He underwent evaluation with two colonoscopies, an EGD, several CT scans, repeated lab work and stool studies; all of which were normal. He was placed on a fentanyl patch which was titrated up to a dose of 100mcg. After several visits to different local emergency departments, he accumulated a stockpile of another narcotic, oxycodone/acetaminophen, and was routinely using hydro-codone/acetaminophen three- four times a day in addition to the fentanyl patch his primary physician had prescribed. His diarrhea had improved, to the point that he was complaining of constipation. He had worsening, frequent, intense crampy abdominal pain and became frustrated with his care prompt-ing presentation to UNC Gastroenterology clinic for another opinion; 11 months after onset of his problems. He was con-cerned that he may have been exposed to something at the chemical plant that may be worsening his abdominal pain.

Unfortunately, A.S.’s story is becoming an increasing presen-tation to our clinic. Patients who undergo diagnostic evalua-tions which turn up negative are routinely prescribed narcotics and sent out the door, without adequate plans for follow-up let alone a diagnosis. In this case, A.S. suffered from a Func-tional Gastrointestinal Disorder (FGID) described as post-infectious irritable bowel syndrome (PI-IBS). Or rather, the development of IBS temporally related to an inciting infection, in this case his c.difficile colitis. For this he was prescribed narcotics which notoriously contribute to constipation. The slowed bowel motility in and of itself could have significantly contributed to his worsening pain.

However, what seems most perplexing to the medical com-munity and largely unrecognized is that there is increasing evidence that the narcotic itself, over sufficient time, can ‘switch’ neurons into a mode that actually causes or exacer-bates pain. But, it is not only the neuron itself that is affected. There is also mounting evidence that cells around the neu-ron, glial cells, and distant neurons in the brain (rostral ventral medulla) can contribute to tolerance of narcotics and contrib-ute to the upregulation of a pain response, respectively. Thus, when A.S. was prescribed increasing doses of narcotics he found himself, paradoxically, in more pain. A detailed review of these mechanisms is beyond the scope of this article, how-ever, can be found in the upcoming review of The Narcotic Bowel Syndrome in Clinical Gastroenterology and Hepatol-ogy (accepted for publication)(1)

Figure 1. The Vicious Cycle of Patient Physician Interaction in the Narcotic Bowel Syndrome (1)





9Guest Column

CASE # 2: S.I.

S.I. was a 22 year old female with a history of situs inversus totalis, a condition in which there is complete right to left re-versal (transposition) of the thoracic and abdominal organs. She had significant difficulties with low back pain working 3rd shift at a packing plant. She had financial difficulties, raising a child as a single mother, and could not take any time off work for doctor’s appointments. She started visiting a local urgent care center and was initially prescribed muscle relaxants and ibuprofen. The ibuprofen caused her to have some nausea, vomiting and epigastric abdominal pain and this was discon-tinued. She was then prescribed oxycodone twice daily. She later developed an acute low back pain episode and her dose of oxycodone was doubled. She found relief of back pain but started with nausea, vomiting and abdominal discomfort. She presented to a local emergency department because she was unable to keep any food or liquid down. She was admit-ted for a night and sent home on her same medical regimen. She developed abdominal pain diffusely across her abdomen and presented to another emergency department, which per-formed a CT scan, which was only remarkable for the situs in-versus totalis and referred her for colonoscopy. Lab work was only remarkable for mild dehydration. The colonoscopy was negative. She was again discharged on her same medical regimen with some anti-nausea medications. Over the course of 4 weeks the patient lost approximately 15% of her total body weight, due to the nausea and vomiting. She insisted on continuing with narcotics so she could work, because the pain was relieved after dosing but would worsen later (‘soar and crash’). She was hospitalized again for nausea, vomiting and abdominal pain. She was diagnosed with a motility disor-der due to her situs inversus totalis, and a feeding tube was placed into her stomach. Her weight stabilized over 6 weeks. Eventually the tube was removed and the patient did well for about a week when the symptoms then recurred with nau-sea, vomiting and abdominal pain. Repeat abdominal x-rays demonstrated diffusely dilated loops of bowel and barium in the colon from a CT scan performed 14 days before. She was discharged again and referred to the UNC GI clinic for another opinion. Prior to her appointment she presented to the emergency department at UNC and was admitted. On the hospital ward, she received intravenous morphine because of continuing complaints of worsening abdominal pain. The GI team was consulted and made the diagnosis of narcotic bowel syndrome, utilizing the criteria in table 1.

According to the National Institute on Drug Abuse (NIDA)(3), in San Francisco, oxycodone emergency department visits increased 110 percent from 2001-2002. NIDA has also indicated that prescription narcotic abuse continues to be on the rise, is widespread around the country, and outpaces other drugs of abuse. NIDA’s Commu-nity Epidemiology Work Group (CEWG) report steady increases in oxycodone medical sales, diversion of the drug from clinics, and increased arrests related to this drug. In 11 of 20 national metro-politan CEWG areas in 2001, the number of narcotic analgesic-related death exceeded those for cocaine, heroin/morphine, mari-juana, and methamphetamine. Although no data are available, it is probable that, because of these changes, the incidence of NBS is increasing.

BEHAVioRAL FEATuRES

However, the narcotic itself is only partially to blame. Both of these cases illustrate a maladaptive behavioral pattern between patient and prescriber that manifests when multiple negative evaluations and diagnostic uncertainty persists (‘furor medicus’). In Case #2, the patient had developed the narcotic bowel syndrome and this contributed to her motility disorder, not her underlying situs inver-sus totalis, which she had her entire life without difficulty. Perhaps a common behavior is for the clinician to seek out a structural ba-sis for unexplained pain as may have occurred here, when in fact most chronic pain is not structurally based. Nevertheless, the pre-scribing of narcotics alleviated the pain within a sufficient period for the patient to leave the emergency department or hospital. Follow-up was not achieved and a pattern of urgent clinic and emergency department visits persisted, for which repeat negative evaluations led to repeated narcotic prescriptions prior to discharge. This vi-cious cycle of patient-physician interactions are diagrammed in figure 1(1).

There is evidence that the benefit of increasingly using narcotics for non-malignant pain, and particularly for functional GI or chronic GI pain is not as great as previously assumed. A recent systematic literature review found a wide range of methadone dosages prescribed had lower than expected effectiveness when used in chronic or non-malignant pain syndromes. In fact what little evidence there is for benefit is based largely on uncontrolled studies (4). Furthermore, patients with functional GI conditions are at greater risk for this scenario to occur because the ehanced sensitivity of the bowel leads to greater GI side effects.

TREATMENT

Our treatment of NBS as summarized in Table 2(1), involves a biopsychosocial approach. An effective physician patient relationship and a consistent plan of narcotic withdrawal coupled with the initiation of effective alternative treatments to manage the pain and bowel symptoms is recommended. Treatment can be initiated when the diagnosis is made and there is reasonable evidence that no other diagnosis explains the symptoms. NBS is a positive diagnosis which occurs independent of other pathological conditions, and it may also be the cause of pain in patients with existing inactive or even active abdominal pathology (e.g. Crohn’s disease, chronic pancreatitis). The key is that the evident data on

AN EPiDEMiC oF NARCoTiC PRESCRiBiNG

Narcotics, such as morphine, fentanyl, oxycodone or hydrocodone, are being prescribed more frequently in the United States. Impres-sively, the United States with 4.6% of the world’s population con-sumes 80% of the prescribed opioids (2). Although treatments with narcotics for these and other conditions should be both con-trolled and limited, prescriptions are actually increasing over time, and associated with this is an accelerating incidence of narcotic abuse. From 1997 to 2002, there was greater than 400% increase in retail sales of oxycodone and methadone (2).





