Setting up a journal club for healthcare professionals in an older people's residential care setting.

With the rise in the number of older people in the population and new developments in older people's services such as integrated care hubs, there is a need for healthcare professionals working with older people to keep up to date with the latest research. This article describes the process of establishing a multidisciplinary journal club in a residential care setting and recognising the potential of such clubs to develop staff members' critical thinking, presentation and communication skills. The authors emphasise the importance of fostering a culture of learning in older people's services and describe how a journal club can support healthcare professionals to maintain their knowledge and improve care.

Impact of eating restriction on gastrointestinal motility in adolescents with IBS.

OBJECTIVE: Gastrointestinal disturbances as a result of changes in eating patterns have been described in eating disorders. Many patients who experience irritable bowel syndrome report changes in eating patterns as a way to cope with their symptoms. Little is known about the consequences of these practices. The aim of this study was to explore whether repeated eating restriction (defined as not eating ≥ 4 hours while hungry) is associated with motility disturbances. METHODS: Of 17 patients with irritable bowel syndrome, subjects were divided into those who habitually restrict their eating (n = 8) and those without eating restriction (n = 9) (age range 15-21, mean 19.2; 64.7% girls). Whole-gut transit time was measured by radiopaque markers, gastric sensitivity was measured by water load test (drinking max of 800 mL of water in 5 minutes or until full), and gastric dysrhythmias by an electrogastrogram. RESULTS: Restrictors drank less water (mean 464.4 mL) than nonrestrictors (mean 613 mL; P = 0.02). No difference was found in gastric dysrhythmias (62.5% vs 77.8%; P = 0.5). Whole-gut transit tended to be slower in the restrictors (mean 51.0 hours) than in nonrestrictors (mean 37.5 hours), but this was not significant. CONCLUSIONS: Eating restriction appears to be associated with increased gastric sensation. More data are needed from larger studies to determine whether eating behaviors are associated with other motility disturbances.

Diagnosis, characterization, and 3-month outcome after detoxification of 39 patients with narcotic bowel syndrome.

UNLABELLED: OBFECTIVES: Narcotic bowel syndrome (NBS) is characterized by a paradoxical increase in abdominal pain associated with continued or escalating dosages of narcotics. This study evaluated the clinical and psychosocial features of patients with NBS and the response to detoxification treatment. METHODS: For 2 years, 39 patients seen by the GI consult service at the University of North Carolina at Chapel Hill (UNC) with presumed NBS were placed on a detoxification program. Clinical, psychosocial, health status, and outcome data were obtained before and after detoxification. Our aims were to: (i) clinically characterize patients with presumed NBS, (ii) assess the clinical response and adverse effects to detoxification, (iii) identify clinical and psychosocial predictors of treatment response, and (iv) determine the clinical outcome at 3 months after detoxification and the time frame for patients who revert back to narcotics. RESULTS: Of the 39 patients detoxified, 89.7% met predefined criteria. Patients were mostly well educated (14.5 ± 2.3 years of school), female (92.3%), and with a variety of diagnoses (21% irritable bowel syndrome IBS/functional, 37% inflammatory bowel disease and other structural, 29% fibromyalgia and other functional somatic, or orthopedic, and 13% postoperative or other). They reported high health-care use (15.3 ± 10.1 MD visits/6 months; 6.5 ± 6.1 hospitalizations/2 years, 6.4 ± 2.0 surgeries/lifetime), and 82.1% were jobless. Despite high dosages of narcotics (total intravenous (IV) morphine equivalent 75.3 ± 78.0 mg/day), pain scores were rated severe (52.9 ± 28.8 visual analog scale (VAS); 257.1 ± 139.6 functional bowel disorder severity index (FBDSI); 17.2 ± 10.2 (McGill Pain and greater than labor or postoperative pain). Multiple symptoms were reported (n = 17.8 ± 9.2) and rated as moderate to severe. Psychosocial scores showed high catastrophizing (19.9 ± 8.6); poor daily function (Short Form-36 (SF-36) physical 28.3 ± 7.7, mental 34.3 ± 11.0; worse than tetraplegia); 28.2% were clinically depressed and 33.3% anxious (Hospital Anxiety and Depression Scale (HADS)). Detoxification was successfully completed by 89.7%; after detoxification, abdominal pain was reduced by 35% (P < 0.03) and nonabdominal pain by 42% (P < 0.01) on VAS, and catastrophizing significantly improved (P < 0.01). Responder status was met in 56.4% with 48.7% achieving a ≥ 30% reduction in pain. By 3 months after detoxification, 45.8% had returned to using narcotics. For those who remained off narcotics at 3 months, the VAS abdominal pain score was 75% lower than pretreatment when compared with those who went back on narcotics (24% lower). Successful detoxification and a good clinical response was associated with low abuse potential (Current Opioid Misuse Measure (COMM) score < 9). CONCLUSIONS: Despite severe pain, poor coping, and poor health status, almost all patients with NBS undergoing detoxification were able to stop using narcotics and have significant improvement in pain and coping. However, almost ½ reverted to narcotic use at 3 months. Those who stayed off narcotics showed greater improvement in pain scores. This study provides a rationale for treating patients with NBS by detoxification in order to improve their clinical status. Further work is needed to understand the reasons for the high recidivism rate.

