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BACKGROUND AND AIMS: Conditions such as irritable bowel syndrome (IBS), functional dyspepsia, and functional constipation are among the prevalent gastrointestinal (GI) disorders classified as disorders of gut-brain interaction (DGBI), which can adversely affect the lives of sufferers. This study aimed to assess the degree and consequences of overlapping DGBI in a large population-based global scale. METHODS: Internet survey data from 54,127 adults (49.1% women) in 26 countries were analyzed by 4 GI anatomic regions (esophageal, gastroduodenal, bowel, and anorectal). The number of DGBI-affected GI regions was assessed, including associations with sex, age, disease severity, quality of life, psychosocial variables, and health care utilization. RESULTS: A total of 40.3% of surveyed individuals met Rome IV criteria for a DGBI. The percentages with 1-4 DGBI-affected GI regions were 68.3%, 22.3%, 7.1%, and 2.3%, respectively. The IBS symptom severity score increased significantly from 1 (207.6) to 4 (291.6) regions, as did non-GI symptom reporting (somatization), anxiety and depression, concerns and embarrassment about bowel function, doctor visits, medications, and abdominal surgeries (all P < .0001). Quality of life decreased with increasing number of DGBI regions (P < .0001). In a logistic mixed model, non-GI symptoms (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.08-1.10), being very vs not concerned (OR, 2.55; 95% CI, 2.27-2.90), being very vs not embarrassed about bowel function (OR, 1.20; 95% CI, 1.08-1.33), and mean number of doctor visits (OR, 1.23; 95% CI, 1.115-1.32) were most strongly associated with number of DGBI regions. CONCLUSIONS: DGBI in multiple anatomic GI regions is associated with increased psychological comorbidity, health care utilization, and IBS severity. Physician awareness of overlap could improve quality of care, prevent unnecessary interventions, and yield more positive health outcomes. ispartof: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY vol:20 issue:5 pages:E945-E956 ispartof: location:United States status: published

Fecal incontinence (FI) is a debilitating gastrointestinal disorder with a devastating impact on quality of life

To estimate the significance of the association between mid-trimester maternal serum alpha-fetoprotein (MSAFP) level and fetal neuroanatomic findings in cases of open neural tube defect (ONTD).Retrospective study of patients referred for prenatal ONTD repair between 2012 and 2018. Cases were classified into three groups based on their MSAFP level: 1)High MSAFP (3.8MoM - n = 22), 2)Moderately high MSAFP (≤3.8 and ≥2.5MoM - n = 28), 3)Normal MSAFP (2.5MoM - n = 18). MRI scans at the time of referral were used to assess the relationship between MSAFP and: A)Type of ONTD; B) Ventriculomegaly; C) Size of the myeloschisis lesion; D) Volume of myelomeningocele; E) Anatomical level of the lesion (LL).Having a high MSAFP level was more likely to be associated ventriculomegaly at mid-gestation than a moderately high or normal MSAFP level (OR = 8.4;CI95[0.9-73.4];p = 0.05 and OR = 2.8;CI95[0.9-8.8];p = 0.07). There were no differences between the three groups regarding type of lesion, size of the myeloschisis lesion, anatomic LL, or volume of the myelomeningocele sac. Myeloschisis cases with normal MSAFP had a larger surface area when compared to myeloschisis cases with moderately high MSAFP (219.8[104.4-551] vs 155.4[38.5-502.4] mm², p = 0.04).A 2nd trimester MSAFP level3.8MoM in a fetus with ONTD is associated with mid-gestation ventriculomegaly.

Summary Background Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo. Methods In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565. Findings Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change −1·5 points, 95% CI −3·4 to 0·4, p=0·12), biofeedback versus education (−0·7 points, −2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (−1·9 points, −4·1 to 0·3, p=0·092) or versus loperamide plus education (−1·1 points, −3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group). Interpretation In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health

