Predictive factors for recurrent acute appendicitis after conservative treatment.

INTRODUCTION: Conservative treatment of acute appendicitis is gaining popularity, and identifying patients with a higher risk of recurrence is becoming increasingly important. Previous studies have suggested that older age, male sex, diabetes, appendicolith and abscess formation may be contributing factors, however, results from the adult population are inconsistent. AIM: This study aims to identify predictive factors for recurrent appendicitis after conservative treatment. METHODS: This retrospective study included patients with conservatively treated acute appendicitis at Skåne University Hospital, Sweden during 2012-2019. Information on patient demographics at index admission and follow-up data were retrieved from medical charts and radiologic images. Uni -and multivariable logistic regression analysis were performed using Stata Statistical Software. RESULTS: In total, 379 patients with conservatively treated acute appendicitis were identified, of which 78 (20.6%) had recurrence. All patients were followed-up for a minimum of 41 months after the first diagnosis of acute appendicitis unless appendectomy after successful conservative treatment or death occurred during follow-up. The median time to recurrence was 6.5 (1-17.8) months. After multivariable logistic regression analysis, external appendix diameter >10 mm [OR 2.4 (CI 1.37-4.21), p = .002] and intra-abdominal abscess [OR 2.05 (CI 1.18-3.56), p = .011] on computed tomography were significant independent risk factors for recurrent appendicitis. Appendicolith was not associated with an increased risk of recurrence. CONCLUSION: This study suggests abscess formation and appendix distension of >10 mm to be potential risk factors for recurrent acute appendicitis after initial successful conservative treatment.

Oesophageal fluoroscopy in adults-when and why?

Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.

Mold Odor from Wood Treated with Chlorophenols despite Mold Growth That Can Only Be Seen Using a Microscope.

We previously reported that indoor odorous chloroanisoles (CAs) are still being emitted due to microbial methylation of hazardous chlorophenols (CPs) present in legacy wood preservatives. Meanwhile, Swedish researchers reported that this malodor, described since the early 1970s, is caused by hazardous mold. Here, we examined to what extent CP-treated wood contains mold and if mold correlates with perceived odor. We found no studies in PubMed or Web of Science addressing this question. Further, we investigated two schools built in the 1960s with odor originating from crawlspaces. No visible mold was evident in the crawlspaces or on the surfaces of treated wood samples. Using a microscope, varying amounts of mold growth were detected on the samples, all containing both CP(s) and CA(s). Some samples smelled, and the odor correlated with the amount of mold growth. We conclude that superficial microscopic mold on treated wood suffices produced the odor. Further, we argue that CPs rather than mold could explain the health effects reported in epidemiological studies that use mold odor as an indicator of hazardous exposure.

Intussusception After Roux-en-Y Gastric Bypass: Correlation Between Radiological and Operative Findings.

INTRODUCTION: Intussusceptions diagnosed on computed tomography (CT) scans in Roux-en-Y gastric bypass (RYGB) patients could cause serious small bowel obstruction (SBO) or be an incidental finding. The objective of this study was to correlate radiological findings with clinical outcomes to differentiate intussusceptions requiring emergent surgery for SBO. METHODS: A search for acute abdominal CT scans reporting intussusceptions in RYGB patients between 2012 and 2019 at Skåne University Hospital, Malmö, Sweden, retrieved 35 scans. These were independently reevaluated by two radiologists for the length and location of the intussusception, whether oral contrast passed through, proximal bowel dilatation, and signs of internal herniation. Clinical outcome in terms of emergency surgery and the diagnosis was determined through chart review. RESULTS: Out of 35 acute patients, 9 patients required emergency surgery within 24 h. Intussusception caused SBO in five patients, and one patient had an internal herniation, while three patients had unremarkable findings. Eight patients were evaluated for intermittent pain with five unremarkable laparoscopies, while 18 patients had intussusceptions as incidental findings. Intussusception length on CT as measured by radiologists O.E. and D.L. predicted acute bowel obstruction (p = .014 and p < .001). A 100 mm threshold predicted bowel obstruction with a sensitivity of 80% and 100% and a specificity of 93% and 86% by radiologists O.E. and D.L., respectively. Proximal bowel dilatation predicted SBOs of any cause as well as SBO caused by an intussusception (all p < .05). CONCLUSION: Intussusception length > 100 mm on CT in RYGB patients is an easy and valuable sign indicating SBO that may require emergent surgery.