Impact of traumatic brain injury on participation in leisure activities.

OBJECTIVE: To determine how participation in leisure activities for people with traumatic brain injury (TBI) changes from before injury to 1 year after injury. DESIGN: Prospective evaluation of leisure participation at 1 year after TBI. SETTING: Level I trauma center. PARTICIPANTS: Rehabilitation inpatients (mean age, 35.3 years; 77% male; 77% white) with moderate to severe TBI (N=160). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Functional Status Examination. RESULTS: At 1 year after injury, 81% had not returned to preinjury levels of leisure participation. Activities most frequently discontinued included partying, drug and alcohol use, and various sports. The activity most often reported as new after injury was watching television. Of the small fraction who returned to preinjury levels, 70% did so within 4 months of injury. Sixty percent of those who did not return to preinjury levels were moderately to severely bothered by the changes. CONCLUSIONS: At 1 year after injury, many TBI survivors engage in a reduced number of leisure activities, which are more sedentary and less social, with a substantial fraction dissatisfied with these changes. While discontinuing some activities may be viewed as a positive change, there are few new ones to replace them.

Cognitive factors affect treatment response to medical and psychological treatments in functional bowel disorders.

OBJECTIVES: For clinical trials in functional bowel disorders (FBD), the definition of a responder, one who meets the predefined criteria for a clinical response, is needed. Factors that determine clinical response aside from treatment itself are unknown. The aim of this study was to determine what baseline and post-treatment factors affect treatment response. METHODS: Females (n=397) with FBD entering a 12-week, four-arm, randomized NIH treatment trial (desipramine (DES), CBT, pill placebo, and education) were studied at baseline and after treatment. Demographic, clinical, psychosocial, and physiological variables were considered in the analysis. A responder was defined as a patient obtaining a score>3.5 on an averaged eight-item, five-point satisfaction-with-treatment questionnaire. Baseline and post-treatment logistic regressions were performed for each treatment condition to predict the responder outcome variable. RESULTS: Similar cognitive features predisposed participants to treatment response across the treatment conditions: sense of control over the condition, positive relationship with therapist or study coordinator, confidence in treatment, improvement in maladaptive cognitions, and quality of life during treatment. Demographic and clinical variables studied were not predictive. Some treatment-specific effects predicting responder status were noted, including a reduction in stool frequency with DES treatment and lack of abuse history in the placebo group. CONCLUSIONS: For medication, psychological, and placebo treatment in FBD, satisfaction with treatment depends on cognitive factors of confidence in treatments, perceived control over illness and symptoms, and reduction in negative cognitions related to symptom experience. Addressing these issues among patients with FBD may enhance treatment response to a variety of treatments.

