Psychometric properties of a questionnaire (HEMO-FISS-QoL) to evaluate the burden associated with haemorrhoidal disease and anal fissures.

AIM: Current questionnaires designed to evaluate the burden of haemorrhoidal disease ignore symptoms such as bleeding, pain and itching. A specific questionnaire is needed to evaluate the global impact of anal disorders on patients' daily lives. METHOD: We developed a questionnaire (HEMO-FISS-QoL) to assess the symptom burden of anal disorders and administered it to 256 patients (mean age 46.2 years; men 60.4%) with haemorrhoidal disease (67.2%), anal fissure (29.3%) or both (3.5%). Psychometric properties were evaluated by testing the acceptability, construct validity and reliability of the questionnaire. Principal components and multi-trait analyses were used to identify dimensions and to assess construct validity. Backward Cronbach alpha curves and a graded response model were used to reduce the number of items and modalities. External validity was evaluated against SF-12 and the Psychological Global Well-Being Index (PGWBI) using Spearman's correlation coefficient. RESULTS: Principal component analysis defined four dimensions: physical disorders, psychology, defaecation and sexuality. The number of questions was reduced from 38 to 23. The HEMO-FISS-QoL scores correlated well with those of the SF-12 and PGWBI (P < 0.001). Cronbach's coefficients (all > 0.7) reflected good internal reliability of the different dimensions. The total score increased with the severity of the anal disorders and with their consequences (days off work and personal spending related to the disease). CONCLUSION: The HEMO-FISS-QoL questionnaire reliably evaluates the global impact of haemorrhoids and anal fissures on patients' daily lives. This simple tool may prove useful for treatment evaluation in clinical trials and daily practice.

Do recent reports about the adverse effects of proton pump inhibitors change providers' prescription practice?

Proton pump inhibitors (PPI) are utilized for a variety of indications, including treatment of gastroesophageal reflux disease, peptic ulcer disease, and prevention of gastrointestinal (GI) bleeding. Several studies have documented an increasing prevalence of inappropriate PPI use. Furthermore, recent media reports have highlighted new research data suggesting a possible association between chronic PPI use and several adverse medical outcomes, leading to frequent patient inquiries about these associations. Thus, providers face the challenge of counseling patients about the balance of risks and benefits related to PPI use. We aimed to explore providers' knowledge and attitudes toward reported adverse effects of PPI use and compare providers' prescription practices. A comprehensive, non-incentivized electronic survey was sent to all providers (residents, fellows, advanced practice providers, and consultants across 8 internal medicine specialties) at our tertiary academic medical center. The survey contained 21 questions covering provider demographics and responses to challenging clinical scenarios dealing with PPI use. Chi-square was used to compare responses from providers. The survey was distributed to 254 providers, of which 94 (24 GI and 70 non-GI) completed the survey (37% response rate). Among those 94 providers, 48 were consultants, 17 were advanced practice providers, and 29 were trainees. Non-GI providers included cardiology, pulmonary, endocrinology, family medicine, general internal medicine, hematology/oncology, and nephrology. Over half of the providers (51 [54%]) described their practice as outpatient setting, 29 (31%) providers defined their practice as a mixed setting (inpatient and outpatient), while 14 (15%) designated it as inpatient only. Nineteen (80%) GI providers and 48 (69%) non-GI providers discussed the risks and benefits with patients (P = 0.64). Fifteen (63%) GI providers and 33 (47%) non-GI providers indicated that recent reports changed their practice (P = 0.49). More GI providers (5 [21%]) lowered the dose of PPI compared with non-GI (1[1%]) (P = 0.004); 18 (26%) of non-GI and 3 (13%) of GI providers discontinued PPI and substituted it with a histamine 2 (H2) blocker (P = 0.29). A larger but nonsignificant percentage of trainees (8 [28%]) switched PPI to H2 blockers compared with consultants (8 [17%]; P = 0.39). Six (25%) of GI providers and 14 (20%) of non-GI providers were concerned about Clostridium difficile infection (P = 0.58). Twenty-four (34%) of the non-GI were worried about kidney diseases compared with 3 (13%) of the GI providers (P = 0.1). Ten (21%) consultants were concerned about risk of osteoporosis compared with 3 (10%) trainees (P = 0.38), while 8 (28%) trainees were worried about the risk of C. difficile infection compared with 10 (21%) consultants (P = 0.69). Most providers (85 [90%]) agreed that educational activities would be helpful to address these challenges. More GI providers lowered the dose of PPI compared with non-GI; non-GI providers were more likely to discontinue PPI and substitute it with an H2 blocker. Educating patients and providers about potential adverse effects of PPI is imperative.

