Behavioral and emotional problems in adolescents with constipation and their association with quality of life.

OBJECTIVES: To assess behavioral and emotional problems in children and adolescents with functional constipation and their relationship with psychological maladjustment and health-related quality of life (HRQoL). DESIGN: A school-based cross-sectional survey conducted in 8 randomly selected schools from 4 randomly selected districts in Sri Lanka. A previously validated questionnaire was used for data collection. Behavioral and emotional problems were assessed using the Sinhala version of the Child Behavior Check List (CBCL-S/4-18). Constipation was diagnosed by applying the Rome III criteria. RESULTS: A total of 1000 questionnaires were distributed, and 913 completed questionnaires were included in the analysis. Sixty adolescents (6.5%) had functional constipation. Scores obtained for isolated psychological problems such as withdrawal (3.1 [3.1] vs. 1.9 [2.4], p<0.001), somatic complaints (3.2 [2.8] vs. 2.3 [2.5], p<0.05) anxiety/depression (5.8 [2.5] vs. 3.9 [3.6], p<0.001), social problems (3.0 [2.7] vs. 2.2 [1.9] p<0.001) and attention problems (5.4 [4.1] vs. 3.9 [3.4], p<0.001), and broadband scale of internalization (12.1 [8.4] vs. 8.3 [7.2], p<0.05) and mean total CBCL-S/4-18 score (29.4 [19.5] vs. 23.2 [17.0], p<0.001) were higher in adolescents with functional constipation. Clinical characteristics, socio-demographic and family factors and psychological maladjustment had no relationship with externalization, internalization and total CBCL-S/4-18 score. Internalization (-0.49, p<0.0001), externalization (-0.30, p<0.05), and total CBCL-S/4-18 (-0.44, p<0.001) scores had a negative impact on HRQoL of adolescents with functional constipation. CONCLUSIONS: Adolescents with functional constipation are suffering from significant behavioral and emotional problems. These problems negatively affect their HRQoL.

Quality of Life in Children with Functional Constipation: A Systematic Review and Meta-Analysis.

OBJECTIVE: To systematically review the literature on health-related quality of life (HRQoL) in children with functional constipation and to identify disease-related factors associated with HRQoL. STUDY DESIGN: The Pubmed, Embase, and PsycINFO database were searched. Studies were included if they prospectively assessed HRQoL in children with functional constipation according to the Rome criteria. Articles were excluded if patients had organic causes of constipation and if HRQoL was only assessed after successful therapeutic interventions. A meta-analysis was performed calculating sample size-weighted pooled mean and SD of HRQoL scores. The quality of the studies was also assessed. RESULTS: A total of 20 of 2658 studies were included, providing HRQoL data for 2344 children. Quality of evidence was considered to be poor in 9 of the 20 studies (45%); 13 of the 20 studies reported sufficient data to be included in the meta-analysis. Pooled total HRQoL scores of children with functional constipation were found to be lower compared with healthy reference samples (65.6 vs 86.1; P < .01). Similar HRQoL scores were found according to self-report and parent proxy report. Hospital-based studies reported lower HRQoL scores as compared with community-based studies. Two studies reported on HRQoL scores of children with and without fecal incontinence, but no significant difference was found. CONCLUSIONS: HRQoL is compromised in children with functional constipation.

Parental Factors in Pediatric Functional Abdominal Pain Disorders: A Cross-sectional Cohort Study.

