In clinical trials, lubiprostone reduced the severity of abdominal pain.
The primary aim was to determine whether lubiprostone raises the threshold for abdominal pain induced by intraluminal balloon distention. A secondary aim was to determine whether changes in pain sensitivity influence clinical pain independently of changes in transit time.
Sixty-two patients with irritable bowel syndrome with constipation (IBS-C) participated in an 8-week crossover study. All subjects completed a 14-day baseline ending with a barostat test of pain and urge sensory thresholds. Half, randomly selected, then received 48 ug/day of lubiprostone for 14 days ending with a pain sensitivity test and a Sitzmark test of transit time. This was followed by a 14-day washout and then a crossover to 14 days of placebo with tests of pain sensitivity and transit time. The other half of the subjects received placebo before lubiprostone. All kept symptom diaries.
Stools were significantly softer when taking lubiprostone compared to placebo (Bristol Stool scores 4.20 vs. 3.44, p<0.001). However, thresholds for pain (17.36 vs. 17.83 mmHg, lubiprostone vs. placebo) and urgency to defecate (14.14 vs. 14.53 mmHg) were not affected by lubiprostone. Transit time was not significantly different between lubiprostone and placebo (51.27 vs. 51.81 hours), and neither pain sensitivity nor transit time was a significant predictor of clinical pain.
Lubiprostone has no effect on visceral sensory thresholds. The reductions in clinical pain that occur while taking lubiprostone appear to be secondary to changes in stool consistency.
AIM: To survey irritable bowel syndrome (IBS) using Rome III criteria among Malays from the north-eastern region of Peninsular Malaysia.
METHODS: A previously validated Malay language Rome III IBS diagnostic questionnaire was used in the current study. A prospective sample of 232 Malay subjects (80% power) was initially screened. Using a stratified random sampling strategy, a total of 221 Malay subjects (112 subjects in a “full time job” and 109 subjects in “no full time job”) were recruited. Subjects were visitors (friends and relatives) within the hospital compound and were representative of the local community. Red flags and psychosocial alarm symptoms were also assessed in the current study using previously translated and validated questionnaires. Subjects with IBS were sub-typed into constipation-predominant, diarrhea-predominant, mixed type and un-subtyped. Univariable and multivariable analyses were used to test for association between socioeconomic factors and presence of red flags and psychosocial alarm features among the Malays with IBS.
RESULTS: IBS was present in 10.9% (24/221), red flags in 22.2% (49/221) and psychosocial alarm features in 9.0% (20/221). Red flags were more commonly reported in subjects with IBS (83.3%) than psychosocial alarm features (20.8%, P < 0.001). Subjects with IBS were older (mean age 41.4 years vs 36.9 years, P = 0.08), but no difference in gender was noted (P = 0.4). Using univariable analysis, IBS was significantly associated with a tertiary education, high individual income above RM1000, married status, ex-smoker and the presence of red flags (all P < 0.05). In multiple logistic regression analysis, only the presence of red flags was significantly associated with IBS (odds ratio: 0.02, 95%CI: 0.004-0.1, P < 0.001). The commonest IBS sub-type was mixed type (58.3%), followed by constipation-predominant (20.8%), diarrhea-predominant (16.7%) and un-subtyped (4.2%). Four of 13 Malay females (30.8%) with IBS also had menstrual pain. Most subjects with IBS had at least one red flag (70.8%), 12.5% had two red flags and 16.7% with no red flags. The commonest red flag was a bowel habit change in subjects > 50 years old and this was reported by 16.7% of subjects with IBS.
CONCLUSION: Using the Rome III criteria, IBS was common among ethnic Malays from the north-eastern region of Peninsular Malaysia.
Irritable bowel syndrome; Malays; Prevalence; Rome III criteria; Malaysia
Adults who suffer from chronic pain are at increased risk for suicide ideation and attempts, but it is not clear whether adolescents with chronic pain are similarly at increased risk. This study investigates whether chronic pain is associated with an increase in suicidal ideation/attempts independent of depression in a population sample of adolescents.
We analyzed data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in the United States (N=9,970). Most chronic pain was related to suicide ideation/attempt both in the last year (OR’s 1.3–2.1) and during the subsequent year (OR’s 1.2–1.8). After controlling for depressive symptoms, headaches (OR=1.3 last year, OR=1.2 subsequent year) and muscle aches (OR=1.3 last year) remained associated with suicide ideation but not suicide attempt.
