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We conducted a study to evaluate the effectiveness of Mom Power, a multifamily parenting intervention to improve mental health and parenting among high-risk mothers with young children in a community-based randomized controlled trial (CB-RCT) design. Participants (N = 122) were high-risk mothers (e.g., interpersonal trauma histories, mental health problems, poverty) and their young children (age <6 years), randomized either to Mom Power, a parenting intervention (treatment condition), or weekly mailings of parenting information (control condition). In this study, the 13-session intervention was delivered by community clinicians trained to fidelity. Pre- and post-trial assessments included mothers' mental health symptoms, parenting stress and helplessness, and connection to care. Mom Power was delivered in the community with fidelity and had good uptake (>65%) despite the risk nature of the sample. Overall, we found improvements in mental health and parenting stress for Mom Power participants but not for controls; in contrast, control mothers increased in parent-child role reversal across the trial period. The benefits of Mom Power treatment (vs. control) were accentuated for mothers with interpersonal trauma histories. Results of this CB-RCT confirm the effectiveness of Mom Power for improving mental health and parenting outcomes for high-risk, trauma-exposed women with young children. ClinicalTrials.gov Identifier: NCT01554215.

Parenting group success begins with attendance. Using archival pilot data from 99 mothers who enrolled in the Mom Power (MP) parenting intervention, this study sought to understand the factors that influenced participant engagement and retention. MP is a group-based, early intervention program grounded in attachment theory that utilizes motivational interviewing as a core component to enhance program engagement. Study aims were to qualitatively describe the reasons why mothers were interested in participating in the program, including what they hoped to gain from the experience, and to quantitatively examine the extent to which attendance was associated with demographic, experiential, and psychosocial factors. The qualitative analysis of intake interviews revealed that mothers expected the MP intervention to provide a warm environment for themselves and their children as well as to support and enhance their parenting, and 95% revealed their hopes that the intervention would help them grow and develop as women. Attendance rates were relatively high, with 62% of mothers missing less than one group session. Quantitative analyses using multiple regression to test associations of demographic, experiential, and psychosocial factors with attendance rates were not significant. Results suggest that motivational interviewing may be an important component in promoting participant engagement efforts in parenting interventions., (© 2017 Michigan Association for Infant Mental Health.)

Background: Chronic lung allograft dysfunction (CLAD), presenting as bronchiolitis obliterans syndrome (BOS) or restrictive allograft syndrome (RAS) is the major limiting factor of long-term survival in lung transplantation. Its pathogenesis is still obscure. In BOS, persistent alloimmune injury and chronic airway inflammation are suggested. One of the main tasks of the lymphatic vessel (LV) system is the promotion of immune cell trafficking. The formation of new LVs has been shown to trigger chronic allograft rejection in kidney transplants. We therefore sought to address the role of lymphangiogenesis in CLAD., Methods: Formalin-fixed paraffin-embedded tissue samples of 22 patients receiving a lung retransplantation due to BOS or RAS were collected. Lymphatic vessel density (LVD) was determined by immunohistochemical staining for podoplanin. Lung tissue obtained from 13 non-CLAD patients served as control. The impact of LVD on graft survival was assessed., Results: Lymphatic vessel density in CLAD patients did not differ from those in control subjects (median number of LVs per bronchiole: 4.75 (BOS), 6.47 (RAS), 4.25 (control), P = 0.97). Moreover, the number of LVs was not associated with regions of cellular infiltrates (median number of LVs per bronchiole: with infiltrates, 5.00 (BOS), 9.00 (RAS), 4.00 (control), P = 0.62; without infiltrates, 4.5 (BOS), 0.00 (RAS), 4.56 (control), P = 0.74). Lymphatic vessel density did not impact the time to development of BOS or RAS in lung transplantation (low vs high LVD: 38.5 vs 86.0 months, P = 0.15 [BOS]; 60.5 vs 69.5 months, P = 0.80 [RAS])., Conclusions: Unlike chronic organ failure in kidney transplantation, lymphangiogenesis is not altered in CLAD patients. Our findings highlight unique immunological processes leading to BOS and RAS.

