The impact of abuse and mood on bowel symptoms and health-related quality of life in irritable bowel syndrome (IBS).

BACKGROUND: Irritable bowel syndrome (IBS) is a common abdominal pain disorder without an organic explanation. Abuse histories (physical, sexual, emotional) are prevalent in IBS. While abuse relates to mood disorders (depression and anxiety) also common in IBS, the influence of abuse on gastrointestinal (GI) symptoms and health-related quality of life (HRQOL) and its independence from psychological symptom comorbidity has not been studied. METHODS: Consecutive GI outpatients completed the ROME III Research Diagnostic Questionnaire and questionnaires on trauma (Life-Stress Questionnaire), mood (Beck Depression/Anxiety Inventories), somatic symptoms (PHQ-12), and HRQOL (SF-36). Current GI symptom severity and bother were assessed using 10-cm Visual Analog Scales. KEY RESULTS: 272 ROME-defined IBS (47.6 ± 0.9 years, 81% female) and 246 non-FGID (51.6 ± 1.0 years, 65% female) subjects participated. IBS patients reported greater rates of physical, sexual, and emotional abuse (p < 0.006 each), and higher depression, anxiety, and somatic symptoms (p < 0.001). Greater bowel symptom bother (7.4 ± 0.2 vs 6.7 ± 0.2, p = 0.040), severity (7.7 ± 0.2 vs 6.5 ± 0.2, p < 0.001), recent symptomatic days (9.8 ± 0.4 vs 8.5 ± 0.3, p = 0.02), and poorer HRQOL (40.9 ± 2.3 vs 55.5 ± 1.7, p < 0.001) were noted in IBS with abuse. Abuse effects were additive, with greater IBS symptom severity and poorer HRQOL noted in cases with multiple forms of abuse. Mediation analyses suggested that abuse effects on GI symptoms and HRQOL were partially mediated by mood. CONCLUSIONS & INFERENCES: Abuse experiences common among IBS sufferers are associated with reports of greater GI symptoms and poorer HRQOL, particularly in those with multiple forms of abuse; this relationship may be partially mediated by concomitant mood disturbances.

Application of a computerized medical decision-making process to the problem of digoxin intoxication.

A computerized medical decision-making system was used to monitor signs and predisposing factors of digoxin intoxication in patients receiving digoxin. This process automatically reviewed the patient's data base nightly for drug interactions, laboratory data and electrocardiographic findings with known association with digoxin intoxication. These decisions were formated into a "digoxin alert report" and sent to line printers in the nursing division to be placed on the individual patients' charts. To assess the effect of these reports on patient management, a randomized double-blind study was undertaken. Patients were assigned to an alert or nonalert group. Alert reports were withheld from charts of patients in the nonalert group. A medical record review was subsequently carried out, wherein the physician's orders were searched to identify actions taken with possible relation to the digoxin alerts. The computer monitored 396 patients over a 3 month period. Of these, 211 (53%) were randomized to the alert group and 185 (47%) to the nonalert group. Seventy-two percent of patients received at least one alert. The most frequently occurring alerts included: hypoxemia, hypokalemia, concurrent use of a beta-adrenergic blocking agent, renal insufficiency and ventricular arrhythmia. Results from the record review demonstrated a 22% increase in physician actions for the alert group. Specifically, patients in the alert group were 2.7 times more likely to have a serum digoxin determination ordered and 2.8 times more likely to have digoxin withheld on the day of a digoxin alert than were patients in the nonalert group.

Acute response to inhaled nitric oxide in newborns with respiratory failure and pulmonary hypertension.

