Long-term efficacy of biofeedback therapy for dyssynergic defecation: randomized controlled trial.

OBJECTIVES: Although biofeedback therapy is effective in the short-term management of dyssynergic defecation, its long-term efficacy is unknown. Our aim was to compare the 1-year outcome of biofeedback (manometric-assisted pelvic relaxation and simulated defecation training) with standard therapy (diet, exercise, laxatives) in patients who completed 3 months of either therapy. METHODS: Stool diaries, visual analog scales (VASs), colonic transit, anorectal manometry, and balloon expulsion time were assessed at baseline, and at 1 year after each treatment. All subjects were seen at 3-month intervals and received reinforcement. Primary outcome measure (intention-to-treat analysis) was a change in the number of complete spontaneous bowel movements (CSBMs) per week. Secondary outcome measures included bowel symptoms, changes in dyssynergia, and anorectal function. RESULTS: Of 44 eligible patients with dyssynergic defecation, 26 agreed to participate in the long-term study. All 13 subjects who received biofeedback, and 7 of 13 who received standard therapy, completed 1 year; 6 failed standard therapy. The number of CSBMs per week increased significantly (P<0.001) in the biofeedback group but not in the standard group. Dyssynergia pattern normalized (P<0.001), balloon expulsion time improved (P=0.0009), defecation index increased (P<0.001), and colonic transit time normalized (P=0.01) only in the biofeedback group. CONCLUSIONS: Biofeedback therapy provided sustained improvement of bowel symptoms and anorectal function in constipated subjects with dyssynergic defecation, whereas standard therapy was largely ineffective.

Effects of spatial transformation on regional brain volume estimates.

Spatial transformation of MR brain images is a standard tool used in automated anatomical parcellation and other quantitative and qualitative methods to assess brain tissue volume, composition, and distribution. Despite widespread use, the quantitative effects of spatial transformation on regional brain volume estimates have been little studied. We report on the effects of transformation on regional brain volumes of 38 (17M, 21F) manually parcellated brains. After tracing in native space, regions of interest were transformed using a classic piecewise-linear Talairach transformation (Tal) or a nonlinear registration (AIR 5th order nonlinear algorithm, 158 parameters) to one of three Talairach-based templates: 1) Tal50, constructed from 50 Talairach-transformed normal brains, 2) the MNI 305 atlas, 3) IA38, constructed from MNI305-transformed scans of the 38 subjects used in this study. Native volumes were compared to the transformed volumes. We found that: 1) significant group-level differences can be obtained in transformed data sets that are in the opposite direction of effects obtained in native space; 2) the effects of transformation are heterogeneous across brain regions, even after covarying for total brain volume and age; 3) volumetric intra-class correlations between native and transformed brains differ by registration method and template choice, region, and tissue type; and 4) transformed brains produced hippocampus and corpus callosum volume proportions that were significantly different from those obtained in native space. Our results suggest that region-based volumetric differences uncovered by spatial-transformation-based methods should be replicated in native-space brains, and that meta-analyses should take into account whether volumes are determined using spatially-transformed images and/or specific automated methods.

Psychological profiles and quality of life differ between patients with dyssynergia and those with slow transit constipation.

BACKGROUND: Pathophysiological characteristics differ between slow transit constipation (STC) and dyssynergic defecation, but whether psychological profiles and quality of life (QOL) are altered and whether they differ among these constipation subtypes are unknown. METHODS: We prospectively evaluated psychological profiles and QOL in 76 patients with dyssynergia, 38 patients with STC, and 44 control subjects using the Revised 90-item Symptom Checklist and 36-item Short-Form Health Survey. In addition, we examined the correlations of psychological and QOL domains with constipation symptoms and pathophysiological subtypes. RESULTS: Symptom scores for hostility and paranoid ideation were higher (P<.001) in patients with dyssynergic defecation than in patients with STC and control subjects. Scores for other psychological domains were higher (P<.0001) in patients with dyssynergic defecation and those with STC than in control subjects. Most QOL subscores were impaired (P<.05) in patients with dyssynergic defecation and some were impaired in patients with STC as compared with control subjects, but the two patient groups did not differ on these. The QOL subscores were strongly correlated (r(c) approximately .9) with the psychological subscores in patients with dyssynergic defecation and those with STC, although more QOL subscores among patients with dyssynergic defecation and more psychological subscores among patients with STC primarily contributed to the canonical correlations. A set of six commonly reported constipation symptoms showed significant correlations with QOL and psychological subscores, more so among patients with STC than among patients with dyssynergic defecation. CONCLUSIONS: Patients with dyssynergic defecation had greater psychological distress and impaired health-related QOL as compared with patients with STC and control subjects. Both patient groups were also more affected as compared with the control group. There was a strong correlation between psychological dysfunction and impaired QOL, and both also correlated with constipation symptoms.

Normal neuroanatomical variation due to age: the major lobes and a parcellation of the temporal region.

We used high-resolution MRI to investigate gray and white matter aging in the major lobes of the cerebrum (frontal, parietal, temporal, occipital) and the major sectors of the temporal lobe (temporal pole, superior temporal gyrus, infero-temporal region, parahippocampal gyrus, amygdala, hippocampus). Subjects included 87 adults between the ages of 22 and 88 years. Regions of interest were hand-traced on contiguous 1.5mm coronal slices. For the cerebrum in general, gray matter decreased linearly with age, resulting in a decline of about 9.1-9.8% between the ages of 30 and 70 years, and a decline of 11.3-12.3% by the age of 80. In contrast, white matter volume increased until the mid-50s, after which it declined at an accelerated rate. At 70 years, white matter volume was only 5.6-6.4% less than at 30 years, but by age 80, a cubic regression model predicted that the decrease would be 21.6-25.0%. Multivariate analyses indicate that the frontal gray matter was most strongly associated with age, while occipital gray and white matter were least associated. Reduction in volume in the hippocampus was best modeled by a cubic regression model rather than a linear model. No sex differences in aging were found for any regions of interest.