10 Guest Column

the disease is not sufficient to explain the pain reported. Therefore confirming whether any abdominal pathology is sufficiently active to require disease specific treatment to alleviate the pain is needed. However, an extensive evaluation to “exclude other disease” is counter-therapeutic, since it reinforces the notion that some other disease is being missed. It is essential that the physician not only understand, but also have enough confidence in the diagnosis of NBS to treat it appropriately.

In case #1, A.S. had several concerns which needed to be addressed, including his belief that a chemical from his job was contributing to his worsening abdominal pain (he worked with inert gases at some distance). A physiologic basis for the pain was explained and the patient made the correlation of increasing narcotic dosing and increasing pain and constipation. He agreed to a withdrawal of the narcotic. His wife was present for this discussion and the plan was reviewed with her as well. Figure 2(1) serves as an example of the narcotic bowel treatment program starting, for example with a morphine dose of 220mg and the adjunctive medications are then used to ease the withdrawal of the narcotic and alleviate some of the opioid induced bowel dysfunction. He was started on PEG solution, duloxetine, clonidine and scheduled lorazepam. On day 5 he called mentioning that his boss had given him 3 projects to complete over as many days, and tried to ‘negotiate’ an increase in his narcotic because he didn’t want to chance having worsened abdominal pain. Reassurance was provided and an as needed dose of lorazepam was offered. Over the course of 14 days he was tapered off his narcotics and remained on the Duloxetine only. His abdominal pain has not recurred.

Here we engaged in a thoughtful patient-physician relationship that addressed his concerns regarding chemical poisoning and his stressful job in a non-judgmental manner (see table 2) (1). Similarly, it is important to validate the patient’s pain as real or there is no hope in developing an effective therapeutic relationship. A.S. demonstrated some insight into the relationship between his pain and the narcotics, and accepted the treatment regimen. His wife was enlisted to support him through the process. An antidepressant should be started prior to narcotic withdrawal and continued indefinitely. These drugs improve general well-being and abdominal pain (5,6,7). However, it is important to help the patient understand that full benefit may not occur for several weeks. Tricyclic antidepressants (TCA) are favored because their noradrenergic action is effective in managing pain (8) independent of its antidepressant effects (9), however the anticholinergic and antihistaminic side effects can lead to constipation and orthostasis. A secondary amine TCA (e.g., desipramine, nortriptyline) has fewer of these side effects and this is preferred over the tertiary amine agents (e.g., amitriptyline, imipramine). Lower dosages (e.g. 50 – 75 mg. desipramine) can be used for analgesic effect unless concomitant major depression is identified, which would require full dosage. A serotonin – noradrenergic reuptake inhibitors (SNRI – e.g., duloxetine) has the advantage of providing pain benefit via its noradrenergic action, yet does not have the bowel related side effects. Selective serotonin reuptake inhibitors (SSRI). (e.g., paroxetine, fluoxetine, citalopram), are not generally recommended since their benefit in pain management is less established. We recommend the temporary use of a medium to long acting benzodiazepine (e.g. lorazepam, clonazepam) to reduce the

anxiety associated with narcotic withdrawal. Non-contingent dosing is needed during the weaning period to avoid breakthrough symptoms of sympathetic activation. The medication should be tapered off when the narcotic withdrawal is completed.

Clonidine, an alpha-2 adrenergic receptor agonist, is effective in reducing the sympathetic symptoms of narcotic withdrawal including anxiety, restlessness, muscle pains and chills, (10,11,12). This agent is started toward the end of the taper as the withdrawal symptoms start. A typical starting dose is 0.1mg TID and titrated up to the desired effect (up to 0.6mg/day) while monitoring blood pressure and orthostasis. Particularly for outpatients, a clonidine patch may be applied for steady dosing and improved compliance. This medication can be tapered off after narcotic withdrawal or alternatively continued indefinitely, since clonidine has independent effects on relieving functional GI symptoms including pain and diarrhea (13,14)

In case #2, S.I., the narcotic withdrawal was done as an inpatient. Desipramine, PEG solution, lorazepam and clonidine were utilized. However, due to her desire to return to home and work she refused any additional narcotics on day 3 and developed withdrawal symptoms(nausea, vomiting, sweating) and abdominal pain for which she received multiple intravenous doses of morphine, leaving her somnolent for most of the following day. Following this she revealed that she is under a lot of stress, becoming tearful requesting to ‘talk to someone’ when she leaves the hospital. The narcotic withdrawal program was restarted with a commitment to follow the taper and with the plan that she could complete the taper as an outpatient, with close follow-up.

Here we see the effect of a rapid withdrawal and what can happen if concerns are not completely addressed at the outset of the program. Her high level of anxiety and feelings of pressure from home and work, left her little to find effective coping strategies, and all of this contributed to the abrupt cessation of the narcotic. Counseling was pursued during the course of her taper and she remains on Duloxetine, without nausea, vomiting or abdominal pain.

Figure 2. Narcotic Withdrawal Protocol for NBS (1)





11

In summary, the Narcotic Bowel Syndrome is the development of chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics, It is underecognized, and the growing and indiscriminate use of narcotics in the United States leads to the NBS becoming a major health care problem. The diagnosis of Narcotic Bowel Syndrome need not be assigned after extensive diagnostic workups if the history is supportive. A withdrawal program can be implemented by any treating physician, the foundation of which rests on an effective physician-patient relationship.

References

1. Grunkemeier, D.M.S., Cassara, J.E., Dalton, C.B., Drossman, D.A., The Narcotic Bowel Syndrome: Clinical features, Pathophysiology and Management. Clinical Gastroenterology and Hepatology. 2007;5:1126-1139.

2. Trescot AM, Boswell MV, Atluri SL, Hansen HC, Deer TR, Abdi S et al. Opioid guidelines in the management of chronic non-cancer pain. Pain Physician. 2006;9:1-39.

3. National Institute on Drug Abuse. http://www.drugabuse.gov/ Infofacts /nationtrends.html. Accessed September 15, 2007

4. Sandoval JA, Furlan AD, Mailis-Gagnon A. Oral methadone for chronic noncancer pain: a systematic literature review of reasons for administration, prescription patterns, effectiveness, and side effects. Clin J Pain. 2005;21:503-12.

5. Drossman DA, Toner BB, Whitehead WE, Diamant NE, Dalton CB, Duncan S et al. Cognitive-Behavioral Therapy vs. education and Desipramine vs. Placebo for Moderate to Severe Functional Bowel Disorders. Gastroenterol. 2003;125:19-31.

6. Jackson JL, O’Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressants: A meta-analysis. Am J Med. 2000;108:65-72.

