Significance of validated symptom assessment versus breath testing for malabsorption after lactose load in children.

BACKGROUND AND OBJECTIVES: Lactose malabsorption and lactose-induced symptoms are poorly correlated, as shown by breath tests and various symptom assessment methods. Validated assessment is the key to overcome the limitations of biased symptom measurements. We characterized lactose-induced symptoms with the population-specific, validated paediatric carbohydrate perception questionnaire (pCPQ) and their correlation with the history of symptoms (HoS). METHODS: A total of 130 patients with functional gastrointestinal symptoms underwent a lactose hydrogen breath and tolerance test (LBTT) allowing for a diagnosis of malabsorption (M+) and lactose sensitivity (S+). HoS indicative of lactose-induced symptoms (abdominal pain, nausea, bloating, flatulence, diarrhoea) in the 4 weeks preceding the test was determined using a validated questionnaire. The pCPQ was used to score lactose-induced symptoms. MAIN RESULTS: The LBTT revealed 41 children (31.5%) with lactose malabsorption (M+), 56 (43.1%) with lactose sensitivity (S+) and 24 (18.5%) were M+/S+. Sensitivity correlated with HoS (P < 0.001), regardless of whether malabsorption was detectable. Malabsorption status did not correlate with HoS (NS). The odds of lactose sensitivity significantly increased when abdominal pain [odds ratio (OR) 3.5, confidence interval (CI) 1.6-7.8], nausea (OR 2.3, CI, 1.1-4.9) and flatulence (OR 3.1, CI 1.4-6.8) were reported in the 4 weeks preceding the LBTT. Symptoms after the lactose load were similar for M+/S+ and M-/S+, except for flatulence, which was more frequent in malabsorbers (P < 0.01). CONCLUSION: Our findings fit well with the emerging view of the important role of a validated symptom assessment after a lactose load. The determination of symptoms may be more relevant than malabsorption for the clinical outcomes of paediatric patients with lactose-related gastrointestinal symptoms.

Anal endosonographic assessment of the accuracy of clinical diagnosis of obstetric anal sphincter injury.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASIS) are a common cause of maternal morbidity with an overall incidence in the UK of 2.9% (range 0-8%). They can cause a range of physical symptoms and psychological distress. This study aims to assess the accuracy of clinical diagnosis of OASIS using endoanal ultrasound (EAUS) and the correlation between confirmed injury and change to anorectal physiology squeeze pressure and the incidence of bowel symptoms. METHODS AND MATERIALS: Retrospective study of prospectively collected data from 1135 women who attended the Third- and Fourth-Degree Tears Clinic at our institution, 12 weeks post-delivery, between June 2008 and October 2019. RESULTS: OASIS was confirmed in 876 (78.8%) women and 236 (21.3%) had no injury. Of the women who underwent anorectal physiology, 45.6% had a mean maximal resting pressure below the normal range and 68.8% had a mean incremental squeeze pressure below normal. Women with confirmed OASIS had significantly lower pressures (p < 0.001) than those without a confirmed sphincter injury. Three hundred ninety-three (34.8%) women reported bowel symptoms, with those with endosonographic evidence of injury more likely to develop flatus incontinence. CONCLUSION: Of the women in this study with a suspected OASIS, 21.2% could be reassured that they did not have an injury. This information is useful for women considering future mode of delivery. Those with confirmed injury are more likely to complain of flatus incontinence and have reduced anal sphincter pressures.

Enhanced recovery pathways vs standard care pathways in esophageal cancer surgery: systematic review and meta-analysis.

