Adherence to guideline-based quality indicators in early pregnancy care in hospitals with and without an early pregnancy assessment unit.

RESEARCH QUESTION: How do hospitals with and without an early pregnancy assessment unit (EPAU) adhere to guideline-based quality indicators for an EPAU relating to logistics, access to services and quality of early pregnancy care? DESIGN: A qualitative interview study assessing the adherence to 19 quality indicators in four hospitals with an EPAU and four hospitals without an EPAU in the Netherlands. For each quality indicator, a ratio for guideline adherence was calculated. Overall non-adherence per hospital was defined as less than 100% adherence to the 19 quality indicators. RESULTS: Non-adherence was seen in three indicators (3/19 [16%]) for hospitals with an EPAU and in five indicators (5/19 [26%]) for hospitals without an EPAU. A standard digital system for the registration of ultrasound findings and clear explanation of all treatment options was present in all hospitals with an EPAU and in three hospitals without an EPAU. Certified ultrasound training for working staff members was absent in all hospitals. A discrete waiting area was present in one hospital with an EPAU compared with none of the hospitals without an EPAU. Self-referrals from women with a previous ectopic pregnancy was accepted in one hospital with and in one hospital without an EPAU. CONCLUSIONS: Non-adherence to guideline-based quality indicators for an EPAU was about the same for hospitals with and without an EPAU in the Netherlands.

Changes in body composition during and after adjuvant or neo-adjuvant chemotherapy in women with breast cancer stage I-IIIB compared with changes over a similar timeframe in women without cancer.

PURPOSE: Body weight and body composition may change during and after adjuvant or neo-adjuvant chemotherapy for breast cancer. However, most studies did not include a comparison group of women without cancer, thus could not assess whether observed changes differed from age-related fluctuations in body weight and body composition over time. We assessed changes in body composition during and after chemotherapy in breast cancer patients compared with age-matched women not diagnosed with cancer. METHODS: We recruited 181 patients with stage I-IIIb breast cancer and 180 women without cancer. In patients, we assessed body composition using a dual-energy X-ray scan before start of chemotherapy (T1), shortly after chemotherapy (T2), and 6 months after chemotherapy (T3); for the comparison group, the corresponding time points were recruitment (T1) and 6 (T2) and 12 (T3) months. RESULTS: Fifteen percent of patients and 8% of the comparison group gained at least 5% in body weight between T1 and T3. Among the comparison group, no statistically significant changes in body weight, or body composition were observed over time. Body weight of patients significantly increased from baseline (72.1 kg ± 0.4 kg) to T2 (73.3 kg ± 0.4 kg), but decreased to 73.0 kg ± 0.4 kg after chemotherapy (T3). Lean mass of patients significantly increased from 43.1 kg ± 0.5 kg at baseline to 44.0 kg ± 0.5 kg at T2, but returned to 43.1 kg ± 0.5 kg at T3. There were no differential changes in fat mass over time between patients and the comparison group. CONCLUSIONS: Changes in body weight and body composition during and after chemotherapy for early stage breast cancer were modest, and did not differ substantially from changes in body weight and body composition among women without cancer.

A longitudinal mixed methods study on changes in body weight, body composition, and lifestyle in breast cancer patients during chemotherapy and in a comparison group of women without cancer: study protocol.

BACKGROUND: More than 60% of women diagnosed with early stage breast cancer receive (neo)adjuvant chemotherapy. Breast cancer patients receiving chemotherapy often experience symptoms such as nausea, vomiting and loss of appetite that potentially affect body weight and body composition. Changes in body weight and body composition may detrimentally affect their quality of life, and could potentially increase the risk of disease recurrence, cardiovascular disease and diabetes. To date, from existing single method (quantitative or qualitative) studies is not clear whether changes in body weight and body composition in breast cancer patients are treatment related because previous studies have not included a control group of women without breast cancer. METHODS: We therefore developed the COBRA-study (Change Of Body composition in BReast cancer: All-in Assessment-study) to assess changes in body weight, body composition and related lifestyle factors such as changes in physical activity, dietary intake and other behaviours. Important and unique features of the COBRA-study is that it used I) a "Mixed Methods Design", in order to quantitatively assess changes in body weight, body composition and lifestyle factors and, to qualitatively assess how perceptions of women may have influenced these measured changes pre-, during and post-chemotherapy, and II) a control group of non-cancer women for comparison. Descriptive statistics on individual quantitative data were combined with results from a thematic analysis on the interviews- and focus group data to understand patients' experiences before, during and after chemotherapy. DISCUSSION: The findings of our mixed methods study, on chemotherapy treated cancer patients and a comparison group, can enable healthcare researchers and professionals to develop tailored intervention schemes to help breast cancer patients prevent or handle the physical and mental changes they experience as a result of their chemotherapy. This will ultimately improve their quality of life and could potentially reduce their risk for other co-morbidity health issues such as cardiovascular disease and diabetes.