7. Thiwan SM, Drossman DA. Treatment of functional GI disorders with psychotropic medicines: A review of evidence with a practical approach. Gastroenterology & Hepatology. 2006;2:678-88.

8. Maizels M, McCarberg B. Antidepressants and antiepileptic drugs for chronic non-cancer pain. Am Fam Physician. 2005;71:483-90.

9. Brannan SK, Mallinckrodt CH, Brown EB, Wohlreich MM, Watkin JG, Schatzberg AF. Duloxetine 60 mg once-daily in the treatment of painful physical symptoms in patients with major depressive disorder. J Psychiatr Res. 2005;39:43-53.

10. Gossop M. Clonidine and the treatment of the opiate withdrawal syndrome. Drug Alcohol Depend. 1988;21:253-59.

11. O’Connor P, Carroll KM, Shi JM, Schottenfeld RS, Kosten TR, Rounsaville BJ. Three methods of opioid detoxification in a primary care setting. Ann Intern Med. 1997;127:526-30.

12. Seiler R, Rickenbacher A, Shaw S, Balsiger BM. alpha- and beta-adrenergic receptor mechanisms in spontaneous contractile activity of rat ileal longitudinal smooth muscle. J Gastrointest Surg. 2005;9:227-35.

13. Camilleri M, Kim DY, McKinzie S, Kim HJ, Thomforde G, Burton D et al. A randomized, controlled exploratory study of clonidine in diarrhea-predominant irritable bowel syndrome. Clinical Gastroenterology and Hepatology. 2003;1:111-21.

14. Viramontes, B., Malcolm, A., Szarka, L., McKinzie, S., Burton, D., Kost, L., Zinsmeister, A., and Camilleri, M. Dose-related effects of α2-adrenergic agent, clonidine, on human gastrointestinal motor, transit and sensory functions. Gastroenterology 118, A666. 2000. Ref Type: Abstract.

Table 1. Diagnostic Criteria for Narcotic Bowel Syndrome (1)

Chronic or frequently recurring abdominal pain that is treated with acute high dose or chronic narcotics and all of the following:

• The pain worsens or incompletely resolves with continued or escalating dosages of narcotics. • There is marked worsening of pain when the narcotic dose wanes and improvement when narcotics are reinstituted (“Soar and Crash”).

• There is a progression of the frequency, duration and intensity of pain episodes.• The nature and intensity of the pain is not explainedby a current or previous gastrointestinal diagnosis*

*A patient may have a structural diagnosis (e.g., inflammato-ry bowel disease, “chronic pancreatitis”) but the character or activity of the disease process is not sufficient to explain the pain.

Physician-Patient Relationship1. Accept the pain as reala. Provide information through dialog with the patientb.

The physiological basis for the paini. The effects of narcotics on pain and GI function ii.

Discuss the rationale for withdrawal c. Present the withdrawal program d. Elicit the patient’s concerns and expectations e. Gauge the patient’s willingness to undergo the programf. Discuss the treatment plan with a family memberg.

Specific Treatment Guidelines2. Narcotic withdrawal protocola. Concomitant medicationsb.

antidepressant (TCA or SNRI)i. benzodiazepineii. clonidineiii. laxativesiv. psychological treatmentv.

Additional Issues to Consider3. Patient “negotiates” to go back on narcoticsa. Patient rapidly tapers or abruptly withdraws narcoticsb. Patient seeks drugs elsewherec.

Table 2. Overview of Treatment of Narcotic Bowel Syndrome (1)





12

Noncardiac Chest Pain: A Growing Medical ProblemEditors: R. Fass, Guy D. EslickPublishers: Plural Publishing inc., San Diego, CA, 2007

Reviewed by: Roy C. Orlando, MDDivision of Gastroenterology and HepatologyUNC School of Medicine

Book Review

The preface by the editors to this slim (175 pages) but substantial volume makes the case for the impetus behind this work on noncardiac chest pain, which is that ‘noncardiac chest pain is a very common and debilitating condition’ and one that remains ‘poorly understood and heterogeneous...with numerous underlying potential mechanisms.’ A brief search supports, as the editors indicate, that this is the first book of its type. A perusal of the ‘Contents’ lists 14 chapters that -- as the book title implies -- attempts to cover noncardiac chest pain in the broadest of strokes ranging from its epidemiology, economics, quality of life and prognosis to its esophageal and nonesophageal causes. Yet the focus of the work is unmistakably and with some justification on noncardiac chest pain and the esophagus with six of the fourteen chapters -- (chapter 3) pathophysiology, (chapter 5) sensory testing, (chapter 7) diagnosis, (chapter 8) therapeutic trial, (chapter 9) brain imaging and (chapter 10) treatment -- exploring in depth this specific territory.

The aforementioned chapters accurately detail the limited and often conflicting literature on gastroesophageal reflux disease (GERD), esophageal motor disorders, and (esophageal) visceral hypersensitivity in the causation of noncardiac chest pain. Controversy is unavoidable even with respect to the prevalence of specific etiologies as the cause for noncardiac chest pain which varies among chapters and reports, and clearly depends upon such variables as: a) setting of the investigation (hospital, clinic, emergency room), b) nature of the participating physician’s practice (internist or specialist), and c) criteria used for concluding causation (e.g. for GERD – abnormal pH monitoring, abnormal endoscopy or responsiveness to proton pump inhibitors). Chapters on the pathophysiology, diagnosis and treatment (including the

Noncardiac Chest Pain: A Growing Medical Problem

results of therapeutic trials of a proton pump inhibitor) are clear and concise and aided by useful algorithms, and chapters on sensory testing and brain imaging nothing short of state-of-the-art reviews. Notable chapters on noncardiac chest pain focused on areas other than the esophagus include: a) an evaluation of chest pain from a cardiologist’s perspective (chapter 2) – which sets the stage for establishing chest pain as ‘noncardiac’; b) noncardiac, nonesophageal causes of chest pain (chapter 4) – which elaborates on the differential diagnosis of noncardiac chest pain with thought and precision; and c) psychological disorders and noncardiac chest pain (chapter 6) – which details the role of panic attacks as a cause of noncardiac chest pain. All are valuable additions and broaden the appeal of this volume.

Among other strengths of the volume are the novelty of the topic, quality of the authors, focused nature of the discussions, and judicious use of tables and black and white figures. Weaknesses include some avoidable redundancy of information and unevenness of voice – though the latter is difficult to avoid in multi-authored texts – and the omission of an emerging role for esophageal histopathology in the diagnosis of nonerosive reflux disease (dilated intercellular spaces in squamous epithelium) and eosinophilic esophagitis (eosinophils infiltrating squamous epithelium in large numbers) as causation for noncardiac chest pain. Overall this slim volume provides the interested reader with an appreciation for the complexity of noncardiac chest pain and a firm basis for understanding current clinical and investigative approaches to the problem. Therefore, the readership that will find this work most valuable include the gastroenterologist (academic and clinician) and other healthcare professionals who typically encounter patients with noncardiac chest pain in their practices.