Enhanced recovery after surgery (ERAS) protocols vs standard care pathways after esophagectomy for malignancy have gained wide popularity among surgeons. However, the current literature is still lacking level-I evidence to show a clear superiority of one approach. The present study is a detailed systematic review and meta-analysis of the published trials. A systematic review of literature databases was conducted for randomized controlled trials (RCTs) and non-randomized, prospective, comparative studies between January 1990 and September 2019, comparing ERAS pathway group with standard care for esophageal resection for esophageal cancer. Mean difference (MD) for continuous variables and odds ratio (OR) or risk difference (RD) for dichotomous variables with 95% confidence interval (CI) were used. Between-study heterogeneity was evaluated. Eight studies with a total of 1133 patients were included. Hospital stay [Standard mean difference (Std. MD) = - 1.92, 95% CI - 2.78, - 1.06, P < 0.0001], overall morbidity (OR 0.68, CI 0.49, 0.96, P = 0.03), pulmonary complications (OR 0.45, CI 0.31, 0.65, P < 0.0001), anastomotic leak rate (OR 0.37, CI 0.18, 0.74, P = 0.005), time to first flatus and defecation (Std. MD = -5.01, CI - 9.53, - 0.49, P = 0.03), (Std. MD = - 1.36, CI - 1.78, - 0.94, P < 0.00001) and total hospital cost (Std. MD = - 1.62, CI - 2.24, - 1.01, P < 0.00001) favored the ERAS group. Patients who undergo ERAS have a clear benefit over the standard care protocol. However, existing protocols in different centers are followed by great variability, while the evaluated parameters suffer from significant heterogeneity. A well-formulated, standardized protocol should be standard-of-care at all centers.

Effectiveness and safety of robotic versus traditional laparoscopic gastrectomy for gastric cancer: An updated systematic review and meta-analysis.

Gastrectomy is considered the gold standard treatment for gastric cancer patients. Currently, there are two minimally invasive surgical methods to choose from, robotic gastrectomy (RG) and laparoscopic gastrectomy (LG). Nevertheless, it is still unclear which is superior between the two. This meta-analysis aimed to investigate the effectiveness and safety of RG and LG for gastric cancer. A systematic literature search was performed using PubMed, Embase, and the Cochrane Library databases until September 2018 in studies that compared RG and LG in gastric cancer patients. Operative and postoperative outcomes analyzed were assessed. The quality of the evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluations. Twenty-four English studies were analyzed. The meta-analysis revealed that the RG group had a significantly longer operation time, lower intraoperative blood loss, and higher perioperative costs compared to the LG group. However, there were no differences in complications, conversion rate, reoperation rate, mortality, number of lymph nodes harvested, days of first flatus, postoperative hospitalization time, and survival rate between the two groups. RG was shown to be associated with decreased intraoperative blood loss and increased perioperative cost and operation time compared to LG. Several higher-quality original studies and prospective clinical trials are required to confirm the advantages of RG.

Intestinal gas and liver steatosis: a casual association? A prospective multicentre assessment.

BACKGROUND & AIMS: Excessive intestinal gas and liver steatosis are frequent sonographic findings. Both of these appear to be caused by variations of the gut microflora. We assessed the relationship between ultrasonographic detection of intestinal gas and liver steatosis. METHODS: This study included 204 consecutive patients (99 male; mean age 53.0 ± 15.6 years), who underwent ultrasonography for abdominal complaints or follow-up of benign lesions. Body mass index, biochemical liver markers, sonographic presence of liver steatosis and/or degree of intestinal gas interfering with the examination were collected. Both sonographic findings were assessed based on standardized criteria. The association between liver steatosis and intestinal gas was evaluated by means of univariate and multivariate analyses. RESULTS: Eighty (39.2%) of patients showed moderate to large amounts of gas preventing an accurate evaluation of the liver or pancreas and 90 (44.1%) had liver steatosis. A significant correlation between the degree of intestinal gas and liver steatosis both in obese (r=.603; P<.001) and in nonobese patients (r=.555; P<.001) was found. Univariate analysis showed that intestinal gas, body mass index, aspartate transaminase, alanine transaminase, gamma-GT, age and sex were predictors of liver steatosis; only intestinal gas (OR 7.4; 95% CI 3.4-16.1) and body mass index (OR; 1.4, 95% CI 1.2-1.5), however, were independent predictors at multivariate analysis. The presence of excessive gas was also significantly correlated with liver steatosis coupled with elevated ALT (P = .001). CONCLUSION: This study shows a significant correlation between excessive intestinal gas and liver steatosis. The reasons of this finding and its clinical implications remain to be defined.

Charges, outcomes, and complications: a comparison of magnetic sphincter augmentation versus laparoscopic Nissen fundoplication for the treatment of GERD.