Irritable bowel syndrome patients' ideal expectations and recent experiences with healthcare providers: a national survey.

UNLABELLED: The purpose of this paper is to identify patients' ideal expectations from their healthcare providers. The IBS-Patient Education Questionnaire was developed using focus groups, and was administered to a national sample of IBS patients. Frequencies of item endorsements were obtained. Subgroup analysis was done comparing the responses for patients' ideal expectations of their healthcare providers vs. their experiences with their last provider. Among the 1,242 patients who completed the survey, the mean age was 39.3 years, educational attainment 15 years, 85% female, IBS duration 6.9 years, 1,028 (83%) had seen a physician for IBS in the past, and 92.6% have used the Internet to obtain health information. Among the subjects who have seen a physician for IBS, the most desired qualities of providers were to give comprehensive information (96%), to refer to a source for additional information (95.8%), to answer questions (95.9%), to listen (94.4%), to provide information about IBS studies and medications (94%), and to provide support (88.6%) and hope (82.1%). Importantly, patients' prior experiences with their last healthcare provider differed from their ideal expectations: "provide information" (38.3%); answer questions during the visit (68%), "to listen" (63.8%), and support (47.1%). Patients' ideal expectations from healthcare providers (what patients ideally would like to experience) relate to obtaining information and relationship needs of receiving support and hope. Notably, their prior experiences with recent healthcare providers (what patients perceived actually occurred) were different from their ideal expectations. A better understanding of different types of expectations is necessary in order to construct an effective therapeutic relationship, which is critical for the management of IBS. PRACTICE IMPLICATIONS: Practice guidelines for IBS should emphasize a better understanding of a patient's expectations and the therapeutic value of patient-provider communication.

International survey of patients with IBS: symptom features and their severity, health status, treatments, and risk taking to achieve clinical benefit.

BACKGROUND: Although clinicians generally make treatment decisions in irritable bowel syndrome (IBS) related to the type of symptoms, other factors such as the perceived severity and the risks patients are willing to tolerate for effective treatment are also important to consider. These factors are not fully understood. OBJECTIVE: To describe among patients with IBS their symptoms and severity, quality of life and health status, medications taken, and the risk that they would take to continue medications for optimal relief. METHODS: Adult patients diagnosed with IBS who accessed the websites of the International Foundation for Functional GI Disorders or the University of North Carolina Center for Functional GI Disorders filled out questionnaires to address the study aims. RESULTS: The 1966 respondents (83% female, 91% white, 78% US/Canada) reported impaired health status: restricting on average 73 days of activity in a year, having poor health-related quality of life particularly with dietary restrictions, mood disturbance, and interference with daily activity, and 35% reported their symptoms as severe defined primarily as pain, bowel difficulties, bloating, and eating/dietary restrictions). These symptoms were reported in some combination by over 90%, and 35.1% endorsed all 4 items. To receive a treatment that would make them symptom free, patients would give up 25% of their remaining life (average 15 y) and 14% would risk a 1/1000 chance of death. Most of the medications being taken were for pain relief and 18% were taking narcotics. Complementary and alternative treatments were used by 37%. CONCLUSIONS: Patients accessing IBS informational websites report moderate-to-severe impairments in health status, and would take considerable risk to obtain symptom benefit. There is an unmet need to find effective treatments for patients with IBS and regulatory agencies might consider raising risk-benefit ratios when approving new medications for IBS.

A very low-carbohydrate diet improves symptoms and quality of life in diarrhea-predominant irritable bowel syndrome.

