Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition

Chronic diarrhoea is a common problem, hence clear guidance on investigations is required. This is an updated guideline from 2003 for the investigations of chronic diarrhoea commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). This document has undergone significant revision in content through input by 13 members of the Guideline Development Group (GDG) representing various institutions. The GRADE system was used to appraise the quality of evidence and grading of recommendations.

Estrés percibido por médicos residentes que realizan guardias de urgencia en dos hospitales de Madrid y determinación de biomarcadores de estrés / Perceived stress by medical residents performing emergency guards in two hospitals of Madrid and determination of stress biomarkers

OBJETIVO: analizar la posible relación entre estrés percibido por médicos internos residentes (MIR) que realizan guardias de Urgencias en dos hospitales de Madrid y biomarcadores de estrés. MATERIAL Y MÉTODOS: Estudio transversal retrospectivo en MIR de segundo a quinto año que realizaban guardias de Urgencias durante 2012-2013. Se les realizó un reconocimiento médico (RM), administrándoseles dos cuestionarios validados: el de Goldberg para ansiedad/ depresión (también se incluyeron los resultados del cuestionario de Goldberg del RM inicial) y percepción de estrés 10 (PSS-10). Se les realizó una extracción de sangre para análisis de cortisol y otros biomarcadores de estrés así como toma de tensión arterial al salir de guardia (antes de las 10 de la mañana). RESULTADOS: La prevalencia de percepción de estrés medida por PSS-10 fue de 94,68% en los 94 MIR reclutados. La mayor percepción de estrés se relacionó con el número de guardias (OR 3,359, IC 95% 1,208-10,189, p = 0,0207) y la ansiedad/depresión en el momento actual (OR 1,447, IC 95% 0,623-2,270, p = 0.0007), aunque no con la ansiedad/depresión al inicio de su contratación. CONCLUSIONES: Los MIR que realizaban guardias de Urgencias presentaron un alto nivel de percepción de estrés en nuestro estudio. No se encontró una asociación entre percepción de estrés y los biomarcadores de estrés considerados. Se proponen medidas preventivas de formación en manejo de situaciones conflictivas para los MIR al inicio de su programa de especialidad

AIM: to study the relationship between perceived stress by resident physicians (MIR) guards performing emergency and biomarkers of stress in two hospitals in Madrid. MATERIAL AND METHODS: a retrospective cross-sectional study of MIR second to fifth year who were on duty emergency during 2012-2013. Underwent medical examination (ME), and given two validated questionnaires: Goldberg about anxiety/depression (as well in the initial ME) and perceived stress 10 (PSS- 10). After medical guard and before 10 am, blood tests (for cortisol and other biomarkers of stress) and blood pressure were performed. RESULTS: The prevalence of perceived stress measured by PSS- 10 was 94.68 % in the 94 MIR included. The high perceived stress was associated with the number of guards (OR 3.359, 95% CI 1.208 to 10.189, p = 0.0207), and actual anxiety/depression (OR 1.447, 95% CI 0.623 to 2.270, p = 0.0007), while not previous anxiety/depression CONCLUSIONS: MIR working in emergency guards showed a high level of perceived stress in our study. No association between perceived stress and stress biomarkers evaluated were found. It has been proposed preventive solutions regarding to training about conflictive situations in the beginning of the medical residency

The triggers or precipitants of the acute migraine attack.

The aim of this study was to evaluate and define the triggers of the acute migraine attack. Patients rated triggers on a 0-3 scale for the average headache. Demographics, prodrome, aura, headache characteristics, postdrome, medication responsiveness, acute and chronic disability, sleep characteristics and social and personal characteristics were also recorded. One thousand two hundred and seven International Classification of Headache Disorders-2 (1.1-1.2, and 1.5.1) patients were evaluated, of whom 75.9% reported triggers (40.4% infrequently, 26.7% frequently and 8.8% very frequently). The trigger frequencies were stress (79.7%), hormones in women (65.1%), not eating (57.3%), weather (53.2%), sleep disturbance (49.8%), perfume or odour (43.7%), neck pain (38.4%), light(s) (38.1%), alcohol (37.8%), smoke (35.7%), sleeping late (32.0%), heat (30.3%), food (26.9%), exercise (22.1%) and sexual activity (5.2%). Triggers were more likely to be associated with a more florid acute migraine attack. Differences were seen between women and men, aura and no aura, episodic and chronic migraine, and between migraine and probable migraine.

The relationship between migraine pain and other associated symptoms.

This study explores the relationship of the pain of the migraine headache and the associated features of migraine. Migraineurs (n=1025) (ICHD-2, 1.1-1.2 and 1.5.1) were evaluated retrospectively using a detailed database (daily unremitting excluded). Variables studied included headache intensity and duration, associated symptoms and pain characteristics. Non-parametric correlations were used to evaluate relationships among variables. Headache intensity correlated with nausea, vomiting, photophobia, phonophobia, dizziness (all P=0.000), running of the nose/tearing of the eyes (P=0.007), and osmophobia (P=0.044), but not with diarrhoea or taste abnormality. Headache duration correlated only with osmophobia (P=0.002) and taste abnormality (P=0.005). Throbbing, pressure and stabbing pain correlated with most of the associated symptoms. Aching correlated only with taste abnormality. This correlational study demonstrates that migraine pain is clearly related to nausea, but is also correlated with other associated migraine symptoms. Taste abnormality and osmophobia are better correlated with headache duration rather than headache intensity.

The postdrome of the acute migraine attack.