These findings show that chronic pain in adolescence is a risk factor for suicide ideation; this effect is partly but not fully explained by depression. Youth with co-morbid depression and chronic pain are at increased risk of thinking about and attempting suicide. Clinicians should be alert to suicide ideation/attempt and co-morbid depression in this at-risk population.
Pain; Suicide; Epidemiology; Adolescents
This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs: chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence available to guide their diagnosis and treatment. This situation appears to be changing: A recently published large randomized, controlled trial by our group comparing biofeedback, electrogalvanic stimulation, and massage for the treatment of chronic proctalgia has shown success rates of 85% for biofeedback when patients are selected based on physical examination evidence of tenderness in response to traction on the levator ani muscle-a physical sign suggestive of striated muscle tension. Excessive tension (spasm) in the striated muscles of the pelvic floor appears to be common to most of the pelvic pain syndromes. This suggests the possibility that similar approaches to diagnostic assessment and treatment may improve outcomes in other pelvic pain disorders.
Biofeedback; Chronic pelvic pain; Chronic proctalgia; Coccygodynia; Levator ani syndrome; Pudendal neuralgia
There is little consensus regarding the indications for surgical CSF diversion (either with implanted temporizing devices [reservoir or subgaleal shunt] or shunt alone) in preterm infants with posthemorrhagic hydrocephalus. The authors determined clinical and neuroimaging factors associated with the use of surgical CSF diversion among neonates with intraventricular hemorrhage (IVH), and describe variations in practice patterns across 4 large pediatric centers.
The use of implanted temporizing devices and conversion to permanent shunts was examined in a consecutive sample of 110 neonates surgically treated for IVH related to prematurity from the 4 clinical centers of the Hydrocephalus Clinical Research Network (HCRN). Clinical, neuroimaging, and so-called processes of care factors were analyzed.
Seventy-three (66%) of the patients underwent temporization procedures, including 50 ventricular reservoir and 23 subgaleal shunt placements. Center (p < 0.001), increasing ventricular size (p = 0.04), and bradycardia (p = 0.07) were associated with the use of an implanted temporizing device, whereas apnea, occipitofrontal circumference (OFC), and fontanel assessments were not. Implanted temporizing devices were converted to permanent shunts in 65 (89%) of the 73 neonates. Only a full fontanel (p < 0.001) and increased ventricular size (p = 0.002) were associated with conversion of the temporizing devices to permanent shunts, whereas center, OFCs, and clot characteristics were not.
Considerable center variability exists in neurosurgical approaches to temporization of IVH in prematurity within the HCRN; however, variation between centers is not seen with permanent shunting. Increasing ventricular size—rather than classic clinical findings such as increasing OFCs—represents the threshold for either temporization or shunting of CSF.
hydrocephalus; preterm infant; temporizing implant; intraventricular hemorrhage; cerebrospinal fluid shunt; Hydrocephalus Clinical Research Network
The aim was to determine whether lower visceral pain thresholds in irritable bowel syndrome (IBS) primarily reflect physiological or psychological factors.
Firstly, 121 IBS patients and 28 controls underwent balloon distensions in the descending colon using the ascending methods of limits (AML) to assess pain and urge thresholds. Secondly, sensory decision theory analysis was used to separate physiological from psychological components of perception: neurosensory sensitivity (p(A)) was measured by the ability to discriminate between 30 mm Hg vs 34 mm Hg distensions; psychological influences were measured by the report criterion—that is, the overall tendency to report pain, indexed by the median intensity rating for all distensions, independent of intensity. Psychological symptoms were assessed using the Brief Symptom Inventory (BSI).
IBS patients had lower AML pain thresholds (median: 28 mm Hg vs 40 mm Hg; p<0.001), but similar neurosensory sensitivity (median p(A): 0.5 vs 0.5; p = 0.69; 42.6% vs 42.9% were able to discriminate between the stimuli better than chance) and a greater tendency to report pain (median report criterion: 4.0 (“mild” pain) vs 5.2 (“weak” pain); p = 0.003). AML pain thresholds were not correlated with neurosensory sensitivity (r = −0.13; p = 0.14), but were strongly correlated with report criterion (r = 0.67; p<0.0001). Report criterion was inversely correlated with BSI somatisation (r = −0.26; p = 0.001) and BSI global score (r = −0.18; p = 0.035). Similar results were seen for the non‐painful sensation of urgency.