OBJECTIVES: Parental factors are suggested to play a role in pediatric irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) and may influence treatment. Since studies on parental factors mainly focus on mothers, this study aims to compare physical health, psychological distress, personality dimensions, and parenting behavior of both parents of children with IBS or FAP-NOS to parents of controls. METHODS: Parents of 91 children with IBS or FAP-NOS were included in this explorative cross-sectional cohort study. Parents of 74 age-matched healthy children were used as controls. Questionnaires were used to measure demographics, physical health, psychological distress and symptoms, personality dimensions, and child-rearing practices. RESULTS: A total of 59 mothers and 52 fathers of 61 children with IBS/FAP-NOS (response rate 61.0%) and 56 mothers and 49 fathers of 59 controls completed the study (response rate 70.9%). Mothers of children with IBS/FAP-NOS reported more physical problems. Psychological distress and symptoms, personality dimensions, and child-rearing practices did not differ between mothers of both groups. Fathers of children with IBS/FAP-NOS had significantly lower scores on the child-rearing practice subscale of ignoring of unwanted behavior. In the IBS/FAP-NOS group, fathers were more depressed and less agreeable than mothers. No differences on all assessed outcomes were found between parents of children with IBS and children with FAP-NOS. CONCLUSIONS: Mothers of children with IBS/FAP-NOS and healthy peers differ with respect to physical health. Fathers in both groups differ with respect to child-rearing style. Clinicians should be aware of these differences when treating children with these disorders.

Attention Deficit Hyperactivity Disorder and Functional Defecation Disorders in Children.

OBJECTIVES: The aim of the study was to assess the prevalence of attention deficit hyperactivity disorder (ADHD) in children presenting with functional defecation disorders (FDDs) and to assess the prevalence of FDDs in children with ADHD. METHODS: A cross-sectional cohort study was carried out between September 2014 and May 2016. Group 1: Parents of children with FDDs according to the Rome III criteria completed the Child Behavior Checklist and the VvGK (Dutch questionnaire based on the American Disruptive Behavior Disorder rating scale). Patients with ADHD subarea scores ≥70 on the Child Behavior Checklist and/or ≥16 on the VvGK were referred for further psychiatric evaluation. Group 2: Parents of children treated for ADHD at a specialized ADHD outpatient clinic completed a standardized questionnaire regarding their child's defecation pattern. RESULTS: In group 1 (282 children with FDDs), 10.3% (7.1%-13.5% bias-corrected and accelerate confidence interval) were diagnosed with ADHD. Group 2 consisted of 198 children with ADHD, 22.7% (17.6-28.8 bias-corrected and accelerate confidence interval) fulfilled the Rome III criteria for an FDD. Children with both an FDD and ADHD reported urinary incontinence significantly more often compared to children with an FDD or ADHD alone: 57.1% in FDD + ADHD versus 22.8% in FDD alone (P < 0.001) and 31.1% in ADHD + FDD versus 7.8% in ADHD alone (P < 0.001). CONCLUSIONS: Approximately 10.3% of children with FDDs had ADHD and 22.7% of children with a known diagnosis of ADHD fulfilled the Rome III criteria for an FDD. This observation suggests that screening for behavioral disorders and FDDs should be incorporated into the diagnostic workup of these groups of children.

Parental characteristics and functional constipation in children: a cross-sectional cohort study.

OBJECTIVE: To evaluate personality, psychological health, physical health and childrearing practices in mothers and fathers of children with functional constipation (FC) compared with mothers and fathers of healthy controls. DESIGN: Cross-sectional cohort study. SETTING: Outpatient paediatric gastroenterology clinic at a tertiary hospital in the Netherlands. PATIENTS: Parents of children (4-16 years) presenting with FC were included between January 2010 and August 2012. Participating parents were asked to recruit parents of another child of the same age without FC as their own controls. Data of 116 mothers and 115 fathers of 127 children with FC, and 84 mothers and 73 fathers of 91 children without FC were collected. MAIN OUTCOME MEASURES: Parental characteristics were evaluated by using the NEO Five-Factor Inventory to assess personality, the Brief Symptom Inventory and Physical Symptom Checklist to assess psychological and physical health and the Ghent Parental Behavior Scale to assess childrearing practices. RESULTS: Mothers of constipated children had significant higher scores on the neuroticism personality factor and reported higher rates of overall psychological distress and depression. Both mothers and fathers of children with FC reported significant more physical symptoms than parents of children without FC. Mothers of children with FC showed more positive childrearing practices compared with controls. CONCLUSIONS: Personality, psychological and physical health, and childrearing practices differ significantly between parents of children with FC and parents of control subjects. Parental factors should be taken into account when evaluating children with FC.