Do Consultation Psychiatrists, Forensic Psychiatrists, Psychiatry Trainees, and Health Care Lawyers Differ in Opinion on Gray Area Decision-Making Capacity Cases? A Vignette-Based Survey.

BACKGROUND: Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds. METHOD: Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS. RESULTS: Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers. CONCLUSIONS: As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity.

[Life-threatening bleeding in obsessive-compulsive disorder]. / Lebensbedrohliche Blutung infolge Zwangsstörung.

We report on a case of life-threatening hemorrhoidal bleeding due to obsessive-compulsive disorder. The patient had irrational fears and felt compelled to defecate at least 3 times a day. This required massive abdominal pressing and caused inguinal hernias and prolapsed hemorrhoids. Severe obsessive-compulsive rituals may often result in physical complications. Conversely, obsessive-compulsive disorder should be considered when patients present with uncommon physical complaints, particularly skin symptoms or abnormalities in the context of micturition and defecation.

Patient burden and patient preference: comparing magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy.

BACKGROUND AND AIM: We aimed to prospectively determine patient burden and patient preference for magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy in patients with suspected or known Crohn's disease (CD) or occult gastrointestinal bleeding (OGIB). METHODS: Consecutive consenting patients with CD or OGIB underwent magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy. Capsule endoscopy was only performed if magnetic resonance enteroclysis showed no high-grade small bowel stenosis. Patient preference and burden was evaluated by means of standardized questionnaires at five moments in time. RESULTS: From January 2007 until March 2009, 76 patients were included (M/F 31/45; mean age 46.9 years; range 20.0-78.4 years): 38 patients with OGIB and 38 with suspected or known CD. Seventeen patients did not undergo capsule endoscopy because of high-grade stenosis. Ninety-five percent (344/363) of the questionnaires were suitable for evaluation. Capsule endoscopy was significantly favored over magnetic resonance enteroclysis and balloon-assisted enteroscopy with respect to bowel preparation, swallowing of the capsule (compared to insertion of the tube/scope), burden of the entire examination, duration and accordance with the pre-study information. Capsule endoscopy and magnetic resonance enteroclysis were significantly preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, and magnetic resonance enteroclysis was significantly preferred over balloon-assisted enteroscopy for bowel preparation, painfulness and burden of the entire examination. Balloon-assisted enteroscopy was significantly favored over magnetic resonance enteroclysis for insertion of the scope and procedure duration. Pre- and post-study the order of preference was capsule endoscopy, magnetic resonance enteroclysis and balloon-assisted enteroscopy. CONCLUSION: Capsule endoscopy was preferred to magnetic resonance enteroclysis and balloon-assisted enteroscopy; it also had the lowest burden. Magnetic resonance enteroclysis was preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, bowel preparation, painfulness and burden of the entire examination, and balloon-assisted enteroscopy over magnetic resonance enteroclysis for scope insertion and study duration.

Factors associated with consultation behaviour for primary symptoms potentially indicating colorectal cancer: a cross-sectional study on response to symptoms.