Increased colonic sensitivity in IBS is strongly influenced by a psychological tendency to report pain and urge rather than increased neurosensory sensitivity.
hypersensitivity; hypervigilance; perceptual response bias; irritable bowel syndrome
Aqueductal stenosis may be caused by a number of etiologies including congenital stenosis, tumor, inflammation, and, very rarely, vascular malformation. However, aqueductal stenosis caused by a developmental venous anomaly presenting as congenital hydrocephalus is even more rare, and, to the best of our knowledge, has not yet been reported in the literature. In this study, we review the literature and report the first case of congenital hydrocephalus associated with aqueductal stenosis from a developmental venous anomaly.
The patient is a three-day-old, African-American baby girl with a prenatal diagnosis of hydrocephalus. She presented with a full fontanelle, splayed sutures, and macrocephaly. Postnatal magnetic resonance imaging showed triventricular hydrocephalus, suggesting aqueductal stenosis. Examination of the T1-weighted sagittal magnetic resonance imaging enhanced with gadolinium revealed a developmental venous anomaly passing through the orifice of the aqueduct. We treated the patient with a ventriculoperitoneal shunt.
Ten cases of aqueductal stenosis due to venous lesions have been reported and, although these venous angiomas and developmental venous anomalies are usually considered congenital lesions, all 10 cases became symptomatic as older children and adults. Our case is the first in which aqueductal stenosis caused by a developmental venous anomaly presents as congenital hydrocephalus. We hope adding to the literature will improve understanding of this very uncommon cause of hydrocephalus and, therefore, will aid in treatment.
Although direct medical costs for constipation-related medical visits are thought to be high, to date there have been no studies examining if longitudinal resource utilization is persistently elevated in children with constipation. Our aim was to estimate the incremental direct medical costs and types of health care utilization associated with constipation from childhood to early adulthood.
A nested case-control study was conducted to evaluate the incremental costs associated with constipation. The original sample consisted of 5,718 children in a population-based birth cohort who were born during 1976–1982 in Rochester, MN. The cases included individuals who presented to medical facilities with constipation. The controls were matched and randomly selected among all non-cases in the sample. Direct medical costs for cases and controls were collected from the time subjects were between 5–18 years of age or until the subject emigrated from the community.
We identified 250 cases with a diagnosis of constipation in the birth cohort. While the mean inpatient costs for cases were $9994 (95% CI=2538, 37201) compared to $2391 (95% CI=923, 7452) for controls (p=0.22) over the time period, the mean outpatient costs for cases were $13927 (95% CI=11325, 16525) compared to $3448 (95% CI=3771, 4621) for controls (p<0.001) over the same time period. The mean annual number emergency department visits for cases were 0.66 (95% CI=0.62, 0.70) compared to 0.34 (95% CI=0.32, 0.35) for controls (p<0.0001).
Individuals with constipation have higher medical care utilization. Outpatient costs and ER utilization were significantly greater for individuals with constipation from childhood to early adulthood.
Childhood constipation; Direct medical costs; Case-control study
Functional gastrointestinal disorders are those in which no abnormal metabolic or physical processes, which can account for the symptoms, can be identified. The irritable bowel syndrome (IBS) is a significant functional disorder, which affects 10-20 percent of the population worldwide. Predominant symptoms of IBS are abnormal defecation associated with abdominal pain, both of which may be exacerbated by psychogenic stress. Our study was designed to test a hypothesis that symptoms in a subset of patients with a diagnosis of IBS are associated with an autoimmune degenerative neuropathy in the enteric nervous system.
Serum was collected from Rome II-IBS patients and controls at the University of North Carolina Functional Gastrointestinal Diseases Center. Assay procedures were immunohistochemical localization of antibody binding to enteric neurons and human protein microarray assay for antigens recognized by antibodies in the sera.