Abdominal Closure With Reinforcing Suture Decreases Incisional Hernia Incidence After CRS/HIPEC.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) entails several risk factors for incisional hernia (IH). A few reports available showing incidences between 7% and 17%. At our institution fascia closure has been performed in a 4:1 suture to wound length manner, with a continuous 2-0 polydiaxanone suture (PDS-group) or with a 2-0 polypropylene suture preceded by a reinforced tension line (RTL) suture (RTL-group). Our hypothesis was that these patients might benefit from reinforcing the suture line with a lower IH incidence in this group. The aim was to evaluate the 1-year IH-incidence of the two different closures. Methods: Patients eligible for inclusion were treated with CRS/HIPEC between 2004 and 2019. IH was diagnosed by scrutinizing CT-scans 1 year ±3 months after surgery. Additional data was retrieved from clinical records and a prospective CRS/HIPEC-database. Results: Of 193 patients, 129 were included, 82 in the PDS- and 47 in the RTL-group. RTL-patients were 5 years younger, had less blood loss and more frequent postoperative neutropenia. No difference regarding sex, BMI, recent midline incisions, excision of midline scars, peritoneal cancer index score, complications (≥Clavien-Dindo 3b), or chemotherapy. Ten IH (7.8%) were found, 9 (11%) in the PDS- and 1 (2.1%) in the RTL-group (p = 0.071). Conclusion: An IH incidence of 7.8% in patients undergoing CRS/HIPEC is not higher than after laparotomies in general. The IH incidence in the PDS-group was 11% compared to 2% in the RTL-group. Even though significance was not reached, the difference is clinically relevant, suggesting an advantage with RTL suture.

Extravascular incidental findings in computed tomography angiography are associated with lower amputation-free survival in patients with acute lower limb ischaemia.

BACKGROUND: Emergency computed tomography angiography (CTA) is the most important imaging modality to visualize arterial occlusions in patients with acute lower limb ischaemia (ALI). Extravascular incidental findings (EVIFs) have received less attention. PURPOSE: The aims of this study were to evaluate the incidence of EVIFs of immediate clinical relevance in patients with ALI undergoing CTA and evaluate the association between EVIFs and emergency revascularization and amputation-free survival at 1 year. METHODS: Retrospective cohort study. Emergency CTA in patients with ALI between 2015 and 2018 were independently scrutinized by two senior radiologists. EVIFs were classified into immediate (category I), potential (category II) or no clinical relevance (category III). Multi-variable binary logistic regression analysis was expressed in Odds ratios (OR) with 95% confidence intervals (CI). RESULTS: The intra-class correlation (ICC) coefficient for EVIF category I between the raters was 0.94 (95% CI 0.92-0.96). Among 118 patients with ALI, 78 patients underwent emergency revascularization. Forty-six EVIFs (34 patients) were category I, of which 63% were found in the chest, including pleural effusion (n = 12), pneumonia (n = 8) and cardiac thrombus (n = 4). Ascites (n = 4) and cancer disease (n = 4) were other category I findings. Category I EVIFs were associated with reduced rate of emergency revascularization (OR 0.26, 95% CI 0.10-0.66) and increased rate of combined major amputation/mortality at 1 year (OR 2.9, 95% CI 1.1-8.2) in adjusted analysis. CONCLUSION: It is important to evaluate EVIFs in emergency CTA in patients with ALI since these findings are both common and associated with reduced emergency revascularization and amputation-free survival at 1 year.

Quantified small bowel motility in patients with ulcerative colitis and gastrointestinal symptoms: a pilot study.