BACKGROUND: Little data exists on the factors associated with health care seeking behaviour for primary symptoms of colorectal cancer (CRC). This study aimed to identify individual, provider and psychosocial factors associated with (i) ever seeking medical advice and (ii) seeking early medical advice for primary symptoms of colorectal cancer (CRC). METHODS: 1592 persons aged 56-88 years randomly selected from the Hunter Community Study (HCS) were sent a questionnaire. RESULTS: Males and those who had received screening advice from a doctor were at significantly higher odds of ever seeking medical advice for rectal bleeding. Persons who had private health coverage, consulted a doctor because the 'symptom was serious', or who did not wait to consult a doctor for another reason were at significantly higher odds of seeking early medical advice (< 2 weeks). For change in bowel habit, persons with lower income, within the healthy weight range, or who had discussed their family history of CRC irrespective of whether informed of 'increased risk' were at significantly higher odds of ever seeking medical advice. Persons frequenting their GP less often and seeing their doctor because the symptom persisted were at significantly higher odds of seeking early medical advice (< 2 weeks). CONCLUSIONS: The seriousness of symptoms, importance of early detection, and prompt consultation must be articulated in health messages to at-risk persons. This study identified modifiable factors, both individual and provider-related to consultation behaviour. Effective health promotion efforts must heed these factors and target sub-groups less likely to seek early medical advice.

Clinical judgment model-based nursing simulation scenario for patients with upper gastrointestinal bleeding: A mixed methods study.

Assisting patients with upper gastrointestinal bleeding is a crucial role for nurses, and as future nurses, students should demonstrate sound clinical judgment. Well-structured, high-quality simulations are useful alternatives to prepare students for clinical practice. However, nursing simulation scenarios focused on enhancing clinical judgment in managing upper gastrointestinal bleeding are limited. This study aims to develop, apply, and evaluate an effective nursing simulation scenario for patients with upper gastrointestinal bleeding based on Tanner's clinical judgment model using a mixed methods study design. A high-fidelity patient simulation was conducted among 80 undergraduate nursing students divided into a simulated control group (n = 39) and an experimental group (n = 41). Subsequent student performance evaluations used questionnaires and video recordings. After scenario simulations, the students showed a statistically significant increase in theoretical knowledge (p = 0.001) and clinical performance skills (p < 0.001), but there was no significant increase in self-confidence (p = 0.291). According to the video analysis, the "noticing" clinical judgment phase was the most frequently observed phase, while "reflection" was the least frequently observed phase. Additionally, "education" was the most frequently observed nursing domain, and "anxiety" was the least frequently observed domain. Although further simulation repetitions are required to reinforce students' self-confidence when caring for patients with upper gastrointestinal bleeding, the scenario was deemed effective. Moreover, emphasis should be placed on developing various scenarios to strengthen students' clinical judgment skills, especially "reflecting" and "emotional care."

[Improvement of outcomes and quality of life of patients with portal esophagogastric bleedings due to using endoscopic haemostatic methods].

Effectiveness of endoscopic haemostatic methods for acute esophagogastric bleedings of portal genesis was analyzed. Under study there were indices of survival and mean life span of 157 patients divided into two groups: main and of comparison. Considerable improvement was established in indices of survival and mean life span in patients of the main group, where haemostatic methods were used for hemostasis. The patients of the main group had higher level of quality of life in long-term periods of follow-up, longer kept ability to work, physical activity and self-service.

Understanding Factors Associated with Quality of Life in Patients with Venous Thromboembolism.