Eighty-seven percent of IBS sera and 59% of control sera contained anti-enteric neuronal antibodies. Antibody immunostaining was seen in the nucleus and cytoplasm of neurons in the enteric nervous system. Protein microarray analysis detected antibody reactivity for autoantigens in serum with anti-enteric neuronal antibodies and no reactivity for the same autoantigens in samples not containing anti-enteric neuronal antibodies in our immunostaining assay. Antibodies in sera from IBS patients recognized only 3 antigens out of an 8,000 immunoprotein array. The 3 antigens were: (1) a nondescript ribonucleoprotein (RNP-complex); (2) small nuclear ribonuclear polypeptide A; and (3) Ro-5,200 kDa.
Results of the present study suggest that symptoms in a subset of IBS patients might be a reflection of enteric neuronal damage or loss, caused by circulating anti-enteric autoimmune antibodies.
Autoimmune neuropathy; Enteric nervous system; Gastrointestinal disorders
Older participants are often excluded from clinical trials, precluding a representative sample.
Using qualitative and quantitative methods, we examined recruitment and retention of older women with pelvic organ prolapse in two surgical trials: the randomized Colpopexy And Urinary Reduction Efforts (CARE) study and the Longitudinal Pelvic Symptoms and Patient Satisfaction After Colpocleisis cohort study. Using focus groups, we developed a questionnaire addressing factors facilitating and impeding the recruitment and retention of older study participants and administered it to research staff. Enrollment-to-surgery ratios, missed visit rates, and dropout rates for older and younger participants were compared using Fisher’s exact test, with cut-points of 70 and 80 years for the CARE and Colpocleisis studies, respectively.
Questionnaires were completed by 23 physician investigators and 11 nurses or coordinators (92% response rate). Respondents indicated it was more difficult to recruit older research participants (32%), obtain informed consent (56%), and retain participants to study completion (50%). Challenges to recruitment included caregiver involvement in the decision to participate and participant comorbidities. Perceived barriers to retention were transportation, caregiver availability, and participant fatigue. Data quality was challenged by sensory and cognitive impairment, resulting in a change from telephone interviews to in-person visits in the Colpocleisis study. Older participants did not have higher dropout rates than younger participants. There were no differences in missed in-person visits or telephone interview rates between age groups.
Strategies, albeit unstudied, could assist investigators in planning surgical trials that successfully enroll and retain older women.
Hypnosis is a therapeutic technique that primarily involves attentive receptive concentration. Even though a small number of health professionals are trained in hypnosis and lingering myths and misconceptions associated with this method have hampered its widespread use to treat medical conditions, hypnotherapy has gained relevance as an effective treatment for irritable bowel syndrome not responsive to standard care. More recently, a few studies have addressed the potential influence of hypnosis on upper digestive function and disease. This paper reviews the efficacy of hypnosis in the modulation of upper digestive motor and secretory function. The present evidence of the effectiveness of hypnotherapy as a treatment for functional and organic diseases of the upper bowel is also summarized, coupled with a discussion of potential mechanisms of its therapeutic action.
Hypnosis; Hypnotherapy; Gastric emptying; Small bowel transit; Functional dyspepsia; Functional esophageal disorders; Functional bowel disorders
Quality improvement techniques are being implemented in many areas of medicine. In an effort to reduce the ventriculoperitoneal shunt infection rate, a standardized protocol was developed and implemented at 4 centers of the Hydrocephalus Clinical Research Network (HCRN).
The protocol was developed sequentially by HCRN members using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied at each HCRN center to all children undergoing a shunt insertion or revision procedure. Infections were defined on the basis of CSF, wound, or pseudocyst cultures; wound breakdown; abdominal pseudocyst; or positive blood cultures in the presence of a ventriculoatrial shunt. Procedures and infections were measured before and after protocol implementation.
Twenty-one surgeons at 4 centers performed 1571 procedures between June 1, 2007, and February 28, 2009. The minimum follow-up was 6 months. The Network infection rate decreased from 8.8% prior to the protocol to 5.7% while using the protocol (p = 0.0028, absolute risk reduction 3.15%, relative risk reduction 36%). Three of 4 centers lowered their infection rate. Shunt surgery after external ventricular drainage (with or without prior infection) had the highest infection rate. Overall protocol compliance was 74.5% and improved over the course of the observation period. Based on logistic regression analysis, the use of BioGlide catheters (odds ratio [OR] 1.91, 95% CI 1.19–3.05; p = 0.007) and the use of antiseptic cream by any members of the surgical team (instead of a formal surgical scrub by all members of the surgical team; OR 4.53, 95% CI 1.43–14.41; p = 0.01) were associated with an increased risk of infection.