Maternal psychopathology and traumatic life experiences may adversely impact family functioning, the quality of the parent-child relationship and the attachment bond, placing the child's early social-emotional development at risk. Attachment-based parenting interventions may be particularly useful in decreasing negative outcomes for children exposed to risk contexts, yet high risk families frequently do not engage in programs to address mental health and/or parenting needs. This study evaluated the effects of Mom Power (MP), a 13-session parenting and self-care skills group program for high-risk mothers and their young children (age <6 years old), focused on enhancing mothers' mental health, parenting competence, and engagement in treatment. Mothers were referred from community health providers for a phase 1 trial to assess feasibility, acceptability, and pilot outcomes. At baseline, many reported several identified risk factors, including trauma exposure, psychopathology, poverty, and single parenthood. Ninety-nine mother-child pairs were initially recruited into the MP program with 68 women completing and providing pre- and post-self-report measures assessing demographics and trauma history (pre-assessment only), maternal mental health (depression and post-traumatic stress disorder (PTSD)), parenting, and intervention satisfaction. Results indicate that MP participation was associated with reduction in depression, PTSD, and caregiving helplessness. A dose response relationship was evident in that, despite baseline equivalence, women who attended ≥70 % of the 10 groups (completers; N = 68) improved on parenting and mental health outcomes, in contrast to non-completers (N = 12). Effects were most pronounced for women with a mental health diagnosis at baseline. The intervention was perceived as helpful and user-friendly. Results indicate that MP is feasible, acceptable, and holds promise for improving maternal mental health and parenting competence among high-risk dyads. Further research is warranted to evaluate the efficacy of MP using randomized controlled designs.

Background: The stomach can either be divided or undivided in performing Roux-en-Y gastric bypass (RGB) for morbid obesity. We evaluated whether surgical technique is the sole contributing factor to the formation of gastrogastric fistula (GGF)., Methods: A retrospective analysis of 1,036 consecutive patients was evaluated. RGB was performed as open undivided, open divided, and laparoscopic (divided). Incidence of GGF was identified for each technique and its relationship to surgical experience was assessed., Results: Overall incidence of GGF was 1.3%. All fistulae occurred in patients who received undivided open RGB. There was a significant difference between the undivided open group and the divided open+laparoscopic groups (2.1% vs 0%, P<.01). Incidence of GGF decreased over time with increasing open undivided RGB volume., Conclusions: GGF was only identified in undivided RGB. The occurrence decreased with increasing surgical experience. Together, overall surgical technique in addition to gastric division must play a role in fistula formation., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: Revisional bariatric surgery may be necessary due to inadequate weight loss or postoperative complications of the primary operation. We sought to identify the reasons for revision, characteristics of the surgery, and outcomes. We hypothesize that revisional surgery, although technically challenging, can produce desirable outcomes., Methods: Patients undergoing bariatric surgery at our institution between 1998 and 2007 were reviewed from a prospective database. Patients who had revisional surgery were compared to those who had primary surgery., Results: We have identified 46 of 1,038 patients who underwent revisional surgery. Twenty of 46 had a primary Roux-en-Y gastric bypass. The most common indication for revisions is inadequate weight loss secondary to gastrogastric fistula (15/20). Leaks occurred more frequently following revisional surgeries (11% vs 1.2%), but intensive care unit (ICU) utilization was less (11% vs 4.4%) and mortality was lower (0% vs .3%) with bariatric revision surgery., Conclusions: Although we saw a 9-fold increase in leaks, a 2-5 fold increase in ICU utilization, and 1.5-fold increase in length of stay, our mortality rate was zero. In experienced hands, bariatric revision surgery can be performed to produce desirable outcomes.

Gastroparesis is a disorder of gastric motility that results in delayed gastric emptying. Common symptoms include early satiety, postprandial fullness, epigastric pain, nausea, vomiting, and weight loss. The underlying etiologies of gastroparesis are many and include diabetes, prior gastric surgery, collagen vascular disorders, and a previous viral illness. Up to one third of cases are classified as idiopathic. Treatment typically consists of a change in diet to small volume, frequent meals and the use of the prokinetic agents metoclopramide, cisapride, erythromycin, or domperidone. Botulinum toxin has recently been shown to be effective in treating disorders of smooth muscle hypertonicity in the GI tract. This case report describes three patients with severe gastroparesis whose symptoms persisted despite dietary changes and the use of high dose prokinetic agents. All three were treated with intrasphincteric injection of the pylorus with botulinum toxin and all had significant symptomatic improvement afterwards. Possible mechanisms of action of botulinum toxin on the pylorus and its effects in patients with gastroparesis are discussed.

Approximately 20% of the general population has irritable bowel syndrome (IBS). Although the majority of these individuals do not consult a physician, IBS accounts for 25% of visits to a gastroenterologist and up to 12% of visits to a primary care physician. Consequently, the direct and indirect costs associated with IBS are estimated at $8 billion annually. IBS symptoms, with no apparent structural pathology, include altered bowel habits, abdominal pain/discomfort, and bloating. The Rome II criteria, a standardized guideline for the diagnosis of IBS, contains in its definition abdominal pain or discomfort associated with altered bowel habits. Bloating may often be present. Three patient subgroups are defined according to the predominant bowel symptom: constipation, diarrhea, or alternating constipation and diarrhea. Hematology, fecal occult blood test, flexible sigmoidoscopy, and lactose intolerance evaluations are recommended for all patients demonstrating symptoms of IBS. When indicated, tests are recommended to rule out bacterial or parasitic infections, pelvic floor muscle dyssynergia, colonic inertia, peptic ulcer, or inflammatory bowel disease.