Background & Aims The diagnostic criteria for fecal incontinence (FI) were made more restrictive in the Rome IV revision. We aimed to determine the characteristics of FI patients defined by the Rome IV criteria, assess how FI frequency and amount affect quality of life, identify risk factors, and compare prevalence values among countries. Methods We performed an internet-based survey of 5931 subjects in the United States, Canada, and the United Kingdom, from September to December 2015. Subjects were stratified by country, sex, and age. Responders answered questions about diagnosis, health care use, and risk factors. We performed multivariate linear regression analysis to identify risk factors for FI. Results FI was reported by 957 subjects (16.1%) but only 196 (3.3%) fulfilled the Rome IV criteria. Frequency of FI was less than twice a month for 672/957 subjects (70.2%) and duration was less than 6 months for 285/957 subjects (29.8%). Quality of life was significantly impaired in all subjects with FI compared to subjects with fecal continence. The strongest risk factors for FI were diarrhea, urgency to defecate, and abdominal pain. FI was more prevalent in the United States than in the United Kingdom. Between-country differences were due to less diarrhea and urgency in the United Kingdom. Conclusions Rome IV FI prevalence is lower than previous estimates because the new criteria exclude many individuals with less frequent or short duration FI. These excluded patients have impaired quality of life. It might be appropriate to make a diagnosis of FI for all patients with FI ≥2 times in 3 months and to provide additional information on frequency, duration, and amount of stool lost to assist clinicians in treatment selection.

Background & Aims Functional nausea and vomiting disorders (FNVDs) are classified as chronic nausea and vomiting syndrome (CNVS) or cyclic vomiting syndrome (CVS)—CVS includes cannabinoid hyperemesis syndrome. We investigated the population prevalence of FNVDs, their characteristics, and associated factors. Methods In the year 2015, an Internet cross-sectional health survey was completed by 5931 adults in the general populations of 3 English-speaking countries; 2100 participants were in the United States, Canada, or the United Kingdom. Quota-based sampling was used to generate demographically balanced and population-representative samples. The survey collected data on demographics, health care visits, medications, somatic symptom severity, quality of life, and symptom-based diagnostic criteria for Rome IV FNVDs as well as for irritable bowel syndrome and functional dyspepsia. Subsequent comparisons were made between Rome IV FNVD subjects and individuals without FNVDs (controls). Results Overall, 2.2% of the population (n = 131) fulfilled symptom-based diagnostic criteria for Rome IV FNVDs: the United States (3%) had a greater prevalence than Canada (1.9%) or the United Kingdom (1.8%) ( P = .02). The prevalence of CNVS was similar among the countries, ranging from 0.8% to 1.2%. However, the prevalence of CVS was higher in the United States (2%) than in Canada (0.7%) or the United Kingdom (1%) ( P = .03). The proportion of subjects with CVS taking cannabis did not differ significantly among countries ( P = .31), although the 7 cases of cannabinoid hyperemesis syndrome were in the United States. A significantly higher proportion of subjects with CVS reported a compulsive need for hot water bathing to alleviate emetic symptoms than subjects with CNVS (44% vs 19%; P = .03); this behavior was independent of cannabis but augmented by its use. Subjects with FNVDs had significantly greater health impairment and health care utilization than controls. On multivariate analysis, independent factors associated with FNVDs were younger age, increasing somatic symptom severity, lower quality of life, presence of irritable bowel syndrome, and functional dyspepsia. However, on subgroup analysis, somatic symptom severity was associated with CVS but not CNVS, whereas poor quality of life was associated with CNVS but not CVS. Conclusions Based on a cross-sectional health survey of adults in the general populations of 3 English-speaking countries, approximately 2% of subjects meet symptom-based criteria for Rome IV FNVDs and have considerable health impairments. Hot water bathing to alleviate emetic symptoms is reported for all FNVDs, and is perpetuated by cannabis use.

Gymnastics is a judgement-based sport whereby the decision-making processes of judges are expected to lead to valid and reliable outcome scores. The concurrent Think Aloud method has been used to study decision-making amongst coaches and athletes in previous sport-related studies but never in judging-based studies. Hence, this project has two aims: 1) to explore decision-making underpinning the judging process in Women’s Artistic Gymnastic (WAG) by using a concurrent verbal report, Think Aloud (TA) and: 2) to examine the utilisation of TA as a means to facilitate judging education with Malaysian WAG judges. 10 qualified judges were required to verbalise (TA) their thought processes whilst judging a balance beam routine. Follow-up interviews investigated the prospective utilisation of TA within judging education. During the judging process participants verbally reported most frequently as to lack of balance, bending of arms and knees, pointing of feet, confidence, rhythm and tempo, and personal style as focal points for scoring. Overall TA was reported prospectively as an appropriate tool for use within judging education, however, some participants reported performance in the primary task of judging was affected by TA. Study outcomes reported the potential utility of TA to study the decision-making process amongst judges to enable deduction scores to be applied objectively. This study will inform future research to investigate the decision-making processes of both expert and novice judging extending to that of all four WAG apparatus.