The standardized protocol for shunt surgery significantly reduced shunt infection across the HCRN. Overall protocol compliance was good. The protocol has established a common baseline within the Network, which will facilitate assessment of new treatments. Identification of factors associated with infection will allow further protocol refinement in the future.
hydrocephalus; quality improvement; shunt; infection; standardized protocol
To assess the validity of the Protect Scale of the Adult Responses to Children’s Symptoms (ARCS) Questionnaire with regard to mothers’ responses to their children’s abdominal pain.
Mothers with High (n = 32) and Low (n = 35) Protect scores on the ARCS questionnaire were recruited from participants in a larger study of family illness behavior. Mothers completed a 28-day diary report of responses to their children’s abdominal pain episodes. Records of their children’s annual health service utilization and costs were obtained from their health maintenance organization (HMO).
Mothers’ scores on the ARCS Protect Scale were significantly correlated with their subsequent diary reports of protective responses to their children’s abdominal pain. Compared to children of mothers in the Low Protect group, children of mothers in the High Protect group made significantly more health care visits for gastrointestinal symptoms and had significantly higher health care costs.
Results supported the validity of the Protect Scale of the ARCS and demonstrated that mothers’ protective responses to children’s abdominal pain complaints at home predicted subsequent health service use for gastrointestinal symptoms.
The solid variant of aneurysmal bone cyst is rare, and only 13 cases involving the spine have been reported to date, including seven in the thoracic vertebrae. The diagnosis is difficult to secure radiographically before biopsy or surgery.
An 18-year-old Hispanic man presented to our facility with a one-year history of left chest pain without any significant neurological deficits. An MRI scan demonstrated a 6 cm diameter enhancing multi-cystic mass centered at the T6 vertebral body with involvement of the left proximal sixth rib and extension into the pleural cavity; the spinal cord was severely compressed with evidence of abnormal T2 signal changes. Our patient was taken to the operating room for a total spondylectomy of T6 with resection of the left sixth rib from a single-stage posterior-only approach. The vertebral column was reconstructed in a 360° manner with an expandable titanium cage and pedicle screw fixation. Histologically, the resected specimen showed predominant solid fibroblastic proliferation, with minor foci of reactive osteoid formation, an area of osteoclastic-like giant cells, and cyst-like areas filled with erythrocytes and focal hemorrhage, consistent with a predominantly solid variant of aneurysmal bone cyst. At 16 months after surgery, our patient remains neurologically intact with resolution of his chest and back pain.
Because of its rarity, location, and radical treatment approach, we considered this case worthy of reporting. The solid variant of aneurysmal bone cyst is difficult to diagnose radiologically before biopsy or surgery, and we hope to remind other physicians that it should be included in the differential diagnosis of any lytic expansile destructive lesion of the spine.
Determine the impact of fecal incontinence (FI) in health care providers’ decisions to refer patients for nursing home (NH) placement.
Survey of members of the American Geriatrics Society (AGS).
The survey presented a clinical scenario of a 70-year-old woman ready for discharge from a hospital and asked their likelihood of making a NH referral if the patient had (a) no incontinence, (b) urinary incontinence (UI) alone, or (c) FI. Subsequent questions modified the clinical situation to include other conditions that might affect the decision to refer. A second survey of respondents to Survey 1 addressed possible moderators of the decision to refer (e.g., family caregiver presence, diarrhea or constipation, other physical or psychiatric limitations). Significance of differences in the relative risk (RR) for NH referral was tested by Chi square.
716 members (24.7% response rate) completed the first survey and 686 of 716 (96%) completed the second. The likelihood of NH referral was increased by FI (RR=4.71, p<0.001) more than UI (RR=1.90, p<0.001). Mobility restrictions, cognitive decline, and multiple chronic illnesses increased the likelihood of NH referral more than FI alone (p<0.001 for each), but in all scenarios, adding FI further increased the likelihood of referral (p<0.001). Having family caregivers willing to help with toileting attenuated the likelihood of referral.
FI increases the probability that geriatricians will refer to a NH. More aggressive outpatient treatment of FI could possibly delay or prevent NH referral, improve quality of life, and reduce healthcare costs.