This pilot study (N = 20) tested the effects of intravenous midazolam administration on learning retention after pacemaker implantation. Patients were randomized to receive teaching at 1 or 3 hours after the last dose of midazolam. Using a standardized teaching format, one of two study nurses performed the teaching that included incision care, activity restrictions, environmental factors potentially affecting pacemaker function, and follow-up requirements. Learning was evaluated by one of the investigators blinded to teaching time. Subjects in the 1-hour group retained significantly less information than those taught at 3 hours after drug administration. Patients taught later answered similar numbers of questions correctly, whereas there was much more variability in correct responses for the group taught earlier. This article reviews the effects of midazolam on memory and learning as well as provides suggestions for alterations in patient education protocols for patients receiving midazolam for pacemaker implantation. The effect of shortened length of stay on care practices is also discussed.

Objective: Abdominal pain has not been reported generally as a significant feature of the clinical presentation of patients with gastroparesis., Methods: Using a standardized questionnaire, we analyzed the clinical features of 28 consecutive patients referred with established or suspected gastroparesis over a 4-yr period. The diagnosis of gastroparesis was supported by abnormalities in gastric emptying studies (GES), electrogastrography (EGG), or upper endoscopy (EGD). Diagnostic tests were reviewed., Results: A total of 12 male (mean age 39.5 yr) and 18 female patients (mean age 39.6 yr) were included in this study. These patients had been symptomatic for an average of 37.8 months before their referral to our center. Seven of these patients had insulin-dependent diabetes. Idiopathic gastroparesis was present in more than half of the patients. The symptom profile of the 28 patients was as follows: nausea, 92.9%; abdominal pain, 89.3%; early satiety, 85.7%; and vomiting, 67.9%. The pain was described as burning, vague, or crampy in nature. Only 36% localized to the upper abdomen. In all, 60% of patients complained of postprandial pain, whereas 80% complained of nocturnal pain that interfered with their normal sleeping pattern. In general, pain responded poorly or not at all to prokinetic agents., Conclusions: Nausea and abdominal pain are the most common complaints of patients with gastroparesis. In 80% of patients, GES and EGG correlated positively.

Fifteen tests were used to assess adrenergic, non-vagal cholinergic, and cardiovagal functions in 11 patients with chronic intestinal pseudo-obstruction (CIP). The three aims of this study were: 1) to ascertain the presence of and spectrum of autonomic involvement; 2) to assess the level of autonomic dysfunction; and 3) to compare the results of autonomic function tests with gastrointestinal motility patterns. Gastrointestinal motility displayed a neuropathic pattern in 10 patients. Adrenergic functions were abnormal in nine patients and non-vagal cholinergic functions in 10 patients. Cardiovagal functions were abnormal in only seven patients. The autonomic dysfunction was localized mostly to the postganglionic pathways. One patient, who had a myopathic pattern and muscle degeneration on small bowel biopsy, demonstrated normal responses to autonomic function tests. The patients with neuropathic CIP demonstrated widespread, mostly postganglionic autonomic dysfunction. Neuropathic CIP can occur with or without cardiovagal involvement.

Irritable bowel syndrome is frequently encountered in clinical practice, and it has been repeatedly suggested that abnormal colonic motor activity is one of the major pathophysiological mechanisms responsible for the origin of symptoms in such disorder. If this statement is true, then high-amplitude propagated colonic contractions (HAPCs), i.e. the mass movements, may play an important role. To test this hypothesis, we conducted an investigation by recording colonic motility for a prolonged (24 h) period in 25 patients with irritable bowel syndrome and in 18 healthy volunteers, to compare the number of mass movements over 24 h in patients (constipation-predominant, alternating bowel habits) and controls. The overall amount of motility was also assessed in twelve patients and 13 controls. We also looked for the possible changes in mass movements and motility which may occur with defecation and after a meal. The results showed that 1) with respect to HAPCs and motility index, neither group was significantly different from controls; 2) HAPCs and the motility index were significantly reduced during sleep in all groups tested; 3) HAPCs were significantly more common before as compared to after defecation and after as compared to before meals; 4) HAPCs are not independent from the segmental contractile activity; 5) the motility index/24 h was lower in the constipation-predominant group of patients with respect to controls. We conclude that in patients with irritable bowel syndrome colonic motility per se may play a pathophysiological role in the genesis of the symptoms, although other mechanisms are likely to concur, or to be responsible for the complaints of these patients. However, colonic prolonged recordings are very useful for studying physiological and pathophysiological correlates of sleep, eating, and defecation.

