Patient-Physician Relationship in Irritable Bowel Syndrome: Review on Empathy and Stigma.

Irritable bowel syndrome (IBS) lacks a clear understanding of the disease's pathogenesis and effective treatments thus producing frustration among providers and patients, leading to the stigmatization of the disease and the patients with the syndrome. A literature search was performed to make a hermeneutical review on empathic patient-provider communication and IBS. The relationship is defined by partners being dependent on one another in the pursuit of obtaining good outcomes. It is a unique interaction depending not only on the individual qualities of each partner but also on the specific patterns of the patient-physician synergy. Empathy is crucial for any relationship. It helps to recognize the other as the other of myself, a person like me. Meanwhile, stigmatization results from identifying and labelling human differences and stereotyping persons who are linked to undesirable characteristics. IBS is at high risk of stigmatization in various contexts and settings including health care, causing patients and physicians misconceptions and distress, which in turn leads to the worsening of the disease in patients and burnout in physicians. Narrative-based medicine helps create a holistic perspective of a patient's problems and health, thus providing a tool for an empathic doctor-patient relationship that fosters mutual understanding and helps patients with IBS make sense of symptoms, increases their ability to manage their IBS in a psychologically flexible manner, subsequently helping them maintain their quality of life.

Circulating microbiome in patients with portal hypertension.

Portal hypertension (PH) in liver cirrhosis leads to increased gut permeability and the translocation of bacteria across the gut-liver axis. Microbial DNA has recently been detected in different blood compartments; however, this phenomenon has not been thoroughly analyzed in PH. This study aimed to explore circulating bacterial DNA signatures, inflammatory cytokines, and gut permeability markers in different blood compartments (peripheral and hepatic veins) of patients with cirrhosis and PH. The 16S rRNA blood microbiome profiles were determined in 58 patients with liver cirrhosis and 46 control patients. Taxonomic differences were analyzed in relation to PH, liver function, inflammatory cytokines, and gut permeability markers. Circulating plasma microbiome profiles in patients with cirrhosis were distinct from those of the controls and were characterized by enrichment of Comamonas, Cnuella, Dialister, Escherichia/Shigella, and Prevotella and the depletion of Bradyrhizobium, Curvibacter, Diaphorobacter, Pseudarcicella, and Pseudomonas. Comparison of peripheral and hepatic vein blood compartments of patients with cirrhosis did not reveal differentially abundant taxa. Enrichment of the genera Bacteroides, Escherichia/Shigella, and Prevotella was associated with severe PH (SPH) in both blood compartments; however, circulating microbiome profiles could not predict PH severity. Escherichia/Shigella and Prevotella abundance was correlated with IL-8 levels in the hepatic vein. In conclusion, we demonstrated a distinct circulating blood microbiome profile in patients with cirrhosis, showing that specific bacterial genera in blood are marginally associated with SPH, Model for End-Stage Liver Disease score, and inflammation biomarkers; however, circulating microbial composition failed to predict PH severity.

Endogenous motion of liver correlates to the severity of portal hypertension.

BACKGROUND: Degree of portal hypertension (PH) is the most important prognostic factor for the decompensation of liver cirrhosis and death, therefore adequate care for patients with liver cirrhosis requires timely detection and evaluation of the presence of clinically significant PH (CSPH) and severe PH (SPH). As the most accurate method for the assessment of PH is an invasive direct measurement of hepatic venous pressure gradient (HVPG), the search for non-invasive methods to diagnose these conditions is actively ongoing. AIM: To evaluate the feasibility of parameters of endogenously induced displacements and strain of liver to assess degree of PH. METHODS: Of 36 patients with liver cirrhosis and measured HVPG were included in the case-control study. Endogenous motion of the liver was characterized by derived parameters of region average tissue displacement signal (d antero, dr etro, d RMS) and results of endogenous tissue strain imaging using specific radiofrequency signal processing algorithm. Average endogenous strain µ and standard deviation σ of strain were assessed in the regions of interest (ROI) (1 cm × 1 cm and 2 cm × 2 cm in size) and different frequency subbands of endogenous motion (0-10 Hz and 10-20 Hz). RESULTS: Four parameters showed statistically significant (P < 0.05) correlation with HVPG measurement. The strongest correlation was obtained for the standard deviation of strain (estimated at 0-10 Hz and 2 cm × 2 cm ROI size). Three parameters showed statistically significant differences between patient groups with CSPH, but only d retro showed significant results in SPH analysis. According to ROC analysis area under the curve (AUC) of the σ ROI[0…10Hz, 2 cm × 2 cm] parameter reached 0.71 (P = 0.036) for the diagnosis of CSPH; with a cut-off value of 1.28 µm/cm providing 73% sensitivity and 70% specificity. AUC for the diagnosis of CSPH for µ ROI[0…10Hz, 1 cm × 1 cm] was 0.78 (P = 0.0024); with a cut-off value of 3.92 µm/cm providing 73% sensitivity and 80% specificity. D retro parameter had an AUC of 0.86 (P = 0.0001) for the diagnosis of CSPH and 0.84 (P = 0.0001) for the diagnosis of SPH. A cut-off value of -132.34 µm yielded 100% sensitivity for both conditions, whereas specificity was 80% and 72% for CSPH and SPH respectively. CONCLUSION: The parameters of endogenously induced displacements and strain of the liver correlated with HVPG and might be used for non-invasive diagnosis of PH.

Plasma Nogo-A and placental growth factor levels are associated with portal hypertension in patients with liver cirrhosis.