Individuals with celiac disease (CD) can experience persisting gastrointestinal symptoms despite adhering to a gluten-free diet (GFD). This may be due to functional gastrointestinal disorders (FGIDs), although there is little data on its prevalence and associated factors.An online health questionnaire was completed by adult members of Celiac UK in October 2018. The survey included validated questions on Rome IV FGIDs, nongastrointestinal somatic symptoms, anxiety, depression, quality of life, health care use, GFD duration, and its adherence using the celiac dietary adherence test score (with a value ≤ 13 indicating optimal adherence). The prevalence of FGIDs and associated health impairment in the celiac cohort was compared against an age- and sex-matched population-based control group.Of the 863 individuals with CD (73% female; mean age, 61 years), all were taking a GFD for at least 1 year, with 96% declaring that they have been on the diet for 2 or more years (2-4 years, 20%; ≥5 years, 76%). The adherence to a GFD was deemed optimal in 61% (n = 523), with the remaining 39% (n = 340) nonadherent. Those adhering to a GFD fulfilled criteria for a FGID in approximately one-half of cases, although this was significantly lower than nonadherent subjects (51% vs 75%; odds ratio [OR], 2.0; P.001). However, the prevalence of FGIDs in GFD-adherent subjects was significantly higher than in matched population-based controls (35%; OR, 2.0; P.001). This was accounted for by functional bowel (46% vs 31%; OR, 1.9; P.0001) and anorectal disorders (14.5% vs 9.3%; OR, 1.7; P = .02) but not functional esophageal (7.6% vs 6.1%; P = .36) or gastroduodenal disorders (8.7% vs 7.4%; P = .47). Finally, GFD-adherent subjects with FGIDs were significantly more likely than their counterparts without FGIDs to have abnormal levels of anxiety (5% vs 2%; OR, 2.8; P = .04), depression (7% vs 2%; OR, 3.6; P = .01), somatization (31% vs 8%; OR, 5.1; P.0001), and reduced quality of life (P.0001).One in 2 people with CD, despite having been on a GFD for a number of years and demonstrating optimal adherence, have ongoing symptoms compatible with a Rome IV FGID. This is 2-fold the odds of FGIDs seen in age- and sex-matched controls. The presence of FGIDs is associated with significant health impairment, including psychological comorbidity. Addressing disorders of gut-brain interaction might improve outcomes in this specific group of patients.

Objectives\ud Three studies involved the investigation of concurrent cognitive processes and pacing behaviour during a 16.1 km cycling time trial (TT) using a novel Think Aloud (TA) protocol. Study 1 examined trained cyclist's cognitions over time whilst performing a real-life 16.1 km time trial (TT), using TA protocol. Study 2, included both trained and untrained participants who performed a 16.1 km TT in a laboratory whilst using TA. Study 3 investigated participants' experiences of using TA during a TT performance.\ud Method\ud Study 1 involved 10 trained cyclists performing a real life 16.1 km TT. Study 2 included 10 trained and 10 untrained participants who performed a laboratory-based 16.1 km TT. In both studies, all participants were asked to TA. Time, power output, speed and heart rate were measured. Verbalisations were coded into the following themes (i) internal sensory monitoring, (ii) active self-regulation, (iii) outward monitoring (iv) distraction. Cognitions and pacing strategies were compared between groups and across the duration of the TT. In study 3 all participants were interviewed post TT to explore perceptions of using TA.\ud Results\ud Study 1 and 2 found cognitions and pacing changed throughout the TT. Active self-regulation was verbalised most frequently. Differences were found between laboratory and field verbalisations and trained and untrained participants. Study 3 provided support for the use of TA in endurance research. Recommendations were provided for future application.\ud Conclusion\ud Through the use of TA this study has been able to contribute to the pacing and cycling literature and to the understanding of endurance athletes’ cognitions.

Objective In this study, we aimed to understand the self-regulatory processes facilitating optimal experiences in running by integrating models of self-regulation with flow and clutch states. Method Using an event-focused approach, we interviewed 16 runners less than one day on average after recreational running activities (M = 22.17 hours later, range = 3–46) they described as positive, rewarding experiences. Our analysis drew on principles for thematic and connecting analyses. Results We structured our analysis of the self-regulatory processes facilitating flow and clutch states into three overarching themes: forethought; monitoring; and control. Flow was facilitated by intrinsic experiential motives and non-specific goals, whereas clutch states involved an intrinsic motive to accomplish specific goals. The perceived ease and pleasure during flow motivated runners to continue this experience, which appeared to be aided by active and involuntary distraction. Conversely, clutch states were described as more effortful and less pleasant during the run, with active self-regulation strategies used to exert control over cognition and manage feelings of difficulty. Attending to specific outward or internal sensory stimuli appeared to initiate changes that contributed to the disruption of flow, although many runners described transitioning into a clutch state after flow disruption. No runner reported transitioning from a clutch state into flow. Conclusions Our study offers novel insights into optimal experiences in running by integrating models of self-regulation with flow and clutch states. We discuss how these insights can inform research and applied practice seeking to develop interventions for promoting optimal experiences during running.