BACKGROUND: Magnetic sphincter augmentation (MSA) is approved for uncomplicated GERD. Multiple studies have shown MSA to compare favorably to laparoscopic Nissen fundoplication (LNF) in terms of symptom control with results out to 5 years. The MSA device itself, however, is an added cost to an anti-reflux surgery, and direct cost comparison studies have not been done between MSA and LNF. The aim of the study was to compare charges, complications, and outcome of MSA versus LNF at 1 year. METHODS: This is a retrospective analysis of all patients who underwent MSA or LNF for the treatment of GERD between January 2010 and June 2013. Patient charges were collected for the surgical admission. We also collected data on 30-day complications and symptom control at 1 year assessed by GERD-HRQL score and PPI use. RESULTS: There were 119 patients included in the study, 52 MSA and 67 LNF. There was no significant difference between the mean charges for MSA and LNF ($48,491 vs. $50,111, p = 0.506). There were significant differences in OR time (66 min MSA vs. 82 min LNF, p < 0.01) and LOS (17 h MSA vs. 38 h LNF, p < 0.01). At 1-year follow-up, mean GERD-HRQL was 4.3 for MSA versus 5.1 for LNF (p = 0.47) and 85 % of MSA patients versus 92 % of LNF patients were free from PPIs (p = 0.37). MSA patients reported less gas bloat symptoms (23 vs. 53 %, p ≤ 0.01) and inability to belch (10 vs. 36 %, p ≤ 0.01) and vomit (4 vs. 19 %, p ≤ 0.01). CONCLUSION: The side effect profile of MSA is better than LNF as evidenced by less gas bloat and increase ability to belch and vomit. LNF and MSA are comparable in symptom control, safety, and overall hospital charges. The charge for the MSA device is offset by less charges in other categories as a result of the shorter operative time and LOS.

Assessment of the impacts of traditional Persian medical schemes and recommendations on functional chronic constipation compared to a classic medicine lactulose, a randomized clinical trial.

BACKGROUND: To manage chronic constipation, numerous lifestyle modification schemes and recommendations as well as applications of natural medicaments have been mentioned in manuscripts of traditional Persian medicine (TPM). This study was aimed to compare the impacts of some of those recommendations with lactulose, on functional chronic constipation. METHODS: Via a blocked randomization, 100 patients were enrolled. Schemes and recommendations from TPM as intervention group were evaluated versus lactulose as control by weekly follow-ups with standard questionnaire for 3 months. Stool frequency, hard stool, painful defecation, incomplete evacuation sensation, anorectal obstruction sensation and manual maneuvers were considered as outcome measures. RESULTS: Eighty-six patients (42 in schemes and 44 in lactulose groups) completed the study. Median weekly stool frequency in 0, 4, 8 and 12 weeks of treatment was 1.76±1.79, 2.88±0.89, 2.95±1.05 and 2.93±1.11 in the schemes and 2.41±1.67, 2.57±0.90, 2.84±0.91 and 2.77±1.00 in lactulose groups, respectively (p=0.10, 0.11, 0.60, 0.51). Thirty-two (76.2%) patients in schemes and 24 (54.5%) patients in lactulose groups were treated at the end of the protocol as they did not meet the Rome III criteria for constipation (p=0.04). In schemes group, patients reported no undesirable effects, whereas seven (15.9%) in lactulose group reported flatulence (p=0.02). CONCLUSIONS: Studied schemes were as effective as lactulose, a gold standard to manage constipation. Results demonstrated that TPM schemes and recommendations, as lifestyle modification, for at least 3 months can be introduced as cheap, available and accessible approaches for the management of constipation.

Totally laparoscopic versus laparoscopic-assisted right colectomy for colon cancer: is there any advantage in short-term outcomes? A prospective comparative assessment in our center.