Perceptions of Dutch health care professionals on weight gain during chemotherapy in women with breast cancer.

PURPOSE: Dutch Health care professionals (HCPs) provide little information concerning health risks associated with weight gain during chemotherapy for breast cancer. Women with breast cancer have specified the need for more information on nutrition and physical activity to deal with weight gain. The aims of this study were to assess the perceptions of Dutch HCPs on weight gain during chemotherapy and in addition evaluate whether and what kind of information on dietary intake and physical activity HCPs provide to prevent/treat weight gain during (neo)adjuvant chemotherapy. METHODS: A qualitative study was conducted using semi-structured interviews with 34 HCPs involved in breast cancer care: general practitioners, oncologists, specialized nurses, and dieticians. RESULTS: To date, little information about nutrition, physical activity, and weight gain is given during chemotherapy because it is not part of most HCPs' training, it is not included in the guidelines and it is not the best time to bring up information in the opinion of HCPs. Weight gain was perceived as just a matter of a few kilos and not an important health issue during treatment. All HCPs felt it is better that women themselves addressed their weight gain after chemotherapy. CONCLUSION: More knowledge about health risks associated with chemotherapy-induced weight gain and how to combat these issues needs to be made readily available to the HCPs and should become part of their training. Existing patient guidelines should include information on how to prevent and/or reduce weight gain through self-management of nutrition intake and physical activity during and post chemotherapy.

Taste and smell perception and quality of life during and after systemic therapy for breast cancer.

PURPOSE: The purpose of the study was to assess self-reported taste and smell perception after chemotherapy in breast cancer patients compared with women without cancer, and to assess whether taste and smell perception is associated with quality of life after the end of chemotherapy. METHODS: We included 135 newly diagnosed breast cancer patients who completed chemotherapy and 114 women without cancer. Questionnaires on taste, smell, and quality of life were completed shortly after and 6 months after chemotherapy (patients) or at two moments with 6 months' time window in between (comparisons). RESULTS: Self-reported taste and smell perception were significantly lower in patients shortly after chemotherapy compared to the comparison group. Most patients recovered 6 months after chemotherapy, although patients who were still receiving trastuzumab then reported a lower taste and smell perception compared to patients who were not. A lower self-reported taste and smell were statistically significantly associated with a worse quality of life, social, emotional, and role functioning shortly after chemotherapy. Six months after chemotherapy, taste and smell were statistically significantly associated with quality of life, social and role functioning, but only in patients receiving trastuzumab. CONCLUSIONS: Most taste and smell alterations recovered within 6 months after the end of chemotherapy for breast cancer, but not for patients receiving trastuzumab. These results highlight the importance of monitoring taste and smell alterations during and after treatment with chemotherapy and trastuzumab, as they may impact quality of life.

Weight change during chemotherapy in breast cancer patients: a meta-analysis.

