The diagnosis of avoidant restrictive food intake disorder in the presence of gastrointestinal disorders: Opportunities to define shared mechanisms of symptom expression.

OBJECTIVE: Individuals with a gastrointestinal (GI) disorder often alter their diet to manage GI symptoms, adding complexity to understanding the diverse motivations contributing to food avoidance/restriction. When a GI disorder is present, the DSM-5 states that Avoidant/Restrictive Food Intake Disorder (ARFID) can be diagnosed only when eating disturbance exceeds that expected. There is limited guidance to make this determination. This study attempts to address this gap by characterizing the presentation of ARFID in adults with and without a self-reported GI disorder. METHOD: Participants were 2,610 adults ages 18-44 who self-identified as "picky eaters." Participants reported on motivations for food avoidance, affective experiences towards food, and perceived impairment. Responses were compared across four groups: GI issues and likely ARFID (L-ARFID/GI), L-ARFID-only, GI-only, and No-ARFID/No-GI. RESULTS: Groups with a GI disorder (L-ARFID/GI, GI-only) reported more fear of aversive consequences of eating than those without a GI disorder, while groups with L-ARFID (L-ARFID, L-ARFID/GI) evidenced significantly greater sensory aversion to food and indifference to food or eating, negative emotional reactions to food and overall disgust sensitivity, and eating related impairment. DISCUSSION: Consideration of the interplay of a GI disorder with ARFID can add precision to case conceptualization. Food avoidance may be attempts to manage fears of aversive consequences that are augmented by a history of GI symptoms, while sensory aversions and negative emotional reactions towards foods may be more elevated in ARFID. These findings emphasize the need to consider an ARFID diagnosis in patients with GI disorders to optimize care.

A genetic polymorphism that is associated with mitochondrial energy metabolism increases risk of fibromyalgia.

Alterations in cellular energy metabolism have been implicated in chronic pain, suggesting a role for mitochondrial DNA. Previous studies reported associations of a limited number of mitochondrial DNA polymorphisms with specific pain conditions. In this study, we examined the full mitochondrial genomes of people with a variety of chronic pain conditions. A discovery cohort consisting of 609 participants either with or without a complex persistent pain conditions (CPPCs) was examined. Mitochondrial DNA was subjected to deep sequencing for identification of rare mutations, common variants, haplogroups, and heteroplasmy associated with 5 CPPCs: episodic migraine, irritable bowel syndrome, fibromyalgia, vulvar vestibulitis, or temporomandibular disorders. The strongest association found was the presence of the C allele at the single nucleotide polymorphism m.2352T>C (rs28358579) that significantly increased the risk for fibromyalgia (odds ratio [OR] = 4.6, P = 4.3 × 10). This relationship was even stronger in women (OR = 5.1, P = 2.8 × 10), and m.2352T>C was associated with all other CPPCs in a consistent risk-increasing fashion. This finding was replicated in another cohort (OR = 4.3, P = 2.6 × 10) of the Orofacial Pain: Prospective Evaluation and Risk Assessment study consisting of 1754 female participants. To gain insight into the cellular consequences of the associated genetic variability, we conducted an assay testing metabolic reprogramming in human cell lines with defined genotypes. The minor allele C was associated with decreased mitochondrial membrane potential under conditions where oxidative phosphorylation is required, indicating a role of oxidative phosphorylation in pathophysiology of chronic pain. Our results suggest that cellular energy metabolism, modulated by m.2352T>C, contributes to fibromyalgia and possibly other chronic pain conditions.

Pharmacological interventions for chronic pain in children: an overview of systematic reviews.

We know little about the safety or efficacy of pharmacological medicines for children and adolescents with chronic pain, despite their common use. Our aim was to conduct an overview review of systematic reviews of pharmacological interventions that purport to reduce pain in children with chronic noncancer pain (CNCP) or chronic cancer-related pain (CCRP). We searched the Cochrane Database of Systematic Reviews, Medline, EMBASE, and DARE for systematic reviews from inception to March 2018. We conducted reference and citation searches of included reviews. We included children (0-18 years of age) with CNCP or CCRP. We extracted the review characteristics and primary outcomes of ≥30% participant-reported pain relief and patient global impression of change. We sifted 704 abstracts and included 23 systematic reviews investigating children with CNCP or CCRP. Seven of those 23 reviews included 6 trials that involved children with CNCP. There were no randomised controlled trials in reviews relating to reducing pain in CCRP. We were unable to combine data in a meta-analysis. Overall, the quality of evidence was very low, and we have very little confidence in the effect estimates. The state of evidence of randomized controlled trials in this field is poor; we have no evidence from randomised controlled trials for pharmacological interventions in children with cancer-related pain, yet cannot deny individual children access to potential pain relief. Prospero ID: CRD42018086900.