BACKGROUND & AIMS: Patients with diarrhea-predominant irritable bowel syndrome (IBS-D) anecdotally report symptom improvement after initiating a very low-carbohydrate diet (VLCD). This study prospectively evaluated a VLCD in IBS-D. METHODS: Participants with moderate to severe IBS-D were provided a 2-week standard diet, then 4 weeks of a VLCD (20 g carbohydrates/d). A responder was defined as having adequate relief of gastrointestinal symptoms for 2 or more weeks during the VLCD. Changes in abdominal pain, stool habits, and quality of life also were measured. RESULTS: Of the 17 participants enrolled, 13 completed the study and all met the responder definition, with 10 (77%) reporting adequate relief for all 4 VLCD weeks. Stool frequency decreased (2.6 +/- 0.8/d to 1.4 +/- 0.6/d; P < .001). Stool consistency improved from diarrheal to normal form (Bristol Stool Score, 5.3 +/- 0.7 to 3.8 +/- 1.2; P < .001). Pain scores and quality-of-life measures significantly improved. Outcomes were independent of weight loss. CONCLUSIONS: A VLCD provides adequate relief, and improves abdominal pain, stool habits, and quality of life in IBS-D.

Atypical antipsychotic quetiapine in the management of severe refractory functional gastrointestinal disorders.

Management of severe refractory functional gastrointestinal disorders (FGIDs) is difficult. Quetiapine, an atypical antipsychotic, may benefit patients by mitigating associated anxiety and sleep disturbances, augmenting the effect of antidepressants, and providing an independent analgesic effect. Outpatient records from a university-based FGID clinic were reviewed, and 21 patients with refractory symptoms who received quetiapine were identified and interviewed. Outcomes included global relief of symptoms, treatment efficacy questionnaire, and change in gastrointestinal (GI) and psychological symptoms. Eleven of 21 patients continued therapy at the time of interview. Six of 11 demonstrated global relief of symptoms, and 9 were satisfied with treatment. The remaining 10 of 21 discontinued therapy because of somnolence and lack of GI benefits. Quetiapine in low doses appeared beneficial in more than half of the adults with severe FGIDs who stayed on treatment. This response in otherwise refractory patients suggests quetiapine might augment the effectiveness of antidepressants in severe FGIDs.

Further characterization of painful constipation (PC): clinical features over one year and comparison with IBS.

BACKGROUND: There has been some question about the classification of painful constipation (PC) and its relationship to irritable bowel syndrome (IBS), and in particular IBS with constipation (IBS-C). We sought to: (1) compare PC with IBS and its subtypes (IBS-C, IBS-D, and IBS-A) in terms of pain scores, stool habit and clinical features, and to determine which factors predict PC over IBS, (2) determine the variation in pain and stool habit for PC relative to IBS over time, and (3) compare whether there are clinical differences between those with high pain constipation (HPC) and low pain constipation (LPC) over time. METHODS: Among 231 women in an National Institutes of Health trial, Rome II moderate to severe PC (n=41), IBS-A (n=55), IBS-C (n=80), and IBS-D (n=55) received diary cards on stool frequency, consistency, and pain (visual analog scale) daily for 14 days before and after 12-week treatment and at 3-month intervals for 1 year. PC was characterized into HPC (high pain) and LPC (low pain) groups based on visual analog scale pain scores (high pain > or = 50 and low pain < 50) at baseline. Descriptive statistics were calculated, and comparisons performed by chi2 for categorical and t tests for continuous variables. Regressions and repeated measures tested between group and within-group associations, respectively. RESULTS: (a) PC is different from IBS with: higher pain scores (P=0.002), lower education (P=0.02), greater healthcare use and surgeries (P=0.05 to 0.003), and poorer daily function (Sickness Impact Profile overall P=0.004), (b) PC is similar to IBS-C and IBS-A but different from IBS-D for stool frequency and consistency (P<0.0001), bloating (P=0.02), laxative/antidiarrheal use (P=0.04 and 0.02), and lower education (P=0.02). (c) Over 1 year, PC: maintained higher pain scores than IBS, had stool frequencies less than IBS-D and between IBS-C and IBS-A, had stool consistency less than IBS-D and similar to IBS-A, (d) for HPC and LPC there was no difference in constipation, and HPC switched to LPC over time, while LPC pain scores stayed low. Limitations include the absence of a painless constipation group, and that studying moderate to severe symptoms, which may not represent all with PC or IBS. CONCLUSIONS: PC is clinically similar in stool pattern and bloating to IBS-C and IBS-A, but with greater pain, healthcare utilization, and poorer daily function. The findings also suggest that PC defines a population where there is greater pain, and poorer health status and daily function, which may be driven more by visceral and/or central pain dysregulation more than the constipation.