Olestra, a dietary fat substitute, was recently made available to consumers in savory snacks in three cities. Early reports of gastrointestinal complaints attributed to olestra attracted media coverage and fostered confusion among physicians and consumers about the nature of olestra and its effects on the digestive system. We reviewed all published studies of olestra's gastrointestinal effects and all relevant unpublished studies submitted to the Food and Drug Administration. Each study was analyzed by a group of expert gastroenterologists and epidemiologists. The symptoms reported with olestra ingestion are similar to those reported with ingestion of fiber and sorbitol, although the mechanisms involved in changing stool characteristics differ among these food additives. Olestra's effects on stool habit and characteristics are due to its presence in the stool. Large amounts are more likely to induce gastrointestinal symptoms than small amounts. There is no evidence that olestra induces pathological change in bowel function: there is no increased fluid or electrolyte nor is there altered gastrointestinal motility or microflora. Olestra and triglyceride ingestion resulted in a similar frequency of symptoms in normal adults and children and in people with chronic inflammatory bowel disease in remission. Olestra traverses the digestive tract intact to become a stool additive. Some subjects develop a change in bowel habit and stool characteristics due to the presence of more olestra in the stool. These changes resemble those associated with ingestion of sorbitol and fiber., (Copyright 1997 Academic Press.)

The aims of this study were to determine whether increased pain sensitivity in patients with irritable bowel is due to physiological differences in perceptual sensitivity or psychological influences on perception, and whether prior sexual abuse accounts for increased pain sensitivity. Seventeen sexually abused and 15 nonabused women with irritable bowel were compared to 13 sexually abused and 14 nonabused women without irritable bowel. Among the nonabused subjects, the volume of rectal distension that produced moderate pain was lower in IBS patients than in controls, replicating earlier studies, but these thresholds were correlated with psychological measures of anxiety and somatization. The ability to discriminate between painful distensions (perceptual sensitivity) was not different between groups. Sexual abuse was not associated with lower pain thresholds. Thus, differences in pain sensitivity appear to be due to psychological influences on perception, but a history of sexual abuse does not contribute significantly to this pain sensitivity.

Cyclic vomiting is a rare syndrome that over the years has variously been ascribed to psychogenic causes, sensory seizures, abdominal migraine, and more recently, to mechanical or electrical disturbances in gastric physiology. We describe the case of a 65-year-old white diabetic female with a 10-yr history of recurrent episodes of nausea and vomiting, occurring every 10-12 days and lasting approximately 1-3 days at a time. These episodes were accompanied by edema, mild temperature elevations, and remarkable elevations in blood pressure. In between these episodes, the patient remained asymptomatic. Initial screening tests were also negative except for moderate gastroparesis. However, antral motility was found to be normal, as was an electrogastrogram. Detailed neurological and psychiatric evaluations were negative. Trials of erythromycin, metoclopramide, naloxone, ondansetron, and amitryptiline were unsuccessful. Serial endocrinological testing revealed that an episode of vomiting was always preceded by an abnormal elevation in at least one of the following: serum adrenocorticotropic hormone, serum cortisol, or urinary cortisol. In the midst of an episode, all three values were exceedingly high (e.g., > 10-fold increases in 24-hr urinary cortisol levels). Fluctuations of a milder degree, though still abnormally high, were also noted in between cycles at times when the patient was completely asymptomatic. High-dose dexamethasone suppressed these hormonal surges completely but not the clinical symptoms, which continued undisturbed. The patient was finally given a trial of intramuscular ketorolac during one of her episodes, which produced prompt and sustained relief. During the next few weeks, she was given this drug each time her symptoms commenced, and each time it appeared that her cycle had been aborted. She has since been able to terminate her episodes promptly and completely by self-administration of ketorolac. We speculate that her syndrome is caused by a poorly characterized disorder of endogenous prostaglandin release, resulting not only in derangements in the hypothalamic pituitary system but also in nausea and vomiting.

Objective: To investigate the mechanisms of constipation and the effect of fiber supplementation on physiology, mechanisms, stool parameters, and colonic transit times in a group of constipated older patients., Design: Single-blind, randomized, placebo-controlled fiber intervention with crossover., Setting: A university-based outpatient center., Patients: Ten community-living older men and women, healthy except for chronic constipation., Interventions: Patients were given either 24 g psyllium fiber or placebo fiber daily for 1 month, then crossed over to the other arm for an additional month. Structured testing, including total gut transit time and rectal and colonic manometry, was performed at the end of each intervention month. Patients recorded stool frequency, consistency, and weights daily., Results: The predominant mechanism for constipation in these patients was outlet delay caused by pelvic dyssynergia. Fiber decreased total gut transit time from 53.9 hours (placebo condition) to 30.0 hours (P < .05). Stool weights and consistency were not significantly improved by fiber, though there was a trend toward an increase in stool frequency (1.3 vs 0.8 bowel movements per day.) Pelvic floor dyssynergia was not remedied by fiber, even when constipation was clinically improved., Conclusions: Fiber supplementation appeared to benefit constipated older patients clinically, and it improved colonic transit time, but it did not rectify the most frequent underlying abnormality, pelvic floor dyssynergia.