Psychological maladjustment and quality of life in adolescents with constipation.

OBJECTIVES: To assess psychological maladjustment in adolescents with functional constipation. STUDY DESIGN: We conducted a cross-sectional survey in five schools. Adolescents aged between 13 and 18 years were included in the study. Validated questionnaires were used to collect bowel habits and demographic data, health-related quality of life (HRQoL) and psychological maladjustment. Rome III criteria were used to diagnose constipation. RESULTS: 1697 adolescents were recruited (boys 779 (45.9%), mean age 15.06 years and SD 1.6 years). Prevalence of constipation was 6.7%, of whom 52 were boys (45.6%) and 62 were girls (54.4%). 38 adolescents (33.3%) with constipation and 230 controls (14.5%) had significant psychological maladjustment. Among seven different personality dimensions used to assess psychological maladjustment, children with constipation had significantly more deficits than controls in hostility and aggression (14.2 vs 12.6 in controls (mean difference 1.54, 95% CI (0.89 to 2.19) p<0.001), negative self-esteem (12.0 vs 10.5 in controls, mean difference 1.54 95% CI (0.96 to 2.06) p<0.001), negative self-adequacy (11.9 vs 9.8 controls, mean difference 2.07 95% CI (1.46 to 2.67) p<0.001), emotional unresponsiveness (12.9 vs 11.5 controls, mean difference 1.44 95% CI (0.84 to 2.04) p<0.001), emotional instability (17.1 vs 15.6, mean difference 1.53 95% CI (0.86 to 2.2) p<0.001) and negative world view (12.1 vs 10.2 controls, mean difference 1.91 95% CI (1.24 to 2.59) p<0.001). The total HRQoL of adolescents with constipation was lower than controls (70.6 vs 79.0 mean difference 9.48 95% CI (1.4 to 6.7) p<0.05). CONCLUSION: A significant proportion of children with constipation are suffering from psychological maladjustment.

Sleep characteristics in type 1 diabetes and associations with glycemic control: systematic review and meta-analysis.

OBJECTIVES: The association between inadequate sleep and type 2 diabetes has garnered much attention, but little is known about sleep and type 1 diabetes (T1D). Our objectives were to conduct a systematic review and meta-analysis comparing sleep in persons with and without T1D, and to explore relationships between sleep and glycemic control in T1D. METHODS: Studies were identified from Medline and Scopus. Studies reporting measures of sleep in T1D patients and controls, and/or associations between sleep and glycemic control, were selected. RESULTS: A total of 22 studies were eligible for the meta-analysis. Children with T1D had shorter sleep duration (mean difference [MD] = -26.4 minutes; 95% confidence interval [CI] = -35.4, -17.7) than controls. Adults with T1D reported poorer sleep quality (MD in standardized sleep quality score = 0.51; 95% CI = 0.33, 0.70), with higher scores reflecting worse sleep quality) than controls, but there was no difference in self-reported sleep duration. Adults with TID who reported sleeping >6 hours had lower hemoglobin A1c (HbA1c) levels than those sleeping ≤6 hours (MD = -0.24%; 95% CI = -0.47, -0.02), and participants reporting good sleep quality had lower HbA1c than those with poor sleep quality (MD = -0.19%; 95% CI = -0.30, -0.08). The estimated prevalence of obstructive sleep apnea (OSA) in adults with TID was 51.9% (95% CI = 31.2, 72.6). Patients with moderate-to-severe OSA had a trend toward higher HbA1c (MD = 0.39%, 95% CI = -0.08, 0.87). CONCLUSION: T1D was associated with poorer sleep and high prevalence of OSA. Poor sleep quality, shorter sleep duration, and OSA were associated with suboptimal glycemic control in T1D patients.

A single night of sleep curtailment increases plasma acylcarnitines: Novel insights in the relationship between sleep and insulin resistance.