BACKGROUND: Gastrointestinal (GI) symptoms are common in patients with ulcerative colitis (UC), even when the disease is in remission, possibly due to abnormalities in GI motility. Small bowel motility can be assessed globally and in specific intestinal regions during magnetic resonance enterography (MRE) using a displacement mapping technique. PURPOSE: To investigate whether small bowel motility in MRE differs between patients with UC and controls, and if altered motility correlates with GI symptoms. MATERIAL AND METHODS: In 2016-2018, patients who were admitted for MRE, regardless of clinical indication, were consecutively invited to the study. Healthy volunteers were recruited. The participants completed a questionnaire regarding GI symptoms and relevant clinical data were reviewed in the medical records. The dynamic imaging series obtained during MRE were sent for motility mapping and a motility index (MI) was calculated in jejunum, ileum and terminal ileum in all participants. RESULTS: In total, 224 patients and healthy volunteers were enrolled in the study. Fifteen were diagnosed with UC and 22 were considered healthy controls. In UC, the prevalence of GI symptoms was higher than in controls (P < 0.001), both in remission and in active disease. There was no correlation between GI symptoms and small bowel motility in UC. Jejunal motility was lower in UC than in controls (P = 0.049). CONCLUSION: Jejunal motility is decreased in UC compared with healthy controls, but there is no relationship between small bowel motility and GI symptoms in UC.

Validation of computed tomography angiography using mean arterial pressure gradient as a reference in stented superior mesenteric artery.

PURPOSE: The aim of this prospective study was to validate the diagnostic performance of computed tomography angiography (CTA) in endoprosthesis stenosis in the superior mesenteric artery (SMA) using mean arterial pressure (MAP) gradients during angiography as a reference method. METHODS: Twenty-nine patients with mesenteric atherosclerotic disease underwent 45 paired measurements of endoprosthesis stenosis in the SMA with CTA and MAP gradients between March 2009 and July 2015. The grade of endoprosthesis stenosis in the SMA at CTA using the TeraRecon Aquarius workstation was correlated with MAP gradients. RESULTS: Grade of endoprosthesis stenosis in the SMA (r = 0.37, p = 0.013) correlated with MAP gradients. The intraclass correlations between the first and second CTA rater was 0.76 (95% CI 0.56-0.87) for estimation of grade of endoprosthesis stenosis in the SMA. The area under the receiver operating characteristics curve was 0.79 for diagnosis of significant endoprosthesis stenosis in the SMA at CTA for different threshold values using MAP gradient of ≥ 10 mmHg as reference. Sensitivity, specificity and positive predictive value for endoprosthesis stenosis in the SMA ≥ 50% at CTA were 52.4% (95% CI 31.0-73.7), 87.5% (95% CI 74.3-100.0) and 78.6 (95% CI 57.1-1.00), respectively. CONCLUSION: Grading endoprosthesis stenosis in the SMA with CTA performed fair when using trans-stenotic MAP gradient as reference. Software development towards reduction of endoprosthesis artefacts may result in more accurate CTA assessment of the narrowest part.

Evaluation of competence in ultrasound-guided procedures-a generic assessment tool developed through the Delphi method.

OBJECTIVES: To develop a generic and objective tool for assessing competence in percutaneous ultrasound-guided procedures. METHODS: Interventional ultrasound experts from the Nordic countries were invited to participate in a three-round Delphi process. A steering committee was formed to manage the process. In round 1, the experts were asked to suggest all aspects to consider when assessing competence in US-guided procedures. Suggestions were analyzed and condensed into assessment items. In round 2, the expert panel rated these items on a 1-5 scale and suggested new items. Items with a mean rating of ≤ 3.5 were excluded. In round 3, the expert panel rated the list items and suggested changes to the items. RESULTS: Twenty-five experts were invited, and response rates in the three rounds were 68% (17 out of 25), 100% (17 out of 17), and 100% (17 out of 17). The three-round Delphi process resulted in a 12-item assessment tool, using a five-point rating scale. The final assessment tool evaluates pre-procedural planning, US technique, procedural technique, patient safety, communication, and teamwork. CONCLUSIONS: Expert consensus was achieved on a generic tool for assessment of competence in percutaneous ultrasound-guided procedures-the Interventional Ultrasound Skills Evaluation (IUSE). This is the initial step in ensuring a valid and reliable method for assessment of interventional US skill. KEY POINTS: • Through a Delphi process, expert consensus was achieved on the content of an assessment tool for percutaneous ultrasound-guided procedures-the Interventional Ultrasound Skills Evaluation (IUSE) tool. • The IUSE tool is comprehensive and covers pre-procedural planning, US technique, procedural technique, patient safety, communication, and teamwork. • This is an important step in ensuring valid and reliable assessment of interventional US skills.