Fecal incontinence (FI), the involuntary passage of stool, is common and can markedly impair the quality of life. Among patients who fail initial options (pads or protective devices, bowel modifying agents, and pelvic floor exercises), the options are pelvic floor biofeedback (BIO), perianal injection with bulking agents (INJ), and sacral nerve electrical stimulation (SNS), which have not been subjected to head-to-head comparisons. This study will compare the safety and efficacy of BIO and INJ for managing FI. The impact of these approaches on quality-of-life and psychological distress, cost effectiveness, and predictors of response to therapy will also be evaluated. Six centers in the United States will enroll approximately 285 patients with moderate to severe FI. Patients who have 4 or more FI episodes over 2 weeks proceed to a 4-week trial of enhanced medical management (EMM) (ie, education, bowel management, and pelvic floor exercises). Thereafter, 194 non-responders as defined by a less than 75% reduction in the frequency of FI will be randomized to BIO or INJ. Three months later, the efficacy, safety, and cost of therapy will be assessed; non-responders will be invited to choose to add the other treatment or SNS for the remainder of the study. Early EMM responders will be re-evaluated 3 months later and non-responders randomized to BIO or INJ. Standardized, and where appropriate validated approaches will be used for study procedures, which will be performed by trained personnel. Prospectively collected data on care costs and resource utilization will be used for cost effectiveness analyses.

While it is well known that maternal temperature affects fetal heart rate, the exact relationship is not well described. The circumstances accompanying most cases of maternal hypothermia and rewarming (e.g. a drowning event) have precluded a precise quantitative description of this relationship. We describe hypothermia and controlled rewarming during resection of a maternal brain stem tumor in the early third trimester. Continuous electronic fetal heart rate and core temperature monitoring demonstrated a near linear relationship during the development of hypothermia and rewarming. Recognition of the close relationship between maternal temperature and fetal heart rate can help safeguard maternal and fetal health, and prevent unnecessary delivery during non-obstetric surgery in pregnancy.

Clostridium perfringens is an important cause of foal necrotizing enteritis and canine acute hemorrhagic diarrhea. A major virulence determinant of the strains associated with these diseases appears to be a beta-sheet pore-forming toxin, NetF, encoded within a pathogenicity locus (NetF locus) on a large tcp-conjugative plasmid. Strains producing NetF also produce the putative toxin NetE, encoded within the same pathogenicity locus, as well as CPE enterotoxin and CPB2 on a second plasmid, and sometimes the putative toxin NetG within a pathogenicity locus (NetG locus) on another separate large conjugative plasmid. Previous genome sequences of two netF-positive C. perfringens showed that they both shared three similar plasmids, including the NetF/NetE and CPE/CPB2 toxins-encoding plasmids mentioned above and a putative bacteriocin-encoding plasmid. The main purpose of this study was to determine whether all NetF-producing strains share this common plasmid profile and whether their distinct NetF and CPE pathogenicity loci are conserved. To answer this question, 15 equine and 15 canine netF-positive isolates of C. perfringens were sequenced using Illumina Hiseq2000 technology. In addition, the clonal relationships among the NetF-producing strains were evaluated by core genome multilocus sequence typing (cgMLST). The data obtained showed that all NetF-producing strains have a common plasmid profile and that the defined pathogenicity loci on the plasmids are conserved in all these strains. cgMLST analysis showed that the NetF-producing C. perfringens strains belong to two distinct clonal complexes. The pNetG plasmid was absent from isolates of one of the clonal complexes, and there were minor but consistent differences in the NetF/NetE and CPE/CPB2 plasmids between the two clonal complexes.

Summary Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders. A stepwise management approach is advocated for patients with IBS. For a substantial proportion of patients with mild symptoms, general management principles, including making a confident diagnosis and offering explanation, reassurance, and dietary and lifestyle advice, are sufficient. However, many patients continue to have moderate-to-severe symptoms and are not satisfied solely with this approach. In these patients, use of pharmacotherapy on the basis of the predominant symptom (constipation, diarrhoea, pain, or bloating) or combination of symptoms is the next step. For patients with symptoms that are refractory to these initial treatment options and those who have comorbid conditions or psychological symptoms, a combination of therapies should be used, and the use of psychotropic drugs and psychological treatment alternatives is often effective. Finally, the key to successful treatment of patients with IBS is a good physician–patient relationship and use of person-centred care principles.