INTRODUCTION: Quality of life (QoL) deficits have been noted among patients with venous thromboembolism (VTE) but understanding of the drivers of that poorer QoL is limited. The objective of this study was to examine associations between a variety of factors and QoL in patients with VTE. METHODS: Adult patients who had experienced at least one VTE episode within the past 2 years completed an online survey between May and July 2016 with responses to a variety of questions designed to ascertain QoL scores, Optum Short Form-12, and potential factors associated with these scores. RESULTS: Most of the 907 patients were female (56.7%) and Caucasian (88.6%). Physical and mental QoL scores below the general population average were present in 76.0 and 56.7% of patients, respectively. Multiple regression modeling revealed several factors associated with below average physical QoL scores including unemployment (odds ratio [OR] 3.77, 95% confidence interval [CI] 1.76-8.05), gastrointestinal bleeding (OR 2.54, 95% CI 1.28-5.01), high depression scores (OR 4.02, 95% CI 1.88-8.58), or difficulty accessing VTE care (OR 4.24, 95% CI 1.77-10.17). Factors associated with below average mental QoL scores included experiencing VTE within the last month (OR 3.85, 95% CI 1.58-9.41), unemployment (OR 2.83, 95% CI 1.30-6.16), or high depression (OR 3.85, 95% CI 1.60-9.28) and/or anxiety (OR 9.17, 95% CI 4.81-17.47) scores. CONCLUSION: Most patients with recently diagnosed VTE reported below average QoL. Many of the factors associated with below average QoL are modifiable, indicating that patients with VTE could potentially benefit from interventions aimed at improving QoL.

Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial.

OBJECTIVES: Data on costs associated with acute upper gastrointestinal bleeding (AUGIB) are scarce. We provide estimates of UK healthcare costs, indirect costs and health-related quality of life (HRQoL) for patients presenting to hospital with AUGIB. SETTING: Six UK university hospitals with >20 AUGIB admissions per month, >400 adult beds, 24 h endoscopy, and on-site access to intensive care and surgery. PARTICIPANTS: 936 patients aged ≥18 years, admitted with AUGIB, and enrolled between August 2012 and March 2013 in the TRIGGER trial of AUGIB comparing restrictive versus liberal red blood cell (RBC) transfusion thresholds. PRIMARY AND SECONDARY OUTCOME MEASURES: Healthcare resource use during hospitalisation and postdischarge up to 28  days, unpaid informal care, time away from paid employment and HRQoL using the EuroQol EQ-5D at 28  days were measured prospectively. National unit costs were used to value resource use. Initial in-hospital treatment costs were upscaled to a UK level. RESULTS: Mean initial in-hospital costs were £2458 (SE=£216) per patient. Inpatient bed days, endoscopy and RBC transfusions were key cost drivers. Postdischarge healthcare costs were £391 (£44) per patient. One-third of patients received unpaid informal care and the quarter in paid employment required time away from work. Mean HRQoL for survivors was 0.74. Annual initial inhospital treatment cost for all AUGIB cases in the UK was estimated to be £155.5 million, with exploratory analyses of the incremental costs of treating hospitalised patients developing AUGIB generating figures of between £143 million and £168 million. CONCLUSIONS: AUGIB is a large burden for UK hospitals with inpatient stay, endoscopy and RBC transfusions as the main cost drivers. It is anticipated that this work will enable quantification of the impact of cost reduction strategies in AUGIB and will inform economic analyses of novel or existing interventions for AUGIB. TRIAL REGISTRATION NUMBER: ISRCTN85757829 and NCT02105532.

Rectal bleeding in Prader-Willi syndrome.

Individuals with Prader-Willi syndrome manifest severe skin picking behavior. We report three patients with this syndrome in whom an extension of this behavior to rectal picking resulted in significant lower gastrointestinal bleeding and anorectal disease. The recognition of this behavior is important to avoid misdiagnosing inflammatory bowel disease in this group of patients.

Personal view: 'don't ask, don't tell'--the undesirable consequences of incidental test results in gastroenterology.

A gastroenterologist is frequently approached to perform an endoscopic procedure after an incidental test has resulted in an unexpected positive finding. Should the incidental test result be ignored or automatically followed by an endoscopic procedure? The present analysis strives to characterize the common pattern of such scenarios and resolve their underlying dilemma. A model of game theory is used as a mathematical tool to develop general management strategies. Three clinical scenarios are used as examples to demonstrate this approach. The model is based on how doctors rank the various outcomes with which they are confronted by the incidental test results. The ranks of different outcomes are listed in a decision matrix that is converted into a two-by-two, non-zero, ordinal game. All scenarios of incidental test results emerge as a similar type of game that is best played by both parties adhering to the same set of strategies: 'Don't do the test' and 'don't respond to whatever test result it yields'. These two strategies lead to a Nash equilibrium for a non-zero game, where neither party can improve its payoff any further by choosing a different strategy. Although the equilibrium does not provide the individual players with their best possible payoff, it yields the best overall outcome available to both parties given the economic and medical constraints of the situation.