We have previously shown that acute sleep curtailment induces insulin resistance, both in healthy individuals as well as in patients with type 1 diabetes, suggesting a causal role for sleep disturbances in pathogenesis of insulin resistance, independent of endogenous insulin production. However, the underlying mechanisms remain unclear. This study aimed to explore the metabolic pathways affected by sleep loss using targeted metabolomics in human fasting plasma samples. Healthy individuals (n = 9) and patients with type 1 diabetes (n = 7) were studied after a single night of short sleep (4 h) versus normal sleep (8 h) in a cross-over design. Strikingly, one night of short sleep specifically increased the plasma levels of acylcarnitines, essential intermediates in mitochondrial fatty acid oxidation (FAO). Specifically, short sleep increased plasma levels of tetradecenoyl-l-carnitine (C14:1) (+32%, p = 2.67*10(-4)), octadecanoyl-l-carnitine (C18:1) (+22%, p = 1.92*10(-4)) and octadecadienyl-l-carnitine (C18:2) (+27%, p = 1.32*10(-4)). Since increased plasma acylcarnitine levels could be a sign of disturbed FAO, it is possible that sleep curtailment acutely induces inefficient mitochondrial function. Our observations provide a basis for further research into the role of acylcarnitines as a potential mechanistic pathway by which sleep deprivation - even short term - causes adverse metabolic effects, such as insulin resistance.

Sexual Response in Women with Type 1 Diabetes Mellitus: A Controlled Laboratory Study Measuring Vaginal Blood Flow and Subjective Sexual Arousal.

Previous studies have indicated that women with diabetes mellitus are at higher risk to develop sexual dysfunctions. In the current study, we hypothesized that lower genital arousal response-as a consequence of diabetes-related damage to nerves and blood vessels-might play a part in these higher prevalence rates. Vaginal blood flow, subjective sexual response, and clitoral sensitivity were compared between women with diabetes and healthy controls, and associations with diabetes complications were investigated. In pre- and postmenopausal women with type 1 diabetes (n = 42) and healthy controls (n = 46), vaginal blood flow was measured as vaginal pulse amplitude (VPA). VPA was assessed at rest, during erotic film viewing, and during vibrotactile clitoral stimulation. Subjective sexual arousal was measured using a questionnaire. Clitoral sensitivity was assessed by a vibration perception test. Data on diabetes complications were obtained from medical records, and neuropathy was assessed by quantitative sensory testing. VPA, subjective sexual arousal, and clitoral sensitivity were not significantly different between women with diabetes and controls. Nevertheless, women with diabetes who had retinopathy showed significantly lower VPA than women without retinopathy, and women with diabetes who had neuropathy showed significantly higher sensation thresholds for vibrotactile clitoral stimulation. The results do not support the hypothesis of a disrupted genital arousal response in women with diabetes. However, the observed associations between retinopathy and vaginal blood flow, and between neuropathy and clitoral sensitivity, suggest that diabetes-related complications might adversely affect the physiological basis of female sexual response.

Parental child-rearing attitudes are associated with functional constipation in childhood.

OBJECTIVE: Parenting factors are assumed to play a role in the development and maintenance of childhood constipation. However, knowledge about the association between parenting factors and childhood constipation is limited. This study investigates the association between parental child-rearing attitudes and prominent symptoms of functional constipation and assesses the strength of this association. DESIGN: Cross-sectional data of 133 constipated children and their parents were collected. SETTING: The gastrointestinal outpatient clinic at the Emma Children's Hospital in the Netherlands. PATIENTS: Children with functional constipation aged 4-18 years referred by general practitioners, school doctors and paediatricians. MAIN OUTCOME MEASURES: Parental child-rearing attitudes were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI). Symptoms of constipation in the child were assessed by a standardised interview. Negative binomial and logistic regression models were used to test the association between child-rearing attitudes and constipation symptoms. RESULTS: Parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. Higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence. More and stronger associations were found for children aged ≥6 years than for younger children. CONCLUSIONS: Parental child-rearing attitudes are associated with functional constipation in children. Any parenting issues should be addressed during treatment of children with constipation. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent-child relationship is at risk. TRIAL REGISTRATION NUMBER: ISRCTN2518556.

Impaired sustained attention in adult patients with type 1 diabetes is related to diabetes per se.