OBJECTIVE: Systemic oxygenation is improved by inhaled nitric oxide therapy in some newborns with respiratory failure and pulmonary hypertension. Our results with inhaled nitric oxide were reviewed to determine factors associated with an acute improvement in systemic oxygenation. METHODS: Newborns with oxygenation indices of 25 to 40 were prospectively randomized to receive conventional therapy with or without 20 ppm inhaled nitric oxide. All newborns with oxygenation indices greater than 40 were treated with inhaled nitric oxide. Hemodynamic, blood gas, and Doppler ultrasound measurements were performed before and after 30 to 60 minutes of observation or therapy. The severity of lung disease was classified by the chest radiograph as: (1) normal or focal disease; (2) moderate diffuse disease-diffuse lung disease with well-defined heart borders; or (3) severe diffuse disease-diffuse lung opacification with indistinct heart borders. RESULTS: Heart rate, blood pressure, and ductal diameters did not change. Blood gases and ductal shunting acutely improved only in patients treated with inhaled nitric oxide. Patients with normal lung fields or focal disease had the greatest degree of improvement in systemic oxygenation. Changes in oxygenation were not influenced by gestational age, baseline blood gases, the proportion of right-to-left ductal shunting, prior treatment with a surfactant, or the use of conventional or high-frequency jet ventilation. Collectively, blood gases and ductal shunting did not improve with inhaled nitric oxide in patients with lung hypoplasia or severe diffuse lung disease. Sustained improvement in oxygenation occurred in 87% of patients with oxygenation indices greater than 40 in whom oxygenation indices less than 40 acutely developed after exposure to nitric oxide, whereas 90% of patients in whom oxygenation indices less than 40 did not acutely develop were treated with extracorporeal membrane oxygenation or ultimately died. CONCLUSIONS: Inhaled nitric oxide acutely improves systemic oxygenation in many newborns with respiratory failure and pulmonary hypertension. The diagnosis and chest radiograph are helpful in identifying patients who will have favorable acute responses to therapy. In patients with severe hypoxemia, the need for invasive support with extracorporeal membrane oxygenation may be determined by an acute trial of inhaled nitric oxide.

Digital separation of primary and scatter components of chest radiographs.

This article describes a technique for digital separation of the primary and scatter components of a radiographic image. The method involves mathematical modeling of the process whereby an antiscatter grid reduces scatter patterns in film radiographs. Two superimposable radiographs (one taken with and the other without an intervening antiscatter grid) are applied to the model. Performance characteristics of the grid (primary and scatter transmittance factors) are also determined and used in the model. Radiographs of a humanoid chest phantom are processed. Scatter/primary separation appears to be accurate to within 15%. Film images that are quantitatively faithful to the calculated primary and scatter fields are included.

Perceptual characteristics of the amiloride-suppressed sodium chloride taste response in the rat.

The contribution of amiloride-sensitive membrane components to the perception of NaCl taste was assessed by using a conditioned taste aversion procedure. Eight independent groups of adult rats were conditioned to avoid either 0.1M NaCl, 0.5M NaCl; 0.1M NH4Cl, or 1.0M sucrose while their tongues were exposed either to water or to the sodium transport blocker amiloride hydrochloride. In contrast to rats exposed to water during conditioning, rats exposed to amiloride were unable to acquire a conditioned taste aversion to 0.1M NaCl. Differences in the acquisition of taste aversions between the amiloride- and nonamiloride-treated groups were not apparent when the conditioned stimulus (CS) was 0.5M NaCl, 0.1M NH4Cl, or 1.0M sucrose. Although the magnitude of the 0.5M NaCl aversion was similar between amiloride- and non-amiloride-treated rats, the perceptual characteristics of the CS differed between groups. Analyses of stimulus generalization gradients revealed that amiloride-treated rats generally avoided all monochloride salts after conditioning to 0.5M NaCl but not nonsodium salts or nonsalt stimuli. In contrast, rats not treated with amiloride only generalized the 0.5M NaCl aversion to sodium salts. No differences in generalization gradients occurred between groups when the CS was 0.1M NH4Cl or 1.0M sucrose. These findings suggest that the "salty" taste of NaCl is primarily related to the amiloride-sensitive portion of the functional taste response in rats. Conversely, the portion of the NaCl response insensitive to amiloride appears to have "sour-salty" perceptual characteristics and does not appear to be perceived as being salty.

Patient awareness of health precautions after splenectomy.

Sepsis after splenectomy is a lifelong risk, and patients who have had splenectomy should be educated about this risk. This study examines patient knowledge after splenectomy. We reviewed hospital records of 118 patients who had splenectomies performed between 1982 and 1988 at New Hanover Memorial Hospital. Twenty-four patients have died since their surgery; one death was suspected to be due to postsplenectomy sepsis. Of the 89 patients alive and eligible for follow-up, we were able to query 63. Only 16% were aware of any health precautions. After prompting, patient awareness improved to 40%. We also surveyed 11 of the 14 surgeons who performed the splenectomies. They indicated that they always discuss with their patients the immunologic consequences of spleen removal and the increased risks of infection, although they do not always recommend pneumococcal vaccine. We conclude that splenectomy patients have a low level of knowledge about postsplenectomy infection risks and precautions. We developed an educational pamphlet to aid the surgeon in patient education.

