Adolescents with irritable bowel syndrome report increased eating-associated symptoms, changes in dietary composition, and altered eating behaviors: a pilot comparison study to healthy adolescents.

BACKGROUND: About half of adult irritable bowel syndrome (IBS) patients report symptoms with eating and disordered eating habits. However, little is known about eating in adolescent IBS patients, a common age at which eating disorders develop. The aim of the study was to investigate if adolescents with IBS are more likely than healthy controls (HCs) to experience eating-associated symptoms (EAS), report disordered eating patterns, and show differences in diet composition. METHODS: A total of 99 adolescents between 15 and 21 years-of-age participated (n = 48 IBS; n = 51 HCs). All subjects completed three 24-h dietary recalls and questionnaires on EAS and disordered eating. KEY RESULTS: IBS patients were more likely to report EASs than HC (91.7% vs 28%, p < 0.001). Eating-associated symptoms were controlled by avoiding the offending food (97.7%), not eating any food even when hungry (43.2%), or vomiting after eating (13.6%). Compared to HC, IBS patients reported reduced daily intake of overall calories (1828 vs 2139; p < 0.05), fat (65.4 g vs 81.4 g, p < 0.05), and lactose (8.2 g vs 12.8 g, p < 0.01). No differences were found between IBS and HC in screening for disordered eating patterns or BMI, though IBS patients endorsed using potentially unhealthy eating behaviors in an attempt to control symptoms. CONCLUSIONS & INFERENCES: Eating-associated symptoms are very common in adolescents with IBS and associated with changes in eating behaviors and dietary composition. They do not appear to change BMI and risk for eating disorders. More research is needed to guide adolescents with IBS in making appropriate dietary changes to control EASs.

Efficacy and safety of infliximab plus naproxen versus naproxen alone in patients with early, active axial spondyloarthritis: results from the double-blind, placebo-controlled INFAST study, Part 1.

OBJECTIVES: To assess whether combination therapy with infliximab (IFX) plus nonsteroidal anti-inflammatory drugs (NSAIDs) is superior to NSAID monotherapy for reaching Assessment of SpondyloArthritis international Society (ASAS) partial remission in patients with early, active axial spondyloarthritis (SpA) who were naïve to NSAIDs or received a submaximal dose of NSAIDs. METHODS: Patients were randomised (2 : 1 ratio) to receive naproxen (NPX) 1000 mg daily plus either IFX 5 mg/kg or placebo (PBO) at weeks 0, 2, 6, 12, 18 and 24. The primary efficacy measure was the percentage of patients who met ASAS partial remission criteria at week 28. Several other measures of disease activity, clinical symptoms and patient-rated outcomes were evaluated. Treatment group differences were analysed with Fisher exact tests or analysis of covariance. RESULTS: A greater percentage of patients achieved ASAS partial remission in the IFX+NPX group (61.9%; 65/105) than in the PBO+NPX group (35.3%; 18/51) at week 28 (p=0.002) and at all other visits (p<0.05, all comparisons). Results of most other disease activity and patient-reported endpoints (including Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, multiple quality of life measures and pain measures) showed greater improvement in the IFX+NPX group than the PBO+NPX group, with several measures demonstrating early and consistent improvement over 28 weeks of treatment. CONCLUSIONS: Patients with early, active axial SpA who received IFX+NPX combination treatment were twice as likely to achieve clinical remission as patients who received NPX alone. NPX alone led to clinical remission in a third of patients.

Maintenance of biologic-free remission with naproxen or no treatment in patients with early, active axial spondyloarthritis: results from a 6-month, randomised, open-label follow-up study, INFAST Part 2.