Bloating in Irritable Bowel Syndrome Is Associated with Symptoms Severity, Psychological Factors, and Comorbidities.

BACKGROUND: Bloating is one of the most bothersome symptoms of irritable bowel syndrome (IBS), but its association with other symptoms is not well described. AIMS: We investigated the association between symptoms of abdominal bloating, other IBS symptoms, psychological distress, and comorbid pain conditions. METHODS: We conducted a cross-sectional study on a large cohort of IBS patients with and without symptoms of abdominal bloating and healthy controls. Subjects were assessed for IBS and its subtypes, pain severity, symptoms severity, psychological disturbances, comorbidities, and dietary restrictions of three fluid groups. RESULTS: A total of 484 subjects were investigated. Compared with IBS - B, IBS + B subjects had higher rates of constipation (30% vs. 15%, p = 0.191) and lower rates of diarrhea, (70% vs. 85%, p = 0.191) although these were not statistically significant. Bloating severity correlated with IBS symptoms severity (r = 0.397, p = 0.000), pain severity (r = 0.364, p = 0.000), and both anxiety and somatization scores (r = 0.167, p = 0.015 and r = 0.219, p = 0.001, respectively). Prevalence of fibromyalgia and depression and somatization scores was significantly higher in IBS with bloating than in IBS without bloating. IBS patients with bloating reported more dietary restriction of three fluid groups to control their symptoms compared with healthy controls and IBS patients without bloating. CONCLUSIONS: Abdominal bloating in IBS is associated with increased symptoms and pain severity, somatization, depression, fibromyalgia, and altered dietary fluids composition. Recognizing and addressing these factors in the diagnosis and management of patients with IBS may improve clinical outcome.

A Parental Report of Youth Transition Readiness: The Parent STARx Questionnaire (STARx-P) and Re-evaluation of the STARx Child Report.

PURPOSE: The STARx Questionnaire is a self-report measure of health care transition (HCT) readiness in youth with chronic diseases. We aimed to improve reliability and generalizability of the STARx and report initial reliability data on the STARx-P Questionnaire, a self-report measure of parent perspective on their child's HCT readiness. METHODS: Participants were recruited in several clinics from a large academic hospital in the southeastern USA and via the therapeutic summer camp for children with chronic disease. Children with chronic conditions responded to the 18-question STARx Questionnaire and their parents responded to the parent version, the STARx-P Questionnaire. RESULTS: IRB-approved consents were obtained from 341 parents (89.4% mothers) and 455 children (Mean age 12.28±2.53; 36.9% Males; 68.6% Caucasian; 22.6% African-American). The most common diagnoses were kidney disease, inflammatory bowel disease, diabetes, cerebral palsy, sickle cell, and cystic fibrosis. Principal component analysis of the STARx-P Questionnaire identified three major subscales in both the child and parent-report: Disease Knowledge, Self-management and Provider Communication. Internal reliability was moderate to good (α=0.545-0.759). CONCLUSIONS: The STARx-P Questionnaire and STARx Version 4 Questionnaire have demonstrated initial reliability in this multi-institution study. It is the first HCT readiness questionnaire that includes a parent-proxy report which is needed in studies of non-verbal and/or developmentally delayed children. Parent-report can also give unique insights not obtained from self-reports.

Psychological Distress and Quality of Life in Pediatric Crohn Disease: Impact of Pain and Disease State.

OBJECTIVES: For patients with Crohn disease (CD), symptom reporting may not coincide with disease state; patients in remission may continue to report symptoms and pain, whereas other patients may be symptom-free despite a flare. This phenomenon has been documented in adults but only recently assessed in pediatric patients. The present study assessed the role of pain reporting and disease state in pediatric patients with CD in understanding psychological distress and quality of life. METHODS: Participants included 116 children and adolescents ages 8 to 18 years with CD who completed self-report questionnaires assessing pain, disease symptoms, depression, anxiety, functional disability, and quality of life. Physicians completed the Pediatric Crohn's Disease Activity Index to assess disease activity (scores ≤10 = remission, scores >10 = flare). RESULTS: Approximately two thirds of participants reported pain concordant with disease state. For patients in remission, those with pain experienced significantly increased disability and decreased quality of life compared to patients in remission without pain. For patients in a flare, those without pain experienced significantly decreased disability and depressive symptoms, and improved quality of life compared to patients in a flare with pain. CONCLUSIONS: For pediatric patients with CD, report of pain, while in remission or a flare, is associated with increased disability and reduced quality of life. Although levels of depression did not differ by disease state, depressive symptoms did differ by pain report (presence or absence) for those in a flare. Pain reporting in CD appears to be associated with both physical and psychological state and should be assessed regardless of disease activity.