Objectives: Chronic intestinal pseudoobstruction (CIP) is difficult to differentiate from true mechanical obstruction, so many patients undergo multiple operations before the diagnosis is established. This is because of a lack of easily identifiable signs and symptoms that can differentiate true intestinal obstruction from pseudoobstruction. The digital arch is the least common (10%) of the three patterns of fingerprints (arches, loops, and whorls) found in primates. Digital arches have also been reported in association with mitral valve prolapse, which in turn is associated with joint laxity. Fingerprints and mitral valve prolapse are congenital features and are influenced by heredity, so we evaluated CIP patients for coexistence of these clinical markers., Methods: Fingerprints were examined in 1566 consecutive gastrointestinal specialty referrals. In 43 patients, the initial diagnosis of CIP was confirmed by subsequent testing. Because of the clinical impression that four features were present with increased frequency in CIP patients, these signs and symptoms were recorded prospectively: 1) number of digital arches (DA); 2) presence of mitral valve prolapse (MVP), 3) presence of joint laxity (JL), and 4) onset of constipation before age 10 (C < 10)., Results: Forty-three CIP patients (39 female, four male, ages 18-62) were seen. Using the test for significance of differences in proportions, the presence of DA, MVP, JL, and C < 10 proved significantly higher (p < 0.001) in CIP patients than in age- and sex-matched controls and the general population., Conclusions: We conclude that: 1) CIP may be a heritable syndrome because it is associated with heritable congenital markers (DA, MVP, JL, and C < 10; 2) these markers are identified with higher frequency in CIP patients than in the general population and in age- and sex-matched patients with other gastrointestinal disorders; 3) all four markers are easily detectable, and their recognition could lead to earlier diagnosis of the disorder.

Objective: Total abdominal colectomy (TAC) for intractable constipation has a variable reported success rate that decreases to 50% beyond 2 yr. We hypothesize that this inconsistent outcome can be explained by a more extensive intestinal involvement in some patients., Design: A consecutive sample of patients with intractable constipation had preoperative evaluations that included both upper and lower GI studies. Stool frequency, constipation, diarrhea, abdominal pain, and laxative or enema requirements were compared before and after operation. The study took place in an academic referral center and included 37 consecutive referred patients with severe intractable constipation and colonic dysmotility documented by radiopaque marker studies., Interventions: TAC, with ileoproctostomy in 34 patients and ileostomy in three., Main Outcome Measures: Patients with motility abnormalities only of the lower GI tract were diagnosed as having colonic inertia (CI). Those with motility disorders of both the upper and the lower GI tracts were considered to have generalized intestinal dysmotility (GID) with colon predominance., Results: Twenty-one patients had CI, and 16 had GID. Ninety percent of CI patients undergoing TAC had a successful outcome with a mean of 23 bowel movements (BMs)/wk at a mean follow-up of 7.5 yr. Although 88% of GID patients had initial improvement, with a mean of 19 BMs/wk at 6 months, only 13% had prolonged relief. After 2 yr, nine of the GID patients had recurrent constipation, and three had severe diarrhea., Conclusions: This study has identified two distinct types of colonic dysmotility, CI and GID. It has demonstrated the long-term success of TAC for CI and the importance of upper GI physiological studies to identify colon-predominant GID, which has a poor long-term response to TAC.

Objectives: The aim of this study was to characterize the frequency and severity of gastrointestinal symptoms in bulimic patients and to determine their response to treatment of the eating disorder., Methods: Forty-three consecutive bulimic patients admitted to the inpatient Eating Disorders Unit of the Psychiatry Service were asked to fill out a gastrointestinal symptoms questionnaire, an Eating Disorders Inventory, and a Zung Depression Inventory on admission and discharge. Thirty-two age- and sex-matched healthy volunteers completed the same questionnaire., Results: In bulimic patients, the most commonly reported gastrointestinal symptoms were bloating (74.4%), flatulence (74.4%), constipation (62.8%), decreased appetite (51.2%), abdominal pain (48.8%), borborygmi (48.8%), and nausea (46.5%). The average symptom score (sum of severity ratings) on the gastrointestinal symptoms questionnaire decreased from 20.6 +/- 10.8 (mean +/- SD) on admission to 13.46 +/- 10.5 (t(27) = 3.31, p < 0.01) on discharge but remained significantly higher than that of the control group (4.4 +/- 6.2, t(43) = 4.02, p < 0.001). However, the severity of reported gastrointestinal symptoms was correlated with the severity of depression (r = 0.43, p < 0.05), and when the possible mediating effects of depression on gastrointestinal symptoms were controlled statistically (analysis of covariance), the effects of treatment on gastrointestinal symptoms were not statistically significant., Conclusion: Gastrointestinal symptoms in bulimics are common, multiple, and often severe and they improve with treatment. However, the most important determinant of gastrointestinal symptoms appears to be depression.