Patient educational media preferences for information about irritable bowel syndrome (IBS).

PURPOSE: To identify the educational media preferences of patients with irritable bowel syndrome (IBS). METHODS: The IBS-Patient Education Questionnaire (PEQ) was administered to a national sample of IBS patients. Frequencies of item endorsements were compared and meaningful clinical differences were used to identify differences among subgroups. RESULTS: 1,242 patients completed the survey, mean age 39.3 years, 85% female, IBS duration 6.9 years, 79% had seen an MD for IBS within 6 months, and 92.6% used the web for medical information. The most desired source of education was "my doctor" (68%), followed by Internet (62%) and brochure (45%). Notably, patients favored an increase in use of media in the future (past vs. future): doctor (43 vs. 68%); Internet (36 vs. 62%); and brochures (26 vs. 45%). CONCLUSION: IBS patients expect more education than they have received. Understanding IBS patients' learning preferences can be highly valuable in the development or implementation of educational interventions.

The narcotic bowel syndrome: clinical features, pathophysiology, and management.

Narcotic bowel syndrome (NBS) is a subset of opioid bowel dysfunction that is characterized by chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics. This syndrome is underrecognized and may be becoming more prevalent. In the United States this may be the result of increases in using narcotics for chronic nonmalignant painful disorders, and the development of maladaptive therapeutic interactions around its use. NBS can occur in patients with no prior gastrointestinal disorder who receive high dosages of narcotics after surgery or acute painful problems, and among patients with functional gastrointestinal disorders or other chronic gastrointestinal diseases who are managed by physicians who are unaware of the hyperalgesic effects of chronic opioids. The evidence for the enhanced pain perception is based on the following: (1) activation of excitatory antianalgesic pathways within a bimodal opioid regulation system, (2) descending facilitation of pain at the rostral ventral medulla and pain facilitation via dynorphin and cholecystokinin activation, and (3) glial cell activation that produces morphine tolerance and enhances opioid-induced pain. Treatment involves early recognition of the syndrome, an effective physician-patient relationship, graded withdrawal of the narcotic according to a specified withdrawal program, and the institution of medications to reduce withdrawal effects.

What patients know about irritable bowel syndrome (IBS) and what they would like to know. National Survey on Patient Educational Needs in IBS and development and validation of the Patient Educational Needs Questionnaire (PEQ).