13

International Foundation for Functional Gastrointestinal DisordersProviding Support for 15 Years

Fall 2007 updateNancy NortonPresident

IFFGD is currently working on many different fronts. We continue our advocacy efforts in Washington DC and plan to hold another Hill Day in the spring of 2008. If you are interested in participating in this effort to improve Congressional awareness of the needs in our field, please contact Nancy Norton at 414-964-1799. As many of you are aware, adequate NIH funding for functional GI research continues to be a challenge. Our past efforts to increase funding have made a positive difference. We need to continue to work with legislators to not only increase the NIDDK budget but also to increase the portfolio for functional GI disorders.

The National Commission on Digestive Diseases (NCDD) will be holding a meeting in Chicago on November 19, 2007 that is open to the public. It is our hope that the report that is developed from the commission addresses the unmet needs of patients as well as a way forward for both clinical and basic research.

IFFGD and the University of North Carolina at Chapel Hill are currently conducting an online survey, “IBS Patient Survey: Unmet Needs.” With in-depth questions about symptoms, quality of life, and attitudes about treatment options, the survey promises to shed new light on the unseen impact of IBS. Patients can find a link to the survey at www.iffgd.org.

IFFGD is also working with the Rome Foundation to conduct several focus groups aimed at a better understanding the personal impact of irritable bowel syndrome. Douglas Drossman, MD and Lin Chang, MD will moderate several focus groups of persons with IBS. The focus groups will take place in Milwaukee, WI on October 27, 2007. Patients interested in participating can contact IFFGD by calling toll-free at 888-964-2001 or going to our website at www.aboutIBS.org.

Mark your calendars for the 9th annual GERD Awareness Week, November 18–24, 2007. IFFGD will once again provide educational messages about GERD to the print media. At this time and throughout the year, patients can call our toll-free heartburn helpline at 888-964-2001 for information and support, or log on to our website at www.aboutGERD.org.

On December 10–12, 2007 the NIH is hosting a State-of-the-Science Conference: Prevention of Fecal and Urinary Incontinence in Adults. This meeting has been a long time coming and both Dr. Bill Whitehead and Nancy Norton have been instrumental in advocating for the conference. We are hopeful that the outcome of this meeting will bring greater awareness to the conditions, in addition to having a direct impact on reducing barriers to treatment and increasing the funding for research directed at fecal and urinary incontinence.

We are in the planning stages for the 8th International Symposium on Functional Gastrointestinal Disorders to be held April 17–April 19, 2009. The excellent response to our past symposia has demonstrated the interest in and importance of continuing this meeting. We appreciate the continuing support of FBG for this meeting while at the same time recognizing the creation of the Joint Meeting of the four professional societies. The IFFGD meeting maintains a structure and audience that is multidisciplinary and somewhat unique. We hope you will, once again, have April 17-19, 2009 saved on your calendars to attend.

Please remember IFFGD has a library of patient educational materials you can distribute to patients. The entire library of over 190 publications is now available online with free access to all IFFGD Professional Members. Visit our Online Learning Center at www.iffgd.org.

For those of you who have been telling us over the years we need to be on “Oprah,” we are pleased to let you know that Nancy Norton was interviewed by Dr. Oz on Oprah’s radio program discussing fecal incontinence. We are creating awareness and moving forward making a difference for so many people.

Thank you again for your continued support as we work to help change lives for the better and celebrate our 16th year of developing a community of support.

Nancy J. NortonPresident and Founder, IFFGD

IFFGD Fall 2007 Update





14 Cross-cultural Column

Clinical PsychologistIRCCS De Bellis HospitalBari, Italy

This is the third column from the FBG Cross-Cultural Committee, following Hong Kong and Mexico. Dr. Piero Porcelli, a clinical psychologist who is on the faculty at a gastro-intestinal tertiary institution in Bari, Italy, provided the following data, guided by Charles and Mary-Joan Gerson, co-chairs of the committee, who edit this column. Dr. Porcelli gave questionnaires to 20 IBS patients and 30 healthy individuals on the administrative staff at his hospital, yielding the following observations.

Background information about iBS in italy

There are no reliable data on the epidemiology of IBS in Italy. A survey was performed in 2001 by the Italian association of general practitioners on 3500 patients (1731 males, 1769 females) referred to 49 GPs in 3 Italian regions. The prevalence of IBS was 8.1% according to the clinical opinions of the GPs, 7.7% according to the Manning criteria, and 5.4% according to the Rome II criteria. The GP diagnoses overlapped with Manning criteria at 47% and with the Rome II criteria at 62%. The male-to-female ratio was 1 to 2. Severity of symptoms was mild in 9.5% of patients, moderate in 66.6%, and severe in 24%. The survey suggested the prevalence of IBS was lower in Italy compared to the US and other Western countries. However, further studies are needed to ascertain if this difference is real or due to methodological flaws of this survey.

The survey

Beliefs about the cause of IBS

Psychological distress and diet were considered to be the main causes of IBS by both healthy controls and IBS patients. 47% of controls and 35% of patients thought that psychological stress was the main cause of IBS, while 33% of controls and 40% of patients attributed symptoms to diet. Genetic inheritance was cited by 10% of patients and 3% of controls.

Responsibility for IBS

The difference between patients and controls was striking. Whereas patients felt that responsibility for their symptoms lay with family members (50%) or doctors who do not understand them (30%), controls felt that patients were personally responsible for their IBS (87%).

Family variables: It is a strong popular belief in Italy (at least in southern Italy where I live and work) that somatic discomfort and illness are caused by interpersonal distress, mainly due to family and emotional relationships. Family is highly valued in Italian culture not only as a place of safety and acceptance but also as a place of personal identity, so that problems in family relationships and communication can be experienced (at a conscious as well as unconscious level) as a sort of decrease in personal strength, a part of the self that is damaged by the conflicts with relatives. Interestingly, while patients did not feel personally responsible for their illness, 30% saw it as a sign of personal weakness.

Physician–patient relationship: Until the 1970s, the general practitioner in Italy was a true family physician who took care of all of the health problems of his patients, physical as well as psychological, with a caring attitude that today we may label as “holistic” and highly empathetic. Today, as everywhere in Western countries, GPs are busy and more educated towards a “technological” and non-empathetic attitude that can be synthesized as “give me your data from lab tests and instrumental exams and I will tell you what you have and how to cure it”. This attitude is of course more pronounced in specialist settings, as in my tertiary care hospital. This might have caused the fact that 30% of patients who were interviewed complained that their symptoms are due to physicians who do not understand their health problems.

The nature of IBS

Here also, there was a marked difference between patients and controls. All non-patients thought IBS is a psychosomatic disorder. By contrast, 65% of patients thought that it was an organic problem while only 35% thought that it was psychosomatic. Thus, while the patients thought psychological issues and diet were responsible for their illness, the experience of having symptoms may have led them to believe they had an organic disease.

Social acceptance of IBS

77% of healthy subjects felt that IBS was socially acceptable. By contrast, patients considered IBS to be socially embarrassing (65%) and they were reluctant to talk about it.

Piero Porcelli, Ph.D.





15Cross-cultural Column

Family history

Most people, in both the non-patient (60%) and the patient (83%) groups, stated that members of their families had IBS-like symptoms, thus suggesting that this syndrome is common in Italy.Main conclusions

Subjects with IBS and healthy subjects have different • representations of the syndrome.