Neuroleptic malignant syndrome complicated by massive intestinal bleeding in a patient with chronic renal failure.

A patient with chronic renal failure (CRF) developed neuroleptic malignant syndrome (NMS) after administration of risperidone and levomepromazine. In addition to the typical symptoms of NMS, massive intestinal bleeding was observed during the episode. This report suggests that NMS in a patient with CRF may be complicated by intestinal bleeding and needs special caution for this complication.

Knowledge of cancer symptoms among patients attending one-stop breast and rectal bleeding clinics.

AIM AND METHOD: The aim of this questionnaire study was to identify knowledge of breast and colorectal cancer symptoms among 100 patients attending one-stop breast clinics and rectal bleeding clinics and to determine the source of the information. RESULTS: Seventy-five breast clinic (mean age 46 years, all female) and 78 colorectal clinic patients (mean age 59 years, 51% male) responded. Knowledge of breast was significantly greater than bowel cancer in both groups (P<0.0001, McNemar's chi(2)). There was no difference in knowledge of symptoms of breast cancer or bowel cancer between patients attending either clinic. There was a positive association between cancer knowledge, family history and female gender but no association with age. Knowledge of Bowel Cancer Awareness Week was positively associated with colorectal cancer knowledge. CONCLUSION: Knowledge of colorectal cancer is much less than breast cancer in clinic attenders. Seventy-five per cent of women attending breast clinic could name a breast cancer symptom whereas only 37% of patients attending colorectal clinic could name a bowel cancer symptom. These findings have implications when considering patients' anxiety, expectations of a cancer diagnosis and breaking bad news.

Survival and quality of life after portal blood flow preserving procedures in patients with portal hypertension and liver cirrhosis.

Between 1979 and 1991, 156 patients with histologically proven liver cirrhosis, good liver function, and bleeding portal hypertension underwent operation with portal blood flow preserving procedures (selective shunts: 101; Sugiura-Futagawa: 55). Long-term results of the procedures and the quality of life of the 145 patients who survived the operation were studied. During the observation period (range 3 to 156 months), 28 patients died. The main causes of death were liver failure and hepatoma. Twenty-three patients were lost for follow-up. Twenty-six patients (18%) developed 1 or more encephalopathic episodes. Four patients (3%) experienced rebleeding. One hundred eight patients (74%) had a good quality of life, and 26 (18%) had a poor quality of life. Eleven (15%) of 73 patients with a history of alcoholism continued drinking. Five-year survival for the selective shunt group was 81% and for the devascularization group was 83%. In 81% of the patients, portal blood flow was maintained. It is concluded that both procedures are effective in the long-term. Most patients are able to rehabilitate from the use of alcohol, and most of them have a good quality of life. For patients with good liver function (whose main problem is bleeding), surgery is the best choice of treatment.

Synthesis and characterization of a diruthenium-ibuprofenato complex comparing its anti-inflammatory activity with that of a copper(II)-ibuprofenato complex.

The ibuprofen complex of diruthenium(II,III) was prepared and characterized by electronic (UV-Vis) and vibrational (FTIR) spectroscopies and thermogravimetry. The copper(II)-ibuprofenato complex was prepared by a different route from that described in the literature. Both complexes were tested in vivo for anti-inflammatory activity. Oral administration of the two complexes inhibited development of carrageenin-induced edema in rats, this inhibition being similar to that observed for oral administration of the parent drug (free ibuprofen). However, gastric irritation was lower as compared to that of ibuprofen. Diruthenium-ibuprofenato exhibited a protective effect at light intensity ulceration while the copper-ibuprofenato complex was more effective in the protection of severe intensity ulceration.

Depression increases mortality and morbidity in acute life-threatening medical illness.