Individuals with hypermobility spectrum disorder or hypermobile Ehlers-Danlos Syndrome (HSD/hEDS) are increasingly encountered by gastroenterologists and pose complex clinical challenges. Uncontrolled studies have found functional gastrointestinal disorders (FGIDs) to be common in patients with HSD/hEDS. Some patients have somatic symptoms (medically unexplained symptoms) that might affect FGIDs. We performed a case-control study to determine the prevalence of and factors associated with Rome IV FGIDs in subjects with HSD/hEDS compared with age- and sex- matched population-based controls.An online general health survey was completed by 603 individuals with HSD/hEDS in October 2018 (cases) and 603 matched individuals from the population of the United Kingdom (controls) in 2015. The mean participant age was 39 yrs, and 96% were women. The survey included questions about Rome IV FGIDs, non-GI and non-musculoskeletal somatic symptoms (maximum number, 10), quality of life, medical history and healthcare use. The prevalence of FGIDs was compared between cases and controls, with subsequent logistic regression models - adjusting for the number of somatic symptoms - used to determine the associations for FGIDs in HSD/hEDS compared with controls.Nearly all subjects (98%) with HSD/hEDS fulfilled symptom-based criteria for 1 or more Rome IV FGIDs, compared with 47% of controls (P.0001). The gastrointestinal regions most commonly affected by FGIDs in individuals with HSD/hEDS and control subjects were the bowel (90% vs 40% of controls), gastroduodenal (70% vs 13% of controls), esophageal (56% vs 6% of controls), and anorectal (53% vs 9% of controls); P.0001. A higher proportion of subjects with HSD/hEDS had FGIDs in 2 or more regions (84% vs 15% of controls; P.0001). Subjects with HSD/hEDS also reported a significantly higher number of non-GI and non-musculoskeletal somatic symptoms (7.1 vs 3.3 in controls), lower quality of life, and greater healthcare use, including abdominal surgeries and medication use (for example, 84% used analgesics compared with 29% of controls). Almost 40% of subjects with HSD/hEDS reported a diagnosis of chronic fatigue syndrome and/or fibromyalgia. Following adjustments for somatic symptoms, the association for FGIDs in subjects with HSD/hEDS was reduced by as much as 4-fold and in some instances was eliminated.In a large case-control study of persons with HSD/hEDS, almost all of the cases met criteria for Rome IV FGIDs, incurred considerable health impairment, and had high healthcare use. Patients with HSD/hEDS frequently have somatic symptoms that should be treated to reduce the high burden of gastrointestinal illness in this population.

The Rome IV Diagnostic Questionnaires were developed to screen for functional gastrointestinal disorders, serve as inclusion criteria in clinical trials, and support epidemiologic surveys. Separate questionnaires were developed for adults, children and adolescents, and infants and toddlers. For the adult questionnaire, we first surveyed 1162 adults without gastrointestinal disorders, and recommended the 90th percentile symptom frequency as the threshold for defining what is abnormal. Diagnostic questions were formulated and verified with clinical experts using a recursive process. The diagnostic sensitivity of the questionnaire was tested in 843 patients from 9 gastroenterology clinics, with a focus on clinical diagnoses of irritable bowel syndrome (IBS), functional constipation (FC), and functional dyspepsia (FD). Sensitivity was 62.7% for IBS, 54.7% for FD, and 32.2% for FC. Specificity, assessed in a population sample of 5931 adults, was 97.1% for IBS, 93.3% for FD, and 93.6% for FC. Excess overlap among IBS, FC, and FD was a major contributor to reduced diagnostic sensitivity, and when overlap of IBS with FC was permitted, sensitivity for FC diagnosis increased to 73.2%. All questions were understandable to at least 90% of individuals, and Rome IV diagnoses were reproducible in three-fourths of patients after 1 month. Validation of the pediatric questionnaires is ongoing.