Motility index measured by magnetic resonance enterography is associated with sex and mural thickness.

BACKGROUND: Recently, a technique has been developed to use magnetic resonance enterography (MRE) for the evaluation of small bowel motility. The hypothesis was that assessment of the motility index (MI) should reflect differences in motility between clinical conditions. AIM: To aim of the present observational, cross-sectional study was to evaluate the use of the MI in daily clinical practice. METHODS: All consecutive patients aged 18-70 years who were referred for MRE at the Department of Radiology during a 2-year period were asked to participate. Healthy volunteers were included as controls. MRE was prepared and conducted in accordance with clinical routines. On the day of examination, all the participants had to complete the visual analog scale for irritable bowel syndrome (IBS) and IBS-symptom severity scale. Maps of MI were calculated from dynamic MR images. ANOVA was used to evaluate differences in MI between groups, classified as healthy, Crohn's disease, ulcerative colitis, IBS, other assorted disorders and dysmotility. Logistic and linear regression were applied to the MI values. All medical records were scrutinized for medical history. RESULTS: In all, 224 examinations were included (inclusion prevalence 76.3%), with 22 controls and 202 patients. There was a significant difference in the MI of the jejunum (P = 0.021) and terminal ileum (P = 0.007) between the different groups. The MI was inversely associated with the mural thickness of the terminal ileum in men (P < 0.001) and women (P = 0.063) after adjustments, and tended to be lower in men than in women (P = 0.056). Subjectively observed reduction of motility on MRI was accomplished by reduced MI of terminal ileum in men (P < 0.001) and women (P = 0.030). In women, diarrhea was inversely associated with the MI of the jejunum (P = 0.029), and constipation was positively associated with the MI of the terminal ileum (P = 0.039). CONCLUSION: Although MIs differ across diseases, a lower MI of the terminal ileum is mainly associated with male sex and an increased mural thickness. Symptoms are weakly associated with the MI.

Volumetric analysis of small bowel motility in an unselected cohort of patients with Crohn's disease.

BACKGROUND: Quantified terminal ileal motility during magnetic resonance enterography (MRE) has been suggested to be used as a biomarker of Crohn's disease (CD). The aim of the present study was to evaluate this method in clinical practice. METHODS: Healthy volunteers and all consecutive patients referred to MRE during a 2-year period were asked to participate and complete the Irritable Bowel Syndrome-Symptom Severity Scale (IBS-SSS) to assess gastrointestinal symptoms. Medical records were scrutinized, and motility indices (MIs) were calculated from MR images. KEY RESULTS: Twenty-two healthy controls and 134 examinations with CD were included (inclusion rate: 76.3%). Patients with CD had increased mural thickness of the terminal ileum, increased fecal calprotectin, and more symptoms than controls. Patients with active CD had increased mural thickness of ileum and terminal ileum, higher MR activity indices, and signs of inflammation in laboratory analyses, but similar symptoms, compared with inactive disease. After exclusion of sole colon disease (n = 13), MI inversely correlated with mural thickness in terminal ileum, and MI was lower in active disease versus controls in ileum (P = .019) and terminal ileum (P = .005), and versus inactive disease in terminal ileum (P = .044). The area under the curve of MI in terminal ileum was 0.736 for active CD against healthy controls (P = .002) and 0.682 for active against inactive CD (P = .001). MIs were similar in controls and inactive CD. CONCLUSIONS AND INTERFERENCES: MI reflects inflammatory activity in the intestine. Alterations in MI did not explain symptomatology in inactive CD, without measurable inflammatory parameters in morphology or laboratory analyses.

Simultaneous X-ray Video-Fluoroscopy and Pulsed Ultrasound Velocimetry Analyses of the Pharyngeal Phase of Swallowing of Boluses with Different Rheological Properties.