BACKGROUND: Weight gain during chemotherapy in women with breast cancer is commonly reported. However, there are important differences between studies that examined weight change during chemotherapy; e.g. type of chemotherapy, menopausal status, time between body weight measurements and sample size. The purpose of this meta-analysis was to quantify changes in body weight during chemotherapy for women with breast cancer, taking these differences into account. METHODS: We identified relevant studies using PubMed, Scopus and Embase databases. The search was limited to human studies published in English up to and including December 2015. Only studies among women with early stage breast cancer treated with chemotherapy, with reported body weight before and after chemotherapy and type of chemotherapy were included. Random-effect models were used, and heterogeneity between studies was explored through stratified analyses and meta-regression. Sensitivity analyses were done to explore whether a specific study markedly affected the results. RESULTS: In total 25 papers were found, including data from 2620 women. Overall, body weight increased during chemotherapy: 2.7 kg (95% CI 2.0, 7.5) with a high degree of heterogeneity (I2 = 94.2%). Stratified analyses showed weight gain in all strata, but did not substantially reduce heterogeneity. Univariate meta-regression showed less weight gain in prospective studies compared to chart review studies (-2.0, 95% CI: -3.1, -0.8). Studies including cyclophosphamide, methotrexate and 5-fluorouracil (CMF) regimes showed a greater weight gain compared to those that did not (2.2, 95% CI: 1.1, 3.3); and papers published until the year 2000 showed a greater weight gain compared to those published after 2000 (1.9, 95% CI:-0.8, 3.1). In the multivariate models only studies including CMF regimes and studies published until 2000 were associated with significant weight gain of respectively 1.3 and 1.4 kg. CONCLUSION: Despite the high heterogeneity, this meta-analysis shows significant weight gain during chemotherapy for women with breast cancer. Weight gain was more pronounced in papers published until 2000 and women receiving CMF as chemotherapy regime. Although weight gain after chemotherapy has decreased over the course of time, weight gain is still substantial and deserves clinical attention.

Differences in dietary intake during chemotherapy in breast cancer patients compared to women without cancer.

PURPOSE: Breast cancer patients receiving chemotherapy often experience symptoms such as nausea, vomiting and loss of appetite that potentially affect dietary habits. This study assessed the intake of energy, macronutrients and food groups before and during chemotherapy in breast cancer patients compared with women without cancer, and determined the association between symptoms and energy and macronutrient intake. METHODS: This study included 117 newly diagnosed breast cancer patients scheduled for chemotherapy and 88 women without cancer. Habitual intake before chemotherapy was assessed with a food frequency questionnaire. Two 24-h dietary recalls were completed on random days for each participant during the whole chemotherapy treatment for patients and within 6 months after recruitment for women without cancer. Shortly, after the dietary recall, participants filled out questionnaires on symptoms. RESULTS: Before chemotherapy, habitual energy and macronutrient intake was similar for breast cancer patients and women without cancer. During chemotherapy, breast cancer patients reported a significantly lower total energy, fat, protein and alcohol intake than women without cancer, as shown by a lower intake of pastry and biscuits, cheese, legumes and meat products. A decline in subjective taste perception, appetite and hunger and experiencing a dry mouth, difficulty chewing, lack of energy and nausea were associated with a lower energy intake. CONCLUSIONS: Symptoms induced by chemotherapy are associated with lower dietary intake and manifested by a lower intake of specific food groups. To ensure an optimal dietary intake during chemotherapy, it is important to monitor nutritional status and symptom burden during chemotherapy in breast cancer patients.

BRCA1 mutation carriers have a lower number of mature oocytes after ovarian stimulation for IVF/PGD.

PURPOSE: The aim of this study was to determine whether BRCA1/2 mutation carriers produce fewer mature oocytes after ovarian stimulation for in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD), in comparison to a PGD control group. METHODS: A retrospective, international, multicenter cohort study was performed on data of first PGD cycles performed between January 2006 and September 2015. Data were extracted from medical files. The study was performed in one PGD center and three affiliated IVF centers in the Netherlands and one PGD center in Belgium. Exposed couples underwent PGD because of a pathogenic BRCA1/2 mutation, controls for other monogenic conditions. Only couples treated in a long gonadotropin-releasing hormone (GnRH) agonist-suppressive protocol, stimulated with at least 150 IU follicle stimulating hormone (FSH), were included. Women suspected to have a diminished ovarian reserve status due to chemotherapy, auto-immune disorders, or genetic conditions (other than BRCA1/2 mutations) were excluded. A total of 106 BRCA1/2 mutation carriers underwent PGD in this period, of which 43 (20 BRCA1 and 23 BRCA2 mutation carriers) met the inclusion criteria. They were compared to 174 controls selected by frequency matching. RESULTS: Thirty-eight BRCA1/2 mutation carriers (18 BRCA1 and 20 BRCA2 mutation carriers) and 154 controls proceeded to oocyte pickup. The median number of mature oocytes was 7.0 (interquartile range (IQR) 4.0-9.0) in the BRCA group as a whole, 6.5 (IQR 4.0-8.0) in BRCA1 mutation carriers, 7.5 (IQR 5.5-9.0) in BRCA2 mutation carriers, and 8.0 (IQR 6.0-11.0) in controls. Multiple linear regression analysis with the number of mature oocytes as a dependent variable and adjustment for treatment center, female age, female body mass index (BMI), type of gonadotropin used, and the total dose of gonadotropins administered revealed a significantly lower yield of mature oocytes in the BRCA group as compared to controls (p = 0.04). This finding could be fully accounted for by the BRCA1 subgroup (BRCA1 mutation carriers versus controls p = 0.02, BRCA2 mutation carriers versus controls p = 0.50). CONCLUSIONS: Ovarian response to stimulation, expressed as the number of mature oocytes, was reduced in BRCA1 but not in BRCA2 mutation carriers. Although oocyte yield was in correspondence to a normal response in all subgroups, this finding points to a possible negative influence of the BRCA1 gene on ovarian reserve.