Hematopoietic marrow regeneration in pediatric patients undergoing spinal irradiation: MR depiction.

PURPOSE: To evaluate changes in vertebral marrow signal intensity that occur over time in children undergoing craniospinal radiation therapy, specifically evaluating for the occurrence and timing of marrow regeneration. METHODS: MR images of nine pediatric patients (ages 4 to 12 years) with posterior fossa medulloblastoma who received total spinal irradiation (24 to 40 Gy) and had at least three MR examinations were reviewed. Signal intensity to vertebral body marrow was graded by two pediatric neuroradiologists who were blinded to patient identity and to the timing of the studies. RESULTS: Eight of nine patients demonstrated increasing signal intensity of the vertebral marrow after irradiation, consistent with conversion of hematopoietic to fatty marrow. In each of these patients, this was followed by subsequent decreasing signal intensity in a mottled or peripheral band pattern indicating recovery of hematopoietic marrow. CONCLUSION: Changes in vertebral body signal intensity consistent with marrow reconversion commonly are seen in pediatric patients 11 to 30 months after they undergo total spinal irradiation.

Peer influences and drug use among urban adolescents: family structure and parent-adolescent relationship as protective factors.

The moderating influences of family structure and parent-adolescent distress on the relationship between peer variables and drug use were examined in a predominantly African American sample of 630 10th graders at 9 urban high schools. Both peer pressure and peer drug use were significantly related to the reported frequency of drug use. The relationship between peer pressure and drug use was stronger among girls than boys, and also among adolescents in families without fathers or stepfathers. The association between peer pressure and drug use also increased as a function of the level of mother-adolescent distress among adolescents who were not living with fathers or stepfathers. Neither gender nor family structure moderated the relationship between peer drug models and drug use. However, the association between peer drug models and drug use increased as a function of the level of mother-adolescent distress.

Structure of anxiety symptoms in urban children: competing factor models of the Revised Children's Manifest Anxiety Scale.

The Revised Children's Manifest Anxiety Scale (RCMAS; C. R. Reynolds & B. O. Richmond, 1985) is among the most widely used self-report measures of children's anxiety. The authors compared its current empirically derived factor structure with theory-driven models derived from 8 experts on child anxiety using concept mapping. Confirmatory factor analyses compared models using data from 898 seventh graders in an urban public school system serving a high percentage of African Americans. The most parsimonious best-fitting model was an expert-derived model with factors reflecting anxious arousal, social evaluation-oversensitivity, worry, and a higher order factor. This model was theoretically meaningful, excluded items less relevant to anxiety, and was invariant across gender. Future research with the RCMAS should consider use of these dimensions. The combination of qualitative and quantitative methodology used in this study appeared to have considerable utility for refining measures.

Imaging of abdominal masses in children.

Abdominal imaging has undergone extensive change over the past several years. In many cases, the developments have been so rapid as to preclude an orderly comparison of competing procedures with prospective comparison studies. Consequently, no rigid imaging protocol will be universally accepted and many issues are unresolved. This article reviews the various imaging procedures used in imaging pediatric abdominal masses with emphasis on technique, indications, risks, and costs. The relative merits of imaging modalities in various clinical situations are outlined and specific recommendations are given.

Quantification of intravenous contrast-enhanced Doppler power spectrum in the rabbit carotid artery.

In vivo evaluation of Doppler contrast agent (DCA) enhancement has been principally qualitative. To quantitate the enhancement of the Doppler signal by perflubron emulsion, an investigational DCA, the audio-Doppler signal from the rabbit carotid artery was recorded during 0.5-ml/kg incremental doses to a total dose of 2.5 ml/kg. A representation of the recorded signal intensity, the Doppler power spectrum (DPS), was determined using a personal computer and commercially available software package. The dose related enhancement from perflubron emulsion was linear (r = 0.986, p = 0.0124) with a 710% (8.5 dB) overall enhancement at 2.5 ml/kg (p = 0.0001). Significant differences in enhancement could be detected with doses as low as 1.0 ml/kg and compared favorably with observer assessment of dose-related enhancement. This relatively simple method of computer analysis can quantify in vivo Doppler signal intensity and enhancement by perflubron emulsion and may enable quantitative comparisons between different DCAs.

Simultaneous chemotherapy and radiotherapy for squamous cell lung cancer.