UNLABELLED: Patient education improves clinical outcomes in patients with chronic illness, but little is known about the education needs of patients with IBS. OBJECTIVES: The objective of this study was to identify: (1) patients perceptions about IBS; (2) the content areas where patients feel insufficiently informed, i.e., "knowledge gaps" about diagnosis, treatment options, etiology, triggers, prognosis, and role of stress; and (3) whether there are differences related to items 1 and 2 among clinically significant subgroups. METHODS: The IBS-Patient Education Questionnaire (IBS-PEQ) was developed using patient focus groups and cognitive item reduction of items. The IBS-PEQ was administered to a national sample of IBS patients via mail and online. ANALYSIS: Frequencies of item endorsements were obtained. Clinically relevant groups, (a) health care seekers or nonhealth care seekers and (b) users or nonusers of the Web, were identified and grouped as MD/Web, MD/non-Web, and non-MD/Web. RESULTS: 1,242 patients completed the survey (371 via mail and 871 online), mean age was 39.3 +/- 12.5 yr, educational attainment 15 +/- 2.6 yr, 85% female, IBS duration 6.9 +/- 4.2 yr, 79% have seen an MD for IBS in the last 6 months, and 92.6% have used the Web for health information. The most prevalent IBS misconceptions included (% of subjects agreeing with the statement): IBS is caused by lack of digestive enzymes (52%), is a form of colitis (42.8%), will worsen with age (47.9%), and can develop into colitis (43%) or malnutrition (37.7%) or cancer (21.4%). IBS patients were interested in learning about (% of subjects choosing an item): (1) foods to avoid (63.3%), (2) causes of IBS (62%), (3) coping strategies (59.4%), (4) medications (55.2%), (5) will they have to live with IBS for life (51.6%), and (6) research studies (48.6%). Patients using the Web were better informed about IBS. CONCLUSION: (1) Many patients hold misconceptions about IBS being caused by dietary habits, developing into cancer, colitis, causing malnutrition, or worsening with age; (2) patients most often seek information about dietary changes; and (3) educational needs may be different for persons using the internet for medical information.

Characterization of health related quality of life (HRQOL) for patients with functional bowel disorder (FBD) and its response to treatment.

BACKGROUND AND AIMS: Assessing health related quality of life (HRQOL) is becoming more important in research and clinical care. However, little information is available on the performance of HRQOL questionnaires for the functional bowel disorders (FBD). The aims of this study were to (a) understand the performance of the Sickness Impact Profile (SIP) and IBS-QOL for the functional bowel disorders at baseline and after treatment, (b) determine which HRQOL subscales best improve with treatment, (c) determine clinically meaningful improvement, and (d) determine the predictors of HRQOL at baseline and in response to treatment. METHODS: Women with moderate to severe FBD were evaluated using both medical (desipramine vs placebo) and psychological (cognitive-behavioral therapy vs education) treatments. Clinical and psychosocial questionnaires along with the SIP and IBS-QOL were given at baseline and after 12-wk treatment. RESULTS: (a) Patients with FBD experience functional limitations in social interactions, home management, and recreational activities, respond emotionally to the pain, feel helpless, out of control, depressed, and irritable, and perceive restrictions in lifestyle relating to toilet accessibility, and eating; (b) HRQOL is not different among the FBD diagnoses or IBS subgroups; (c) the IBS-QOL is more responsive to treatment than the SIP; (d) meaningful clinical improvement is 2.8 points for SIP and 14 for IBS-QOL; and (e) improvement is demonstrated primarily in psychosocial rather than physical domains. In addition, we found that expectation of benefit is greater for taking a pill over a psychological intervention, and the predictive effects of abuse history and pain on outcome is mediated by psychosocial factors. CONCLUSIONS: The data support the value of the IBS-QOL over the SIP, and provide new information on the profile of impairment in FBD, and the ways in which medical and psychological treatments produce improvement in HRQOL.

Continuous real-time analysis of products from the reaction of some monoterpenes with ozone using atmospheric sampling glow discharge ionization coupled to a quadrupole ion trap mass spectrometer.

An on-line technique has been demonstrated for the analysis of photochemical oxidation reaction products. The technique is based on the direct introduction of gas and particulate oxidation products into a custom-built atmospheric sampling glow discharge ionization source (ASGDI) coupled to a quadrupole ion trap mass spectrometer (QITMS). Operational parameters of the ASGDI system were investigated to determine their influence on the ion signal for the analysis of oxidation products in real time. These parameters include the discharge current, ion accumulation time, and type of reagent gas. Reference mass spectra from standards were generated for a variety of biogenic compounds and terpene reaction products containing keto, hydroxy, aldehyde, carboxylic acid, or epoxy groups to better understand the fragmentation that occurs in the glow discharge ion source. Results are presented for ozonolysis reactions of four biogenic monoterpenes (alpha-pinene, beta-pinene, D-limonene, Delta(3)-carene) monitored with the ASGDI quadrupole ion trap to demonstrate the ability to obtain real-time measurements. The reaction products identified with ASGDI-QITMS correspond to those products identified with other techniques, including on-line atmospheric pressure chemical ionization techniques. Efficient differentiation of multifunctional products including mono-/di-/hydroxy-/keto-carboxylic acid and keto-/hydroxy-aldehyde was possible by use of the MS/MS capability of the instrument.