No change in rectal sensitivity after gut-directed hypnotherapy in children with functional abdominal pain or irritable bowel syndrome.

OBJECTIVES: Gut-directed hypnotherapy (HT) has recently been shown to be highly effective in treating children with functional abdominal pain (FAP) and irritable bowel syndrome (IBS). This study was conducted to determine the extent to which this treatment success is because of an improvement in rectal sensitivity. METHODS: A total of 46 patients (aged 8-18 years) with FAP (n=28) or IBS (n=18) were randomized to either 12 weeks of standard medical therapy (SMT) or HT. To assess rectal sensitivity, a pressure-controlled intermittent distension protocol (barostat) was performed before and after the therapy. RESULTS: Rectal sensitivity scores changed in SMT patients from 15.1+/-7.3 mm Hg at baseline to 18.6+/-8.5 mm Hg after 12 weeks of treatment (P=0.09) and in HT patients from 17.0+/-9.2 mm Hg to 22.5+/-10.1 mm Hg (P=0.09). The number of patients with rectal hypersensitivity decreased from 6 of 18 to 0 of 18 in the HT group (P=0.04) vs. 6 of 20 to 4 of 20 in the SMT group (P=0.67). No relationship was established between treatment success and rectal pain thresholds. Rectal sensitivity scores at baseline were not correlated with intensity, frequency, or duration of abdominal pain. CONCLUSIONS: Clinical success achieved with HT cannot be explained by improvement in rectal sensitivity. Furthermore, no association could be found between rectal barostat findings and clinical symptoms in children with FAP or IBS. Further studies are necessary to shed more light on both the role of rectal sensitivity in pediatric FAP and IBS and the mechanisms by which hypnotherapy results in improvement of clinical symptoms.

Circulating microRNAs as potential biomarkers for psychiatric and neurodegenerative disorders.

Circulating microRNAs (cimiRNAs) are a class of non-encoding RNAs found in bodily fluids such as blood, cerebrospinal fluid (CSF) and tears. CimiRNAs have been implicated as promising biomarkers for central nervous system (CNS) disorders because they are actively secreted as messengers and are profoundly involved in fine-tuning of developmental and differentiation processes. Furthermore, they are attractive biomarkers because they are extremely stable, tissue enriched and can be determined in a quantitative manner. This review aims to provide a comprehensive assessment on the current progress regarding the potential value of cimiRNAs as CNS biomarkers. Within this framework five CNS disorders are explored which share a common pathological hallmark namely cognitive impairment. The CNS disorders include Major depression disorder (MDD), Bipolar disorder (BD), Schizophrenia (SZ), Alzheimer's disease (AD) and Parkinson disease (PD). The similarities and differences between altered cimiRNAs in the different disorders are described. The miR-29 family, miR-34a-5p and miR-132-3p are discussed as common dysregulated cimiRNAs found in the CNS disorders. Furthermore, it is shown that the type of bodily fluid used for measuring cimiRNAs is important as inconsistencies in cimiRNAs expression directions are found when comparing CSF, blood cell-free and blood cell-bound samples.

Morphological changes of the enteric nervous system, interstitial cells of cajal, and smooth muscle in children with colonic motility disorders.