Fecal Incontinence; Nursing Home referral; Hospital discharge; Physician survey; Caregiver; Urinary incontinence
Background & Aims
Levator ani syndrome (LAS) might be treated using biofeedback to teach pelvic floor relaxation, electrogalvanic stimulation (EGS), or massage of levator muscles. We performed a prospective, randomized controlled trial to compare the effectiveness of these techniques and assess physiological mechanisms for treatment.
Inclusion criteria were Rome II symptoms plus weekly pain. Patients were categorized as “highly likely” to have LAS if they reported tenderness with traction on the levator muscles, or as “possible” LAS if they did not. All 157 patients received 9 sessions including psychological counseling plus biofeedback, EGS, or massage. Outcomes were reassessed at 1, 3, 6, and 12 months.
Among patients with “highly likely” LAS, adequate relief was reported by 87% for biofeedback, 45% for EGS, and 22% for massage. Pain days per month decreased from 14.7 at baseline to 3.3 after biofeedback, 8.9 after EGS, and 13.3 after massage. Pain intensity decreased from 6.8 (0–10 scale) at baseline to 1.8 after biofeedback, 4.7 after EGS, and 6.0 after massage. Improvements were maintained for 12 months. Patients with only a “possible” diagnosis of LAS did not benefit from any treatment. Biofeedback and EGS improved LAS by increasing the ability to relax pelvic floor muscles and evacuate a water-filled balloon, and by reducing the urge and pain thresholds.
Biofeedback is the most effective of these treatments, and EGS is somewhat effective. Only patients with tenderness on rectal examination benefit. The pathophysiology of LAS is similar to that of dyssynergic defecation.
Proctalgia; Biofeedback; Electrogalvanic stimulation; Dyssynergic defecation
This study investigated whether catastrophic thinking about pain by children with functional abdominal pain or by their parents is associated with health outcomes in the child. Subjects were 132 parent-child dyads. Child catastrophizing predicted child depression, anxiety and functional disability. Parents’ catastrophizing cognitions about their own pain predicted self-reported protective responses to their children’s abdominal pain (responding in ways that encourage illness behavior). Protectiveness, in turn, predicted child functional disability. All findings held despite controlling for child age, gender, and symptom severity. These results suggest that catastrophic cognitions play an important role in how children and parents cope and respond to functional abdominal pain, and may have implications for assessment and treatment in the clinical setting.
Catastrophizing; Abdominal pain; Children; Illness behavior; Functional disability
There is debate about how best to measure patient reported outcomes (PROs) in irritable bowel syndrome (IBS). We pooled data from clinical trials to measure the psychometric properties of IBS endpoints, including binary responses (e.g. “adequate relief”) and 50% improvement in symptom severity.
We pooled patient-level data from 12 IBS drug trials involving 10,066 participants. We tested the properties of binary response and 50% improvement endpoints, including the impact of baseline severity on performance, and measured construct validity using clinical anchors. We calculated confidence intervals for the psychometric parameters of each endpoint, and compared estimates side-by-side between PROs.
There were 9044 evaluable subjects (age=44; 85% F; 58% IBS-C; 31% IBS-D). Using the binary endpoint, the proportion responding in the mild, moderate, and severe groups was 42%, 40%, and 38%, respectively (p=0.0008). There was no effect of baseline severity on binary response (OR=0.99; CI=0.99–1.0; p=0.07). The proportions reaching 50% improvement in pain were 45%, 41%, and 41% respectively; there was a small, yet significant, impact of baseline severity (OR=1.04; CI=1.03–1.05; p<0.0001) that did not meet criteria for clinical relevance. Both endpoints revealed strong construct validity, and detected “minimally clinically important differences” (0.5 SD) in bowel symptoms. Both endpoints provided better discriminant spread in IBS-D than IBS-C subgroups.
Both the traditional binary and 50% improvement endpoints are equivalent in their psychometric properties. Neither is impacted by baseline severity, and both demonstrate excellent construct validity. They are optimized for the IBS-D population, but also appear valid in IBS-C.
Irritable Bowel Syndrome; Endpoints; Outcomes; Meta-analysis; Psychometrics
The aims of this secondary analysis of the “Colpopexy And Urinary Reduction Efforts” (CARE) study were to estimate the incidence of post-operative gastrointestinal complications and identify risk factors.
