A cross-cultural investigation of attachment style, catastrophizing, negative pain beliefs, and symptom severity in irritable bowel syndrome.

BACKGROUND: Little information exists regarding whether psychosocial variables in irritable bowel syndrome (IBS) vary by geographic location. Adult attachment is an important psychological concept rooted in childhood relationship experience that has not been previously studied in IBS. Catastrophizing and negative pain beliefs have been described in IBS and may be affected by attachment. AIMS: In this cross-cultural study, we determined: (i) whether attachment differs between IBS patients and controls, (ii) whether geographic location has a significant effect on attachment style, catastrophizing and negative pain beliefs, and (iii) how all three variables correlate with IBS symptom severity. METHODS: 463 IBS patients, with moderate to severe symptom scores, and 192 healthy controls completed validated questionnaires about attachment, catastrophizing, negative pain beliefs and IBS-SSS in nine locations, USA (New York, Los Angeles), Mexico, Italy (Rome, Bari), Romania, Iran, India, and China. KEY RESULTS: Attachment anxiety and avoidance scores were significantly higher in IBS patients than in controls (p < 0.001). This was particularly true for the fearful-avoidant attachment category, especially in China and Romania. Path analysis showed that attachment anxiety and avoidance had indirect effects on IBS-SSS through catastrophizing (p < 0.0001) and negative pain beliefs (p = 0.005). All three psychosocial measures varied significantly depending on location. CONCLUSIONS & INFERENCES: In the IBS population studied, attachment style was significantly different in IBS compared to a control population. Geographic differences in attachment, catastrophizing and negative pain beliefs were documented and their correlation with symptom severity and thus, research of psychosocial variables in IBS should take into account the location of the population studied.

A four-country comparison of healthcare systems, implementation of diagnostic criteria, and treatment availability for functional gastrointestinal disorders: a report of the Rome Foundation Working Team on cross-cultural, multinational research.

BACKGROUND: Variations in healthcare provision around the world may impact how patients with functional gastrointestinal disorder (FGIDs) are investigated, diagnosed, and treated. However, these differences have not been reviewed. PURPOSES: The Multinational Working Team of the Rome Foundation, established to make recommendations on the conduct of multinational, cross-cultural research in FGIDs, identified seven key issues that are analyzed herein: (i) coverage afforded by different healthcare systems/providers; (ii) level of the healthcare system where patients with FGIDs are treated; (iii) extent/types of diagnostic procedures typically undertaken to diagnose FGIDs; (iv) physicians' familiarity with and implementation of the Rome diagnostic criteria in clinical practice; (v) range of medications approved for FGIDs and approval process for new agents; (vi) costs involved in treating FGIDs; and (vii) prevalence and role of complementary/alternative medicine (CAM) for FGIDs. Because it was not feasible to survey all countries around the world, we compared a selected number of countries based on their geographical and ethno-cultural diversity. Thus, we included Italy and South Korea as representative of nations with broad-based coverage of healthcare in the population and India and Mexico as newly industrialized countries where there may be limited provision of healthcare for substantial segments of the population. In light of the paucity of formal publications on these issues, we included additional sources from the medical literature as well as perspectives provided by local experts and the media. Finally, we provide future directions on healthcare issues that should be taken into account and implemented when conducting cross-cultural and multinational research in FGIDs.

Technical report: an ePRO patient reported outcome program for the evaluation of patients with irritable bowel syndrome.

BACKGROUND: Patient reported outcome (PRO) is an important healthcare concept that describes patient's participation in their care by self-evaluation, usually in the form of questionnaires. This report describes an unique computerized technique, electronic PRO (ePRO), for following the progress of patients with irritable bowel syndrome (IBS). METHODS: Patients first completed a series of questionnaires, including questions about their illness history, symptom severity, and, in this application, psychological and relationship issues. The symptom severity and psychological questionnaires were then completed at intervals by the patients on their own computers. The ePRO was constructed to allow scores to be automatically summed and placed on a time-line graph for review at the time of the next office visit. KEY RESULTS: Of the 32 patients who completed the initial set of questionnaires, 20 maintained participation in the program for a 6-month period. Of those 20 patients, median number of submissions was 7.0; median interval between questionnaire submissions was 3.0 weeks, whereas median interval between office visits was 5.9 weeks. On average, questionnaire completion took less than 5 min and was positively experienced by the patients. CONCLUSIONS & INFERENCES: The ePRO program proved to be technically feasible, clinically useful, and positively experienced by the patients. It provides a focus on a collaborative conversation between physician and patient. It has significant potential as a technique for evaluating outcome in response to various therapies.

The small intestine.

Clinical investigation of the small bowel at The Mount Sinai Hospital began with David Adlersberg's arrival in 1931. His research interests were in bile acids, cholesterol, carotene, and vitamin A. In 1952, he was given a Nutrition Laboratory and later, a Nutrition Clinic. His vitamin A tolerance test and interest in malabsorption led him to a comprehensive study of sprue, the separation of the tropical and non-tropical forms, and their different etiologies and treatments. Adlersberg's work was complemented by (a) Marshak and Wolf's radiologic examination of the small bowel (especially in sprue and other malabsorption disorders); (b) Gerson s perfusion experiments; and (c) Friedman, Waye and Wolf's motility studies. Lieber and his colleagues explored the deleterious effects of alcohol on the function and structure of the small intestine. Gerson explored the nutrition of patients with Crohn's disease of the small intestine, especially after extensive resection or bypass leading to ascorbic and folic acid deficiencies and hypergastrinemia.