Healthy subjects think IBS is a common (more frequent in • women) psychosomatic condition caused by psychological distress and/or bad eating, and that the causes should be found within the mind or the personality of the individual.

Patients with IBS think it is a true disease, common but • hidden because of social embarrassment, and more frequent in women. They also think the main responsibility for their symptoms is connected to the quality of their family and personal relationships, and the attitudes and understanding of their treating physicians.

Editorial comment by Charles and Mary-Joan Gerson

The most striking observation is the difference between healthy individuals and IBS patients. Patients seem to attribute their symptoms to quality of family relationships, previously shown to affect IBS symptom severity, and to non-empathetic physicians. It would appear that physicians are not providing adequate explanation and empathy to their IBS patients. This may contribute to the false idea that the patients have an organic disease. It would be interesting to study whether lack of empathy results in more catastrophizing in patients

In a recent international eight country survey of IBS patients, Italian subjects had the highest pain score (1). In a study of IBD patients in Europe, Italy and Portugal, representing southern Europe, had the highest scores for overall concern regarding their illness (2). In view of the above observations by Dr. Porcelli, it is possible that pain is a way for patients to reach out for support from family members as well as physicians. On the other hand, pain may result from heightened awareness of physical discomfort as a result of being misunderstood by others. Once again, this column illustrates that cultural phenomena in a particular geographic area may affect the illness experience of an IBS patient.

References

Gerson CD, Gerson M-J, Awad RA, Chowdhury A, Dancey 1. C, Poitras P, Porcelli P, Sperber A, Wang W-A. Irritable bowel syndrome: an international study of symptoms in eight countries. In press, European J Gastro and Hepatology, 2007.

Levenstein S, Li Z, Almer S, Barbosa A, Marquis P, Moser G, 2. Sperber A, Toner B, Drossman DA. Cross-cultural variation in disease-related concerns among patients with inflammatory bowel disease. Amer J Gastro 96: 1822-30, 2001.





16 FBG Awards Committee

The FBG Awards Committee has announced the recipients of this year’s awards:

International Travel Dr. Xiaojun Yang

Young Investigators Dr. Charlie Murray Dr. Elena F. Verdu

Research Scientist Dr. Jyoti N. Sengupta

Rona Levy, MSW, PhD, MPHChair, FBG Awards Committee

The following paragraphs were provided by the award winners

International Travel Award

Xiaojun Yang, MDTongji Medical CollegeHuazhong University of Science and TechnologyHubei, China

I am a PhD student of Tongji Medical College, Huazhong University of Science and Technology. Now, my study is focusing on clinical and basic aspects of functional gastrointestinal diseases. Through an investigation of the neurogastroenterology mechanism of post-infection irritable bowel syndrome, my study results indicate that synaptic plasticity may play an important role in visceral hyper-sensitivity of PI-IBS. Although the pathophysiology mechanism of FGID’s is very complex, I think the interrelation between CNS and ENS would be one of the most important. In the two projects granted by National Natural Science Foundation of China, I will continue to concentrate my attention on the role of immunology and neurogastroenterology in FGID’s.

Young Investigator Award

Charlie Murray, MD, PhDConsultant and Senior Lecturer in Gastroenterology, Royal Free Hospital, London

Charlie Murray undertook his initial medical studies at Cambridge University in 1990, later qualifying with distinction from the Uni-versity of London in 1996. His training continued on the London gastroenterology and internal medicine specialist scheme, becom-ing a Member of the Royal College of Physicians in 1999 and ac-crediting in both specialities in 2007. Between 2001 and 2005, he undertook his initial research period at St. Mark’s Hospital, con-centrating on both basic and clinical science, leading to the award of a PhD in 2006 from Imperial College London. While a research fellow at St. Mark’s, Dr. Murray developed his specialist interest in neurogastroenterology, and a specific interest in the physiology of the upper gut and the role of brain-gut peptides. His other main ongoing research is in the field of visceral hypersensitivity. Future research interests include establishing human pharmacodynamic models of visceral pain and undertaking work assessing the ef-fects of different pharmacological manipulations on these models. He is also interested in the physiological changes and brain-gut interactions associated with bariatric surgery and the potential to harness these changes in the pharmacological modulation of obesity. Dr Murray has recently been appointed Consultant and Senior Lecturer in Gastroenterology at the Royal Free Hospital in London.

The FBG Awards





17

Young Investigator Award

Elena F Verdu, MD, PhDAssistant ProfessorDepartment of MedicineMcMaster UniversityHamilton, Canada

Dr. Verdu graduated from medical school at the University of Bue-nos Aires, Argentina, in 1988. After completing a residency in In-ternal Medicine, Dr. Verdu enrolled at the University of Lausanne, Switzerland, to pursue post-graduate studies under the supervi-sion of Prof. Andre Blum involving the interaction between Helico-bacter pylori infection and anti-secretory therapy. Her work result-ed in various publications in international peer-reviewed journals and an MD thesis degree in physiology awarded by the University of Lausanne. She successfully obtained a fellowship from UNES-CO to pursue a PhD degree in Immunology at the Department of Microbiology and Gnotobiology at the Czech Academy of Science, directed by Prof. Helena Tlaskalova. Upon completion of her PhD studies, Dr. Verdu obtained a post-doctoral fellowship from the Ca-nadian Association of Gastroenterology. During her post-doctoral fellowship at the Intestinal Disease Research Program (IDRP) at McMaster University, Canada, under the supervision of Prof. Ste-phen Collins, Dr. Verdu gained experience with animal models of functional gastrointestinal disorders. Her work resulted in the iden-tification of specific probiotic strains with potential for the treatment of irritable bowel syndrome. Her current research interests center around the pathogenesis of chronic inflammatory and functional gut disorders. In July 2007, she was appointed assistant professor at the IDRP, McMaster University, where she is currently investi-gating the role of altered immune responses to dietary antigens in the generation of gut dysfunction. An important area of her re-search relates to gut-brain interactions, in particular in the context of probiotic bacteria. She is funded by the Canadian Association of Gastroenterology Fellow-to-Faculty award, the New Investigator’s award CAG/CIHR, and the Canadian Celiac Association.