BACKGROUND: Patients with type 1 diabetes have altered sleep characteristics and are thought to have deficits in sustained attention. We compared the sustained attention to response task (SART) of patients with type 1 diabetes to that of healthy controls, and related results with sleep characteristics and disease-related factors. METHODS: SART was applied in 122 patients and 109 controls. Glucoregulation was assessed by HbA1c values and a questionnaire assessing glycaemic history. Clinical parameters were obtained from medical charts. Polyneuropathy was assessed by neurological examination and quantitative sensory testing. Sleep characteristics were assessed with sleep questionnaires. Anxiety and depression scores were assessed by the Hospital Anxiety and Depression Scale. RESULTS: The SART reaction time (RT) was significantly longer than in controls (327 ± 5 vs. 285 ± 3 ms, p < 0.001), although there were no significant differences in error scores. Repeated measurement analyses showed that diabetes per se was associated with prolonged RT (p < 0.001) and more commission errors (p = 0.010). None of the sleep-related and diabetes-related factors were significantly associated with these SART parameters. CONCLUSIONS: Patients with type 1 diabetes had impaired sustained attention, which was associated with diabetes per se but not with disturbed sleep characteristics.

Health care experiences of HIV-infected women with fertility desires in Mexico: a qualitative study.

Increased access to antiretroviral therapy has enabled Mexican HIV-infected women to resume healthy sexual and reproductive lives and reduce the risk of mother-to-child transmission of HIV infection. However, little information is available on the experiences of HIV-infected women desiring children. In this qualitative study, we conducted in-depth interviews with 31 HIV-infected women in four Mexican cities. The findings indicated that most of the women were given limited information on their pregnancy options. With some exceptions, the women felt they were denied the option to have (or to have more) children and advised to undergo tubal ligations or abortions. The findings of this study indicate that ongoing efforts are needed to promote the reproductive rights of HIV-infected women in Mexico and to ensure that they receive options aligned with their fertility desires.

Ensuring intercultural maternal health care for Mayan women in Guatemala: a qualitative assessment.

Indigenous (Mayan) women in Guatemala experience a disproportionate burden of maternal mortality and morbidity, as well as institutional failures to respect their rights. The Guatemalan Ministry of Health has started to offer 'intercultural' services that respect Mayan obstetric practices and integrate them with biomedical care. We purposefully selected 19 secondary-level public health facilities of 9 departments that provided maternal healthcare to indigenous women. We carried out semi-structured interviews with biomedical providers (44), Mayan midwives or comadronas (45), and service users (18), exploring the main characteristics of intercultural care. We found that most facilities initiated the implementation of culturally appropriate services, such as accompaniment by a comadrona or family member, use the traditional teas or choosing the birthing position, but they still lacked standardisation. Comadronas generally felt excluded from the health system, although most biomedical providers reported that they were making important strides to be respectful and inclusive. Most users wanted the option of culturally appropriate services but typically did not receive them. In the health facilities, biomedicine is still the dominant discourse. Efforts at offering intercultural care still need strengthening and further monitoring. Involvement and participation of comadronas and indigenous women is key to moving forward to true intercultural services.

The female condom: a promising but unavailable method for Dominican sex workers, their clients, and their partners.

Despite evidence of the potential of the female condom as a method that effectively protects against sexually transmitted infections (STIs), HIV, and pregnancy, it is still not widely available. We conducted in-depth interviews with 18 sex workers, 15 male clients, and seven partners in the Dominican Republic to assess the acceptability of the female condom. The majority of the sex workers found the female condom acceptable and welcomed the option of a female-controlled method. Clients and partners of the sex workers were also positive about the female condom and, particularly with regard to pleasure; almost all preferred it to the male condom. These findings suggest that the female condom offers an acceptable option for protection against HIV, STIs, and pregnancy. The positive attitudes of women and men could be developed into messages in marketing campaigns for the female condom, targeting not only vulnerable groups but also the general population.

Use of magnesium sulfate for treatment of pre-eclampsia and eclampsia in Mexico.