Background & Aims Little is known about the population prevalence or demographic distributions of Rome IV functional bowel disorders (FBDs) or their effects on quality of life. We examined these in a multinational survey. Methods We analyzed data from a population-based survey of adults in the United States, Canada, and United Kingdom (5931 valid responders; 49.2% female; mean age, 47.4 years; range, 18–92 years). The survey included the Rome IV Diagnostic Questionnaire, Rome III irritable bowel syndrome (IBS) and constipation questions, and the SF-8 quality of life questionnaire. Results The prevalence values of census-adjusted Rome IV FBDs were similar among the 3 countries; ranges were: 4.4%–4.8% for IBS, 7.9%–8.6% for functional constipation, 3.6%–5.3% for functional diarrhea, 2.0%–3.9% for functional bloating or distention, 1.1%–1.9% for opioid-induced constipation, 7.5%–10.0% for unspecified FBDs, and 28.6%–31.7% for any Rome IV FBD. FBDs were less common in older individuals, and all except functional diarrhea were more common in women. IBS was only half as prevalent by Rome IV as by Rome III criteria (4.6% vs 9.0% overall), primarily due to higher Rome IV minimum pain frequency. Functional diarrhea and functional constipation were more prevalent by Rome IV than Rome III criteria. Subjects with FBD had significant reductions in quality of life and reported more gastrointestinal doctor consultations than other subjects. Conclusions More than 1 in 4 adults in the general population meet the Rome IV criteria for FBDs. These disorders affect quality of life and increase use of gastrointestinal health care. The switch from Rome III to Rome IV criteria reduces the prevalence of IBS by half, but increases the prevalence of functional constipation and functional diarrhea.

Background & Aims The balloon evacuation test (BET) measures the time required to evacuate a balloon filled with 50 mL water; it has been incorporated into many algorithms for diagnosis of pelvic floor dyssynergia. We aimed to assess the reproducibility of the BET, determine the upper limit of normal, and assess its concordance with evaluation of pelvic floor dyssynergia by anorectal manometry (ARM) and pelvic floor surface electromyography (EMG). Methods The BET was tested in 286 consecutive patients with chronic constipation (mean age, 44 years; 91% female) before and after 30 days of conservative treatment at a tertiary gastroenterology clinic in Italy from March 2010 through May 2012. The BET was tested twice, 7 days apart, in 40 healthy individuals (controls: mean age, 38 years; 92% female). The 238 constipated patients who responded incompletely to conservative therapy were examined by ARM, EMG, and digital rectal examination. Forty-seven patients with conflicting ARM and BET results underwent defecography. Results The balloon was evacuated within 1 minute by 37 controls (93%; 3 individuals required 1–2 minutes). Among patients with constipation, 148 (52%) passed the balloon within 5 minutes (110 passed the balloon in 1 minute, 35 passed it in 1–2 minutes, and 3 passed it in 2–5 minutes). The BET showed perfect reproducibility in 280 of the patients with constipation (98%) when a time less than 2 minutes was set as abnormal. The level of agreement between BET and ARM for dyssynergia was 78%, and between BET and EMG it was 83%. Thirty-two patients had abnormal results from the BET but normal results from ARM; 31 cases had inadequate straining (n = 11) or anatomic defects (n = 20), which could account for the abnormal findings from BET. Conclusions The BET is reliable for analysis of pelvic floor dyssynergia; the optimal upper limit of normal is 2 minutes. Findings from the BET have a high level of agreement with those from ARM and EMG.

PurposeWe compared proton beam therapy (PBT) with intensity modulated radiation therapy (IMRT) for pediatric craniopharyngioma in terms of disease control, cyst dynamics, and toxicity.Methods and MaterialsWe reviewed records from 52 children treated with PBT (n=21) or IMRT (n=31) at 2 institutions from 1996-2012. Endpoints were overall survival (OS), disease control, cyst dynamics, and toxicity.ResultsAt 59.6 months' median follow-up (PBT 33 mo vs IMRT 106 mo; P

Summary Objectives Ginger is one of the most commonly used herbal medicines for irritable bowel syndrome (IBS) but no data exists about its effectiveness. Design Double blind randomized controlled trial. Setting University of North Carolina, Chapel Hill, North Carolina, USA. Intervention Forty-five IBS patients were randomly assigned to three groups: placebo, 1 g of ginger, and 2 g of ginger daily for 28 days. Main outcome measures The IBS severity scale (IBS-SS) was administered, as well as adequate relief of symptoms scale. A responder was defined as having at least 25% reduction in IBS-SS post-treatment. Results There were 57.1% responders to placebo, 46.7% to 1 g and 33.3% to 2 g of ginger. Adequate relief was reported by 53.3% on placebo and 53.3% in both ginger groups combined. Side effects were mild and reported by 35.7% in the placebo and 16.7% in the ginger groups. Conclusions This double blind randomized controlled pilot study suggests ginger is well tolerated but did not perform better than placebo. Larger trials are needed before any definitive conclusions can be drawn.