BACKGROUND: Several techniques are described in the literature about laparoscopic treatment of the right colon. Among them, laparoscopic-assisted colectomy (LAC) with creation of an extracorporeal ileocolonic anastomosis remains the favourite approach in most centers. So far, total laparoscopic colectomy (TLC) with intracorporeal anastomosis is not widely performed, because it requires adequate skills and competence in the use of mechanical linear staplers and laparoscopic manual sutures. The purpose of this study was to determine prospectively if TLC offers some advantages in short-term outcomes over LAC. METHODS: A prospective comparative study was designed for 80 consecutive patients who were alternatively treated with TLC and LAC for right colon neoplasms. The following data were collected: operative time, intra- and postoperative complication rate, time to bowel movement, hospitalization time, length of minilaparotomy, number of harvested lymph nodes, and specimen length. RESULTS: Operative time in TLC resulted significantly longer than in LAC (230 vs. 203 min), complication rate was similar in both groups, with no case of anastomotic dehiscence, two anastomotic bleedings in TLC vs. three in LAC and one case of postoperative ileus for each group. One case of death occurred in LAC patient developing a postoperative severe cardiopulmonary syndrome. Time to first flatus was in favour of TLC (2.2 vs. 2.6 days), whereas hospitalization was comparable. As regards to the oncological parameters of radicality, the specimen length was superior in TLC group, but the number of lymph nodes excised was equivalent. The length of the minilaparotomy was clearly shorter in TLC group (5.5 vs. 7.2 cm). CONCLUSIONS: No evidence of relevant differences in terms of functional and safety outcomes between the two laparoscopic procedures. TLC determines less abdominal manipulation and shorter incision length, but clear advantages must be still demonstrated. Larger series are necessary to test the superiority of totally laparoscopic procedures for right colectomy.

Laparoscopy-assisted versus open distal gastrectomy for early gastric cancer: evidence from randomized and nonrandomized clinical trials.

OBJECTIVE: To evaluate the safety and efficacy of laparoscopy-assisted distal gastrectomy (LADG) in patients with early gastric cancer (EGC) to determine whether LADG is an acceptable alternative to open distal gastrectomy (ODG). BACKGROUND: LADG combined with less than D2 or D2 lymphadenectomy for EGC is still a controversial surgical intervention for its uncertain oncological safety and economic benefit. We conducted this systematic review and meta-analysis that included randomized control trials (RCTs) and non-RCTs of LADG versus ODG to evaluate whether the safety and efficacy of LADG in patients with EGC are equivalent to those of ODG. METHODS: A comprehensive search of PubMed, EMBASE, Cochrane Library, and China Knowledge Resource Integrated Database was performed. Eligible trials published between January 1, 1994, and December 31, 2010, were included in the study. Data synthesis and statistical analysis were carried out by RevMan 5.0 software. The quality of evidence was assessed by GRADEpro 3.2.2. RESULTS: Twenty-two studies with 3411 participants were included in this study. The mean number of lymph nodes retrieved in LADG was close to that retrieved in ODG (in the less than D2 resection: weighted mean difference [WMD] = -1.79; 95% confidence interval [95% CI], -5.78 to 2.19; P = 0.38; heterogeneity: P < 0.00001, I = 98%; and in the D2 resection: WMD = -1.53; 95% CI, -3.56 to 0.51; P = 0.14; heterogeneity: P = 0.23, I = 26%). The overall postoperative morbidity was significantly less in LADG than in ODG (relative risk = 0.58; 95% CI, 0.46-0.74; P < 0.00001; heterogeneity: P = 0.94, I = 0%). LADG reduced the intraoperative blood loss, postoperative analgesic consumption, and hospital duration, without increasing the total hospitalization costs and cancer recurrence rate. The long-term survival rate of patients undergoing LADG was similar to that of patients undergoing ODG. However, LADG was still a technically dependent and time-consuming procedure. Conversion rate of LADG was 0% to 2.94%. The reported reasons for conversion were bleeding, adhesion, and safety resection margin requirement. LIMITATIONS: : There were potential biases and significant heterogeneity in some clinical outcome measures in this study. Methodologically high-quality controlled clinical trials were sparse for this new surgical intervention. According to The Grading of Recommendations Assessment, Development and Evaluation approach, when assessing the safety and efficacy of LADG by comparing with those of ODG with the defined clinical outcomes in patients with EGC, the quality of the currently available clinical evidence was very low. CONCLUSIONS: LADG may be a technically feasible alternative for EGC when it is performed in experienced surgical centers in which patients undergoing LADG may benefit from the faster postoperative recovery. However, the currently available evidence cannot exclude the potential clinical benefits or harms, especially in the node-positive cases. Methodologically high-quality comparative studies are needed for further evaluation.