Research Scientist Award

Jyoti N. SenguptaPhD Division of Gastroenterology Medical College of Wisconsin

Dr. Jyoti N. Sengupta is currently Associate Professor of Medicine at the Medical College of Wisconsin. He graduated with a major in physiology at the University of Calcutta College of Science and Technology, India. He received formal exposure to the area of neu-rophysiology when he was doing his postgraduate coursework. Af-ter completing his Masters degree, he joined the laboratory of Dr. Juthika Koley in the Department of Physiology at the University of Calcutta to obtain his PhD degree. In 1985, he went to Ohio State University as a post-doctoral fellow to work with Prof. Popat N. Patil in the College of Pharmacy. After two years of training, Dr. Sengupta moved to Boston to work with Dr. Raj K. Goyal at Beth Israel Hospital/Harvard Medical School to pursue his inter-est in gastrointestinal neurophysiology and motility. While working in Beth Israel Hospital, his interest shifted to the study of visceral sensation and pain. In 1991, he joined the Department of Pharma-cology at the University of Iowa to further his training in the area of visceral pain and collaborate with Dr. Gerald F. Gebhart. He spent seven years in Dr. Gebharts laboratory exploring the role of primary sensory neurons in visceral pain. During this time, he published several papers, review articles and book chapters and was awarded na NIH grant. It was also during this time that he was exposed to the rewards associated with fostering young investiga-tors to succeed in the field of academic medicine. Dr. Sengupta’s laboratory is involved with training several clinical scientist and post-doctoral fellows. Currently, multiple projects are being con-ducted in his laboratory, investigating the neurophysiological basis of chronic abdominal pain. In the last few years, his laboratory has developed several animal models of visceral pain. By using electrophysiological techniques, his laboratory is studying the role of primary sensory afferents, spinal dorsal horn neurons, and the brainstem in the transmission and regulation of visceral pain. In 2004, Dr. Sengupta received a Senior Basic Scientist award from the International Foundation of Functional Gastrointestinal Dis-orders (IFFGD), and in 2007 he received 10th Annual Research Scientist Award from Functional Brain-Gut Research Group. His

FBG Awards Committee





18 Announcements

Mark Fox MD MA MRCPClinic for Gastroenterology and Hepatology,University Hospital of Zürich

Preparations are well advanced for the 2nd Joint Meeting of the European, International and American Neurogastroenterology and Motility Societies, together with the Functional Brain-Gut Research Group. Scientists and clinicians from around the world will be gathering in the beautiful medieval city of Lucerne, to review the tremendous progress being made in our understanding of neurogastroenterology, motility and functional gas-trointestinal disease. The scientific program is exciting and comprehensive, and stand-out lectures include ‘The Stress Response and GI Function, ‘New Advances in Clinical Measurement’, and the ‘Regulation of Feed-ing and Body Weight’. Each session aims to highlight the exchange of ideas ‘from bench to bedside and back again’, bringing new ideas from young investigators in the field and invited speak-ers from related fields of inquiry. The meeting will also provide workshops -- ranging from ‘What Happens to Children with FGID’ to ‘Neural Plasticity and Repair’ and updates from the Rome Committees -- in which topics can be considered in detail and discussed with the experts with fresh insight into the causes of GI symptoms and dysfunction and their treatment. The meeting will take place at the lakeside conference center in Lucerne, a beautiful city in the center of Switzerland less than one hour from the international hub of Zürich Airport and the Alps. An exciting social program has been organized for attendees and their partners (this is one location which should not be missed). The conference is within walking distance of hotels and the heart of the cultural, entertainment and shopping centers of the city, so that conversations begun at the meeting can continue into the evening. We look forward to meeting you there!

Young Investigator Activities at the Joint International Meeting A meeting dedicated to young investigators in the field of Neurogas-troenterology and Motility will bring together promising basic and clinical scientists with established experts in the field. Personal links will be established through the social program and professional con-tact through the discussions and career advice that forms the basis of the seminar. Encourage your junior faculty to apply! All young investigators that submit an abstract to the Neurogastroenterology and Motility meeting will have the option to apply. A number of travel grants are available. The meeting will have an even balance

between clinical and basic scientists at every level and representa-tion from every continent.

On the evening of Wednesday 5th November there will be a re-ception and dinner party by the Lake of Lucerne. The after dinner talk on ‘Work-Life Balance’ by Oswald Oelz, Professor of Medicine and Climber of the Seven Summits, is an important topic for any young researcher who wants to be productive and successful, but also to remain sane. The meeting on Thursday morning will begin with personal stories describing how established scientists entered academia, discovered their research interests, and overcame

hurdles to establish their career. This serves as an introduction to the ‘professional advice’ later in the program, by providing practical examples of problem and conflict solving. This will be followed by a talks on ‘Why choose an academic career?’ by Rick Locke and ‘How to get published’ by Robin Spiller, the editor of Gut. The second ses-sion will divide experts and at-tendees into four groups based on geographic regions, because grant applications and career building is very different in Eu-rope, America and Asia. Within each group, basic and clinical scientists will be available to answer questions and discuss how to move forwards in their chosen careers.

Further information and the link to upload abstracts (from 15. Feb 2008) can be found on our website http://www.ngm2008.com/

Joint International Meeting for Neurogastroenterology & Motility:Lucerne Switzerland, Nov. 6-9, 2008

Important Dates: 15 February 2008 – Opening of abstract submission20 June 2008 – Closing of abstract submission16 July 2008 – Early registration deadline26 July 2008 – Notification acceptance / rejection of abstracts6 - 9 November 2008 – NGM 2008





19Announcements

Satish SC Rao, MD, PhD, FRCP (Lon)

The American Neurogastroenterology and Motility Society (ANMS) Clinical Training Program for Fellows in Gastrointestinal Motility and Neurogastroenterology is beginning it’s second term. This program offers a one-month training for GI fellows to learn the various GI motility procedures used to evaluate patients at a GI motility center of excellence and will provide a platform for better understanding of GI motility disorders and treatment of patients.

For further information and application material, visit the AMS website at www.motilitysociety.org or email the AMS at [email protected]

The First European Hands-on Course in Gastrointestinal Function Testing will be held in Munich, Germany March 12th to 14th, 2008, directed by Paul Enck, with Joerg Schirra responsible for the local organisation. It will combine high-class lectures from world-leading experts with life demonstrations from the motility laboratory, and

News from the European Society of Neurogastroenterology and Motility

Paul Enck,PhDUniversitat Tubingen, Germany

First European Hands-on Course in Gastrointestinal Function Testing

The ten centers participating are:

Cedars-Sinai Medical Center: Jeff Conklin and • Mark Pimentel

Medical College of Wisconsin: Benson Massey (Adult), • Manu Sood, Colin Rudolph (Pediatric) Northwestern University: Peter Kahrilas and Michael Jones • Ohio State University/Columbus Children’s Hospital: •

Hayat Mousa and Carlo DiLorenzo (Pediatrics) Temple University: Henry Parkman and Robert Fisher • University of Iowa: Satish Rao and Robert Summers • University of Kansas: Richard McCallum (Adult) and •

Paul Hyman (Pediatric)University of Michigan: Bill Chey and Bill Hasler• University of North Carolina at Chapel Hill: •

Doug Drossman and Bill Whitehead

American Neurogastroenterology and Motility Society Clinical Training Program for Fellows in Gastrointestinal Motility and Neurogastroenterology

the possibility to see and learn motility recordings in the laboratory (“hands-on”) with support from the experts and the respective indus-try. Seats will be limited to a maximum of 250. Registration will be opened November 1st, 2007 at www.neurogastroenterology.eu.





20

The 21st ISNM symposium was held September 2-5, 2007 at the Shilla Jeju Hotel, Jeju Island, South Korea. The symposium was a huge success, with 400 physicians from 29 countries attending. From the opening ceremony/reception to the excellent programs /talks, to the Gala dinner, experiencing the Korean traditional mu-sic, dancing while enjoying Korean cuisine, networking with new and old friends, the symposium was a wonderful experience. At the awards ceremony, FBG councilor Lesley Houghton was pre-sented a certificate for her poster presentation.