OBJECTIVE: To investigate whether biologic-free remission can be achieved in patients with early, active axial spondyloarthritis (SpA) who were in partial remission after 28 weeks of infliximab (IFX)+naproxen (NPX) or placebo (PBO)+NPX treatment and whether treatment with NPX was superior to no treatment to maintain disease control. METHOD: Infliximab as First-Line Therapy in Patients with Early Active Axial Spondyloarthritis Trial (INFAST) Part 1 was a double-blind, randomised, controlled trial in biologic-naïve patients with early, active, moderate-to-severe axial SpA treated with either IFX 5 mg/kg+NPX 1000 mg/d or PBO+NPX 1000 mg/d for 28 weeks. Patients achieving Assessment of SpondyloArthritis international Society (ASAS) partial remission at week 28 continued to Part 2 and were randomised (1:1) to NPX or no treatment until week 52. Treatment group differences in ASAS partial remission and other efficacy variables were assessed through week 52 with Fisher exact tests. RESULTS: At week 52, similar percentages of patients in the NPX group (47.5%, 19/40) and the no-treatment group (40.0%, 16/40) maintained partial remission, p=0.65. Median duration of partial remission was 23 weeks in the NPX group and 12.6 weeks in the no-treatment group (p=0.38). Mean Bath Ankylosing Spondylitis Disease Activity Index scores were low at week 28, the start of follow-up treatment (NPX, 0.7; no treatment, 0.6), and remained low at week 52 (NPX, 1.2; no treatment, 1.7). CONCLUSIONS: In axial SpA patients who reached partial remission after treatment with either IFX+NPX or NPX alone, disease activity remained low, and about half of patients remained in remission during 6 months in which NPX was continued or all treatments were stopped.

Longitudinal direct medical costs associated with constipation in women.

BACKGROUND: Although direct medical costs for constipation-related medical visits are thought to be high, to date, there have been no studies examining longitudinal resource utilisation in adults with constipation. AIM: To estimate the incremental direct medical costs associated with constipation in women. METHODS: This is a nested case-control study. The study population consisted of all mothers of 5718 children in the population-based birth cohort born during 1976-1982 in a community. The cases presented to the medical facilities with constipation. The controls were randomly selected and matched to cases in a 2:1 ratio. Direct medical costs for constipated women and controls were collected for the years 1987-2002. RESULTS: We identified 168 women with a diagnosis of constipation. The total direct medical costs over the 15-year period for constipated subjects were more than double those of controls [$63 591 (95% CI: 49 786-81 396) vs. $24 529 (95% CI: 20 667-29 260)]. The overall out-patient costs for constipated women were $38 897 (95% CI: 31 381-48 253) compared to $15 110 (95% CI: 12 904-17 781) for controls. The median of annual out-patient visits for constipated women was 0.16 compared to 0.11 for controls. CONCLUSION: Women with constipation have significantly higher medical care utilisation and expenditures compared with women without constipation.

The clinical approach to chronic abdominal pain and irritable bowel syndrome in children.

Chronic recurrent abdominal pain is a common complaint evaluated by pediatricians, and a cause of concern for children and parents. Population and school based studies have reported that approximately 8% of children experience chronic abdominal pain. About half of these children will contact a physician about their pain. These children report reduced quality of life and interferences with school and play due to their pain. The large majority of children will not have a readily identified cause for their symptoms, and chronic abdominal pain is frequently classified as a functional gastrointestinal disorder (FGID). The below case study illustrates the presentation, evaluation, and clinical management of a child with chronic abdominal pain.

Small intestinal bacterial overgrowth in irritable bowel syndrome: association with colon motility, bowel symptoms, and psychological distress.