This study was performed to document the frequency, duration and types of symptoms of postdrome in migraine patients. Eight hundred and twenty-seven consecutive headache clinic patients (IHS 1.1, 1.2 and 1.5.1) were evaluated at first visit. Postdrome frequency, duration and characteristics were analysed. Sixty-eight per cent of 827 patients reported postdrome (69.1% females; 56.8% males, P<0.007). The average duration of the postdrome was 25.2 h. Fifty-six per cent had postdrome for 24 h. The commonest symptoms were tiredness (71.8%), head pain (33.1%), cognitive difficulties (11.7%), 'hangover' (10.7%), gastrointestinal symptoms (8.4%), mood change (6.8%), and weakness (6.2%). Patients with postdrome compared with patients without postdrome have more characteristic and more frequent migraine features. This study demonstrated postdrome in 68% of patients, duration

The place of osmophobia and taste abnormalities in migraine classification: a tertiary care study of 1237 patients.

This study evaluates osmophobia and taste abnormalities in relationship to sensitivity and specificity in the classification of migraine. Consecutive International Headache Society (IHS) classified patients (n = 1237) were evaluated. Symptoms were graded from 0 to 3. Osmophobia and taste abnormalities were tested for sensitivity and specificity in migraine diagnosis. The patients were 85.4% female and their mean age was 38.1 years. Of 673 patients 24.7% complained of osmophobia, and 24.6% of 505 complained of taste abnormalities. In the absence of nausea and vomiting the combinations of two symptoms gave the following sensitivity and specificity percentages, respectively: photophobia and phonophobia, 10.6 and 84.9; photophobia and osmophobia, 1.1 and 99.0; phonophobia and osmophobia, 1.1 and 98.6; photophobia and taste abnormality, 9.6 and 99.0; phonophobia and taste abnormality, 9.6 and 98.8; and osmophobia and taste abnormality, 4.2 and 99.4. Osmophobia and taste abnormalities were demonstrated to be very specific in diagnosing migraine IHS 1.1-1.6, but very insensitive.

The aura: a tertiary care study of 952 migraine patients.

The aim of this study was to document the frequency and types of aura symptoms, to define the relationship between aura symptoms and to define the aura frequency in different migraine types. In 952 migraine patients, aura frequency, duration, time to headache, characteristics and percentage of headaches with aura were analysed. Thirty-eight percent of IHS 1.1-1.5 patients reported aura, 38.1% of females and 33.0% of males. Average percentage of aura occurrence with headache was 19.7% of headaches, average aura duration 27.3 min and aura was followed by headache in 10.4 min on average. Visual disturbances occurred in 92.1% and aura without visual aura was rare. Aura frequency was headache-type dependent. The highest frequency of aura was seen in the more 'full-blown' migraine attack. Visual aura is the overwhelming aura symptom. Even in patients with aura the percentage of aura with migraine attacks is limited.

Institutional policies of U.S. medical schools regarding tenure, promotion, and benefits for part-time faculty.

PURPOSE: To collect data on institutional policies regarding tenure, promotions, and benefits for part-time faculty at U.S. medical schools and determine the extent to which part-time work is a feasible or attractive option for academic physicians. METHOD: In July 1996, the authors sent a 29-item questionnaire regarding tenure, promotions, and benefit policies for part-time faculty to respondents identified by the deans' offices of medical schools in the United States and Puerto Rico. Responses were analyzed using descriptive statistics and chi-square analyses. RESULTS: Respondents from 104 of 126 medical schools (83%) completed the questionnaire; 58 responded that their schools had written policies about tenure, promotion, or benefits for part-time faculty. Tenure. Of the 95 medical schools with tenure systems, 25 allowed part-time faculty to get tenure and 76 allowed for extending the time to tenure. Allowable reasons to slow the tenure clock included medical leave (65), maternity leave (65), paternity leave (54), other leave of absence (59). Only 23 allowed part-time status as a reason to slow the tenure clock. Policies written by the dean's office and from schools in the midwest or west were more favorable to part-time faculty's being allowed to get tenure. Promotions. The majority of respondents reported that it was possible for part-time faculty to serve as clinical assistant, assistant, associate, and full professors. Benefits. The majority of schools offered retirement benefits and health, dental, disability, and life insurance to part-time faculty, although in many cases part-time faculty had to buy additional coverage to match that of full-time faculty. CONCLUSIONS: Most medical schools do not have policies that foster tenure for part-time faculty, although many allow for promotion and offer a variety of benefits to part-time faculty.

The effects of amino acids on albumin synthesis by the isolated perfused rat liver.

Albumin synthesis was measured in the isolated perfused rat liver by using the livers of both well-fed and starved rats. Starvation markedly decreased albumin synthesis. The livers from starved rats were unable to increase synthesis rates after the addition to the perfusates of single amino acids or the addition of both glucagon and tryptophan. Arginine, asparagine, isoleucine, leucine, lysine, methionine, phenylalanine, proline, threonine, tryptophan and valine, added together to ten times their normal peripheral blood concentrations, restored synthesis rates to normal. The plasma aminogram (i.e. the relative concentrations, of amino acids) was altered by depriving rats of protein for 48h. The use of blood from the deprived rats as perfusate, instead of normal blood, decreased albumin synthesis rates significantly by livers obtained from well-fed rats. The addition of single amino acids, including the non-metabolizable amino acid, alpha-aminoisobutyric acid, to the above mixture increased albumin synthesis rates to normal values. It is concluded that amino acids play an important role in the control of albumin synthesis and that more than one mechanism is probably involved.