OBJECTIVES: To evaluate the relation between colonic manometry findings and the colonic enteric nervous system, interstitial cells of Cajal, and smooth muscle morphology. PATIENTS AND METHODS: Colonic specimens from surgical resections or full-thickness biopsy specimens were assessed from a cohort of children who underwent colonic manometry before surgery. Colonic manometric patterns were subdivided into high-amplitude propagating contractions, low-amplitude propagating contractions, absence of contractions, and low-amplitude simultaneous contractions. Immunohistochemistry was performed to identify abnormalities in the enteric nervous system, interstitial cells of Cajal, and smooth muscle layers. RESULTS: Study participants included patients with Hirschsprung disease (n = 4), chronic intestinal pseudo-obstruction (n = 1), and idiopathic intractable constipation (n = 8). Thirty-seven ganglionic segments were studied. Abnormalities in myenteric plexus were recognized in segments of all manometry groups, and no differences could be identified when they were compared with segments with high-amplitude propagating contractions. All of the segments showed an abnormal interstitial cells of Cajal plexus, and no statistical difference could be identified between the 4 groups (n = 0.08). Homogeneous expression of smooth muscle actin was observed in all of the segments. CONCLUSIONS: In this cohort we were unable to classify specific manometric findings as reflective of myopathic or neuropathic abnormalities in patients with motility disorders. Caution should be used when predicting the type of neuromuscular disorder based on colonic manometry.

Rectal compliance and rectal sensation in constipated adolescents, recovered adolescents and healthy volunteers.

OBJECTIVES: A subgroup of children with functional constipation (FC) are unresponsive to conventional treatment. Abnormal rectal function due to increased distensibility (compliance) might be an underlying mechanism of therapy-resistant FC. It is hypothesised that rectal compliance is normal in patients who are successfully recovered from FC (RC). METHODS: Using a barostat, a pressure-controlled intermittent distension protocol was performed in FC patients, RC subjects free of symptoms for at least 4 years and healthy volunteers (HVs). Rectal compliance was calculated using a non-linear mixed-effect model for volume-pressure curves. RESULTS: Forty-seven FC patients, median (range) age of 12 (11-17) years, and 20 RC subjects, 15 (11-18) years, were studied and compared with 22 HVs, 14 (8-16) years. The median (5th-95th percentile) rectal compliance in HVs was 16 (12-20) ml/mm Hg. FC patients had a median rectal compliance of 25 (13-47) ml/mm Hg and RC subjects 20 (12-35) ml/mm Hg, which was significantly higher compared with HVs (p<0.001 and p = 0.003). RC subjects had lower rectal compliance when compared with FC patients (p = 0.02). Forty-five percent of RC subjects had a rectal compliance above the upper limit of normal (>95th percentile of HVs), which was significantly less compared with 75% of FC patients (p = 0.02). CONCLUSION: While rectal compliance in RC subjects is lower when compared with adolescents with FC, almost half of the RC subjects showed an increased rectal compliance. The role of rectal compliance in therapy-resistant FC seems limited, because recovery is possible despite an increased rectal compliance.

Patient-centered early pregnancy care: a systematic review of quantitative and qualitative studies on the perspectives of women and their partners.

BACKGROUND: Early pregnancy complications, defined as miscarriage, recurrent miscarriage or ectopic pregnancy, affect the physical and psychological well-being of intended parents. Research in this field so far has focused mainly on improving accuracy of diagnostic tests and safety and effectiveness of therapeutic management. An overview of aspects of care valued by women and/or their partners is missing. OBJECTIVE AND RATIONALE: This systematic review aims to provide an overview of aspects of care valued by women and/or their partners faced with early pregnancy complications and to identify potential targets for improvement in early pregnancy healthcare. SEARCH METHODS: We searched five electronic databases for empirical quantitative or qualitative studies on patients' perspectives of early pregnancy care in July 2017. We first identified aspects of early pregnancy care valued by women and/or their partners based on qualitative and quantitative data and organized these aspects of care according to the eight dimensions of patient-centered care. Second, we extracted the assessment of service quality from women and/or their partners on each of these aspects of care based on quantitative data. Third, we combined the findings on patients' values with the findings of service quality assessment to identify potential targets for improvement in five groups according to how likely these targets are to require improvement. OUTCOMES: The search yielded 6240 publications, of which 27 studies were eligible for inclusion in this review. All included studies focused on miscarriage or recurrent miscarriage care. We identified 24 valued aspects of care, which all covered the eight dimensions of patient-centered care. The most frequently reported valued aspect was 'being treated as an individual person experiencing a significant life event rather than a common condition'. Assessment of service quality from women and/or their partners was available for 13 of the 24 identified aspects of care. Quantitative studies all documented service quality as problematic for these 13 aspects of care. We thus identified 13 potential targets for improvement in the patient-centeredness of miscarriage and recurrent miscarriage care of which none were very likely, four were likely, six were unlikely and three were very unlikely, to require improvement. The four likely potential targets for improvement were 'Understandable information provision about the etiology of pregnancy', 'Staff discussing patients' distress', 'Informing patients on pregnancy loss in the presence of a friend or partner' and 'Staff performing follow-up phone calls to support their patients after a miscarriage'. WIDER IMPLICATIONS: It is important for clinicians to realize that women and their partners undergoing a miscarriage experience a significant live event and appreciate an individual approach. Future qualitative studies are needed to explore the identified potential targets for improvement of (recurrent) miscarriage care and to explore patients' perspectives in women suspected and treated for ectopic pregnancy.