OBJECTIVE: To establish a baseline of magnesium sulfate utilization prior to publication of the updated 2006 technical guidelines on pre-eclampsia and eclampsia in Mexico, and to examine barriers to treating pregnant women with magnesium sulfate as perceived by maternal health experts. METHODS: In collaboration with the Federal Ministry of Health, medical charts were reviewed for 87 maternal deaths due to hypertensive disorders that occurred in Mexico in 2005. Evidence was gathered on whether magnesium sulfate had been indicated or administered. In-depth interviews with experts were conducted to identify barriers to treatment utilization. RESULTS: Magnesium sulfate had been used in 37.5% of severe pre-eclampsia and 47.7% of eclampsia cases. Thematic analysis of expert interview data revealed 4 primary barriers to the implementation of evidence-based guidelines and use of magnesium sulfate: lack of knowledge of magnesium sulfate, lack of acceptance, drug-related barriers, and insufficient monitoring or supervision. It was found that magnesium sulfate was not the treatment used for Mexican women who died of pregnancy-related hypertensive disorders in public facilities, and there was suboptimal implementation of evidence-based practices and official guidelines. CONCLUSION: The results highlight barriers to magnesium sulfate use, which constitutes a significant gap in treating women with eclampsia in Mexico.

Barriers to the use of maternity waiting homes in indigenous regions of Guatemala: a study of users' and community members' perceptions.

Maternal mortality among indigenous women in Guatemala is high. To reduce deaths during transport from far-away rural communities to the hospital, maternity waiting homes (MWH) were established near to hospitals where women with high-risk pregnancies await their delivery before being transferred for labour to the hospital. However, the homes are under-utilised. We conducted a qualitative study with 48 stakeholders (MWH users, family members, community leaders, MWH staff, Mayan midwives and health centre and hospital medical staff) in Huehuetenango and Cuilco to identify barriers before, during and after the women's stay in the homes. The women most in need - indigenous women from remote areas - seemed to have least access to the MWHs. Service users' lack of knowledge about the existence of the homes, limited provision of culturally appropriate care and a lack of sustainable funding were the most important problems identified. While the strategy of MWHs has the potential to contribute to the prevention of maternal (as well as newborn) deaths in rural Guatemala, they can only function effectively if they are planned and implemented with community involvement and support, through a participatory approach.

Insulin resistance in multiple tissues in patients with type 1 diabetes mellitus on long-term continuous subcutaneous insulin infusion therapy.

BACKGROUND: The aim of this study was to determine whether insulin resistance is present in lean patients with uncomplicated type 1 diabetes mellitus on long-term continuous subcutaneous insulin infusion (CSII), compared with matched healthy controls. METHODS: We studied eight patients (four men and four women) with type 1 diabetes mellitus on continuous subcutaneous insulin infusion and eight healthy controls, matched for age, gender and body mass index. Insulin sensitivity was measured by hyperinsulinemic euglycemic clamp studies with infusion of [6,6-(2) H(2)] glucose. RESULTS: Endogenous glucose production did not differ in the basal state between patients and controls. However, endogenous glucose production was less suppressed during clamp conditions in patients compared with controls (64% vs 79%, p = 0.01), indicating decreased hepatic insulin sensitivity. During the clamp study, glucose disposal rate was ~38% lower in patients compared with controls (24.4 ± 2.5 vs 39.7 ± 5.6 µmol/kgLBM/min, p = 0.04). Accordingly, the rate of infusion of glucose was ~51% lower in patients (17.7 ± 2.8 vs 39.7 ± 5.7 µmol/kgLBM/min, p = 0.02). Finally, non-esterified fatty acids levels were ~2.5 times higher in patients during steady state clamp conditions (150 ± 26 vs 58 ± 4 pmol/L, p = 0.01), reflecting decreased insulin sensitivity of lipolysis. CONCLUSIONS: Insulin resistance is a prominent feature of lean patients with type 1 diabetes mellitus, despite long term and stable treatment with continuous subcutaneous insulin infusion. Insulin resistance in type 1 diabetes involves both lipolysis, hepatic and peripheral glucose metabolism.