Objective Malignant middle cerebral artery infarction (mMCAI) is a life-threatening condition in pediatric patients. Despite strong evidence showing decreased morbidity and mortality in adult mMCAI patients with decompressive hemicraniectomy (DCH), there is a paucity of data on the use of DCH in children with similar conditions. Here we report experience from our center and perform a systematic review of published literature on outcomes after use of DCH in pediatric mMCAI patients. Methods By retrospective chart review, we identified 3 children with large ischemic stroke who underwent DCH for life-threatening cerebral edema. Information was obtained about patient characteristics on admission, radiological features of the stroke, surgical procedures, complications of the DCH and cranioplasty, and functional outcomes during follow-up visits. We also reviewed the current literature on DCH in pediatric stroke. Results DCH was performed in all 3 cases after development of pupillary dilatation. All 3 children survived and were ambulatory at the time of follow-up. Review of literature identified 12 other published case series describing 26 cases of DCH in pediatric patients with ischemic stroke. Descriptive statistical analysis of these cases is presented. Published reports suggest that a good outcome is possible even in the presence of signs of herniation, low preoperative Glasgow Coma Scale score, involvement of multiple vascular territories, or longer time to surgery in pediatric ischemic stroke patients. Conclusions The current data suggest a role for DCH in the management of cerebral edema in pediatric patients with mMCAI. Factors that help in prognostication for adult stroke patients undergoing DCH do not appear to convey similar information about the pediatric population. This highlights the urgent need for collaboration across institutes to further investigate this potentially life-saving procedure in pediatric stroke.

There is evidence that psychological factors affect the onset, severity and duration of irritable bowel syndrome (IBS). However, it is not clear which psychological factors are the most important and how they interact. The aims of the current study are to identify the most important psychological factors predicting IBS symptom severity and to investigate how these psychological variables are related to each other.Study participants were 286 IBS patients who completed a battery of psychological questionnaires including neuroticism, abuse history, life events, anxiety, somatization and catastrophizing. IBS severity measured by the IBS Severity Scale was the dependent variable. Path analysis was performed to determine the associations among the psychological variables, and IBS severity.Although the hypothesized model showed adequate fit, post hoc model modifications were performed to increase prediction. The final model was significant (Chi(2)=2.2; p=0.82; RMSEA.05) predicting 36% of variance in IBS severity. Catastrophizing (standardized coefficient (β)=0.33; p.001) and somatization (β=0.20; p.001) were the only two psychological variables directly associated with IBS severity. Anxiety had an indirect effect on IBS symptoms through catastrophizing (β=0.80; p.001); as well as somatization (β=0.37; p.001). Anxiety, in turn, was predicted by neuroticism (β=0.66; p.001) and stressful life events (β=0.31; p.001).While cause-and-effect cannot be determined from these cross-sectional data, the outcomes suggest that the most fruitful approach to curb negative effects of psychological factors on IBS is to reduce catastrophizing and somatization.

To create and validate empirically derived questionnaires that measure non-gastrointestinal symptoms and disorders that co-exist with irritable bowel syndrome (IBS).A systematic review of the world literature identified all non-GI symptoms and diagnoses known to have excess frequency in IBS patients. These data were used to create the Recent Physical Symptoms Questionnaire (RPSQ), which measures somatization (the psychological tendency to report multiple physical symptoms), and the Comorbid Medical Conditions Questionnaire (CMCQ). The psychometric properties of these questionnaires were assessed in two studies: 109 IBS patients in Study I; 286 IBS patients and 67 healthy controls in Study II.In Study I, the RPSQ and CMCQ showed high test-retest reliability (r=.88 and .95) and good internal consistency (Cronbach alphas: .86 and .70, respectively). In Study II, principal components analysis demonstrated that the RPSQ is a homogeneous somatization scale, but the CMCQ could be divided into 4 subscales: one for psychiatric disorders and 3 for different types of somatic disorders. Concurrent validity of the RPSQ was shown by strong correlations with the Cornell Medical Index (CMI) and the Brief Symptom Inventory-18 (BSI-18) somatization scales. The validity of CMCQ responses was not assessed. Discriminant validity was modest: the BSI-18 anxiety and depression scales were less strongly correlated with the RPSQ than the BSI-18 somatization scale. The RPSQ and CMCQ scores of IBS patients were significantly higher than the scores of healthy controls (P.001).The RPSQ and CMCQ are psychometrically sound measures of somatization and medical comorbidities in IBS.