Drs. Locke, Kim

Deb with new member Dr. Amen Ali of Sudan, representing a new country for FBG.

FBG Supports the 21st International Symposium of Neurogastroenterology and Motility (ISNM)

With FBG’s new interactions with the ISNM, ESNM and AMS, FBG wanted to show support for the ISNM symposium by having a booth, further recognizing FBG as an international organization. The interactions with attending physicians lead to many new mem-bers and friends for the FBG, further spreading the word of FBG’s mission. It was decided at this meeting that the ISNM would host the 2011 Joint International Neurogastroenterology and Motility Meeting in Australia.

Lesley Houghton Dr. Kim,presenting her certificate.





21

At the Big Brain Little Brain meeting

Opening ceremony reception

Group Photo

At the Gala Dinner





22 Announcements

We have completed our headquarters move to Milwaukee. Our new Program Director, Judy Babiasz, has moved into the posi-tion with a flare and has been handling a variety of programs. Please contact her freely with questions, comments, updates. Our usual scientific focus has suffered in the transition but that is turn-ing around. Our Scientific Policy Committee has a new structure which will include policy for receiving funding requests for pilot studies. We also hope to be able to distribute a request for propos-als before too long.

There is recurring talk of our long overdue 3rd International Scien-tific Symposium on CVS. This is much on our minds since we all recognize the need for bringing together our next interdisciplinary set of experts to present and then collaborate on investigations about CVS. Drs. Fleisher and Li continue on the international speaking circuit about CVS. I’m guessing that there are others out there doing the same. Please let me know about your work in that realm.

CVSA Board of Directors set as one of its goals for 2007 to begin a formal process of educating Emergency Room physicians and para-professionals about Cyclic Vomiting Syndrome. A multidisci-plinary team led by B Li, M.D. is writing a grant for a pilot project in Wisconsin. Also under the leadership of Dr. Li, the manuscript “The North American Society for Pediatric Gastroenterology, He-patology and Nutrition Diagnosis and Management of Cyclic Vom-iting Syndrome – A Technical Report” has been submitted for pub-lication to the Journal of Pediatr Gastroenterol & Nutr. Needless to say, this is one of the most important landmark accomplishments for CVS patients and their caregivers.

Another landmark manuscript has been submitted for publication to Neurogastroenterology and Motility by CVSA advisor Henry Parkman, MD – Temple University Hospital [editor]. This paper re-sulted from 2 scientific meetings on CVS in adults. CVS is now being diagnosed more commonly in adults and there is high need to meet the call for more informed and effective care. Under the direction of Thangam Venkatesan, MD, the Program for CVS in Adults at the Medical College of Wisconsin is now fully functioning and accepting patients.

Joint US-Isreal Meeting on IBSFebruary 7-8, 2008Dan Panorama Hotel, Tel-Aviv

Ami Sperber, MD Soroka Medical Center Beer-Sheva, Israel

A binational meeting on IBS and other FGIDs, under the joint aus-pices of the American Gastroenterological Association (AGA) and the Israel Gastroenterological Association (IGA), will take place in Tel-Aviv, Israel on Feb. 7-8, 2008. The meeting is being planned and organized by Drs. Ami Sperber (IGA) and Douglas Drossman (AGA). The purpose of the meeting is to help clinicians, research-ers, and health care providers to become up-to-date on IBS and the other functional gastrointestinal disorders, and to meet col-leagues with similar interests. Researchers can submit abstracts of their work for presentation at the meeting.

The meeting will feature a faculty of eight internationally-recog-nized experts from the United States who, together with Israeli leaders in the field, will speak on pathophysiology, epidemiology, diagnosis, treatment, clinical tips, and future research directions.

The meeting should interest gastroenterologists and trainees in gastroenterology. In addition, the broad scope of presentations will also appeal to family physicians, gynecologists, surgeons; pain specialists; and also investigators in epidemiology, cross-cultural studies, women’s health and complementary and alternative medi-cine.

Details on the scientific program, faculty, venue, accommodations, abstract submission, and registration for the meeting can be found at the following website http://www.reg.co.il/ibs/.

Cyclic Vomiting Syndrome AssociationKathleen Adams, BSN, RNPresident & Research Liaison Cyclic Vomiting Syndrome AssociationElm Grove, WI





23Special Report

Romania is, to our knowledge, the sole Central-Eastern European country having its own society of neurogastroenterology. Of course, the possibilities for uncovering innovative scientific findings are limited in this area, but members of the society are very active at national and international meetings. A session on neurogastroenterology was present in the last 4-5 years in every national yearly meeting of the Romanian Society of Gastroenterology. Emphasis is put on the dissemination of information and increasing the awareness of physicians about functional GI disorders. In a local survey, Romanian GPs showed very good knowledge of the Rome criteria, superior to data collected from other countries.

Recently in Cluj, we held the 2nd International Symposium of Neurogastroenterology in Romania. As in the first meeting (2005 in Brasov), this meeting aimed to put together specialists from Eastern

Europe with leaders of opinion from the USA and Western Europe. The symposium opened with a state of the art lecture from Prof. Drossman, Chapel Hill, on the functional GI disorders and the Rome III criteria. This lecture had a great impact on the audience, which included attendees from Romania, Moldova, Bulgaria, Croatia etc. as well as international students from several other countries. There were two full days of lectures given by outstanding scientists, such as Paul Enck, Piero Portincasa, Radu Tutuian, Juergen Barnert and many others, including regional and local speakers and few young investigators, represented a consistent program to update attendees on the problems of neurogastroenterology. The last day was dedicated to a trip for those who remained in Cluj. The echo of this meeting was very positive, giving to the organizer, Dan Dumitrascu, the incentive to organize a third symposium in the future.

2nd International Symposium of Neurogastroenterology of the Romanian Society of NeurogastroenterologyOctober 4–7, 2007

Dan Dumitrascu, MD

Speakers in the picture from left to right:Dorin Farcau, Cluj, Romania; Corina Dima-Cosma, Iasi, Romania; Piero Portincasa, Bari, Italy; Vasile Drug, Iasi, Romania; Dan Dumitrascu, Cluj, Romania; Adrian Goldis, Timisoara, Romania; Douglas Drossman, Chapel Hill, USA; Juergen Barnert, Augsburg Germany; Gabriella Garruti, Bari, Italy; Zachary Krastev, Sofia, Bulgaria; Paul Porr, Sibiu, Romania; Nikolai Lazarov, Sofia, Bulgaria; Andreas Schneider, Mannheim, Germany; Gunta Ancane, Riga, Latvia; Valentina Tzaneva, Stara Zagora, Bulgaria.





24 Rome Foundation

Rome CD Slide Sets

The Rome Foundation has launched a project to produce a set of slide sets on the functional GI disorders to be used for self-learning and presentation. It is based on the work of the Rome III book and is being updated with the latest information from the scientific literature since publication of the book.

The work is being accomplished by an internationally recognized panel of clinicians and investigators, many of whom were involved with the Rome III book. The project began in early 2006 with a series of conference calls, followed by a meeting in May 2006 of the entire group during Digestive Disease Week (DDW 2006) in Los Angeles, CA. At that time, 30 individuals working in 6 committees received an orientation to the expectations and standards of the project and began working to identify content areas. Special attention was given during this meeting to the exercise of developing and refining one or two slides.