Characterization of episodes of irritable bowel syndrome using ecological momentary assessment.

OBJECTIVES: Patients with irritable bowel syndrome (IBS) report that symptoms occur as episodes. The nature and frequency of episodes have not been well studied. METHODS: Using modified ecological momentary assessment (EMA), we examined clinical factors attributed to IBS symptom episodes and compared them with nonsymptom episode periods in patients with IBS-D (N=21), IBS-C (N=18), or IBS-M (N=19), and healthy controls (N=19). Symptoms were rated over 14 days on a visual ordinal scale (VOS: 0-10) randomly in morning, midday, and evening, and at wake up, bedtime, prebowel movement, and postbowel movement. Scores were evaluated for total group and across subgroups and between EMA and daily diary cards on the same day. RESULTS: Subjects (n=57/59) reported symptom episodes 34% of the time. Episodes showed significantly higher pain levels (3.6 vs. 1.64, P<0.0001), bloating (4.57 vs. 3.02, P<0.0001), stress (3.54 vs. 2.59, P<0.0001), and decreased well-being (5.29 vs. 6.16, P<0.0001). Episode frequency/2 weeks was greatest for IBS-D (10.7±7.05) than IBS-C (8.4±5.76) and IBS-M (7.1±4.45) (P=nonsignificant). IBS-D also had shorter episodes (9 h 23 min) compared with IBS-M (15 h 01 min) and IBS-C (15 h 25 min) (P<0.04). Stool frequency and looser consistency were greater with IBS-D and similar between IBS-C and IBS-M. Abdominal pain was the greatest predictor of episode status. Diary card ratings of pain and stool frequency overestimate levels reported by EMA. CONCLUSIONS: Episodes of IBS are associated with greater pain (strongest relationship), bloating, and stress scores, and poorer global well-being. Compared with IBS-D, IBS-C and IBS-M are similar in clinical features. Patients overreport pain and stool frequency by diary compared with EMA.

Incontinence in women prisoners: an exploration of the issues.

AIM: This paper is a report of a study exploring the extent and management of bladder and bowel problems in order to inform the provision and practice of prison nursing services and health care services in women's prisons. BACKGROUND: Nurses and general practitioners provide primary care services inside prisons in the United Kingdom. While high levels of mental health and addiction problems in women prisoners are recognized, there has been less focus on physical problems. Incontinence symptoms are perceived as shameful and stigmatizing, and frequently help is not sought from healthcare professionals. Guidance for assessing prisoner health does not refer to bladder and bowel symptoms. METHODS: Women prisoners in a large, closed prison in the United Kingdom were surveyed in 2005 using an anonymous self-completed questionnaire. Women resident in the detoxification unit and the hospital unit, absent from their unit at the time of questionnaire distribution or deemed vulnerable by prison health staff were excluded. RESULTS: Questionnaires were offered to 283 women and 246 agreed to take it. Of those taken, 148 (60%) were returned. Twenty-four per cent indicated that they disclosed information about bladder and bowel problems in the survey not previously disclosed to anyone else. Forty-three per cent reported urinary symptoms. Five per cent reported nocturnal enuresis. The majority of women with symptoms reported using sanitary pads and toilet paper for containment of leakage. CONCLUSION: Prison nurses and nurse practitioners involved in reception into prison assessments should ask direct but sensitive questions about women's bladder and bowel symptoms.

Traditional healers in Riyadh region: reasons and health problems for seeking their advice. A household survey.