Clinical response to tricyclic antidepressants in functional bowel disorders is not related to dosage.

BACKGROUND: As shown in the per protocol analysis of a recent randomized, controlled trial, when tolerated, Desipramine (DES) is effective over placebo (PLA) in treating moderate-to-severe functional bowel disorders (FBD). Clinical experience suggests that the benefit from tricyclic antidepressants (TCA) in FBD can be achieved at doses lower than those used to treat major depression. Within psychiatry, when using higher dosage of TCAs, plasma levels can be used to adjust daily dosage to optimize a treatment response. However, in FBD, it is not known whether plasma levels at the lower dosage are similarly related to a clinical response. AIM: To determine in treating FBD, whether DES blood levels or dose taken can predict a clinical response. METHODS: As part of a study of 12 wk of antidepressant and psychological treatment in 431 patients with FBD at UNC and U of Toronto, we studied those participants who completed treatment (per protocol analysis) taking DES (N = 97, dose 50-150 mg/day) or pill placebo (PLA) (N = 55 1-3 pills/day). The primary outcome measure was defined as a composite score (Satisfaction with Treatment, McGill Pain Questionnaire, Global Well-being, and IBS-QOL). The composite score was correlated with: (i) DES plasma levels at week 6, and (ii) number of pills taken over the duration of the 12-wk treatment period. In addition, we also compared DES dose with DES plasma levels. RESULTS: There was a modest correlation between mean DES dose at weeks 5 and 6 and DES blood level at week 6 (R = 0.2 p < 0.07). However, there were no significant correlations between the composite score either with DES dose or with DES blood levels. CONCLUSIONS: Detectable blood levels of DES are associated with a clinical response in FBD. However, with dosages up to 150 mg, there is no relationship between total dose or plasma level and the clinical response.

A prospective assessment of bowel habit in irritable bowel syndrome in women: defining an alternator.

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is subtyped as IBS with diarrhea (IBS-D) or IBS with constipation (IBS-C) based on Rome II guidelines. The remaining group is considered as having mixed IBS (IBS-M). There is no standard definition of an alternator (IBS-A), in which bowel habit changes over time. Our aim was to use Rome II criteria to prospectively assess change in bowel habit for more than 1 year to understand IBS-A. METHODS: Female patients (n=317) with IBS entering a National Institutes of Health treatment trial were studied at baseline with questionnaires and 2-week daily diary cards of pain and stool frequency and consistency. Studies were repeated at the end of treatment (3 months) and at four 3-month intervals for one more year. Algorithms to classify subjects into IBS-D, IBS-C, and IBS-M groups used diary card information and modified Rome II definitions. Changes in bowel habit at 3-month intervals were then assessed using these surrogate diary card measures. RESULTS: At baseline, 36% had IBS-D, 31% IBS-M, and 34% IBS-C. Except for stool frequency, there were no differences between groups. While the proportion of subjects in each subgroup remained the same over the year, most individuals (more than 75%) changed to either of the other 2 subtypes at least once. IBS-M was the least stable (50% changed out by 12 weeks). Patients were more likely to transition between IBS-M and IBS-C than between IBS-D and IBS-M. Notably, only 29% switched between the IBS-D and IBS-C subtypes over the year. CONCLUSIONS: While the proportion of subjects in each of the IBS subtypes stays the same, individuals commonly transition between subtypes, particularly between IBS-M and IBS-C. We recommend that IBS-A be defined as at least one change between IBS-D and IBS-C by Rome II criteria over a 1-year period.