Brain processing of rectal sensation in adolescents with functional defecation disorders and healthy controls.

BACKGROUND: Decreased sensation of urge to defecate is often reported by children with functional constipation (FC) and functional nonretentive fecal incontinence (FNRFI). The aim of this cross-sectional study was to evaluate cerebral activity in response to rectal distension in adolescents with FC and FNRFI compared with healthy controls (HCs). METHODS: We included 15 adolescents with FC, 10 adolescents with FNRFI, and 15 young adult HCs. Rectal barostat was performed prior to functional magnetic resonance imaging (fMRI) to determine individual pressure thresholds for urge sensation. Subjects received 2 sessions of 5 × 30 seconds of barostat stimulation during the acquisition of blood oxygenation level-dependent fMRI. Functional magnetic resonance imaging signal differences were analyzed using SPM8 in Matlab. KEY RESULTS: Functional constipation and FNRFI patients had higher thresholds for urgency than HCs (P < .001). During rectal distension, FC patients showed activation in the anterior cingulate cortex, dorsolateral prefrontal cortex, inferior parietal lobule, and putamen. No activations were observed in controls and FNRFI patients. Functional nonretentive fecal incontinence patients showed deactivation in the hippocampus, parahippocampal gyrus, fusiform gyrus (FFG), lingual gyrus, posterior parietal cortex, and precentral gyrus. In HCs, deactivated areas were detected in the hippocampus, amygdala, FFG, insula, thalamus, precuneus, and primary somatosensory cortex. In contrast, no regions with significant deactivation were detected in FC patients. CONCLUSIONS & INFERENCES: Children with FC differ from children with FNRFI and HCs with respect to patterns of cerebral activation and deactivation during rectal distension. Functional nonretentive fecal incontinence patients seem to resemble HCs when it comes to brain processing of rectal distension.

[Defecation disorders in children: treatment with colonic irrigation through an appendicostomy]. / Defecatiestoornissen bij kinderen: behandeld met colonspoeling via een appendicostoma.

In 3 patients with serious constipation or faecal incontinence the appendix was sewn open-ended into the abdominal wall (Malone-stoma) allowing antegrade bowel washouts. The patients were a 4-year-old boy with Hirschsprung's disease, a 15-year-old boy with chronic functional constipation and encopresis, and a 5.5-year-old boy with incontinence associated with a meningomyelocele. Following the procedure they were free from bowel problems. Faecal incontinence has a major detrimental effect on the psychosocial development of children. Severe constipation and faecal incontinence which do not optimally respond to conventional therapy can be treated by this procedure. Treatment is effective in around three-quarters of these children. Complications occur in an equal number of children, stenosis being the most frequently seen.

Recurrent miscarriage clinics.

A recurrent miscarriage clinic offers specialist investigation and treatment of women with recurrent first- and second-trimester miscarriages. Consultant-led clinics provide a dedicated and focused service to couples who have experienced at least two prior miscarriages. The best treatment strategy for couples with recurrent miscarriage is to discuss a treatment plan for a future pregnancy. Evidence-based up-to-date guidelines are required to reduce ineffective management of recurrent miscarriage couples, including overdiagnostics and underdiagnostics. Scientific research is necessary to study the effectiveness of new interventions, to study patient preferences, and to evaluate health care and costs or other outcomes.