OBJECTIVES: The objectives were to study sociodemographic characteristics of complementary and alternative medicine (CAM) visitors, rate of their visits, health problems, and reasons for the visits. DESIGN: This was a cross-sectional study. SETTING: This study was conducted in Riyadh city and its suburbs. SUBJECTS: The sample size was calculated to be 462 families, selected according to the World Health Organization multistage random cluster sampling technique and was divided into 40 clusters. The 40 clusters were distributed proportionally according to the size of population in the catchment area. INTERVENTION AND OUTCOME MEASURES: A well-structured questionnaire that contains the items that fulfill the research objectives was used to collect the data by trained research assistants. RESULTS: The study includes 1408 individuals; 61% were female. About 42% of the participants consulted traditional healers (TH) sometime before and 24% within the past 12 months. There were more visits to TH in elderly people (> or =60 years), females, married, divorced, or widows and illiterate people. Common types of traditional healing included reciting the Holy Quran (62.5%), herb practitioners (43.2%), cautery (12.4%), and cupping (4.4%). Cautery was used more in suburban areas than in the city. The nationalities of the TH were Saudis (86%), Sudanese (3%), Yemenis (1%), Indians (1%), and others (9%). The common medical problems for seeking TH help were abdominal pain, flatulence, low back pain, sadness, depression, and headache. The common reasons for visiting TH were belief of success of CAM (51%), preference of natural materials (29%), and nonresponse to medical treatment (25%). Factors independently associated with consultation of TH were dissatisfaction with physician diagnosis (odds ratio [OR] = 122), failure of medical treatment (OR = 80), success of TH (OR = 79), long waiting time for physicians (OR = 20) and knowledge that some herbs are harmful (OR = 1.4). CONCLUSIONS: In this study, about half of the participants have visited TH. Abdominal pain was the most common presenting health problem. CAM is a reality and it deserves more investigation and appropriate legislation and control.

Early enteral feeding after upper digestive tract surgeries and clinical assessment of post-operative ileus / Nutrição enteral precoce após cirurgias do trato digestivo alto e avaliação clínica de íleos pós-operatórios

In general, feeding after a gastrointestinal surgery should only occur after resolution of the postoperative ileus. However, early enteral feeding has shown such advantages (i) as faster recovery of the gastrointestinal motility, (ii) a shorter hospital stay and (iii) a better nitrogen balance. Our aim is to demonstrate that early feeding does provide these advantages and is also tolerable. The patients submitted to surgeries of the upper digestive tract were randomly distributed in two groups: the control group, with oral feeding 72h after surgery, and the test group with enteral feeding through a nasojejunal catheter 24h after surgery. The following were assessed: abdominal diameter, abdominal aspect, bowel sounds, flatulence and stools elimination, presence or absence of reflux, diarrhoea, abdominal pain, náuseas and/or vomits, all of which on a daily basis. On the fourth post-operative day, the nitrogen balance was assessed for all patients. The date of discharge from hospital was also recorded. Patients in both the test group and the control group did not show any difference as to the period of hospital stay, recovery time of post-operative ileus and diet tolerance. The nitrogen balance was statistically significant (p<0.000) and better in the test group. Early enteral feeding after surgeries of the upper digestive tract is tolerable and enables a better nitrogen balance.

É comum que a realimentação precoce após cirurgias do trato gastrointestinal ocorra somente após a resolução do íleo pós-operatório. A nutrição enteral precoce tem demonstrado vantagens como recuperação mais rápida da motilidade gastrointestinal, menor tempo de permanência hospitalar e melhor balanço nitrogenado. Objetiva-se demonstrar que a alimentação precoce proporciona essas vantagens, além de ser tolerável. Os pacientes submetidos a cirurgias do trato digestório alto foram distribuídos aleatoriamente em dois grupos: o controle com início da dieta por via oral a partir de 72H após a cirurgia, e o estudo com introdução de dieta enteral via cateter nasojejunal 24H após a cirurgia. Foram coletados: diâmetro abdominal, aspecto do abdome, ruídos hidroaéreos intestinais, eliminação de flatos e fezes, presença ou ausência de regurgitação, diarréia, dor abdominal, náuseas e/ou vômitos diariamente. No quarto dia de pós-operatório foi calculado o balanço nitrogenado em todos os pacientes. A data de alta hospitalar dos pacientes foi também registrada. Os pacientes do grupo estudo (8) e controle (8) não apresentaram diferenças quanto ao tempo de permanência hospitalar, tempo de recuperação do íleo pós-operatório e tolerância à dieta. O balanço nitrogenado foi estatisticamente significativo (p<0,000) e melhor no grupo controle. A introdução precoce de dieta após cirurgias do trato digestório alto é tolerável e permite um melhor balanço nitrogenado.