Previous studies suggest that the ways in which parents respond to children's health complaints (reinforcement) and the ways in which they cope with their own illnesses (modeling) influence the frequency of symptoms, disability days, and health care visits made by these children when they grow up. However, previous studies have not controlled for the mediating influence of stress, neuroticism, and physical examination findings. This study investigated the influence of childhood social learning on adult illness behavior in 383 women aged 20 to 40 years. Illness behavior was measured prospectively for 12 months by the frequency of symptoms, disability days, and physician visits for menstrual, bowel, and cold (upper respiratory) symptoms. Childhood reinforcement and modeling was measured retrospectively by validated questionnaires. Other independent variables were stress, neuroticism, and selected demographic variables. Multiple regression analysis was used to assess the relative contribution of each independent variable to each category of illness behavior. The principal findings were as follows. First, childhood reinforcement of menstrual illness behavior significantly predicted adult menstrual symptoms and disability days, and childhood reinforcement of cold illness behavior significantly predicted adult cold symptoms and disability days. These effects were independent of stress and neuroticism. Second, childhood reinforcement scales were useful to predict which functional disorders (dysmenorrhea or irritable bowel syndrome) these subjects had even after we controlled for stress and neuroticism.

Objectives: The relationship between menstrual and bowel symptoms, the overlap between the diagnoses of dysmenorrhea (DYS) and functional bowel disorder (FBD), and markers that may be useful in discriminating functional bowel disorders from DYS were studied in 383 women (20-40 yr of age)., Methods: All women completed the NEO Personality Inventory at intake and completed the Moos' Menstrual Distress Questionnaire and a bowel symptom inventory every 3 months for 12 months. Prostaglandin levels were measured in vaginal dialysate on the first day of menses., Results: DYS was diagnosed in 19.8% of the total sample. Functional bowel disorder, defined as abdominal pain with altered bowel function, was diagnosed in 61% of the DYS group compared with 20% of controls (p < 0.05). Neuroticism scores were significantly higher in subjects with functional bowel disorder with or without DYS. However, bowel symptoms were significantly correlated with menstrual symptoms even after statistically controlling for the effects of neuroticism. Painful menses and water retention distinguished the DYS group from the functional bowel disorder group. Prostaglandin levels were elevated in women with DYS, but did not consistently differentiate the diagnostic groups., Conclusions: The strong covariation of menstrual and bowel symptoms, along with the overlap in diagnoses of DYS and function bowel disorder, suggest a common physiological basis.

We evaluated the clinical performance of a new dual chamber pacemaker, ELA Chorus, in 35 patients. This device incorporates linear rate adaptive AV delay (AVDR), rate smoothing, fallback, impedance telemetry, pacemaker mediated tachycardia (PMT) recognition and reprogramming software, intracardiac electrogram displays, autothreshold testing, diagnostic data, battery depletion curves, and laptop computer programming. Mean patient age was 68 years; 18 patients had AV block, six had sinus node dysfunction (one with AV block), nine had carotid sinus hypersensitivity (three with AV block), and two had vagally mediated syncope. At hospital discharge, programming was DDD with a mean low rate of 60 (50-70) beats/min, mean high rate of 126 (120-154) beats/min; AVDR was ON in 21 patients, rate smoothing ON in six patients, fallback ON in six patients, and PMT reprogramming algorithm ON in 27 patients. Pacemaker follow-up involved 500 clinic visits over 14.3 months (1-36). Three patients developed atrial fibrillation, reprogrammed to DDI mode (two patients) or fallback (one patient). Fallback was used 617 times. PMT occurred 427 times in six patients; the PMT algorithm reprogrammed AV delay and postventricular atrial refractory period (PVARP) automatically, a function unique to the Chorus. Intracardiac electrograms and autothreshold testing improved follow-up efficiency. This new dual chamber pacemaker enhances programming flexibility and improves diagnostic accuracy at follow-up.

A standardised inventory of stressful life events and a bowel symptom questionnaire were administered at three month intervals for one year to 383 women who were unselected with respect to bowel symptoms. A NEO Personality Inventory was given initially to assess neuroticism. Subjects who satisfied restrictive diagnostic criteria for irritable bowel syndrome were compared with those who complained of abdominal pain plus altered bowel habits but who did not meet restrictive diagnostic criteria (functional bowel disorder) and with controls without bowel dysfunction. The irritable bowel group showed significantly higher levels of stress than the other two groups even when the confounding effects of neuroticism were statistically controlled for. Time lagged correlations showed that stress in one three month interval was significantly correlated with bowel symptoms in the subsequent three month interval for all groups. The slope of the regression line relating stress to bowel symptoms was significantly steeper for the irritable bowel group than for the other two groups at three and six months, suggesting that subjects with irritable bowel syndrome show a greater reactivity to stress. Stress scores were also significantly correlated with the number of disability days and the number of medical clinic visits for bowel symptoms.