Perceptions of physicians and patients with organic and functional gastrointestinal diagnoses.

BACKGROUND AND AIMS: We studied patient after-hours telephone calls to gastrointestinal (GI) fellows at a university program to determine requests made, physicians' responses, and perceptions of patients and physicians to these requests. METHODS: During a 4-month period, 4 GI fellows taking call were asked about reasons for patient-initiated after-hours telephone calls, actions taken, and their perceptions about the nature of the request, the illness impact, and their role in the care administered. Patients were telephoned within 1 week and asked the same questions about their perceptions of the call. RESULTS: Patients (N = 102) made 103 telephone calls, averaging 8.7 minutes, for symptoms (56%), procedure-related concerns (19%), and medications (18%). Physicians usually referred the patient to the clinic or emergency room (40%) or provided discussion and reassurance (36%). Patients' perceptions differed from physicians' perceptions: patients believed their problems to be more severe and more disabling and requests were more reasonable than perceived by the physician. Furthermore, their interactions with physicians (physician helpfulness, satisfaction with the recommendation, and likeability of the physician) were more positive than believed by physicians. Physicians believed phone calls from patients with functional disorders were less serious and less reasonable, that these patients were less disabled, and also that these patients were less liked than patients with an organic diagnosis. CONCLUSIONS: In this study, physicians carried a lower perception of the importance of telephone requests, the impact of the disorder, and their perceived helpfulness to patients than did patients making these requests. Physician perceptions were significantly lower for all these factors for patients with functional GI diagnoses. Additional studies are needed to understand the reasons for differing perceptions between physicians and patients.

Electrospray-atmospheric sampling glow discharge ionization source for the direct analysis of liquid samples.

Coupling electrospray with atmospheric sampling glow discharge ionization for the direct analysis of liquid-phase samples is demonstrated. Electrospray is utilized for nebulizing and transporting intact sample molecules into the glow discharge where ionization occurs through various pathways, including electron ionization and ion-molecule reactions with reagent ions. Reagent ions are formed through ionization of air molecules in an area of reduced pressure. The effects of discharge current, electrospray voltage, and solution flow rate on the absolute and relative ion intensities observed in the mass spectra are discussed. This technique is applicable to compounds containing various functional groups and encompassing a range of volatility. Analysis of organic compounds with varying volatility and polarity is discussed to illustrate the utility of this ionization technique.

Flexible sigmoidoscopy: the patients' perception.

BACKGROUND: Anxiety, discomfort, and high levels of concern can affect patient attitude toward endoscopic procedures as well as compliance and adherence to current recommendations for the examination. This study evaluated how patients perceive flexible sigmoidoscopy. METHODS: A prospective study was conducted at two sites of 764 patients presenting for GI endoscopy (flexible sigmoidoscopy 175, colonoscopy 384, EGD 205). Before these procedures, patients rated their anticipated (preprocedure) difficulty and degree of concern for each of 30 specific concerns. After the procedure, the patients rated their actual (postprocedure) difficulty. Patients' levels of concerns and difficulty were compared before and after the procedure and among the 3 procedure types. RESULTS: Before the procedure, patients who were to undergo flexible sigmoidoscopy had fewer concerns and lower scores for the severity of the concerns than did patients having colonoscopy or EGD. After the procedure, patients who had flexible sigmoidoscopy rated it as more difficult than patients who had colonoscopy or EGD. Patients who had colonoscopy and EGD graded their actual difficulty as less than their anticipated difficulty. However, patients who had flexible sigmoidoscopy rated the actual difficulty the same as the anticipated difficulty. CONCLUSIONS: Although patients have fewer concerns regarding flexible sigmoidoscopy than for the other endoscopic procedures, after the procedure they rate sigmoidoscopy as more difficult compared with postprocedure ratings by patients who underwent colonoscopy or EGD. This suggests that it may be necessary to change the perception of flexible sigmoidoscopy as being the best tolerated of the endoscopic procedures.