The Ultrasound Velocity Profiling (UVP) technique allows real-time, non-invasive flow mapping of a fluid along a 1D-measuring line. This study explores the possibility of using the UVP technique and X-ray video-fluoroscopy (XVF) to elucidate the deglutition process with the focus on bolus rheology. By positioning the UVP probe so that the pulsed ultrasonic beam passes behind the air-filled trachea, the bolus flow in the pharynx can be measured. Healthy subjects in a clinical study swallowed fluids with different rheological properties: Newtonian (constant shear viscosity and non-elastic); Boger (constant shear viscosity and elastic); and shear thinning (shear rate-dependent shear viscosity and elastic). The results from both the UVP and XVF reveal higher velocities for the shear thinning fluid, followed by the Boger and the Newtonian fluids, demonstrating that the UVP method has equivalent sensitivities for detecting the velocities of fluids with different rheological properties. The velocity of the contraction wave that clears the pharynx was measured in the UVP and found to be independent of bolus rheology. The results show that UVP not only assesses accurately the fluid velocity in a bolus flow, but it can also monitor the structural changes that take place in response to a bolus flow, with the added advantage of being a completely non-invasive technique that does not require the introduction of contrast media.

Radiological findings in anastomotic leakage after anterior resection may predict a permanent stoma.

BACKGROUND: Permanent stoma (PS) is common following treatment of anastomotic leakage (AL) after anterior resection (AR) and ways of predicting successful treatment outcome are missing. PURPOSE: To explore radiological variables in rectal contrast studies in their relation to end-result of PS following treatment for AL after AR. MATERIAL AND METHODS: The Swedish Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the region of Skåne from 1 January 2001 to 31 December 2011. Among identified AL cases, patients subjected to radiological imaging consistent with AL were evaluated according to a predetermined set of radiological variables. Information of PS as the end-result after AL treatment were retrieved from medical records. RESULTS: Thirty-two patients had radiological imaging available for analysis confirming AL after AR; PS rate after a median follow-up of 87 months (range = 21-165) after AR was 62%. Radiological findings compatible with abscess (P = 0.023) and a leak size ≤6 mm (P = 0.049) were significantly associated with PS. CONCLUSION: In this limited explorative study, our findings suggest that abscess status and leak size could correspond to outcome of PS in treatment for AL after AR. Additional studies are warranted to further explore this subject.

Assessment of the Food-Swallowing Process Using Bolus Visualisation and Manometry Simultaneously in a Device that Models Human Swallowing.

The characteristics of the flows of boluses with different consistencies, i.e. different rheological properties, through the pharynx have not been fully elucidated. The results obtained using a novel in vitro device, the Gothenburg Throat, which allows simultaneous bolus flow visualisation and manometry assessments in the pharynx geometry, are presented, to explain the dependence of bolus flow on bolus consistency. Four different bolus consistencies of a commercial food thickener, 0.5, 1, 1.5 and 2 Pa s (at a shear rate of 50 s-1)-corresponding to a range from low honey-thick to pudding-thick consistencies on the National Dysphagia Diet (NDD) scale-were examined in the in vitro pharynx. The bolus velocities recorded in the simulator pharynx were in the range of 0.046-0.48 m/s, which is within the range reported in clinical studies. The corresponding wall shear rates associated with these velocities ranged from 13 s-1 (pudding consistency) to 209 s-1 (honey-thick consistency). The results of the in vitro manometry tests using different consistencies and bolus volumes were rather similar to those obtained in clinical studies. The in vitro device used in this study appears to be a valuable tool for pre-clinical analyses of thickened fluids. Furthermore, the results show that it is desirable to consider a broad range of shear rates when assessing the suitability of a certain consistency for swallowing.

Prospective Study on Diagnostic Performance of Color Doppler Ultrasound Using Trans-stenotic Mean Arterial Pressure Gradient as a Reference in Stented Superior Mesenteric Artery.