Chronological age when healthcare transition skills are mastered in adolescents/young adults with inflammatory bowel disease.

AIM: To describe the longitudinal course of acquisition of healthcare transition skills among adolescents and young adults with inflammatory bowel diseases. METHODS: We recruited adolescents and young adults (AYA) with inflammatory bowel diseases (IBD), from the pediatric IBD clinic at the University of North Carolina. Participants completed the TRxANSITION Scale™ at least once during the study period (2006-2015). We used the electronic medical record to extract participants' clinical and demographic data. We used ordinary least square regressions with robust standard error clustered at patient level to explore the variations in the levels and growths of healthcare transition readiness. RESULTS: Our sample (n = 144) ranged in age from 14-22 years. Age was significantly and positively associated with both the level and growth of TRxANSITION Scale™ scores (P < 0.01). Many healthcare transition (HCT) skills were acquired between ages 12 and 14 years, but others were not mastered until after age 18, including self-management skills. CONCLUSION: This is one of the first studies to describe the longitudinal course of HCT skill acquisition among AYA with IBD, providing benchmarks for evaluating transition interventions.

Psychological Factors May Play an Important Role in Pediatric Crohn's Disease Symptoms and Disability.

OBJECTIVE: To examine the relative contributions of disease activity and psychological factors to self-reported symptoms and disability in children with Crohn's disease. STUDY DESIGN: Participants (n = 127 children age 8-18 years) completed questionnaires on symptom severity and disability, as well as psychological measures assessing anxiety, depression, pain beliefs and coping. Disease activity was measured by the Pediatric Crohn's Disease Activity Index. Structural equation modeling was used to test the effects of disease activity and psychological factors on symptoms and disability. RESULTS: In the hypothesized model predicting symptoms, psychological factors (ß = 0.58; P < .001) were significantly associated with disease symptoms but disease activity was not. The model for disability yielded significant associations for both psychological factors (ß = 0.75; P < .001) and disease activity (ß = 0.61, P < .05). CONCLUSION: Crohn's disease symptoms in children and adolescents are not only driven by disease activity. Coping, anxiety, depression, and cognition of illness are important in the patient-reporting of symptom severity and disability. Physicians need to be aware that symptom self-reporting can be driven by psychological factors and may not always be simply an indicator of disease activity. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00679003.

Increased colonic pain sensitivity in irritable bowel syndrome is the result of an increased tendency to report pain rather than increased neurosensory sensitivity.

OBJECTIVE: The aim was to determine whether lower visceral pain thresholds in irritable bowel syndrome (IBS) primarily reflect physiological or psychological factors. METHODS: Firstly, 121 IBS patients and 28 controls underwent balloon distensions in the descending colon using the ascending methods of limits (AML) to assess pain and urge thresholds. Secondly, sensory decision theory analysis was used to separate physiological from psychological components of perception: neurosensory sensitivity (p(A)) was measured by the ability to discriminate between 30 mm Hg vs 34 mm Hg distensions; psychological influences were measured by the report criterion-that is, the overall tendency to report pain, indexed by the median intensity rating for all distensions, independent of intensity. Psychological symptoms were assessed using the Brief Symptom Inventory (BSI). RESULTS: IBS patients had lower AML pain thresholds (median: 28 mm Hg vs 40 mm Hg; p<0.001), but similar neurosensory sensitivity (median p(A): 0.5 vs 0.5; p = 0.69; 42.6% vs 42.9% were able to discriminate between the stimuli better than chance) and a greater tendency to report pain (median report criterion: 4.0 ("mild" pain) vs 5.2 ("weak" pain); p = 0.003). AML pain thresholds were not correlated with neurosensory sensitivity (r = -0.13; p = 0.14), but were strongly correlated with report criterion (r = 0.67; p<0.0001). Report criterion was inversely correlated with BSI somatisation (r = -0.26; p = 0.001) and BSI global score (r = -0.18; p = 0.035). Similar results were seen for the non-painful sensation of urgency. CONCLUSION: Increased colonic sensitivity in IBS is strongly influenced by a psychological tendency to report pain and urge rather than increased neurosensory sensitivity.