Anorectic and bulimic patients frequently report symptoms of constipation, bloating, and abdominal pain suggestive of abnormal gastrointestinal motility or transit. However, except for studies of gastric emptying, gastrointestinal motility and transit in these eating disorders have not been investigated. Ten anorectic and 18 bulimic inpatients were compared with 10 healthy controls. Whole-gut transit was tested by the radiopaque marker technique, and mouth-to-cecum transit time was assessed by the lactulose breath test. All anorectics and 67% of bulimics complained of constipation. Whole-gut transit time was significantly delayed in both anorectics (66.6 +/- 29.6 hours) and bulimics (70.2 +/- 32.4 hours) compared with controls (38.0 +/- 19.6 hours). Mouth-to-cecum transit time also tended to be longer in anorectics (109.0 +/- 33.5 minutes) and bulimics (106.2 +/- 24.5 minutes) than in controls (84.0 +/- 27.7 minutes), but these differences were not statistically significant. Delayed transit could contribute to or perpetuate the eating disorders by (a) causing the patient to feel bloated, thereby exacerbating fear of fatness, or (b) causing rectal distention, which may reflexly inhibit gastric emptying.

This study monitored high-amplitude propagated contractions (HAPCs) in ambulating subjects over a 24-h period using a new ambulatory recording system. Twelve healthy volunteers aged 34 +/- 5.96 yr participated. Approximately 12 h after a Colyte bowel prep, a small catheter (OD less than 3 mm), containing three solid-state pressure transducers spaced 5 cm apart, was positioned by flexible sigmoidoscope at 40-50 cm from the anal verge. A battery-operated data recorder sampled the pressure at each port at 1 Hz and stored the values on all ports if any port exceeded 75 mmHg. At the conclusion of the 24-h period, an X-ray was taken to confirm the location of the catheter. Fifty-four percent of all HAPCs preceded a bowel movement by less than or equal to 1 h. Forty-nine percent of all HAPCs occurred within 1 h after a high-fat meal, and 33% occurred within 1 h of morning awakening. Reverse propagated waves, not previously described in the colon, were observed in three individuals. Spontaneous high-amplitude caudally propagated contractions occur 6.9 +/- 1.5 times/24 h in the sigmoid colon in ambulating asymptomatic individuals and are temporally related to defecation and meals. Peristaltic activity is decreased during sleep. This recording technique was reliable and well tolerated in all participants.

New, restrictive criteria discriminate the irritable bowel syndrome (IBS) from normals and other gastrointestinal disorders with a high degree of specificity but lesser sensitivity. The diagnosis is based on positive features that include these criteria. In addition, some structural or biochemical disorders are ruled out by routine tests, whereas others require specialized tests when specific symptoms indicate. Extracolonic and extraintestinal symptoms that often accompany IBS suggest a generalized smooth-muscle or autonomic disorder that may require further investigation as well.

Patients with functional bowel disorders frequently complain of bloating and abdominal pain, but no practical method is available to measure intestinal gas objectively. To evaluate a new technique, we evaluated 54 abdominal radiographs from 19 patients. A gastroenterologist and a radiologist independently outlined the intestinal gas bubbles in these films. Areas of gas bubbles were measured with a computer digitizing board. Bowel gas was also measured in 24 healthy controls, and in five emergency room patients, supine and erect radiographs were compared to evaluate the effects of position on bowel gas patterns. The two evaluators agreed well on the measured areas of bowel gas (r = 0.96), showing that this is a reliable method. Bowel gas was significantly greater in patients than in controls but did not correlate with symptoms. Bowel gas was significantly greater in supine than upright films, showing that the position of the patient must be standardized.

Many women report that bowel symptoms are associated with menstruation, but neither the prevalence of these complaints nor their physiological basis is known. This study aimed to estimate prevalence, to determine whether patients with irritable bowel syndrome are more likely to make such complaints, and to determine whether bowel complaints during menstruation are attributable to psychological traits such as increased somatization. To estimate prevalence, 369 clients of Planned Parenthood of Maryland were asked whether gas, diarrhea, or constipation occurred during menstruation. These subjects were compared with women referred to a gastroenterology clinic and found to have irritable bowel syndrome or functional bowel disorder (abdominal pain plus altered bowel habits but not satisfying restrictive criteria for irritable bowel syndrome). Thirty-four percent of 233 Planned Parenthood clients who denied symptoms of irritable bowel syndrome or functional bowel disorder reported that menstruation was associated with one or more bowel symptoms. Gastroenterology clinic patients with irritable bowel syndrome were significantly more likely to experience exacerbations of each of these bowel symptoms, but especially increased bowel gas. Self-reports of bowel symptoms during menstruation were not associated with psychological traits or with menses-related changes in affect.