BACKGROUND: Clinically significant portal hypertension (CSPH) and severe portal hypertension (SPH) increase the risk for decompensation and life-threatening complications in liver cirrhosis. Pathologic angiogenesis might contribute to the formation of these conditions. Placental growth factor (PlGF) and Nogo-A protein are biomarkers of pathological angiogenesis, but data on their role in liver cirrhosis and portal hypertension is scarce. AIM: To determine plasma levels of PlGF and Nogo-A in patients with liver cirrhosis, CSPH, SPH and potential to predict portal hypertension. METHODS: A cohort of 122 patients with hepatitis C virus and/or alcohol-induced liver cirrhosis with characterized hepatic venous pressure gradient (HVPG) were included in the study. Demographic data, medical history, Child-Turcotte-Pugh and Model of End Stage liver disease score, clinical chemistry, liver stiffness values were recorded on the day of the procedure prior HVPG measurement. The degree of portal hypertension was determined by the invasive HVPG measurement. Nogo-A and PlGF plasma levels were evaluated using enzyme linked immunosorbent assay. The control group consisted of 30 healthy age- and sex- matched individuals. RESULTS: Peripheral PlGF levels were higher and Nogo-A levels were lower in patients with liver cirrhosis (23.20 vs 9.85; P < 0.0001 and 2.19 vs 3.12; P = 0.004 respectively). There was a positive linear correlation between peripheral levels of PlGF and HVPG (r = 0.338, P = 0.001) and negative linear correlation between the peripheral Nogo-A levels and HVPG (r = -0.267, P = 0.007). PlGF levels were higher in CSPH and SPH (P = 0.006; P < 0.0001) whereas Nogo-A levels were lower (P = 0.01; P < 0.033). Area under the curve for the diagnosis of CSPH for PlGF was 0.68 (P = 0.003) and for Nogo-A - 0.67 (P = 0.01); for SPH 0.714 (P < 0.0001) and 0.65 (P = 0.014) respectively. PlGF levels were higher and Nogo-A levels were lower in patients with esophageal varices (P < 0.05). PlGF cut-off value of 25 pg/mL distinguished patients with CSPH at 55.7% sensitivity and 76.7% specificity; whereas Nogo-A cut-off value of 1.12 ng/mL was highly specific (93.1%) for the diagnosis of CSPH. CONCLUSION: Plasma PlGF levels were higher while Nogo-A levels were lower in patients with liver cirrhosis and portal hypertension. Biomarkers showed moderate predictive value in determining CSPH and SPH.

Investigation of Radiofrequency Ultrasound-Based Fibrotic Tissue Strain Imaging Method Employing Endogenous Motion.

OBJECTIVES: The paper presents the results of an initial clinical study, which were obtained using the strain elastography imaging method based on radio frequency ultrasound signal analysis. METHODS: The technique employs endogenous motion of the liver induced by beating heart and vascular pulsatility as an excitation source of tissue microdisplacement. The potential for fibrotic tissue characterization was demonstrated using a clinical data set of radio frequency ultrasound signals (23 healthy controls, 21 subjects with hepatitis, and 16 subjects with liver cirrhosis). Parametric maps, which represent the tissue strain, were derived from the gradient of the integrated spectral coefficient parameter, and correlations with the stage of liver disease were evaluated. Average endogenous strain derived from the gradient of the integrated spectral coefficient parameter and variability (standard deviation) of the strain were evaluated in the rectangular regions of interest (sizes, 1 × 1 and 2 × 2 cm) defined by the observer. The assessment of strain was performed in different frequency subbands of endogenous motion (0-10 Hz and 10-20 Hz). RESULTS: The best distinction between the groups was observed for the average strain derived from the gradient of the integrated spectral coefficient parameter: the controls, 13.30 ± 6.62; hepatitis, 7.12 ± 7.45; cirrhosis, 3.95 ± 2.44 µm/cm (region of interest, 1 × 1 cm; frequency subband 0-10 Hz), and 10.48 ± 6.02, 8.27 ± 5.41, 3.89 ± 2.07 µm/cm, respectively (2 × 2 cm, 0-10 Hz). CONCLUSION: The investigated strain parameters showed statistically significant differences (P < .001) for the different stages of liver fibrosis in most of the cases and proved this method to be feasible.

Application of acetylcholinesterase histochemistry for the diagnosis of Hirschsprung's disease in neonates and infants: a twenty-year experience.

BACKGROUND: The acetylcholinesterase (AChE) histochemical staining of intestinal mucosal-submucosal biopsy specimens is believed to be the most reliable diagnostic method for Hirschsprung's disease (HD). The aim of our study was to evaluate advantages and disadvantages of this method for HD diagnosis in infants and neonates. MATERIAL AND METHODS: The results of AChE histochemistry of rectal biopsy specimens, obtained from 11 neonates and 29 infants treated in the Clinic of Pediatric Surgery, Hospital of the Lithuanian University of Health Sciences, from 1991 to 2010 were analyzed. AChE activity of neural structures was evaluated using Karnovsky-Roots method modified by El-Badawi and Schenk. RESULTS: Two neonates were diagnosed with HD. The diagnosis was not confirmed in 9 cases, but clinical symptoms progressed in 3 cases, and HD was diagnosed after the repeated biopsy performed in infancy. The results of primary biopsy were rated as false negative. Test sensitivity and specificity in neonates were 40.0% and 100%, respectively. A total of 21 infants were diagnosed with HD. All of them underwent surgery. The diagnosis of HD was confirmed in 20 cases; in one case, intestinal neuronal dysplasia type B was diagnosed. The diagnosis was not confirmed in 8 cases. In infants, the test had a sensitivity of 100% and a specificity of 88.8%. CONCLUSIONS: The analysis of AChE activity in rectal biopsy specimens is a reliable method for diagnosing HD in infancy. This test is less valuable in neonates. If test results are negative, infants should be observed, and if symptoms persist, the biopsy should be repeated at the age of 3 months. Rectal biopsy specimens in neonates should include mucosa and submucosa.