Small intestinal bacterial overgrowth (SIBO) has been implicated in the pathogenesis of irritable bowel syndrome (IBS), although the issue is still under debate. The aim of this study was to determine the prevalence of SIBO in those with IBS and its association with colonic motility, bowel symptoms and psychological distress. Sucrose hydrogen and methane breath tests were performed in 158 IBS patients and 34 healthy controls (HC). Thresholds for pain and urgency were tested by barostat in the descending colon. The motility index (MI) was calculated as the average area under the curve for all phasic contractions. Questionnaires assessed psychological distress, IBS symptom severity (IBS-SS), IBS quality of life (IBS-QOL) and self-reported bowel symptoms. Fifty-two of 158 (32.9%) IBS patients had abnormal breath tests compared with six of 34 (17.9%) HC (chi(2) = 0.079). SIBO (SIBO+) and non-SIBO (SIBO-) patients did not differ in the prevalence of IBS subtypes, IBS-SS, IBS-QOL and psychological distress variables. IBS patients had a greater post-distension increase in MI than HC, but there was no difference between SIBO+ and SIBO- patients. Predominant methane producers had higher urge thresholds (28.4 vs 18.3, P < 0.05) and higher baseline MI (461 vs 301.45, P < 0.05) than SIBO- IBS patients, and they reported more 'hard or lumpy stools' when compared with predominant hydrogen producers (P < 0.05) and SIBO- IBS patients (P < 0.05). SIBO is unlikely to contribute significantly to the pathogenesis of IBS. Methane production is associated with constipation.

From the bench to the 'crib'-side: implications of scientific advances to paediatric neurogastroenterology and motility.

Paediatric gastrointestinal motility disorders may present in the neonatal period as the result of a congenital insult that occurred during embryonic development or as a manifestation of an abnormal genetic background. Functional gastrointestinal and motility disorders may also be acquired and present during childhood as the first presentation of a condition that can persist or re-occur throughout adolescence and adulthood. These disorders can have a significant psychological and financial impact on the lives of the affected children and their families. Recently, enteric neuroscience research has advanced the understanding of the pathogenesis and treatment of uncommon congenital or developmental gastrointestinal motility disorders such as Hirschsprung disease and chronic intestinal pseudo-obstruction. In addition, research has contributed to improvements in the understanding of more prevalent functional gastrointestinal disorders in children, such as chronic constipation and functional abdominal pain syndromes. The purpose of this review is to highlight these advances with particular regard to the clinical impact they have in the understanding and management of disorders in the field of paediatric neurogastroenterology and motility.

Aerophagia in adults: a comparison with functional dyspepsia.

BACKGROUND: Aerophagia is a functional upper gastrointestinal disorder that has not previously been well described in a large patient group. AIMS: To describe the initial evaluation of patients who presented with symptoms of aerophagia at a tertiary medical centre. METHODS: A computerized search was used to identify all patients who were diagnosed with aerophagia at the Mayo Clinic, Rochester between 1996 and 2003 (n = 79). Individual medical charts were abstracted for information on the demographics, clinical features, co-morbid diagnoses, diagnostic workup and treatment. Information on presenting symptoms was also collected for a group of patients who were classified as having functional dyspepsia for comparison (n = 121). RESULTS: The median duration of symptoms in patients with aerophagia was 24 months. The most common symptoms were belching (56%), abdominal pain (19%), bloating (27%) and abdominal distension (19%). Patients with functional dyspepsia had a higher prevalence of reporting nausea, vomiting, early satiety, weight loss and abdominal pain (all P < 0.01, adjusting for age, gender and body mass index). Significantly more patients with aerophagia had anxiety (19%) than those with functional dyspepsia (6%, P < 0.01). CONCLUSIONS: Individuals with aerophagia experience prolonged upper gastrointestinal symptoms. Initial presenting symptoms appear to be distinctly different from those who have functional dyspepsia.

Aerophagia in children: characterization of a functional gastrointestinal disorder.

The purpose of this study was to describe presenting symptoms, diagnostic testing, treatments and outcomes in a group of children with a diagnosis of aerophagia. A computerized diagnostic index was used to identify all children between the age of 1 and 17 years diagnosed with aerophagia at a tertiary care medical centre between 1975 and 2003. Individual medical charts were abstracted for information on the demographics, clinical features, co-morbid diagnoses, diagnostic work up and treatment of children with aerophagia. Information on presenting symptoms was also collected for a group of children who were retrospectively classified as having functional dyspepsia for comparison (n = 40). Forty-five children had a diagnosis of aerophagia. The mean duration of symptoms in children with aerophagia was 16 +/- 5 months. The most common gastrointestinal symptoms were abdominal pain, distention and frequent belching. Children with functional dyspepsia had a higher prevalence of nausea, vomiting, abdominal pain and unintentional weight loss compared to children with aerophagia (all P < 0.05). In conclusion, aerophagia is a disorder that is diagnosed in neurologically normal males and females, who can experience prolonged symptoms. Although many children with aerophagia present with upper gastrointestinal symptoms, the disorder appears to be distinct from functional dyspepsia.