Objectives (1) Characterize physicians’ management practices for fecal incontinence (FI) among elderly patients, (2) describe physician perceptions of the quality of care for FI provided in nursing homes (NH), and (3) identify physician views and attributes associated with referral of elderly patients with FI to an NH. Design Cross-sectional. Setting United States. Participants Physician members of the American Geriatrics Society. Measurements Questionnaire pertaining to physician views on (1) their own FI management practices, (2) management of FI in NHs, and (3) referral of an elderly patient with FI to an NH. Results Of the respondents (n = 606), 54.1% reported screening for FI and 59.3% thought FI could be managed conservatively on an outpatient basis. Only 32.9% believed NHs provide good care for FI, and 27.1% believed NH care conditions exacerbate FI. Responding to a hypothetical vignette, 10.6% would probably or definitely refer an older adult patient with only FI to an NH, and 17.2% were uncertain about whether or not to refer. Logistic regression analysis identified physician characteristics associated with decreased likelihood of NH referral as the belief that FI can be managed conservatively, the belief that NHs provide poor care for FI, longer practice experience, and practicing in an academic medical center. Conclusion Most geriatricians believe FI can be managed conservatively and that NHs provide poor care for FI. These beliefs plus longer years of practice and practice in an academic setting decrease the likelihood of referral to NH for patients with FI.

Introduction The population prevalence of Rome IV functional gastrointestinal disorders (FGIDs) and their cumulative effect on health impairment is unknown. We used data from a large cross-sectional study of the general population to address this, and compared somatisation, quality of life (QOL), and healthcare utilisation in those fulfilling criteria for Rome IV FGIDs with non-GI and organic-GI disease controls. Method An internet-based health survey was completed by 6300 general population adults from three English-speaking countries (2100 each from US, Canada, and UK). Quota-based sampling was used to ensure equal sex, age and education distribution across the countries. The survey included questions on demographics, medication, surgical history, doctor-diagnosed organic-GI diseases, criteria for the Rome IV FGIDs, the patient health questionnaire-12 somatisation measure, and the Short Form-8 QOL questionnaire. Results Data was available for analysis from 5931 subjects (49.2% female; mean-age 47.4 years). The number of subjects having symptoms compatible with a FGID was 2083 (35%) compared to 3421 (57.7%) non-GI and 427 (7.2%) organic-GI disease controls. Per GI region, the diagnostic criteria for bowel disorders were the most frequently met of all the FGIDs (n=1665, 28.1%), followed by gastroduodenal (n=627, 10.6%), anorectal (n=440, 7.4%), esophageal (n=414, 7%), and gallbladder disorders (n=10, 0.2%). On average, the 2083 individuals who met FGID criteria qualified for 1.5 FGID diagnoses, and 742 of them (36%) qualified for FGID diagnoses in more than one GI region. The presence of FGIDs in multiple regions was associated with increasing somatisation, worse mental and physical QOL, greater use of medical therapies and a higher prevalence of abdominal surgeries (all p Conclusion Roughly a third of the general adult population fulfil diagnostic criteria for a Rome IV FGID. In a third of this subset multiple GI regions are involved and this overlap is associated with increased somatisation, poorer QOL, and greater healthcare utilisation. Disclosure of Interest None Declared

Adults who suffer from chronic pain are at increased risk for suicide ideation and attempts, but it is not clear whether adolescents with chronic pain are similarly at elevated risk. This study investigates whether chronic pain is associated with an increase in suicidal ideation/attempts independent of depression in a population sample of adolescents. We analyzed data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in the United States (N = 9,970). Most chronic pain was related to suicide ideation/attempt both in the last year (odds ratio [OR] 1.3–2.1) and during the subsequent year (OR 1.2–1.8). After controlling for depressive symptoms, headaches (OR = 1.3 last year, OR = 1.2 subsequent year) and muscle aches (OR = 1.3 last year) remained associated with suicide ideation but not suicide attempt. These findings show that chronic pain in adolescence is a risk factor for suicide ideation; this effect is partly but not fully explained by depression. Youth with comorbid depression and chronic pain are at increased risk of thinking about and attempting suicide. Clinicians should be alert to suicide ideation/attempt and comorbid depression in this at-risk population. Perspective Adolescents who suffer from chronic pain are at increased risk for suicide ideation and attempt. Depressive symptoms account for the link between chronic pain and suicide attempt, but do not completely explain why adolescents with chronic pain show suicide ideation.