During the remainder of 2006, the committees met periodically by phone conferences to continue the identification of appropriate material and to modify and improve the visual presentation of this content. In January 2007, all committees met for 3 days in the Bahamas to further revise the slide set via feedback from all committee members. An additional meeting was held during DDW in May 2007. At that time, each committee came to agreement on the content and number of slides necessary for their subject, and then presented and defended their work for review by all committees. At this time, the text material is being completed and the slides will be sent out for external review by the end of the year.

The total number of slides from all committees is approximately 700. In addition to PowerPoint slides, a number of animations and videos are being finalized. This will add significant appeal and value to the final product, which will be available for purchase by download from the website or on CD as MS PowerPoint files by DDW 2008. Please check the Rome Foundation website www.theromefoundation.org for updates on the release date.

Rome Foundation Slide Set Project Project Administration

Douglas A. Drossman MD (Editor), Jerry Schoendorf (Medical Illustrator), Carlar Blackman (Project Coordinator)

Modules & Team MembersBasic/physiology/pharmacokinetics -- Jackie Wood (Chair), 1. Lionel Bueno, John KellowPsychosocial/sociocultural/quality of life, brain imaging -- 2. Ami D. Sperber (Chair), Elspeth Guthrie, Rona Levy, Bruce Naliboff, Kevin OldenEpidemiology -- Paul Moayyedi (Chair), George Longstreth, 3. Nicholas J. TalleyDiagnosis and Criteria -- Arnold Wald, (Chair), Brooks Cash, 4. Enrico Corazziari, Tony Lembo, Stuart Spechler, Jan TackPediatric -- Carlo DiLorenzo, (Chair), Marc Benninga, 5. Ernesto Guiraldes, Jeffrey Hyams, Paul HymanManagement and Design of Treatment Trials -- Bill Chey, 6. (Chair), Lin Chang, E. Jan Irvine, Max Schmulson, W. Grant Thompson

Rome iii Lay/Consumer Book

W. Grant Thompson MD, a member of the Rome Foundation Board, recently completed writing an interpretation of the book Rome III: The Functional Gastrointestinal Disorders. This “trade” book will serve the lay public, including patients, primary care physicians and health care extenders. The book discusses the concept of functional gastrointestinal disorders, epidemiology, rationale for using symptom-based diagnostic criteria, and the unpredictable pattern of illness that people with these disorders experience. The book also reviews the importance of the physi-cian/patient relationship, current and proposed management and treatment options, and the evidence for these treatments. Written in easily understood language, the book will be a valuable contri-bution to the field, helping patients and people who care for them to better understand and cope with their symptoms. The book begins with “A Doctor’s View” by Douglas Drossman, MD and “A Patient’s View” by Nancy Norton, President and Founder of the International Foundation of Functional Gastrointestinal Disorders, to set the stage for the chapters to come. There are over 30 illus-trations and 17 chapters as well as a glossary. There are several appendices, including the Rome III diagnostic criteria for FGIDs and explanations of common tests performed for diagnosis. The planned publication date is spring 2008. For ordering informa-tion when the book is available, whether individual or bulk orders, email your contact information to [email protected] with “Rome III lay book” in the subject line, or check the website at www.theromefoundation.org.

The new Rome Foundation’s AGA lectureship series

The Rome Foundation is sponsoring a new lectureship at the American Gastroenterological Association (AGA) to be held an-nually at Digestive Diseases Week (DDW). This lectureship will address broad aspects of health care that is relevant to diges-tive diseases and the functional GI disorders. The first lecture will be on Tuesday, May 20, 2008, 10:30am to noon, Room 6A at the 2008 DDW meeting in San Diego, California. The inaugural speaker will be New York Times science award-winning writer and author Gina Kolata. Ms. Kolata has reported on broad environ-mental and medical topics including breast cancer and silicone im-plants, experimental AIDS drugs, abuse, obesity, diet and health, the relationship of environment and cancer, and cloning. She has an undergraduate degree in microbiology, a master’s degree in applied mathematics, and studied molecular biology at Massachu-setts Institute of Technology (MIT). She previously worked as a writer for Science. The topic of her lecture will focus on how the breakdown in communication between physicians and patients can affect making the correct diagnosis.





25Rome Foundation





26

Nominating Committee Report George Longstreth, Chair

FBG has received a fourth DDW abstract descriptor (anorectal disorders). Abstract Review Committee members for 2008 are:

Functional Gi Disorders: Psychosocial and Psychotherapeutic Jeffrey Lackner (Chair), Laurie Keefer, Magnus Simren, Peter Whorwell

Functional Gi Disorders: Epidemiology and Symptoms Richard Locke (Chair), Lars Agreus, David Armstrong, Douglas Drossman

Pharmacotherapeutics of Functional and Motility Gi Disorders Jay Pasricha (Chair), Tony Lembo, Martin Storr, Kirsten Tillisch

Fecal incontinence, Pelvic Floor Disorders and other Anorectal Functional and Motility Disorders William Whitehead (Chair), Satish Rattan, John Hutson, Jose Maria Remes Troche

FBG News

FBG proposals selected to be presented as symposia by NGM at DDW 2008

Three proposals were selected:

Emerging role of genetics in functional gastrointestinal 1. disorders (Bill Whitehead)Narcotic Bowel Syndrome (Doug Drossman)2. Emerging topics in functional esophageal disorders 3. (Ronnie Fass)

This is a great success for FBG!

Sincerely,

Lin Chang, MD Chair of Program Development

Rick Locke, MD President

Muhammad Nabeel Ghayur, MD Hamilton, Ontario, CA

Clive H Wilder-Smith, MD Bern, Switzerland

Amin Ali, MD Khartoum, Sudan *

Hiroshi Kaneko, MD, PhDNagoya, Japan

Osama El Bialy, MRCS, MSCCairo, Egypt *

Gerard Victor, MD Toulouse, France

Jun Zhang,PhD Xiian, China

Jeremy Hetzel, AB Chicago, IL

Shang Zhanmin, MDBeijing, China

Jorge Gonzales Boston, MA

Myung-Gyu Choi, MDSeoul, Korea

Josephine Pangilinan, MDBethesda, MD

Yuqiang Nie,China

Venkatachala Mohan, MDBellevue, WA

Hassan Borghei, MDBrooklyn, NY

Sheila ThierefelderMilwaukee, WI

Jose Velasquez, MDCaracas, Venezuela

Ajay Kaul, MDCincinnati, OH

Kadakkal Radhakrishnan, MDCleveland, OH

Kelly Miller, MDPittsburgh PA

Chelsa Wozniak, MDSavannah, GA

John Northup JR, MDSavannah, GA

Alan Kleven, MDDuluth, GA

New Members

*A new country for FBG





27Cartoon Corner

“We’re going to beat this thing apart.”

We would like to thank our corporate sponsors:

Novartis Pharmaceuticals•Takeda Pharmaceuticals•Proctor & Gamble Pharmaceuticals•SmartPill Pharmaceuticals•Axcan Pharmaceuticals•

Corporate Sponsors

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