Assessment of gastric accommodation: overview and evaluation of current methods.

Gastric accommodation is considered important in the pathophysiology of several upper gastrointestinal disorders including functional dyspepsia. The gold standard for its measurement is the barostat-balloon study which requires intubation. The aim was explore the reliability and performance characteristics of the techniques proposed for measurement of gastric accommodation. We undertook a literature search using MEDLINE with a broad range of key words. The accommodation reflex and its control are briefly described, based on human data. The performance characteristics of the intragastric barostat, transabdominal ultrasound, magnetic resonance imaging, single photon emission computed tomography, and satiation drinking tests are described. For each technique, we summarize the following: principle, validation studies, advantages, disadvantages, and potential applications. Three-dimensional methods to measure gastric volume non-invasively are promising and among the best validated to date. Simpler techniques would be of considerable appeal for clinical and research studies, but further validation is necessary before satiation drinking tests can be used as surrogates for more sophisticated measurements of gastric accommodation.

Effectiveness of topical diclofenac in relieving photophobia after pupil dilation.

PURPOSE: To test the effectiveness of topical diclofenac in relieving photophobia after pupil dilation. SETTING: Department of Ophthalmology, Newcastle General Hospital, Newcastle-upon-Tyne, United Kingdom. METHODS: Twenty healthy patients and volunteers from the outpatient ophthalmology clinic were enrolled in a prospective, double-blind, placebo-controlled comparison in which the patient's fellow eye served as a control. Photophobia after pupil dilation was tested subjectively using a visual analog scale and a neutralization scale at 30 minute intervals for 2 hours after instillation of topical diclofenac. RESULTS: Both tests show a statistically significant reduction in photophobia in the diclofenac-treated eyes at each time interval (P < or = .05). This difference was also considered clinically relevant. CONCLUSION: Topical diclofenac given at the time of pupil dilation significantly reduced photophobia. The mechanism of action is unknown and requires further evaluation.

Risk factors, complications, and results in extracapsular cataract extraction.

PURPOSE: To examine a large series of extracapsular cataract extractions (ECCEs) to determine the risk factors for posterior capsule rupture with vitreous loss (PCR + VL) and the complications and results of this cataract surgery technique. SETTING: North Riding infirmary, Middlesbrough, United Kingdom. METHODS: In this retrospective study, the records of 1552 patients who had ECCE performed by two surgeons were examined. Follow-up was 4 months to 4 years. The main outcome measures were the incidence of risk factors, PCR + VL, major and minor postoperative complications, and the visual outcome. RESULTS: Three hundred twenty-two cases were considered high risk for PCR + VL. In this group, the PCR + VL rate was 5.3%; it was 3.7% in the low-risk group and 4.0% overall. Visual acuity of 6/9 or better was achieved by 76% of all eyes. Postoperative complications were 3 cases of endophthalmitis, 4 of retinal detachment, and 1 of pseudophakic bullous keratopathy. In 323 eyes, loose or broken sutures were removed and in 175, a neodymium: YAG capsulotomy was performed because of posterior capsule opacification. CONCLUSIONS: The incidence of perioperative and postoperative complications was comparable with those reported in other series. Factors that increased the risk of PCR + VL included pseudoexfoliation, diabetes mellitus, and a traumatic etiology. Previous glaucoma surgery and axial myopia of greater than 26.0 mm did not increase the PCR + VL risk. Loose or broken corneal sutures was a common finding that could be reduced substantially by planned suture removal.