Bioavailability of digoxin tablets in patients with gastrointestinal dysfunction.

In 47 patients with disorders of the gastrointestinal tract, the bioavailability of digoxin tablets was assessed by measuring the area under the serum concentration-time curve (AUC) after the oral administration of single 0.5 mg doses. In 13 or 14 patients who had undergone a previous ileal resection, in 10 of 10 patients with sprue and in 14 of 14 patients with a variety of disorders of the gastrointestinal tract, digoxin absorption was normal despite marked steatorrhea in many. A patient with extensive jejunal and ileal resection, and inflammation of the remaining small bowel,was the sole exception. Impaired digoxin bioavailability was found in five of nine patients who had undergone jejunoileal bypass procedures (bypass patients. A strong correlation was noted between the length of jejunum remaining in continuity and the AUC (r = 0.86, p less than 0.01). Two of three bypass patients also showed decreased absorption of more rapidly dissolving tablets or an elixir. Digoxin bioavailability correlated significantly with and 2 hour serum xylose levels but not with urinary xylose excretion, fecal fat or the Schilling test result. The findings are consistent with the role of the upper small bowel as the predominant site of digoxin absorption as well as the reserve function of the ileum in the event of jejunal dysfunction or bypass.

Anemia and intestinal dysfunction in former residents of the Caribbean.

A group of subjects had common features of megaloblastic anemia due to vitamin B12 deficiency, normal or high serum folate, and evidence of intestinal malabsorption. They were all former residents of the Caribbean area now living in New York City. Despite similar symptoms and diagnostic studies, two subjects were found to have pernicious anemia and three to have tropical sprue. Achlorhydria, serum anti-intrinsic factor antibody, the severity of small intestinal abnormalities, and posttherapy Schilling tests were helpful differential factors. These subjects illustrate the problems that may be encountered in differentiating tropical sprue and pernicious anemia.

The effect of ascorbic acid on uric acid excretion with a commentary on the renal handling of ascorbic acid.

Under spontaneous conditions in man and dog, very little ascorbic acid is excreted in urine. Ascorbic acid clearance (C ascorbic acid) is promptly augmented when plasma ascorbic acid is increased by intravenous injection. No net tubular secretion of ascorbic acid is demonstrable in either man or dog when plasma ascorbic acid is elevated to levels as high as 12 mg/100 ml in man, and 28 mg/100 ml in the dog. Nevertheless, both in men and the Dalmatian dog, when the glomerular filtration rate (GFR) is decreased, excreted ascorbic acid in relation to the amount filtered is exaggerated so that C ascorbic acid:GFR approaches unity. It is possible that secreted ascorbic acid is masked under ordinary circumstances, with a more significant contribution of secreted ascorbic acid to total urinary ascorbic acid becoming apparent under conditions of low GFR. In man, when the plasma ascorbic acid level is raised to above 6 mg/100 ml, C urate:GFR rises from control value of 0.081 +/- 0.020, to 0.116 +/- 0.026. In both mongrel and Dalmatian dogs an effect of ascorbic acid on urate excretion is not conclusively shown. The uricosuric effect of ascorbic acid in man may be due to competition with uric acid for renal tubular reabsorptive transport. The difference in the metabolism of ascorbic acid in the dog as compared to man may help account for the inconsistent effect of ascorbic acid on uric acid excretion in the dog.

Bioavailability of ascorbic acid in orange juice.

Several orange juice preparations were analyzed for biologically active and inactive ascorbic acid derivatives --L-ascorbic acid , dehydro-L-ascorbic acid, and inactive 2,3-diketo-L-gulonic acid. Fresh orange juice contained from 4 to 7 mg/100 ml of inactive ascorbic acid. In contrast, pasteurized orange juice contained from 15 to 30 mg/100 ml of inactive ascorbic acid (up to 400% more than fresh orange juice). Samples of fresh orange juice contained as much as 100% more active ascorbic acid than samples of pasteurized orange juice. There is great variability in prepared orange juice derivatives with a substantial decrease in bioavailability of active ascorbic acid.

Folic acid absorption in regional enteritis.

The authors have investigated intestinal absorption of folic acid by jejunal perfusion with a triple lumen tube in five subjects with regional enteritis. The subjects' intestinal disabilities ranged from terminal ileitis to short bowel syndrome. Two had steatorrhea and two had low serum folate levels. Absorption of pteroylglutamic acid was normal in all five. This suggests that folic acid deficiency, common in this disorder, is largely caused by malnutrition, not malabsorption.

Effect of parenteral acetazolamide on intestinal absorption of salt and water in man.

Acetazolamide was administered intravenously during jejunal perfusion of isotonic saline in six subjects. Bicarbonate was present in very low concentration intraluminally and there was net bicarbonate secretion during control and acetazolamide perfusions. Acetazolamide significantly inhibited sodium chloride, and water absorption. As this occurred in the absence of an effect on net bicarbonate secretion, it may have been due to an action other than carbonic anhydrase inhibition.