The presence of depression in consecutive admissions with life-threatening illness was assessed using the Montgomery-Asberg Depression Rating Scale (MADRS). The 211 patients had one of four conditions, myocardial infarction (N = 100), subarachnoid haemorrhage (N = 41), pulmonary embolism (N = 40), and acute upper gastrointestinal haemorrhage (N = 30). Depression was measured using both the standard MADRS, and a modified version excluding somatic items which might be influenced by the underlying illness. The patients were also assessed for severity of illness and cognitive dysfunction. The results showed that immediately following a life-threatening illness approximately 34% of the patients were depressed, using the modified scale, but that the depressed group did not have a more severe physical illness. However, the depressed patients had a significantly poorer outcome over the 28 days following admission, with 47% of the depressed patients dying or having life-threatening complications, as opposed to 10% of the non-depressed group. This study demonstrates that the psychological state of an individual can affect their individual risk of mortality following physical illness.

Changes in depression scores following life-threatening illness.

Measuring depression in medically ill patients can be affected by the somatic symptoms occurring due to the underlying illness. This study used the Montgomery and Asberg Depression Rating Scale, over a 21-day period in 211 patients with acute life-threatening illness, to assess the influence of three factors upon the incidence of depression. These were time of measurement, the cut-off point used, and the effect of excluding somatic items. Using the standard rating scale, and a cut-off point for depression of 7, 63% of the patients were depressed on admission, 46% at one week and 37% at two weeks. Raising the cut-off point for depression to 14 and 21 led to 39% and 16% being depressed on admission and only 8% and 2% at one week respectively. In those patients scoring up to 14 over 75% of this score was accounted for by somatic symptoms. If the rating scale was modified to exclude somatic items from the score the rating scale performed more consistently, and the influence of somatic items was reduced. This study shows that the time of interview, the cut-off point used, and the influence of somatic items are all important in determining the incidence of psychiatric morbidity detected in this patient population.

The surgical management of massive gastro-intestinal hemorrhage due to stress ulcer following surgery.

In this paper, thirty-six cases complicated by gastrointestinal bleeding after various operations were reviewed. The mortality rate was 47.2%. In 20 surgical cases, the mortality rate was 35.0%. Especially in the cases of post-intracranial surgery, a remarkably better result was obtained by surgical than by conservative treatment. With reference to the better results of surgical treatment, we suggested that the surgical indication depended on a stressor due to the original postoperative phase, which induced a stress ulcer. In post-CNS surgery, operative treatment should not be performed in a comatose patients. As regards jaundiced patients, those with low improved bilirubin levels should be preferred to those with infected bile ducts. In cases of abdominal surgery, sepsis and functional failure of the liver and kidney must be taken into consideration. From our clinical experience, subtotal gastrectomy combined with truncal vagotomy appears to be a more satisfactory treatment for stress ulcers than gastrectomy or vagotomy alone.

Rectal bleeding in general practice patients.

OBJECTIVE: To determine the prevalence of observed rectal bleeding in general practice patients, the health seeking behaviour of those with rectal bleeding, and what rectal bleeding 'means' to patients in terms of perceived health risk. METHOD: Self administered questionnaire survey of general practice patients aged 50 years and over in northern Tasmania recruited as they visited their general practitioner (GP). RESULTS: The reported lifetime prevalence of rectal bleeding in our sample was 33% (299 of 903 respondents). It was more common in younger people, becoming less common with increasing age. Many respondents do not examine for bleeding. Only 45% of respondents with rectal bleeding consulted their GP about the most recent bleed. Patients were more likely to consult if they reported blood in the toilet pan and if they sought advice from a family member. There were significant differences between the meaning of bleeding for GP consulters and non consulters. This may have important implications for health education. CONCLUSION: Colorectal cancer (CRC) is a common problem managed by a combination of screening and case finding. With the high prevalence of rectal bleeding and low consultation rates for this problem there is potential to enhance the effectiveness of early detection of CRC through general practice based public health and education campaigns.