We prospectively identified gastrointestinal complications and serious adverse events (SAE) for 12 months after sacrocolpopexy. Two surgeons independently reviewed reports of ileus or small bowel obstruction (SBO).
Eighteen percent of 322 women (average age 61.3 years) reported “nausea, emesis, bloating, or ileus” during hospitalization and 9.8% at 6 weeks. Nineteen women (5.9%; CI 3.8%, 9.1%) had a possible ileus or SBO that generated SAE reports: four (1.2%, CI 0.5%,3.2%) were re-operated for SBO, 11 (3.4%, CI 1.9%,6.1%) were readmitted for medical management, and four had a prolonged initial hospitalization. Older age (p<0.001) was a risk factor for ileus or SBO.
One in twenty women experiences significant gastrointestinal morbidity after sacrocolpopexy. This information will aid pre-operative counseling.
Ileus; Small bowel obstruction; Nausea; Sacrocolpopexy
Background & Aims
The study aims were to estimate the prevalence of different types and frequencies of fecal incontinence (FI), describe demographic factors, and identify risk factors.
The National Health and Nutrition Examination Survey (NHANES) assesses health status in the civilian non-institutionalized U.S. population. The validated Fecal Incontinence Severity Index was added to NHANES in 2005-2006. Participants were 2,229 women and 2,079 men aged 20 or older. FI was defined as accidental leakage of solid, liquid or mucus at least once in the preceding month. Sampling weights were used to obtain prevalence estimates for the national population. Multivariate logistic regression identified independent risk factors.
The estimated prevalence of FI in non-institutionalized U.S. adults is 8.3% (CI 7.1, 9.5) and consists of liquid stool in 6.2%, solid stool in 1.6%, and mucus in 3.1%. It occurs at least weekly in 2.7%. Prevalence is similar in women (8.9%) and men (7.7%), and increases with age from 2.6% in 20-29 year-olds up to 15.3% in participants aged 70 and over. FI is not significantly associated with race/ethnicity, education, income, or marital status after adjusting for age. Independent risk factors in women are advancing age, loose or watery stools, more than 21 stools per week, multiple chronic illnesses, and urinary incontinence. Independent risk factors in men are age, loose or watery stools, poor self-rated health, and urinary incontinence.
FI is a prevalent, age-related disorder. Chronic diarrhea is a strong modifiable risk factor which may form the basis for prevention and treatment.
Introduction and hypothesis
Our objective was to evaluate bowel symptoms after colpocleisis.
This was a planned ancillary analysis of a prospective, colpocleisis cohort study of 152 women. Those with baseline and 1-year questionnaires (Colorectal-Anal Distress Inventory (CRADI) and the Colorectal-Anal Impact Questionnaire (CRAIQ)) were included. “Bothersome” CRADI symptoms (score>2(“moderately”, “quite a bit”)) were identified. CRADI and CRAIQ scores were compared, and postoperative symptom resolution and new symptom development were measured.
Of 121 (80%) subjects with complete data, mean age was 79.2±5.4 years and all had stage 3–4 prolapse. Procedures performed: partial colpocleisis (61%), total colpocleisis (39%), levator myorrhaphy (71%), and perineorrhaphy (97%). Bothersome bowel symptom(s) were present in 77% at baseline (obstructive (17–26%), incontinence (12–35%) and pain/irritation (3–34%)). All bothersome obstructive and most bothersome incontinence symptoms were less prevalent 1 year after surgery. CRADI and CRAIQ scores significantly improved. The majority of bothersome symptoms resolved (50–100%) with low rates of de novo symptoms (0–14%).
Most bothersome bowel symptoms resolve after colpocleisis, especially obstructive and incontinence symptoms, with low rates of de novo symptoms.
Bothersome; Bowel symptoms; Colpocleisis; CRADI; Obstructive prolapse
The purpose of this study was to define the incidence of permanent shunt placement and infection in patients who have undergone the 2 most commonly performed temporizing procedures for posthemorrhagic hydrocephalus (PHH) of prematurity: ventriculosubgaleal (VSG) shunt placement and ventricular reservoir placement for intermittent tapping.