The prevalence of diverticular disease shows a striking correlation with advancing age. The spectrum of disease ranges from the entirely asymptomatic to a life-threatening surgical emergency. The diagnosis of acute diverticulitis is often particularly difficult to make in the elderly because of muted symptoms and signs. Current concepts of diagnosis and therapy are discussed.

Two hypotheses were tested: (a) lowered tolerance for balloon distention of the rectosigmoid in patients with irritable bowel syndrome is caused by a psychological tendency to exaggerate the painfulness of any aversive stimulus, and (b) contractions elicited by balloon distention are responsible for pain reports. Tolerance for stepwise distention of a balloon in the rectosigmoid was compared with tolerance for holding one hand in ice water in 16 irritable bowel patients, 10 patients with functional bowel disorder who did not satisfy restrictive criteria for irritable bowel, 25 lactose malabsorbers, and 18 asymptomatic controls. Contractile activity was measured 5 cm above and 5 cm below the distending balloon. Psychometric tests were used to assess neuroticism, anxiety, and depression, and a standardized psychiatric interview was administered. Patients with irritable bowel syndrome had significantly lower tolerance for balloon distention but not ice water, and balloon tolerance was not correlated with neuroticism or other psychological traits measured. Rectosigmoid and rectal motility were also not related to tolerance for balloon distention. Both hypotheses were rejected. A peripheral mechanism such as altered receptor sensitivity may be the cause of distention pain in irritable bowel syndrome.

To determine whether bowel symptoms covary in a pattern consistent with the existence of irritable bowel as a distinct syndrome, bowel symptom questionnaires from 2 independent samples were factor analyzed. Samples consisted of 351 18-40-yr-old women who visited Planned Parenthood clinics for contraception and 149 18-89-yr-old women recruited through church women's societies. Factor analysis of 23 bowel symptoms identified 4 factors (clusters of symptoms that were correlated with each other) in both samples. The factor accounting for the most variance in both samples included relief of pain with defecation, looser stools with pain onset, more frequent stools with pain, and gastrointestinal reactions to eating. This irritable bowel factor was not correlated with an objective measure of lactose intolerance. An independent constipation factor was found in both samples to include self-reported constipation, straining with bowel movements, feeling of incomplete evacuation, and rectal bleeding. Thus factor analysis of bowel symptoms supports the existence of a specific irritable bowel syndrome and suggests symptoms that may be used to diagnose this syndrome.

Pneumatic perforation of the bowel is a rare complication of colonoscopy. Pneumatic ileal perforation complicating this procedure has not been reported. We describe a case of pneumatic ileal perforation during colonoscopy in an elderly lady who also had adhesions from previous abdominal surgery. A relative lack of symptomatology, the finding of a clean ileal perforation at surgery, and a benign postoperative period characterized her course. Possible etiological factors are discussed with reference to the literature dealing with intraluminal pressures in the bowel. Pressure much higher than the physiological pressure is likely to be reached during colonoscopy, with reflux of air across the ileocecal sphincter acting as a safety mechanism. Bursting pressures differ for different layers of the bowel and from segment to segment. This report calls attention to certain risk factors which might lead to a remote perforation during colonoscopy.

Because of reports suggesting the efficacy of metronidazole therapy in the healing of perianal fistulae in Crohn's disease, the effect of metronidazole on symptoms of Crohn's disease and associated perianal fistulae were evaluated in eight consecutive patients. The criterion for entry into the study was the presence of resistant fistulae in patients with Crohn's disease. The duration of intestinal Crohn's ranged from 1/2-30 years and fistulae from 1-14 years. All patients had ileocolitis or pancolitis. Two had enteroenteric fistulae in addition to perianal fistulae. All had had previous surgery, half for fistulae and half for intestinal complications, usually obstruction. All had been on Prednisone. All but one had received multiple other drugs including Azathioprine, Azulfidine, antibiotics, and rectal steroids. Patients were placed on metronidazole 1000 to 1500 mg/day orally in divided doses. The number of draining fistulae was reduced 20-fold and the number of detectable fistulous openings by 50%. All patients had relief of fistula-associated pain; general Crohn's disease symptoms improved as well. Complete resolution of all symptoms occurred in half the patients. All patients experienced side effects, six had numbness of toes and five had metallic taste. Resolution of side effects occurred on discontinuation of metronidazole after 1-3 wk off the drug in all except one patient. All patients noted continued improvement in Crohn's symptoms during 6 months of follow-up after cessation of their therapy. Other side effects that have been reported with metronidazole therapy were not seen in our patients.