Rectal sensorimotor dysfunction in constipation.

The pathophysiological mechanisms underlying chronic constipation in both adults and children remain to be unravelled. This is a not inconsiderable challenge, but is fundamental to improving management of such patients. Rectal sensorimotor function, which encompasses both sensation and motility, as well as biomechanical components (compliance, capacity), is now strongly implicated in the pathogenesis of constipation. Rectal hyposensitivity, rectal hypercompliance, increased rectal capacity, rectal motor dysfunction (phasic contractility and tone), and altered rectoanal reflex activity are all found in constipated patients, particularly in association with 'functional' disorders of defaecation (i.e. pelvic floor dyssynergia). This review covers contemporary understanding of how components of rectal sensorimotor function may contribute to symptom development in both adult and paediatric populations. The complex interaction between sensory/motor/biomechanical domains, and how best to measure these functions are addressed, and where data exist, the impact of sensorimotor dysfunction on therapeutic outcomes is highlighted.

Distention of the colon is associated with initiation of propagated contractions in children.

The presence of high-amplitude propagating contractions (HAPCs) has been identified as a marker of colonic neuromuscular integrity. The physiologic mechanisms of HAPCs initiation have yet to be determined. Distention secondary to colonic filling has been hypothesized as physiologic initiator. The aim of this study was to study the effect of intraluminal balloon distention in the colon of children with defecatory disorders. Colonic manometry was performed with a polyethylene balloon situated at the proximal end of the catheter, which was placed in the most proximal colonic segment reached during colonoscopy. A stepwise pressure controlled distention of the balloon was performed using barostat computer (10-50 mmHg). Propagated contractions were defined as those that migrated over at least three recording sites. They were divided into HAPCs, amplitude >60 mmHg and low-amplitude propagating contractions (LAPCs), amplitude <60 mmHg. Children with spontaneous HAPCs or HAPCs after bisacodyl provocation were considered to have normal motility. Twenty children completed the study. Among the 14 children with normal colonic motility, balloon distention elicited HAPCs in four and LAPCs in 10 children. No HAPC were elicited in six children with abnormal motility and LAPCs were seen in four of them. The balloon-induced propagated contractions had similar characteristics as those occurring spontaneously and after bisacodyl provocation but the pressure needed to elicit them and their amplitude was inconsistent. These findings suggest that intraluminal distention can trigger propagated contractions in children. This mechanism of action for induction of propagated contractions is not as consistent as the motor response found in response to bisacodyl administration.

Colonic manometry catheter placement with primary fluoroscopic guidance.

The purpose of this paper is to describe our experience with a new technique of colonic manometry catheter placement using fluoroscopic guidance. Between 2000 and 2004, 44 colonic manometry catheters were placed with primary fluoroscopic guidance in 38 patients (25 males; median age, 7 years; range, 0.4-31 years) with severe defecation disorders. Fourteen colonoscopic placements were reviewed to compare the different procedures. Manometry catheters were inserted through the rectum (16 patients), cecostomy (9), ileostomy (2), and colostomy (17). Placements through diverted colons were successful in 24 of 28 (86%). Insertion through the rectum was successful in 10 of 16 (63%) fluoroscopic-guided placements vs. 12 of 14 (86%) colonoscopic placements (P=0.23). Significantly longer fluoroscopic exposure was required for fluoroscopic compared to colonoscopic placement (P=0.004). In conclusion, placement of colonic manometry catheters with primary fluoroscopic guidance is feasible in children. An important disadvantage of the fluoroscopic methodology is the prolonged fluoroscopic exposure time.

Functional constipation in infants: a follow-up study.

Our objective of this study was to describe the clinical course of severe functional constipation in early childhood. Eligible patients were 47 children (60% boys; median age, 3.5 months) who had constipation in their first year of life. Follow-up data were obtained through a standardized questionnaire. Success was defined as a period of at least 4 weeks with > or =3 painless bowel movements per week. Six months after initial evaluation, 69% of the children were recovered. After initial success, a relapse occurred in 15% of the children within 3 years. A duration of symptoms <3 months before referral correlated significantly with better outcome. We conclude that most infants with severe constipation evaluated at a tertiary center are recovered after 6 months. Early therapeutic intervention may beneficially contribute to the resolution of constipation.