Simultaneous chemotherapy and radiotherapy was evaluated in 13 patients with inoperable, limited stage squamous cell lung cancer. The chemotherapeutic agents bleomycin, methotrexate, 5-fluorouracil, vinblastine, and cisplatin were administered on days 1 and 5 of two treatment cycles given 5 weeks apart. Radiation therapy was given in three 2-week cycles, the first two starting on the second day of each chemotherapy cycle and the third starting 3 weeks after the second course of radiation. The total dose was 5000-5500 rad (50-55 Gy) in 180 rad fractions. The objective response rate (complete response + partial response) was 85%, with 38% complete responders. Median survival was 7 months with two patients surviving 34 months, one with disease and one disease-free. Treatment toxicity was predominantly hematopoietic and renal. Two patients died with massive pulmonary hemorrhage while receiving treatment and a third patient died of acute respiratory failure 1 month after completing therapy. The severe toxicity and the failure to obtain long duration tumor control makes this regimen unsuitable for future use.

Immediate isolated interventricular septal defect from nonpenetrating thoracic trauma.

Interventricular septal defect following nonpenetrating trauma is a rare event. In a review of 207,548 autopsies, only 30 (0.01%) cases of traumatic ventricular septal defects were noted, and only 5 (0.002%) were isolated. We report an isolated interventricular septal defect following nonpenetrating trauma.

The rigid transparent dome protector: a new dressing for free-tissue transfers and skin grafts.

We have presented a transparent, inexpensive, rigid dome that allows a window to the wound, humidity chamber effect to continuously observe difficult skin-grafted wounds or free-tissue transfers allowing constant monitoring by visualization. The dome is inexpensive because it is simply a discarded breast implant package.

Thoracic imaging of pediatric lymphomas.

Lymphoma (Hodgkin and non-Hodgkin types) is the most common intra-thoracic neoplasm in the pediatric age group. Diagnostic strategies and treatment approaches for these tumors are largely determined by protocols established by one of the large, multi-institutional cooperative groups. In this paper, Hodgkin and non-Hodgkin lymphoma is discussed in the context of these cooperative group protocols. The basic biology, patterns of primary and metastatic disease distribution, treatment approaches, imaging follow-up, and areas of active research are discussed.

Reduced need for sedation in patients undergoing helical CT of the chest and abdomen.

Since 15 July 1993, we have used helical CT exclusively in chest and abdomen exams. The purpose of this study was to compare sedation rates in children undergoing conventional and helical CT of the chest and abdomen. Data for all CT examinations of the head (n = 1121), chest (n = 427), and abdomen (n = 315) performed between 1 April 1993 and 31 October 1993 were evaluated. Examinations were divided by anatomic site, patient age, date, whether motion was noted in the radiology report, and whether or not sedation was used. The oldest patient requiring sedation was 5 years old. All examinations in patients 5 years old or less (n = 1048) formed the study group. Because no head CT examinations were done helically, this constituted a control group. Comparisons of motion and sedation rates before and after 15 July 1993 were made with the chi 2 test. There was no statistically significant difference in the sedation rate in the control group (patients having conventional head CT examinations). In contrast, the use of helical technique for chest and abdomen CT coincided with a reduction of the sedation rate from 18% to 10% (P = 0.3). There was no statistically significant difference in reported motion for either head or chest/abdomen examinations over the study period. The implementation of helical CT coincided with a 45% reduction in the sedation rate of patients undergoing CT of the chest and abdomen. At the current volume of CT examinations at our institution, this decrease would result in an estimated 60 fewer sedations per year.

Evaluation of laboratory management training.

The purpose of this study was to determine if motivation to manage increased simultaneously with planned-for cognitive learning of management. A management course designed to stimulate cognitive learning was studied. It was presented to supervisors in hospital, independent, and public health laboratories. Two groups of 22 and 26 participants, respectively, were identified to be studied. Measures of cognition and motivation were taken before and after training. The analysis revealed statistically significant increases in cognitive learning in both study groups. The analysis of motivational data did not reveal a statistically significant increase in motivation to manage for either group. It was concluded that it is possible to stimulate cognitive learning of management if such learning is consciously planned. It was also concluded that under the experimental conditions, motivation to manage does not increase when it is treated as incidental to the planned-for cognitive learning.

Invited article: helical/spiral CT scanning: a pediatric radiology perspective.

Helical/spiral CT technology has several potential benefits for scanning pediatric patients. These benefits include reduced sedation rates, decreased radiation exposure with scanning at extended pitch, improved image quality, and better three-dimensional and reformatted images. This paper reviews the technical and clinical considerations relevant to scanning the pediatric patient and offers suggestions for protocol development.