Development of a technique for the in vivo assessment of flatulence in dogs.

OBJECTIVE: To develop a noninvasive method for the in vivo assessment of flatulence in dogs. ANIMALS: 8 adult dogs. PROCEDURE: Rectal gases were collected via a perforated tube held close to each dog's anus and attached to a monitoring pump fitted with a sensor that recorded hydrogen sulfide concentrations every 20 seconds. Patterns of flatulence were monitored for 14 hours after feeding on 4 days, and within- and between-dog variation was assessed over 4 hours on 4 consecutive days. Rate of hydrogen sulfide production (flatulence index) and frequency and number of emissions were evaluated as potential indicators of flatus characteristics. An odor judge assigned an odor rating to each flatulence episode, and the relationship between that rating and hydrogen sulfide concentration was determined. RESULTS: Flatulence patterns varied within and between dogs. Variation was most pronounced for flatulence index; mean coefficients of variance within dogs over time and between dogs on each day were 75 and 103%, respectively. Flatus with hydrogen sulfide concentrations > 1 parts per million could be detected by the odor judge, and severity of malodor was highly correlated with hydrogen sulfide concentration. Odor ratings were accurately predicted by use of the equation 1.51 X hydrogen sulfide concentration(0.28). CONCLUSIONS AND CLINICAL RELEVANCE: The technique described in this report appears to provide sensitive, reliable, and relevant data and will enable further studies of the factors that influence flatulence in dogs. Use of this technique also has the potential to aid in investigations of colonic physiology and pathology.

Hypercholesterolemia: a look at low-cost treatment and treatment adherence.

PURPOSE: To determine whether a positive cholesterol-lowering effect could be achieved with a psyllium dose of 6 grams per day instead of the usual 10 grams per day as advocated by other researchers. DATA SOURCES: Randomized trial of 46 males and females with hypercholesterolemia; multivariate analysis of variance with repeated measures on 1 factor done on 28 subjects (18 in treatment group, 10 in control group) remaining after 16 weeks of treatment. CONCLUSIONS: Lipoprotein analysis at 2, 8, and 16 weeks indicated that a daily dose of 6 grams of psyllium hydrophilic mucilloid did not significantly affect serum total cholesterol nor low-density lipoproteins in either men or women with hypercholesterolemia. The effects of psyllium on hypercholesterolemia appear to be dose dependent. PRACTICE IMPLICATIONS: Although it is a low cost option, the addition of psyllium to the diet has unpleasant side-effects, including abdominal distention, flatulence, and discomfort. Because these side effects are troublesome, the lowest effective dose of psyllium may be an important factor in improving treatment adherence.

Patient satisfaction following laparoscopic and open antireflux surgery.

OBJECTIVE: To compare laparoscopic (LNF) with open Nissen fundoplication (ONF) in terms of hospital charges, efficacy, and patient satisfaction. DESIGN: A prospective, nonrandomized study with a median follow-up of 370 days. SETTING: Two tertiary care university hospitals. PATIENTS: Eighty-six patients with complications of gastroesophageal reflux who had not had previous antireflux surgery were studied. Patients chose ONF or LNF following discussion with the surgeon; 12 underwent ONF and 74 underwent LNF, of whom eight required conversion to laparotomy. MAIN OUTCOME MEASURES: Hospital charges, disability, satisfaction, and side effects of fundoplication. RESULTS: Patients were demographically similar. Total charges (mean +/- SD) for LNF ($11,673 +/- $4723) were significantly less than for ONF ($18,394 +/- $17,264). Patients who underwent LNF returned to work sooner (10 +/- 3 days) than those who underwent ONF (28 +/- 1 days). Bloating, dysphagia, and recurrent heartburn occurred with equal frequency in both groups. Recurrent reflex occurred in four of 74 LNF patients and one of 12 ONF patients. Overall satisfaction scores were similar, irrespective of operative technique (LNF, 3.35 +/- 0.87; ONF, 3.50 +/- 0.94. CONCLUSIONS: Laparoscopic Nissen fundoplication is as effective as ONF in the treatment of complications of gastroesophageal reflux disease and appears to cost less and lead to faster recovery from surgery, but does not result in higher patient satisfaction than ONF. The most important factor in patient satisfaction is the abolition of preoperative symptoms rather than the type of operation.