The 4 centers of the Hydrocephalus Clinical Research Network participated in a retrospective chart review of infants with PHH who underwent treatment at each institution between 2001 and 2006. Patients were included if they had received a diagnosis of Grade 3 or 4 intraventricular hemorrhage, weighed < 1500 g at birth, and had received surgical intervention. The authors determined the incidence of conversion from a temporizing device to a permanent shunt, the incidence of CSF infection during temporization, and the 6-month CSF infection rate after permanent shunt placement.
Thirty-one (86%) of 36 patients who received VSG shunts and 61 (69%) of 88 patients who received ventricular reservoirs received permanent CSF diversion with a shunt (p = 0.05). Five patients (14%) in the VSG shunt group had CSF infections during temporization, compared with 11 patients (13%) in the ventricular reservoir group (p = 0.83). The 6-month incidence of permanent shunt infection in the VSG shunt group was 16% (5 of 31), compared with 12% (7 of 61) in the reservoir placement group (p = 0.65). For the first 6 months after permanent shunt placement, infants with no preceding temporizing procedure had an infection rate of 5% (1 of 20 infants) and those who had undergone a temporizing procedure had an infection rate of 13% (12 of 92; p = 0.45).
The use of intermittent tapping of ventricular reservoirs in this population appears to lead to a lower incidence of permanent shunt placement than the use of VSG shunts. The incidence of infection during temporization and for the initial 6 months after conversion appears comparable for both groups. The apparent difference identified in this pilot study requires confirmation in a more rigorous study.
hydrocephalus; premature birth; intraventricular hemorrhage
Patients with functional gastrointestinal (GI) disorders treated with tricyclic antidepressants may report non-GI symptoms. It is unclear whether these symptoms are side effects of the medication or reflect a general behavioral tendency to report symptoms. This study 1) evaluated whether a checklist of symptoms reported by patients prior to taking desipramine increased in number or worsened in severity after being on a tricyclic antidepressant (desipramine), and 2) assessed baseline factors that predispose patients to report symptoms.
Female patients in the drug arm of a multi-center NIH treatment trial for functional bowel disorders completed a 15 item symptom questionnaire at baseline before randomization and at 2 weeks after starting Desipramine (n=81), or placebo (n=40) and at study completion 12 weeks later. Patients were asked on each occasion if they experienced any of 15 Symptoms and its level of severity and frequency, and the results were compared.
A total of 57 patients in the desipramine arm who completed the questionnaire at both week 0 and week 2 comprised the study sample. Certain symptoms reported as side effects: dizziness, dry mouth/thirstiness, lightheadedness, feeling jittery or tremors and flushing not only were reported more often but also worsened at week 2 indicating a drug effect. Conversely, other symptoms that were also reported as side effects: feeling tired in AM, nausea, blurred vision, headaches, decreased appetite, and trouble sleeping either did not change in severity or showed improvement at week 2 (tiredness). All these symptoms except trouble sleeping were reported less often at Week 2 than at baseline (Week 2). Psychological distress but not desipramine level significantly correlated with symptom reporting.
The majority of symptoms often attributed to side effects of desipramine were present prior to treatment, and only a few related to its anticholinergic effects worsened 2 weeks after beginning treatment, suggesting that most symptoms considered as side effects were not related to drug per se. Clinicians should consider that “Side effects” may relate more to psychological distress than to drug effects.
Solicitous parental responses to stomach aches may perpetuate chronic abdominal pain in children. Discussing these issues in clinical practice is difficult as parents feel misunderstood and blamed for their child’s pain. Focusing on parental worries and beliefs that motivate solicitous responses may be better accepted.
Our aim was to determine parental fears, worries and beliefs about their child’s chronic abdominal pain that influence parental responses to child’s pain.
In two studies, a large online sample and a smaller community sample consisting of parents with children who suffer from abdominal pain, we developed and evaluated a self-report questionnaire to assess parental Worries and Beliefs about Abdominal Pain (WAP).
Principal component analysis identified four subscales: (1) Pain-is-Real; (2) Desire for Care; (3) Worry about Coping; and (4) Exacerbating Factors. The WAP is easily understood and possesses adequate initial reliability (Cronbach alphas of .7–.9) and shows good initial validity (i.e., families who consulted a physician for their child’s pain scored higher on the WAP than families who did not consult a physician and the WAP correlates with parental reactions to the child’s pain).
Discussing parents’ fears and worries about their children’s chronic abdominal pain may facilitate discussions of social learning of gastrointestinal illness behavior.