BACKGROUND: The aim of this study was to evaluate the diagnostic performance of color Doppler ultrasound (CDU) after stenting of superior mesenteric artery (SMA) stenosis using mean arterial pressure (MAP) gradients as a reference method. METHODS: This is a prospective study. Thirty-one patients underwent 51 paired measurements of MAP gradients and CDU after endovascular intervention with endoprosthesis in the SMA for mesenteric atherosclerotic disease between March 2009 and July 2016. RESULTS: Peak systolic velocities (PSVs; r = 0.44, P = 0.001) and end-diastolic velocities (EDVs; r = 0.59, P < 0.001) correlated with MAP gradients. The area under the receiver-operating characteristics curve for diagnosis of significant in-stent stenosis for different threshold values of PSV and EDV using MAP gradient of ≥10 mm Hg as reference was 0.75 and 0.80, respectively. Sensitivity and specificity for PSV >3.3 m/s were 43.5% (95% confidence interval [CI] 23.2-63.7) and 92.9% (95% CI 83.3-100.0), respectively. Sensitivity and specificity for EDV >0.50 m/s were 63.6% (95% CI 43.5-83.7) and 92.3% (95% CI 82.1-100.0), respectively. Specificity and positive predictive value were both 100% for combined PSV >3.0 m/s and EDV >0.5 m/s. CONCLUSIONS: PSV and EDV were equally useful in evaluation of significant SMA stent stenosis, when using trans-stenotic MAP gradient as reference. Finding of a significant stenosis on CDU should be considered as a true significant SMA stent stenosis.

Evaluation of direct oral anticoagulants and vitamin K antagonists in mesenteric venous thrombosis.

BACKGROUND/AIM: Mesenteric venous thrombosis is a rare lethal disease. The main aim of the present study was to evaluate clinical efficacy and safety of direct oral anticoagulants and vitamin K antagonists in mesenteric venous thrombosis patients. METHODS: Retrospective study of 102 mesenteric venous thrombosis patients treated between 2004 and 2017 at a center with a conservative medical first approach. Median clinical follow-up was 4 years. RESULTS: Computed tomography showed successful recanalization of thrombosis in 71% of patients on vitamin K antagonists and 69% of patients on direct oral anticoagulants ( p = 0.88). Overall major and esophageal variceal bleeding rate was 14.7% and 2.9%, respectively. No difference in major bleeding ( p = 0.54) was found between vitamin K antagonists and direct oral anticoagulants. No mesenteric venous thrombosis recurrence occurred during follow-up, and one venous thromboembolism occurred after cessation of anticoagulation. CONCLUSION: Anticoagulation with direct oral anticoagulants and vitamin K antagonists was efficient in patients with mesenteric venous thrombosis. Bleeding complications was a concern during treatment in both groups.

Longer colonic transit time is associated with laxative and drug use, lifestyle factors, and symptoms of constipation.

BACKGROUND: Gastrointestinal symptoms and changes in colonic transit time (CTT) are common in the population. PURPOSE: To evaluate consecutive patients who had been examined for CTT, along with completion of a diary about laxative and drug use, lifestyle factors, and gastrointestinal symptoms, to identify possible associations with longer or prolonged CTT. MATERIAL AND METHODS: A total of 610 consecutive patients had undergone the radiopaque marker method with an abdominal X-ray for clinical purposes. The patients had completed a diary regarding medical treatment, lifestyle factors, stool habits, and their perceived constipation and abdominal pain during the examination period. The associations between CTT and laxative use, lifestyle factors, stool habits, and symptoms were calculated by logistic regression. RESULTS: Women had longer CTT (2.5 [1.6-3.9] vs. 1.7 [1.1-3.0] days, P < 0.001), lower weekly stool frequency (6 [3-10] vs. 8 [5-12], P = 0.001), and perceived more constipation (P = 0.025) and abdominal pain (P = 0.001) than men. High coffee consumption (P = 0.045), bulk-forming (P = 0.007) and osmotic (P = 0.001) laxatives, and lower stool frequency, shaped stool, and perceived constipation (P for trend < 0.001) were associated with longer CTT. In total, 382 patients (63%) were treated with drugs affecting motility. In the 228 patients without drug treatment, longer CTT was associated with female sex and smoking, and lower frequency of symptoms and prolonged CTT were observed compared to patients using drugs. Tea, alcohol, and abdominal pain did not associate with CTT. CONCLUSIONS: Female sex, coffee, smoking, drug use, infrequent stools, shaped stool, and perception of constipation are associated with longer or prolonged CTT.