Secondary implantation of open-loop, flexible, anterior chamber intraocular lenses.

PURPOSE: To assess the results of implantation of secondary, open-loop, flexible, anterior chamber intraocular lenses (IOLs) and compare the findings with those of other published studies. SETTING: A combined ophthalmology and ear, nose, and throat hospital in Middlesbrough, Cleveland, England. METHODS: This retrospective study comprised 81 patients who had secondary implantation of a flexible, open-loop, anterior chamber IOL by the one surgeon. The incidence of postoperative complications was ascertained, and best corrected preoperative and postoperative visual acuities were compared. RESULTS: Two serious complications occurred: one severe loss of vision that is still under investigation and one retinal detachment that was repaired with good residual visual function. Of all 81 patients, 92.5% were within one Snellen line of their preoperative best corrected visual acuity. These results compare favorably with those of other published studies. CONCLUSION: Using an open-loop, flexible, anterior chamber lens for secondary implantation is still an acceptable way to treat aphakia. The poor reputation of these lenses is undeserved.

Flexible open-loop anterior chamber intraocular lens implantation after posterior capsule complications in extracapsular cataract extraction.

OBJECTIVES: To analyze 50 cases of flexible open-loop anterior chamber intraocular lens (IOL) implantation after posterior capsule rupture and vitreous loss and compare the results with those of other published series. SETTING: North Riding Infirmary, Cleveland, England. METHODS: This retrospective study, with a follow-up between 3 and 81 months, comprised all patients who had a flexible open-loop anterior chamber IOL implanted because of significant posterior capsule problems during extracapsular cataract extraction. The incidence of postoperative complications and best corrected visual acuity results were determined. RESULTS: Three patients with cystoid macular edema achieved final best corrected visual acuity of 6/9 (20/30). There was one retinal detachment and one traumatic incision rupture with IOL loss 6 weeks postoperatively and subsequent retinal detachment and phthisis. Seventy-two percent achieved a best corrected visual acuity of 6/9 (20/30). CONCLUSIONS: Our results agree with those of other published series. Implantation of a flexible open-loop anterior chamber IOL as a primary lens is still an acceptable way of treating posterior capsule complications in cataract surgery.

Anterior chamber aspirate cultures in small incision cataract surgery.

BACKGROUND: Anterior chamber aspirates on completion of extracapsular cataract surgery contain significant numbers of organisms, particularly coagulase negative staphylococci, an important cause of endophthalmitis. METHODS: Culture rates were compared in 50 patients after phacoemulsification surgery, which allows the possible benefits of a small, self sealing wound and maintenance of positive intraocular pressure, with a similar number of extracapsular cases. RESULTS: A culture positive rate of 20% and 24% respectively was found, an insignificant difference. CONCLUSION: Small incision surgery has no proved advantage over extracapsular surgery in terms of reducing the intraoperative bacterial inoculum. The significance of this result in terms of causation of endophthalmitis is discussed.

Lack of effect of preoperative norfloxacin on bacterial contamination of anterior chamber aspirates after cataract surgery.

Eighty patients undergoing routine standardised extracapsular cataract surgery with lens implantation were divided randomly into two groups in a prospective double blind study comparing effects of preoperative norfloxacin eyedrops with placebo on bacterial contamination of anterior chamber aspirates after surgery. Pathogenic organisms were identified from 19 (24%) of the aspirates. The most commonly isolated organisms were coagulase negative Staphylococcus species. There was no statistical difference between the norfloxacin treated and placebo groups. This study demonstrates that routine use of topical preoperative antibiotics to eliminate the entry of bacteria into the eye during surgery is debatable.

Titanium tetrachloride burns to the eye.

We present eight cases of chemical burns of the eyes from titanium tetrachloride, an acidic corrosive liquid. However it causes severe chemical burns which have a protracted course and features more akin to severe alkali burns. Injuries related to titanium tetrachloride should be treated seriously and accordingly appropriate management is suggested.