Oncotic pressure, albumin and ileus: the effect of albumin replacement on postoperative ileus.

The effect of decreased colloid oncotic pressure, as seen in hypoalbuminemia and hypoproteinemia, upon intestinal function has been well delineated in the surgical literature. Patients undergoing abdominal aortic aneurysm resection or aortoiliac or aortofemoral bypass grafts are almost uniformly hypoalbuminemic postoperatively; with these two facts in mind, a prospective, randomized clinical study was undertaken to identify the role of serum albumin concentration on the length of postoperative ileus in this population. The main hypothesis was that patients whose albumin levels dropped below 3.5 gm/dL would have a more prolonged postoperative hospital course as a result of delay in return of bowel function when compared with those patients in whom the low albumin levels were exogenously acutely replenished to > 3.5 gm/dL. Albumin was replaced to a level greater-than or equal to 3.5 g/dL in one group of 37 patients (AR), with a control group of 32 patients (NR) not receiving any albumin. Return of bowel function was measured by the postoperative day that flatus was documented, as well as the postoperative day oral intake was resumed. Mean values were determined for each group, and t tests did not reveal a significant difference in postoperative day of flatus (AR mean = 4.06 days, NR mean = 4.16 days) or postoperative day of oral intake (AR mean = 4.0, NR mean = 3.75). Additional comparisons between the groups involving the number of postoperative days until a regular diet was begun (AR mean = 6.06, NR mean = 5.48) and length of postoperative hospital stay (AR mean = 9.16, NR mean = 8.43) failed to reveal significant differences.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-effective treatment of constipation in the elderly: a randomized double-blind comparison of sorbitol and lactulose.

PURPOSE: The purpose of this study was to evaluate the use of sorbitol as an inexpensive alternative to lactulose for treating constipation in the elderly. PATIENTS AND METHODS: Thirty men aged 65 to 86 with chronic constipation were studied in a randomized, double-blind, cross-over trial in which lactulose and 70% sorbitol (0 to 60 mL daily) were each given for 4 weeks preceded by a 2-week washout period. RESULTS: The average number of bowel movements per week was 6.71 with sorbitol and 7.02 with lactulose (95% confidence interval of the difference: -0.43 to 1.06), and the average number of days per week with bowel movements was 5.23 with sorbitol and 5.31 with lactulose (95% confidence interval of the difference: -0.32 to 0.48). Eleven patients stated a preference for sorbitol, 12 for lactulose, and seven had no preference. On a visual analogue scale measuring severity of constipation (0 to 100 mm), the average score for sorbitol was 35.6 mm versus 37.1 mm for lactulose (95% confidence interval of the difference: -6.4 to 9.3). The sorbitol and lactulose treatment periods were also similar in percent of bowel movements recorded as "normal," frequency and severity of symptoms such as bloating, cramping, and excessive flatulence, and overall health status as assessed by a previously validated five-category questionnaire. There were no significant differences between sorbitol and lactulose in any outcome measured except nausea, which was increased with lactulose (p less than 0.05). CONCLUSION: These results support the hypothesis that sorbitol and lactulose have no clinically significant differences in laxative effect. Sorbitol can be recommended as a cost-effective alternative to lactulose for the treatment of constipation in the elderly.

Folk medicine in the Southwest. Myths and medical facts.

The three folk illnesses described in this article--caida de mollera, susto, and empacho--can all be linked to recognized biologic conditions and therefore cannot be analyzed solely on the basis of sociocultural factors. Clearly, it would be a mistake to continue ignoring these syndromes in the Southwest on the assumption that they are "all in the mind" of Mexican-American patients. They must be assessed from the view that they are culturally different labels for serious medical conditions (eg, caida de mollera), that they are useful screening labels for patients with high disease loads (eg, susto), or that they are harmless in and of themselves but their treatment may have significant medical consequences (eg, empacho).